Multimodal analgesia with ropivacaine wound infiltration and intravenous flurbiprofen axetil provides enhanced analgesic effects after radical thyroidectomy: a randomized controlled trial

Abdominal muscles infiltration analgesia for donor-site pain in autologous ear reconstruction: A randomized controlled clinical trial

BACKGROUND

Costal cartilage donor-site pain is an adverse effect of autologous ear reconstruction. This study aimed to introduce rectus abdominis and external oblique muscle infiltration analgesia (RAM+EOM-IA) for costal cartilage donor-site pain and evaluate its efficacy and safety.

METHODS

The study was a randomized controlled clinical trial. Patients were randomized between intermittent RAM+EOM-IA combined with intravenous patient-controlled anesthesia (IPCA) and IPCA alone. Thirty patients were followed in the RAM+EOM-IA combined with the IPCA group and 30 patients in the IPCA alone group. The primary outcome was the numerical rating score (NRS) of pain recorded during 48 h postoperatively. Secondary outcomes included the Barthel index (BI) and rescue analgesic consumption. Sensory block areas were tested using a cold stimulus.

RESULTS

NRS was significantly lower with RAM+EOM-IA combined with IPCA than with IPCA alone at 28 h (P < 0.01), 32 h (P < 0.01), 36 h (P < 0.01), 44 h (P < 0.001), and 48 h (P < 0.01) postoperatively. The number of patients who received rescue analgesics (P < 0.01) and consumption (P < 0.01) was significantly higher for IPCA alone. RAM+EOM-IA improved the BI at 24 h postoperatively (P < 0.001), especially for mobility (P < 0.001), using the stairs (P < 0.001) and toilet use domains (P < 0.001). At 10 and 60 min after RAM+EOM-IA, the total sensory block area in the abdomen had not extended proximally beyond the xiphoid, distally beyond the navel, and beyond midaxillary and midsternal lines on either side.

CONCLUSION

RAM+EOM-IA effectively and safely prevented costal cartilage donor-site pain by blocking anterior and lateral cutaneous branches of intercostal nerves from T6 to T10 in microtia patients.

Efficacy and Safety of Magnesium Sulfate as an Adjunct to Ropivacaine Wound Infiltration in Thyroid Surgery: A Prospective, Double-Blind, Randomized Controlled Trial

Background/Objective: Wound infiltration with local anesthetics emerges as a promising modality for postoperative pain alleviation. However, such strategies in neck surgery have not been a well-established practice. To assess wound infiltration with ropivacaine plus magnesium sulfate for pain relief following thyroid surgery. Methods: This prospective, double-blind, randomized study enrolled 68 patients who underwent thyroid surgery. Concerning the solution used for surgical wound infiltration, the study participants were randomly allocated into three groups: (1) 100 mg of ropivacaine (Group R); (2) 100 mg of ropivacaine plus magnesium sulfate 10 mg/kg (Group RMg); and (3) normal saline which served as a placebo (Group P). Pain perception both at rest and at movement, was measured using the Visual Analogue Scale (VAS) at 30 min, as well as at 1, 2, 4, 6, 12, and 24 h postoperatively. The total consumption of analgesics in morphine equivalents was also recorded. Moreover, adverse effects and patient satisfaction were recorded. Cortisol, TNF-α, and IL-6 levels were measured 30 min before infiltration and 6 h and 24 h postoperatively. Results: Demographics and clinical characteristics were similar between the groups. The VAS scores at rest and during movement were significantly lower in the RMg group compared to the saline or ropivacaine groups. Total analgesic consumption was also significantly lower in the RMg group. No operation-, wound-, or infiltration-related adverse effects were recorded in the study groups. Better overall satisfaction was obtained for the RMg group. Conclusions: Ropivacaine plus magnesium sulfate wound infiltration provided better pain control and the analgesic effect was more significant, contributing to effective postoperative analgesia in patients undergoing thyroid surgery.

Administration of flurbiprofen axetil and dezocine for the postoperative analgesia in patients with non‑small cell lung cancer: A randomized, controlled study

Flurbiprofen axetil or dezocine monotherapy has been applied for analgesia of postoperative non-small cell lung cancer (NSCLC); however, their combination is rarely investigated. Consequently, the present study aimed to explore the effect of flurbiprofen axetil plus dezocine on postoperative pain, surgical outcomes and its safety profile in patients with NSCLC. A total of 150 patients with resectable NSCLC were enrolled and randomized into three groups: i) The flurbiprofen axetil plus dezocine group (n=50), ii) the flurbiprofen axetil group (n=51) and iii) the dezocine group (n=49). A total of 50 mg flurbiprofen axetil, 5 mg of dezocine or their combination were administered intravenously 3 h prior to surgery and subsequently every 12 h until day 3 (D3) following surgery. The postoperative pain was lower in the flurbiprofen axetil plus dezocine group compared with that of the flurbiprofen axetil group at 6 h (P=0.008), 12 h (P=0.003), day 1 (D1) (P=0.013), day 2 (D2) (P=0.036) and D3 (P=0.010); in addition, it was lower in the flurbiprofen axetil plus dezocine group compared with that of the dezocine group at 6 h (P=0.010), 12 h (P=0.012) and D1 (P=0.020). Patient-controlled analgesia consumption was also lower in the flurbiprofen axetil plus dezocine group compared with that of the flurbiprofen axetil (P=0.010) and dezocine (P=0.002) groups. Furthermore, the length of hospital stay was lower in the flurbiprofen axetil plus dezocine group compared with that of the flurbiprofen axetil (P=0.008) and dezocine (P=0.048) groups, while other surgical outcomes and adverse events were similar among these three groups. Moreover, the expression of tumor necrosis factor-α was lower in the flurbiprofen axetil plus dezocine group compared with that of the dezocine group at 12 h (P<0.001), D1 (P<0.001) and D3 (P=0.033). The data indicated that flurbiprofen axetil and dezocine combination was superior to monotherapy for postoperative analgesia in patients with resectable NSCLC.

Post-thyroidectomy pain relief is enhanced by wound infiltration. A systematic review of randomized controlled trials

INTRODUCTION

Thyroidectomy is a common surgical procedure. Traditional options for pain management, such as analgesics and nonsteroidal anti-inflammatory medications (NSAIDs), are limited by their side effects. Surgical wound infiltration with local anesthetics has the potential to reduce the need for analgesics in a number of surgical procedures. This systematic review and meta-analysis wanted to resolve these concerns and assess the efficacy of WI in the management of postoperative pain after thyroidectomy.

MATERIAL AND METHODS

The review adhered to Cochrane Collaboration and PRISMA standards. RCTs comparing WI with no infiltration or placebo were included. Patients with benign or malignant thyroid disease who underwent open thyroidectomy were eligible. Postoperative pain was assessed using a visual analogue scale (VAS) as the primary outcome. Time to first rescue dose, the need for analgesic rescue in the first 24 h, and total opioid analgesic consumption were secondary outcomes. Standardized mean difference (SMD) and odds ratio (OR) were used to analyze the data.

RESULTS

16 randomized controlled trials involving 1202 patients were included. At 6 and 8 h postoperatively, WI exhibited a statistically significant impact on pain management. In the WI group, the need for analgesic rescue was significantly reduced. At 4 h postoperatively, non-anesthetic medications demonstrated a significant analgesic effect.

CONCLUSIONS

This systematic review and meta-analysis support the use of WI with local anesthetics for postoperative pain management after thyroidectomy. These findings have significant implications for improving perioperative care, especially in ambulatory settings where effective pain management is essential.

Local Wound Infiltration for Thyroidectomized Patients in the Era of Multimodal Analgesia

The first few hours following thyroidectomy are the most crucial for pain management. Adequate postoperative pain control, reduction in opioid abuse and the possibility of implementing one-day operations are the considered parameters when developing the postoperative analgesic strategy. A study of the available literature was conducted, exploring the efficacy of (open) thyroidectomy wound infiltration. Seventeen full-text RCTs were extracted. Local anesthetics and non-steroidal anti-inflammatory drugs were infiltrated. Emphasis was given to postoperative pain scores and requirements for rescue analgesia with opioids. Most authors agree that local wound infiltration for thyroidectomized patients is effective in the management of postoperative pain parameters. In the era of multimodal analgesia, thyroidectomy wound infiltration could represent an essential adjunct contributing to lower VAS scores and reduced opioid requirements.

Ketamine infiltration improves analgesia after thyroid surgery

Background: Postoperative pain increases the risk of postoperative complications and may predispose patients to chronic post-surgical pain. This study aims to evaluate the impact of ketamine wound infiltration versus placebo at the end of thyroid surgery on postoperative pain and analgesic requirements. Methods: In this randomized controlled trial, we prospectively studied patients who underwent thyroid surgery. Patients were randomized into two groups: group S, where local infiltration was performed using 10 ml of a physiological saline solution; and group K, where 10 ml of a solution containing 2 mg/kg ketamine was infiltrated. Standardized thyroidectomies were performed in the 2 groups. Pain perception was measured using a visual analog scale (VAS) every 10 minutes in the post-anesthetic care unit (PACU) for 2 hours and thereafter every 6 hours during the first 24 hours. The opioid requirement in the PACU was evaluated. A comparison between the 2 groups was carried out. Results: Postoperatively, the mean VAS was higher in group S compared to group K during all PACU stay periods and the first 24 hours. Pain scores during swallowing were significantly lower for group K in the PACU at 0, 10, and 20 minutes. The mean morphine consumption in the PACU was 0.71 mg and 0 mg respectively in group S and group K (p=0.03). The incidence of nausea and vomiting was similar in both groups. Conclusions: Ketamine wound infiltration is an efficient modality to reduce postoperative opioid consumption compared to a placebo after thyroid surgery.

Predictive factors of postoperative acute pain in laparoscopic inguinal hernia repair in men: A single-centre retrospective study in Japan

INTRODUCTION

Laparoscopic inguinal hernia repair has significantly reduced the incidence of postoperative acute and chronic pain compared to open repair, but it remains problematic. This study's purpose was to retrospectively identify predictive factors of acute pain after laparoscopic inguinal hernia repair.

METHODS

We reviewed the medical records of 193 patients. After excluding atypical cases and female patients, 156 patients were analysed. Factors affecting rescue analgesic requirements were investigated via multivariable logistic regression analysis. Independent variables included age, body mass index, analgesics used during surgery and surgical factors (unilateral/bilateral, primary/recurrent). The degree of postoperative pain and the hospital stay duration after surgery were also investigated.

RESULTS

Of the 156 patients, 40 (25.6%) required rescue analgesics. Patients under 60 years of age were about seven times more likely to need rescue analgesics than patients over 80 years of age. Primary surgery patients were about 5.5 times more likely to need rescue analgesics than recurrent surgery patients. The maximum verbal rating scale score was less than 3 in 89% of patients. All patients were discharged by two days postoperatively.

CONCLUSION

Laparoscopic inguinal hernia repair results in less postoperative acute pain. However, analgesia management should be considered prudently for younger patients and primary surgery patients.

Opioid-Sparing Effects of Flurbiprofen Axetil as an Adjuvant to Ropivacaine in Pre-Emptive Scalp Infiltration for Post-Craniotomy Pain: Study Protocol for a Multicenter, Randomized Controlled Trial

Background

Pain after craniotomy remains a poorly controlled problem that is mainly caused by the inflammatory reaction at the incision site. Nowadays, systemic opioids use, as first-line analgesics, is often limited because of adverse effects. Flurbiprofen axetil (FA) is a non-steroidal anti-inflammatory drug merged into emulsified lipid microspheres, which represent a strong affinity to inflammatory lesions. Local administration of flurbiprofen into a surgical wound has induced enhanced analgesic efficacy and few systemic or local adverse effects after oral surgery. However, the impact of local FA, as a non-opioid pharmacologic alternative, remains elusive on postoperative pain in craniotomy. In this study, we presume that pre-emptive infiltration of scalp with FA as an adjuvant to ropivacaine can lead to less sufentanil consumption postoperatively in patient controlled intravenous analgesia (PCIA) compared with ropivacaine alone.

Methods/Design

We design a multicenter, randomized controlled study that will enroll 216 subjects who are planned to receive supratentorial craniotomy. Patients will receive pre-emptive infiltration of scalp either with 50 mg FA and 0.5% ropivacaine, or with 0.5% ropivacaine alone. Primary outcome is total consumption of sufentanil with PCIA device at 48 h postoperatively.

Discussion

This is the first study attempting to explore the analgesic and safety profile of local FA as an adjuvant to ropivacaine for incisional pain in patients undergoing craniotomy. It will provide additional insights into the opioid-sparing analgesia pathways by local administration of NSAIDs for neurosurgery.

Analgesic effects of different concentrations of ropivacaine in transversalis fascia plane block during laparotomy

Objective

To explore the analgesic effects of different concentrations of ropivacaine in transversalis fascia plane (TFP) block during laparotomy.

Methods

Ninety patients who underwent laparotomy admitted to our hospital from March 2019 to March 2020 were selected as the study subjects and were divided equally into a low concentration group, a medium concentration group, and a high concentration group according to the randomized grouping method. The low concentration group adopted 0.4% ropivacaine 40 ml, the medium concentration group was given 0.5% ropivacaine 40 ml, and the high concentration group was given 0.6% ropivacaine 40 ml. The hemodynamic indexes and the incidence of adverse reactions in the two groups were compared. The Numerical Rating Scale (NRS) was used to assess the postoperative pain in the three groups, the Bruggrmann comfort scale (BCS) was used to assess the comfort level in the three groups, and the Mini-mental State Examination (MMSE) was used to evaluate the postoperative cognitive function of the three groups of patients.

Results

The mean artery pressure (MAP) and heart rate (HR) levels at T1 and T2 were significantly lower in the medium concentration group than in the other two groups (P < 0.05). The low concentration group had a significantly higher NRS score at T2 than the medium concentration group and the high concentration group (P < 0.05). A significantly higher BCS score was observed in the high concentration group than the other two groups (P < 0.05). There were significantly higher Ramsay scores and MMSE scores in the medium concentration group than in the low concentration and high concentration groups (P < 0.05). The overall incidence of adverse reactions of the high concentration group was significantly higher than that of the low concentration group (P < 0.05), but showed similar results with the medium concentration group.

Conclusion

The medium concentration group exhibits a better analgesic effect than the low concentration group and higher safety than the high concentration group. Therefore, the use of medium concentration ropivacaine in TFP block may provide a referential basis for clinical treatment.

Impact of Liposomal Bupivacaine on Post-Operative Pain and Opioid Usage in Thyroidectomy

OBJECTIVES

Opioid analgesia has been integral in post-operative pain control for decades. The over-prescription of opioids, commonly in the surgical patient, has contributed to the current opioid epidemic. Liposomal bupivacaine (LB), a long-acting analgesia formulation, has demonstrated decreased post-operative pain and opioid requirements in patients treated across multiple surgical subspecialties. The aims of this retrospective study are to assess post-operative pain and opioid use in patients who received LB at the time of thyroidectomy.

METHODS

A cohort-matched retrospective review of patients who underwent thyroidectomy by 2 surgeons between January 2010 and December 2019 was performed. Patients were divided into those that received LB intraoperatively and those that did not. Statistical analyses were performed using the Chi-square or Fisher's exact test, and 2-sample T-test or Wilcoxon rank sum test.

RESULTS

Of the 201 patients included in this study, 113 patients received LB and 88 did not. Patients who received LB had a lower median visual analog scale (VAS) pain score (2 vs 3, P = .2252), lower maximum VAS pain score (6 vs 7, P = .0898), were less likely to require opioid medications (73.5% vs 85.2%, P = .0434), and had a lower percentage of daily morphine milligram equivalent value ≥45 (89.8% vs 95.3%, P = .1581) during the post-operative period when compared to those that did not.

CONCLUSION

This study suggests a role for incisional infiltration with LB for post-operative pain management in patients undergoing transcervical thyroidectomy. We report reduced post-operative pain scores and opioid analgesia requirements in patients who received LB.

Comparison of supra-inguinal fascia iliaca versus pericapsular nerve block for ease of positioning during spinal anaesthesia: A randomised double-blinded trial

Background and Aims

Regional analgesic techniques such as supra-inguinal fascia-iliaca compartment block (S-FICB) and pericapsular nerve group (PENG) block have been found to be effective in providing good pain relief in hip-fracture patients. However, comparative studies between PENG and S-FICB are lacking. The aim of this study was to compare the analgesic efficacy of S-FICB and PENG block and assess their efficacy in optimal patient positioning for spinal anaesthesia.

Methods

A prospective randomised double-blind study was conducted in 66 patients randomly divided to receive either S-FICB or PENG block under ultrasound guidance. Primary outcome measures were numerical rating scale (NRS) pain score at rest and on passive 15° limb lifting, 30 minutes after the block and ease of spinal positioning. The secondary outcome measures were NRS over 24 hours, amount of tramadol used (number of rescue doses), patients' satisfaction and block-related complications. The results were analysed using statistical software (MedCalc version 19.2.1). Continuous and categorical data were analysed using appropriate statistical analysis and P < 0.05 was considered significant.

Results

Post-block, the NRS score decreased significantly in PENG and S-FICB groups at rest and movement (P < 0.0001). The EOSP score was significantly better in PENG group (P < 0.0001). First analgesic request and pain relief in the first 24-hour period were similar between the groups (P = 0.524).

Conclusion

PENG block provided better pain relief and ease of positing during SA in patients with fractured hip scheduled for hip surgery.

Perioperative pain management for thyroid and parathyroid surgery: A systematic review

INTRODUCTION

A growing body of evidence suggests that surgeons have historically over-prescribed opioid pain medications following thyroid and parathyroid surgery, thereby potentially contributing to the current US opioid epidemic. We reviewed the evidence supporting multimodal methods of pain control after cervical endocrine surgery.

METHODS

Fifty-one randomized clinical trials, 9 prospective cohort studies, 7 retrospective studies/reviews, and 1 survey regarding pain management for cervical endocrine surgery were include.

RESULTS

Most studies reported in-hospital pain scores and opioid consumption. Data on pain scores following discharge were limited. In several studies, the interventional dose was much greater than what is commonly used clinically.

CONCLUSION

Several evidence-based, non-opioid interventions can be incorporated into a standardized pain management protocol following cervical endocrine surgery. Little is known regarding the effects of these interventions on post-discharge pain scores and patient quality of life during recovery.

Risk factors for postoperative nausea and vomiting after thoracoscopic pulmonary wedge resection: pitfalls of an increased fentanyl dose

Background

Thoracoscopic pulmonary wedge resection (TPWR) is a surgical procedure that can maintain lung function and is less physically invasive to a patient. However, the risk factors for postoperative nausea and vomiting (PONV) following TPWR remain unknown. We aimed to evaluate multiple risk factors of PONV after TPWR and the impact of PONV on postoperative outcomes.

Methods

We retrospectively reviewed consecutive patients who underwent TPWR for malignant pulmonary tumors at our institution between October 2017 and March 2020. We assessed the differences in the clinical and perioperative parameters between the PONV and non-PONV groups.

Results

We reviewed 160 patients, of whom 27 (16.9%) had PONV. Sixteen (59.3%) patients with PONV required postoperative antiemetics. Failed mobilization was associated with PONV requiring postoperative antiemetics (P=0.048). In the multivariate analysis, increased fentanyl dose was an independent risk factor for PONV (P=0.022). Using the receiver operating characteristic curve, the optimal cut-off value for PONV was 3.58 µg/kg/hr (area under the curve =0.665; sensitivity =85.2%; specificity =53.4%; 95% confidence interval: 0.562–0.768; P=0.007). For example, in a case of a 50-kg patient who underwent a 70-min operation (our median operative time), the total dose of fentanyl within 208 µg was the cut-off value for preventing PONV.

Conclusions

An increased dose of fentanyl/kg/h was the strongest risk factor for PONV during TPWR. The optimal cut-off value for PONV was 3.58 µg/kg/hr. It is important to avoid the inadvertent administration of intraoperative fentanyl.