Role of Multimodal Analgesia in the Evolving Enhanced Recovery after Surgery Pathways

The impact of multimodal analgesia in coronary artery bypass graft surgery-a population-based analysis

OBJECTIVE

Multimodal pain management aims to concurrently target several pain pathways for improved treatment efficacy and recovery. We investigated associations between multimodal analgesia use and postoperative complications, length of hospital stay (LOS), and opioid consumption among patients undergoing coronary artery bypass graft surgery.

METHODS

This retrospective cohort study included 349,940 adult patients undergoing elective coronary artery bypass graft surgery (January 2006 to December 2019), from the national Premier Healthcare claims dataset. The study intervention was multimodal analgesia, defined as opioid use with the addition of nonopioid analgesic modalities. These included, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, paracetamol/acetaminophen, neuraxial anesthesia, steroids, gabapentin/pregabalin, and ketamine. Analgesic management was stratified into 4 categories: opioids only and multimodal analgesia with the addition of 1, 2 or ≥3 nonopioid analgesic modalities. Mixed-effects regression models measured associations between multimodal analgesia and postoperative complications, LOS, and opioid consumption measured in milligram oral morphine equivalents.

RESULTS

Multimodal analgesia was associated with a beneficial dose response pattern. With increasing nonopioid analgesic modalities added to opioid analgesia, a stepwise decrease in complication risk was consistently observed, eg, with the addition of 1, 2, or ≥3 nonopioid modalities the odds for any complication decreased by 8% (odds ratio [OR], 0.92; confidence interval [CI], 0.90-0.94), 17% (OR, 0.83; CI, 0.81-0.86), and 22% (OR, 0.78; CI 0.69-0.79), respectively. This stepwise pattern was consistent in respiratory, cardiac, and renal complications individually. Similarly, LOS decreased stepwise with added analgesic modalities.

CONCLUSIONS

These nationally representative data indicate that enhanced pain management by multiple pain pathways is associated with significant reductions in postoperative complications and shortened patient recovery.

Comprehensive Pain Management in Total Joint Arthroplasty: A Review of Contemporary Approaches

Background: Total hip and knee arthroplasties are among the most effective and widely performed procedures in modern medicine, providing substantial benefits to patients with end-stage osteoarthritis. These surgeries have transformed the treatment of degenerative joint disease, significantly enhancing functionality and quality of life for patients. Despite considerable advancements in surgical techniques and postoperative care, managing postoperative pain remains a major challenge, impacting both clinical recovery and patient satisfaction. The persistence of postoperative pain as a barrier to recovery underscores the need for improved pain management strategies. Methods: A comprehensive narrative review of the literature was conducted, focusing on the physiological mechanisms underlying surgical pain, the role of anesthesia techniques, and the development of multimodal pain management approaches used in total joint arthroplasty. This review emphasizes the components of modern multimodal strategies, which combine multiple pharmacologic and non-pharmacologic methods to address the various mechanisms of postoperative pain. Results: Current pain management strategies employ a dynamic, multimodal approach that covers the perioperative period. These strategies aim to optimize pain control while minimizing side effects. They incorporate a range of methods, including nerve blocks, non-opioid analgesics, opioids, and non-pharmacologic techniques such as physical therapy. However, evidence regarding the efficacy and optimal combinations of these interventions varies widely across studies. Conclusions: This variation has led to inconsistent pain management practices across institutions. To standardize and improve care, this paper presents the authors' institutional pain management model, offering a potential framework for broader application and adaptation in the field of joint arthroplasty.

Postoperative Multimodal Analgesia Strategy for Enhanced Recovery After Surgery in Elderly Colorectal Cancer Patients

Enhanced Recovery After Surgery (ERAS) protocols have substantially proven their merit in diminishing recuperation durations and mitigating postoperative adverse events in geriatric populations undergoing colorectal cancer procedures. Despite this, the pivotal aspect of postoperative pain control has not garnered the commensurate attention it deserves. Typically, employing a multimodal analgesia regimen that weaves together nonsteroidal anti-inflammatory drugs, opioids, local anesthetics, and nerve blocks stands paramount in curtailing surgical complications and facilitating reduced convalescence within hospital confines. Nevertheless, this integrative pain strategy is not devoid of pitfalls; the specter of organ dysfunction looms over the geriatric cohort, rooted in the abuse of analgesics or the complex interplay of polypharmacy. Revolutionary research is delving into alternative delivery and release modalities, seeking to allay the inadvertent consequences of analgesia and thereby potentially elevating postoperative outcomes for the elderly post-colorectal cancer surgery populace. This review examines the dual aspects of multimodal analgesia regimens by comparing their established benefits with potential limitations and offers insight into the evolving strategies of drug administration and release.

Knowledge, attitude, and practice of non-emergency surgical patients toward anesthesia

This study aimed to investigate the knowledge, attitude, and practice (KAP) of non-emergency surgical patients toward anesthesia. This cross-sectional study was conducted between May and October 2023 at Zibo Central Hospital among non-emergency surgical patients. A total of 429 valid questionnaires were enrolled (mean age: 42.81 ± 13.17 years old; 227 (52.91%) females). The mean KAP scores were 7.79 ± 3.95 (possible range: 0-18), 32.35 ± 2.80 (possible range: 8-40), and 18.14 ± 3.96 (possible range: 6-24), respectively. Multivariate logistic regression analysis showed that knowledge (OR = 1.095, 95% CI 1.036-1.158, P = 0.001) and previous poor anesthesia experience (OR = 0.081, 95% CI 0.017-0.386, P = 0.002) were independently associated with practice. Non-emergency surgical patients had inadequate knowledge, positive attitude, and proactive practice towards anesthesia. It is crucial for healthcare professionals to implement targeted educational interventions to inform patients about the anesthesia process, potential risks, and benefits.

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

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

The effect of an ultrasound-guided sacral erector spinae plane block on the postoperative pain of lumbar discectomy: a randomized controlled trial

BACKGROUND

Pain management is essential after discectomy, the surgical treatment for lumbar disc herniation. This study evaluated the effect of sacral erector spinae plane block (SESPB) versus standard analgesic methods on postoperative analgesia and opioid consumption in lumbar discectomy operations.

METHODS

Over 18 years of age, ASA 1-3 group, 54 patients undergoing elective lumbar discectomy were included in the prospective, randomized, controlled, double-blind, study. They were randomly divided into groups, SESPB and non-block (control). Both groups completed surgery under general anesthesia. At the end of the surgery, group SESPB received a bilateral 20 cc block with 0.25% bupivacaine at the level of the second sacral vertebra. Both groups received tramadol via a patient-controlled analgesia (PCA) device. The primary outcome was total opioid consumption in the first 24 hours after surgery. Pain assessment by Visual Analog Scale (VAS), rescue analgesic requirements, time to first rescue analgesic requirement and adverse effects were recorded 24 hours postoperatively.

RESULTS

Total tramadol consumption was 168.8±143 mg (P<0.04) higher in the control group. The first six-hour VAS scores and the number of rescue analgesic users were lower in the SESPB group (P<0.01). The first rescue analgesic use time was 440±140.3 minutes in SESPB group and 47.5±116.1 minutes in control group (P<0.01). Nausea-vomiting was more frequent in the control group (P<0.01) and patient satisfaction was higher in the SESPB group (P<0.01).

CONCLUSIONS

In lumbar discectomy surgery, ultrasound-guided SESPB provided adequate analgesia by reducing opioid consumption and pain scores without complications.

Single Dose Intravenous Paracetamol versus Placebo in Postorthognathic Surgery Pain: A Randomized Clinical Trial

Background

The postorthognathic surgery patients experienced moderate to severe pain and could be at risk for opioid-related side effects. The aim of this study was to evaluate the efficacy of a single dose of intravenous paracetamol to control postorthognathic surgery pain and reduce opioid consumption.

Methods

The patients were randomized into two groups. The study group received intravenous paracetamol and the control group received a placebo immediately postoperation. The visual analogue pain scale (VAS) at 1-, 4-, 8-, 12-, 16-, 20-, and 24 -h postoperatively, morphine consumption, side effects from morphine, and patient satisfaction were analyzed.

Results

Sixty-two patients (thirty-one patients in each group) were included. The postoperative VAS in the study group was significantly lower than those in the control group (p value <0.001) at all time points. The total postoperative morphine consumption in the study group (45.1 ± 21.2 mcg/kg) was significantly lower compared with the control group (136.5 ± 49.9 mcg/kg) (p value <0.001). Patient satisfaction was significantly higher in the study group (4.7 ± 0.5 out of 5 points) than in the control group (4.1 ± 0.7 out of 5 points) (p value <0.001). The incidence of nausea and vomiting was significantly lower in the study group compared with the control group (p value <0.001 and 0.002, respectively).

Conclusion

A single dose of intravenous paracetamol as part of multimodal analgesia was effective for postorthognathic surgery pain. It provided significant benefits to patients, including reduced pain scores, decreased opioid consumption, reduced nausea and vomiting, and improved satisfaction. This trial is registered with TCTR20210908002.

Application on perioperative ERAS concept in elderly lung cancer patients undergoing surgery

Investigating the applying effects of the enhanced recovery after surgery (ERAS) in the perioperative period of elderly lung cancer patients undergoing the surgery. We randomly selected 98 elderly patients with lung cancer who were admitted to our hospital and underwent surgery from January 2022 to September 2023 as study subjects. The control group received conventional care during the perioperative period, and the intervention group received ERAS-guided care measures. The differences in perioperative-related indices, pulmonary function, pain level, inflammatory factors, and postoperative complication rates between these 2 groups were compared. The postoperative extubation time, the activity time since getting out of bad and hospital stay were lower in the observation group than those in the control group (P  < .05). At 3 days postoperatively, the FEV1, forced vital capacity and maximum ventilation volume of these 2 groups were lower than those of their same groups before surgery, and those of the observation group were higher than those of the control group (P  < .05). At 3 days postoperatively, the numerical rating scale in both groups were lower than those of their same groups at 6 hours postoperatively, and the numerical rating scale of the observation group was lower than that of the control group (P  < .05). At 3 days postoperatively, tumor necrosis factor-α, IL-6, and CRP in both groups were higher than those in their same groups before surgery, and those of the observation group was lower than those of the control group (P  < .05). The incidence of postoperative complications in the observation group was lower than that in the control group (P  < .05). ERAS applied in the perioperative period of elderly lung cancer patients undergoing surgery can shorten the hospital stay, promote the postoperative recovery on pulmonary function, alleviate inflammation, and reduce the risk of postoperative complications.

Analgesic Efficacy and Safety of Tapentadol Immediate Release in Bunionectomy: A Meta-Analysis

The aim of this systematic review and meta-analysis was to evaluate the analgesic effect of different doses of tapentadol immediate release (IR) and its adverse effects after a bunionectomy. Pubmed, Cochrane, Lilacs, Medline, and Imbiomed were used to identify abstracts of scientific publications related to the keywords of this systematic review (PROSPERO ID CRD42023437295). Moreover, the risk of bias in all included articles was assessed using the Cochrane Collaboration risk of bias tool. Data on the sum of pain intensity, total pain relief, global assessment, and adverse effects were extracted. The statistical method of inverse variance with means difference was used to evaluate the numerical data and the Mantel-Haenszel and Odd Ratio test to analyze the dichotomous data. In addition, the number needed to treat, the number needed to harm, and the 95% confidence intervals were calculated. A qualitative evaluation (n = 2381) was carried out according to the conclusions of the authors. Tapentadol (n = 1772) was more effective in relieving postoperative pain than the placebo (n = 609) after a bunionectomy. In addition, the analgesic efficacy of IR tapentadol (n = 1323) versus the placebo (n = 390) was evaluated in a total of 1713 patients using a global evaluation of the treatments. All three doses of IR tapentadol showed better results compared to the placebo after a bunionectomy. Finally, the adverse effects have a direct relationship with the dose, and the greatest number of adverse effects are most observed with tapentadol IR 100 mg (n = 2381). It is concluded that tapentadol IR (100 mg) leads to the best satisfaction score in this meta-analysis.

Outcomes of an enhanced recovery after surgery (ERAS) program to limit perioperative opioid use in outpatient minimally invasive GI and hernia surgeries

BACKGROUND

Perioperative pain management is important for patient satisfaction while returning to homeostasis in the safest way possible. Studies show that patients don't require as much opioids as once thought. The benefits of ERAS pathways extend beyond enhancement of patients' perioperative experience, and include reducing opioid prescriptions in the face of the ongoing nationwide opioid crisis and evidence of prescription opioids as a contributor.

METHODS

We performed a retrospective cohort study of patients undergoing same day minimally invasive surgery (MIS) procedures for GI and hernia disease using a minimal-opioid ERAS protocol at two community hospitals between January 2020 and May 2022. We included elective laparoscopic cholecystectomy (LC), laparoscopic appendectomy (LA) for acute appendicitis without perforation, and minimally invasive (laparoscopic and robotic) inguinal and ventral hernia repair or abdominal wall reconstruction (AWR). Primary outcome was postoperative opioid use.

RESULTS

A total of 509 patients were included, undergoing procedures of MIS hernia repair (52.5%), LC (43.6%), and LA (7.9%). Only 9.4% of patients received opioid prescriptions at discharge, with no difference between groups. Among the patients receiving a prescription at discharge, there was a significant difference in morphine milligram equivalents (MME) prescribed (25.0 ± 0.0 in the LA group, 65.0 ± 41.4 in the LC group, 100.6 ± 46.2 in the MIS hernia/AWR group; P = 0.015). Nine percent of patients called with pain management concerns postoperatively. ASA score ≥ 3 was associated with increased odds for postoperative opioid prescription (OR 2.084; P = 0.014).

CONCLUSIONS

We demonstrate that an opioid-sparing ERAS program effectively manages pain for patients undergoing multiple outpatient MIS GI/hernia procedures, and suggests generalizability across a diverse range of operations. Therefore, the use of ERAS may safely and effectively expand beyond inpatient MIS and open surgeries that target reduced length of stay to also minimize opioids for outpatient procedures.

Effect of acupuncture inclusion in the enhanced recovery after surgery protocol on tumor patient gastrointestinal function: a systematic review and meta-analysis of randomized controlled studies

Introduction

Acupuncture has been shown to be effective in restoring gastrointestinal function in tumor patients receiving the enhanced recovery after surgery (ERAS) protocol. The present systematic review and meta-analysis aimed to evaluate the rationality and efficacy of integrating acupuncture in the ERAS strategy to recuperate gastrointestinal function.

Methods

We searched eleven databases for relevant randomized clinical trials (RCTs) of acupuncture for the treatment of gastrointestinal dysfunction in tumor patients treated with the ERAS protocol. The quality of each article was assessed using the Cochrane Collaboration risk of bias criteria and the modified Jadad Scale. As individual symptoms, the primary outcomes were time to postoperative oral food intake, time to first flatus, time to first distension and peristaltic sound recovery time (PSRT). Pain control, adverse events, and acupoint names reported in the included studies were also investigated.

Results

Of the 211 reviewed abstracts, 9 studies (702 patients) met eligibility criteria and were included in the present systematic review and meta‑analysis. Compared to control groups, acupuncture groups showed a significant reduction in time to postoperative oral food intake [standardized mean difference (SMD) = -0.77, 95% confidence interval (CI) -1.18 to -0.35], time to first flatus (SMD=-0.81, 95% CI -1.13 to -0.48), time to first defecation (SMD=-0.91, 95% CI -1.41 to -0.41, PSRT (SMD=-0.92, 95% CI -1.93 to 0.08), and pain intensity (SMD=-0.60, 95% CI -0.83 to -0.37).The Zusanli (ST36) and Shangjuxu (ST37) acupoints were used in eight of the nine included studies. Adverse events related to acupuncture were observed in two studies, and only one case of bruising was reported.

Discussion

The present systematic review and meta‑analysis suggested that acupuncture significantly improves recovery of gastrointestinal function and pain control in tumor patients receiving the ERAS protocol compared to the control group. Moreover, ST36 and ST37 were the most frequently used acupoints. Although the safety of acupuncture was poorly described in the included studies, the available data suggested that acupuncture is a safe treatment with only mild side effects. These findings provide evidence-based recommendations for the inclusion of acupuncture in the ERAS protocol for tumor patients.

Systematic review registration

https://www.crd.york.ac.uk/prospero/ PROSPERO, identifier CRD42023430211.

Perioperative gabapentin usage in pediatric patients: A scoping review

BACKGROUND

There has been a recent focus among anesthesiologists on reducing the use of perioperative opioids in favor of multimodal analgesic regimens. Gabapentin has played an integral role in this evolution of practice. This comprehensive review assesses the current clinical evidence on the efficacy of perioperative gabapentin regarding postoperative pain and opioid requirements among the pediatric surgery population.

DATA SOURCES

Pubmed, CINAHL, Embase, Scopus, and Web of Science Review.

METHODS

This scoping review of the above databases includes all studies examining the use of gabapentin perioperatively in pediatric patients and its association with postoperative pain intensity and postoperative opioid consumption through July 2021. The inclusion criteria encompassed all studies evaluating gabapentin in the perioperative pediatric population through randomized controlled trials (RCTs) and retrospective studies. Relevant metadata from each study were abstracted and descriptive statistics were used to summarize the results.

RESULTS

Fifteen papers met the inclusion criteria for this review, including 11 RCTs and 4 retrospective studies. Sample sizes ranged from 20 to 144 patients. Administered doses varied widely, mainly between 5 and 20 mg/kg. The studies included primarily orthopedic (10) and neck surgery cases (3). Seven papers had gabapentin provided preoperatively only, two postoperative only, and six both pre- and postoperatively. Of the studies assessing postoperative pain, 6/11 studies saw a decrease in postoperative pain in at least one period for the gabapentin group. Of the studies considering opioid requirements, 6/10 reported a reduction, 1/10 an increase, and 3/10 no difference in opioid requirements for the gabapentin groups. Yet, most of these pain and opioid requirement findings were only significant at one to two time points in the study follow-up periods, and the actual decreases had minimal clinical significance.

CONCLUSIONS

The current data on perioperative gabapentin in pediatric patients are insufficient to support the routine use of gabapentin in pediatric patients. Additional high-quality RCTs with more standardized protocols for gabapentin administration and outcome measures are necessary to provide more definitive conclusions.

Analgesic Efficacy of COX-2 Inhibitors in Periodontal Surgery: A Systematic Review and Meta-Analysis

The objective of this systematic review and meta-analysis was to evaluate the analgesic efficacy of COX-2 inhibitors versus other drugs in periodontal surgery. Two researchers searched PubMed, Google Scholar, ACM Digital, BASE, EBSCOhost, Scopus, or Web of Science for clinical trials using various combinations of words. All articles that met the selection criteria were assessed using the Cochrane Collaboration’s risk of bias tool. For data analysis, the inverse variance and mean difference statistical method was used with Review Manager 5.3 software for Windows. According to the conclusion of each study (qualitative evaluation), only one clinical trial had results in favor of a COX-2 inhibitor when compared to placebo, one clinical study informed that a COX-2 was better that an active control, four studies showed similar analgesic efficacy to active controls, and one clinical study informed the analgesic effect of one celecoxib-caffeine combination in comparison with celecoxib alone and placebo (n = 337). The COX-2 inhibitors showed a decrease in the rescue analgesic consumption (n = 138; I2 = 15%; mean difference = −0.31; 95%CIs = −0.6 to −0.01), and lower pain intensity at four hours (n = 178; I2 = 0%; mean difference = −2.25; 95%CIs = −2.94 to −1.55; p = 0.00001) when compared to active controls after periodontal surgery. In conclusion, the data indicate that COX-2 agents produce better pain relief in comparison to placebo and other drugs after periodontal surgery.

Bilateral Ultrasound-Guided Erector Spinae Plane Block for Perioperative Analgesia in Breast Reduction Surgery: A Prospective Randomized and Controlled Trial

BACKGROUND

Ultrasound-guided erector spinae plane block (ESPB) is an interfascial plane block used for analgesia of the chest and abdominal wall. This study aimed to evaluate the perioperative analgesic efficacy of bilateral single-shot ESPB at T5 vertebral level in breast reduction surgery.

MATERIALS AND METHODS

Sixty adult female patients scheduled for breast reduction surgery were included and randomly allocated to two groups to receive either preoperative ESPB with a local anesthetic mixture of 10 mL 0.5% bupivacaine, 5 mL 2% lidocaine, and 5 mL saline, or sham block. Patients in both groups received intraoperative remifentanil infusion and, postoperatively, morphine via the patient-controlled analgesia (PCA) device. The primary outcome was 24-h total morphine consumption, and secondary outcomes included intraoperative opioid consumption, postoperative pain intensity, time to first PCA request, supplement analgesic requirements, functional recovery, patient satisfaction, length of hospital stay, and side effects and complications.

RESULTS

The 24-h total morphine consumption was significantly lower in the ESPB group vs. the sham group (mean ± SD, 6.7 ± 3.9, and 13.9 ± 5.7 mg, respectively, p < 0.001). Compared with sham block, ESPB reduced pain scores, intraoperative opioid consumption, supplement analgesic requirements, delayed time to first PCA request, and improved functional recovery and patient satisfaction.

CONCLUSION

In breast reduction surgery, preoperative single-shot ESPB reduces perioperative opioid consumption and provides adequate pain relief within 24 h postoperatively compared to systemic analgesics alone.

TRIAL REGISTRATION NUMBER

NCT03621345 LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Efficacy Of Quadratus Lumborum Blocks (QLBs) in Robotic Nephrectomy: A Retrospective Study

INTRODUCTION

Abdominal blocks such as quadratus lumborum block (QLB) have been used as an effective analgesic in abdominal surgeries. However, their efficacy in kidney surgery remains unknown. To the best of our knowledge, there are no clinical studies exploring the relationship between QLBs and post-operative opioid consumption in robotic laparoscopic nephrectomy.

OBJECTIVES

To assess the analgesic efficacy of QLB and its impact on perioperative opioid consumption in robotic laparoscopic nephrectomy.

MATERIALS AND METHODS

A retrospective chart review was conducted by querying the electronic medical record system of a 2,200-bed tertiary academic hospital center in New York City. The primary measured outcome was postoperative morphine milligram equivalents (MME) consumption for the first 24 hours. Secondary outcomes include intra-operative MME as well as postoperative pain scores measured on a visual analogue scale (VAS) scale at 2, 6, 12, 18, and 24 hours postoperatively.

RESULTS

The mean total postoperative MME in the posterior QLB (pQLB) group was 11 in the QLB group (interquartile range (IQR) 4, 18) and 15 in the control group (IQR 5.6, 28) . There was a significant reduction in intraoperative MME in the QLB group in comparison to the control group. This reduction was not seen in postoperative MME. There was no significant difference in pain scores at any of the measured time points up to 24 hours postoperatively.

CONCLUSION

Our study provides compelling support that ultrasound guided QLB significantly decreased intraoperative opioid requirements but did not have the same effect on postoperative opioid requirements following robotic kidney surgeries in the context of an enhanced recovery after surgery (ERAS) pathway.

ASSESSMENT OF THE EFFICIENCY OF ANALGETIC ACTION OF LAPAROSCOPICALLY ASSISTED TAP BLOCK AS A COMPONENT OF PERIOPERATIVE MULTIMODAL ANALGESIA PLAN IN OBESE PATIENTS UNDERGOING METABOLIC SURGERY

OBJECTIVE

The aim: To assess the effectiveness and feasibility of laparoscopically assisted TAP block utilization in the system of multimodal analgesia by comparing the severity of pain and associated postoperative recovery indicators in obese patients after laparoscopic sleeve gastrectomy.

PATIENTS AND METHODS

Materials and methods: The retrospective study included 39 patients, who underwent metabolic surgery from 2013-2022. All patients were divided into 2 groups depending on the chosen perioperative analgesia protocol. Group 1 included 19 patients who prior to skin incision a local infiltration of the trocar puncture areas of the abdominal wall. Group 2 included 20 patients, whom in addition to the above-described anaesthesia procedure after completion of the main stage of surgery, a laparoscopically assisted bilateral subcostal TAP block was additionally performed.

RESULTS

Results: The need to use opioid analgesics in the rescue analgesia mode arose in 17.6% (3/17) of patients of the first group, and 5% (1/20) of patients in the second group Average duration of postoperative hospitalization in group 1 was 7.2±1.1 days, and in group 2 it was 6.2±1.4 days (P <0.05).

CONCLUSION

Conclusions: Subcostal TAP block in obese patients is a safe and effective method of regional anaesthesia. Further study of this option of regional anaesthesia is required in order to be able to form clearer recommendations for its routine use in clinical practice.

Solve study: a study to capture global variations in practices concerning laparoscopic cholecystectomy

BACKGROUND

There is a lack of published data on variations in practices concerning laparoscopic cholecystectomy. The purpose of this study was to capture variations in practices on a range of preoperative, perioperative, and postoperative aspects of this procedure.

METHODS

A 45-item electronic survey was designed to capture global variations in practices concerning laparoscopic cholecystectomy, and disseminated through professional surgical and training organisations and social media.

RESULTS

638 surgeons from 70 countries completed the survey. Pre-operatively only 5.6% routinely perform an endoscopy to rule out peptic ulcer disease. In the presence of preoperatively diagnosed common bile duct (CBD) stones, 85.4% (n = 545) of the surgeons would recommend an Endoscopic Retrograde Cholangio-Pancreatography (ERCP) before surgery, while only 10.8% (n = 69) of the surgeons would perform a CBD exploration with cholecystectomy. In patients presenting with gallstone pancreatitis, 61.2% (n = 389) of the surgeons perform cholecystectomy during the same admission once pancreatitis has settled down. Approximately, 57% (n = 363) would always administer prophylactic antibiotics and 70% (n = 444) do not routinely use pharmacological DVT prophylaxis preoperatively. Open juxta umbilical is the preferred method of pneumoperitoneum for most patients used by 64.6% of surgeons (n = 410) but in patients with advanced obesity (BMI > 35 kg/m2, only 42% (n = 268) would use this technique and only 32% (n = 203) would use this technique if the patient has had a previous laparotomy. Most surgeons (57.7%; n = 369) prefer blunt ports. Liga clips and Hem-o-loks® were used by 66% (n = 419) and 30% (n = 186) surgeons respectively for controlling cystic duct and (n = 477) 75% and (n = 125) 20% respectively for controlling cystic artery. Almost all (97.4%) surgeons felt it was important or very important to remove stones from Hartmann's pouch if the surgeon is unable to perform a total cholecystectomy.

CONCLUSIONS

This study highlights significant variations in practices concerning various aspects of laparoscopic cholecystectomy.

Doctors' and Nurses' Attitudes of Acupuncture and Acupressure use in Perioperative Care: An Australian National Survey

BACKGROUND

Acupuncture and acupressure are not being systematically used in the management of postoperative nausea and vomiting and pain, despite being included in the guidelines.

AIM

To examine the beliefs, attitudes, and knowledge of Australian nurses/midwives and doctors toward the perioperative use of AA for the management of postoperative nausea and vomiting and pain; to explore the barriers and enablers influencing acupuncture and acupressure integration into hospital setting.

METHODS

A mixed-mode approach was undertaken for data collection. An online approach was used to recruit respondents from Australian College of Perioperative Nurses. Three hospitals from three different Australian states were selected via convenience sampling.

RESULTS

A total of 421 usable surveys were included in data analysis. The respondents comprised 14.3% doctors and 72.9% nurses/midwives. Overall, 69.4% were female, 85% were trained in Australia with 35% and 51.4% having knowledge or personal exposure to AA in general respectively. Over 60% of the respondents agreed AA should be routinely integrated into perioperative care, and over 80% would recommend AA to their patients if it was provided at their hospital, and, 75% would be willing to receive further education. The three main reported barriers included: perceived lack of scientific evidence (80.9%), unavailability of credentialed provider (77.2%) and lack of reimbursement (60.4%).

CONCLUSIONS

Positive attitudes are reported by Australian doctors and nurses toward AA. This is despite of low levels of knowledge or personal exposure to AA. Further studies are required to explore the implementation of barriers and address respondent calls for further education.

Opioid-Free Anesthesia: The Pros and Cons

Appropriate perioperative pain control is essential to aid in patients' recovery after surgery; however, acute postsurgical pain remains poorly treated and there continues to be an overreliance on opiates. Perioperative pain control starts in the operating room, and opiate-free anesthesia (OFA), where no opiates are used intraoperatively, has been proposed as a feasible strategy to further minimize opiates in the perioperative period. In this article, we address the potential benefits and shortcomings of OFA, while exploring tools available to accomplish multimodal anesthesia and ideally OFA, and the evidence behind the techniques proposed.

Risk of serious adverse events associated with non-steroidal anti-inflammatory drugs in orthopaedic surgery. A protocol for a systematic review

BACKGROUND

Postoperative pain is a common condition following orthopaedic surgeries and causes prolonged hospitalisation, delayed rehabilitation and hamper the quality of life. Non-steroidal anti-inflammatory drugs (NSAIDs) are effective analgesics and anti-inflammatory mediators in the treatment of postoperative pain. The association of NSAIDs with serious adverse events may however keep some clinicians and clinical decision makers from using NSAIDs perioperatively. The evidence regarding the risks of serious adverse events following perioperative use of NSAIDs in orthopaedic surgery is sparse and needs to be assessed in a systematic review. This is a protocol for a systematic review that aims to identify the risks of serious adverse events from perioperative use of NSAIDs in orthopaedic patients.

METHODS

Our methodology is based on the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols and the eight-step assessment procedure suggested by Jakobsen and colleagues. We wish to assess if NSAIDs versus placebo, usual care or no intervention, will influence the risks of serious adverse events in patients undergoing orthopaedic surgery. We will include all randomised trials assessing the use of NSAIDs perioperatively. To identify trials we will search the Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Cochrane Central Register, Science Citation Index Expanded on Web of Science and BIOSIS. Two authors will screen the literature and extract data. We will use the 'Risk of Bias 2 tool' to assess trials. Extracted data will be analysed using RStudio and Trial Sequential Analysis. We will create a 'Summary of Findings' table in which we will present our primary and secondary outcomes. We will assess the quality of evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE).

DISCUSSION

This systematic review can potentially aid clinicians and clinical decision makers in the use of NSAIDs for treatment of postoperative pain following orthopaedic surgeries.

The therapeutic potential of ultra-short-acting β-receptor antagonists in perioperative analgesic: Evidence from preclinical and clinical studies

Perioperative multimodal analgesia can reduce the side effects of a high concentration of opioids, improving the comfort of the patient. However, insufficient analgesia of this model has prompted researchers to explore new adjuvant analgesics. Recently, an increasing number of studies have found a low-grade analgesic effect in the clinical application of ultra-short-acting β-adrenergic receptor antagonists, which are conventionally used as pharmacologic agents in the cardiovascular system. The mechanism by which ultra-short-acting β-antagonists exert antinociceptive effects has not been clarified yet. In this review, we intend to address its potential reasons from the side of neurotransmitters, inflammatory cytokines, and signaling pathways, providing theoretical proof for the application of β-adrenergic receptor antagonists in analgesia.

The outcome of enhanced recovery after surgery vs. a traditional pathway in adolescent idiopathic scoliosis surgery: A retrospective comparative study

Objectives

Methods

Results

Conclusions

Comparison of the Analgesic Effect of Subcutaneous Bupivacaine Infiltration and Intravenous Diclofenac vs. Intravenous Diclofenac Monotherapy After Inguinal Hernioplasty: A Retrospective Study

Background

Postoperative pain is a significant problem encountered by patients after a surgical intervention, and there is a crucial need for effective postoperative pain control. The studies have shown that multimodal analgesia and wound infiltration are effective ways to reduce this pain and have a substantial role in the reduction of postoperative medications requirement. This study aimed to evaluate the effect of subcutaneous infiltration of bupivacaine hydrochloride and intravenous (IV) diclofenac as postoperative pain relief in adults undergoing inguinal hernia repair.

Methods

A single-center retrospective study included 104 patients aged 18-65 undergoing unilateral inguinal herniorrhaphy at the selected hospital. The patients were in two groups of 52 each. Group A received a 75 mg dose of IV diclofenac plus a subcutaneous injection of 10 mL of bupivacaine hydrochloride (HCl) 0.5% while Group B only received the IV diclofenac without the bupivacaine injection. The postoperative pain was assessed at one, two, three, six, and 12 hrs after the operation using the visual analog scale (VAS), which exhibited a range of pain from zero (no pain) to 10 (extreme pain).

Results

Of a total of 104 patients, 92% of patients were male. The patients' mean age was 36 ± 11 years, and the mean body mass index (BMI) was 22 ±3 kg/m². American Society of Anesthesiologists physical class I was similar in both groups (90.4% versus 84.6%). Patients in Group A had significantly lower VAS pain scores at one, two, three, six, and 12 hrs after the operation and a longer emergence time than Group B (all p-values were < 0.001). Subcutaneous bupivacaine infiltration and IV diclofenac were also found to be an effective analgesic technique in open hernia repair with mesh (p-value < 0.001 for all).

Conclusion

Subcutaneous injection of bupivacaine combined with IV diclofenac provides superior analgesia to monotherapy intravenous diclofenac after inguinal hernia repair.

Effects of Multimodal Analgesia Combined with Auricular Point Therapy on Physical and Mental Stress and Rehabilitation Quality of Patients with Meniscus Injury during the Perioperative Period

Objective

To investigate the effect of multimodal analgesia combined with auricular point therapy on physical and mental stress and rehabilitation quality of patients with meniscus injury during the perioperative period.

Methods

148 patients in our hospital from October 2019 to October 2021 who were scheduled to undergo meniscus surgery were selected and grouped according to the order of file establishment, with 74 cases in each. The control group was given routine analgesia, and the observation group was given multimodal analgesia combined with auricular point therapy. The pain level (visual analogue scale (VAS)), physical and mental stress (heart rate (HR), mean arterial pressure (MAP), depression scale (PHQ-9), and anxiety scale (GAD-7)), complications, rehabilitation quality, and analgesia satisfaction were observed.

Results

The VAS scores of pain in the observation group were lower than those in the control group at 6 hours before operation and at 6 hours, 24 hours, and 72 hours after operation (P < 0.05). The MAP, HR, PHQ-9, and GAD-7 scores of the observation group were lower than those of the control group 6 hours before operation (P < 0.05). There was no significant difference in MAP, HR, PHQ-9, and GAD-7 scores between the two groups at 6 hours and 24 hours after operation (P > 0.05). The analgesic satisfaction of the observation group was better than that of the control group (P < 0.05). The incidence of complications in the observation group was 8.11% compared with 12.16% in the control group, which was not statistically significant (P > 0.05). The first exhaust, getting out of bed, and hospital stay in the observation group were shorter than those in the control group (P < 0.05).

Conclusion

Multimodal analgesia combined with auricular acupuncture therapy is effective in perioperative patients with meniscus injury. It can reduce perioperative pain, reduce physical and mental stress, and promote early postoperative recovery through a variety of analgesic mechanisms.

Parasternal After Cardiac Surgery (PACS): a prospective, randomised, double-blinded, placebo-controlled trial study protocol for evaluating a continuous bilateral parasternal block with lidocaine after open cardiac surgery through sternotomy

BACKGROUND

Multimodal analgesia that provides optimal pain treatment with minimal side effects is important for optimal recovery after open cardiac surgery. Regional anaesthesia can be used to block noxious nerve signals. Because sternotomy causes considerable pain that lasts several days, a continuous nerve block is advantageous. Previous studies on continuous sternal wound infusion or parasternal blocks with long-acting local anaesthetics have shown mixed results. This study aims to determine whether a continuous bilateral parasternal block with lidocaine, which is a short-acting local anaesthetic that has a favourable safety/toxicity profile, results in effective analgesia. We hypothesise that a 72-hour continuous parasternal block with 0.5% lidocaine at a rate of 7 ml/hour on each side provides effective analgesia and reduces opioid requirement. We will evaluate whether recovery is enhanced.

METHODS

In a prospective, randomised, double-blinded manner, 45 patients will receive a continuous parasternal block with either 0.5% lidocaine or saline. The primary endpoint is cumulated intravenous morphine by patient-controlled analgesia at 72 hours. Secondary end-points include the following: (1) the cumulated numerical rating scale (NRS) score recorded three times daily at 72 hours; (2) the cumulated NRS score after two deep breaths three times daily at 72 hours; (3) the NRS score at rest and after two deep breaths at 2, 4, 8 and 12 weeks after surgery; (4) oxycodone requirement at 2, 4, 8 and 12 weeks after surgery; (5) Quality of Recovery-15 score preoperatively compared with that at 24, 48 and 72 hours, and at 2, 4, 8 and 12 weeks after surgery; (6) preoperative peak expiratory flow compared with postoperative daily values for 3 days; and (7) serum concentrations of interleukin-6 and lidocaine at 1, 24, 48 and 72 hours postoperatively compared with preoperative values.

DISCUSSION

Adequate analgesia is important for quality of care and vital to a rapid recovery after cardiac surgery. This study aims to determine whether a continuous parasternal block with a short-acting local anaesthetic improves analgesia and recovery after open cardiac procedures.

TRIAL REGISTRATION

The study was registered in the European Clinical Trials Database on 27/9/2019 (registration number: 2018-004672-35).

Analgesic and Sedative Effects of Different Doses of Dexmedetomidine Combined with Butorphanol in Continuous Analgesia after a Cesarean Section

Objective

The present study is designed to study the analgesic and sedative effect of different doses of dexmedetomidine combined with butorphanol in continuous analgesia after a cesarean section.

Methods

A total of 60 puerperae undergoing a cesarean section recruited from a single center were divided into three groups according to the postoperative continuous analgesia protocol: control group (100 mL of normal saline containing 10 µg/kg fentanyl and 0.25 mg of palonosetron, 2 mL/h for continuous analgesia for 48 h), DB1 group (100 mL of normal saline containing 1.0 µg/kg dexmedetomidine, 4 mg of butorphanol, 10 µg/kg fentanyl, and 0.25 mg of palonosetron, 2 mL/h for continuous analgesia for 48 h), and DB2 group (100 mL normal saline containing 2.0 µg/kg dexmedetomidine, 4 mg of butorphanol, 10 µg/kg fentanyl, and 0.25 mg of palonosetron, 2 mL/h for continuous analgesia for 48 h). We compared the blood pressure, heart rate, oxygen saturation, VAS score, Ramsay score, and adverse reactions of puerperae among the three groups after surgery.

Results

The baseline data all have no significant difference in the three groups (p > 0.05). Compared with those in the control group, the systolic blood pressure, diastolic blood pressure, heart rate, and VAS score of the puerperae in the DB1 group and DB2 group were significantly decreased at 6, 24, and 48 h (P < 0.05), while the Ramsay scores of the puerperae in DB1 group and DB2 group were significantly increased at 6, 24, and 48 h (p < 0.05). At the same time, the systolic blood pressure, diastolic blood pressure, heart rate, and VAS score of the puerperae in the DB2 group were significantly lower than those in the DB1 group (P < 0.05), while the Ramsay scores of the puerperae in DB2 group were significantly higher than those in the DB1 group (P < 0.05). Also, there is no significant difference in oxygen saturation and adverse reactions of puerperae among the three groups after surgery (p > 0.05).

Conclusion

Dexmedetomidine combined with butorphanol can improve the analgesic and sedative effects in continuous analgesia after a cesarean section, and the analgesic and sedative effects of dexmedetomidine in the high-dose group are better than those in the low-dose group.

A critical review of oliceridine injection as an IV opioid analgesic for the management of severe acute pain

INTRODUCTION

Oliceridine is a G protein-selective (biased) agonist at the μ-opioid receptor, with less recruitment of β-arrestin-2, a signaling pathway associated with opioid-related adverse events. Nonclinical evidence showed that oliceridine elicits a rapid systemic analgesic effect while attenuating opioid-related adverse events.

AREAS COVERED

Three pivotal studies in patients with moderate to severe acute pain, including two randomized, double-blind, placebo- and morphine-controlled efficacy studies following either orthopedic surgery-bunionectomy or plastic surgery-abdominoplasty; and an open-label safety study following a surgical procedure or due to a medical condition.

EXPERT OPINION

Poorly controlled acute postoperative pain is associated with poorer recovery, longer hospitalization, increased complications, and worse healthcare outcomes. Recently, oliceridine intravenous injection was approved for use in adults for the management of acute pain severe enough to require an intravenous opioid analgesic and for whom alternative treatments are inadequate. Introduction of this new IV opioid provides a valuable option to manage postoperative pain.

Analgesic effects of sufentanil in combination with flurbiprofen axetil and dexmedetomidine after open gastrointestinal tumor surgery: a retrospective study

Background

To investigated the effects of sufentanil in combination with flurbiprofen axetil and dexmedetomidine for patient-controlled intravenous analgesia (PCIA) on patients after open gastrointestinal tumor surgery, and compared this combination with traditional PCIA with pure opioids or epidural analgesia (PCEA).

Methods

Patients (n = 640) who underwent open gastrointestinal tumor surgery and received patient-controlled analgesia (PCA) were included. According to the type of PCA, patients were assigned to three groups: MPCIA (PCIA with sufentanil, flurbiprofen axetil, dexmedetomidine and metoclopramide), OPCIA (PCIA with sufentanil, tramadol and metoclopramide) and PCEA group (PCEA with sufentanil and ropivacaine). The characteristics of patients, intraoperative use of analgesics, postoperative visual analogue scale (VAS), postoperative adverse reactions and postoperative recovery were collected. The primary outcome was postoperative VAS score. One-way ANOVA, Kruskal-Wallis H test, Fisher exact probability method, and binary logistic regression analysis were used for analysis.

Results

There were no significant differences in the characteristics of patients, operation time, tumor site and the use of postoperative rescue analgesics among the groups. In the first two days after open gastrointestinal tumor surgery, the VAS (expressed by median and interquartile range) of MPCIA (24^th h, resting: 1,1; movement: 3,2. 48^th h, resting: 0,1; movement: 2,1.) and PCEA (24^th h, resting: 0,1; movement: 2,1. 48^th h, resting: 0,1; movement: 2,2.) groups were significantly lower than those of OPCIA group (24^th h, resting: 2.5,2; movement: 4,2. 48^th h, resting: 1.5,1.75; movement: 3,1.) (all p <  0.01). The incidence of postoperative nausea and vomiting in MPCIA group was 13.6% on the first day after surgery, which was significantly higher than that in PCEA group. There was no significant difference in the incidence of other postoperative adverse events. Higher intraoperative sufentanil dosage (OR (95%CI) = 1.017 (1.002–1.031), p = 0.021), lower body mass index (OR (95%CI) = 2.081 (1.059–4.089), p = 0.033), and tumor location above duodenum (OR (95%CI) = 2.280 (1.445–3.596), p <  0.001) were associated with poor postoperative analgesia.

Conclusions

The analgesic effects of PCIA with sufentanil in combination with flurbiprofen axetil and dexmedetomidine on postoperative analgesia was better than that of traditional pure opioids PCIA, and similar with that of PCEA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01670-0.

Fabrication of Ropivacaine/Dexamethasone-Eluting Poly(D, L-lactide-co-glycolide) Microparticles via Electrospraying Technique for Postoperational Pain Control

Microencapsulation plays an important role in biomedical technology owing to its particular and attractive characteristics. In this work, we developed ropivacaine and dexamethasone loaded poly(D, L-lactide-co-glycolide) (PLGA) microparticles via electrospraying technique and investigated the release behavior of electrosprayed microparticles. The particle morphology of sprayed particles was assessed using scanning electron microscopy (SEM). The in vitro drug release kinetics were evaluated employing an elution method, and the in vivo pharmaceutical release as well as its efficacy on pain relief were tested using an animal activity model. The microscopic observation suggested that sprayed microparticles exhibit a size distribution of 5-6 µm. Fourier-transform infrared spectrometry and differential scanning calorimetry demonstrated the successful incorporation of pharmaceuticals in the PLGA particulates. The drugs-loaded particles discharged sustainably high concentrations of ropivacaine and dexamethasone at the target region in vivo for over two weeks, and the drug levels in the blood remained low. By adopting the electrospraying technique, we were able to prepare drug-embedded polymeric microparticles with effectiveness and with a sustainable capability for postoperative pain control.

An Enhanced Recovery After Surgery protocol for robotic-assisted laparoscopic nephrectomies utilizing a quadratus lumborum block

Enhanced Recovery After Surgery (ERAS) protocols have been developed in several fields to reduce hospitalization lengths and overall costs. There have also been developments in multimodal analgesia methods to curtail opioid usage after surgery. Herein, we present the results of our initiation of an ERAS protocol for robotic-assisted laparoscopic partial and radical nephrectomies, employing a quadratus lumborum (QL) regional anesthetic block. We retrospectively reviewed 614 patients in our Institutional Review Board approved database who underwent robotic-assisted laparoscopic partial or radical nephrectomies from January 2017 to February 2020. An ERAS protocol utilizing multimodal analgesia (acetaminophen and gabapentin) and a QL block was developed and introduced in February 2019. We then compared the opioid consumption and perioperative outcomes of patients before and after ERAS protocol initiation. 192 ERAS patients (February 2019 to February 2020) were compared to 422 non-ERAS patients (January 2017 to January 2019). Baseline characteristics and the proportion of preoperative opioids users were similar between the two groups. There were no statistically significant differences in surgery length, hospitalization length, or complication rates. There were statistically significant differences in our primary endpoint, opioid consumption, on post-operative days 0 (p < 0.001), 1 (p < 0.001), and 2 (p < 0.001). The total opioid requirements over the course of admission were lower in the ERAS group compared to the non-ERAS group (p = 0.03). The initiation of an ERAS protocol employing multimodal analgesia and a QL block, for patients undergoing robotic-assisted laparoscopic partial or radical nephrectomies, can decrease opioid requirements without compromising perioperative outcomes.

Intraoperatively local infiltration anesthesia in hemiarthroplasty patients reduces the needs of opioids: a randomized, double-blind, placebo-controlled trial with 96 patients in a fast-track hip fracture setting

Background and purpose - Local infiltration analgesia (LIA) is commonly used as a component in multimodal analgesia. Pain management directed towards hip fracture patients operated on with hemiarthroplasty is often based on knowledge regarding pain treatment following elective surgery. In this elderly patient population, it is of value to clarify whether adding local infiltration analgesia (LIA) to the postoperative analgesic regimen might reduce postoperative pain or have an opioid-reducing effect. Patients and methods - 96 hip fracture patients undergoing hemiarthroplasty in spinal anesthesia were included. All patients received a multimodal pain regimen and were randomized to receive either ropivacaine or placebo. All patients received morphine depot-opioid and morphine as rescue medication postoperatively. The primary endpoint was pain during mobilization in the recovery unit on the day of surgery. Secondary endpoints were pain during mobilization the day after surgery and postoperative opioid requirements on the first postoperative day. Results - The levels of pain (NRS) during mobilization both in the recovery unit and on the day after surgery were similar in the 2 groups, with median 4 and 0.5 in the placebo group and median 3.5 and 1 in the ropivacaine group respectively. Total consumption of opioids on day 0 and day 1 were 4.6 mg lower in the ropivacaine group (p = 0.04). Pain during mobilization was registered for only 44 of 96 patients for several reasons, including lack of mobilization. Interpretation - There were similar pain scores in both the local infiltration and placebo group postoperatively. However, substantially reduced opioid consumption was found in patients receiving LIA.

The pain in the Emergency Department: Choosing and treating wisely before and during the COVID-19 era

Pain is a frequent reason for referral to the Emergency Department (ED). Adequate management of pain is a moral and ethical imperative. If not correctly treated, acute pain can cause physical and psychological complications, and become chronic with severe consequences such as anxiety, depression, and social isolation. As consequence, emergency clinicians should treat pain as soon as possible, avoiding delays even in case of acute abdominal pain. Pain management is particularly complex in the elderly and emergency clinicians should always consider AGS Beers criteria ® to avoid inappropriate medications, severe side-effects, and drug-drug interactions. Pain is also a common cause of delirium in older patients. The SARS CoV-2 infection not only can cause acute pain, but also exacerbate chronic pain, particularly in the elderly, who are at high risk to be infected. Looking at all this evidence, emergency clinicians should treat pain with different strategies according to their experience and cultural background, making the right choice for each patient. This work is a critical review of the pain management in the ED, with a particular attention on the effects of COVID-19 in the EDs. We conducted a systematic search of the following databases: PubMed, Google Scholar, Science Direct, Medline from 2000 to 2020, using the keywords of “pain”, “emergency”, “COVID19”, “elderly”, “palliative care”, “ketamine”, “dexmedetomidine”, and “post-traumatic stress disorder”. The aim of this review is to help emergency clinicians to correctly manage pain in the ED with a new point of view regarding the pain management in COVID-19 patients.

Analgesia and patient comfort after enhanced recovery after surgery in uvulopalatopharyngoplasty: a randomised controlled pilot study

Background

Uvulopalatopharyngoplasty(UPPP) is the most prevalent surgical treatment of obstructive sleep apnea, but postoperative pharyngeal pain may affect patient comfort. The enhanced recovery after surgery pathway has been proved beneficial to many types of surgery but not to UPPP yet. The aim of this pilot study was to preliminarily standrize an enhanced recovery after surgery protocol for UPPP, to assess whether it has positive effects on reducing postoperative pharyngeal pain and improving patient comfort, and to test its feasibility for an international multicentre study.

Methods

This randomised controlled study analysed 116 patients with obstructive sleep apnoea (OSA) who were undergoing UPPP in a single tertiary care hospital. They were randomly divided according to treatment: the ERAS group (those who received ERAS treatment) and the control group (those who received traditional treatment). Ninety-five patients completed the assessment (ERAS group, 59 patients; control group, 36 patients). Pharyngeal pain and patient comfort were evaluated using a visual analogue scale (VAS) at 30 min and at 6, 12, 24 and 48 h after UPPP. Complications, hospitalisation duration, and hospital cost were recorded.

Results

The VAS scores for resting pain and swallowing pain were significantly lower in the ERAS group than those in the control group at 30 min and at 6, 12, 24 and 48 h after surgery. Patient comfort was improved in the ERAS group. The hospitalisation duration and cost were comparable between the groups. The incidence of complications showed an increasing trend in the ERAS group.

Conclusion

The ERAS protocol significantly relieved pharyngeal pain after UPPP and improved comfort in patients with OSA, which showed the prospect for an larger study. Meanwhile a potential increase of post-operative complications in the ERAS group should be noticed.

Trial registration

Chinese Clinical Trial Registry (23/09/2018, ChiCTR1800018537)

Impact of intravenous dexmedetomidine on postoperative bowel movement recovery after laparoscopic nephrectomy: A consort-prospective, randomized, controlled trial

BACKGROUND

Postoperative ileus is a frequent postoperative complication, especially after abdominal surgery. Sympathetic excitation is the primary factor for postoperative ileus. Sympathetic activation becomes increased by surgical stress, postoperative pain, and inflammation. Dexmedetomidine (DEX) can inhibit sympathetic nerve activity, inflammation, and pain.

AIM

To observe whether DEX promotes bowel movements in patients after laparoscopic nephrectomy.

METHODS

One hundred and twenty patients undergoing laparoscopic nephrectomy were assigned to three groups: C (normal saline infusion), D1 (DEX 0.02 µg/kg/h), and D2 (DEX 0.04 µg/kg/h). The primary outcomes were the recorded times to first flatus, defecation, and eating after surgery. The secondary outcomes were postoperative pain, assessed using the numerical rating scale (NRS), adverse effects, and the duration of the postoperative hospital stay.

RESULTS

The times to first flatus, defecation, and eating in groups D1 and D2 were significantly shorter than those in group C (P < 0.01). The NRS scores at 8 h and 24 h after surgery were significantly lower in groups D1 and D2 than in group C (P < 0.05). No adverse effects were observed (P > 0.05).

CONCLUSION

Postoperative infusion of DEX at 0.04 µg/kg/h facilitates bowel movements in patients undergoing laparoscopic nephrectomy.

Implementation of a multimodal opioid-sparing enhanced recovery pathway for robotic-assisted radical prostatectomy

The purpose of the study is to evaluate the impact of a multimodal Enhanced Recovery After Surgery (ERAS) protocol on perioperative opioid consumption and hospital length of stay (LOS) after robotic-assisted radical prostatectomy (RARP). We compared the first 176 patients enrolled in the protocol (ERAS group) with the previous 176 patients (non-ERAS group) at a single quaternary institution from December 2017 to June 2019. The ERAS protocol included a multimodal opioid-sparing regimen utilizing acetaminophen, gabapentin, celecoxib, and liposomal bupivacaine. Demographic data, co-morbidities, post-operative pain scores, post-operative opiate consumption measured by morphine milligram equivalents (MME), operating time, and LOS were collected. The two groups were compared using chi-squared, Fisher exact, or Student t tests as appropriate. Multivariable logistic regression analysis was performed to identify predictors of prolonged LOS (> 1 day). The ERAS and non-ERAS groups were equivalent in terms of baseline characteristics and pathological data. The ERAS group had lower post-operative pain scores, post-operative opiate consumption (MME 15 vs. 46, p < 0.01), and LOS (1.2 vs. 1.7 days, p < 0.01) compared to the non-ERAS group. Only 22% in the ERAS cohort had a prolonged LOS compared to 39% of the non-ERAS group (p < 0.01). The ERAS protocol was a negative predictor of prolonged LOS on multivariable logistic regression analysis (odds ratio 0.39, 95% confidence interval 0.22-0.70, p < 0.01). A limitation of this study is its single-center retrospective design. The implementation of a multimodal opioid-sparing ERAS protocol was associated with improved pain control, reduced perioperative opioid usage, and shorter LOS after RARP.

Developing an enhanced recovery after surgery program for oncology patients who undergo hip or knee reconstruction surgery

Enhanced recovery after surgery (ERAS) protocols are applied in orthopedic surgery and are intended to reduce perioperative stress by implementing combined evidence-based practices with the cooperation of various health professionals as an interdisciplinary team. ERAS pathways include pre-operative patient counselling, regional anesthesia and analgesia techniques, post-operative pain management, early mobilization and early feeding. Studies have shown improvement in the recovery of patients who followed an ERAS program after hip or knee arthroplasty, compared with those who followed a traditional care approach. ERAS protocols reduce post-operative stress, contribute to rapid recovery, shorten length of stay (LOS) without increasing the complications or readmissions, improve patient satisfaction and decrease the hospital costs. We suggest that the ERAS pathway could reduce the LOS in hospital for patients undergoing total hip replacement or total knee replacement. These programs require good organization and handling by the multidisciplinary team. ERAS programs increase patient's satisfaction due to their active participation which they experience as personalized treatment. The aim of the study was to develop an ERAS protocol for oncology patients who undergo bone reconstruction surgeries using massive endoprosthesis, with a view to improving the surgical outcomes.

Scheduled Prophylactic 6-Hourly IV AcetaminopheN to Prevent Postoperative Delirium in Older CaRdiac SurgicAl Patients (PANDORA): protocol for a multicentre randomised controlled trial

INTRODUCTION

Postoperative delirium is common among older cardiac surgery patients. Often difficult to predict and address prophylactically, delirium complicates the postoperative course by increasing morbidity and mortality as well as prolonging both hospital and intensive care unit (ICU) lengths of stay. Based on our pilot trial, we intend to study the effect of scheduled 6-hourly acetaminophen administration for 48 hours post-cardiac surgery with cardiopulmonary bypass (CPB) on the incidence of in-hospital delirium and long-term neurocognitive outcomes. Additionally, effect on duration and severity of delirium, rescue analgesic consumption, acute and chronic pain scores and lengths of hospital and ICU stay will also be explored.

METHODS AND ANALYSIS

This multicentre, randomised, placebo-controlled, quadruple-blinded trial will include 900 older (>60 years) cardiac surgical patients requiring CPB. Patients meeting the inclusion criteria and not meeting any exclusion criteria will be enrolled at seven centres across the USA with Beth Israel Deaconess Medical Center (BIDMC), Boston, as the central coordinating centre. Additional sites may be included to broaden or speed accrual. The primary outcome measure is the incidence of in-hospital delirium till day 30. Secondary outcomes include the duration and severity of in-hospital delirium, hospital and ICU lengths of stay, postoperative pain scores, postoperative rescue analgesic consumption, postoperative cognitive function and chronic sternal pain. Creation of a biorepository and the use of intraoperative-blinded electroencephalogram (EEG) and cerebral oximetry data will support exploratory endpoints to determine mechanistic predictors of postoperative delirium.

ETHICS AND DISSEMINATION

This trial is approved and centrally facilitated by the Institutional Review Board at BIDMC. An independent Data Safety and Monitoring Board is responsible for maintaining safety oversight. Protocol # 2019 P00075, V.1.4 (dated 20 October 2020).

TRIAL REGISTRATION NUMBER

NCT04093219.

Effectiveness of thoracic epidural anesthesia in reducing morbidity and mortality in adults with acute pancreatitis: a systematic review protocol and meta-analysis

OBJECTIVE

The objective of this review is to evaluate the effectiveness of thoracic epidural in reducing morbidity and mortality in adults with acute pancreatitis.

INTRODUCTION

Acute pancreatitis is a common disease that often results in significant morbidity and mortality. Although the use of a thoracic epidural anesthesia in patients with acute pancreatitis provides effective analgesia, there appears to be additional non-analgesic benefits associated with thoracic epidural anesthesia.

INCLUSION CRITERIA

Randomized controlled trials will be sought for inclusion, but this review will also consider quasi-experimental studies, cohort studies, case-controlled studies, cross-sectional studies, and case-series studies. Studies will include patients 18 years of age and older with acute pancreatitis, with no exclusion to comorbidity. Studies published in a language other than English will be excluded unless a translated version is available.

METHODS

The key databases to be searched include MEDLINE, CINAHL, OpenGrey, ClinicalTrials.gov, and Google Scholar. Studies will be assessed for inclusion by at least two independent reviewers. Included studies will be critically appraised by two independent reviewers using standardized critical appraisal instruments from JBI. Data will be extracted from studies included in the review using a standardized extraction tool. Studies will, where possible, be pooled in statistical meta-analysis using JBI SUMARI.

SYSTEMATIC REVIEW REGISTRATION NUMBER

The title of this protocol has been registered with the JBI Systematic Review Register. This manuscript has been registered with PROSPERO (CRD42020177756).

Overview of multimodal analgesia initiated in the perioperative setting

Despite progress in pain management in the perioperative setting, the literature is full of evidence that managing postoperative pain is suboptimal. Since the mechanism of pain is complex, the use of multimodal technique allows clinicians to use a combination of two or more drugs targeting different areas of pain transmission because of surgery. As part of enhanced recovery initiatives after surgery, healthcare and professional organisations incorporate the use of multimodal analgesia in surgical guidelines to improve patient satisfaction. This review aims to understand and summarise the current body of evidence involving the most common pharmacological therapies to manage postoperative pain in the preoperative setting.

Quadratus lumborum block versus transversus abdominis plane block for postoperative analgesia in patients undergoing abdominal surgeries: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Abdominal surgery is common and is associated with severe postoperative pain. The transverse abdominal plane (TAP) block is considered an effective means for pain control in such cases. The quadratus lumborum (QL) block is another option for the management of postoperative pain. The aim of this study was to conduct a meta-analysis and thereby evaluate the efficacy and safety of QL blocks and TAP blocks for pain management after abdominal surgery.

METHODS

We comprehensively searched PubMed, EMBASE, EBSCO, the Cochrane Library, Web of Science and CNKI for randomized controlled trials (RCTs) that compared QL blocks and TAP blocks for pain management in patients undergoing abdominal surgery. All of the data were screened and evaluated by two researchers. RevMan5.3 was adopted for the meta-analysis.

RESULTS

A total of 8 RCTs involving 564 patients were included. The meta-analysis showed statistically significant differences between the two groups with respect to postoperative pain scores at 2 h (standardized mean difference [Std.MD] = - 1.76; 95% confidence interval [CI] = - 2.63 to - 0.89; p < .001), 4 h (Std.MD = -0.77; 95% CI = -1.36 to - 0.18; p = .01),6 h (Std.MD = -1.24; 95% CI = -2.31 to - 0.17; p = .02),12 h (Std.MD = -0.70; 95% CI = -1.27 to - 0.13; p = .02) and 24 h (Std.MD = -0.65; 95% CI = -1.29 to - 0.02; p = .04); postoperative morphine consumption at 24 h (Std.MD = -1.39; 95% CI = -1.83 to - 0.95; p < .001); and duration of postoperative analgesia (Std.MD = 2.30; 95% CI = 1.85 to 2.75; p < .001). There was no statistically significant difference between the two groups with regard to the incidence of postoperative nausea and vomiting (PONV) (RR = 0.55;95% CI = 0.27 to 1.14;p = 0.11).

CONCLUSION

The QL block provides better pain management with less opioid consumption than the TAP block after abdominal surgery. In addition, there are no differences between the TAP block and QL block with respect to PONV.

Evaluation of Pain Management after Surgery: An Observational Study

Background and Objectives: Choosing a pain management strategy is essential for improving recovery after surgery. Effective pain management reduces the stress response, facilitates mobilization, and improves the quality of the postoperative period. The aim of the study was to assess the effectiveness of pain management in patients after surgery. Materials and Methods: The study included 216 patients operated on in the following surgical wards: the Department of Cardiosurgery and the Department of General and Endocrine Surgery. Patients were hospitalized on average for 6 ± 4.5 days. Patients were randomly selected for the study using a questionnaire technique with a numerical rating scale. Results: Immediately after surgery, pre-emptive analgesia, multimodal analgesia, and analgosedation were used significantly more frequently than other methods (p < 0.001). In the subsequent postoperative days, the method of administering drugs on demand was used most often. Patients with confirmed complications during postoperative wound healing required significantly more frequent use of drugs from Steps 2 and 3 of the World Health Organization (WHO) analgesic ladder compared with patients without complications. Conclusion: The mode of patient admission for surgery significantly affected the level of pain perception. Different pain management methods were used and not every method was effective.