Side Effect Rates of Opioids in Equianalgesic Doses via Intravenous Patient-Controlled Analgesia

Consensus Statement on Pain Management for Pregnant Patients with Opioid-Use Disorder from the Society for Obstetric Anesthesia and Perinatology, Society for Maternal-Fetal Medicine, and American Society of Regional Anesthesia and Pain Medicine

Pain management in pregnant and postpartum people with an opioid-use disorder (OUD) requires a balance between risks associated with opioid tolerance, including withdrawal or return to opioid use, considerations around social needs of the maternal-infant dyad, and the provision of adequate pain relief for the birth episode that is often characterized as the worst pain a person will experience in their lifetime. This multidisciplinary consensus statement between the Society for Obstetric Anesthesia and Perinatology (SOAP), Society for Maternal-Fetal Medicine (SMFM), and American Society of Regional Anesthesia and Pain Medicine (ASRA) provides a framework for pain management in obstetric patients with OUD. The purpose of this consensus statement is to provide practical and evidence-based recommendations and is targeted to health care providers in obstetrics and anesthesiology. The statement is focused on prenatal optimization of pain management, labor analgesia, and postvaginal delivery pain management, and postcesarean delivery pain management. Topics include a discussion of nonpharmacologic and pharmacologic options for pain management, medication management for OUD (eg, buprenorphine, methadone), considerations regarding urine drug testing, and other social aspects of care for maternal-infant dyads, as well as a review of current practices. The authors provide evidence-based recommendations to optimize pain management while reducing risks and complications associated with OUD in the peripartum period. Ultimately, this multidisciplinary consensus statement provides practical and concise clinical guidance to optimize pain management for people with OUD in the context of pregnancy to improve maternal and perinatal outcomes.

Comparison of intrathecal fentanyl as an adjunct in spinal anaesthesia to ultrasound-guided quadratus lumborum block as an effective postoperative analgesia for Caesarean section surgery

BACKGROUND

Postoperative pain in patients, if dealt with inadequately, has been a significant cause of morbidity. The present study compared the postoperative analgesic efficacy of intrathecal fentanyl and ultrasound-guided quadratus lumborum block following Caesarean surgery.

METHODS

A prospective randomised controlled study was planned for parturients who underwent Caesarean surgery under spinal anaesthesia. Patients received bupivacaine (10mg) and 25µg of intrathecal fentanyl in the spinal anaesthesia (group intrathecal fentanyl, n = 30) or 20mL of 0.375% ropivacaine bilateral quadratus lumborum block (group quadratus lumborum; n = 30) after surgery. The visual analogue scale score, quality of recovery-15 score and incidence of ill effects were recorded.

RESULTS

The postoperative haemodynamic parameters were comparable between the two groups. The visual analogue scale score at different time intervals decreased after the quadratus lumborum block (p < 0.05). The mean global quality of recovery score was better in the quadratus lumborum group (p < 0.001). In the quadratus lumborum group, the mean time to first ambulation was lower than that in the intrathecal fentanyl group (p < 0.05). The requirement for first-rescue analgesia was earlier in the intrathecal fentanyl group (4.67 ± 0.72) than in the quadratus lumborum group (4.92 ± 0.88).

CONCLUSION

Intrathecal fentanyl and quadratus lumborum block had effective postoperative analgesic effects on Caesarean surgery patients. However, the quadratus lumborum block group exhibited better analgesia and early ambulation than the intrathecal fentanyl group, with an improved quality of recovery.

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

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

Erector spinae plane block versus quadratus lumborum block for postoperative analgesia after laparoscopic nephrectomy: A randomized controlled trial

STUDY OBJECTIVE

We compared the analgesic effects of erector spinae plane block versus quadratus lumborum block following laparoscopic nephrectomy.

DESIGN

A randomized controlled trial.

SETTING

A tertiary hospital in Beijing, China.

PATIENTS

Patients scheduled for elective laparoscopic nephrectomy.

INTERVENTIONS

A total of 110 patients were enrolled and randomized to receive either erector spinae plane block (n = 55) or quadratus lumborum block (n = 55) under ultrasound guidance. Patient-controlled sufentanil analgesia was provided after surgery.

MEASUREMENTS

Our primary outcome was cumulative opioid consumption within 24 h after surgery. Secondary outcomes included postoperative pain intensity, subjective sleep quality, and quality of recovery.

MAIN RESULTS

All 110 patients (mean 53 years, 57.3% female) were included in the intention-to-treat analysis. Cumulative sufentanil equivalent within 24 h was lower in patients given erector spinae plane block (median 13 μg, interquartile range 4 to 33) than in those given quadratus lumborum block (median 25 μg, interquartile range 13 to 39; median difference - 8 μg, 95% CI -15 to 0, P = 0.041). Pain intensity (0-10 range where 0 = no pain and 10 = the worst pain) at 2, 6, 12, and 24 h after surgery was lower with erector spinae plane block (at rest: median differences -1 point, all P ≤ 0.009; with movement: median differences -2 to -1 points, all P < 0.001). Subjective sleep quality on the night of surgery (the Richards-Campbell Sleep Questionnaire: 0-100 range, higher score better; median difference 12, 95% CI 2 to 23, P = 0.018) and quality of recovery at 24 h (the Quality of Recovery-15: 0-150 range, higher score better; median difference 8, 95% CI 2 to 15, P = 0.012) were better with erector spinae plane block. No procedure-related adverse events occurred.

CONCLUSIONS

Compared with quadratus lumborum block, erector spinae plane block provided better analgesia as manifested by lower opioid consumption and pain intensity for up to 24 h after laparoscopic nephrectomy.

Impact of Replacing Fentanyl With Hydromorphone as the First-Line Postoperative Opioid Among Patients Undergoing Outpatient Cancer Surgery

PURPOSE

In response to a nationwide fentanyl shortage, our institution assessed whether changing our first-line postoperative intravenous opioid from fentanyl to hydromorphone impacted patient outcomes. The primary research aim was to evaluate the association between first-line opioid and rapidity of recovery.

DESIGN

The study team retrospectively obtained data on all consecutive patients extracted from the electronic medical record. The rapidity of recovery was defined as the time from entry into the postanesthesia care unit to the transition to Phase 2 for ambulatory extended recovery patients and as the length of total postanesthesia care unit stay for outpatients.

METHODS

Following intent-to-treat-principles, we tested the association between study period and rapidity of recovery (a priori clinically meaningful difference: 20 minutes) using multivariable linear regression, adjusting for anesthesia type (general vs monitored anesthesia care), American Society of Anesthesiologst physical status (ASA) score (1-2 vs 3-4), age, service, robotic procedure, and surgery start time.

FINDINGS

Ambulatory extended recovery patients treated in the hydromorphone period had, on average, a 0.25 minute (95% confidence interval [CI] -6.5, 7.0), nonstatistically significant (P > .9) longer time to transition. For outpatient procedures, those who received hydromorphone had, on average, 8.5-minute longer stays (95% CI 3.7-13, P < .001). Although we saw statistical evidence of an increased risk of resurgery associated with receiving hydromorphone (0.5%; 95% CI -0.1%, 1.0%; P = .039 on univariate analysis), the size of the estimate is clinically and biologically implausible and is most likely a chance finding related either to multiple testing or confounding.

CONCLUSIONS

The multidisciplinary team concluded that the increase in postoperative length of stay associated with hydromorphone was not clinically significant and the decrease waste of prefilled syringes outweighed the small potential increased risk of resurgery compared to the shorter-acting fentanyl. We will therefore use hydromorphone moving forward.

Prehospital analgesia in suspected hip fracture patients: adherence to national prehospital pain management guidelines

PURPOSE

Patients with hip fractures frequently present at the emergency department (ED). Despite high pain scores, prehospital pain management is often inadequate and insufficient. In the Netherlands, the emergency medical services (EMS) exhibit a high level of training, supported by a comprehensive pain treatment protocol. This study aimed to assess adherence to the protocol and hypothesized that prehospital pain management in hip fracture patients was both sufficient and adequate.

METHODS

This was a retrospective observational cohort study of patients with suspected hip fractures. The median differences in numerical rating scale (NRS) pain scores between the initial score in the ambulance and upon arrival at the ED were compared. Furthermore, adherence to the ambulance pain protocol was studied.

RESULTS

From September 2016 to March 2021, 436 ambulance-transported hip fracture patients were included, of whom 81% received analgesics by EMS. The median initial pain score measured by EMS was 8; this number decreased to 5 at ED presentation, a significant decrease (ρ < 0.001). In case a prehospital NRS pain score was assessed, 66.5% of the patients were treated according to the protocol. In 80% of patients, the protocol was not followed correctly, primarily due to missing NRS pain scores.

CONCLUSION

In suspected hip fracture patients, initial prehospital pain scores were high and most patients received analgesics from EMS. This resulted in a significant decrease in pain. In nearly 67% of patients in whom an NRS pain score was assessed in the prehospital phase, pain management was according to protocol. However, in 80% of the total population the pain protocol was not adhered to, mainly due to missing NRS pain scores.

Wilderness Medical Society Clinical Practice Guidelines for the Treatment of Acute Pain in Austere Environments: 2024 Update

The Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded based on the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians. This is an update of the 2014 version of the "WMS Practice Guidelines for the Treatment of Acute Pain in Remote Environments" published in Wilderness & Environmental Medicine 2014; 25:41-49.

Minimal important difference in postoperative morphine consumption after hip and knee arthroplasty using nausea, vomiting, sedation and dizziness as anchors

BACKGROUND

Morphine-sparing effects are often used to evaluate non-opioid analgesic interventions. The exact effect that would warrant the implementation of these interventions in clinical practice (a minimally important difference) remains unclear. We aimed to determine this with anchor-based methods.

METHODS

This was a post hoc analysis of three studies investigating pain management after hip or knee arthroplasty (PANSAID [NCT02571361], DEX-2-TKA [NCT03506789] and Pain Map [NCT02340052]). The overall population was median aged 70, median ASA 2, 54% female. We examined the correlation between 0 and 24 h postoperative iv morphine equivalent consumption and the severity of nausea, vomiting, sedation and dizziness. The anchor was different severity degrees of these opioid-related adverse events. The primary outcome was the difference in morphine consumption between patients experiencing no versus only mild events. Secondary outcomes included the difference in morphine consumption between patients with mild versus moderate and moderate versus severe events. We used Hodges-Lehmann median differences, exact Wilcoxon-Mann-Whitney tests and quantile regression.

RESULTS

The difference in iv morphine consumption was 6 mg (95% confidence interval: 4-8) between patients with no versus only mild events, 5 mg (2-8) between patients with mild versus moderate events and 0 mg (-4 to 4) between patients with moderate versus severe events.

CONCLUSIONS

In populations comparable to this post-hoc analysis (orthopaedic surgery, median age 70 and ASA 2), we suggest a minimally important difference of 5 mg for 0-24 h postoperative iv morphine consumption.

Sick of Feeling Sick: Management of Opioid Treatment-Induced Refractory Nausea Resulting in Suicidal Ideations With a Plan and Intent

In this case report, we present the case of a 60-year-old Caucasian male with a history of depression, anxiety, opioid dependence, and idiopathic polyneuropathy, admitted to an inpatient psychiatric unit for suicidal ideation. The patient's symptoms were characterized by months of intractable nausea, severe anxiety, suicidal ideation (SI), and significant unintentional weight loss in the context of methadone-assisted treatment. Over nine days in the hospital, a treatment strategy was developed and refined, which eventually achieved sustained relief from nausea and significant improvement in anxiety. The most effective pharmacological interventions included mirtazapine, scopolamine, and gabapentin.

ED50 of remimazolam combined with different doses butorphanol for first trimester artificial abortion

Introduction

Remimazolam (RMZ) is a novel intravenous sedative drug of ultra-short benzodiazepine. The optimal dose of RMZ plus butorphanol for sedation during first trimester artificial abortion is unknown. Therefore, the present study aimed to evaluate the median effective dose (ED50) of RMZ combined with different doses of butorphanol on the sedative effect for first-trimester artificial abortion.

Methods

Sixty-one female patients were randomly assigned to Group B10 (31 patients) and Group B15 (30 patients). RMZ was administered 5 min after IV butorphanol at doses of 10 μg/kg (Group B10) and 15 μg/kg (Group B15). Cervical dilatation at the time of using a cervical dilating rod, if the patient has body movement and affects the gynecologist's operation, we define it as "Ineffective." Therefore, the dose of RMZ was increased in the next patient. Otherwise, it was defined as "Effective," and the dose of RMZ was reduced in the next patient. According to the pre-experiment, the first dose of RMZ in the first patient was 0.35 mg/kg, and the adjacent geometric dose ratio was 0.9. The centered isotonic regression was performed to determine the ED50 of RMZ. The total RMZ dose administered, recovery time, and anesthesia-related adverse events were all recorded.

Results

The ED50 (90% CI) of RMZ was 0.263 (0.215-0.310) mg/kg in Group B10, and 0.224 (0.191-0.261) mg/kg in Group B15, respectively. The recovery time in Group B10 was significantly shorter than in Group B15 (9.8 ± 2.3 vs. 12.5 ± 3.6 min, p ≤ 0.001). There was no significant difference in the incidence rate of all anesthesia-related adverse events between the two groups (p > 0.05).

Conclusion

The ED50 of RMZ combined with a 10 μg/kg or 15 μg/kg dose of butorphanol was 0.263 and 0.224 mg/kg during painless first trimester artificial abortion. However, RMZ combined with a 10 μg/kg dose of butorphanol seems to have a shorter recovery time.

Clinical trial registration

https://www.chictr.org.cn/bin/project/edit?pid=166623.

Comparison of patient-controlled analgesia and sedation (PCAS) with remifentanil and propofol versus total intravenous anesthesia (TIVA) with midazolam, fentanyl, and propofol for colonoscopy

BACKGROUND

Colonoscopy is a commonly performed gastroenterological procedure in patients associated with anxiety and pain. Various approaches have been used to provide sedation and analgesia during colonoscopy, including patient-controlled analgesia and sedation (PCAS). This study aims to evaluate the feasibility and efficiency of PCAS administered with propofol and remifentanil for colonoscopy.

METHODS

This randomized controlled trial was performed in an authorized and approved endoscopy center. A total of 80 outpatients were recruited for the colonoscopy studies. Patients were randomly allocated into PCAS and total intravenous anesthesia (TIVA) groups. In the PCAS group, the dose of 0.1 ml/kg/min of the mixture was injected after an initial bolus of 3 ml mixture (1 ml containing 3 mg of propofol and 10 μg of remifentanil). Each 1 ml of bolus was delivered with a lockout time of 1 min. In the TIVA group, patients were administered fentanyl 1 μg/kg, midazolam 0.02 mg/kg, and propofol (dosage titrated). Cardiorespiratory parameters and auditory evoked response index were continuously monitored during the procedure. The recovery from anesthesia was assessed using the Aldrete scale and the Observer's Assessment of Alertness/Sedation Scale. The Visual Analogue Scale was used to assess the satisfaction of patients and endoscopists.

RESULTS

No statistical differences were observed in the Visual Analogue Scale scores of the patients (9.58 vs 9.50) and the endoscopist (9.43 vs 9.30). A significant decline in the mean arterial blood pressure, heart rate, and auditory evoked response index parameters was recorded in the TIVA group (P < 0.05). The recovery time was significantly shorter in the PCAS group than in the TIVA group (P = 0.00).

CONCLUSION

The combination of remifentanil and propofol could provide sufficient analgesia, better hemodynamic stability, lighter sedation, and faster recovery in the PCAS group of patients compared with the TIVA group.

Opioid-free anesthesia using a combination of ketamine and dexmedetomidine in patients undergoing laparoscopic cholecystectomy: a randomized controlled trial

BACKGROUND

Opioids administered as bolus doses or continuous infusions are widely used for major and daycare surgeries. Opioid-free anesthesia is multimodal anesthesia and analgesia that does not use opioids, benefiting patients from opioid-related adverse effects. We compared the postoperative analgesic requirements of patients scheduled for elective laparoscopic cholecystectomy under opioid-free and opioid-based anesthesia.

METHODS

Study included 88 patients aged 18-60 years with American Society of Anesthesiologists physical status 1 and 2 who underwent elective laparoscopic cholecystectomy. Participants were randomly divided into two groups with 44 in each. The opioid-free group was administered an intravenous bolus of ketamine and dexmedetomidine, whereas fentanyl was used in opioid group. Primary outcome was to compare the total amount of fentanyl consumed by both groups during 6 h postoperative period. Episodes of postoperative nausea and vomiting (PONV) and vital signs were noted throughout the postoperative period to analyze the secondary outcomes.

RESULTS

Both groups had similar demographic characteristics. The opioid-free group required lesser analgesia within the first 2 h (61.4 ± 17.4 vs. 79.0 ± 19.4 of fentanyl, P < 0.001), which was statistically significant. However, fentanyl consumption was comparable between the groups at 6 h (152 ± 28.2 vs. 164 ± 33.4, P = 0.061). Compared with 4.5% of the participants in the opioid-free group, 34% of those in the opioid-based group developed moderate PONV.

CONCLUSIONS

Opioid-free anesthesia in patients undergoing laparoscopic cholecystectomy reduced the requirement of analgesia in first two-hour postoperative period and was associated with decreased PONV.

Acupoint Selection in Postoperative Ophthalmic Pain Management: A Data Mining Protocol

Background

Postoperative ophthalmic pain not only induces anxiety and depression among patients, but also prolongs the recovery cycle. However, the management of postoperative pain in ophthalmology is still not standardized. The effectiveness of acupuncture in treating postoperative pain has been validated based on numerous clinical trials and meta-analysis. Our study is to conduct the first data mining analysis to identify the most effective acupoints selection and combinations for treating postoperative ophthalmic pain, inform.

Methods

We will search bibliographic databases from inception to November 2023. Clinical trials evaluating the effectiveness of acupuncture therapy in the management of postoperative ophthalmic pain will be selected. Reviews, protocols, animal studies, case reports, systematic evaluations and Meta-analyses will be excluded. Primary outcome indicators will be clinical outcomes related to postoperative ophthalmic pain. Descriptive statistics will be performed in Excel 2019. Association rule analysis will be performed in SPSS Modeler 18.0. Exploratory factor analysis and cluster analysis will be performed in SPSS Statistics 25.0.

Results

This study will investigate the most effective point selection and combination of acupuncture points for the treatment of postoperative ophthalmic pain.

Conclusion

Our findings will provide evidence for the effectiveness and potential therapeutic prescription of acupuncture for postoperative ophthalmologic pain, helping clinicians and patients work together to make more informed decisions.

Association between esketamine interventions and postpartum depression and analgesia following cesarean delivery: a systematic review and meta-analysis

OBJECTIVE

This study aimed to compare the efficacy and safety of the use of esketamine to reduce the risk for postpartum depression and pain after cesarean delivery.

DATA SOURCES

Literature searches were conducted in PubMed, Embase, Cochrane Library, Web of Science, CNKI, and Wan fang from inception to August 2023.

STUDY ELIGIBILITY CRITERIA

The eligibility criteria were all randomized controlled trials of people who underwent a cesarean delivery and who were randomized to receive esketamine interventions irrespective of age or ethnicity. The outcomes that were assessed included the incidence of postpartum depression and the Edinburgh Postnatal Depression Scale score within 7 days and at 28 to 42 days after delivery, the pain score (visual analog scale or numerical rating scale, 0-10), the consumption of opioids, and intraoperative and postoperative adverse events.

METHODS

The Cochrane collaboration's tool was used for quality appraisal of the included studies. Statistical analysis of the data was performed using Review Manager 5.3 software, and the results were expressed as mean differences with 95% confidence intervals. Assessments were pooled using a random-effects or fixed-effects model. Study heterogeneity was assessed using the standard I2 statistic.

RESULTS

Among the 11 included randomized controlled trials that used the Edinburgh Postnatal Depression Scale for postpartum depression assessment, patients in esketamine group had a lower risk for postpartum depression within a week of surgery (risk ratio, 0.45; 95% confidence interval, 0.33-0.62). Intraoperative use of esketamine maintained a lower Edinburgh Postnatal Depression Scale score after surgery (mean difference, -1.64; 95% confidence interval, -2.14 to -1.14). Esketamine was associated with a beneficial effect in terms of the other outcomes, including a significant decline in pain score within 48 hours (mean difference, -0.71; 95% confidence interval, -0.89 to 0.52). Esketamine increased the risk for adverse neurologic and mental events during surgery without harming health, and there was no significant difference after delivery when compared with the control group.

CONCLUSION

Esketamine may reduce the risk for postpartum depression among patients who are undergoing cesarean delivery in the short term. In addition, as an adjunct to reduce analgesia, esketamine also effectively assists in pain management. Because of the lack of more high-quality evidence, we need more compelling evidence to confirm the value of esketamine in improving postpartum recovery.

Effect of opioid-free versus opioid-based strategies during multimodal anaesthesia on postoperative morphine consumption after bariatric surgery: a randomised double-blind clinical trial

Background

The efficacy and safety of opioid-free anaesthesia during bariatric surgery remain debated, particularly when administering multimodal analgesia. As multimodal analgesia has become the standard of care in many centres, we aimed to determine if such a strategy coupled with either dexmedetomidine (opioid-free anaesthesia) or remifentanil with a morphine transition (opioid-based anaesthesia), would reduce postoperative morphine requirements and opioid-related adverse events.

Methods

In this prospective double-blind study, 172 class III obese patients having laparoscopic gastric bypass surgery were randomly allocated to receive either sevoflurane-dexmedetomidine anaesthesia with a continuous infusion of lidocaine and ketamine (opioid-free group) or sevoflurane-remifentanil anaesthesia with a morphine transition (opioid-based group). Both groups received at anaesthesia induction a bolus of magnesium, lidocaine, ketamine, paracetamol, diclofenac, and dexamethasone. The primary outcome was 24-h postoperative morphine consumption. Secondary outcomes included postoperative quality of recovery (QoR40), incidence of hypoxaemia, bradycardia, and postoperative nausea and vomiting (PONV).

Results

Eighty-six patients were recruited in each group (predominantly women, 70% had obstructive sleep apnoea). There was no significant difference in postoperative morphine consumption (median [inter-quartile range]: 16 [13-26] vs 15 [10-24] mg, P=0.183). The QoR40 up to postoperative day 30 did not differ between groups, but PONV was less frequent in the opioid-free group (37% vs 59%, P=0.005). Hypoxaemia and bradycardia were not different between groups.

Conclusions

During bariatric surgery, a multimodal opioid-free anaesthesia technique did not decrease postoperative morphine consumption when compared with a multimodal opioid-based strategy. Quality of recovery did not differ between groups although the incidence of PONV was less in the opioid-free group.

Clinical trial registration

NCT05004519.

Evaluation of basal rate infusion in intravenous patient-controlled analgesia for post-cesarean section pain management: A randomized pilot study

OBJECTIVE

Administering opioids via intravenous patient-controlled analgesia is a prevalent approach for managing postoperative pain. Nevertheless, due to concerns about opioid-related side effects and the potential for opioid tolerance, there is a growing emphasis on adopting opioid-sparing techniques for postoperative pain management. We aimed to investigate the effect of adding a basal rate infusion in fentanyl-based IVA following a cesarean section (CS).

METHOD

Forty-eight patients, who received pain management through IVA after CS, were assigned randomly into 3 groups based on the background rate setting: Group 0 (0 mcg/hour, n = 16), Group 1 (15 mcg/hour, n = 16), and Group 2 (30 mcg/hour, n = 16). We assessed the impact of the basal infusion rate on opioid consumption and the visual analog scale (VAS) scores during the first 48 hours post-CS and also investigated opioid-induced side effects and the requirement for rescue analgesics in the ward during the first 48 hours after CS.

RESULTS

In the initial 24 hours following CS, fentanyl consumption significantly increased in Group 2 compared with Group 0 and Group 1 (P = .037). At 24 hours, VAS scores both at rest and during movement, tended to decrease, as the basal rate increased; however, no significant differences were observed between the groups (P = .218 and 0.827, respectively). Between the first 24- and 48-hours post-CS, fentanyl consumption showed a marked increase in both Group 1 and Group 2 compared to Group 0 (P < .001). At 48 hours, the VAS scores at rest displayed a trend toward reduction; however, no significant differences between groups were evident (P = .165). Although the incidence of opioid-induced complications was noted, no statistically significant differences were recorded between groups during the initial 24 hours and subsequent 24 to 48 hours period (P = .556 and P = .345, respectively).

CONCLUSION

The inclusion of a basal fentanyl infusion in the IVA protocol did not provide any advantages over an IVA devoid of a basal rate infusion in managing acute pain following CS.

Analgesic Effect of Quadratus Lumborum Block Type III and Type II Versus Lateral Transversus Abdominis Plane Block in Cesarean Section: A Randomized Controlled Multicenter Trial

Background

Appropriate pain management promotes immediate mobilization and allows the parturient to adequately care for her neonate after cesarean section (CS).

Objectives

This trial objective was to compare the type III and type II quadratus lumborum block (QLB) to transversus abdominis plane block (TAPB) regarding postoperative analgesic effect in CS.

Methods

This randomized, controlled, single-blind trial involved 60 women presenting for CS under spinal anesthesia. The patients were assigned randomly to either the QLB type III, QLB type II, or lateral TAPB group. All blocks were performed using 20 mL of bupivacaine 0.25% bilaterally at the end of the operation with ultrasound guidance. Pain was assessed using the numerical rating scale (NRS) score at the post-anesthesia care unit (PACU) at 2, 4, 6, 8, 12, 18, and 24 hours. The level of patient satisfaction was graded on a 5-point Likert scale.

Results

Numerical rating scale measurements at 6, 8, and 12 hours and total consumed meperidine in the 1st 24 hours after the operation were reduced significantly in QLB III than in QLB II and TAPB groups (P < 0.05) with an insignificant difference between the QLB II and TAPB groups (P > 0.05). The onset of the first request for analgesia was delayed significantly in QLB III, compared to QLB II and TAPB groups (P < 0.05), without a significant difference between the QLB II and TAPB groups (P > 0.05). Patient satisfaction and adverse events (e.g., postoperative nausea and vomiting, bradycardia, and hypotension) exhibited insignificant differences among the three groups (P > 0.05).

Conclusions

The QLB type III ensured better analgesia as evidenced by significantly lower pain measurements and amount of meperidine in the first 24 hours after the operation with delayed time of the first rescue analgesia in comparison to QLB II and TAPB; however, QLB II and TAPB were similar.

Efficacy and Safety of Erector Spinae Plane Block Versus Thoracolumbar Interfascial Plane Block in Patients Undergoing Spine Surgery: A Systematic Review and Meta-analysis

OBJECTIVES

As 2 novel peripheral nerve blocks, the erector spinae plane block (ESPB) and thoracolumbar interfascial plane (TLIP) block can relieve postoperative pain in spinal surgery. This systematic review and meta-analysis aimed to determine the efficacy and safety of ESPB versus TLIP block in patients undergoing spine surgery.

METHODS

An extensive search of English online databases, including PubMed, Web of Sciences, Embase, Medline, and Cochrane Central Register of Controlled Trials, and Chinese online databases like Wanfang Data, CNKI, and CQVIP until March 31, 2023, with no language restrictions, was performed. This systematic review and meta-analysis are based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and have been registered on PROSPERO (International Prospective Register of Systematic Reviews) with registered ID: CRD42023420987.

RESULTS

Five studies involving 457 patients were eligible for inclusion in this study. Compared with TLIP block, ESPB had lower postoperative opioid consumption at postoperative 48 hours (standard mean difference =-1.31, 95% CI:-2.54 to -0.08, P =0.04, I2 =80%) and postoperative pain score at postoperative 24 hours (standard mean difference =-0.72, 95% CI=-1.43 to -0.02, P =0.04, I2 =95%) in patients undergoing spine surgery. Complications associated with ESPB and TLIP block were not reported in the included studies.

DISCUSSION

ESPB and TLIP block are 2 novel and effective block methods. Patients receiving ESPB had lower postoperative opioid consumption and postoperative pain scores compared with patients receiving TLIP block; there was no statistically significant difference's between the 2 groups in intraoperative opioid consumption, adverse events, and rescue analgesia.

Mechanisms and treatment of opioid-induced pruritus: Peripheral and central pathways

BACKGROUND AND OBJECTIVE

Pruritus (also known as itch) is defined as an unpleasant and irritating sensation of the skin that provokes an urge to scratch or rub. It is well known that opioid administration can cause pruritus, which is paradoxical as itch and pain share overlapping sensory pathways. Because opioids inhibit pain but can cause itching. Significant progress has been made to improve our understanding of the fundamental neurobiology of itch; however, much remains unknown about the mechanisms of opioid-induced pruritus. The prevention and treatment of opioid-induced pruritus remains a challenge in the field of pain management. The objective of this narrative review is to present and discuss the current body of literature and summarize the current understanding of the mechanisms underlying opioid-induced pruritus, and its relationship to analgesia, and possible treatment options.

RESULTS

The incidence of opioid-induced pruritus differs with different opioids and routes of administration, and the various mechanisms can be broadly divided into peripheral and central. Especially central mechanisms are intricate, even at the level of the spinal dorsal horn. There is evidence that opioid receptor antagonists and mixed agonist and antagonists, especially μ-opioid antagonists and κ-opioid agonists, are effective in relieving opioid-induced pruritus. Various treatments have been used for opioid-induced pruritus; however, most of them are controversial and have conflicting results.

CONCLUSION

The use of a multimodal analgesic treatment regimen combined with a mixed antagonist and κ agonists, especially μ-opioid antagonists, and κ-opioid agonists, seems to be the current best treatment modality for the management of opioid-induced pruritus and pain.

SIGNIFICANCE

Opioids remain the gold standard for the treatment of moderate to severe acute pain as well as cancer pain. It is well known that opioid-induced pruritus often does not respond to regular antipruritic treatment, thereby posing a challenge to clinicians in the field of pain management. We believe that our review makes a significant contribution to the literature, as studies on the mechanisms of opioid-induced pruritus and effective management strategies are crucial for the management of these patients.

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

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

A systematic review and meta-analysis comparing the efficacy and safety of ketamine versus morphine for the treatment of acute pain

INTRODUCTION

Ketamine is reported as a potent opioid alternative that provides significant reduction in pain with no severe adverse events. However, some studies didn't find its use satisfactory and reported less reduction in pain score with ketamine. The purpose of this study is to compare the efficacy and safety of ketamine versus morphine for the treatment of acute pain in emergency situations.

EVIDENCE ACQUISITION

The PubMed, MEDLINE, PsycINFO EMBASE, Cochrane Library, PROSPERO registry platform, and ClinicalTrials.gov websites were queried in accordance with the PRISMA guidelines in order to locate relevant studies. According to the predefined PICOS criteria, articles were included and event data pertaining to changes in Visual Analog Scale or Numeric Rating Scale pain scales were extracted. Using RevMan and MedCalc, a meta-analysis was conducted to compare the effects of ketamine and morphine for the treatment of acute pain.

EVIDENCE SYNTHESIS

Twelve studies met the criteria for inclusion in this meta-analysis. Ketamine was found to be more effective than morphine at reducing pain scores, with an odds ratio of 0.60 (95% CI 0.48 to 0.76). Similarly, no severe adverse events related to ketamine were reported in any study, and it has a low-risk ratio of 0.78 (95% CI 0.70 to 0.87). Egger's Test P values (0.3052) and Begg's Test P values (0.3869) indicate a low risk of bias, and the Bland-Altman plot demonstrates a high degree of concordance.

CONCLUSIONS

Ketamine is a potent and effective alternative to morphine for the management of acute pain, and it reduces pain score significantly with minimal side effects.

Efficacy of prescribed opioids for acute pain after being discharged from the emergency department: A systematic review and meta-analysis

BACKGROUND

Opioids are often prescribed for acute pain to patients discharged from the emergency department (ED), but there is a paucity of data on their short-term use. The purpose of this study was to synthesize the evidence regarding the efficacy of prescribed opioids compared to nonopioid analgesics for acute pain relief in ED-discharged patients.

METHODS

MEDLINE, EMBASE, CINAHL, PsycINFO, CENTRAL, and gray literature databases were searched from inception to January 2023. Two independent reviewers selected randomized controlled trials investigating the efficacy of prescribed opioids for ED-discharged patients, extracted data, and assessed risk of bias. Authors were contacted for missing data and to identify additional studies. The primary outcome was the difference in pain intensity scores or pain relief. All meta-analyses used a random-effect model and a sensitivity analysis compared patients treated with codeine versus those treated with other opioids.

RESULTS

From 5419 initially screened citations, 46 full texts were evaluated and six studies enrolling 1161 patients were included. Risk of bias was low for five studies. There was no statistically significant difference in pain intensity scores or pain relief between opioids versus nonopioid analgesics (standardized mean difference [SMD] 0.12; 95% confidence interval [CI] -0.10 to 0.34). Contrary to children, adult patients treated with opioid had better pain relief (SMD 0.28, 95% CI 0.13-0.42) compared to nonopioids. In another sensitivity analysis excluding studies using codeine, opioids were more effective than nonopioids (SMD 0.30, 95% CI 0.15-0.45). However, there were more adverse events associated with opioids (odds ratio 2.64, 95% CI 2.04-3.42).

CONCLUSIONS

For ED-discharged patients with acute musculoskeletal pain, opioids do not seem to be more effective than nonopioid analgesics. However, this absence of efficacy seems to be driven by codeine, as opioids other than codeine are more effective than nonopioids (mostly NSAIDs). Further prospective studies on the efficacy of short-term opioid use after ED discharge (excluding codeine), measuring patient-centered outcomes, adverse events, and potential misuse, are needed.

Is PONV still a problem in pediatric surgery: a prospective study of what children tell us

Background

Postoperative nausea and vomiting (PONV) is an unpleasant complication after surgery that commonly co-occurs with pain. Considering the high prevalence among pediatric patients, it is important to explore the main risk factors leading to PONV in order to optimize treatment strategies. The objectives of this study are as follows: (1) to determine the prevalence of PONV on the day of surgery by conducting interviews with pediatric patients, (2) to assess PONV prevalence in the recovery room and on the ward by analyzing nursing records, and (3) to collect information on PONV risk factors on the day of surgery and the following postoperative days. We wanted to investigate real-life scenarios rather than relying on artificially designed studies.

Methods

A prospective analysis [according to STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines] of PONV on the day of surgery and the following postoperative days was conducted by evaluating demographic and procedural parameters, as well as conducting interviews with the children under study. A total of 626 children and adolescents, ranging in age from 4 to 18 years, were interviewed on the ward following their surgery. The interviews were conducted using a questionnaire, as children aged 4 and above can participate in an outcome-based survey.

Results

On the day of surgery, several multivariable independent predictors were identified for PONV. The type of surgery was found to be a significant factor (p = 0.040) with the highest odds ratio (OR) in patients with procedural investigations [OR 5.9, 95% confidence interval (CI): 1.8-19.2], followed by abdominal surgery (OR 3.1, 95% CI: 0.9-11.1) when inguinal surgery was used as the reference category. In addition, the study identified several predictors, including the amount of fentanyl administered during anesthesia (µg/kg body weight) (OR 1.4, 95% CI: 1.1-1.8), intraoperative use of piritramide (OR 2.6, 95% CI: 1.5-4.4) and diclofenac (OR 2.0, 95% CI: 1. 3-3.1), opioid administration in the recovery room (OR 3.0, 95% CI: 1.9-4.7), and piritramide use on the ward (OR 4.5, 95% CI: 1.7-11.6).

Conclusions

The main risk factors for PONV include the intraoperative administration of opioids during the recovery room stay and at the ward, the intraoperative use of non-opioids (diclofenac), and the specific type of surgical procedure. Real-life data demonstrated that in clinical praxis, there is a gap between the adherence to established guidelines and the use of antiemetic prophylaxis in surgeries that are generally not associated with a high PONV prevalence. Further efforts are needed to improve the existing procedures and thus improve the overall outcome.

Systemic Diclofenac Sodium Reduces Postoperative rhBMP-2 Induced Neuroinflammation: A Rodent Model Study

STUDY DESIGN

This is a basic science, animal research study.

OBJECTIVE

This study aims to explore, in rodent models, the effectiveness of systemic nonsteroidal anti-inflammatory drugs in reducing recombinant human bone morphogenetic protein-2 (rhBMP-2) induced neuroinflammation.

SUMMARY OF BACKGROUND DATA

rhBMP-2 is increasingly used to augment fusion in lumbar interbody fusion surgeries, although it can cause complications including postoperative radiculitis.

MATERIALS AND METHODS

Eighteen 8-week-old Sprague-Dawley rats underwent Hargreaves testing to measure the baseline thermal withdrawal threshold before undergoing surgical intervention. The L5 nerve root was exposed and wrapped with an Absorbable Collagen Sponge containing rhBMP-2. Rats were randomized into 3 groups: (1) Low dose (LD), (2) high dose (HD) diclofenac sodium, and (3) saline, receiving daily injection treatment. Hargreaves testing was performed postoperatively on days 5 and 7. Seroma volumes were measured by aspiration and the nerve root was then harvested for hematoxylin and eosin, immunohistochemistry, Luxol Fast Blue staining, and real-time quantitative polymerase chain reaction. The Student t test was used to evaluate the statistical significance among groups.

RESULTS

The intervention groups showed reduced seroma volume, and a general reduction of inflammatory markers (MMP12, MAPK6, GFAP, CD68, and IL18) compared with controls, with the reduction in MMP12 being statistically significant ( P = 0.02). Hematoxylin and eosin and immunohistochemistry of the nerve roots showed the highest macrophage density in the saline controls and the lowest in the HD group. Luxol Fast Blue staining showed the greatest extent of demyelination in the LD and saline groups. Lastly, Hargreaves testing, a functional measure of neuroinflammation, of the HD group demonstrated a minimal change in thermal withdrawal latency. In contrast, the thermal withdrawal latency of the LD and saline groups showed a statistically significant decrease of 35.2% and 28.0%, respectively ( P < 0.05).

CONCLUSION

This is the first proof-of-concept study indicating that diclofenac sodium is effective in alleviating rhBMP-2-induced neuroinflammation. This can potentially impact the clinical management of rhBMP-2-induced radiculitis. It also presents a viable rodent model for evaluating the effectiveness of analgesics in reducing rhBMP-2-induced inflammation.

Effect of Erector Spinae Plane Block in Terms of Analgesic Efficacy in Elderly Patients Undergoing Posterior Lumbar Spine Surgery: A Retrospective, Propensity-Score Matched Study

INTRODUCTION

For preoperative analgesia during a variety of operations, the erector spinae plane block (ESPB) has grown in popularity. However, its effectiveness in lumbar surgery is still unknown. The purpose of this study was to investigate the potential benefits of ESPB in enhancing analgesic efficacy in elderly individuals following posterior lumbar spine surgery.

METHODS

Patients aged 65 years or older who underwent elective posterior lumbar instrumented fusion (with or without decompression) at our institution between January 2019 and June 2022 were included. Demographic data, comorbidities, and results of preoperative screening were retrospectively collected. Propensity score matching (PSM) was performed in a ratio of 1:1 for control and ESPB groups. The primary outcome was opioid consumption at 24 h after surgery. Secondary outcomes was visual analog scale (VAS) pain scores at rest in the first 24 h. Additional secondary outcomes included number of patients requesting rescue analgesia, incidence of nausea and vomiting, time to the first request for analgesia via patient-controlled analgesia, and length of stay.

RESULTS

A total of 382 patients were included, of whom 119 received ESPB. The mean age of the study patients was 70.6 years old, and 254 (66.5%) were male. After PSM, each group comprised 115 patients. Patients in the ESPB group showed a significantly lower opioid consumption at 24 h after surgery. Compared with the control group, VAS pain scores at rest in the first 24 h, number of patient-controlled intravenous analgesia (PCIA) pump compressions, ratio of patients requesting rescue analgesia, incidence of nausea and vomiting, and length of stay were significantly reduced in the ESPB group. There were no significant differences between the two groups regarding safety outcomes.

CONCLUSIONS

ESPB reduces short-term opioid consumption while providing safe and effective analgesia in elderly patients undergoing posterior lumbar surgery.

Efficacy of a continuous wound infiltration system for postoperative pain management in gynecologic patients who underwent single-port access laparoscopy for adnexal disease

Introduction

Single-port access (SPA) laparoscopy requires only one incision, unlike conventional laparoscopy. However, its umbilical incision is larger than that of conventional laparoscopy and can be vulnerable to postoperative pain. This study aimed to evaluate whether simultaneous use of a continuous wound infiltration (CWI) system and intravenous patient-controlled analgesia (IV PCA) effectively decreases surgical site pain in patients who underwent SPA laparoscopy due to gynecologic adnexal disease.

Methods

A total of 371 patients who underwent SPA laparoscopy and who received IV PCA or CWI was retrospectively reviewed (combined group [CWI + IV PCA, n = 159] vs. PCA group [IV PCA only, n = 212]). To evaluate postoperative pain management, the numeric rating scale (NRS) pain score after surgery, total amount of fentanyl administered via IV PCA, and additional pain killer consumption were collected.

Results

The NRS scores at 12 h (1.90 ± 1.11 vs. 2.70 ± 1.08, p < 0.001) and 24 h (1.82 ± 0.82 vs. 2.11 ± 1.44, p = 0.026) after surgery were significantly lower in the combined group than in the PCA group. The total amount of PCA fentanyl was significantly smaller in the combined group than in the PCA group (p < 0.001). The total quantity of rescue analgesics was smaller in the combined group than in the PCA group (p < 0.05).

Conclusion

Combined use of the CWI system and IV PCA is an effective postoperative pain management strategy in patient who underwent SPA laparoscopy for adnexal disease.

Morphine and Hydromorphone Effects, Side Effects, and Variability: A Crossover Study in Human Volunteers

BACKGROUND

Balancing between opioid analgesia and respiratory depression continues to challenge clinicians in perioperative, emergency department, and other acute care settings. Morphine and hydromorphone are postoperative analgesic standards. Nevertheless, their comparative effects and side effects, timing, and respective variabilities remain poorly understood. This study tested the hypothesis that IV morphine and hydromorphone differ in onset, magnitude, duration, and variability of analgesic and ventilatory effects.

METHODS

The authors conducted a randomized crossover study in healthy volunteers. Forty-two subjects received a 2-h IV infusion of hydromorphone (0.05 mg/kg) or morphine (0.2 mg/kg) 1 to 2 weeks apart. The authors measured arterial opioid concentrations, analgesia in response to heat pain (maximally tolerated temperature, and verbal analog pain scores at discrete preset temperatures to determine half-maximum temperature effect), dark-adapted pupil diameter and miosis, end-expired carbon dioxide, and respiratory rate for 12 h after dosing.

RESULTS

For morphine and hydromorphone, respectively, maximum miosis was less (3.9 [3.4 to 4.2] vs. 4.6 mm [4.0 to 5.0], P < 0.001; median and 25 to 75% quantiles) and occurred later (3.1 ± 0.9 vs. 2.3 ± 0.7 h after infusion start, P < 0.001; mean ± SD); maximum tolerated temperature was less (49 ± 2 vs. 50 ± 2°C, P < 0.001); verbal pain scores at end-infusion at the most informative stimulus (48.2°C) were 82 ± 4 and 59 ± 3 (P < 0.001); maximum end-expired CO2 was 47 (45 to 50) and 48 mmHg (46 to 51; P = 0.007) and occurred later (5.5 ± 2.8 vs. 3.0 ± 1.5 h after infusion start, P < 0.001); and respiratory nadir was 9 ± 1 and 11 ± 2 breaths/min (P < 0.001), and occurred at similar times. The area under the temperature tolerance-time curve was less for morphine (1.8 [0.0 to 4.4]) than hydromorphone (5.4°C-h [1.6 to 12.1] P < 0.001). Interindividual variability in clinical effects did not differ between opioids.

CONCLUSIONS

For morphine compared to hydromorphone, analgesia and analgesia relative to respiratory depression were less, onset of miosis and respiratory depression was later, and duration of respiratory depression was longer. For each opioid, timing of the various clinical effects was not coincident. Results may enable more rational opioid selection, and suggest hydromorphone may have a better clinical profile.

EDITOR’S PERSPECTIVE

Effect of Educational Tools on the use of Patient-Controlled Analgesia Devices

Objective

In the literature, there are confusing data about educational tools and device use. Therefore, it is not clear which method is superior to the other. The aim of this study was to evaluate the effects of educational tools on patient-controlled analgesia (PCA) usage in patients undergoing hysterectomy.

Methods

Ninety-six patients undergoing hysterectomy were enrolled in the study. Patients were randomly assigned to a group (verbal, brochure, or video) consisting of 32 patients each using the closed envelope method. After operations, all patients were sent to the ward and evaluated with numerical rating scale score for pain at 15^th min., 2^nd, 4^th, 6^th, 12^th, 18^th, 2^nd, 4^th, 6^th, 12^th, 18^th, 24^th hours. Given dose, the number of button presses, presence of nausea and vomiting, and static and dynamic pain scores were recorded. During visits, patients who had a pain score ≥4 were administered paracetamol 1 g IV. Ondansetron 8 mg IV was injected into patients who had nausea and vomiting.

Results

No significant differences were determined in resting and dynamic pain scores, number of button presses, and given doses between groups at 15^th min., 2^nd, 4^th, 6^th, 12^th, 18^th, 24^th hours.

Conclusion

In this study, education type did not affect PCA device use. We believe that whatever method the infrastructure of hospitals is suitable for, should be used for PCA device education.

Bibliometric Analysis on Global Analgesia in Labor from 2002 to 2021

Background

Maternal pain during labor is one of the most important factors contributing to increased cesarean delivery rates and poor pregnancy outcomes, and this pain can be managed by labor analgesia. Many studies exist on labor analgesia, and the quantity and quality of these studies have not been reported. Therefore, we aimed to perform a bibliometric analysis of studies from 2002 to 2021.

Methods

We used the Web of Science database to obtain publications related to labor analgesia from January 2002 to December 2021. Various bibliographic information was collected, including country; author; journal; grant; discipline; institution and research hotspot. A total of 4536 papers were included.

Results

A total of 4536 articles were included in the study. The country with the most published articles on labor analgesia and the country of the funding agency was the United States. Most articles were published in the disciplines Anesthesiology and Obstetrics & Gynecology. The journal that published the most articles in this category was International Journal of Obstetric Anesthesia. In addition, we found different research hotspots for labor analgesia in the United States, Japan, and China.

Conclusion

This paper provides a bibliometric analysis of research on labor analgesia and highlights the differences in research hotspots for labor analgesia between countries.

The initial experience of 4.5/6.5 Fr ureteroscopic laser lithotripsy under topical intraurethral anesthesia supplemented by preoperative and intraoperative medications

PURPOSE

To assess the safety and effectiveness of the 4.5/6.5 Fr ureteroscopic laser lithotripsy (URSL) under topical intraurethral anesthesia (TIUA) compared to spinal anesthesia (SA).

METHODS

A retrospective study was conducted on 47 (TIUA: SA = 23:24) patients receiving 4.5/6.5 Fr URSL from July 2022 to September 2022. For the TIUA group, atropine, pethidine, and phloroglucinol were used apart from lidocaine. In the SA group, patients received lidocaine and bupivacaine. We compare the two groups including stone-free rate (SFR), procedure time, anesthesia time, overall operative time, hospital stay, anesthesia failure, intraoperative pain, need for additional analgesia, cost, and complications.

RESULTS

The conversion rate in the TIUA group was 4.35% (1/23). SFR was 100% in both groups. Surgical waiting time and anesthesia time were longer in the SA group (P < 0.001). There were no statistical differences in operational time and intraoperative pain. Patients developed grade 0-1 ureteral injuries. Post-surgical time out of bed was noticeably faster in the TIUA group (P < 0.001). The post-operative complication rate including vomiting and back pain was lower in the TIUA group (P = 0.005).

CONCLUSION

TIUA had an equal surgical success rate and controlled patients' intraoperative pain as SA. It was superior in terms of TIUA's patient admission, waiting time for surgery, anesthesia time, post-operative time out of bed, low complications, and costs, especially for females.

Risk factors for delayed recovery in postanesthesia care unit after surgery: a large and retrospective cohort study

BACKGROUND

Delayed recovery in the postanesthesia care unit (PACU) after surgery, as a severe occurrence, influences enhanced recovery after surgery. The data from the observational clinical study is a paucity.

MATERIALS AND METHODS

This large, retrospective, and observational cohort study initially included 44 767 patients. The primary outcome was risk factors for delayed recovery in PACU. A generalized linear model and nomogram were employed to identify risk factors. Discrimination and calibration were used to evaluate the performance of the nomogram via internal and external validation.

RESULTS

Of 38 796 patients, 21 302 (54.91%) were women. The delayed recovery aggregate rate was 1.38% [95% CI, (1.27, 1.50%)]. In a generalized linear model, risk factors for delayed recovery were old age [RR, 1.04, 95% CI, (1.03,1.05), P <0.001], neurosurgery [RR, 2.75, 95% CI, (1.60, 4.72), P <0.001], using antibiotics during surgery [RR, 1.30, 95% CI, (1.02, 1.66), P =0.036], long anesthesia duration [RR, 1.0025, 95% CI, (1.0013, 1.0038), P <0.001], ASA grade of III [RR, 1.98, 95% CI, (1.38, 2.83), P <0.001], and postoperative analgesia [RR, 1.41, 95% CI, (1.10, 1.80), P =0.006]. In the nomogram, old age and neurosurgery had high scores in the model and contributed significantly to the increased probability of delayed recovery. The area under the curve value of the nomogram was 0.77. The discrimination and calibration of the nomogram estimated by internal and external validation were generally satisfactory.

CONCLUSION

This study demonstrates that delayed recovery in PACU after surgery was associated with old age, neurosurgery, long anesthesia duration, an ASA grade of III, using antibiotics during surgery, and postoperative analgesia. These findings provide predictors of delayed recovery in PACU, especially neurosurgeries and old age.

Intestinal microbiomics and hepatic metabolomics insights into the potential mechanisms of probiotic Bifidobacterium pseudolongum CCFM1253 preventing acute liver injury in mice

BACKGROUND

Bifidobacterium pseudolongum is widely exists in mammal gut and its abundance is associated with human and animal health. The present study aimed to investigate the potential mechanisms of B. pseudolongum CCFM1253 on protecting against lipopolysaccharide (LPS)-induced acute liver injury (ALI) by metagenomic analysis and liver metabolomic profiles.

RESULTS

Bifidobacterium pseudolongum CCFM1253 preintervention remarkably attenuated the influence of LPS on serum alanine transaminase and aspartate amino transferase activities. B. pseudolongum CCFM1253 preintervention remarkably attenuated the inflammation responses (tumor necrosis factor-α, interleukin-1β, and interleukin-6) and elevated antioxidative enzymes activities [total antioxidant capacity, superoxide dismutase, catalase, and glutathione peroxidase] in ALI mice by intervening in the Nf-kβ and Nrf2 pathways, respectively. Bifidobacterium pseudolongum CCFM1253 treatment elevated the proportion of Alistipes and Bifidobacterium, and decreased the proportion of uncultured Bacteroidales bacterium, Muribaculum, Parasutterella and Ruminococcaceae UCG-010 in ALI mice, which were strongly correlated with the inhibition of inflammation responses and oxidative stress. Untargeted liver metabolomics exhibited that the hepatoprotective efficacy of B. pseudolongum CCFM1253 might be achieved by altering liver metabolites-related riboflavin metabolism, phenylalanine metabolism, alanine, citrate cycle (tricarboxylic acid cycle), and so on. Furthermore, riboflavin exposure could control the contents of malondialdehyde, superoxide dismutase, and catalase in hydrogen peroxide-treated HepG2 cells.

CONCLUSION

Bifidobacterium pseudolongum CCFM1253 can effectively alleviate inflammatory response and oxidative stress, and regulate the intestinal microbiota composition and liver metabolism, and elevate the liver riboflavin content in LPS-treated mice. Therefore, B. pseudolongum CCFM1253 could serves as a potential probiotic to ameliorate the host health. © 2023 Society of Chemical Industry.

Efficacy and safety of intravenous dexmedetomidine as an adjuvant to general anesthesia in gynecological surgeries: A systematic review and meta-analysis of randomized controlled trials

This study investigated the efficacy and safety of intravenous dexmedetomidine as an adjuvant to general anesthesia in patients undergoing gynecological surgery. We systemically searched for randomized controlled trials (RCTs), and performed a meta-analysis on studies that met the inclusion criteria. The primary outcomes were postoperative nausea and vomiting (PONV), bradycardia, hypotension, and 24 h opioid consumption. The secondary outcomes include postoperative shivering, postoperative pain score, intraoperative anesthetic consumption, extubation time, postoperative sedation, and the time to first flatus. Twenty-five RCTs were included in this study. Meta-analysis showed that intravenous dexmedetomidine significantly reduced the risk of PONV (RR, 0.57 [0.47, 0.68]) and postoperative shivering (RR: 0.31 [0.22, 0.42]), 24 h opioid consumption (Mean Difference: - 4.85 mg [-8.60, -1.11]) and postoperative pain score within 24 h. However, these benefits were at the cost of increased bradycardia (RR, 3.21 [2.41, 4.28]) and hypotension (RR, 2.17 [1.50, 3.14]). Notably, no serious adverse effects were reported in any of the included studies. Thus, our study showed that intravenous dexmedetomidine provided significant antiemetic and anti-shivering effects and moderate analgesic effects in patients that underwent gynecological surgery. However, its benefits should be weighed against the significantly increased risk of bradycardia and hypotension.

Efficacy and Safety of Parenteral Injection of an Extended Release κ-receptor Opioid Sebacoyl Dinalbuphine Ester for Acute and Chronic Pain After Laparoscopic Bariatric Surgery: a Randomized, Placebo-Controlled, Double-Blind Trial

PURPOSE

μ-receptor opioids are associated with unwanted gastrointestinal side effects and respiratory depression. A long-acting non-μ-receptor parenteral opioid is not currently available for management of acute and chronic postsurgical pain (CPSP). This double-blind clinical trial tested an extended-release κ-receptor agonist, sebacoyl dinalbuphine ester (SDE, Naldebain®) for management of surgical pain after laparoscopic bariatric surgery.

MATERIALS AND METHODS

Patients were randomly assigned to receive a single intramuscular injection of SDE (150 mg, n = 30) or vehicle solution (n = 30) at > 12 h before surgery. All patients received standard perioperative multimodal analgesia (MMA). The primary endpoint was the pain intensity in the beginning 7 days after operation. The secondary endpoints were adverse reactions up to 7 days and incidence of CPSP at 3 months after surgery.

RESULTS

Compared with placebos, the area under curves of visual analog scale (VAS) for 0-48 h after operation were significantly reduced in SDE group (143.3 ± 65.4 and 105.9 ± 36.3, P = 0.025). There were significantly fewer patients in the SDE group who had moderate-to-severe pain (VAS ≥ 4) (16.7% vs 50%; P = 0.012) at postoperative 48 h. Pain intensities were similar between the two groups at 72 h and 7 days postoperatively. The incidence of CPSP at 3 months was not different. SDE did not increase drug-related systemic adverse events.

CONCLUSION

In addition to the standard perioperative MMA, a single-dose injection of long-acting κ-receptor agonist SDE provides significantly better pain management for 48 h following laparoscopic bariatric surgery. A long-acting κ-receptor agonist opioid could improve in-hospital pain management and potentiate early discharge after operation without increasing drug-related systemic complications.

Minimal important difference in opioid consumption based on adverse event reduction-A study protocol

BACKGROUND

The patient-relevant minimal important difference for opioid consumption remains undetermined, despite its frequent use as primary outcome in trials on postoperative pain management. A minimal important difference is necessary to evaluate whether significant trial results are clinically relevant. Further, it can be used as effect size to ensure that trials are powered to find clinically relevant effects. By exploring the dose-response relationship between postoperative opioid consumption and opioid-related adverse effects, we aim to approximate the minimal important difference in opioid consumption anchored to opioid-related adverse effects.

METHODS

This is a post-hoc analysis of aggregated data from two clinical trials (PANSAID NCT02571361 and DEX2TKA NCT03506789) and one observational cohort study (Pain Map NCT02340052) on pain management after total hip and knee arthroplasty. The primary outcome is the Hodges-Lehmann median difference in opioid consumption between patients with no opioid-related adverse effects and patients experiencing the mildest degree of one or more opioid-related adverse effects (i.e., mild nausea, sedation and/or dizziness or vomiting). Secondary outcomes include the Hodges-Lehmann median difference in opioid consumption that corresponds to one point on a cumulated opioid-related adverse event 0-10 scale. Further, we will explore the proportion of patients that experience opioid-related adverse effects for consecutive opioid dose intervals of 2 mg iv morphine equivalents. Quantile regression will be used to assess any significant interactions with patient baseline characteristics.

CONCLUSIONS

This study will hopefully bring us one step closer to determining relevant opioid reductions and thereby improve our understanding of intervention effects and planning of future trials.

A Novel Multi-Target Mu/Delta Opioid Receptor Agonist, HAGD, Produced Potent Peripheral Antinociception with Limited Side Effects in Mice and Minimal Impact on Human Sperm Motility In Vitro

Pain is a common clinical symptom among patients. Although various opioid analgesics have been developed, their side effects hinder their application. This study aimed to develop a novel opioid analgesic, HAGD (H-Tyr-D-AIa-GIy-Phe-NH₂), with limited side effects. In vivo studies on mouse models as well as in vitro studies on Chinese hamster ovary (CHO) cells expressing human mu, delta, or kappa opioid receptors (CHO_hMOP, CHO_hDOP, and CHO_hKOP, respectively) and human sperm were conducted. Compared with subcutaneous morphine (10 mg/kg), subcutaneous HAGD (10 mg/kg) produced equipotent or even greater antinociception with a prolonged duration by activating mu/delta opioid receptors in preclinical mouse pain models. The analgesic tolerance, rewarding effects (i.e., conditioned place preference and acute hyperlocomotion), and gastrointestinal transit inhibition of HAGD were significantly reduced compared with those of morphine. Both HAGD and morphine exhibited a withdrawal response and had no impacts on motor coordination. In CHO_hMOP and CHO_hDOP, HAGD showed specific and efficient intracellular Ca²⁺ stimulation. HAGD had minimal impact on human sperm motility in vitro, whereas 1 × 10^-7 and 1 × 10^-8 mol/L of morphine significantly declined sperm motility at 3.5 h. Overall, HAGD may serve as a promising antinociceptive compound.

Bilateral ultrasound-guided erector spinae plane block versus wound infiltration for postoperative analgesia in lumbar spinal fusion surgery: a randomized controlled trial

PURPOSE

Both erector spinae plane block and wound infiltration are used to improve analgesia following spinal fusion surgery. Herein, we compared the analgesic effect of bilateral erector spinae plane block with wound infiltration in this patient population.

METHODS

In this randomized trial, 60 patients scheduled for elective open posterior lumbar interbody fusion surgery were randomized to receive either ultrasound-guided bilateral erector spinae plane block before incision (n = 30) or wound infiltration at the end of surgery (n = 30). Both groups received standardized general anesthesia and postoperative analgesia, including patient-controlled analgesia with sufentanil and no background infusion. Opioid consumption and pain intensity were assessed at 2, 6, 12, 24, and 48 h after surgery. The primary outcome was cumulative opioid consumption within 24 h after surgery.

RESULTS

All 60 patients were included in the intention-to-treat analysis. The equivalent dose of sufentanil consumption within 24 h was significantly lower in patients given erector spinae plane block (median 11 μg, interquartile range 5-16) than in those given wound infiltration (20 μg, 10 to 43; median difference - 10 μg, 95% CI - 18 to - 3, P = 0.007). The cumulative number of demanded PCA boluses was significantly lower with erector spinae plane block at 6 h (median difference - 2, 95% CI - 3 to 0, P = 0.006), 12 h (- 3, 95% CI - 6 to - 1, P = 0.002), and 24 h (- 5, 95% CI - 8 to - 2, P = 0.005) postoperatively. The proportion given rescue analgesia was also significantly lower in patients given erector spinae plane block group within 48 h (relative risk 0.27, 95% CI 0.07 to 0.96, P = 0.037). There were no statistical differences in pain intensity at any timepoints between groups. No procedure-related adverse events occurred.

CONCLUSIONS

Compared with wound infiltration, bilateral ultrasound-guided erector spinae plane block decreases short-term opioid consumption while providing similar analgesia in patients following lumbar spinal fusion surgery. Chinese Clinical Trial Registry: ChiCTR2100053008.

Acupuncture-assisted anaesthesia for catheter ablation of atrial fibrillation to reduce the consumption of morphine hydrochloride and postoperative nausea and vomiting (PONV): study protocol for a randomised controlled trial

BACKGROUND

Patients often experience postoperative nausea and vomiting (PONV) after catheter ablation of atrial fibrillation (AF) because of the use of opioids for anaesthesia and analgesia during the procedure. Some clinical trials have demonstrated that acupuncture-assisted anaesthesia (AAA) reduces opioid consumption and prevents PONV. Although several studies have been conducted on AAA, its safety and efficacy in AF catheter ablation remain unclear due to small sample sizes and a paucity of methodologically rigorous designs. Therefore, this trial was designed to evaluate the safety and efficacy of AAA in reducing PONV and morphine hydrochloride consumption during catheter ablation.

METHODS

This single-centre, patient-blinded, randomised, non-penetrating sham-controlled trial will be conducted in China. A total of 100 patients will be randomly assigned to the AAA and conventional anaesthesia (CA) groups in a ratio of 1:1. The patients will receive AAA or CA plus sham acupuncture during catheter ablation and will be followed up for 30 days. The primary outcomes include the total amount of morphine hydrochloride consumed during catheter ablation and PONV within the first 24 hours after the procedure. The secondary outcomes include pain, nausea and vomiting, anxiety, patient's ability to cope during catheter ablation, AF recurrence and quality of life, as assessed using the numeric rating scale. Adverse events will be recorded and their influence will be analysed at the end of the trial.

DISCUSSION

This study will help in evaluating the safety and efficacy of AAA applied for AF catheter ablation in reducing opioid doses during the procedure and the occurrence of PONV.

ETHICS AND DISSEMINATION

The study has been approved by the Medical Ethics Committee of Second Affiliated Hospital of Shandong University of Traditional Chinese Medicine. The results of the study will be published in peer-reviewed journals and presented at conferences if possible.

TRIAL REGISTRATION NUMBER

ChiCTR 2100042646; Chinese Clinical Trial Registry.

Pre-anesthetic use of butorphanol for the prevention of emergence agitation in thoracic surgery: A multicenter, randomized controlled trial

Background

Emergence agitation (EA) is common in patients after general anesthesia (GA) and is associated with poor outcomes. Patients with thoracic surgery have a higher incidence of EA compared with other surgery. This study aimed to investigate the impact of pre-anesthetic butorphanol infusion on the incidence of EA in patients undergoing thoracic surgery with GA.

Materials and methods

This prospective randomized controlled trial (RCT) was conducted in 20 tertiary hospitals in China. A total of 668 patients undergoing elective video-assisted thoracoscopic lobectomy/segmentectomy for lung cancer were assessed for eligibility, and 620 patients were enrolled. In total, 296 patients who received butorphanol and 306 control patients were included in the intention-to-treat analysis. Patients in the intervention group received butorphanol 0.02 mg/kg 15 min before induction of anesthesia. Patients in the control group received volume-matched normal saline in the same schedule. The primary outcome was the incidence of EA after 5 min of extubation, and EA was evaluated using the Riker Sedation-Agitation Scale (RSAS). The incidence of EA was determined by the chi-square test, with a significance of P < 0.05.

Results

In total, 296 patients who received butorphanol and 306 control patients were included in the intention-to-treat analysis. The incidence of EA 5 min after extubation was lower with butorphanol treatment: 9.8% (29 of 296) vs. 24.5% (75 of 306) in the control group (P = 0.0001). Patients who received butorphanol had a lower incidence of drug-related complications (including injecting propofol pain and coughing with sufentanil): 112 of 296 vs. 199 of 306 in the control group (P = 0.001) and 3 of 296 vs. 35 of 306 in the control group (P = 0.0001).

Conclusion

The pre-anesthetic administration of butorphanol reduced the incidence of EA after thoracic surgery under GA.

Clinical trial registration

[http://www.chictr.org.cn/showproj.aspx?proj=42684], identifier [ChiCTR1900025705].

AUGS-IUGA Joint Clinical Consensus Statement on Enhanced Recovery After Urogynecologic Surgery: Developed by the Joint Writing Group of the International Urogynecological Association and the American Urogynecologic Society. Individual writing group members are noted in the Acknowledgements section

INTRODUCTION AND HYPOTHESIS

Enhanced recovery after surgery (ERAS) evidence-based protocols for perioperative care can lead to improvements in clinical outcomes and cost savings. This article aims to present consensus recommendations for the optimal perioperative management of patients undergoing urogynecological surgery.

METHODS

A review of meta-analyses, randomized clinical trials, large nonrandomized studies, and review articles was conducted via PubMed and other databases for ERAS and urogynecological surgery. ERAS protocol components were established, and then quality of the evidence was both graded and used to form consensus recommendations for each topic. These recommendations were developed and endorsed by the writing group, which is comprised of the American Urogynecologic Society and the International Urogynecological Association members.

RESULTS

All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. The components of ERAS with a high level of evidence to support their use include fasting for 6 h and taking clear fluids up to 2 h preoperatively, euvolemia, normothermia, surgical site preparation, antibiotic and antithrombotic prophylaxis, strong antiemetics and dexamethasone to reduce postoperative nausea and vomiting, multimodal analgesia and restrictive use of opiates, use of chewing gum to reduce ileus, removal of catheter as soon as feasible after surgery and avoiding systematic use of drains/vaginal packs.

CONCLUSIONS

The evidence base and recommendations for a urogynecology-relevant ERAS perioperative care pathway are presented in this consensus review. There are several elements of ERAS with strong evidence of benefit in urogynecological surgery.

New insight into the analgesic recipe: A cohort study based on smart patient-controlled analgesia pumps records

Purpose: Intravenous patient-controlled analgesia (IV-PCA) has been widely used; however, regimen criteria have not yet been established. In China, the most often used opioid is sufentanil, for which repeated doses are a concern, and empirical flurbiprofen axetil (FBP) as an adjuvant. We hypothesized that hydromorphone would be a better choice and also evaluated the effectiveness of FBP as an adjuvant.

Methods: This historical cohort study was conducted in two tertiary hospitals in China and included 12,674 patients using hydromorphone or sufentanil for IV-PCA between April 1, 2017, and January 30, 2021. The primary outcome was analgesic insufficiency at static (AIS). The secondary outcomes included analgesic insufficiency with movement (AIM) and common opioid-related adverse effects such as postoperative nausea and vomiting (PONV) and dizziness.

Results: Sufentanil, but not the sufentanil-FBP combination, was associated with higher risks of AIS and AIM compared to those for hydromorphone (OR 1.64 [1.23, 2.19], p < 0.001 and OR 1.42 [1.16, 1.73], p < 0.001). Hydromorphone combined with FBP also decreased the risk of both AIS and AIM compared to those for pure hydromorphone (OR 0.74 [0.61, 0.90], p = 0.003 and OR 0.80 [0.71, 0.91], p < 0.001). However, the risk of PONV was higher in patients aged ≤35 years using FBP (hydromorphone-FBP vs. hydromorphone and sufentanil-FBP vs. hydromorphone, OR 1.69 [1.22, 2.33], p = 0.001 and 1.79 [1.12, 2.86], p = 0.015).

Conclusion: Hydromorphone was superior to sufentanil for IV-PCA in postoperative analgesia. Adding FBP may improve the analgesic effects of both hydromorphone and sufentanil but was associated with an increased risk of PONV in patients <35 years of age.

Patient-controlled intravenous analgesia with opioids after thoracoscopic lung surgery: a randomized clinical trial

Background

Opioids remain the mainstream therapy for post-surgical pain. The choice of opioids administered by patient-controlled intravenous analgesia (PCIA) for thoracoscopic lung surgery is unclear. This study compared 3 opioid analgesics for achieving satisfactory analgesia with minimal emesis (SAME).

Methods

This randomized clinical trial enrolled patients scheduled for thoracoscopic lung surgery randomized to receive 1 of 3 opioids for PCIA: oxycodone (group O), hydromorphone (group H), and sufentanil (group S). The primary outcome was the proportion of subjects achieving SAME, i.e., no-to-mild pain (pain score < 4/10) with minimal nausea/vomiting (PONV score < 2/4) when coughing during the pulmonary rehabilitation exercise in the first 3 postoperative days.

Results

Of 555 enrolled patients, 184 patients in group O, 186 in group H and 184 in group S were included in the final analysis. The primary outcome of SAME was significantly different among group O, H and S (41.3% vs 40.3% vs 29.9%, P = 0.043), but no difference was observed between pairwise group comparisons. Patients in groups O and H had lower pain scores when coughing on the second day after surgery than those in group S, both with mean differences of 1 (3(3,4) and 3(3,4) vs 4(3,4), P = 0.009 and 0.039, respectively). The PONV scores were comparable between three groups (P > 0.05). There were no differences in other opioid-related side effects, patient satisfaction score, and QoR-15 score among three groups.

Conclusions

Given clinically relevant benefits detected, PCIA with oxycodone or hydromorphone is superior to sufentanil for achieving SAME as a supplement to multimodal analgesia in patients undergoing thoracoscopic lung surgery.

Trial registration

This study was registered at (ChiCTR2100045614, 19/04/2021).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01785-4.

Epidural Oxycodone for Acute Pain

Epidural analgesia is commonly used in labour analgesia and in postoperative pain after major surgery. It is highly effective in severe acute pain, has minimal effects on foetus and newborn, may reduce postoperative complications, and enhance patient satisfaction. In epidural analgesia, low concentrations of local anaesthetics are combined with opioids. Two opioids, morphine and sufentanil, have been approved for epidural use, but there is an interest in evaluating other opioids as well. Oxycodone is one of the most commonly used opioids in acute pain management. However, data on its use in epidural analgesia are sparse. In this narrative review, we describe the preclinical and clinical data on epidural oxycodone. Early data from the 1990s suggested that the epidural administration of oxycodone may not offer any meaningful benefits over intravenous administration, but more recent clinical data show that oxycodone has advantageous pharmacokinetics after epidural administration and that epidural administration is more efficacious than intravenous administration. Further studies are needed on the safety and efficacy of continuous epidural oxycodone administration and its use in epidural admixture.

Efficacy and safety of rhomboid intercostal block for analgesia in breast surgery and thoracoscopic surgery: a meta-analysis

BACKGROUND

Rhomboid intercostal block (RIB) is a new regional anesthesia technique that provides postoperative analgesia for breast surgery and thoracoscopic surgery. The published papers are not yet fully integrated and do not adequately address the impact and safety of the RIB on postoperative pain.

METHODS

The PubMed, Web of Science and Embase were searched from 2016 to 2021 for all available randomized controlled trials (RCTs) that evaluated the analgesic efficacy and safety of RIB after thoracic surgery and breast surgery. Random and fixed-effects meta-analytical models were used where indicated, and between-study heterogeneity was assessed. The primary outcome was Postoperative Numerical Rating Scale (NRS) scores of patients at rest recorded 0-1, 6-8, 24 h after surgery. The secondary outcomes included rate of postoperative nausea and vomiting (PONV), postoperative fentanyl consumption and presence of complications of the block.

RESULTS

From 81 records identified, four studies met our inclusion criteria, including 216 patients (RIB:108 patients; no block: 108 patients). In the primary outcome, RIB group showed significantly lower postoperative NRS at rest at first 0-1 h and 6-8 h (weighted mean difference [WMD] = -1.55; 95% confidence internal [CI] = -2.92 to -0.19; p < 0.05), (WMD = -0. 69; 95% CI = -1.29 to -0. 09; p < 0. 05). And there was no significant difference between groups in NRS at rest at 24 h (WMD = -0.78; 95% CI = -1.64 to -0.08; p = 0.77). Also, RIB group showed significantly lower postoperative NRS of breast surgery and thoracoscopic surgery at 0-1 h (WMD = -3.00; 95% CI = -3.13 to -2.87; p < 0.01), (WMD = -1.08; 95% CI = -1.98 to -0.18; p < 0.05). In the secondary outcome, the analysis also showed RIB group had significant lower of POVN rates (summary relative risk (RR) = 0.212;95%CI = 0.10 to 0.45; p < 0. 01) and the postoperative consumption of fentanyl (WMD = -57.52;95%CI = -106.03 to -9.02; p < 0. 05).

CONCLUSION

This review shows that RIB was more effective in controlling acute pain after breast surgery and thoracoscopic surgery than general analgesia. And it is a trend that RIB may be a kind of effective and safe nerve bock technology and it requires further studies.

Mas-Related G Protein–Coupled Receptor-X2 and Its Role in Non-immunoglobulin E–Mediated Drug Hypersensitivity

A diverse group of Food and Drug Administration-approved cationic drugs including antibiotics, neuromuscular blocking drugs, opioids, antidepressants, and radiocontrast media activate mast cells and cause hypersensitivity reactions by both an immunoglobulin E IgE-dependent and independent manner. The recent discovery that these drugs activate mast cells via the G protein-coupled receptor known as Mas-related GPCR-X2 (MRGPRX2) has represented a paradigm shift of how drug hypersensitivity reactions are viewed. This article provides an overview of the current status of the role of MRGPRX2 on non-IgE-mediated drug hypersensitivity. Potential risk factors and evaluation for suspected MRGPRX2-mediated drug reactions are also discussed.

Comparison of propofol-nalbuphine and propofol-fentanyl sedation for patients undergoing endoscopic retrograde cholangiopancreatography: a double-blind, randomized controlled trial

Background

Endoscopic retrograde cholangiopancreatography (ERCP) has been increasingly used to treat patients with biliary/pancreatic duct obstruction or stricture outside the operating room. Effective and safe sedation techniques are needed because of painful stimuli and the long duration of the ERCP procedure.Nalbuphine has been shown to cause less respiratory depression during sedation than similar cases without nalbuphine. This study compared the effects of propofol-nalbuphine (PN) and propofol-fentanyl (PF) sedation in patients undergoing ERCP.

Methods

Four hundred patients scheduled for ERCP procedures were divided into two groups: the PF group (receiving PF sedation,n = 199) and the PN group (receiving PN sedation,n = 201). Vital signs, adverse events during surgery, patient movement scores, pain scores, and adverse events one day post-ERCP were recorded.

Results

Stable haemodynamics were observed in both groups.Compared to the PF group, the PN group showed significantly decreased respiratory depression (P < 0.0001) and surgical interruptions (P = 0.048).Nalbuphine decreased patient movement by reducing pain from ERCP.

Conclusion

Nalbuphine, instead of fentanyl, precipitated less respiratory depression while permitting adequate/equivalent sedation for ERCP and therefore provides more efficient and safer sedation.

Trial registration

ChiCTR, ChiCTR1800016018, Registered 7 May 2018, http://www.chictr.org.cn/showproj.aspx?proj=27085

Clinical Update on Patient-Controlled Analgesia for Acute Postoperative Pain

Patient-controlled analgesia (PCA) is an effective method for controlling acute pain, including postoperative pain in adults and in children from five years of age, pain resulting from labor, trauma, or other medical situations, or chronic and malignant pain. The treatment consists of a mini-computer-controlled infusion pump permitting the administration of on-demand, continuous, or combined doses of analgesic (mainly opioid) variations in response to therapy, which allows pain to be significantly controlled. Intravenous (IV)-PCA minimizes individual pharmacodynamics and pharmacokinetic differences and is widely accepted as a reference method for mild or severe postoperative pain. IV-PCA is the most studied route of PCA; other delivery methods have been extensively reported in the literature. In addition, IV-PCA usually voids the gap between pain sensation and analgesic administration, permitting better recovery and fewer side effects. The most commonly observed complications are nausea and vomiting, pruritus, respiratory depression, sedation, confusion and urinary retention. However, human factors such as pharmacy preparation and device programming can also be involved in the occurrence of these complications, while device failure is much less of an issue.

Comparison between Tramadol and Butorphanol for Treating Postoperative Catheter-Related Bladder Discomfort: A Randomized Controlled Trial

Background

Intraoperative catheterization often leads to postoperative catheter-related bladder discomfort (CRBD) during the restoration period. This study aimed to assess the curative effect of butorphanol as a K receptor agonist in the treatment of postoperative CRBD. Patients and Approaches. Sixty patients with CRBD who underwent elective nonurological surgery at the postanesthesia care unit were randomly and evenly assigned to two groups. The control group was slowly injected with tramadol 1.5 mg/kg using a Murphy dropper, whereas the experimental group was intravenously injected with butorphanol 0.02 mg/kg. Severity, pain score, and sedation score of CRBD were evaluated at 0 min, 5 min, 15 min, 30 min, 1 h, and 6 h later.

Results

The severity score of CRBD and visual analog scale pain score were lower in the butorphanol group than in the control group, whereas the sedation score was higher in the butorphanol group than in the control group.

Conclusion

Butorphanol relieves on postoperative urination discomfort and pain compared with tramadol.