Liposomal Bupivacaine Offers No Benefit Over Ropivacaine for Multimodal Periarticular Injection in Total Knee Arthroplasty

The Analgesic Effect of Dexmedetomidine Loaded with Nano-Hydrogel as a Novel Nano-Drug Delivery System for Thoracic Paravertebral Block After Thoracic Surgery

Objective: To understand the effect of dexmedetomidine (Dex) thoracic paravertebral block combined with an injectable nano-drug delivery system in postoperative analgesia after thoracic surgery, an injectable nano-drug delivery system. Methods: Dex-loaded nano-hydrogel was first prepared in this study and its characteristics and drug release performance in vitro was investigated. Then, it was applied to the postoperative analgesia of 140 patients undergoing thoracic surgery. Results: It was found that the loading efficiency reached the highest when the ratio of Dex to injectable nano-hydrogel was 1:1; and at pH = 7.5, the cumulative release of 95.4%. The visual analogue scale (VAS) score and cumulative effective pressure times of analgesia pump in the observation group were lower than those of the control group. The sleep time per day and satisfaction of analgesia within 48 h in patients from the observation group were higher than those of the control group. The proportion of patients with remedial analgesia within 48 hours, and the proportion of patients with nausea and vomiting were significantly lower in patients treated with Dex-loaded with nano-hydrogel. Conclusion: Injectable nano-drug delivery system had good drug release and combination of Dex thoracic paravertebral block and nano-drug delivery system could significantly relieve pain after thoracic surgery and improve patients’ sleep quality.

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.

A randomized controlled trial of liposomal bupivacaine for pain following obstetrical laceration

BACKGROUND

Postpartum pain management is critical after vaginal delivery involving a second, third, or fourth degree laceration as patients heal from their repair. Uncontrolled postpartum pain can affect both the physical and mental recovery period, extend hospital stays, and increase the potential for serious adverse reactions with pain medications. In light of the opioid crisis and increase in dependency after utilization, finding alternatives for pain management after procedures is paramount. The need for a safe, effective, long-acting medication to treat postpartum and postoperative pain has reached a critical point in the current healthcare climate.

OBJECTIVE

To minimize pain after vaginal delivery, we assessed the effectiveness of liposomal bupivacaine vs plain bupivacaine injected into the perineum after second, third, or fourth degree lacerations. We hypothesized that the liposomal bupivacaine study group would have less vaginal pain, analgesic usage, and improved quality of life compared with the plain bupivacaine control group.

MATERIALS AND METHODS

This is a single-blinded randomized controlled trial with 120 subjects enrolled at Walter Reed National Military Medical Center, Bethesda, Maryland, from February 2018 to February 2019. After vaginal delivery and repair, study participants were randomized into 20-mL liposomal bupivacaine (study group) or 20-mL 0.25% plain bupivacaine (control group) injected into and around the perineal body bilaterally. On postpartum days 1, 3, and 7, pain scores and analgesics were recorded. Our primary outcome was vaginal pain score at postpartum day 3, analyzed with Wilcoxon rank-sum test. Our secondary outcomes included vaginal pain at postpartum days 1 and 7, pain with bowel movement, sleep disturbance, and pain's impact on activity, stress, and mood. Desired statistical power was achieved with 48 patients per group (total of 96 patients).

RESULTS

A total of 60 patients were randomized to each group; 108 patients completed the study. Most patients (94%) had regional anesthesia. There was no statistically significant difference in the demographics between these groups. There were 25 obstetric anal sphincter injuries, equally distributed between the 2 groups (P>.99). There was no significant difference between vaginal pain scores at postpartum day 3 (control, 2 [1-3]; study, 2 [0-3]) (P=.63). This was also seen at postpartum day 1 (control, 2 [0-3]; study, 2 [0-3]) (P=.82) and postpartum day 7 (control, 1 [0-3]; study, 1 [0-2]) (P=.47). Cumulative pain scores for postpartum days 1, 3, and 7 failed to reach significance (study, 5 [3-8]; control, 6 [3-8]) (P=.83). Secondary analysis of pain with bowel movement and impact on sleep, activity, stress, and mood found no differences. Given that only 3 patients required outpatient opioids, there were insufficient data to calculate morphine equivalent differences.

CONCLUSION

After obstetric lacerations, there is no proven benefit to lateral and intraperineal injection of liposomal bupivacaine over plain bupivacaine in postpartum vaginal pain scores, quality of life scores, or pain medication utilized. This may be due to low pain scores and opioid usage, both groups benefiting from the intervention, or ineffective perineal injection location.