The opioid epidemic from the acute care hospital front line

Latest Advances in Regional Anaesthesia

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

Implementation of a peri-operative pain-management algorithm reduces the use of opioid analgesia following pelvic exenteration surgery

AIM

This study aimed to investigate the implementation and pain-related outcomes of a peri-operative pain-management regimen for patients undergoing pelvic exenteration surgery at a university teaching hospital.

METHOD

This is a single-site prospective observational cohort study involving 100 patients who underwent pelvic exenteration surgery between January 2017 and December 2018. A pain-management algorithm regarding the use of opioid-sparing multimodal analgesia was developed between the departments of anaesthesia, pain management and intensive care. The primary outcomes were: compliance with a pain-treatment algorithm compared with a similar retrospective surgical patient cohort in 2013-2014; and requirements for regular doses of opioid analgesia at discharge, measured in oral morphine equivalent daily dose (oMEDD).

RESULTS

Following the introduction of a pain-management algorithm, regional anaesthesia techniques (spinal anaesthesia, transversus abdominus plane block, preperitoneal catheters or epidural analgesia) were used in 83/98 (84.7%) of the 2017-2018 cohort compared with 13/73 (17.8%) of the 2013-2014 cohort (p < 0.001). There was a reduction in the median dose of opioid analgesics (oMEDD) at time of discharge, from 150 mg (interquartile range [IQR]: 75.0-235.0 mg) in the 2013-2014 cohort to 10 mg (IQR: 0.00-45.0 mg) in the 2017-2018 cohort (p < 0.001). There was no change in pain intensity (assessed using the Verbal Numerical Rating Score) or oMEDD in the first 7 days following surgery.

CONCLUSION

Since implementation of a novel peri-operative pain-treatment algorithm, the use of opioid-sparing regional techniques and preperitoneal catheters has increased. Additionally, the dose of opioids required at the time of discharge has reduced significantly.

The efficacy and safety of midazolam with fentanyl versus midazolam with ketamine for bedside invasive procedural sedation in pediatric oncology patients: A randomized, double-blinded, crossover trial

Children with cancer often require sedation before undergoing invasive procedures. Fentanyl, ketamine, and midazolam are effective drugs widely used for procedural sedation. This study aimed to investigate the efficacy and safety of midazolam-fentanyl (M-F) compared with midazolam-ketamine (M-K) for bedside procedural sedation among pediatric oncology patients. A randomized, double-blinded, crossover trial was conducted among children with cancer requiring procedural sedation for invasive procedures. Patients were randomly assigned either intravenous M-F or M-K and subsequently received the alternate regimens following the crossover design of the study. The efficacy and safety of the sedations including sedation time intervals, nausea score, vomiting episodes, pain score, adverse effects, and parent's satisfaction were evaluated. In all, 58 patients with 116 procedural sedations were enrolled. M-K provided a shorter induction time (0:58 vs. 1:23 min) (p = 0.005), but longer sedation (9:02 vs. 5:50 min) (p = 0.019) and emergence time (4:26 vs. 0:56 min) (p = 0.011) compared with M-F. Sedation routes affected the sedation time intervals. Patients had higher rates of vomiting (0, range 0-8 vs. 0, range 0-2) (p = 0.033) but experienced less pain (0 vs. 2) (p = 0.008) in the M-K group. Overall satisfaction and other adverse effects were comparable among both sedation regimens. Combined sedative drugs are recommended to improve the effectiveness of bedside procedural sedation. M-K provided shorter induction, but longer sedation and emergence time compared with M-F. These findings correlated with sedative routes. Patients receiving M-K experienced a higher rate of vomiting, but less painfulness compared with M-F. Overall satisfaction and tolerable side effects were comparable among both sedative regimens.