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Zhou R, Jiang W, Miao Q, Li X, Xiong L. Current Status and Global Trend of Rebound Pain After Regional Anesthesia: A Bibliometric Analysis. Local Reg Anesth 2024; 17:67-77. [PMID: 38742096 PMCID: PMC11090126 DOI: 10.2147/lra.s455347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 04/12/2024] [Indexed: 05/16/2024] Open
Abstract
Purpose Rebound pain after regional anesthesia, a common phenomenon when the analgesic effect wears off, has been recognized in the last a few years. The aim of this study is to analyze the status and tendency of this area in a macroscopic perspective. Methods Bibliometric analysis is the primary methodology of this study. Literature retrieval was conducted in Web of Science (WoS) Core Collection. WoS, Excel, VOSviewer and CiteSpace were employed to do the analyses and visualization. Parameters were analyzed, such as publications, citations, journals, and keywords, etc. Results In total, 70 articles in the past 10 years were identified eligible. Most articles (14 pieces) were published in 2021, followed by 2022 and 2023 with 13 articles. Researchers come from 134 institutions and 20 countries. Huang Jung-Taek, Hallym College, and USA are the most productive author, institution and country, respectively. The articles were mainly published on the top journals of anesthesiology, orthopedics and surgery. The topic of these articles is primarily about the clinical issues of rebound pain. Peripheral nerve block, brachial plexus block and femoral nerve block are the activist keywords in the area, while perioperative management, fracture surgery and outcome may become hotpots in the next years. Conclusion Our results show that the study of rebound pain after regional anesthesia starts relatively late and is in upward tendency, future studies can focus on the perioperative management and outcomes of fracture patients, and the definition and mechanism of rebound pain after regional anesthesia.
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Affiliation(s)
- Rui Zhou
- Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Clinical Research Center for Anesthesiology and Perioperative Medicine, Translational Research Institute of Brain and Brain-Like Intelligence, Department of Anesthesiology and Perioperative medicine, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai City, People’s Republic of China
| | - Wencai Jiang
- Department of Anesthesiology, Deyang People’s Hospital, Deyang City, People’s Republic of China
| | - Qingyuan Miao
- Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Clinical Research Center for Anesthesiology and Perioperative Medicine, Translational Research Institute of Brain and Brain-Like Intelligence, Department of Anesthesiology and Perioperative medicine, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai City, People’s Republic of China
| | - Xinyang Li
- Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Clinical Research Center for Anesthesiology and Perioperative Medicine, Translational Research Institute of Brain and Brain-Like Intelligence, Department of Anesthesiology and Perioperative medicine, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai City, People’s Republic of China
| | - Lize Xiong
- Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Clinical Research Center for Anesthesiology and Perioperative Medicine, Translational Research Institute of Brain and Brain-Like Intelligence, Department of Anesthesiology and Perioperative medicine, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai City, People’s Republic of China
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Wiesmann T, Steinfeldt T, Schubert AK. [Peripheral Regional Anesthesia Techniques - Standards in Flux?!]. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:180-189. [PMID: 38513642 DOI: 10.1055/a-2065-7696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
This review article provides an overview of current developments in peripheral regional anaesthesia (RA). The authors present a subjective compilation based on discussions at professional events and inquiries to the Working Group on Regional Anaesthesia of the German Society for Anaesthesiology and Intensive Care Medicine (DGAI). The article addresses several relevant topics, including the handling of antithrombotic medication in peripheral blockades with reference to European guidelines, the debate on the discharge timing after plexus anaesthesia, and the consideration of rebound pain as an independent pain entity following RA.Furthermore, the contentious discussion regarding the administration of peripheral nerve blockades under general anaesthesia is illuminated. The authors express no fundamental concerns in this regard but emphasize the importance of preoperative evaluation and individual patient needs. The question of mixing local anaesthetics is also addressed, with the authors critically questioning this tradition and recommending the use of individual, long-acting substances.Another focal point is the application of peripheral nerve blockades in emergency medicine, both in preclinical and emergency room settings. The authors highlight the necessity for high-quality studies and discuss the complex organizational issues associated with the preclinical application of RA techniques.
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Korkusuz M, Basaran B, Et T, Bilge A, Yarimoglu R, Kurucay Y. The effects of dexamethasone added to ilioinguinal/iliohypogastric nerve (IIN/IHN) block on rebound pain in inguinal hernia surgery: a randomized controlled trial. Hernia 2023; 27:1571-1580. [PMID: 37477788 DOI: 10.1007/s10029-023-02841-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/09/2023] [Indexed: 07/22/2023]
Abstract
PURPOSE The purpose of the present study was to evaluate the effects of IV dexamethasone added to one single injection Ilioinguinal/Iliohypogastric Nerve (IIN/IHN) block on tramadol consumption and Modified Rebound Pain Score (MRPS) in the first postoperative 24 h in inguinal hernia surgery. METHODS Five mg IV dexamethasone as an analgesic adjunct in the multimodal analgesia was administered to the patients who were scheduled for Inguinal Hernia Surgery and randomized to Group Dex and normal saline was administered to the patients who were randomized to the Control Group in addition to IIN/IHN Block. Postoperative tramadol consumption, Modified Rebound Pain Score (MRPS), the incidence of Rebound Pain, Rebound Pain time, postoperative 48-h opioid consumption, Numerical Rating Scale (NRS) scores, Quality of Recovery Score (QoR-15), Sleep Quality, and adverse events were evaluated in the patients. RESULTS The mean scores of MRPS were lower in Group Dex than in the Control Group, both at rest (p = 0.001) and with motion (p = 0.001). Tramadol consumption in the first postoperative 24 h was 45.17 ± 49.59 mg in Group Dex and 95 ± 59.23 mg in the Control Group. The difference between the groups was statistically significant (p < 0.001). CONCLUSIONS In conclusion, adding IV dexamethasone as a part of multimodal analgesia to IIN/IHN block for inguinal hernia surgery resulted in lower MRPS and lower postoperative opioid (tramadol) consumption. For this reason, IV dexamethasone can be added to the IIN/IHN block after inguinal hernia surgery to reduce the incidence of rebound pain, rebound pain scores, and NRS scores for pain, decrease postoperative opioid consumption, and improve the quality of recovery. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov: Ref; NCT05172908, Date: December 29, 2021.
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Affiliation(s)
- Muhammet Korkusuz
- Department of Anesthesiology and Reanimation, Karamanoglu Mehmetbey University School of Medicine, Karaman, Turkey.
| | - Betul Basaran
- Department of Anesthesiology and Reanimation, Karamanoglu Mehmetbey University School of Medicine, Karaman, Turkey
| | - Tayfun Et
- Department of Anesthesiology and Reanimation, Karamanoglu Mehmetbey University School of Medicine, Karaman, Turkey
| | - Aysegul Bilge
- Department of Anesthesiology and Reanimation, Karamanoglu Mehmetbey University School of Medicine, Karaman, Turkey
| | - Rafet Yarimoglu
- Department of Anesthesiology and Reanimation, Karaman Training and Research Hospital, Karaman, Turkey
| | - Yıldıray Kurucay
- Department of Surgery, Karaman Training and Research Hospital, Karaman, Turkey
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Schubert AK, Wiesmann T, Volberg C, Riecke J, Schneider A, Wulf H, Dinges HC. Rebound pain and postoperative pain profile following brachial plexus block compared to general anaesthesia-An observational study. Acta Anaesthesiol Scand 2023; 67:1414-1422. [PMID: 37642227 DOI: 10.1111/aas.14318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 07/19/2023] [Accepted: 08/08/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Regional anaesthesia has the benefit of reducing the need for systemic analgesia and therefore, potentially reducing undesired side effects. With the end of the sensory nerve block however, many patients report severe pain that requires therapy with opioids and often compromise the initial opioid sparing effect. This study aimed to characterise the postoperative pain profile and the phenomenon of rebound pain after axillary brachial plexus anaesthesia (RA) compared to general anaesthesia (GA). DESIGN Single-centre observational, stratified cohort study. SETTING The study was conducted at University Hospital Marburg from May 2020 until September 2022. PARTICIPANTS One hundred thirty-two patients receiving elective hand and forearm surgery were enrolled in this study. INTERVENTIONS Group RA received ultrasound-guided brachial plexus anaesthesia via the axillary approach with 30 mL of prilocaine 1% and 10 mL ropivacaine 0.2%. Group GA received balanced or total intravenous general anaesthesia. MAIN OUTCOME MEASURES Primary endpoint were integrated pain scores (IPS) within 24 h postoperatively. Secondary endpoints were pain scores (NRS 0-10), morphine equivalents, patient satisfaction, quality of recovery and opioid-related side effects. RESULTS One hundred thirty-two patients were analysed of which 66 patients received brachial plexus block and 66 patients received general anaesthesia. Following RA significantly lower IPS were seen directly after surgery (p < .001) and during the post-anaesthesia care unit interval (p < .001) but equalised after 3 h at the ward. No overshoot in pain scores or increased opioid consumption could be detected. Patient satisfaction and postoperative recovery were comparable between both groups. CONCLUSION The IPS and NRS was initially lower in the RA group, increased with fading of the block until equal to the GA group and equal thereafter. Although various definitions of rebound pain were met during this phase, the opioid sparing effect of regional anaesthesia was not counteracted by it. The incidence of episodes with uncontrolled, severe pain did not differ between groups. We found no clinical implications of rebound pain in this setting, since the RA group did not show higher pain scores than the GA group at any time point. TRIAL REGISTRATION German Clinical Trials Register (DRKS00021764).
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Affiliation(s)
- Ann-Kristin Schubert
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University of Marburg, Marburg, Germany
| | - Thomas Wiesmann
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University of Marburg, Marburg, Germany
- Department of Anaesthesiology and Intensive Care Medicine, Diakoneo Diak Klinikum Schwäbisch-Hall, Schwäbisch-Hall, Germany
| | - Christian Volberg
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University of Marburg, Marburg, Germany
| | - Jenny Riecke
- Department of Clinical Psychology and Psychotherapy, Philipps University Marburg, Marburg, Germany
| | - Alexander Schneider
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University of Marburg, Marburg, Germany
| | - Hinnerk Wulf
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University of Marburg, Marburg, Germany
| | - Hanns-Christian Dinges
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University of Marburg, Marburg, Germany
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Et T, Basaran B, Bilge A, Yarımoğlu R, Korkusuz M, Tülüce İ. Rebound pain after interscalene brachial plexus block for shoulder surgery: a randomized clinical trial of the effect of different multimodal analgesia regimens. Ann Saudi Med 2023; 43:339-347. [PMID: 38071444 PMCID: PMC11182429 DOI: 10.5144/0256-4947.2023.339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/09/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Rebound pain is characterized by sudden, significant acute postoperative pain occurring after the resolution of inter-scalene block (ISB); it affects the quality of recovery postoperatively. Dexamethasone increases ISB resolution time and decreases opioid consumption and the incidence of rebound pain. OBJECTIVE Evaluate whether multimodal analgesia including intravenous dexamethasone administration with preoperative ISB reduces the incidence of rebound pain. DESIGN Prospective, randomized, controlled trial. SETTING Tertiary university hospital. SAMPLE SIZE 60 patients. PATIENTS AND METHODS Patients who underwent shoulder surgery under general anesthesia were assigned randomly to two different multimodal analgesia protocols. Thirty patients received 5 mg IV dexamethasone with non-steroid, paracetamol, and ISB with 15 mL 0.5% bupivacaine, while the control patients received the same regimen and ISB with 15 mL 0.5% bupivacaine without dexamethasone. Postoperative opioids were given to any patient on demand. MAIN OUTCOMES MEASURES Effect of IV dexamethasone on pain score and incidence of rebound pain after ISB resolution and postoperative opioid consumption at 0-48 hours, numerical pain rating scale (NPRS) scores, sleep scale scores, and quality of recovery-15 scores (QoR-15). RESULTS The incidence of rebound pain was lower in the dexamethasone group than in the control group (73.3% and 30%, respectively, P=.001). NPRS scores after ISB resolution were lower in the dexamethasone group (5 ([4-7]), 8 ([5.75-8]), P<.001, respectively). Those who received IV dexamethasone had less sleep disturbances (P<.001) and higher QoR-15 on day 1 (P<.001) and day 7 (P=.020) postoperatively. CONCLUSIONS IV dexamethasone added to the ISB block resulted in a lower incidence of rebound pain. In addition, better results were obtained in postoperative sleep quality and QoR-15. LIMITATIONS Single-center study.
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Affiliation(s)
- Tayfun Et
- From the Department of Anesthesiology and Intensive Care Medicine, Karamanoglu Mehmetbey University, Karaman, Turkey
| | - Betul Basaran
- From the Department of Anesthesiology and Intensive Care Medicine, Karamanoglu Mehmetbey University, Karaman, Turkey
| | - Aysegul Bilge
- From the Department of Anesthesiology and Intensive Care Medicine, Karamanoglu Mehmetbey University, Karaman, Turkey
| | - Rafet Yarımoğlu
- From the Department of Anesthesiology and Intensive Care Medicine, Karamanoglu Mehmetbey University, Karaman, Turkey
| | - Muhammet Korkusuz
- From the Department of Anesthesiology and Intensive Care Medicine, Karamanoglu Mehmetbey University, Karaman, Turkey
| | - İbrahim Tülüce
- From the Department of Orthopedics and Traumatology, Karaman Training and Research Hospital, Karaman, Turkey
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Kim MK, Park YH, Lee JS, Jung HS. How Does the Addition of Dexamethasone to a Brachial Plexus Block Change Pain Patterns After Surgery for Distal Radius Fractures? A Randomized, Double-blind Study. Clin Orthop Relat Res 2023; 481:1966-1974. [PMID: 37053082 PMCID: PMC10499086 DOI: 10.1097/corr.0000000000002640] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/27/2023] [Accepted: 03/07/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Although brachial plexus block in volar plating surgery for distal radius fractures is reportedly associated with lower postoperative pain scores, rebound pain has been reported to occur after the initial block wears off. Dexamethasone can be used in multimodal strategies for antiemesis and to control pain postoperatively. Although prior studies have suggested that anesthesia can be prolonged by adding dexamethasone to regional blocks, no randomized trials we are aware of have ascertained whether doing so will make a clinically important difference in pain after surgery for distal radius fractures. QUESTIONS/PURPOSES Do patients who receive supplemental dexamethasone in a brachial plexus block for volar plating of unstable distal radius fractures have (1) better pain scores at 4, 8, 24, and 48 hours postoperatively than patients who have not received dexamethasone, and (2) lower fentanyl consumption and administration of antiemetic drugs without change in serum blood glucose, as well as a longer analgesic duration from the block after surgery than patients who have not received dexamethasone? METHODS This randomized, double-blind trial included 69 patients undergoing surgery for distal radius fractures under ultrasound-guided supraclavicular brachial plexus blocks who were randomly allocated into two groups: a nondexamethasone group receiving a brachial plexus block with 0.5% ropivacaine and a dexamethasone group receiving 0.5% ropivacaine and 5 mg of dexamethasone. Thirty-four patients were allocated to the dexamethasone group and 35 were allocated to the nondexamethasone group. Nine patients (four in the dexamethasone group and five in the nondexamethasone group) were excluded after randomization because local anesthetics were used during their surgical procedures owing to an incomplete block or they requested patient-controlled analgesia after surgery. The treatment groups did not differ in any important ways, including age, gender, BMI, hand dominance, and AO/Orthopaedic Trauma Association classification. All patients received the same surgical procedure and perioperative care protocol, except for the injected agents during their brachial plexus block. The primary outcome was postoperative pain, evaluated using a 10-mm VAS at 4, 8, 12, 24, and 48 hours after surgery. The minimum clinically important difference for the VAS score was 2 of 10 points. Secondary outcome variables included fentanyl administration as a rescue analgesic, the number of patients receiving antiemetic medications because of fentanyl administration, and the duration of brachial plexus block. Serum blood glucose was measured 1 day before, immediately after, and 24 hours after surgery. Patients, surgeons, and outcome assessors were blinded to treatment allocation. RESULTS The only clinically important between-group difference in VAS pain scores was at 8 hours, favoring the group that received dexamethasone over the group that did not (1.9 ± 1.6 versus 4.7 ± 2.7; mean difference -2.8 [95% CI -3.9 to -1.6]; p < 0.001). After brachial plexus block, the most severe pain score in both groups was reported at 12 hours postoperatively and gradually diminished over time. There was no between-group difference in fentanyl use between those who received dexamethasone and those who did not (21 ± 38 mcg versus 31 ± 29 mcg; mean difference -10 [95% CI -27.4 to 7.4]; p = 0.26). Furthermore, the use of antiemetics did not differ between the groups (27% [eight of 30] versus 37% [11 of 30]; odds ratio 1.6 [95% CI 0.5 to 4.8]; p = 0.41). Baseline and 24-hour postoperative serum blood glucose level did not differ between the groups. However, the immediately postoperative serum blood glucose level was higher in the dexamethasone group than in the nondexamethasone group (121 ± 29 versus 104 ± 20; mean difference 16 [95% CI 3.3 to 28.8]; p = 0.02). The brachial plexus block duration was 3 hours longer (95% CI 0.8 to 5.2 hours) in the dexamethasone group than that in the nondexamethasone group (11 ± 5 hours versus 8 ± 3 hours; p = 0.01). CONCLUSION The postoperative pain level in patients who received supplemental dexamethasone in a regional block was not clinically different from that of patients who received conventional brachial plexus block anesthesia when undergoing volar plating for distal radius fractures. However, patients who received a brachial plexus block with dexamethasone experienced slight prolongation of their block and decrease in pain 8 hours after surgery. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
- Min Kyoung Kim
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea
| | - Yong-Hee Park
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, Seoul, Korea
| | - Jae Sung Lee
- Department of Orthopaedic Surgery, Chung-Ang University Hospital, Seoul, South Korea
| | - Hyoung-Seok Jung
- Department of Orthopaedic Surgery, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, South Korea
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Sun X, Kong M. Effects of posterior lumbar plexus block on anesthesia and sedation in postmenopausal patients with osteoporotic subtrochanteric comminuted fractures. Biotechnol Genet Eng Rev 2023:1-14. [PMID: 37037007 DOI: 10.1080/02648725.2023.2200988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
To study the effect of posterior lumbar plexus nerve block on anaesthesia and sedation in postmenopausal patients with osteoporotic subtrochanteric femoral comminuted fractures. The research subjects selected 48 patients with postmenopausal osteoporotic subtrochanteric comminuted fractures who were hospitalized between January 2020 and January 2022, and were allocated to clusters according to the random number TBL approach. The controlling cluster (24 situations) underwent dura mater Under external anesthesia, the test cluster (24 situations) underwent posterior lumbar plexus block, and the block effect, anesthesia effect, sedation effect, hemodynamics, vital signs and reactions of adverse nature were contrasted involving the two clusters. In comparison to the control group, the test group had a longer duration of anesthesia and motor block, higher oxygenation indices but lower ITBVI, GEDVI, and ScrO2 values, lower MAP levels, and lower BIS contraction values at 5, 15, and 30 minutes following anesthesia (P < 0.05). The test group had shorter induction time and block onset time compared to the control group (P < 0.05), and a lower incidence of adverse reactions (16.67% vs. 29.17% in the control group), but the variation was not noTBL (P < 0.05). Posterior lumbar plexus nerve block in postmenopausal patients with osteoporotic subtrochanteric femoral comminuted fractures has a better sedative effect, shortens the induction time of anaesthesia and the onset of block, promotes sTBL haemodynamic indexes and has fewer adverse effects to ensure safety.
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Affiliation(s)
- Xiaoshan Sun
- Anaesthesiology department, The Second Affiliated Hospital of Shandong First Medical University, Taian, Shandong, China
| | - Minmin Kong
- Anaesthesiology department, The Second Affiliated Hospital of Shandong First Medical University, Taian, Shandong, China
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Lantieri MA, Novicoff WM, Yarboro SR. Regional anesthesia provides limited decreases in opioid use following distal tibia and ankle fracture surgery. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03486-1. [PMID: 36781480 DOI: 10.1007/s00590-023-03486-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 02/05/2023] [Indexed: 02/15/2023]
Abstract
PURPOSE Regional anesthesia (RA) is used for pain control, but its impacts on the orthopedic trauma population are not well known. This study evaluated the impact of peripheral nerve blocks after distal tibia and ankle fracture repair on opioid use and pain scores and quantified the magnitude and duration of any changes. METHODS This retrospective cohort study included patients treated operatively for distal tibia and ankle fractures over a 5-year period, both with and without peripheral nerve blocks. Total inpatient 5 mg oxycodone equivalents (OEs) used in the post-operative period, from 0-24, 24-48, to 48-72 h and maximum visual analog scale (VAS) pain ratings from 0-24, 24-48, to 48-72 h were recorded. RESULTS 540 non-polytrauma patients and 183 polytrauma patients were included. Patients in the non-polytrauma group who received nerve blocks required fewer opioids on post-operative day (POD) 1 compared to the non-nerve block group (4.8 [95% CI 4.2-5.4] vs. 10.5 [95% CI: 9.2-11.8]; p < 0.001) and had lower VAS scores on POD1 (5.0 [95% CI 4.6-5.4] vs. 7.7 [95% CI: 7.3-8.1]; p < 0.001). However, there were no differences between these groups on POD2 or POD3 and no differences at any timepoints in the polytrauma group. CONCLUSION Patients with isolated distal tibia and ankle fractures who receive peripheral nerve blocks demonstrate modest reductions in inpatient opioids and pain scores on POD1. However, there are no clear benefits beyond this point. Furthermore, polytrauma patients do not experience any reductions in opioid consumption or pain scores.
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Affiliation(s)
- Mark A Lantieri
- Department of Orthopaedic Surgery, University of Virginia, 2280 Ivy Road, Charlottesville, VA, 22903, USA
| | - Wendy M Novicoff
- Department of Orthopaedic Surgery, University of Virginia, 2280 Ivy Road, Charlottesville, VA, 22903, USA
| | - Seth R Yarboro
- Department of Orthopaedic Surgery, University of Virginia, 2280 Ivy Road, Charlottesville, VA, 22903, USA.
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Li M, Zhang K, Li T, Chen Y, Zang H, Hu Y, Yao W. Sciatic Nerve Block Combined with Flurbiprofen Inhibits Spinal Cord Inflammation and Improves Postoperative Pain in Rats with Plantar Incision. J Pain Res 2023; 16:1533-1546. [PMID: 37193359 PMCID: PMC10182802 DOI: 10.2147/jpr.s404226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 04/28/2023] [Indexed: 05/18/2023] Open
Abstract
Background and Purpose Peripheral nerve block is often used to relieve postoperative pain. But the effect of nerve block on inflammatory response is not fully understood. Spinal cord is the primary center of pain processing. This study is to investigate the effect of single sciatic nerve block on the inflammatory response of the spinal cord in rats with plantar incision and the combined effect with flurbiprofen. Methods The plantar incision was used to establish a postoperative pain model. Single sciatic nerve block, intravenous flurbiprofen or the combination of both were used for intervention. The sensory and motor functions after nerve block and incision were evaluated. The changes of IL-1β, IL-6, TNF-α, microglia and astrocytes in the spinal cord were examined by qPCR and immunofluorescence respectively. Results Sciatic nerve block with 0.5% ropivacaine in rats induced sensory block for 2h and motor block for 1.5h. In the rats with plantar incision, the single sciatic nerve block did not alleviate postoperative pain or inhibit the activation of spinal microglia and astrocytes, but the levels of IL-1β and IL-6 in spinal cord were decreased when the nerve block wore off. The combined effect of a single sciatic nerve block and intravenous flurbiprofen not only decreased the levels of IL-1β, IL-6, and TNF-α, but also relieved the pain and alleviated the activation of microglia and astrocytes. Conclusion The single sciatic nerve block cannot improve postoperative pain or inhibit the activation of spinal cord glial cells, but can reduce the expression of spinal inflammatory factors. Nerve block combined with flurbiprofen can inhibit spinal cord inflammation and improve postoperative pain. This study provides a reference for rational clinical application of nerve block.
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Affiliation(s)
- Meihong Li
- Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, and Wuhan Clinical Research Center for Geriatric Anesthesia, Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People’s Republic of China
| | - Kaiwen Zhang
- Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, and Wuhan Clinical Research Center for Geriatric Anesthesia, Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People’s Republic of China
| | - Ting Li
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, 200032, People’s Republic of China
| | - Yuye Chen
- Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, and Wuhan Clinical Research Center for Geriatric Anesthesia, Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People’s Republic of China
| | - Hu Zang
- Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, and Wuhan Clinical Research Center for Geriatric Anesthesia, Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People’s Republic of China
| | - Yingjie Hu
- Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, and Wuhan Clinical Research Center for Geriatric Anesthesia, Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People’s Republic of China
| | - Wenlong Yao
- Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, and Wuhan Clinical Research Center for Geriatric Anesthesia, Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People’s Republic of China
- Correspondence: Wenlong Yao, Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, and Wuhan Clinical Research Center for Geriatric Anesthesia, Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People’s Republic of China, Tel +86 13720271159, Email
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Admassie BM, Tegegne BA, Alemu WM, Getahun AB. Magnitude and severity of rebound pain after resolution of peripheral nerve block and associated factors among patients undergoes surgery at university of gondar comprehensive specialized hospital northwest, Ethiopia, 2022. Longitudinal cross-sectional study. Ann Med Surg (Lond) 2022; 84:104915. [PMID: 36536717 PMCID: PMC9758353 DOI: 10.1016/j.amsu.2022.104915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 11/01/2022] [Accepted: 11/13/2022] [Indexed: 11/19/2022] Open
Abstract
Background Rebound pain is extreme pain that persists after the effects of regional anesthesia wear off. Rebound pain occurrence and intensity are influenced by patient, surgical, and anesthesia-related factors. The incidence and severity of rebound pain after peripheral nerve block resolution are both reduced by the use of perioperative multimodal strategy. The purpose of the current paper was to evaluate the frequency, seriousness, and risk factors for rebound pain following peripheral nerve block resolution. Method A cross-sectional study centred on 384 patients who had received peripheral nerve blocks was carried out from August 20, 2021, to June 30, 2022. A semi-structured questionnaire was used to gather information within 24 h following the block's performance. SPSS 25 was used to enter and analyze the data. The change from well-controlled pain while the block is operating to severe pain within 24 h of block performance is known as rebound pain. Both univariate and multivariable analyses were used to examine the relationship between various parameters (patient, surgical, and anesthetic-related factors) and rebound pain. In the multivariable analysis, a P-value of 0.05 or lower is regarded as statistically significant. Results The incidence of rebound pain after peripheral nerve block was resolved was 61.7% (95% CI: 56.5-66.7) with a mean rebound pain score of 4.19 ± 2. Of the total 237, 120(50.6%) had severe rebound pain after the peripheral nerve block was resolved. The use of preoperative intravenous dexamethasone (AOR: 2.6, 95%CI: 20.29-24.57), preoperative pain (AOR: 3.9, 95%CI: 41-57.4), type of surgery (AOR: 6.5, 95%CI: 1.45-11.7), post-operative NSAID (AOR: 2.2, 95%CI: 17.69-20.8), and opioid use (AOR: 2.2, 95%CI: 19.1-22.56) were independent risks associated with rebound pain. Conclusions and Recommendation: Rebound pain occurred in 61.7% of patients and had independent associations with preoperative pain, dexamethasone premedication, type of surgery, use of an adjuvant, use of postoperative opioids, and NSAIDs. Therefore, clinicians should continue to use preventative strategies, especially for patients at higher risk of experiencing rebound pain.
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Affiliation(s)
- Belete Muluadam Admassie
- Department of Anesthesia, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Biresaw Ayen Tegegne
- Department of Anesthesia, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Wudie Mekonnen Alemu
- Department of Anesthesia, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Amare Belete Getahun
- Department of Anesthesia, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Samineni AV, Seaver T, Sing DC, Salavati S, Tornetta P. Peripheral Nerve Blocks Associated With Shorter Length of Stay Without Increasing Readmission Rate for Ankle Open Reduction Internal Fixation in the Outpatient Setting: A Propensity-Matched Analysis. J Foot Ankle Surg 2022; 61:1165-1169. [PMID: 34848109 DOI: 10.1053/j.jfas.2021.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 10/01/2021] [Accepted: 10/10/2021] [Indexed: 02/03/2023]
Abstract
Peripheral nerve blocks (PNB) have become an important modality for pain management in ankle fracture surgery. Previous studies have reported their efficacy, but concerns with rebound pain and readmissions have been cited as possible deterrents. The purpose of this study was to evaluate the effects of PNB on hospital length of stay (LOS), narcotic intake, visual analog scale (VAS) for pain, and associated complications in patients undergoing outpatient ankle open reduction internal fixation (ORIF). Adult patients undergoing ankle ORIF were matched 2:1 (no block:block) using propensity-score matching. Preoperative patient characteristics and postoperative outcomes were compared between cohorts. VAS and total narcotic intake were evaluated for each of the first 3 postoperative 8-hour shifts. Narcotic medication was converted to morphine milligram equivalents (MME). Thirty-two patients who received PNB were matched to 64 patients who did not. The PNB group had lower VAS and MME during each of the 8-hour shifts after surgery: 0 to 8 hours (VAS 1.8 vs 6.3; MME 10.6 vs 77.9; p < .001), 8 to 16 hours (VAS 1.2 vs 5.9; MME 9.2 vs 28.2; p < .001), 16 to 24 hours (VAS 3.7 vs 6.2; MME 13.2 vs 24.2; p = .006 and 0.019). PNB had a shorter LOS (average 16.7 hours vs 26.8 hours; p < .001). There were no differences in rates of ED presentations after discharge, hospital readmissions, or complications between cohorts. Peripheral nerve blocks after ankle ORIF are associated with shorter hospital LOS, lower VAS, and reduced narcotic intake without increasing rates of ED visits, hospital readmissions, or complications.
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Affiliation(s)
| | - Thomas Seaver
- Resident, Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA.
| | - David C Sing
- Resident, Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA
| | - Seroos Salavati
- Anesthesiologist, Director of Regional Anesthesiology, Assistant Professor, Boston Medical Center, Boston, MA
| | - Paul Tornetta
- Orthopaedic Surgeon, Chief, Chair, Professor of Orthopaedic Surgery, and Director of Orthopaedic Trauma, Boston Medical Center, Boston, MA
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Regional anesthesia and analgesia for trauma: an updated review. Curr Opin Anaesthesiol 2022; 35:613-620. [PMID: 36044292 DOI: 10.1097/aco.0000000000001172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW This narrative review is an updated summary of the value of regional anesthesia and analgesia for trauma and the special considerations when optimizing pain management and utilizing regional analgesia for acute traumatic pain. RECENT FINDINGS In the setting of the opioid epidemic, the need for multimodal analgesia in trauma is imperative. It has been proposed that inadequately treated acute pain predisposes a patient to increased risk of developing chronic pain and continued opioid use. Enhanced Regional Anesthesia techniques along with multimodal pain therapies is thought to reduce the stress response and improve patient's short- and long-term outcomes. SUMMARY Our ability to save life and limb has improved, but our ability to manage acute traumatic pain continues to lag. Understanding trauma-specific concerns and tailoring the analgesia to a patient's specific injuries can increase a patient's immediate comfort and long-term outcome as well.
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Stone A, Lirk P, Vlassakov K. Rebound Pain After Peripheral Nerve Blockade-Bad Timing or Rude Awakening? Anesthesiol Clin 2022; 40:445-454. [PMID: 36049873 DOI: 10.1016/j.anclin.2022.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Patients who have perioperatively benefited from regional anesthesia frequently report moderate to severe pain when the nerve block effects fade away. Over the past years, the term "rebound pain" has been introduced, suggesting a specific pathologic process. It is debated whether significant pain on block resolution reflects a separate and distinct pathologic mechanism potentially involving proinflammatory and neurotoxic effects of local anesthetics, or is simply caused by the recovery of sensory function at a timepoint when nociceptive stimuli are still intense, and moderate to severe pain should be anticipated. In that latter case, the phenomenon referred to as rebound pain could be considered a failure of pain management providers to devise an adequate analgesia plan. Whatever the ultimate designation, management of rebound pain should be proactive, by implementing multimodal analgesia, or tailoring the blockade to the expected trajectory of postoperative pain and managing patient expectations accordingly. Until we know more about the etiology and impact of this phenomenon, the authors suggest a more neutral designation such as "pain on block resolution."
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Affiliation(s)
- Alexander Stone
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA; Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Philipp Lirk
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
| | - Kamen Vlassakov
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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Cunningham DJ, Paniaugua AR, LaRose MA, DeLaura IF, Blatter MK, Gage MJ. Regional anesthesia does not decrease inpatient or outpatient opioid demand in distal femur fracture surgery. Arch Orthop Trauma Surg 2022; 142:1873-1883. [PMID: 33938985 DOI: 10.1007/s00402-021-03892-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 03/31/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Regional anesthesia (RA) is sometimes used to decrease pain and opioid consumption in distal femur fractures. However, the real-world impact of RA on inpatient opioid consumption and outpatient opioid demand is not well known. The hypothesis of this study is that RA would be associated with decreased inpatient opioid consumption and outpatient opioid demand. METHODS This study evaluated inpatient post-operative opioid consumption (0-24 h, 24-48 h, 48-72 h) and outpatient opioid demand (discharge to 2 weeks, 6 weeks, and 90 days) in all patients ages 18 and older undergoing operative treatment of distal femur fractures at a single institution from 7/2013 to 7/2018 (n = 230). Unadjusted and adjusted multivariable models were used to evaluate the impact of RA and other baseline patient and operative characteristics on inpatient opioid consumption and outpatient opioid demand. RESULTS Adjusted models demonstrated a small, significant increase in inpatient opioid consumption in patients with RA compared to no RA (4.7 estimated OE's without RA vs 6.2 OE's with RA from 24- to 48-h post-op, p < 0.05) but otherwise no significant differences at other timepoints (6.7 estimated OE's without RA vs 6.9 OE's with RA from 0- to 24-h post-op and 4.5 vs 4.4 from 48- to 72-h post-op, p > 0.05). Estimated cumulative outpatient opioid demand was significantly higher in patients with RA from discharge to 6 weeks and to 90 days (55.8 OE's without RA vs 63.9 with RA from discharge to 2 weeks, p > 0.05; 74.9 vs 95.1 OE's to 6 weeks, and 85 vs 113.1 OE's to 90 days, p < 0.05). DISCUSSION In distal femur fracture surgery, RA was associated with increased inpatient and outpatient opioid demand after adjusting for baseline patient and treatment characteristics. These results call into question the routine use of RA in distal femur fractures. LEVEL OF EVIDENCE Level III, retrospective, therapeutic cohort study.
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Affiliation(s)
- Daniel J Cunningham
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA.
| | - Ariana R Paniaugua
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA
| | - Micaela A LaRose
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA
| | - Isabel F DeLaura
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
| | - Michael K Blatter
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
| | - Mark J Gage
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
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15
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Hip Fracture Surgery: Regional Anesthesia and Opioid Demand. J Am Acad Orthop Surg 2022; 30:e979-e988. [PMID: 35312633 DOI: 10.5435/jaaos-d-21-00786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 02/17/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Hip fracture surgery is painful, and regional anesthesia (RA) has been used in an attempt to reduce pain and opioid consumption after surgery. Despite potential analgesic benefits, the effect of RA on inpatient and outpatient opioid demand is not well known. We hypothesized that RA would be associated with decreased inpatient opioid demand and has little effect on outpatient opioid demand in hip fracture surgery. METHODS This study retrospectively evaluated all patients of 18 years and older undergoing hip fracture surgery from July 2013 to July 2018 at a single, level I trauma center (n = 1,659). Inpatient opioid consumption in 24-hour increments up to 72-hour postoperative and outpatient opioid prescribing up to 90-day postoperative were recorded in oxycodone 5-mg equivalents (OE's). Adjusted models evaluated the effect of RA on opioid demand after adjusting for other baseline and treatment variables. RESULTS After adjusting for baseline and treatment variables, there were small increases in inpatient opioid consumption in patients with RA (2.6 estimated OE's without RA versus three OE's with RA from 0 to 24 hours postoperatively, 2.1 versus 2.4 from 24 to 48 hours postoperatively, and 1.6 versus 2.2 from 48 to 72 hours postoperatively, all P values for RA <0.001). However, there were no notable differences in outpatient opioid demand. DISCUSSION RA did not decrease inpatient or outpatient opioid demand in patients undergoing hip fracture surgery in this pragmatic study. In fact, there were slight increases in inpatient opioid consumption, although these differences are likely clinically insignificant. These results temper enthusiasm for RA in hip fracture surgery. LEVEL OF EVIDENCE Level III, retrospective, therapeutic cohort study.
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Loewenstein SN, Bamba R, Adkinson JM. Emergency Department Utilization After Administration of Peripheral Nerve Blocks for Upper Extremity Surgery. Hand (N Y) 2022; 17:624-629. [PMID: 35815366 PMCID: PMC9274871 DOI: 10.1177/1558944720963867] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
BACKGROUND The purpose of this study was to determine the impact of upper extremity peripheral nerve blocks on emergency department (ED) utilization after hand and upper extremity surgery. METHODS We reviewed all outpatient upper extremity surgeries performed in a single Midwestern state between January 2009 and June 2019 using the Indiana Network for Patient Care. These encounters were used to develop a database of patient demographics, comorbidities, concurrent procedures, and postoperative ED visit utilization data. We performed univariate, bivariate, and multivariate logistic regression analyses. RESULTS Among 108 451 outpatient surgical patients, 9079 (8.4%) received blocks. Within 1 week of surgery, a greater proportion of patients who received peripheral nerve blocks (1.4%) presented to the ED than patients who did not (0.9%) (P < .001). The greatest risk was in the first 2 postoperative days (relative risk, 1.78; P < .001). Pain was the principal reason for ED utilization in the block cohort (53.6%) compared with those who did not undergo a block (35.1%) (P < .001). When controlling for comorbidities and demographics, only peripheral nerve blocks (adjusted odds ratio [OR], 1.71; P = 0.007) and preprocedural opioid use (adjusted OR, 1.43; P = .020) conferred an independently increased risk of ED utilization within the first 2 postoperative days. CONCLUSIONS Peripheral nerve blocks used for upper extremity surgery are associated with a higher risk of unplanned ED utilization, most likely related to rebound pain. Through proper patient education and pain management, we can minimize this unnecessary resource utilization.
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Affiliation(s)
| | - Ravinder Bamba
- Indiana University School of Medicine, Indianapolis, USA
| | - Joshua M. Adkinson
- Indiana University School of Medicine, Indianapolis, USA,Joshua M. Adkinson, Division of Plastic Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Emerson Hall (EH), Suite 232, Indianapolis, IN 46202, USA.
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17
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Kim Y, Bae H, Yoo S, Park SK, Lim YJ, Sakura S, Kim JT. Effect of remifentanil on post-operative analgesic consumption in patients undergoing shoulder arthroplasty after interscalene brachial plexus block: a randomized controlled trial. J Anesth 2022; 36:506-513. [PMID: 35732849 DOI: 10.1007/s00540-022-03085-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 06/02/2022] [Indexed: 01/30/2023]
Abstract
PURPOSE Remifentanil is useful in balanced anesthesia; however, there is concern regarding opioid-induced hyperalgesia. The effect of remifentanil on rebound pain, characterized by hyperalgesia after peripheral nerve block has rarely been studied. This study evaluated whether intraoperative remifentanil infusion may increase postoperative analgesic requirement in patients receiving preoperative interscalene brachial plexus block (IBP). METHODS Sixty-eight patients undergoing arthroscopic shoulder surgery under general anesthesia were randomly allocated to remifentanil (R) or control (C) group. Preoperative IBP with 0.5% ropivacaine 15 mL was performed in all patients. Intraoperative remifentanil was administered only in the R group. Postoperative pain was controlled using intravenous patient-controlled analgesia (IV-PCA) and rescue analgesics. The primary outcome was the dosage of fentanyl-nefopam IV-PCA infused over 24 h postoperatively. The secondary outcomes included the numeric rating scale (NRS) score recorded at 4-h intervals over 24 h, amount of rescue analgesics and total postoperative analgesics used over 24 h, occurrence of intraoperative hypotension, postoperative nausea and vomiting (PONV) and delirium. RESULTS The dosage of fentanyl-nefopam IV-PCA was significantly less in C group than R group for postoperative 24 h. Fentanyl 101 [63-158] (median [interquartile range]) µg was used in the C group, while fentanyl 161 [103-285] µg was used in the R group (median difference 64 µg, 95% CI 10-121 µg, P = 0.02). Nefopam 8.1 [5.0-12.6] mg was used in the C group, while nefopam 12.9 [8.2-22.8] mg was used in the R group (median difference 5.1 mg, 95% CI 0.8-9.7 mg, P = 0.02). The total analgesic consumption: the sum of PCA consumption and administered rescue analgesic dose, converted to morphine milligram equivalents, was higher in the R group than C group (median difference 10.9 mg, 95% CI 3.0-19.0 mg, P = 0.01). The average NRS score, the incidence of PONV and delirium, were similar in both groups. The incidence of intraoperative hypotension was higher in R group than C group (47.1% vs. 20.6%, P = 0.005). CONCLUSIONS Remifentanil administration during arthroscopic shoulder surgery in patients undergoing preoperative IBP increased postoperative analgesic consumption.
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Affiliation(s)
- Youngwon Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Hansu Bae
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, 27, Dongguk-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, 10326, South Korea
| | - Seokha Yoo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Sun-Kyung Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Young-Jin Lim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Shinichi Sakura
- Department of Anesthesiology, Faculty of Medicine, Shimane University, Izumo City, Shimane, Japan
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.
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18
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Jen TTH, Ke JXC, Wing KJ, Denomme J, McIsaac DI, Huang SC, Ree RM, Prabhakar C, Schwarz SKW, Yarnold CH. Development and internal validation of a multivariable risk prediction model for severe rebound pain after foot and ankle surgery involving single-shot popliteal sciatic nerve block. Br J Anaesth 2022; 129:127-135. [PMID: 35568510 DOI: 10.1016/j.bja.2022.03.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/20/2022] [Accepted: 03/28/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Rebound pain occurs after up to 50% of ambulatory surgeries involving regional anaesthesia. To assist with risk stratification, we developed a model to predict severe rebound pain after foot and ankle surgery involving single-shot popliteal sciatic nerve block. METHODS After ethics approval, we performed a single-centre retrospective cohort study. Patients undergoing lower limb surgery with popliteal sciatic nerve block from January 2016 to November 2019 were included. Exclusion criteria were uncontrolled pain in the PACU, use of a perineural catheter, or loss to follow-up. We developed and internally validated a multivariable logistic regression model for severe rebound pain, defined as transition from well-controlled pain in the PACU (numerical rating scale [NRS] 3 or less) to severe pain (NRS ≥7) within 48 h. A priori predictors were age, sex, surgery type, planned admission, local anaesthetic type, dexamethasone use, and intraoperative anaesthesia type. Model performance was evaluated using area under the receiver operating characteristic curve (AUROC), Nagelkerke's R2, scaled Brier score, and calibration slope. RESULTS The cohort included 1365 patients (mean [standard deviation] age: 50 [16] yr). The primary outcome was abstracted in 1311 (96%) patients, with severe rebound pain in 652 (50%). Internal validation revealed poor model performance, with AUROC 0.632 (95% confidence interval [CI]: 0.602-0.661; bootstrap optimisation 0.021), Nagelkerke's R2 0.063, and scaled Brier score 0.047. Calibration slope was 0.832 (95% CI: 0.623-1.041). CONCLUSIONS We show that a multivariable risk prediction model developed using routinely collected clinical data had poor predictive performance for severe rebound pain after foot and ankle surgery. Prospective studies involving other patient-related predictors are needed. CLINICAL TRIAL REGISTRATION NCT05018104.
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Affiliation(s)
- Tim T H Jen
- Department of Anesthesia, St Paul's Hospital/Providence Health Care, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada.
| | - Janny X C Ke
- Department of Anesthesia, St Paul's Hospital/Providence Health Care, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada; Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
| | - Kevin J Wing
- Department of Orthopedics, University of British Columbia, Vancouver, BC, Canada
| | - Justine Denomme
- Department of Anesthesia, St Paul's Hospital/Providence Health Care, Vancouver, BC, Canada
| | - Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, ON, Canada; Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Shih-Chieh Huang
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada; Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ronald M Ree
- Department of Anesthesia, St Paul's Hospital/Providence Health Care, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Christopher Prabhakar
- Department of Anesthesia, St Paul's Hospital/Providence Health Care, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Stephan K W Schwarz
- Department of Anesthesia, St Paul's Hospital/Providence Health Care, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Cynthia H Yarnold
- Department of Anesthesia, St Paul's Hospital/Providence Health Care, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
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19
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Cunningham DJ, LaRose M, Zhang G, Patel P, Paniagua A, Gadsden J, Gage MJ. Regional Anesthesia Associated With Decreased Inpatient and Outpatient Opioid Demand in Tibial Plateau Fracture Surgery. Anesth Analg 2022; 134:1072-1081. [PMID: 35313323 DOI: 10.1213/ane.0000000000005980] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Regional anesthesia (RA) has been used to reduce pain and opioid usage in elective orthopedic surgery. The hypothesis of this study was that RA would be associated with decreased opioid demand in tibial plateau fracture surgery. METHODS Inpatient opioid consumption and 90-day outpatient opioid prescribing in all patients ≥18 years of age undergoing tibial plateau fracture surgery from July 2013 to July 2018 (n = 264) at a single, level I trauma center were recorded. The presence or absence of perioperative RA was noted. Of 60 patients receiving RA, 52 underwent peripheral nerve blockade (PNB) with single-shot sciatic-popliteal (40.0%; n = 24), femoral (26.7%; n = 16), adductor canal (18.3%; n = 11), or fascia iliaca (1.7%; n = 1) block with ropivacaine. Ten patients received epidural analgesia (EA) with either single-shot spinal (11.7%; n = 7) blocks or continuous epidural (5.0%; n = 3). Additional baseline and treatment characteristics were recorded, including age, sex, race, body mass index (BMI), smoking, chronic opioid use, American Society of Anesthesiologists (ASA) score, injury mechanism, additional injuries, open injury, and additional inpatient surgery. Statistical models, including multivariable generalized linear models with propensity score weighting to adjust for baseline patient and treatment characteristics, were used to assess perioperative opioid demand with and without RA. RESULTS RA was associated with reduced inpatient opioid usage from 0 to 24 hours postoperatively of approximately 5.2 oxycodone 5-mg equivalents (0.74 incident rate ratio [IRR]; 0.63-0.86 CI; P < .001) and from 24 to 48 hours postoperatively of approximately 2.9 oxycodone 5-mg equivalents (0.78 IRR; 0.64-0.95 CI; P = .014) but not at 48 to 72 hours postoperatively. From 1 month preoperatively to 2 weeks postoperatively, RA was associated with reduced outpatient opioid prescribing of approximately 24.0 oxycodone 5-mg equivalents (0.87; 0.75-0.99; P = .044) and from 1 month preoperatively to 90 days postoperatively of approximately 44.0 oxycodone 5-mg equivalents (0.83; 0.71-0.96; P = .011), although there was no significant difference from 1 month preoperatively to 6 weeks postoperatively. There were no cases of acute compartment syndrome in this cohort. CONCLUSIONS In tibial plateau fracture surgery, RA was associated with reduced inpatient opioid consumption up to 48 hours postoperatively and reduced outpatient opioid demand up to 90 days postoperatively without an associated risk of acute compartment syndrome. RA should be considered for patients undergoing tibial plateau fracture fixation.
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Affiliation(s)
- Daniel J Cunningham
- From the Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Micaela LaRose
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Gloria Zhang
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Preet Patel
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Ariana Paniagua
- From the Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey Gadsden
- From the Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Mark J Gage
- From the Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
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20
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Cunningham DJ, Paniagua A, DeLaura I, Zhang G, Kim B, Kim J, Lee T, LaRose M, Adams S, Gage MJ. Regional Anesthesia Decreases Inpatient But Not Outpatient Opioid Demand in Ankle and Distal Tibia Fracture Surgery. Foot Ankle Spec 2022:19386400221088453. [PMID: 35440214 DOI: 10.1177/19386400221088453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Regional anesthesia (RA) is commonly used in ankle and distal tibia fracture surgery. However, the pragmatic effects of this treatment on inpatient and outpatient opioid demand are unclear. The hypothesis was that RA would decrease inpatient opioid consumption and have little effect on outpatient demand in patients undergoing ankle and distal tibia fracture surgery compared with patients not receiving RA. METHODS All patients aged 18 years and older undergoing ankle and distal tibia fracture surgery at a single institution between July 2013 and July 2018 were included in this study (n = 1310). Inpatient opioid consumption (0-72 hours postoperatively) and outpatient opioid prescribing (1 month preoperatively to 90 days postoperatively) were recorded in oxycodone 5-mg equivalents (OEs). Adjusted models were used to evaluate the impact of RA versus no RA on inpatient and outpatient opioid demand. RESULTS Patients without RA had higher rates of high-energy mechanism of injury, additional injuries, open fractures, and additional surgery compared with patients with RA. Adjusted models demonstrated decreased inpatient opioid consumption in patients with RA (12.1 estimated OEs without RA vs 8.8 OEs with RA from 0 to 24 hours postoperatively, P < .001) but no significant difference after that time (9.7 vs 10.4 from 24 to 48 hours postoperatively, and 9.5 vs 8.5 from 48 to 72 hours postoperatively). Estimated cumulative outpatient opioid demand was significantly increased in patients receiving RA at all time points (112.5 OEs without RA vs 137.3 with RA from 1 month preoperatively to 2 weeks, 125.6 vs 155.5 OEs to 6 weeks, and 134.6 vs 163.3 OEs to 90 days, all P values for RA <.001). DISCUSSION In ankle and distal tibia fracture surgery, RA was associated with decreased early inpatient opioid demand but significantly increased outpatient demand after adjusting for baseline patient and treatment characteristics. This study encourages the use of RA to decrease inpatient opioid use, although there was a worrisome increase in outpatient opioid demand. LEVEL OF EVIDENCE Level III: Retrospective, therapeutic cohort study.
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Affiliation(s)
- Daniel J Cunningham
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ariana Paniagua
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Isabel DeLaura
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Gloria Zhang
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Billy Kim
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Jonathan Kim
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Terry Lee
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Micaela LaRose
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Samuel Adams
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Mark J Gage
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
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Makvana S, Faroug R, Venturini S, Alcorn E, Gulati A, Gaur A, Mangwani J. Are Hindfoot Procedures More Painful than Forefoot Procedures? A Prospective Observational Study in Elective Foot and Ankle Surgery. J Foot Ankle Surg 2022; 61:23-26. [PMID: 34325971 DOI: 10.1053/j.jfas.2021.04.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 12/13/2020] [Accepted: 04/03/2021] [Indexed: 02/03/2023]
Abstract
Pain after lower limb orthopedic surgery can be severe. Poorly controlled pain is associated with adverse outcomes. Peripheral nerve blocks (PNB) have become popular in foot and ankle surgery for their effective pain control and low complication rates. It has always been assumed that hindfoot procedures are more painful than midfoot/forefoot procedures often requiring inpatient stay for pain relief. There are no published studies evaluating this assumption. To investigate whether hindfoot procedures are more painful than forefoot/midfoot procedures by measuring pain scores, assessing effectiveness of PNBs and patient satisfaction. One hundred forty patients undergoing elective foot and ankle surgery were prospectively studied. Inclusion criteria: Adults undergoing elective foot and ankle surgery. Exclusion criteria: Patients 16 years or under, those with alternate sources of pain, peripheral neuropathy, known substance abuse, psychiatric illness and incomplete pain scores. Pain was measured via the Visual Analog Scale at 3 time intervals: immediately, 6 hours and at 24 hours postoperatively. Analysis was via t-test. A p value of <.05 demonstrated a statistical significance. Forefoot/midfoot versus hindfoot surgery pain scores showed that there was no significant difference at any postoperative interval. PNB versus no PNB pain scores showed there was no significant difference, except at 24 hours postoperatively (p value .024). Patients who had a PNB experienced rebound pain at 24 hours. Hindfoot surgery is not more painful than forefoot/midfoot surgery. Patients who had a PNB experienced rebound pain at 24 hours postoperatively, a finding that requires further research.
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Affiliation(s)
- Sonia Makvana
- Academic Team of Musculoskeletal Surgery (AToMS) Leicester General Hospital, Leicester, UK.
| | - Radwane Faroug
- Academic Team of Musculoskeletal Surgery (AToMS) Leicester General Hospital, Leicester, UK
| | - Sara Venturini
- Academic Team of Musculoskeletal Surgery (AToMS) Leicester General Hospital, Leicester, UK
| | - Edward Alcorn
- Academic Team of Musculoskeletal Surgery (AToMS) Leicester General Hospital, Leicester, UK
| | - Aashish Gulati
- Academic Team of Musculoskeletal Surgery (AToMS) Leicester General Hospital, Leicester, UK
| | - Atul Gaur
- Academic Team of Musculoskeletal Surgery (AToMS) Leicester General Hospital, Leicester, UK
| | - Jitendra Mangwani
- Academic Team of Musculoskeletal Surgery (AToMS) Leicester General Hospital, Leicester, UK
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22
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Hillesheim RA, Kumar P, Brolin TJ, Bernholt DL, Sethi PM, Kowalsky MS, Azar FM, Throckmorton TW. Periarticular liposomal bupivacaine mixture injection vs. single-shot interscalene block for postoperative pain in arthroscopic rotator cuff repair: a prospective randomized controlled trial. J Shoulder Elbow Surg 2021; 30:2691-2697. [PMID: 34537339 DOI: 10.1016/j.jse.2021.08.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 08/04/2021] [Accepted: 08/10/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND The pain control efficacy, postoperative opioid requirements, and costs among patients undergoing major shoulder surgery using different perioperative analgesia modalities have been topics of active debate. Several studies have compared periarticular injection (PAI) to interscalene block (ISB) in shoulder arthroplasty, but there is a paucity of data comparing them in arthroscopic rotator cuff repair. METHODS Patients aged 18-80 years with full-thickness rotator cuff tears and undergoing primary arthroscopic rotator cuff repair at 2 different shoulder centers were screened and subsequently randomized to receive either periarticular injection (PAI) of liposomal bupivacaine mixed with 0.25% bupivacaine (n = 41) or single-shot interscalene nerve block (ISB) (n = 36). Visual analog scale (VAS) pain scores, oral morphine equivalent (OME) use, Single Assessment Numerical Evaluation (SANE) scores, and costs were collected. Differences with P <.05 were considered statistically significant. RESULTS Day of surgery VAS score and OME usage were significantly reduced with ISB vs. PAI (0.69 vs. 4.65, P < .001, and 18.66 vs. 34.39, P < .001, respectively). There were no significant differences between groups regarding VAS score on postoperative days (PODs) 1-3; however, OME usage on PODs 1 (50.5 vs. 38.8, P = .03) and 2 (48.1 vs. 37.8, P = .04) was significantly more in the ISB group. At POD 3, VAS score (4.13 vs. 3.97, P = .60) and OME use (28.60 vs. 31.16, P = .51) were similar. At 6 and 12 weeks, there were also no significant differences between groups regarding VAS and OME use. There was no difference in SANE score at 12 weeks following surgery between groups and no difference between average 12-week cumulative OME use between groups. The average charge for the PAI was $455, and the average charge for ISB was $745. CONCLUSION Both ISB and PAI provide acceptable pain control following arthroscopic rotator cuff repair. Patients have less pain on the day of surgery with ISB, but rebound pain is significant after the block wears off, resulting in substantially increased opioid use in the first 2 PODs. However, cumulative opioid use between groups was similar. There were also no significant differences at the end of the 12-week episode of care in any of the other variables studied. The charge per patient for PAI is approximately $300 less than ISB. Thus, PAI may offer surgeons and patients an effective postoperative analgesic modality as an alternative to ISB.
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Affiliation(s)
- Richard A Hillesheim
- University of Tennessee-Campbell Clinic Department of Orthopedic Surgery & Biomedical Engineering, Memphis, TN, USA
| | - Padam Kumar
- University of Tennessee Health Science Center, College of Medicine, Memphis, TN, USA
| | - Tyler J Brolin
- University of Tennessee-Campbell Clinic Department of Orthopedic Surgery & Biomedical Engineering, Memphis, TN, USA
| | - David L Bernholt
- University of Tennessee-Campbell Clinic Department of Orthopedic Surgery & Biomedical Engineering, Memphis, TN, USA
| | - Paul M Sethi
- Orthopedic & Neurosurgical Specialists, ONS Foundation, Greenwich, CT, USA
| | - Marc S Kowalsky
- University of Tennessee Health Science Center, College of Medicine, Memphis, TN, USA
| | - Frederick M Azar
- University of Tennessee-Campbell Clinic Department of Orthopedic Surgery & Biomedical Engineering, Memphis, TN, USA
| | - Thomas W Throckmorton
- University of Tennessee-Campbell Clinic Department of Orthopedic Surgery & Biomedical Engineering, Memphis, TN, USA.
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Sellbrant I, Karlsson J, Jakobsson JG, Nellgård B. Supraclavicular block with Mepivacaine vs Ropivacaine, their impact on postoperative pain: a prospective randomised study. BMC Anesthesiol 2021; 21:273. [PMID: 34753423 PMCID: PMC8577027 DOI: 10.1186/s12871-021-01499-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 10/31/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Supraclavicular block (SCB) with long-acting local anaesthetic is commonly used for surgical repair of distal radial fractures (DRF). Studies have shown a risk for rebound pain when the block fades. This randomised single-centre study aimed to compare pain and opioid consumption the first three days post-surgery between SCB-mepivacaine vs. SCB-ropivacaine, with general anaesthesia (GA) as control. METHODS Patients (n = 90) with ASA physical status 1-3 were prospectively randomised to receive; SCB with mepivacine 1%, 25-30 ml (n = 30), SCB with ropivacaine 0.5%, 25-30 ml (n = 30) or GA (n = 30) with propofol/fentanyl/sevoflurane. Study objectives compared postoperative pain with Numeric Rating Scale (NRS) and sum postoperative Opioid Equivalent Consumption (OEC) during the first 3 days post-surgery between study-groups. RESULTS The three groups showed significant differences in postoperative pain-profile. Mean NRS at 24 h was significantly lower for the SCB-mepivacaine group (p = 0.018). Further both median NRS and median OEC day 0 to 3 were significanly lower in the SCB-mepivacaine group as compared to the SCB-ropivacaine group during the first three days after surgery; pain NRS 1 (IQR 0.3-3.3) and 2.7 (IQR 1.3-4.2) (p = 0.017) and OEC 30 mg (IQR 10-80) and 85 mg (IQR 45-125) (p = 0.004), respectively. The GA-group was in between both in pain NRS and median sum OEC. Unplanned healthcare contacts were highest among SCB-ropivacaine patients (39.3%) vs. SCB-mepivacaine patients (0%) and GA-patients (3.4%). CONCLUSIONS The potential benefit of longer duration of analgesia, associated to a long-acting local anaesthetic agent, during the early postoperative course must be put in perspective of potential worse pain progression following block resolution. TRIAL REGISTRATION NCT03749174 (clinicaltrials.gov, Nov 21, 2018, retrospectively registered).
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Affiliation(s)
- Irén Sellbrant
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Jon Karlsson
- Department of Orthopedic Surgery, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jan G Jakobsson
- Department of Anaesthesia & Intensive Care, Institute of Clinical Science, Karolinska Institute, Danderyd University Hospital, Stockholm, Sweden
| | - Bengt Nellgård
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
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Cunningham DJ, LaRose MA, DeLaura IF, Zhang GX, Paniagua AR, Gage MJ. Regional anesthesia does not decrease inpatient or outpatient opioid demand in femoral shaft fracture surgery. Injury 2021; 52:3075-3084. [PMID: 34294430 DOI: 10.1016/j.injury.2021.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 07/07/2021] [Accepted: 07/10/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Regional anesthesia (RA) may be used in femoral shaft fracture surgery to decrease pain and opioid consumption. However, the impact of RA on inpatient and outpatient opioid demand in patients undergoing femoral shaft fracture surgery is largely unknown. The aim of this study was to evaluate the impact of RA on inpatient opioid consumption and outpatient opioid demand in patients undergoing femoral shaft fracture surgery. METHODS Inpatient opioid consumption and outpatient opioid demand in all patients undergoing femoral shaft fracture surgery was recorded at a single, Level I trauma center from 7/2013 - 7/2018 (n=436). In addition to RA, baseline and treatment factors including age, sex, race, body mass index (BMI), smoking, chronic opioid use, American Society of Anesthesiologists (ASA) score, injury mechanism, additional injuries, open injury, and additional inpatient surgery were recorded. Unadjusted and adjusted multivariable models were used to evaluate the impact of RA on inpatient opioid consumption and outpatient opioid demand. RESULTS Adjusted models demonstrated increases in inpatient opioid consumption in patients with RA (6.9 estimated OE's without RA vs 8.8 OE's with RA from 48-72 hours post-op, p<0.05) but no significant differences at other timepoints (10.3 estimated OE's without RA vs 9.2 OE's with RA from 0-24 hours post-op, 8.2 vs 8.8 from 24-48 hours post-op, p>0.05). Estimated cumulative outpatient opioid demand did not differ significantly in patients with RA (82.3 OE's without RA vs 94.8 with RA from discharge to two-weeks, 105.4 vs 116.3 OE's to 6-weeks, and 124.5 vs 137.9 OE's to 90-days, all p>0.05). Late opioid refills were significantly more common in patients with RA (1.57 odds at 2-weeks to 6-weeks, 1.69 odds at 6-weeks to 90-days, p<0.05) DISCUSSION: In femoral shaft fracture surgery, RA was not associated with decreased opioid demand after adjusting for baseline patient and treatment characteristics. These results provide a real-world estimate of the impact of RA on opioid demand in femoral shaft fracture surgery and encourage providers to seek alternative analgesic modalities. LEVEL OF EVIDENCE Level III, retrospective, therapeutic cohort study.
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Affiliation(s)
- Daniel J Cunningham
- Duke University Medical Center, Department of Orthopaedic Surgery, 200 Trent Drive, Durham, NC 27710, United States.
| | - Micaela A LaRose
- Duke University School of Medicine, Duke University Medical Center 3710, Durham, NC 27710, United States
| | - Isabel F DeLaura
- Duke University School of Medicine, Duke University Medical Center 3710, Durham, NC 27710, United States
| | - Gloria X Zhang
- Duke University School of Medicine, Duke University Medical Center 3710, Durham, NC 27710, United States
| | - Ariana R Paniagua
- Duke University School of Medicine, Duke University Medical Center 3710, Durham, NC 27710, United States
| | - Mark J Gage
- Duke University Medical Center, Department of Orthopaedic Surgery, 200 Trent Drive, Durham, NC 27710, United States
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25
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Wang AY, Malavasi L, Craft R. Evaluation of bupivacaine liposome injectable suspension efficacy in single-use vials over five days of multiple use. Vet Anaesth Analg 2021; 48:956-961. [PMID: 34561182 DOI: 10.1016/j.vaa.2021.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 08/03/2021] [Accepted: 08/11/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To test the anesthetic effect of a bupivacaine liposome injectable suspension (BLIS), used in a multiple-dose manner for up to 5 consecutive days. STUDY DESIGN Prospective, randomized, experimental study. ANIMALS A total of 30 male and female Sprague-Dawley rats (Rattus norvegicus), aged 97 (75-130) days and weighing 337.2 (219.6-465.9) g, mean (range). METHODS Rats were assigned to one of five BLIS vial groups, in which drug was administered from a newly opened vial or 1, 2, 3 and 4 days after the vial was opened. The vials were refrigerated between uses. A 14 gauge needle attached to an injection plug was used to puncture each vial once and was not removed; BLIS was withdrawn from the injection plug in a multiple-dose fashion. A dose rate of 0.4 mL kg-1 was administered subcutaneously into the left pelvic limb paw. Antinociception was evaluated using a paw pressure test on both injected and uninjected paws before (time 0, baseline) and 1, 24, 48 and 72 hours after injection. RESULTS Age of BLIS vial had no significant effect on anesthetic efficacy (p = 0.97). Across all groups, paw withdrawal latency averaged 5.23 ± 0.24 seconds at baseline (before BLIS injection), increased to 16.45 ± 0.65 seconds at 1 hour after BLIS injection, declined to 7.50 ± 0.76 seconds at 24 hours after BLIS injection, and further declined thereafter (p < 0.001). There was no significant change in paw withdrawal latency in the uninjected paw over time. CONCLUSIONS AND CLINICAL RELEVANCE BLIS single-use vials retained efficacy when used up to 5 days in a multiple-dose fashion. Because anesthetic effects declined substantially after 24 hours, multimodal pain management remains important for providing analgesia care.
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Affiliation(s)
- Alison Y Wang
- College of Veterinary Medicine, Washington State University, Pullman, WA, USA.
| | - Lais Malavasi
- Department of Anesthesiology, College of Veterinary Medicine, Washington State University, Pullman, WA, USA
| | - Rebecca Craft
- Department of Psychology, College of Arts and Sciences, Washington State University, Pullman, WA, USA
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Cunningham DJ, Robinette JP, Paniagua AR, LaRose MA, Blatter M, Gage MJ. Regional anesthesia does not decrease opioid demand in pelvis and acetabulum fracture surgery. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:1357-1370. [PMID: 34519897 DOI: 10.1007/s00590-021-03114-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 09/02/2021] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Patients with pelvic and acetabular fractures often have considerable pain in the perioperative period. Regional anesthesia (RA) including peripheral nerve blocks and spinal analgesia may reduce pain. However, the real-world impact of these modalities on inpatient opioid consumption and outpatient opioid demand is largely unknown. The purpose of this study was to evaluate the impact of perioperative RA on inpatient opioid consumption and outpatient opioid demand. METHODS This is a retrospective, observational review of inpatient opioid consumption and outpatient opioid demand in all patients ages 18 and older undergoing operative fixation of pelvic and acetabular fractures at a single Level, I trauma center from 7/1/2013-7/1/2018 (n = 205). Unadjusted and adjusted analyses were constructed to evaluate the impact of RA on inpatient opioid consumption and outpatient opioid demand while controlling for age, sex, race, body mass index (BMI), smoking, chronic opioid use, ASA score, injury mechanism, additional injuries, open injury, and additional inpatient surgery. RESULTS Adjusted models demonstrated increases in inpatient opioid consumption in patients with RA (12.6 estimated OE's without RA vs 16.1 OE's with RA from 48 to 72 h post-op, p < 0.05) but no significant differences at other timepoints (17.5 estimated OE's without RA vs 16.8 OE's with RA from 0 to 24 h post-op, 15.3 vs 17.1 from 24 to 48 h post-op, p > 0.05). Estimated cumulative outpatient opioid demand was significantly higher in patients with RA at discharge to 90 days post-op (and 156.8 vs 207.9 OE's to 90 days, p < 0.05) but did not differ significantly before that time (121.5 OE's without RA vs 123.9 with RA from discharge to two weeks, 145.2 vs 177.2 OE's to 6 weeks, p > 0.05). DISCUSSION In pelvis and acetabulum fracture surgery, RA was associated with increased inpatient and outpatient opioid demand after adjusting for baseline patient and treatment characteristics. Regional anesthesia may not be beneficial for these patients.
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Affiliation(s)
- Daniel J Cunningham
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA.
| | - J Patton Robinette
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
| | - Ariana R Paniagua
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA
| | - Micaela A LaRose
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA
| | - Michael Blatter
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
| | - Mark J Gage
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
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Lehto PM, Vakkala MA, Alahuhta S, Liisanantti JH, Kortekangas THJ, Hiltunen K, Nyman E, Kaakinen TI. Difference in postoperative opioid consumption after spinal versus general anaesthesia for ankle fracture surgery-A retrospective cohort study. Acta Anaesthesiol Scand 2021; 65:1109-1115. [PMID: 33963533 DOI: 10.1111/aas.13845] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 04/22/2021] [Accepted: 04/28/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Surgical treatment of ankle fracture is associated with significant pain and high postoperative opioid consumption. The anaesthesia method may affect early postoperative pain. The main objective of the study was to compare postoperative opioid consumption after ankle-fracture surgery between patients treated with spinal anaesthesia and general anaesthesia. METHODS We reviewed retrospectively the files of 586 adult patients with surgically treated ankle fracture in the years 2014 through 2016. The primary outcome was opioid consumption during the first 48 postoperative hours. Secondary outcomes were maximal pain scores, postoperative nausea and vomiting, the length of stay in the post-anaesthesia care unit, and opioid use in different time periods up to 48 h postoperatively. Propensity score matching was used to mitigate confounding variables. RESULTS Total opioid consumption 48 h postoperatively was significantly lower after spinal anaesthesia (propensity score-matched population: effect size -13.7 milligrams; 95% CI -18.8 to -8.5; P < .001). The highest pain score on the numerical rating scale in the post-anaesthesia care unit was significantly higher after general anaesthesia (propensity score-matched population: effect size 3.7 points; 95% CI 3.2-4.2; P < .001). A total of 60 patients had postoperative nausea and vomiting in the post-anaesthesia care unit, 53 (88.3%) of whom had general anaesthesia (P = .001). CONCLUSIONS Patients with surgically treated ankle fracture whose operation was performed under general anaesthesia used significantly more opioids in the first 48 h postoperatively, predominantly in the post-anaesthesia care unit, compared with patients given spinal anaesthesia.
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Affiliation(s)
- Pasi M. Lehto
- Research Group of Surgery, Anaesthesiology and Intensive Care Medicine Medical Research Center of Oulu University Oulu University Hospital Oulu Finland
| | - Merja A. Vakkala
- Research Group of Surgery, Anaesthesiology and Intensive Care Medicine Medical Research Center of Oulu University Oulu University Hospital Oulu Finland
| | - Seppo Alahuhta
- Research Group of Surgery, Anaesthesiology and Intensive Care Medicine Medical Research Center of Oulu University Oulu University Hospital Oulu Finland
| | - Janne H. Liisanantti
- Research Group of Surgery, Anaesthesiology and Intensive Care Medicine Medical Research Center of Oulu University Oulu University Hospital Oulu Finland
| | - Tero H. J. Kortekangas
- Research Group of Surgery, Anaesthesiology and Intensive Care Medicine Medical Research Center of Oulu University Oulu University Hospital Oulu Finland
| | - Kaisu Hiltunen
- Research Group of Surgery, Anaesthesiology and Intensive Care Medicine Medical Research Center of Oulu University Oulu University Hospital Oulu Finland
| | - Emma‐Sofia Nyman
- Research Group of Surgery, Anaesthesiology and Intensive Care Medicine Medical Research Center of Oulu University Oulu University Hospital Oulu Finland
| | - Timo I. Kaakinen
- Research Group of Surgery, Anaesthesiology and Intensive Care Medicine Medical Research Center of Oulu University Oulu University Hospital Oulu Finland
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Li Y, Zhang Q, Wang Y, Yin C, Guo J, Qin S, Zhang Y, Zhu L, Hou Z, Wang Q. Ultrasound-guided single popliteal sciatic nerve block is an effective postoperative analgesia strategy for calcaneal fracture: a randomized clinical trial. BMC Musculoskelet Disord 2021; 22:735. [PMID: 34452610 PMCID: PMC8400756 DOI: 10.1186/s12891-021-04619-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 08/13/2021] [Indexed: 12/04/2022] Open
Abstract
Objectives The aim of this study was to evaluate the postoperative analgesia effect of ultrasound-guided single popliteal sciatic nerve block for calcaneal fracture. Methods A total of 120 patients scheduled for unilateral open reduction and internal fixation of calcaneal fracture were enrolled in this prospective randomized study. Patients in group B received ultrasound-guided single popliteal sciatic nerve block after operation, but Patients in group A did not. All patients received patient-controlled intravenous analgesia (PCIA) after operation. The time to initiation of PCIA, the time of first pressing the analgesia pump, duration of analgesia pump use and the total number of times the patient pressed the analgesia pump were recorded. The time of rescue analgesia and the adverse reactions were recorded. Pain magnitude of the patients immediately after discharge from operating room (T1), and at 4th (T2), 8th (T3), 12th (T4), 16th (T5), 24th (T6) and 48th (T7) h after the operation were assessed with visual analog scale (VAS). In addition, patient, surgeon and nurse satisfaction were recorded. Results The VAS scores at T2 ~ T5, the time of rescue analgesia and the adverse reactions, the total number of times the patient pressed the analgesia pump were significantly declined in group B (p < 0.001). The time to initiation of PCIA, the time of first pressing the analgesia pump, duration of analgesia pump use were prolonged and patient surgeon and nurse satisfaction were improved in group B (p < 0.05). Conclusion Ultrasound-guided single popliteal sciatic nerve block is an effective postoperative analgesia strategy for calcaneal fracture. Trial registration ChiCTR, ChiCTR2100042340. Registered 19 January 2021, URL of trial registry record: http://www.chictr.org.cn/showproj.aspx?proj=66526.
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Affiliation(s)
- Yanan Li
- Department of Anesthesiology, the Third Hospital of Hebei Medical University, NO.139, Ziqiang Road, Shijiazhuang, Hebei Province, China
| | - Qi Zhang
- Department of Anesthesiology, the Third Hospital of Hebei Medical University, NO.139, Ziqiang Road, Shijiazhuang, Hebei Province, China.,Department of Anesthesiology, Children's Hospital of Hebei province Affiliated to Hebei Medical University, Shijiazhuang, Hebei, China
| | - Ying Wang
- Department of Anesthesiology, the Third Hospital of Hebei Medical University, NO.139, Ziqiang Road, Shijiazhuang, Hebei Province, China
| | - Chunping Yin
- Department of Anesthesiology, the Third Hospital of Hebei Medical University, NO.139, Ziqiang Road, Shijiazhuang, Hebei Province, China
| | - Junfei Guo
- Department of Orthopaedics, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China.,Key Laboratory of Orthopaedic Biomechanics of Hebei Province, Shijiazhuang, Hebei, China
| | - Shiji Qin
- Department of Foot and Ankle Surgery, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Yahui Zhang
- Department of Nursing, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Lian Zhu
- Department of Orthopaedics, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China.,Key Laboratory of Orthopaedic Biomechanics of Hebei Province, Shijiazhuang, Hebei, China
| | - Zhiyong Hou
- Department of Orthopaedics, the Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China.,Key Laboratory of Orthopaedic Biomechanics of Hebei Province, Shijiazhuang, Hebei, China
| | - Qiujun Wang
- Department of Anesthesiology, the Third Hospital of Hebei Medical University, NO.139, Ziqiang Road, Shijiazhuang, Hebei Province, China.
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Hade AD, Okano S, Pelecanos A, Chin A. Factors associated with low levels of patient satisfaction following peripheral nerve block. Anaesth Intensive Care 2021; 49:125-132. [PMID: 33784851 DOI: 10.1177/0310057x20972404] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Peripheral nerve blocks can provide surgical anaesthesia as well as excellent postoperative analgesia. When questioned postoperatively, however, some patients report low levels of satisfaction with their nerve block experience. At our hospital, patients undergoing regional anaesthesia have their patient characteristics, block characteristics and postoperative feedback routinely recorded in a block registry. We analysed data from 979 consecutive patients undergoing peripheral nerve block for orthopaedic surgery to identify factors associated with low levels of patient satisfaction. The primary outcome was patient satisfaction with their peripheral nerve block (scale 1-5: 4-5 is 'satisfied', 1-3 is 'not satisfied'). Eighty-nine percent (871/979) of patients reported being 'satisfied' with their block. Factors negatively associated with patient satisfaction were rebound pain (adjusted odds ratio (aOR) 0.19, 95% confidence interval (CI) 0.04 to 0.85 for moderate rebound pain; aOR 0.11, 95% CI 0.03 to 0.48 for severe rebound pain), discomfort during the block (aOR 0.37, 95% CI 0.16 to 0.82 for moderate discomfort; aOR 0.19, 95% CI 0.05 to 0.76 for severe discomfort) and pain in the post-anaesthesia care unit (aOR 0.30, 95% CI 0.17 to 0.55 for pain ≥8/10). Only 24% (26/108) of patients who reported being 'not satisfied' stated that they would be unwilling to undergo a hypothetical future nerve block. Rebound pain of at least moderate intensity, procedural discomfort of at least moderate intensity and severe pain in the post-anaesthesia care unit are all negatively associated with patient satisfaction. Of these factors, rebound pain occurs most frequently, being present in 52% (403/777) of our respondents.
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Affiliation(s)
- Anthony D Hade
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Satomi Okano
- Statistics Unit, QIMR Berghofer Medical Research Institute, Herston, Australia
| | - Anita Pelecanos
- Statistics Unit, QIMR Berghofer Medical Research Institute, Herston, Australia
| | - Adrian Chin
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Herston, Australia
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30
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Severe rebound pain after peripheral nerve block for ambulatory extremity surgery is an underappreciated problem. Comment on Br J Anaesth 2021; 126: 862-71. Br J Anaesth 2021; 126:e204-e205. [PMID: 33773754 DOI: 10.1016/j.bja.2021.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/09/2021] [Accepted: 02/23/2021] [Indexed: 11/24/2022] Open
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Fang J, Shi Y, Du F, Xue Z, Cang J, Miao C, Zhang X. The effect of perineural dexamethasone on rebound pain after ropivacaine single-injection nerve block: a randomized controlled trial. BMC Anesthesiol 2021; 21:47. [PMID: 33579199 PMCID: PMC7879628 DOI: 10.1186/s12871-021-01267-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 02/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rebound pain after a single-shot nerve block challenges the real benefit of this technique. We aimed to investigate whether perineural dexamethasone addition decreased the incidence of rebound pain after a single-shot nerve block. METHODS We randomly allocated 132 patients scheduled for open reduction internal fixation of an upper extremity closed fracture under single-shot peripheral nerve block and sedation into two groups. Patients in the dexamethasone group received nerve block with 0.375% ropivacaine and 8 mg dexamethasone, while those in the control group received ropivacaine only. Sixty-three patients in the dexamethasone group and 60 patients in the control group were analyzed for the incidence of rebound pain 48 h after block administration, which was the primary outcome. The secondary outcomes included the highest self-reported numeric rating scale (NRS) pain score, and NRS at 8, 12, 24, and 48 h after the block, sufentanil consumption, sleep quality on the night of surgery, patient satisfaction with the pain therapy, blood glucose at 6 h after the block, pain and paresthesia at 30 days after surgery. RESULTS The incidence of rebound pain was significantly lower in the dexamethasone group (7 [11.1%] of 63 patients) than in the control group (28 [48.8%] of 60 patients [RR = 0.238, 95% CI (0.113-0.504), p = 0.001]. Dexamethasone decreased opioid consumption in 24 h after surgery (p < 0.001) and improved the sleep quality score on the night of surgery (p = 0.01) and satisfaction with pain therapy (p = 0.001). Multivariate logistic regression analysis showed that only group allocation was associated with the occurrence of rebound pain [OR = 0.062, 95% CI (0.015-0.256)]. Patients in the dexamethasone group reported later onset pain (19.7 ± 6.6 h vs 14.7 ± 4.8 h since block administration, mean ± SD, p < 0.001) and lower peak NRS scores [5 (3, 6) vs 8 (5, 9), median (IQR), p < 0.001] than those in the control group. CONCLUSIONS The perineural administration of 8 mg dexamethasone reduces rebound pain after a single-shot nerve block in patients receiving ORIF for an upper limb fracture. TRIAL REGISTRATION This study was retrospectively registered in the Chinese Clinical Trial Registry ( ChiCTR-IPR-17011365 ) on May 11th, 2017.
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Affiliation(s)
- Jie Fang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuncen Shi
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Fang Du
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhanggang Xue
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jing Cang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Changhong Miao
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaoguang Zhang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China. .,Department of Anesthesiology, Jinshan Hospital of Fudan University, Shanghai, China.
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32
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Hamilton DL. Rebound pain: distinct pain phenomenon or nonentity? Br J Anaesth 2021; 126:761-763. [PMID: 33551124 DOI: 10.1016/j.bja.2020.12.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/31/2020] [Indexed: 11/26/2022] Open
Affiliation(s)
- Duncan L Hamilton
- Department of Anaesthesia, James Cook University Hospital, Middlesbrough, UK; School of Medicine, University of Sunderland, Sunderland, UK.
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33
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Sort R, Brorson S, Gögenur I, Hald LL, Nielsen JK, Salling N, Hougaard S, Foss NB, Tengberg PT, Klausen TW, Møller AM. Peripheral nerve block anaesthesia and postoperative pain in acute ankle fracture surgery: the AnAnkle randomised trial. Br J Anaesth 2021; 126:881-888. [PMID: 33546844 DOI: 10.1016/j.bja.2020.12.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/07/2020] [Accepted: 12/29/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Peripheral nerve blocks (PNBs) are increasingly popular in acute ankle fracture surgery but rebound pain may outweigh the benefits. The AnAnkle Trial was designed to assess the postoperative pain profile of PNB anaesthesia compared with spinal anaesthesia (SA). METHODS The AnAnkle Trial was a randomised, two-centre, blinded outcome analysis trial. Eligible adults booked for primary ankle fracture surgery were randomised to PNB or SA. The PNBs were ultrasound-guided popliteal sciatic and saphenous blocks with ropivacaine and SAs were with hyperbaric bupivacaine. Postoperatively, all subjects received paracetamol, ibuprofen, and patient-controlled i.v. morphine for pain. The primary endpoint was 27 h Pain Intensity and Opioid Consumption (PIOC) score. Secondary endpoints included longitudinal pain scores and morphine consumption separately, and questionnaires on quality of recovery. RESULTS This study enrolled 150 subjects, and the PNB success rate was >94%. PIOC was lower with PNB anaesthesia (median, -26.5% vs +54.3%; P<0.001) and the probability of a better PIOC score with PNB than with SA was 74.8% (95% confidence interval, 67.0-82.6). Pain scores and morphine consumption analysed separately also yielded a clear benefit with PNB, despite substantial rebound pain when PNBs subsided. Quality of recovery scores were similar between groups, but 99% having PNB vs 90% having SA would choose the same anaesthesia form again (P=0.03). CONCLUSIONS PNB anaesthesia was efficient and provided a superior postoperative pain profile compared with SA for acute ankle fracture surgery, despite potentially intense rebound pain after PNB. CLINICAL TRIAL REGISTRATION Clinicaltrialsregister.eu, EudraCT number: 2015-001108-76.
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Affiliation(s)
- Rune Sort
- Department of Anaesthesiology, Herlev and Gentofte University Hospital, Gentofte, Denmark.
| | - Stig Brorson
- Department of Orthopaedic Surgery, Zealand University Hospital, Køge, Denmark
| | - Ismail Gögenur
- Department of Surgery, Centre for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - Lasse L Hald
- Department of Anaesthesiology, Herlev and Gentofte University Hospital, Gentofte, Denmark
| | - Jesper K Nielsen
- Department of Anaesthesiology, Herlev and Gentofte University Hospital, Gentofte, Denmark
| | - Nanna Salling
- Department of Orthopaedic Surgery, Herlev and Gentofte University Hospital, Herlev, Denmark; Department of Orthopaedic Surgery, Nykøbing Falster Hospital, Nykøbing Falster, Denmark
| | - Sine Hougaard
- Department of Anaesthesiology, Amager and Hvidovre University Hospital, Hvidovre, Denmark
| | - Nicolai B Foss
- Department of Anaesthesiology, Amager and Hvidovre University Hospital, Hvidovre, Denmark
| | - Peter T Tengberg
- Department of Orthopaedic Surgery, Amager and Hvidovre University Hospital, Hvidovre, Denmark
| | - Tobias W Klausen
- Department of Haematology, Herlev and Gentofte University Hospital, Herlev, Denmark
| | - Ann M Møller
- Department of Anaesthesiology, Herlev and Gentofte University Hospital, Gentofte, Denmark
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Garnaud B, Mares O, L'hermite J, Vialles N, Gricourt Y, Lannelongue A, Lefrant JY, Cuvillon P. Multimodal oral analgesia strategy after ambulatory arthroscopic shoulder surgery: case series using adaptive therapeutic approaches by sequential analysis. J Shoulder Elbow Surg 2021; 30:250-257. [PMID: 32950669 DOI: 10.1016/j.jse.2020.08.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/25/2020] [Accepted: 08/31/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Pain control and quality of recovery (QoR) at home remains a challenge after ambulatory shoulder arthroscopy. This study aims to assess the QoR and pain relief using a sequential implementation strategy for rescue analgesic drugs. METHODS After institutional review board approval, patients (>18 years, American Society of Anesthesiology [ASA] score 1-3 stable) scheduled for ambulatory surgery under general anesthesia with a single-shot interscalene nerve block were enrolled. After discharge, patients received standard information regarding the postoperative recovery and care consisting of a multimodal analgesic regime (acetaminophen and ketoprofen for 5 days). The first 48 postoperative hours allowed us to compare 3 different rescue drug regimes with a control group, in sequential order: tramadol (control group), tramadol + nefopam, immediate-release oxycodone (IR), and extended-release oxycodone (ER). The primary endpoint was the QoR 40 score at 48 hours after surgery. Secondary endpoints were pain relief and adverse events over a 7-day period. An intention-to-treat statistical analysis was performed with sequential analysis (as an interim analysis) every 20 patients. Results were recorded as medians and interquartiles (25-75). RESULTS We analyzed 109 patients with similar characteristics among groups. The QoR 40 scores were similar for the tramadol group (168 [161-172]), the tramadol + nefopam group (161 [151-173], P = .09), and the IR group (164 [153-169], P = .17), but higher for the ER group (176 [167-181], P = .03). Concerning adverse events, drugs were interrupted more frequently in the tramadol + nefopam group (36 %). In the ER group, a higher quality of postoperative relief was attained in the domains of pain and sleep. CONCLUSION The present study shows that a combination of IR and ER oxycodone over a short period of time (<48 hours) is associated with a better QoR at home after ambulatory shoulder surgery.
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Affiliation(s)
- Benjamin Garnaud
- Department of Anesthesiology and Pain Management, Centre Hospitalo-Universitaire (CHU) Carémeau, Nîmes, France; Medical Department, Montpellier University 1, Montpellier, France
| | - Olivier Mares
- Medical Department, Montpellier University 1, Montpellier, France; Department of Traumatology and Orthopedic Surgery, Centre Hospitalo-Universitaire (CHU) Carémeau, Nîmes, France
| | - Joel L'hermite
- Department of Anesthesiology and Pain Management, Centre Hospitalo-Universitaire (CHU) Carémeau, Nîmes, France; Medical Department, Montpellier University 1, Montpellier, France
| | - Nathalie Vialles
- Department of Anesthesiology and Pain Management, Centre Hospitalo-Universitaire (CHU) Carémeau, Nîmes, France; Medical Department, Montpellier University 1, Montpellier, France
| | - Yann Gricourt
- Department of Anesthesiology and Pain Management, Centre Hospitalo-Universitaire (CHU) Carémeau, Nîmes, France; Medical Department, Montpellier University 1, Montpellier, France
| | - Ariane Lannelongue
- Department of Anesthesiology and Pain Management, Centre Hospitalo-Universitaire (CHU) Carémeau, Nîmes, France; Medical Department, Montpellier University 1, Montpellier, France
| | - Jean Yves Lefrant
- Department of Anesthesiology and Pain Management, Centre Hospitalo-Universitaire (CHU) Carémeau, Nîmes, France; Medical Department, Montpellier University 1, Montpellier, France
| | - Philippe Cuvillon
- Department of Anesthesiology and Pain Management, Centre Hospitalo-Universitaire (CHU) Carémeau, Nîmes, France; Medical Department, Montpellier University 1, Montpellier, France.
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Kim JY, Kang MW, Lee HW, Noh KC. Suprascapular Nerve Block Is an Effective Pain Control Method in Patients Undergoing Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial. Orthop J Sports Med 2021; 9:2325967120970906. [PMID: 33553443 PMCID: PMC7841678 DOI: 10.1177/2325967120970906] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/01/2020] [Indexed: 12/22/2022] Open
Abstract
Background Effective pain control in patients who have undergone arthroscopic rotator cuff surgery improves functional recovery and early mobilization. Interscalene blocks (ISBs), a widely used approach, are safe and provide fast pain relief; however, they are associated with complications. Another pain management strategy is the use of a suprascapular nerve block (SSNB). Hypothesis We hypothesized that indwelling SSNB catheters are a more effective pain control method than single-shot ISBs. We also hypothesized that indwelling SSNB catheters will reduce the level of rebound pain and the demand for opioid analgesics. Study Design Randomized controlled trial; Level of evidence, 1. Methods Included in this study were 93 patients who underwent arthroscopic rotator cuff surgery between May 2012 and January 2019. These patients were assigned to either the indwelling SSNB catheter group, the single-shot ISB group, or the control (sham/placebo) group (31 patients per group). Level of pain was measured with a visual analog scale (VAS; 0 to 10 [worst pain]) on the day of the operation. The preoperative VAS score was recorded at 6 AM on the day of operation, and the postoperative scores were recorded at 1, 8, and 16 hours after surgery and then every 8 hours until postoperative day 3. Results The VAS pain scores were lower in the SSNB and ISB groups than in the control group up to postoperative hour (POH) 8, with the most significant difference at POH 8. At POH 1 and POH 8, the mean VAS scores for each group were 2.29 and 1.74 (SSNB), 2.59 and 2.50 (ISB), and 3.42 and 4.48 (control), respectively. VAS scores in the SSNB and ISB groups were consistently <3, compared with a mean VAS score of 3.1 ± 1.58 in the control group (P < .001). Compared with the ISB group, the SSNB group had significantly fewer side effects such as rebound pain duration as well as lower VAS scores (P < .001). Conclusion VAS scores were the lowest in the indwelling SSNB catheter group, with the most pronounced between-group difference in VAS scores at POH 8. Severity and recurring frequency of pain were lower in the indwelling SSNB catheter group than in the single-shot ISB group.
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Affiliation(s)
- Jung Youn Kim
- Shoulder & Elbow Clinic, Department of Orthopedic Surgery, Kangnam Sacred Heart Hospital, Hallym University Medical Center, Seoul, Republic of Korea
| | - Min Wook Kang
- Shoulder & Elbow Clinic, Department of Orthopedic Surgery, Kangnam Sacred Heart Hospital, Hallym University Medical Center, Seoul, Republic of Korea
| | - Ho Won Lee
- Shoulder & Elbow Clinic, Department of Orthopedic Surgery, Kangnam Sacred Heart Hospital, Hallym University Medical Center, Seoul, Republic of Korea
| | - Kyu Cheol Noh
- Shoulder & Elbow Clinic, Department of Orthopedic Surgery, Kangnam Sacred Heart Hospital, Hallym University Medical Center, Seoul, Republic of Korea
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Muñoz-Leyva F, Cubillos J, Chin KJ. Managing rebound pain after regional anesthesia. Korean J Anesthesiol 2020; 73:372-383. [PMID: 32773724 PMCID: PMC7533186 DOI: 10.4097/kja.20436] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 12/19/2022] Open
Abstract
Rebound pain after regional anesthesia can be defined as transient acute postoperative pain that ensues following resolution of sensory blockade, and is clinically significant, either with regard to the intensity of pain or the impact on psychological well-being, quality of recovery, and activities of daily living. Current evidence suggests that it represents an unmasking of the expected nociceptive response in the absence of adequate systemic analgesia, rather than an exaggerated hyperalgesic phenomenon induced by local anesthetic neural blockade. In the majority of patients, it does not appear to significantly impact cumulative postoperative opioid consumption, quality of recovery, or patient satisfaction, and is not associated with longer-term sequelae such as persistent post-surgical pain. Nevertheless, it must be considered whenever regional anesthesia is incorporated into perioperative management. Strategies to mitigate the impact of rebound pain include routine prescribing of a systemic multimodal analgesic regimen, as well as patient education on appropriate expectations regarding block offset and expected surgical pain, and timely initiation of analgesic medication. Prolonging the duration of action of regional anesthesia with continuous catheter techniques or local anesthetic adjuncts may also help alleviate rebound pain, although further research is required to confirm this.
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Affiliation(s)
- Felipe Muñoz-Leyva
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Javier Cubillos
- Department of Anesthesia and Perioperative Medicine, University Hospital, London Health Sciences Center, Western University, London, ON, Canada
| | - Ki Jinn Chin
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
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Rhyner P, Kirkham K, Hirotsu C, Farron A, Albrecht E. A randomised controlled trial of shoulder block vs. interscalene brachial plexus block for ventilatory function after shoulder arthroscopy. Anaesthesia 2019; 75:493-498. [PMID: 31854463 DOI: 10.1111/anae.14957] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2019] [Indexed: 11/29/2022]
Abstract
The shoulder block may impair ventilatory function and diaphragmatic movement less than the interscalene brachial plexus block. We randomly allocated 30 adults who underwent shoulder arthroscopy under general anaesthesia to ultrasound-guided shoulder block or interscalene block with 20 ml bupivacaine 0.5%. The primary outcome, rate of ultrasound-measured hemidiaphragmatic excursion < 25% of baseline 30 min after blockade, was reduced from 12/15 with brachial plexus block to 2/15 with shoulder block, a difference (95%CI) of 67% (40-93%), p < 0.001. The mean (SD) numeric rating scale pain scores at rest after shoulder block were higher than after interscalene block at two postoperative hours, 1.4 (1.2) vs. 0.3 (0.7), p = 0.02, but lower at 24 postoperative hours, 1.3 (1.3) vs. 3.4 (2.3), p = 0.008. Mean (SD) pain scores on movement in the shoulder and interscalene blocks were similar, with respective values of 1.9 (1.9) vs. 0.7 (1.2), p = 0.13 at two postoperative hours and 3.7 (2.3) vs. 5.3 (2.5), p = 0.41, at 24 postoperative hours.
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Affiliation(s)
- P Rhyner
- Department of Anaesthesia, Lausanne University Hospital, University of Lausanne, Switzerland
| | - K Kirkham
- Department of Anaesthesia, Toronto University Western Hospital, Toronto, ON, Canada
| | - C Hirotsu
- Center for Investigation and Research in Sleep, Lausanne University Hospital, University of Lausanne, Switzerland
| | - A Farron
- Department of Orthopaedic Surgery, Lausanne University Hospital, University of Lausanne, Switzerland
| | - E Albrecht
- Department of Anaesthesia, Lausanne University Hospital, University of Lausanne, Switzerland
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Nobre LV, Cunha GP, Sousa PCCBD, Takeda A, Cunha Ferraro LH. [Peripheral nerve block and rebound pain: literature review]. Rev Bras Anestesiol 2019; 69:587-593. [PMID: 31690509 DOI: 10.1016/j.bjan.2019.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/03/2019] [Accepted: 05/15/2019] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To investigate, describe, and assess the phenomenon of "rebound pain" as a clinically relevant problem in anesthetic practice. CONTENT The phenomenon of "rebound pain" has been demonstrated and described as a very severe pain, which occurs after a peripheral nerve block resolution with the recovery of sensitivity. The incidence of rebound pain is unknown. Usually, it occurs between 12 to 24hours after surgery and adversely affecting sleep quality. It is not yet possible to establish a mechanism as a definitive cause or trigger factor of rebound pain. Studies suggest that rebound pain is a side effect of peripheral nerve blocks, despite their effectiveness in pain control. Currently, the extent and clinical significance of rebound pain cannot be well determined due to the lack of large prospective studies. CONCLUSION Rebound pain assessment should always be considered in clinical practice, as it is not a rare side effect of peripheral nerve blocks. There are still many challenging questions to be answered about rebound pain, so large prospective studies are needed to address the issue. For prevention, the use of peripheral nerve block techniques that avoid nerve damage and adequate perioperative analgesia associated with patient education on the early administration of analgesics, even during the period of analgesia provided by peripheral nerve block, is recommended. A better understanding of the "rebound pain" phenomenon, its pathophysiology, associated risk factors, and long-term consequences may help in developing more effective preventive strategies.
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Affiliation(s)
- Layana Vieira Nobre
- Universidade Federal de São Paulo (Unifesp), Escola Paulista de Medicina, Grupo de Anestesia Regional Disciplina de Anestesiologia, Dor e Medicina Intensiva, São Paulo, SP, Brasil
| | - Graziella Prianti Cunha
- Universidade Federal de São Paulo (Unifesp), Escola Paulista de Medicina, Grupo de Anestesia Regional Disciplina de Anestesiologia, Dor e Medicina Intensiva, São Paulo, SP, Brasil
| | - Paulo César Castello Branco de Sousa
- Universidade Federal de São Paulo (Unifesp), Escola Paulista de Medicina, Grupo de Anestesia Regional Disciplina de Anestesiologia, Dor e Medicina Intensiva, São Paulo, SP, Brasil
| | - Alexandre Takeda
- Universidade Federal de São Paulo (Unifesp), Escola Paulista de Medicina, Grupo de Anestesia Regional Disciplina de Anestesiologia, Dor e Medicina Intensiva, São Paulo, SP, Brasil
| | - Leonardo Henrique Cunha Ferraro
- Universidade Federal de São Paulo (Unifesp), Escola Paulista de Medicina, Grupo de Anestesia Regional Disciplina de Anestesiologia, Dor e Medicina Intensiva, São Paulo, SP, Brasil.
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Nobre LV, Cunha GP, Sousa PCCBD, Takeda A, Cunha Ferraro LH. Peripheral nerve block and rebound pain: literature review. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2019. [PMID: 31690509 PMCID: PMC9391878 DOI: 10.1016/j.bjane.2019.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background and objectives To investigate, describe, and assess the phenomenon of “rebound pain” as a clinically relevant problem in anesthetic practice. Content The phenomenon of “rebound pain” has been demonstrated and described as a very severe pain, which occurs after a peripheral nerve block resolution with the recovery of sensitivity. The incidence of rebound pain is unknown. Usually, it occurs between 12 and 24 hours after surgery and, adversely affecting sleep quality. It is not yet possible to establish a mechanism as a definitive cause or trigger factor of rebound pain. Studies suggest that rebound pain is a side effect of peripheral nerve blocks, despite their effectiveness in pain control. Currently, the extent and clinical significance of rebound pain cannot be well determined due to the lack of large prospective studies. Conclusion Rebound pain assessment should always be considered in clinical practice, as it is not a rare side effect of peripheral nerve blocks. There are still many challenging questions to be answered about rebound pain, so large prospective studies are needed to address the issue. For prevention, the use of peripheral nerve block techniques that avoid nerve damage and adequate perioperative analgesia associated with patient education on the early administration of analgesics, even during the period of analgesia provided by peripheral nerve block, is recommended. A better understanding of the “rebound pain” phenomenon, its pathophysiology, associated risk factors, and long-term consequences may help in developing more effective preventive strategies.
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Affiliation(s)
- Layana Vieira Nobre
- Universidade Federal de São Paulo (Unifesp), Escola Paulista de Medicina, Grupo de Anestesia Regional Disciplina de Anestesiologia, Dor e Medicina Intensiva, São Paulo, SP, Brasil
| | - Graziella Prianti Cunha
- Universidade Federal de São Paulo (Unifesp), Escola Paulista de Medicina, Grupo de Anestesia Regional Disciplina de Anestesiologia, Dor e Medicina Intensiva, São Paulo, SP, Brasil
| | - Paulo César Castello Branco de Sousa
- Universidade Federal de São Paulo (Unifesp), Escola Paulista de Medicina, Grupo de Anestesia Regional Disciplina de Anestesiologia, Dor e Medicina Intensiva, São Paulo, SP, Brasil
| | - Alexandre Takeda
- Universidade Federal de São Paulo (Unifesp), Escola Paulista de Medicina, Grupo de Anestesia Regional Disciplina de Anestesiologia, Dor e Medicina Intensiva, São Paulo, SP, Brasil
| | - Leonardo Henrique Cunha Ferraro
- Universidade Federal de São Paulo (Unifesp), Escola Paulista de Medicina, Grupo de Anestesia Regional Disciplina de Anestesiologia, Dor e Medicina Intensiva, São Paulo, SP, Brasil.
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Capdevila X, Iohom G, Choquet O, Delaney P, Apan A. Catheter use in regional anesthesia: pros and cons. Minerva Anestesiol 2019; 85:1357-1364. [PMID: 31630506 DOI: 10.23736/s0375-9393.19.13581-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Continuous peripheral nerve blocks refer to a local anesthetic solution administered via perineurally placed catheters in an effort to extend the benefits of a single-shot peripheral nerve block. They offer several advantages in the postoperative period including excellent analgesia, reduced opioid consumption and associated side effects, enhanced rehabilitation and improved patient satisfaction. The current trend towards less invasive, one-day surgery and enhanced recovery programs may decrease the requirement of catheter use. Prolonged motor block in particular is associated with undesirable outcomes. Should we routinely use continuous peripheral nerve blocks in our daily practice? This PRO-CON debate aims at answering the question from the experts' perspectives. Fascial compartment and wound catheters are outside the scope of this debate.
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Affiliation(s)
- Xavier Capdevila
- Department of Anesthesia and Critical Care, Lapeyronie University Hospital, Montpellier, France
| | - Gabriella Iohom
- Department of Anaesthesia and Intensive Care Medicine, Cork University Hospital, Cork, Ireland
| | - Olivier Choquet
- Department of Anesthesia and Critical Care, Lapeyronie University Hospital, Montpellier, France
| | - Paudie Delaney
- Department of Anaesthesia and Intensive Care Medicine, Cork University Hospital, Cork, Ireland
| | - Alparslan Apan
- Department of Anesthesia and Intensive Care Medicine, Giresun University Hospital, Giresun, Turkey -
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Dang DY, McGarry SM, Melbihess EJ, Haytmanek CT, Stith AT, Griffin MJ, Ackerman KJ, Hirose CB. Comparison of Single-Agent Versus 3-Additive Regional Anesthesia for Foot and Ankle Surgery. Foot Ankle Int 2019; 40:1195-1202. [PMID: 31307211 DOI: 10.1177/1071100719859020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study compared the results of regional blocks containing a single anesthetic, bupivacaine, with those containing bupivacaine and 3 additives (buprenorphine, clonidine, and dexamethasone) in patients undergoing foot and ankle surgery. METHODS Eighty patients undergoing foot and ankle surgery over a 9-month period were prospectively enrolled and randomized to receive a peripheral nerve block containing either a single anesthetic (SA) or one with 3 additives (TA). Patients, surgeons, and anesthesiologists were blinded to the groups. Patients maintained pain diaries and were evaluated at 1 and 12 weeks postoperatively. Fifty-six patients completed the study. RESULTS The TA group had a longer duration of analgesic effect than the SA group (average 82 vs 34 hours, P < .05). Forty-eight hours after surgery, 93% of SA blocks, compared with 34% of TA blocks, had completely worn off. The TA group had a longer duration of sensory effects. At 3 months, 10 of 26 (38.5%) TA patients, compared with 3 of 30 (10%) SA patients, reported postoperative neurologic symptoms. Pain scores in both groups were not statistically different at 1 week or 3 months after surgery. Patients in both groups were similarly satisfied with their blocks. CONCLUSION Both types of nerve blocks provided equivalent pain control and patient satisfaction in patients undergoing foot and ankle surgery. The 3-additive agent blocks were associated with a longer duration of pain relief and a longer duration of numbness, as well as higher rates of postoperative neurologic symptoms. Longer pain relief may be obtained at the cost of prolonged sensory deficits. LEVEL OF EVIDENCE Level II, prospective comparative study.
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Affiliation(s)
- Debbie Y Dang
- Saint Alphonsus Regional Medical Center Coughlin Clinic, Boise, ID, USA
| | | | | | | | - Andrew T Stith
- Wyoming Orthopaedics and Sports Medicine, Cheyenne, WY, USA
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Dada O, Gonzalez Zacarias A, Ongaigui C, Echeverria-Villalobos M, Kushelev M, Bergese SD, Moran K. Does Rebound Pain after Peripheral Nerve Block for Orthopedic Surgery Impact Postoperative Analgesia and Opioid Consumption? A Narrative Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E3257. [PMID: 31491863 PMCID: PMC6765957 DOI: 10.3390/ijerph16183257] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 08/21/2019] [Accepted: 09/01/2019] [Indexed: 12/14/2022]
Abstract
Regional anesthesia has been considered a great tool for maximizing post-operative pain control while minimizing opioid consumption. Post-operative rebound pain, characterized by hyperalgesia after the peripheral nerve block, can however diminish or negate the overall benefit of this modality due to a counter-productive increase in opioid consumption once the block wears off. We reviewed published literature describing pathophysiology and occurrence of rebound pain after peripheral nerve blocks in patients undergoing orthopedic procedures. A search of relevant keywords was performed using PubMed, EMBASE, and Web of Science. Twenty-eight articles (n = 28) were included in our review. Perioperative considerations for peripheral nerve blocks and other alternatives used for postoperative pain management in patients undergoing orthopedic surgeries were discussed. Multimodal strategies including preemptive analgesia before the block wears off, intra-articular or intravenous anti-inflammatory medications, and use of adjuvants in nerve block solutions may reduce the burden of rebound pain. Additionally, patient education regarding the possibility of rebound pain is paramount to ensure appropriate use of prescribed pre-emptive analgesics and establish appropriate expectations of minimized opioid requirements. Understanding the impact of rebound pain and strategies to prevent it is integral to effective utilization of regional anesthesia to reduce negative consequences associated with long-term opioid consumption.
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Affiliation(s)
- Olufunke Dada
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, 520 Doan Hall, 410 West 10th Avenue, Columbus, OH 43210, USA.
| | - Alicia Gonzalez Zacarias
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, 520 Doan Hall, 410 West 10th Avenue, Columbus, OH 43210, USA.
| | - Corinna Ongaigui
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, 520 Doan Hall, 410 West 10th Avenue, Columbus, OH 43210, USA.
| | - Marco Echeverria-Villalobos
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, 520 Doan Hall, 410 West 10th Avenue, Columbus, OH 43210, USA.
| | - Michael Kushelev
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, 520 Doan Hall, 410 West 10th Avenue, Columbus, OH 43210, USA.
| | - Sergio D Bergese
- Department of Anesthesiology, Stony Brook University, Stony Brook, New York, NY 11794, USA.
| | - Kenneth Moran
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, 520 Doan Hall, 410 West 10th Avenue, Columbus, OH 43210, USA.
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Edgley C, Hogg M, De Silva A, Braat S, Bucknill A, Leslie K. Severe acute pain and persistent post-surgical pain in orthopaedic trauma patients: a cohort study. Br J Anaesth 2019; 123:350-359. [DOI: 10.1016/j.bja.2019.05.030] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/16/2019] [Accepted: 05/08/2019] [Indexed: 12/29/2022] Open
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