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El-Boghdadly K, Levy NA, Fawcett WJ, Knaggs RD, Laycock H, Baird E, Cox FJ, Eardley W, Kemp H, Malpus Z, Partridge A, Partridge J, Patel A, Price C, Robinson J, Russon K, Walumbe J, Lobo DN. Peri-operative pain management in adults: a multidisciplinary consensus statement from the Association of Anaesthetists and the British Pain Society. Anaesthesia 2024; 79:1220-1236. [PMID: 39319373 DOI: 10.1111/anae.16391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2024] [Indexed: 09/26/2024]
Abstract
BACKGROUND Nearly half of adult patients undergoing surgery experience moderate or severe postoperative pain. Inadequate pain management hampers postoperative recovery and function and may be associated with adverse outcomes. This multidisciplinary consensus statement provides principles that might aid postoperative recovery, and which should be applied throughout the entire peri-operative pathway by healthcare professionals, institutions and patients. METHODS We conducted a directed literature review followed by a four-round modified Delphi process to formulate recommendations for organisations and individuals. RESULTS We make recommendations for the entire peri-operative period, covering pre-admission; admission; intra-operative; post-anaesthetic care unit; ward; intensive care unit; preparation for discharge; and post-discharge phases of care. We also provide generic principles of peri-operative pain management that clinicians should consider throughout the peri-operative pathway, including: assessing pain to facilitate function; use of multimodal analgesia, including regional anaesthesia; non-pharmacological strategies; safe use of opioids; and use of protocols and training for staff in caring for patients with postoperative pain. CONCLUSIONS We hope that with attention to these principles and their implementation, outcomes for adult patients having surgery might be improved.
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Affiliation(s)
- Kariem El-Boghdadly
- Department of Anaesthesia and Perioperative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Nicholas A Levy
- Department of Anaesthesia and Perioperative Medicine, West Suffolk NHS Foundation Trust, Suffolk, UK
| | - William J Fawcett
- Department of Anaesthesia and Pain Medicine, Royal Surrey NHS Foundation Trust, Surrey, UK
- School of Medicine, University of Surrey, Guildford, UK
| | - Roger D Knaggs
- School of Pharmacy, Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - Helen Laycock
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital, London, UK
| | - Emma Baird
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Felicia J Cox
- Pain Management Service, Critical Care and Anaesthesia, Royal Brompton and Harefield Hospitals (part of Guy's and St Thomas' NHS Foundation Trust), London, UK
| | - Will Eardley
- Department of Orthopaedics and Trauma, James Cook University Hospital, Middlesbrough, UK
| | - Harriet Kemp
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Zoey Malpus
- Manchester NHS Pain Service, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | | | - Judith Partridge
- Department of Peri-operative Care for Older People Undergoing Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Anjna Patel
- Department of Pre-operative Assessment, Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
| | - Cathy Price
- Pain Management, Department of Chronic Pain, Solent NHS Trust, UK
| | | | - Kim Russon
- Department of Anaesthesia, Rotherham NHS Foundation Trust, Rotherham, UK
| | - Jackie Walumbe
- Department of Physiotherapy, University College London Hospitals NHS Foundation Trust, London, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Dileep N Lobo
- Nottingham Digestive Diseases Centre, Division of Translational Medical Sciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK
- Division of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Yang ZS, Lai HC, Jhou HJ, Chan WH, Chen PH. Rebound pain prevention after peripheral nerve block: A network meta-analysis comparing intravenous, perineural dexamethasone, and control. J Clin Anesth 2024; 99:111657. [PMID: 39454286 DOI: 10.1016/j.jclinane.2024.111657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 08/19/2024] [Accepted: 10/09/2024] [Indexed: 10/28/2024]
Abstract
STUDY OBJECTIVE Peripheral nerve blocks (PNBs) are widely used for postoperative analgesia, but rebound pain following block resolution poses a significant clinical challenge. Dexamethasone, administered either intravenously (IV) or perineurally, has shown promise in reducing rebound pain incidence, but the optimal route remains unclear. This network meta-analysis (NMA) aims to compare the effectiveness of different routes of dexamethasone administration, including IV, perineural, and control, in reducing the incidence of rebound pain following PNBs. DESIGN Network meta-analysis. SETTING Operating room, postoperative recovery area and ward. PATIENTS Seven randomized controlled trials involving 561 patients undergoing peripheral nerve block for postoperative pain management. INTERVENTIONS Intravenous and perineural dexamethasone compared to control for preventing rebound pain. MEASUREMENTS The primary outcome was the incidence of rebound pain. Secondary outcomes included median time to first analgesic request, rebound pain resolution time, difference in pain scores before and after PNB resolution, and nausea/vomiting. MAIN RESULTS Both IV and perineural dexamethasone significantly reduced the incidence of rebound pain following peripheral nerve blocks compared to the control group. IV dexamethasone ranked first based on P-score (OR, 0.13; 95 % CI, 0.07-0.23; P-score, 0.92). Secondary outcomes, including time to the first analgesic request, pain score difference, and nausea/vomiting, also favored both IV and perineural dexamethasone over the control group. CONCLUSION Both IV and perineural dexamethasone are preferred over no dexamethasone for preventing rebound pain after PNBs, with IV dexamethasone being the more effective route. Despite limitations, these findings provide valuable insights for clinical decision-making in postoperative pain management. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42024530943.
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Affiliation(s)
- Zih-Sian Yang
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
| | - Hou-Chuan Lai
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
| | - Hong-Jie Jhou
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan
| | - Wei-Hung Chan
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan.
| | - Po-Huang Chen
- Division of Hematology and Oncology Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
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Wang H, Bao Q, Cao D, Zhu L, Chen L, Yu Y. Effect of low-volume ropivacaine in ultrasound-guided superior trunk block on diaphragmatic movement in patients undergoing shoulder arthroscopy: a randomized controlled trial. J Orthop Surg Res 2024; 19:604. [PMID: 39342253 PMCID: PMC11437893 DOI: 10.1186/s13018-024-05083-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 09/13/2024] [Indexed: 10/01/2024] Open
Abstract
OBJECTIVES The incidence of hemidiaphragmatic paresis (HDP) in superior trunk block (STB) usually depends on the dose of local anesthetic. This study aimed to further evaluate the impact of a lower volume (10 mL) of the same low concentration (0.25%) ropivacaine compared to a conventional volume (15 mL), on diaphragmatic function and analgesic efficacy under a multimodal analgesia regimen for shoulder arthroscopy. METHODS Patients scheduled to undergo shoulder arthroscopy were randomized allocated to receive either 10 mL or 15 mL of 0.25% ropivacaine in the STB under ultrasound guidance prior to general anesthesia. The primary outcome was the percentage reduction in diaphragm excursion (ΔDE) between baseline and 30 min after block. Secondary outcomes included DE and diaphragm thickening fraction (DTF) before and after block, incidence of HDP, onset of sensory/motor block, duration of analgesia/motor block, dermatomal coverage area of the block, postoperative pain severity, pre- and post-block respiratory function and intraoperative hemodynamic parameters, the use of other anesthetic and analgesic drugs, post-block complications, and adverse events post-surgery. RESULTS Compared with 15 mL volume, 10 mL ropivacaine significantly reduced the incidence of post-block HDP (as measured by ΔDE: 39.47% vs. 64.10%; and by post-block DTF: 13.16% vs. 33.33%). There was no significant difference in onset of sensory block, duration of analgesia/motor block, dermatomal coverage area of the block, postoperative pain severity between the two groups, except that the onset of motor block was significantly slower in the 10 mL group than in the 15 mL group. Pre- and post-block respiratory function and intraoperative hemodynamic parameters, the use of other anesthetic and analgesic drugs, post-block complications, or postoperative adverse events were not significantly different between the two groups. CONCLUSION In shoulder arthroscopy, STB with 10 mL of ropivacaine can reduce the incidence of HDP with no significant difference in analgesic effects under a multimodal analgesia regimen compared with 15 mL. TRIAL REGISTRATION We registered the study at chictr.org ( ChiCTR2200057543 , 14/03/2022. https://www.chictr.ogr.cn.
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Affiliation(s)
- Huijun Wang
- Department of Anesthesia, Wenzhou Medical University Affiliated Taizhou Hospital of Zhejiang Province, No.150 Ximen Street, Linhai, Taizhou, 317000, Zhejiang, China
| | - Qianqian Bao
- Operating Room, Wenzhou Medical University Affiliated Taizhou Hospital of Zhejiang Province, Taizhou, 317000, Zhejiang, China
| | - Donghang Cao
- Department of Anesthesia, Wenzhou Medical University Affiliated Taizhou Hospital of Zhejiang Province, No.150 Ximen Street, Linhai, Taizhou, 317000, Zhejiang, China
| | - Lijun Zhu
- Department of Anesthesia, Wenzhou Medical University Affiliated Taizhou Hospital of Zhejiang Province, No.150 Ximen Street, Linhai, Taizhou, 317000, Zhejiang, China
| | - Lingyang Chen
- Department of Anesthesia, Wenzhou Medical University Affiliated Taizhou Hospital of Zhejiang Province, No.150 Ximen Street, Linhai, Taizhou, 317000, Zhejiang, China.
| | - Yulong Yu
- Department of Anesthesia, Wenzhou Medical University Affiliated Taizhou Hospital of Zhejiang Province, No.150 Ximen Street, Linhai, Taizhou, 317000, Zhejiang, China.
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Park KB, Cho HO, Kim MS, Jeon YD. Rebound Pain After Arthroscopic Cuff Repair With Interscalene Brachial Plexus Block Anesthesia Is Reduced by Surgeon-Administered Multimodal Shoulder Injections: A Prospective Randomized Controlled Trial. Arthroscopy 2024:S0749-8063(24)00557-7. [PMID: 39128682 DOI: 10.1016/j.arthro.2024.07.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 07/18/2024] [Accepted: 07/19/2024] [Indexed: 08/13/2024]
Abstract
PURPOSE To compare the effects of additional multimodal shoulder injections on postoperative rebound pain in patients undergoing arthroscopic rotator cuff repair (ASRCR) under interscalene brachial plexus block (ISBPB) anesthesia. METHODS A single-blind randomized controlled trial was conducted with 67 patients between April and December 2023. Patients undergoing ASRCR who received ISBPB anesthesia, rather than general anesthesia, with a minimum follow-up period of 48 hours were included. The injection group received 40 mL of 0.75% ropivacaine, 20 mg morphine, 1:200,000 epinephrine, and saline solution, totaling 100 mL. After surgery, the injection was administered to the subacromial space (50 mL) with blind suprascapular nerve block (25 mL) and blind axillary nerve block (25 mL). Control subjects received 100 mL of saline solution. Intravenous patient-controlled analgesia (IV-PCA) was used as adjuvant analgesia for all patients. The primary outcome was evaluated using the visual analog scale (VAS) pain score at 12 hours after surgery, with secondary outcomes of the incidence of rebound pain and VAS pain scores at 0, 2, 4, 8, 24, 36, and 48 hours postoperatively. Fentanyl in the IV-PCA and rescue analgesic amounts, complications, and patient satisfaction were recorded. RESULTS Sixty-seven patients (32 in the injection group, 35 in the control group) with a mean age of 61.1 ± 9.0 years were included. The primary outcome assessment, VAS pain score at 12 hours, significantly favored the injection group (2.7 ± 0.93 vs 4.1 ± 1.70, P < .001). The incidence of rebound pain was 18.8% and 65.7% in the injection and control groups, respectively (18.8% vs 65.7%, P < .001). The injection group reported better VAS pain scores at 24, 36, and 48 hours and lower fentanyl use over the 48-hour postoperative period (P = .014). The use of rescue analgesics was similar between groups, and no complications were associated with multimodal shoulder injections. Satisfaction levels were similar in both groups. CONCLUSIONS The present study found that patients who underwent multimodal shoulder injections during ASRCR under ISBPB anesthesia had significantly lower VAS pain scores at 12 hours postoperatively and reduced incidence of rebound pain compared with the control group. Pain levels were consistently lower from 12 to 48 hours postoperatively. Additionally, the injection group had reduced opioid consumption within the first 48 hours postoperatively, with no complications observed. LEVEL OF EVIDENCE Level I, randomized controlled trial.
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Affiliation(s)
- Ki-Bong Park
- Department of Orthopaedic Surgery, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, Republic of Korea
| | - Hyun-Oh Cho
- Department of Anesthesia and Pain Medicine, Ulsan University College of Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Min Seok Kim
- Department of Orthopaedic Surgery, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, Republic of Korea
| | - Young Dae Jeon
- Department of Orthopaedic Surgery, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, Republic of Korea.
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Admassie BM, Debas SA, Admass BA. Prevention and management of rebound pain after resolution of regional block: a systematic review. Ann Med Surg (Lond) 2024; 86:4732-4737. [PMID: 39118752 PMCID: PMC11305791 DOI: 10.1097/ms9.0000000000002299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 06/11/2024] [Indexed: 08/10/2024] Open
Abstract
Background An extreme pain known as rebound pain develops after regional blockage wears off. Patient, surgical, and anesthesia-related factors influence the occurrence and intensity of rebound pain. Prior to the peripheral nerve block (PNB) being resolved, multimodal therapy should use. The objective of this review was to explore rebound pain prevention and management following PNB resolution. Methods We conducted a thorough search across Pub Med, Hinari, Google Scholar, and Cochrane review databases, utilizing relevant keywords and search parameters to identify studies meeting our inclusion criteria. These studies aimed to provide sufficient evidence regarding the prevention and management of rebound pain following the resolution of regional blocks. Duplicate entries were removed using Endnote software. Screening of the literature was performed using a rigorous appraisal checklist. The findings of this review are reported in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement. Results Using an electronic search, 3526 items were found from databases and websites. After removing duplicates (n=500), 3026 articles remained. Of these, 2813 were excluded after going through their titles and abstracts. Of the 213 articles screened, 126 were removed for such reasons as ineligibility or similarity in objectives. Of the remaining 87 studies, 37 were excluded for such reasons as the inaccessibility of free full texts. Finally, 50 studies were included for review. Conclusions and recommendation Proper patient education about rebound pain, combined with the utilization of multimodal systemic analgesia before the resolution of PNBs, perineural dexamethasone, and employing a combination of nerve blocks, has been demonstrated to decrease the incidence of rebound pain. Therefore, clinicians should aim to prevent and manage rebound pain by implementing perioperative multimodal strategies before the resolution of regional blocks.
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Affiliation(s)
- Belete Muluadam Admassie
- Department of Anesthesia, College of Medicine and Health Sciences, University of Gondar, North Gondar
| | - Simachew Amogne Debas
- Department of Anesthesia, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Biruk Adie Admass
- Department of Anesthesia, College of Medicine and Health Sciences, University of Gondar, North Gondar
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Liu J, Liu M, Shi S, Jiang F, Zhang Y, Guo J, Gong X. Evaluation of the effect of intraoperative tropisetron on postoperative rebound pain after brachial plexus block: a randomized controlled trial. Pain Rep 2024; 9:e1163. [PMID: 38756786 PMCID: PMC11098252 DOI: 10.1097/pr9.0000000000001163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 03/07/2024] [Accepted: 03/24/2024] [Indexed: 05/18/2024] Open
Abstract
Introduction Postoperative rebound pain after peripheral nerve block increases patient suffering and delays recovery after surgery. Objectives We tested whether the 5HT-3 receptor antagonist and α7nAChR agonist tropisetron could prevent postoperative rebound pain. Methods A total of 115 patients were randomized to receive 5-mg/5-mL tropisetron or the same volume of normal saline. Pain intensity was measured with the numerical rating scale of pain (NRS). Rebound pain was defined as a change from mild pain (NRS ≤ 3) measured in the postanesthesia care unit to severe pain (NRS ≥ 7) within 24 hours after peripheral nerve blockade. Logistic regression was used to identify relevant factors associated with postoperative rebound pain. Results Tropisetron did not affect the NRS score or the incidence of rebound pain after peripheral nerve block. Logistic regression revealed that preoperative pain, bone surgery, and length of incision were risk factors for postoperative rebound pain, and patient-controlled analgesia was protective against postoperative rebound pain. Conclusion Tropisetron does not affect the incidence of rebound pain after peripheral nerve block. Patients at high risk of postoperative rebound pain should be identified for appropriate management. Registration site: www.chictr.org.cn (ChiCTR2300069994).
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Affiliation(s)
- Junli Liu
- Department of Anesthesiology, Xiangyang Central Hospital, Institution of Neuroscience and Brain Disease, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Mingming Liu
- Department of Anesthesiology, Xiangyang Central Hospital, Institution of Neuroscience and Brain Disease, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Shengnan Shi
- Department of Anesthesiology, Xiangyang Central Hospital, Institution of Neuroscience and Brain Disease, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Fei Jiang
- Department of Anesthesiology, Xiangyang Central Hospital, Institution of Neuroscience and Brain Disease, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Ye Zhang
- Department of Anesthesiology, Xiangyang Central Hospital, Institution of Neuroscience and Brain Disease, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Jing Guo
- Department of Anesthesiology, Xiangyang Central Hospital, Institution of Neuroscience and Brain Disease, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Xingrui Gong
- Department of Anesthesiology, Xiangyang Central Hospital, Institution of Neuroscience and Brain Disease, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
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Aguilera G, Tabilo C, Jara Á, Aliste J. 0.25% bupivacaine-1% lidocaine vs 0.5% bupivacaine for ultrasound-guided infraclavicular brachial plexus block: a randomized controlled trial. Reg Anesth Pain Med 2024:rapm-2024-105511. [PMID: 38754989 DOI: 10.1136/rapm-2024-105511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 05/03/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION In an effort to shorten onset time, a common practice is to add lidocaine to bupivacaine. In the setting of infraclavicular block, it is unclear what the block characteristics of this practice are compared with bupivacaine alone. We hypothesized that bupivacaine alone increases the duration of motor block, sensory block, and postoperative analgesia while resulting in a slower onset time compared with a bupivacaine and lidocaine mixture. METHODS 40 patients receiving ultrasound-guided infraclavicular brachial plexus block were randomly assigned to receive either 35 mL of 0.25% bupivacaine and 1% lidocaine or 0.5% bupivacaine, both associated with perineural adjuvants (epinephrine 5 µg/mL and dexamethasone 4 mg). After the block was performed, a blinded observer evaluated the success of the block, the onset time, and the incidence of surgical anesthesia. Postoperatively, a blinded observer contacted patients who had successful blocks to inquire about the duration of motor block, sensory block, postoperative analgesia, and the presence of rebound pain. RESULTS When comparing patients having bupivacaine alone versus bupivacaine and lidocaine, the mean (SD) motor block duration was 28.4 (5.2) vs 18.9 (3.1) hours, respectively; the mean difference 9.5 hours (95% CI 6.5 to 12.4; p<0.001); the mean (SD) sensory block duration was 29.3 (5.8) vs 18.7 (4.0) hours, respectively; the mean difference 10.6 hours (95% CI 7.1 to 14.0; p<0.001); the mean (SD) postoperative analgesia duration was 38.3 (7.4) vs 24.3 (6.6) hours, respectively; the mean difference 14 hours (95% CI 9.2 to 18.8; p<0.001); and the median (IQR) onset time was 35 (15) vs 20 (10) min, respectively; p<0.001. No other significant differences were detected. CONCLUSIONS Compared with mixed bupivacaine-lidocaine, 0.5% bupivacaine significantly prolongs sensorimotor block and postoperative analgesia at the expense of a delayed onset time. TRIAL REGISTRATION NUMBER NCT05834023.
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Affiliation(s)
| | | | - Álvaro Jara
- Department of Anesthesiology and Perioperative Medicine, University of Chile, Santiago, Chile
| | - Julián Aliste
- Department of Anesthesiology and Perioperative Medicine, University of Chile, Santiago, Chile
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Zhou R, Jiang W, Miao Q, Li X, Xiong L. Current Status and Global Trend of Rebound Pain After Regional Anesthesia: A Bibliometric Analysis. Local Reg Anesth 2024; 17:67-77. [PMID: 38742096 PMCID: PMC11090126 DOI: 10.2147/lra.s455347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 04/12/2024] [Indexed: 05/16/2024] Open
Abstract
Purpose Rebound pain after regional anesthesia, a common phenomenon when the analgesic effect wears off, has been recognized in the last a few years. The aim of this study is to analyze the status and tendency of this area in a macroscopic perspective. Methods Bibliometric analysis is the primary methodology of this study. Literature retrieval was conducted in Web of Science (WoS) Core Collection. WoS, Excel, VOSviewer and CiteSpace were employed to do the analyses and visualization. Parameters were analyzed, such as publications, citations, journals, and keywords, etc. Results In total, 70 articles in the past 10 years were identified eligible. Most articles (14 pieces) were published in 2021, followed by 2022 and 2023 with 13 articles. Researchers come from 134 institutions and 20 countries. Huang Jung-Taek, Hallym College, and USA are the most productive author, institution and country, respectively. The articles were mainly published on the top journals of anesthesiology, orthopedics and surgery. The topic of these articles is primarily about the clinical issues of rebound pain. Peripheral nerve block, brachial plexus block and femoral nerve block are the activist keywords in the area, while perioperative management, fracture surgery and outcome may become hotpots in the next years. Conclusion Our results show that the study of rebound pain after regional anesthesia starts relatively late and is in upward tendency, future studies can focus on the perioperative management and outcomes of fracture patients, and the definition and mechanism of rebound pain after regional anesthesia.
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Affiliation(s)
- Rui Zhou
- Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Clinical Research Center for Anesthesiology and Perioperative Medicine, Translational Research Institute of Brain and Brain-Like Intelligence, Department of Anesthesiology and Perioperative medicine, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai City, People’s Republic of China
| | - Wencai Jiang
- Department of Anesthesiology, Deyang People’s Hospital, Deyang City, People’s Republic of China
| | - Qingyuan Miao
- Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Clinical Research Center for Anesthesiology and Perioperative Medicine, Translational Research Institute of Brain and Brain-Like Intelligence, Department of Anesthesiology and Perioperative medicine, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai City, People’s Republic of China
| | - Xinyang Li
- Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Clinical Research Center for Anesthesiology and Perioperative Medicine, Translational Research Institute of Brain and Brain-Like Intelligence, Department of Anesthesiology and Perioperative medicine, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai City, People’s Republic of China
| | - Lize Xiong
- Shanghai Key Laboratory of Anesthesiology and Brain Functional Modulation, Clinical Research Center for Anesthesiology and Perioperative Medicine, Translational Research Institute of Brain and Brain-Like Intelligence, Department of Anesthesiology and Perioperative medicine, Shanghai Fourth People’s Hospital, School of Medicine, Tongji University, Shanghai City, People’s Republic of China
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Ferry J, Lewis O, Lloyd J, El-Boghdadly K, Kearns R, Albrecht E, Altermatt F, Ashokka B, Ayad AE, Aziz ES, Aziz L, Jagannathan B, Bouarroudj N, Chin KJ, Delbos A, de Gracia A, Ip VHY, Kwofie K, Layera S, Lobo CA, Mohammed M, Moka E, Moreno M, Morgan B, Polela A, Rahimzadeh P, Tangwiwat S, Uppal V, Vaz Perez M, Volk T, Wong PBY, Bowness JS, Macfarlane AJR. Research priorities in regional anaesthesia: an international Delphi study. Br J Anaesth 2024; 132:1041-1048. [PMID: 38448274 PMCID: PMC11103078 DOI: 10.1016/j.bja.2024.01.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 01/05/2024] [Accepted: 01/24/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Regional anaesthesia use is growing worldwide, and there is an increasing emphasis on research in regional anaesthesia to improve patient outcomes. However, priorities for future study remain unclear. We therefore conducted an international research prioritisation exercise, setting the agenda for future investigators and funding bodies. METHODS We invited members of specialist regional anaesthesia societies from six continents to propose research questions that they felt were unanswered. These were consolidated into representative indicative questions, and a literature review was undertaken to determine if any indicative questions were already answered by published work. Unanswered indicative questions entered a three-round modified Delphi process, whereby 29 experts in regional anaesthesia (representing all participating specialist societies) rated each indicative question for inclusion on a final high priority shortlist. If ≥75% of participants rated an indicative question as 'definitely' include in any round, it was accepted. Indicative questions rated as 'definitely' or 'probably' by <50% of participants in any round were excluded. Retained indicative questions were further ranked based on the rating score in the final Delphi round. The final research priorities were ratified by the Delphi expert group. RESULTS There were 1318 responses from 516 people in the initial survey, from which 71 indicative questions were formed, of which 68 entered the modified Delphi process. Eleven 'highest priority' research questions were short listed, covering themes of pain management; training and assessment; clinical practice and efficacy; technology and equipment. CONCLUSIONS We prioritised unanswered research questions in regional anaesthesia. These will inform a coordinated global research strategy for regional anaesthesia and direct investigators to address high-priority areas.
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Affiliation(s)
- Jenny Ferry
- Department of Anaesthesia, Aneurin Bevan University Health Board, Newport, South Wales, UK
| | - Owen Lewis
- Department of Anaesthesia, Aneurin Bevan University Health Board, Newport, South Wales, UK
| | - James Lloyd
- Department of Anaesthesia, Aneurin Bevan University Health Board, Newport, South Wales, UK
| | - Kariem El-Boghdadly
- Department of Anaesthesia & Perioperative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK; Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Rachel Kearns
- Department of Anaesthesia, Glasgow Royal Infirmary, Glasgow, UK; School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Eric Albrecht
- University Hospital of Lausanne, Lausanne, Switzerland; Department of Anaesthesia, University of Lausanne, Lausanne, Switzerland
| | - Fernando Altermatt
- Department of Anesthesiology, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Amany E Ayad
- Department of Anesthesia, ICU and Pain, Cairo University, Cairo, Egypt
| | - Ezzat S Aziz
- Department of Anesthesia, ICU and Pain, Cairo University, Cairo, Egypt
| | - Lutful Aziz
- Department of Anaesthesia and Pain Medicine, Evercare Hospital, Dhaka, Bangladesh
| | | | | | - Ki Jinn Chin
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, Toronto, ON, Canada
| | - Alain Delbos
- Department of Anesthesia, Medipole Garonne, Toulouse, France
| | - Alex de Gracia
- Hospital Rafael Estevez, Caja de Seguro Social, Aguadulce, Panama
| | - Vivian H Y Ip
- Department of Anesthesia and Pain Medicine, University of Alberta Hospital, Edmonton, AB, Canada
| | - Kwesi Kwofie
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
| | - Sebastian Layera
- Department of Anesthesiology and Perioperative Medicine, University of Chile, Santiago, Chile
| | | | | | - Eleni Moka
- Creta InterClinic Hospital, Hellenic Healthcare Group (HHG), Heraklion, Crete, Greece
| | - Milena Moreno
- Department of Anaesthesiology, Pontifical Xavierian University, Bogotá, Colombia; Hospital Universitario San Ignacio, Bogotá, Columbia
| | - Bethan Morgan
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Arthur Polela
- Department of Anaesthesia and Critical Care, Levy Mwanawasa University Teaching Hospital, Lusaka, Zambia
| | - Poupak Rahimzadeh
- Pain Research Center, Department of Anesthesiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Suwimon Tangwiwat
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Vishal Uppal
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
| | - Marcelo Vaz Perez
- Departament of Anesthesiology and Pain Therapy of Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Centre, Homburg, Germany; Faculty of Medicine, Saarland University, Homburg, Germany
| | - Patrick B Y Wong
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
| | - James S Bowness
- Department of Anaesthesia, Aneurin Bevan University Health Board, Newport, South Wales, UK; Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, UK.
| | - Alan J R Macfarlane
- Department of Anaesthesia, Glasgow Royal Infirmary, Glasgow, UK; School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
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10
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Singh NP, Makkar JK, Chawla JK, Sondekoppam RV, Singh PM. Prophylactic dexamethasone for rebound pain after peripheral nerve block in adult surgical patients: systematic review, meta-analysis, and trial sequential analysis of randomised controlled trials. Br J Anaesth 2024; 132:1112-1121. [PMID: 38501226 DOI: 10.1016/j.bja.2023.09.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 09/01/2023] [Accepted: 09/26/2023] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Rebound pain occurs after the resolution of peripheral nerve block and hampers patient recovery in the postoperative period. We sought to synthesise available data from randomised controlled trials (RCTs) evaluating the efficacy of prophylactic dexamethasone for rebound pain in adult patients undergoing surgery with a peripheral nerve block. METHODS In this systematic review and meta-analysis, RCTs reporting rebound pain and use of dexamethasone in the context of a peripheral nerve block were searched in various databases and updated in May 2023. The primary outcome was the incidence of rebound pain; secondary outcomes included the severity and time to onset of rebound pain, patient satisfaction with pain control, sleep disturbance because of pain, and adverse effects of dexamethasone. Subgroup analysis was conducted based on the effect of route of administration (intravenous or perineural) on the incidence of rebound pain. Trial sequential analysis was performed to rule out the possibility of a false positive result. RESULTS Seven RCTs comprising 574 patients were included in this review. The dexamethasone group was associated with a reduction in the incidence of rebound pain with an odds ratio of 0.16 (95% confidence interval 0.10-0.27, P=0.00, I2=0%) compared with the control group. Trial sequential analysis confirmed the adequate information size for the beneficial effect of dexamethasone. Subgroup analysis showed that both intravenous and perineural administration were associated with a significant reduction in the incidence of rebound pain. CONCLUSIONS Current evidence suggests that both intravenous and perineural dexamethasone reduce the incidence of rebound pain after a peripheral nerve block provided for postoperative analgesia. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42023424031.
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Affiliation(s)
- Narinder P Singh
- Department of Anesthesia and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada.
| | - Jeetinder K Makkar
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Rakesh V Sondekoppam
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Preet M Singh
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
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11
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Fallon F, Moorthy A, Skerritt C, Crowe GG, Buggy DJ. Latest Advances in Regional Anaesthesia. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:735. [PMID: 38792918 PMCID: PMC11123025 DOI: 10.3390/medicina60050735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 04/22/2024] [Accepted: 04/26/2024] [Indexed: 05/26/2024]
Abstract
Training and expertise in regional anaesthesia have increased significantly in tandem with increased interest over the past two decades. This review outlines the most recent advances in regional anaesthesia and focuses on novel areas of interest including fascial plane blocks. Pharmacological advances in the form of the prolongation of drug duration with liposomal bupivacaine are considered. Neuromodulation in the context of regional anaesthesia is outlined as a potential future direction. The growing use of regional anaesthesia outside of the theatre environment and current thinking on managing the rebound plane after regional block regression are also discussed. Recent relevant evidence is summarised, unanswered questions are outlined, and priorities for ongoing investigation are suggested.
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Affiliation(s)
- Frances Fallon
- Department of Anaesthesia, Mater Misericordiae University Hospital, Eccles St, D07 WKW8 Dublin, Ireland;
| | - Aneurin Moorthy
- Department of Anaesthesia, National Orthopaedic Hospital Cappagh/Mater Misericordiae University Hospital, Eccles St, D07 WKW8 Dublin, Ireland; (A.M.)
- School of Medicine, University College Dublin, D04 V1W8 Dublin, Ireland
| | - Conor Skerritt
- Department of Anaesthesia, National Orthopaedic Hospital Cappagh/Mater Misericordiae University Hospital, Eccles St, D07 WKW8 Dublin, Ireland; (A.M.)
| | - Gillian G. Crowe
- Department of Anaesthesia, Cork University Hospital, Wilton, T12 DC4A Cork, Ireland
| | - Donal J. Buggy
- Department of Anaesthesia, Mater Misericordiae University Hospital, Eccles St, D07 WKW8 Dublin, Ireland;
- School of Medicine, University College Dublin, D04 V1W8 Dublin, Ireland
- The ESA-IC Oncoanaesthesiology Research Group and Outcomes Research, Cleveland, OH 44195, USA
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12
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Ramjit S, Davey MG, Loo C, Moran B, Ryan EJ, Arumugasamy M, Robb WB, Donlon NE. Evaluating analgesia strategies in patients who have undergone oesophagectomy-a systematic review and network meta-analysis of randomised clinical trials. Dis Esophagus 2024; 37:doad074. [PMID: 38221857 DOI: 10.1093/dote/doad074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/20/2023] [Accepted: 12/08/2023] [Indexed: 01/16/2024]
Abstract
Optimal pain control following esophagectomy remains a topic of contention. The aim was to perform a systematic review and network meta-analysis (NMA) of randomized clinical trials (RCTs) evaluating the analgesia strategies post-esophagectomy. A NMA was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-NMA guidelines. Statistical analysis was performed using Shiny and R. Fourteen RCTs which included 565 patients and assessed nine analgesia techniques were included. Relative to systemic opioids, thoracic epidural analgesia (TEA) significantly reduced static pain scores at 24 hours post-operatively (mean difference (MD): -13.73, 95% Confidence Interval (CI): -27.01-0.45) (n = 424, 12 RCTs). Intrapleural analgesia (IPA) demonstrated the best efficacy for static (MD: -36.2, 95% CI: -61.44-10.96) (n = 569, 15 RCTs) and dynamic (MD: -42.90, 95% CI: -68.42-17.38) (n = 444, 11 RCTs) pain scores at 48 hours. TEA also significantly reduced static (MD: -13.05, 95% CI: -22.74-3.36) and dynamic (MD: -18.08, 95% CI: -31.70-4.40) pain scores at 48 hours post-operatively, as well as reducing opioid consumption at 24 hours (MD: -33.20, 95% CI: -60.57-5.83) and 48 hours (MD: -42.66, 95% CI: -59.45-25.88). Moreover, TEA significantly shortened intensive care unit (ICU) stays (MD: -5.00, 95% CI: -6.82-3.18) and time to extubation (MD: -4.40, 95% CI: -5.91-2.89) while increased post-operative forced vital capacity (MD: 9.89, 95% CI: 0.91-18.87) and forced expiratory volume (MD: 13.87, 95% CI: 0.87-26.87). TEA provides optimal pain control and improved post-operative respiratory function in patients post-esophagectomy, reducing ICU stays, one of the benchmarks of improved post-operative recovery. IPA demonstrates promising results for potential implementation in the future following esophagectomy.
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Affiliation(s)
- Sinead Ramjit
- Department of Surgery, Trinity College Dublin, Dublin, Ireland
| | - Matthew G Davey
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Caitlyn Loo
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Brendan Moran
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Eanna J Ryan
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - William B Robb
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Noel E Donlon
- Department of Surgery, Trinity College Dublin, Dublin, Ireland
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
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13
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Lee B, Jang J, Lim JR, Kim EJ, Kim D, Chun YM, Choi YS. Continuous Superior Trunk Block versus Single-Shot Superior Trunk Block with Intravenous Dexmedetomidine for Postoperative Analgesia in Arthroscopic Shoulder Surgery: A Prospective Randomized Controlled Trial. J Clin Med 2024; 13:1845. [PMID: 38610610 PMCID: PMC11012364 DOI: 10.3390/jcm13071845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/12/2024] [Accepted: 03/19/2024] [Indexed: 04/14/2024] Open
Abstract
Background/Objectives: Intravenous dexmedetomidine (DEX) can increase the analgesia duration of peripheral nerve block; however, its effect in combination with superior trunk block (STB) remains unclear. We examined whether combining single-shot STB (SSTB) with intravenous DEX would provide noninferior postoperative analgesia comparable to that provided by continuous STB (CSTB). Methods: Ninety-two patients scheduled for elective arthroscopic rotator cuff repair were enrolled in this prospective randomized trial. Patients were randomly assigned to the CSTB or SSTB + DEX group. Postoperatively, each CSTB group patient received 15 mL of 0.5% ropivacaine and a continuous 0.2% ropivacaine infusion. Each SSTB group patient received a 15 mL postoperative bolus injection of 0.5% ropivacaine. DEX was administered at 2 mcg/kg for 30 min post anesthesia, then maintained at 0.5 mcg/kg/h till surgery ended. Pain scores were investigated every 12 h for 48 h post operation, with evaluation of rebound pain incidence and opioid consumption. Results: The SSTB + DEX group had significantly higher median pain scores at 12 h post operation (resting pain, 8.0 vs. 3.0; movement pain, 8.0 vs. 5.0) and a higher incidence of rebound pain (56% vs. 20%) than the CSTB group. However, no significant between-group differences were observed in pain scores postoperatively at 24, 36, or 48 h. The CSTB group required less opioids and fewer rescue analgesics within 12-24 h post operation than the SSTB + DEX group. Conclusions: Compared with CSTB, SSTB + DEX required additional adjuvant or multimodal analgesics to reduce the risk and intensity of postoperative rebound pain in patients who underwent arthroscopic rotator cuff repair.
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Affiliation(s)
- Bora Lee
- Department of Anesthesiology and Pain Medicine, Severance Hospital and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seoul 03722, Republic of Korea
| | - Jaewon Jang
- Department of Anesthesiology and Pain Medicine, Severance Hospital and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seoul 03722, Republic of Korea
| | - Joon-Ryul Lim
- Department of Orthopedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Eun Jung Kim
- Department of Anesthesiology and Pain Medicine, Severance Hospital and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seoul 03722, Republic of Korea
| | - Donghu Kim
- Department of Anesthesiology and Pain Medicine, Severance Hospital and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seoul 03722, Republic of Korea
| | - Yong-Min Chun
- Department of Orthopedic Surgery, Arthroscopy and Joint Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Yong Seon Choi
- Department of Anesthesiology and Pain Medicine, Severance Hospital and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seoul 03722, Republic of Korea
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14
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Luo Z, Zeng W, Chen X, Xiao Q, Chen A, Chen J, Wang H, Zhou Z. Cocktail of Ropivacaine, Morphine, and Diprospan Reduces Pain and Prolongs Analgesic Effects after Total Knee Arthroplasty: A Prospective Randomized Controlled Trial. Int J Clin Pract 2024; 2024:3697846. [PMID: 38450292 PMCID: PMC10917473 DOI: 10.1155/2024/3697846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 11/26/2023] [Accepted: 01/17/2024] [Indexed: 03/08/2024] Open
Abstract
Background Local infiltration analgesia (LIA) provides postoperative analgesia for total knee arthroplasty (TKA). The purpose of this study was to evaluate the analgesic effect of a cocktail of ropivacaine, morphine, and Diprospan for TKA. Methods A total of 100 patients from September 2018 to February 2019 were randomized into 2 groups. Group A (control group, 50 patients) received LIA of ropivacaine alone (80 ml, 0.25% ropivacaine). Group B (LIA group, 50 patients) received an LIA cocktail of ropivacaine, morphine, and Diprospan (80 ml, 0.25% ropivacaine, 0.125 mg/ml morphine, and 62.5 μg/ml compound betamethasone). The primary outcomes were the levels of inflammatory markers C-reactive protein (CRP) and interleukin-6 (IL-6), pain visual analog scale (VAS) scores, opioid consumption, range of motion (ROM), functional tests, and sleeping quality. The secondary outcomes were adverse events, satisfaction rates, HSS scores, and SF-12 scores. The longest follow-up was 2 years. Results The two groups showed no differences in terms of characteristics (P > 0.05). Group B had lower resting VAS pain scores (1.54 ± 0.60, 95% CI = 1.37 to 1.70 vs. 2.00 ± 0.63, 95% CI = 2.05 to 2.34) and active VAS pain scores (2.64 ± 0.62, 95% CI = 2.46 to 2.81 vs. 3.16 ± 0.75, 95% CI = 2.95 to 3.36) within 48 h postoperatively than Group A (P < 0.001), while none of the pain differences exceeded the minimal clinically important difference (MCID). Group B had significantly lower CRP levels (59.49 ± 13.01, 95% CI = 55.88 to 63.09 vs. 65.95 ± 14.41, 95% CI = 61.95 to 69.94) and IL-6 levels (44.11 ± 13.67, 95% CI = 40.32 to 47.89 vs. 60.72 ± 15.49, 95% CI = 56.42 to 65.01), lower opioid consumption (7.60 ± 11.10, 95% CI = 4.52 to 10.67 vs. 13.80 ± 14.68, 95% CI = 9.73 to 17.86), better ROM (110.20 ± 10.46, 95% CI = 107.30 to 113.09 vs. 105.30 ± 10.02, 95% CI = 102.52 to 108.07), better sleep quality (3.40 ± 1.03, 95% CI = 3.11 to 3.68 vs. 4.20 ± 1.06, 95% CI = 3.90 to 4.49), and higher satisfaction rates than Group A within 48 h postoperatively (P < 0.05). Adverse events, HSS scores, and SF-12 scores were not significantly different within 2 years postoperatively. Conclusions A cocktail of ropivacaine, morphine, and Diprospan prolongs the analgesic effect up to 48 h postoperatively. Although the small statistical benefit may not result in MCID, the LIA cocktail still reduces opioid consumption, results in better sleeping quality and faster rehabilitation, and does not increase adverse events. Therefore, cocktails of ropivacaine, morphine, and Diprospan have good application value for pain control in TKA. This trial is registered with ChiCTR1800018372.
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Affiliation(s)
- Zhenyu Luo
- Department of Orthopedics, Institute of Orthopedic Research, West China Hospital, West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Weinan Zeng
- Department of Orthopedics, Institute of Orthopedic Research, West China Hospital, West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Xi Chen
- Department of Operative Dentistry and Endodontics, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
| | - Qiang Xiao
- Department of Orthopedics, Institute of Orthopedic Research, West China Hospital, West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Anjing Chen
- Department of Orthopedics, Institute of Orthopedic Research, West China Hospital, West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Jiali Chen
- Department of Orthopedics, Institute of Orthopedic Research, West China Hospital, West China School of Medicine, Sichuan University, Chengdu 610041, China
- Department of Orthopedics, West China Hospital, West China School of Nursing, Sichuan University, Chengdu 610041, China
| | - Haoyang Wang
- Department of Orthopedics, Institute of Orthopedic Research, West China Hospital, West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Zongke Zhou
- Department of Orthopedics, Institute of Orthopedic Research, West China Hospital, West China School of Medicine, Sichuan University, Chengdu 610041, China
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15
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Wang T, Wang X, Yu Z, Li M. Programmed Intermittent Bolus for Erector Spinae Plane Block Versus Intercostal Nerve Block With Patient-controlled Intravenous Analgesia in Video-assisted Thoracoscopic Surgery: A Randomized Controlled Noninferiority Trial. Clin J Pain 2024; 40:99-104. [PMID: 37975501 PMCID: PMC10779491 DOI: 10.1097/ajp.0000000000001174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 10/21/2023] [Accepted: 10/30/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVE Postoperative analgesia is crucial after video-assisted thoracoscopic surgery (VATS). This study was designed to investigate whether the analgesic effect of programmed intermittent bolus (PIB) erector spinae plane block (ESPB) is noninferior to that of intercostal nerve block with patient-controlled intravenous analgesia (ICNB-PCIA) for VATS. METHODS The study was a single-center, open labeled, randomized noninferiority trial. A total of 80 patients (American Society of Anesthesiologists I to III) undergoing elective video-assisted thoracoscopic lobectomy or bulla resection were randomly allocated to the ICNB-PCIA (n=40) or the ESPB (n=40) group using a PIB injection. The primary outcome was pain intensity at movement at 4 hours postoperatively using the Numeric Rating Scale (NRS). Secondary outcomes included pain scores at rest and movement in the recovery room, at 8, 24, and 48 hours postoperatively, perioperative analgesics, adverse effects, hospital stay, and patient satisfaction. RESULTS The mean difference in NRS scores at movement at 4 hours postoperatively between the ESPB (n=39) and the ICNB-PCIA (n=37) groups was under the noninferiority margin. NRS scores were significantly higher in the ICNB-PCIA group than the ESPB group at movement postoperatively. At rest, NRS scores were significantly elevated in the ICNB-PCIA at 4, 8, and 24 hours. The postoperative opioids consumption was decreased in the ESPB group. No difference was found in rescue analgesics, hospital stay, and patient satisfaction. DISCUSSION ESPB using a PIB injection offers noninferior analgesia to ICNB-PCIA after VATS.
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16
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Korkusuz M, Basaran B, Et T, Bilge A, Yarimoglu R, Kurucay Y. The effects of dexamethasone added to ilioinguinal/iliohypogastric nerve (IIN/IHN) block on rebound pain in inguinal hernia surgery: a randomized controlled trial. Hernia 2023; 27:1571-1580. [PMID: 37477788 DOI: 10.1007/s10029-023-02841-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/09/2023] [Indexed: 07/22/2023]
Abstract
PURPOSE The purpose of the present study was to evaluate the effects of IV dexamethasone added to one single injection Ilioinguinal/Iliohypogastric Nerve (IIN/IHN) block on tramadol consumption and Modified Rebound Pain Score (MRPS) in the first postoperative 24 h in inguinal hernia surgery. METHODS Five mg IV dexamethasone as an analgesic adjunct in the multimodal analgesia was administered to the patients who were scheduled for Inguinal Hernia Surgery and randomized to Group Dex and normal saline was administered to the patients who were randomized to the Control Group in addition to IIN/IHN Block. Postoperative tramadol consumption, Modified Rebound Pain Score (MRPS), the incidence of Rebound Pain, Rebound Pain time, postoperative 48-h opioid consumption, Numerical Rating Scale (NRS) scores, Quality of Recovery Score (QoR-15), Sleep Quality, and adverse events were evaluated in the patients. RESULTS The mean scores of MRPS were lower in Group Dex than in the Control Group, both at rest (p = 0.001) and with motion (p = 0.001). Tramadol consumption in the first postoperative 24 h was 45.17 ± 49.59 mg in Group Dex and 95 ± 59.23 mg in the Control Group. The difference between the groups was statistically significant (p < 0.001). CONCLUSIONS In conclusion, adding IV dexamethasone as a part of multimodal analgesia to IIN/IHN block for inguinal hernia surgery resulted in lower MRPS and lower postoperative opioid (tramadol) consumption. For this reason, IV dexamethasone can be added to the IIN/IHN block after inguinal hernia surgery to reduce the incidence of rebound pain, rebound pain scores, and NRS scores for pain, decrease postoperative opioid consumption, and improve the quality of recovery. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov: Ref; NCT05172908, Date: December 29, 2021.
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Affiliation(s)
- Muhammet Korkusuz
- Department of Anesthesiology and Reanimation, Karamanoglu Mehmetbey University School of Medicine, Karaman, Turkey.
| | - Betul Basaran
- Department of Anesthesiology and Reanimation, Karamanoglu Mehmetbey University School of Medicine, Karaman, Turkey
| | - Tayfun Et
- Department of Anesthesiology and Reanimation, Karamanoglu Mehmetbey University School of Medicine, Karaman, Turkey
| | - Aysegul Bilge
- Department of Anesthesiology and Reanimation, Karamanoglu Mehmetbey University School of Medicine, Karaman, Turkey
| | - Rafet Yarimoglu
- Department of Anesthesiology and Reanimation, Karaman Training and Research Hospital, Karaman, Turkey
| | - Yıldıray Kurucay
- Department of Surgery, Karaman Training and Research Hospital, Karaman, Turkey
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17
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Lee JH, Kim HJ, Kim JK, Cheon S, Shin YH. Does intravenous patient-controlled analgesia or continuous block prevent rebound pain following infraclavicular brachial plexus block after distal radius fracture fixation? A prospective randomized controlled trial. Korean J Anesthesiol 2023; 76:559-566. [PMID: 37089120 PMCID: PMC10718626 DOI: 10.4097/kja.23076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/17/2023] [Accepted: 04/23/2023] [Indexed: 04/25/2023] Open
Abstract
BACKGROUND The purpose of this study was to investigate the role of opioid-based intravenous patient-controlled analgesia (IV PCA) or continuous brachial plexus block (BPB) in controlling rebound pain after distal radius fracture (DRF) fixation under BPB as well as total opioid consumption. METHODS A total of 66 patients undergoing surgical treatment for a displaced DRF with volar plate fixation were randomized to receive a single infraclavicular BPB (BPB only group) (n = 22), a single infraclavicular BPB with IV PCA (IV PCA group) (n = 22), or a single infraclavicular BPB with continuous infraclavicular BPB (continuous block group) (n = 22). The visual analog scale (VAS) for pain and the amount of pain medication were recorded at 4, 6, 9, 12, 24, and 48 h and two weeks postoperatively. RESULTS At postoperative 9 h, the pain VAS score was significantly higher in the BPB only group (median: 2; Q1, Q3 [1, 3]) than in the IV PCA (0 [0, 1.8], P = 0.006) and continuous block groups (0 [0, 0.5], P = 0.009). At postoperative 12 h, the pain VAS score was significantly higher in the BPB only group (3 [3, 4]) than in the continuous block group (0.5 [0, 3], P = 0.004). The total opioid equivalent consumption (OEC) was significantly higher in the IV PCA group (350.3 [282.1, 461.3]) than in the BPB only group (37.5 [22.5, 75], P < 0.001) and continuous block group (30 [15, 75], P < 0.001); however, OEC was not significantly different between the BPB only group and the continuous block group (P = 0.595). CONCLUSIONS Although continuous infraclavicular BPB did not reduce total opioid consumption compared to BPB only, this method is effective for controlling rebound pain at postoperative 9 and 12 h following DRF fixation under BPB.
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Affiliation(s)
- Jong-hyuk Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ha-jung Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Kwang Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sungjoo Cheon
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Ho Shin
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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18
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Et T, Basaran B, Bilge A, Yarımoğlu R, Korkusuz M, Tülüce İ. Rebound pain after interscalene brachial plexus block for shoulder surgery: a randomized clinical trial of the effect of different multimodal analgesia regimens. Ann Saudi Med 2023; 43:339-347. [PMID: 38071444 PMCID: PMC11182429 DOI: 10.5144/0256-4947.2023.339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 10/09/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Rebound pain is characterized by sudden, significant acute postoperative pain occurring after the resolution of inter-scalene block (ISB); it affects the quality of recovery postoperatively. Dexamethasone increases ISB resolution time and decreases opioid consumption and the incidence of rebound pain. OBJECTIVE Evaluate whether multimodal analgesia including intravenous dexamethasone administration with preoperative ISB reduces the incidence of rebound pain. DESIGN Prospective, randomized, controlled trial. SETTING Tertiary university hospital. SAMPLE SIZE 60 patients. PATIENTS AND METHODS Patients who underwent shoulder surgery under general anesthesia were assigned randomly to two different multimodal analgesia protocols. Thirty patients received 5 mg IV dexamethasone with non-steroid, paracetamol, and ISB with 15 mL 0.5% bupivacaine, while the control patients received the same regimen and ISB with 15 mL 0.5% bupivacaine without dexamethasone. Postoperative opioids were given to any patient on demand. MAIN OUTCOMES MEASURES Effect of IV dexamethasone on pain score and incidence of rebound pain after ISB resolution and postoperative opioid consumption at 0-48 hours, numerical pain rating scale (NPRS) scores, sleep scale scores, and quality of recovery-15 scores (QoR-15). RESULTS The incidence of rebound pain was lower in the dexamethasone group than in the control group (73.3% and 30%, respectively, P=.001). NPRS scores after ISB resolution were lower in the dexamethasone group (5 ([4-7]), 8 ([5.75-8]), P<.001, respectively). Those who received IV dexamethasone had less sleep disturbances (P<.001) and higher QoR-15 on day 1 (P<.001) and day 7 (P=.020) postoperatively. CONCLUSIONS IV dexamethasone added to the ISB block resulted in a lower incidence of rebound pain. In addition, better results were obtained in postoperative sleep quality and QoR-15. LIMITATIONS Single-center study.
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Affiliation(s)
- Tayfun Et
- From the Department of Anesthesiology and Intensive Care Medicine, Karamanoglu Mehmetbey University, Karaman, Turkey
| | - Betul Basaran
- From the Department of Anesthesiology and Intensive Care Medicine, Karamanoglu Mehmetbey University, Karaman, Turkey
| | - Aysegul Bilge
- From the Department of Anesthesiology and Intensive Care Medicine, Karamanoglu Mehmetbey University, Karaman, Turkey
| | - Rafet Yarımoğlu
- From the Department of Anesthesiology and Intensive Care Medicine, Karamanoglu Mehmetbey University, Karaman, Turkey
| | - Muhammet Korkusuz
- From the Department of Anesthesiology and Intensive Care Medicine, Karamanoglu Mehmetbey University, Karaman, Turkey
| | - İbrahim Tülüce
- From the Department of Orthopedics and Traumatology, Karaman Training and Research Hospital, Karaman, Turkey
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19
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Cunningham D, LaRose M, Patel P, Zhang G, Morriss N, Paniagua A, Gage M. Regional anesthesia improves inpatient but not outpatient opioid demand in tibial shaft fracture surgery. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:2921-2931. [PMID: 36912951 DOI: 10.1007/s00590-023-03504-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 02/26/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Patients undergoing operative treatment of tibial shaft fractures have considerable pain largely managed with opioids. Regional anesthesia (RA) has been increasingly used to reduce perioperative opioid use. METHODS This was a retrospective study of 426 patients that underwent operative treatment of tibial shaft fractures with and without RA. Inpatient opioid consumption and 90-day outpatient opioid demand were measured. RESULTS RA significantly decreased inpatient opioid consumption for 48 h post-operatively (p = 0.008). Neither inpatient use after 48 h nor outpatient opioid demand differed in patients with RA (p > 0.05). CONCLUSIONS RA may help with inpatient pain control and reduce opioid use in tibial shaft fracture. LEVEL OF EVIDENCE Level III, retrospective, therapeutic cohort study.
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Affiliation(s)
- Daniel Cunningham
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
| | - Micaela LaRose
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA
| | - Preet Patel
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA
| | - Gloria Zhang
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA
| | - Nicholas Morriss
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA.
| | - Ariana Paniagua
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA
| | - Mark Gage
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
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20
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Luebbert E, Rosenblatt MA. Postoperative Rebound Pain: Our Current Understanding About the Role of Regional Anesthesia and Multimodal Approaches in Prevention and Treatment. Curr Pain Headache Rep 2023; 27:449-454. [PMID: 37389683 DOI: 10.1007/s11916-023-01136-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2023] [Indexed: 07/01/2023]
Abstract
PURPOSE OF REVIEW Rebound pain (RP) is a common occurrence after peripheral nerve block placement, especially when blocks are used for orthopedic surgery. This literature review focuses on the incidence and risk factors for RP as well as preventative and treatment strategies. RECENT FINDINGS The addition of adjuvants to a block, when appropriate, and starting patients on oral analgesics prior to sensory resolution are reasonable approaches. Using continuous nerve block techniques can provide extended analgesia through the immediate postoperative phase when pain is the most intense. Peripheral nerve blocks (PNBs) are associated with RP, a frequent phenomenon that must be recognized and addressed to prevent short-term pain and patient dissatisfaction, as well as long-term complications and avoidable hospital resource utilization. Knowledge about the advantages and limitations of PNBs allows the anesthesiologists to anticipate, intervene, and hopefully mitigate or avoid the phenomenon of RP.
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Affiliation(s)
- Elizabeth Luebbert
- Department of Anesthesiology, Perioperative, and Pain Medicine, Mount Sinai Morningside and West Hospitals, New York, NY, USA
| | - Meg A Rosenblatt
- Department of Anesthesiology, Perioperative, and Pain Medicine, Mount Sinai Morningside and West Hospitals, New York, NY, USA.
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21
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Lee HJ, Woo JH, Chae JS, Kim YJ, Shin SJ. Intravenous Versus Perineural Dexamethasone for Reducing Rebound Pain After Interscalene Brachial Plexus Block: A Randomized Controlled Trial. J Korean Med Sci 2023; 38:e183. [PMID: 37337808 DOI: 10.3346/jkms.2023.38.e183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 02/24/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Interscalene brachial plexus block (ISB) is a common regional technique to manage acute postoperative pain for arthroscopic rotator cuff tear repair. However, rebound pain may compromise its overall benefit. Our aim was to investigate the primary hypothesis that perineural and intravenous dexamethasone have different effects on rebound pain after resolution of ISB for arthroscopic rotator cuff tear repair. METHODS Patients aged ≥ 20 years scheduled for elective arthroscopic rotator cuff tear repair under general anesthesia with preoperative ISB were included. The participants were randomized to receive dexamethasone either perineurally (perineural group) or intravenously (intravenous group). In the perineural group, patients received ISB with 12 mL of 0.5% ropivacaine containing 5 mg of dexamethasone; simultaneously, 1 mL of 0.9% normal saline was administered intravenously. In the intravenous group, patients received ISB with 12 mL of 0.5% ropivacaine; simultaneously, 1 mL of dexamethasone 5 mg was administered intravenously. The primary outcome was the difference in the pain score (0-10 on numeric rating scale) between before and after ISB resolution. The secondary outcomes were the incidence of rebound pain; onset, duration, and intensity of rebound pain; time to the first analgesic request; and pain-related sleep disturbance. RESULTS A total of 71 patients were randomized to either perineural group (n = 36) or intravenous group (n = 35). After block resolution, pain scores increased significantly more in the perineural group (mean ± standard deviation, 4.9 ± 2.1) compared to the intravenous group (4.0 ± 1.7, P = 0.043). The duration of ISB was more prolonged in the perineural group (median [interquartile range], 19.9 [17.2-23.1] hours) than the intravenous group (15.1 [13.7-15.9] hours, P < 0.001). The incidence of rebound pain and pain-related sleep disturbance during the first postoperative week was significantly higher in the perineural group than in the intravenous group (rebound pain: 44.4% vs. 20.0%, P = 0.028; sleep disturbance: 55.6% vs. 25.7%, P = 0.011). The duration and intensity of rebound pain were similar between the two groups. CONCLUSION Although perineural dexamethasone provided longer postoperative analgesia, intravenous dexamethasone was more beneficial in reducing pain increase after ISB resolution, incidence of rebound pain, and pain-related sleep disturbance. TRIAL REGISTRATION Clinical Research Information Service Identifier: KCT0006795.
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Affiliation(s)
- Hyun Jung Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University Seoul Hospital, Seoul, Korea
| | - Jae Hee Woo
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University Seoul Hospital, Seoul, Korea.
| | - Ji Seon Chae
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University Seoul Hospital, Seoul, Korea
| | - Youn Jin Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University Seoul Hospital, Seoul, Korea
| | - Sang-Jin Shin
- Department of Orthopedic Surgery, College of Medicine, Ewha Womans University Seoul Hospital, Seoul, Korea
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22
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Dubilet M, Gruenbaum BF, Semyonov M, Ishay SY, Osyntsov A, Friger M, Geftler A, Zlotnik A, Brotfain E. Erector Spinae Plane (ESP) Block for Postoperative Pain Management after Open Oncologic Abdominal Surgery. Pain Res Manag 2023; 2023:9010753. [PMID: 37360747 PMCID: PMC10287517 DOI: 10.1155/2023/9010753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 05/28/2023] [Accepted: 06/02/2023] [Indexed: 06/28/2023]
Abstract
Patients undergoing abdominal oncologic surgical procedures require particular surgical and anesthesiologic considerations. Traditional pain management, such as opiate treatment, continuous epidural analgesia, and non-opioid drugs, may have serious side effects in this patient population. We evaluated erector spinae plane (ESP) blocks for postoperative pain management following elective oncologic abdominal surgeries. In this single-center, prospective, and randomized study, we recruited 100 patients who underwent elective oncological abdominal surgery between December 2020 and January 2022 at Soroka University Medical Center in Beer Sheva, Israel. We compared postoperative pain levels in patients who were treated with a preincisional ESP block in addition to traditional pain management with intravenous opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and acetaminophen, compared to patients who were only given traditional pain management (control). Patients who were treated with a preincisional ESP block demonstrated significantly lower Visual Analog Scale scores at 60 minutes and 4, 8, and 12 hours following the surgery, compared to the control group (p < 0.001). Accordingly, patients in the ESP group required less morphine from 60 minutes to 12 hours after surgery, but they required increased non-opioid postoperative analgesia management at 4, 8, and 12 hours after surgery (p from 0.002 to <0.001) compared to the control group. In this study, we found ESP blocks to be a safe, technically simple, and effective treatment for postoperative pain management after elective oncologic abdominal procedures.
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Affiliation(s)
- Michael Dubilet
- Department of Anesthesiology and Critical Care, General Intensive Care Unit, Soroka Medical Center, Faculty of Health Science, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Benjamin F. Gruenbaum
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Michael Semyonov
- Department of Anesthesiology and Critical Care, General Intensive Care Unit, Soroka Medical Center, Faculty of Health Science, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Shlomo Yaron Ishay
- Department of Cardiothoracic Surgery, Soroka Medical Center, Faculty of Health Science, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Anton Osyntsov
- Department of General Surgery B, Soroka Medical Center, Faculty of Health Science, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Michael Friger
- Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Alexander Geftler
- Department of Orthopedic Surgery, Soroka Medical Center, Faculty of Health Science, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Alexander Zlotnik
- Department of Anesthesiology and Critical Care, General Intensive Care Unit, Soroka Medical Center, Faculty of Health Science, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Evgeni Brotfain
- Department of Anesthesiology and Critical Care, General Intensive Care Unit, Soroka Medical Center, Faculty of Health Science, Ben-Gurion University of the Negev, Beer Sheva, Israel
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23
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Domagalska M, Wieczorowska-Tobis K, Reysner T, Geisler-Wojciechowska A, Grochowicka M, Kowalski G. Pericapsular Nerves Group (PENG) Block in Children under Five Years of Age for Analgesia in Surgery for Hip Dysplasia: Case Report. J Pers Med 2023; 13:454. [PMID: 36983637 PMCID: PMC10059249 DOI: 10.3390/jpm13030454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 03/05/2023] Open
Abstract
INTRODUCTION The Pericapsular Nerve Group (PENG) block is a novel technique that allows for analgesia of the anterior hip capsule via the articular branches of the accessory obturator nerve and femoral nerve, which have a significant role in the innervation of the hip capsule. A PENG (Pericapsular Nerves Group) blockade is effective in both adult and pediatric patients. However, no studies on patients under five are available in the literature. Herein, we describe our experience with two pediatric patients with hip dysplasia. PURPOSE This study aimed to evaluate the analgesic effect of the pericapsular nerves group (PENG) in preschool children undergoing hip surgery. PATIENTS AND METHODS This study included two patients, aged 4 and 2 years old, who were qualified for hip surgery. Spinal or general anesthesia with the addition of a PENG block was performed. During the procedure, the basic hemodynamic parameters were monitored. The pain was assessed using the FALCC (Face, Legs, Activity, Cry, Consolability scale) score. A dose of 15 mg/kg-1 of metamizole was administered if the FLACC score was 3. In the case of a score of 4 on the FLACC scale, the application of 0.2 mg/kg-1 of nalbuphine was ordered. RESULTS After the surgery, the patients received 15 mg/kg-1 IV paracetamol every 6 h to prevent rebound pain. The patient's hemodynamic parameters were stable and within normal range. In the first 24 h period, the FLACC scores from all patients ranged from 0 to 3. One patient required metamizole 12 h after surgery. No evidence of block complications was observed. CONCLUSIONS This case series showed that the PENG block assured opioid-free pain management and provided adequate postoperative analgesia. However, we are convinced that future randomized, controlled trials are needed in this field.
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Affiliation(s)
- Małgorzata Domagalska
- Chair and Department of Palliative Medicine, University of Medical Sciences, 61-701 Poznań, Poland
| | | | - Tomasz Reysner
- Department of Anesthesiology and Intensive Care, W.Dega Orthopedic and Rehabilitation Clinical Hospital, University of Medical Sciences, 61-545 Poznań, Poland
| | | | - Monika Grochowicka
- Chair and Department of Palliative Medicine, University of Medical Sciences, 61-701 Poznań, Poland
| | - Grzegorz Kowalski
- Chair and Department of Palliative Medicine, University of Medical Sciences, 61-701 Poznań, Poland
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24
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Kang R, Ko JS. Recent updates on interscalene brachial plexus block for shoulder surgery. Anesth Pain Med (Seoul) 2023; 18:5-10. [PMID: 36746896 PMCID: PMC9902626 DOI: 10.17085/apm.22254] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 12/20/2022] [Indexed: 01/11/2023] Open
Abstract
Interscalene brachial plexus block (ISBPB) provides optimal analgesia for shoulder surgery. However, several limitations still exist, including the short duration of analgesia, rebound pain, a high incidence of unilateral diaphragmatic paresis, and potential risk of nerve damage, prompting the search for alternative techniques. Many alternatives to ISBPB have been studied to alleviate these concerns, and clinicians should choose an appropriate option based on the patient's condition. In this mini-review, we aimed to present recent updates on ISBPB while discussing our clinical experiences in shoulder surgery.
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Affiliation(s)
| | - Justin Sangwook Ko
- Corresponding author: Justin Sangwook Ko, M.D., Ph.D. Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea Tel: 82-2-3410-2454 Fax: 82-2-3410-0361 E-mail:
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25
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Zhu Y, Li Q, Liu G, Sheng F, Zhang X, Jiang L, Li S, He J, Zou Z, Zhang B, Wang C, Jiang X, Zhao Y. Effects of esketamine on postoperative rebound pain in patients undergoing unilateral total knee arthroplasty: a single-center, randomized, double-blind, placebo-controlled trial protocol. Front Neurol 2023; 14:1179673. [PMID: 37181565 PMCID: PMC10174246 DOI: 10.3389/fneur.2023.1179673] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 04/10/2023] [Indexed: 05/16/2023] Open
Abstract
Introduction Rebound pain, transient and acute postoperative pain after the disappearance of regional block anesthesia, has been a concern in recent years. Insufficient preemptive analgesia and hyperalgesia induced by regional block are the main mechanisms. At present, the evidence for the treatment of rebound pain is limited. The esketamine, as an antagonist of the N-methyl-D-aspartate receptor, has been proven to prevent hyperalgesia. Therefore, this trial aims to evaluate the impact of esketamine on postoperative rebound pain in patients undergoing total knee arthroplasty. Methods/design This study is a single-center, prospective, double-blind, randomized, placebo-controlled trial. Participants who plan to undergo total knee arthroplasty will be randomly assigned to the esketamine group (N = 178) and placebo group (N = 178) in a ratio of 1:1. This trial aims to evaluate the impact of esketamine on postoperative rebound pain in patients undergoing total knee arthroplasty. The primary outcome of this trial is the incidence of rebound pain within 12 h after the operation in the esketamine group and the placebo group. The secondary outcome will be to compare (1) the incidence of rebound pain 24 h after the operation; (2) the time to enter the pain cycle for the first time within 24 h after the procedure; (3) the first time of rebound pain occurred within 24 h after surgery; (4) the modified rebound pain score; (5) NRS score under rest and exercise at different time points; (6) the cumulative opioid consumption at different time points; (7) patient's prognosis and knee joint function evaluation; (8) blood glucose and cortisol concentration; (9) patient's satisfaction score; (10) adverse reactions and adverse events. Discussion The effect of ketamine on preventing postoperative rebound pain is contradictory and uncertain. The affinity of esketamine to the N-methyl-D-aspartate receptor is about four times higher than levo-ketamine, the analgesic effect is 3 times higher than levo-ketamine, and there are fewer adverse mental reactions. To our knowledge, there is no randomized controlled trial to verify the impact of esketamine on postoperative rebound pain in patients undergoing total knee arthroplasty. Therefore, this trial is expected to fill an important gap in relevant fields and provide novel evidence for individualized pain management. Clinical Trial Registration http://www.chictr.org.cn, identifier ChiCTR2300069044.
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Affiliation(s)
- Youzhuang Zhu
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Qun Li
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Guilin Liu
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Fang Sheng
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xiaotian Zhang
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lili Jiang
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Shaona Li
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jianshuai He
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zhijin Zou
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Baobo Zhang
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Changyao Wang
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xin Jiang
- Phase I Clinical Trial Center, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yang Zhao
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China
- *Correspondence: Yang Zhao,
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26
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Bhatia P, Metta R. Rebound pain: Undesired, yet unexplored. J Anaesthesiol Clin Pharmacol 2022; 38:527-528. [PMID: 36778810 PMCID: PMC9912880 DOI: 10.4103/joacp.joacp_435_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 02/15/2022] [Indexed: 12/30/2022] Open
Affiliation(s)
- Pradeep Bhatia
- Department of Anaesthesiologyand Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Rajasekhar Metta
- Department of Anesthesiology, All India Institute of Medical Sciences, Mangalagiri, Andhra Pradesh, India
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Stone A, Lirk P, Vlassakov K. Rebound Pain After Peripheral Nerve Blockade-Bad Timing or Rude Awakening? Anesthesiol Clin 2022; 40:445-454. [PMID: 36049873 DOI: 10.1016/j.anclin.2022.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Patients who have perioperatively benefited from regional anesthesia frequently report moderate to severe pain when the nerve block effects fade away. Over the past years, the term "rebound pain" has been introduced, suggesting a specific pathologic process. It is debated whether significant pain on block resolution reflects a separate and distinct pathologic mechanism potentially involving proinflammatory and neurotoxic effects of local anesthetics, or is simply caused by the recovery of sensory function at a timepoint when nociceptive stimuli are still intense, and moderate to severe pain should be anticipated. In that latter case, the phenomenon referred to as rebound pain could be considered a failure of pain management providers to devise an adequate analgesia plan. Whatever the ultimate designation, management of rebound pain should be proactive, by implementing multimodal analgesia, or tailoring the blockade to the expected trajectory of postoperative pain and managing patient expectations accordingly. Until we know more about the etiology and impact of this phenomenon, the authors suggest a more neutral designation such as "pain on block resolution."
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Affiliation(s)
- Alexander Stone
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA; Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Philipp Lirk
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
| | - Kamen Vlassakov
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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Kwon HJ, Kim YJ, Lee D, Lee D, Kim D, Cho H, Kim DH, Lee JH, Jeong SM. Factors Associated with Rebound Pain After Patient-controlled Epidural Analgesia in Patients Undergoing Major Abdominal Surgery: A Retrospective Study. Clin J Pain 2022; 38:632-639. [PMID: 36037091 DOI: 10.1097/ajp.0000000000001067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 08/18/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Although patient-controlled epidural analgesia (PCEA) is an effective form of regional analgesia for abdominal surgery, some patients experience significant rebound pain after the discontinuation of PCEA. However, risk factors for rebound pain associated with PCEA in major abdominal surgery remain unknown. This study evaluated the incidence of rebound pain related to PCEA and explored potential associated risk factors. METHODS We performed a retrospective review of 236 patients using PCEA following hepatobiliary and pancreas surgery between 2018 and 2020 in a tertiary hospital in South Korea. Rebound pain was defined as an increase from well-controlled pain (numeric rating scale <4) during epidural analgesia to severe pain (numeric rating scale ≥7) within 24 hours of discontinuation of PCEA. Logistic regression analysis was performed to determine the factors associated with rebound pain. RESULTS A total of 236 patients were included in this study. Patients were categorized into the non-rebound pain group (170 patients; 72%) and the rebound pain group (66 patients; 28%). Multivariable logistic regression analysis revealed that preoperative prognostic nutritional index (PNI) below 45 (odds ratio [OR]=2.080, 95% confidential interval [CI]=1.061-4.079, P=0.033) and intraoperative transfusion (OR=4.190, 95% CI=1.436-12.226, P=0.009) were independently associated with rebound pain after PCEA discontinuation. DISCUSSION Rebound pain after PCEA occurred in approximately 30% of patients who underwent major abdominal surgery, resulting in insufficient postoperative pain management. Preoperative low PNI and intraoperative transfusion may be associated with rebound pain after PCEA discontinuation.
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Affiliation(s)
- Hyun-Jung Kwon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Yeon Ju Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Dokyeong Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Dongreul Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Dongseok Kim
- Department of Anesthesiology and Pain Medicine, Veterans Health Service Medical Center, Seoul, Republic of Korea
| | - Hakmoo Cho
- Department of Anesthesiology and Pain Medicine, Veterans Health Service Medical Center, Seoul, Republic of Korea
| | - Doo-Hwan Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Jong-Hyuk Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
| | - Sung-Moon Jeong
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul 05505, Republic of Korea
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Li YS, Chang KY, Lin SP, Chang MC, Chang WK. Group-based trajectory analysis of acute pain after spine surgery and risk factors for rebound pain. Front Med (Lausanne) 2022; 9:907126. [PMID: 36072941 PMCID: PMC9441669 DOI: 10.3389/fmed.2022.907126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 07/29/2022] [Indexed: 11/18/2022] Open
Abstract
Background This retrospective study was designed to explore the types of postoperative pain trajectories and their associated factors after spine surgery. Materials and methods This study was conducted in a single medical center, and patients undergoing spine surgery with intravenous patient-controlled analgesia (IVPCA) for postoperative pain control between 2016 and 2018 were included in the analysis. Maximal pain scores were recorded daily in the first postoperative week, and group-based trajectory analysis was used to classify the variations in pain intensity over time and investigate predictors of rebound pain after the end of IVPCA. The relationships between the postoperative pain trajectories and the amount of morphine consumption or length of hospital stay (LOS) after surgery were also evaluated. Results A total of 3761 pain scores among 547 patients were included in the analyses and two major patterns of postoperative pain trajectories were identified: Group 1 with mild pain trajectory (87.39%) and Group 2 with rebound pain trajectory (12.61%). The identified risk factors of the rebound pain trajectory were age less than 65 years (odds ratio [OR]: 1.89; 95% CI: 1.12–3.20), female sex (OR: 2.28; 95% CI: 1.24–4.19), and moderate to severe pain noted immediately after surgery (OR: 3.44; 95% CI: 1.65–7.15). Group 2 also tended to have more morphine consumption (p < 0.001) and a longer length of hospital stay (p < 0.001) than Group 1. Conclusion The group-based trajectory analysis of postoperative pain provides insight into the patterns of pain resolution and helps to identify unusual courses. More aggressive pain management should be considered in patients with a higher risk for rebound pain after the end of IVPCA for spine surgery.
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Affiliation(s)
- Yi-Shiuan Li
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Kuang-Yi Chang
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Pin Lin
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ming-Chau Chang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Orthopedics, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Kuei Chang
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- *Correspondence: Wen-Kuei Chang,
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Getachew M, Lerdal A, Småstuen MC, Gay CL, Aamodt A, Tesfaye M, Lindberg MF. Worst pain intensity and opioid intake during the early postoperative period were not associated with moderate-severe pain 12 months after total knee arthroplasty - a longitudinal study. Scand J Pain 2022; 23:364-371. [PMID: 35938939 DOI: 10.1515/sjpain-2022-0007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 07/05/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES There are several known predictors of pain after total knee arthroplasty (TKA). However, it is unclear whether acute postoperative pain intensity and postoperative opioid intake are associated with pain 12 months after TKA. Thus, the aim of this study was to assess whether worst pain intensity and opioid intake during the early postoperative period are associated with moderate-severe pain 12 months after TKA. METHODS A total of 202 patients undergoing primary TKA between October 2012 and September 2014 were prospectively enrolled. Age, sex, contralateral knee pain, BMI, physical status and opioid intake were collected preoperatively. Ketamine and daily opioid intake were collected on postoperative days (POD) 0-3. Using the Brief Pain Inventory, patients' "worst pain intensity" was measured preoperatively, on POD 0-4, and 12 months after TKA. Two logistic regression models evaluated the independent association of early postoperative pain intensity (model 1) and postoperative opioid intake (model 2) with moderate-severe pain 12 months after TKA, adjusting for possible confounders. RESULTS In total, 187 patients with data at the 12 month postoperative follow-up were included in this analysis. Pain intensity on POD2 and POD3, as well as preoperative pain and BMI, were significantly associated with pain at 12 months in univariate models. However, in multivariable models adjusted for preoperative pain and BMI, neither pain intensity on POD 0-4 (model 1) nor opioid intake on POD 0-3 (model 2) were associated with pain at 12 months. Preoperative pain was still significant in both models, but BMI remained significant only in model 2. CONCLUSIONS Worst pain intensity and opioid intake during the early postoperative period were not associated with moderate-severe pain 12 months after TKA when controlling for potential confounders. More research is needed to confirm these findings.
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Affiliation(s)
- Mestawet Getachew
- Department of Clinical Pharmacy, School of Pharmacy, Institute of Health, Jimma University, Jimma, Ethiopia.,Department of Nursing Science, Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Anners Lerdal
- Department of Interdisciplinary Health Sciences, Institute of Health and Scociety, Faculty of Medicine, University of Oslo, Oslo, Norway.,Research Department, Lovisenberg Diaconal Hospital, Oslo, Norway
| | - Milada Cvancarova Småstuen
- Research Department, Lovisenberg Diaconal Hospital, Oslo, Norway.,Faculty of Health Science, Oslo Metropolitan University, Oslo, Norway
| | - Caryl L Gay
- Research Department, Lovisenberg Diaconal Hospital, Oslo, Norway.,Department of Family Health Care Nursing, University of California, San Francisco, CA, USA
| | - Arild Aamodt
- Department of Orthopaedic Surgery, Lovisenberg Diaconal Hospital, Oslo, Norway
| | - Million Tesfaye
- Department of Anesthesiology, Faculty of Medicine, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Maren Falch Lindberg
- Department of Nursing Science, Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway.,Department of Orthopaedic Surgery, Lovisenberg Diaconal Hospital, Oslo, Norway
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31
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Cunningham DJ, Paniaugua AR, LaRose MA, DeLaura IF, Blatter MK, Gage MJ. Regional anesthesia does not decrease inpatient or outpatient opioid demand in distal femur fracture surgery. Arch Orthop Trauma Surg 2022; 142:1873-1883. [PMID: 33938985 DOI: 10.1007/s00402-021-03892-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 03/31/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Regional anesthesia (RA) is sometimes used to decrease pain and opioid consumption in distal femur fractures. However, the real-world impact of RA on inpatient opioid consumption and outpatient opioid demand is not well known. The hypothesis of this study is that RA would be associated with decreased inpatient opioid consumption and outpatient opioid demand. METHODS This study evaluated inpatient post-operative opioid consumption (0-24 h, 24-48 h, 48-72 h) and outpatient opioid demand (discharge to 2 weeks, 6 weeks, and 90 days) in all patients ages 18 and older undergoing operative treatment of distal femur fractures at a single institution from 7/2013 to 7/2018 (n = 230). Unadjusted and adjusted multivariable models were used to evaluate the impact of RA and other baseline patient and operative characteristics on inpatient opioid consumption and outpatient opioid demand. RESULTS Adjusted models demonstrated a small, significant increase in inpatient opioid consumption in patients with RA compared to no RA (4.7 estimated OE's without RA vs 6.2 OE's with RA from 24- to 48-h post-op, p < 0.05) but otherwise no significant differences at other timepoints (6.7 estimated OE's without RA vs 6.9 OE's with RA from 0- to 24-h post-op and 4.5 vs 4.4 from 48- to 72-h post-op, p > 0.05). Estimated cumulative outpatient opioid demand was significantly higher in patients with RA from discharge to 6 weeks and to 90 days (55.8 OE's without RA vs 63.9 with RA from discharge to 2 weeks, p > 0.05; 74.9 vs 95.1 OE's to 6 weeks, and 85 vs 113.1 OE's to 90 days, p < 0.05). DISCUSSION In distal femur fracture surgery, RA was associated with increased inpatient and outpatient opioid demand after adjusting for baseline patient and treatment characteristics. These results call into question the routine use of RA in distal femur fractures. LEVEL OF EVIDENCE Level III, retrospective, therapeutic cohort study.
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Affiliation(s)
- Daniel J Cunningham
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA.
| | - Ariana R Paniaugua
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA
| | - Micaela A LaRose
- Duke University School of Medicine, Duke University Medical Center, 3710, Durham, NC, 27710, USA
| | - Isabel F DeLaura
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
| | - Michael K Blatter
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
| | - Mark J Gage
- Department of Orthopaedic Surgery, Duke University Medical Center, 200 Trent Drive, Durham, NC, 27710, USA
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Exsteen OW, Svendsen CN, Rothe C, Lange KHW, Lundstrøm LH. Ultrasound-guided peripheral nerve blocks for preoperative pain management in hip fractures: a systematic review. BMC Anesthesiol 2022; 22:192. [PMID: 35729489 PMCID: PMC9210678 DOI: 10.1186/s12871-022-01720-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 05/30/2022] [Indexed: 11/18/2022] Open
Abstract
Systematic reviews associate peripheral nerve blocks based on anatomic landmarks or nerve stimulation with reduced pain and need for systemic analgesia in hip fracture patients. We aimed to investigate the effect of ultrasound-guided nerve blocks compared to conventional analgesia for preoperative pain management in hip fractures. Five databases were searched until June 2021 to identify randomised controlled trials. Two independent authors extracted data and assessed risk of bias. Data was pooled for meta-analysis and quality of evidence was evaluated using Grades of Recommendation Assessment, Development and Evaluation (GRADE). We included 12 trials (976 participants) comparing ultrasound-guided nerve blocks to conventional systemic analgesia. In favour of ultrasound, pain measured closest to two hours after block placement decreased with a mean difference of -2.26 (VAS 0 to 10); (p < 0.001) 95% CI [–2.97 to –1.55]. In favour of ultrasound, preoperative analgesic usage of iv. morphine equivalents in milligram decreased with a mean difference of –5.34 (p=0.003) 95% CI [–8.11 to –2.58]. Time from admission until surgery ranged from six hours to more than three days. Further, ultrasound-guided nerve blocks may be associated with a lower frequency of delirium: risk ratio 0.6 (p = 0.03) 95% CI [0.38 to 0.94], fewer serious adverse events: risk ratio 0.33 (p = 0.006) 95% CI [0.15 to 0.73] and higher patient satisfaction: mean difference 25.9 (VAS 0 to 100) (p < 0.001) 95% CI [19.74 to 32.07]. However, the quality of evidence was judged low or very low. In conclusion, despite low quality of evidence, ultrasound-guided blocks were associated with benefits compared to conventional systemic analgesia.
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Affiliation(s)
- Oskar Wilborg Exsteen
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital, Nordsjællands Hospital, Hillerød, Denmark.
| | - Christine Nygaard Svendsen
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital, Nordsjællands Hospital, Hillerød, Denmark
| | - Christian Rothe
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital, Nordsjællands Hospital, Hillerød, Denmark
| | - Kai Henrik Wiborg Lange
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital, Nordsjællands Hospital, Hillerød, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lars Hyldborg Lundstrøm
- Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital, Nordsjællands Hospital, Hillerød, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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33
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Jen TTH, Ke JXC, Wing KJ, Denomme J, McIsaac DI, Huang SC, Ree RM, Prabhakar C, Schwarz SKW, Yarnold CH. Development and internal validation of a multivariable risk prediction model for severe rebound pain after foot and ankle surgery involving single-shot popliteal sciatic nerve block. Br J Anaesth 2022; 129:127-135. [PMID: 35568510 DOI: 10.1016/j.bja.2022.03.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/20/2022] [Accepted: 03/28/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Rebound pain occurs after up to 50% of ambulatory surgeries involving regional anaesthesia. To assist with risk stratification, we developed a model to predict severe rebound pain after foot and ankle surgery involving single-shot popliteal sciatic nerve block. METHODS After ethics approval, we performed a single-centre retrospective cohort study. Patients undergoing lower limb surgery with popliteal sciatic nerve block from January 2016 to November 2019 were included. Exclusion criteria were uncontrolled pain in the PACU, use of a perineural catheter, or loss to follow-up. We developed and internally validated a multivariable logistic regression model for severe rebound pain, defined as transition from well-controlled pain in the PACU (numerical rating scale [NRS] 3 or less) to severe pain (NRS ≥7) within 48 h. A priori predictors were age, sex, surgery type, planned admission, local anaesthetic type, dexamethasone use, and intraoperative anaesthesia type. Model performance was evaluated using area under the receiver operating characteristic curve (AUROC), Nagelkerke's R2, scaled Brier score, and calibration slope. RESULTS The cohort included 1365 patients (mean [standard deviation] age: 50 [16] yr). The primary outcome was abstracted in 1311 (96%) patients, with severe rebound pain in 652 (50%). Internal validation revealed poor model performance, with AUROC 0.632 (95% confidence interval [CI]: 0.602-0.661; bootstrap optimisation 0.021), Nagelkerke's R2 0.063, and scaled Brier score 0.047. Calibration slope was 0.832 (95% CI: 0.623-1.041). CONCLUSIONS We show that a multivariable risk prediction model developed using routinely collected clinical data had poor predictive performance for severe rebound pain after foot and ankle surgery. Prospective studies involving other patient-related predictors are needed. CLINICAL TRIAL REGISTRATION NCT05018104.
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Affiliation(s)
- Tim T H Jen
- Department of Anesthesia, St Paul's Hospital/Providence Health Care, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada.
| | - Janny X C Ke
- Department of Anesthesia, St Paul's Hospital/Providence Health Care, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada; Department of Anesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
| | - Kevin J Wing
- Department of Orthopedics, University of British Columbia, Vancouver, BC, Canada
| | - Justine Denomme
- Department of Anesthesia, St Paul's Hospital/Providence Health Care, Vancouver, BC, Canada
| | - Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, ON, Canada; Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Shih-Chieh Huang
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada; Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ronald M Ree
- Department of Anesthesia, St Paul's Hospital/Providence Health Care, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Christopher Prabhakar
- Department of Anesthesia, St Paul's Hospital/Providence Health Care, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Stephan K W Schwarz
- Department of Anesthesia, St Paul's Hospital/Providence Health Care, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Cynthia H Yarnold
- Department of Anesthesia, St Paul's Hospital/Providence Health Care, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
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34
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[Rebound pain-From definition to treatment]. Anaesthesist 2022; 71:638-645. [PMID: 35513729 PMCID: PMC9352600 DOI: 10.1007/s00101-022-01120-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 11/21/2022]
Abstract
Hintergrund Rebound pain als Nebenwirkung einer Regionalanästhesie ist ein übermäßiges Schmerzempfinden nach Abklingen der Wirkung der lokalen Betäubung, welches deutlich über den normalen Wundschmerz nach einer Operation hinausgeht. Dieses Phänomen rückt seit ca. 10 Jahren stärker in den Fokus der Forschung. Die konkreten Ursachen sind bisher unklar, und es existieren auch noch keine zielgerichteten Therapieempfehlungen. Ziel der Arbeit Dieser Übersichtsartikel soll der Leserschaft einen Überblick über den aktuellen Stand der Forschung geben. Es werden die Theorien zur Pathophysiologie vorgestellt und Prophylaxe- sowie Behandlungsstrategien erläutert. Material und Methoden Für diese Übersichtsarbeit wurden die von 2005 bis Mai 2021 auf PubMed erschienenen Publikationen zum Thema Rebound pain durchgesehen und die Definitionen der Autoren zu Rebound pain sowie die Annahmen zur Pathophysiologie und Therapieempfehlungen zusammengefasst. Ergebnisse und Diskussion Insgesamt wurden 22 Originalarbeiten im Hinblick auf die Definition von Rebound pain, die Annahme der Entstehung sowie Therapieoptionen ausgewertet. Dabei zeigt sich, dass keine einheitliche Definition existiert, die Pathophysiologie nicht eindeutig geklärt ist und zum aktuellen Zeitpunkt auch noch keine klaren Empfehlungen zu Prophylaxe sowie Therapie gegeben werden können. Zusatzmaterial online Die Online-Version dieses Beitrags (10.1007/s00101-022-01120-z) enthält eine tabellarische Zusammenstellung über Studiendesign sowie Kernaussagen der vorgestellten Studien.
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Le-Short C, Katragadda K, Nagda N, Farris D, Gelter MH. Interventional Pain Management for the Pediatric Cancer Patient: A Literature Review. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9030389. [PMID: 35327761 PMCID: PMC8947062 DOI: 10.3390/children9030389] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/01/2022] [Accepted: 02/15/2022] [Indexed: 04/08/2023]
Abstract
This literature review examines the use of interventional treatments for pain management in pediatric cancer patients. While interventional procedures may be effective in cancer pain management, these procedures are infrequently employed in pediatric cohorts. This underutilization of interventional procedures may be supported by a deficit in randomized, controlled studies and literature regarding their role in pediatric cancer populations. Particularly because literature on the efficacy of interventional treatments in adult populations may not directly translate to pediatric populations, more research about the role of interventional procedures in managing pediatric cancer pain is necessary for a strengthened understanding of pediatric cancer pain treatment.
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Affiliation(s)
- Christina Le-Short
- Department of Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (D.F.); (M.H.G.)
- Correspondence:
| | - Kavya Katragadda
- Institute of Society and Genetics, The University of California, Los Angeles, CA 90095, USA;
| | - Neil Nagda
- Department of Anesthesiology, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA;
| | - David Farris
- Department of Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (D.F.); (M.H.G.)
| | - Marianne Halphen Gelter
- Department of Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (D.F.); (M.H.G.)
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Touil N, Pavlopoulou A, Barbier O, Libouton X, Lavand'homme P. Evaluation of intraoperative ketamine on the prevention of severe rebound pain upon cessation of peripheral nerve block: a prospective randomised, double-blind, placebo-controlled study. Br J Anaesth 2022; 128:734-741. [PMID: 35219449 DOI: 10.1016/j.bja.2021.11.043] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 11/21/2021] [Accepted: 11/29/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Pain after resolution of peripheral nerve block, known as 'rebound pain' (RP), is a major problem in outpatient surgery. The primary objective was to evaluate the benefit of intraoperative ketamine at an anti-hyperalgesic dose on the incidence of rebound pain after upper limb surgery under axillary plexus block in ambulatory patients. The secondary objective was to better understand the rebound pain phenomenon (individual risk factors). METHODS In this prospective, double-blind study, patients were randomised to receive either a single dose of i.v. ketamine (0.3 mg kg-1) or a placebo. Preoperative mechanical temporal summation and central sensitization inventory were applied to question underlying central sensitisation. Pain catastrophising and Douleur Neuropathique 4 questionnaires were used. Rebound pain was defined as pain intensity score >7 (numeric rating scale, 0-10) after block resolution. Postoperative pain was recorded at Days 1, 4, and 30 after discharge. RESULTS A total of 109 subjects completed the study, and 40.4% presented with rebound pain. Ketamine administration did not reduce rebound pain incidence or intensity. Temporal summation and central sensitisation inventory scores did not differ between subjects with and without rebound pain. The predictive risk factors were bone surgery (odds ratio [OR]=5.2; confidence interval [CI], 1.9-14.6), severe preoperative pain (OR=4.2; CI, 1.5-11.7), and high pain catastrophising (OR=4.8; CI, 1.0-22.3). At Day 30, the average daily pain was higher in the rebound pain group involving neuropathic characteristics. CONCLUSION Ketamine at an anti-hyperalgesic dose showed no benefit on rebound pain development. Although central sensitisation might not be involved, preoperative pain intensity, and catastrophising stand as risk factors. Because rebound pain remains frequent despite adequate procedure-specific postoperative analgesia, future studies should focus on patient-specific pain management.
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Affiliation(s)
- Nassim Touil
- Department of Anaesthesiology, Cliniques Universitaires St Luc, University Catholic of Louvain, Brussels, Belgium.
| | - Athanasia Pavlopoulou
- Department of Anaesthesiology, Cliniques Universitaires St Luc, University Catholic of Louvain, Brussels, Belgium
| | - Olivier Barbier
- Department of Orthopaedic Surgery, Cliniques Universitaires St Luc, University Catholic of Louvain, Brussels, Belgium
| | - Xavier Libouton
- Department of Orthopaedic Surgery, Cliniques Universitaires St Luc, University Catholic of Louvain, Brussels, Belgium
| | - Patricia Lavand'homme
- Department of Anaesthesiology, Cliniques Universitaires St Luc, University Catholic of Louvain, Brussels, Belgium
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Et T, Korkusuz M, Basaran B, Yarımoğlu R, Toprak H, Bilge A, Kumru N, Dedeli İ. Comparison of iPACK and periarticular block with adductor block alone after total knee arthroplasty: a randomized clinical trial. J Anesth 2022; 36:276-286. [PMID: 35157136 PMCID: PMC8853355 DOI: 10.1007/s00540-022-03047-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/01/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE The infiltration between the popliteal artery and the capsule of the posterior knee (iPACK) has been described to provide analgesia without loss of muscle strength and is effective in functional recovery. This study compared iPACK + ACB (adductor canal block) with PAI (periarticular infiltration) + ACB and ACB alone in terms of postoperative analgesia and functional improvement. METHODS This double-blinded randomized controlled trial included 105 patients undergoing unilateral total knee arthroplasty. Patients received ACB, iPACK + ACB, and PAI + ACB along with spinal anesthesia. The primary outcome was the area under the curve (AUC) numeric rating scale (NRS) at 48 h. Secondary outcomes were cumulative postoperative analgesic consumption within 48 h, timed up-and-go test, range of motion, length of hospital stay, patient satisfaction, and adverse events. RESULTS The 48-h AUC movement NRS score in the iPACK + ACB group was significantly lower than in the PAI + ACB and ACB groups (p < 0.05). At the postoperative 48th h, the opioid consumption of the iPACK + ACB group was lower than those of the ACB and PAI + ACB groups (p < 0.001). The patients in the iPACK + ACB group had significantly shorter discharge and mobilization days than the ACB and PAI + ACB groups (p < 0.001). CONCLUSIONS The adding of an iPACK block to the ACB improves postoperative analgesia and reduces opioid consumption. In addition, this approach improves functional performance and reduces hospital stay.
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Affiliation(s)
- Tayfun Et
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Karamanoglu Mehmetbey University, Karaman, Turkey.
- Department of Anesthesiology and Intensive Care Medicine, Karaman Training and Research Hospital, Karaman, Turkey.
| | - Muhammet Korkusuz
- Department of Anesthesiology and Intensive Care Medicine, Karaman Training and Research Hospital, Karaman, Turkey
| | - Betül Basaran
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Karamanoglu Mehmetbey University, Karaman, Turkey
| | - Rafet Yarımoğlu
- Department of Anesthesiology and Intensive Care Medicine, Karaman Training and Research Hospital, Karaman, Turkey
| | - Hatice Toprak
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Karamanoglu Mehmetbey University, Karaman, Turkey
| | - Ayşegül Bilge
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Karamanoglu Mehmetbey University, Karaman, Turkey
| | - Nuh Kumru
- Department of Anesthesiology and Intensive Care Medicine, Karaman Training and Research Hospital, Karaman, Turkey
| | - İlker Dedeli
- Department of Orthopedics and Traumatology, Karaman Training and Research Hospital, Karaman, Turkey
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38
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Chang WK, Li YS, Wu HL, Tai YH, Lin SP, Chang KY. Group-based trajectory analysis of postoperative pain in epidural analgesia for video-assisted thoracoscopic surgery and risk factors of rebound pain. J Chin Med Assoc 2022; 85:216-221. [PMID: 34698693 DOI: 10.1097/jcma.0000000000000647] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The current study aimed to investigate the patterns of postoperative pain trajectories over time and their associated risk factors in patients receiving video-assisted thoracoscopic surgery (VATS) and epidural analgesia (EA) for non-small cell lung cancer (NSCLC). METHODS This retrospective study was conducted at a tertiary medical center and included patients undergoing VATS for stage I NSCLC between 2011 and 2015. Maximal pain intensity was recorded daily during the first postoperative week. Group-based trajectory analysis was performed to categorize variations in pain scores over time. Associations between pain trajectory classification and amount of EA administered and length of hospital stay (LOS) after surgery were also evaluated. RESULTS A total of 635 patients with 4647 pain scores were included in the analysis, and 2 postoperative pain trajectory groups were identified: group 1, mild pain trajectory (78%); and group 2, rebound pain trajectory (22%). Risk factors for rebound pain trajectory were a surgical time longer than 3 hours (odds ratio [OR], 1.97; 95% CI, 1.27-3.07), female sex (OR, 1.62; 95% CI, 1.04-2.53), and higher pain score on postoperative day 0 (OR, 1.21; 95% CI, 1.08-1.36; linear effect). Although group 2 had a longer LOS (p < 0.001), they did not receive more EA than group 1 (p = 0.805). CONCLUSION Surgical time, sex, and pain intensity after surgery were major determinants of rebound pain trajectory, and more aggressive pain control strategies should be considered in high-risk patients.
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Affiliation(s)
- Wen-Kuei Chang
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yi-Shiuan Li
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Hsiang-Ling Wu
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Ying-Hsuan Tai
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan, ROC
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
| | - Shih-Pin Lin
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Kuang-Yi Chang
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
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Tan ESJ, Tan YR, Liu CWY. Efficacy of perineural dexamethasone in prolonging duration of analgesia with peripheral nerve blocks compared to intravenous dexamethasone: A systematic review and meta-analysis. Korean J Anesthesiol 2021; 75:255-265. [PMID: 34963269 PMCID: PMC9171542 DOI: 10.4097/kja.21390] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/23/2021] [Indexed: 11/10/2022] Open
Abstract
Background Perineural dexamethasone has been regarded as a promising adjunct for prolonging the duration of nerve blocks. However, it is uncertain whether its effects are due to local effects on the nerves or from systemic absorption. This systematic review aimed to compare the duration of postoperative analgesia associated with perineural versus intravenous dexamethasone as an adjunct to peripheral nerve blocks. Methods A total of 2,216 relevant academic articles were identified after a comprehensive search of PubMed, Embase, Scopus, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov from 1967 until 2020. All randomized controlled trials that compared perineural and intravenous dexamethasone as adjuncts to peripheral nerve limb blocks were included. Results Fifteen randomized controlled trials (1,467 cases; 738 perineural dexamethasone, 729 intravenous dexamethasone) were eligible. The primary outcome (duration of analgesia) was significantly longer in the perineural than in the intravenous dexamethasone group (mean difference [MD]: 2.72 h, 95% CI [1.42, 4.01], P < 0.001). Perineural dexamethasone was also found to prolong the sensory block (MD: 3.45 h, 95% CI [1.36, 5.54], P = 0.001) and lower 24 h postoperative pain scores (MD: −0.74 h, 95% CI [−1.40, −0.07], P = 0.03). Conclusions This review confirms the greater efficacy of perineural compared to intravenous dexamethasone in prolonging the analgesic duration of peripheral nerve blocks. However, the extent of prolongation was small and may not represent a clinically meaningful difference.
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Affiliation(s)
| | - Yan Ru Tan
- Department of Anesthesiology, Singapore General Hospital, Singapore
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Hong B, Oh C, Jo Y, Chung W, Park E, Park H, Yoon S. The Effect of Intravenous Dexamethasone and Dexmedetomidine on Analgesia Duration of Supraclavicular Brachial Plexus Block: A Randomized, Four-Arm, Triple-Blinded, Placebo-Controlled Trial. J Pers Med 2021; 11:jpm11121267. [PMID: 34945739 PMCID: PMC8703270 DOI: 10.3390/jpm11121267] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 11/16/2021] [Accepted: 11/28/2021] [Indexed: 12/25/2022] Open
Abstract
Intravenous dexamethasone and dexmedetomidine, in conjunction with peripheral nerve blockade, have each been reported to prolong the duration of analgesia. This study tested whether combined use further prolongs analgesia duration after supraclavicular brachial plexus block (BPB) in patients undergoing orthopedic upper extremity surgery. One hundred twenty patients were randomized 1:1:1:1 to Control (saline bolus and midazolam infusion [0.05 mg/kg loading, 20 µg/kg/h thereafter]); DMED (saline bolus and dexmedetomidine infusion [1 μg/kg loading, 0.4 μg/kg/h thereafter]); DEXA (dexamethasone [10 mg] bolus and midazolam infusion); and DMED-DEXA (dexmedetomidine infusion and dexamethasone bolus) groups. The primary outcome was the duration of postoperative analgesia, defined as the time from the end of the BPB to the first dose of analgesia via a patient-controlled device. Median (interquartile range) times to first dose of analgesia in the Control, DMED, DEXA, and DMED-DEXA groups were 8.1 (6.2–11.6), 9.0 (8.1–11.3), 10.7 (8.1–20.5), and 13.2 (11.5–19.1) hours, respectively (p < 0.001). Pairwise comparisons showed significant prolongation of analgesia in the DEXA included groups compared with the non-DEXA included groups (DEXA vs. control, p = 0.045; DEXA vs. DMED, p = 0.045; DMED-DEXA vs. control, p < 0.001; DMED-DEXA vs. DMED, p < 0.001). A mixed effect model showed that dexamethasone was the only significant factor for the prolongation of analgesia (p < 0.001). Intravenous dexamethasone prolonged the analgesia duration of supraclavicular BPB after orthopedic upper extremity surgery. The concurrent use of mild to moderate sedation dose of intravenous dexmedetomidine in addition to intravenous dexamethasone showed no additional benefit to the prolongation of analgesia.
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Affiliation(s)
- Boohwi Hong
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (B.H.); (C.O.); (Y.J.); (W.C.); (E.P.); (H.P.)
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Korea
- Big Data Center, Biomedical Research Institute, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea
| | - Chahyun Oh
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (B.H.); (C.O.); (Y.J.); (W.C.); (E.P.); (H.P.)
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Korea
| | - Yumin Jo
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (B.H.); (C.O.); (Y.J.); (W.C.); (E.P.); (H.P.)
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Korea
| | - Woosuk Chung
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (B.H.); (C.O.); (Y.J.); (W.C.); (E.P.); (H.P.)
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Korea
| | - Eunhye Park
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (B.H.); (C.O.); (Y.J.); (W.C.); (E.P.); (H.P.)
| | - Hanmi Park
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (B.H.); (C.O.); (Y.J.); (W.C.); (E.P.); (H.P.)
| | - Seokhwa Yoon
- Department of Anesthesiology and Pain Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea; (B.H.); (C.O.); (Y.J.); (W.C.); (E.P.); (H.P.)
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chungnam National University, 266 Munhwa-ro, Jung-gu, Daejeon 35015, Korea
- Correspondence:
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Kim H, Kim HJ, Lee ES, Lee S, Park JH, Kim H, Jeon IH, Koh WU, Koh KH. Postoperative Pain Control After Arthroscopic Rotator Cuff Repair: Arthroscopy-Guided Continuous Suprascapular Nerve Block Versus Ultrasound-Guided Continuous Interscalene Block. Arthroscopy 2021; 37:3229-3237. [PMID: 33989719 DOI: 10.1016/j.arthro.2021.04.067] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 04/14/2021] [Accepted: 04/23/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE To compare the clinical efficacy and safety of arthroscopy-guided continuous suprascapular nerve block and ultrasound-guided continuous interscalene block in postoperative analgesia in patients undergoing arthroscopic rotator cuff repair. METHODS A prospective study was performed between March and November 2020. In total, 76 patients were enrolled and divided into 2 groups: in the 38 patients of group 1 (arthroscopy-guided continuous suprascapular nerve block), an indwelling catheter was introduced via the Neviaser portal under arthroscopic view before closing the portal at the end of the surgery; and in the 38 patients of group 2 (ultrasound-guided continuous interscalene block), an indwelling catheter was inserted and directed toward the interscalene brachial plexus prior to the surgery under ultrasound guidance. The primary outcome was the pain score measured by the visual analog scale at postoperative 24 hours during admission. Comparisons were conducted at different time points (postoperative 4, 8, 24, and 48 hours). The secondary outcome was any of these events: neurologic complications, such as sensory/motor change in the upper extremities; hemidiaphragmatic paresis; dyspnea; dysphonia; and Horner's syndrome. Opioid usage until postoperative 3 weeks was compared between the groups. RESULTS The visual analog scale scores in groups 1 and 2 were comparable at each postoperative time point (analysis of variance, P = .919; trends, P = .132). Neurologic deficits were more common in group 2 than in group 1 (8 vs 32 patients, P < .001). Decreased excursion of the diaphragm was more common in group 2 (partial or complete paresis of the hemidiaphragm: 1 vs 29 patients, P < .001). Opioid consumption was similar in both groups (morphine milligram equivalents per kilogram; 1.75 vs 1.55, P = .195). CONCLUSIONS Our findings show that arthroscopy-guided continuous suprascapular nerve block is not inferior to ultrasound-guided continuous interscalene block for postoperative pain control after arthroscopic rotator cuff repair while showing fewer temporary neurologic complications. LEVEL OF EVIDENCE Level II, prospective cohort study, interventional study.
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Affiliation(s)
- Hyojune Kim
- Department of Orthopaedic Surgery, Daejeon Eulji Medical Center, Eulji University School of Medicine, Daejeon, Republic of Korea; Department of Orthopaedic Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Republic of Korea
| | - Ha-Jung Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Republic of Korea
| | - Eui-Sup Lee
- Department of Orthopaedic Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Republic of Korea
| | - Seonjeong Lee
- Department of Orthopaedic Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Republic of Korea
| | - Jeong Hee Park
- Department of Orthopaedic Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Republic of Korea
| | - Hyungtae Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Republic of Korea
| | - In-Ho Jeon
- Department of Orthopaedic Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Republic of Korea
| | - Won Uk Koh
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Republic of Korea
| | - Kyoung Hwan Koh
- Department of Orthopaedic Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Republic of Korea.
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Cunningham DJ, LaRose MA, DeLaura IF, Zhang GX, Paniagua AR, Gage MJ. Regional anesthesia does not decrease inpatient or outpatient opioid demand in femoral shaft fracture surgery. Injury 2021; 52:3075-3084. [PMID: 34294430 DOI: 10.1016/j.injury.2021.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 07/07/2021] [Accepted: 07/10/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Regional anesthesia (RA) may be used in femoral shaft fracture surgery to decrease pain and opioid consumption. However, the impact of RA on inpatient and outpatient opioid demand in patients undergoing femoral shaft fracture surgery is largely unknown. The aim of this study was to evaluate the impact of RA on inpatient opioid consumption and outpatient opioid demand in patients undergoing femoral shaft fracture surgery. METHODS Inpatient opioid consumption and outpatient opioid demand in all patients undergoing femoral shaft fracture surgery was recorded at a single, Level I trauma center from 7/2013 - 7/2018 (n=436). In addition to RA, baseline and treatment factors including age, sex, race, body mass index (BMI), smoking, chronic opioid use, American Society of Anesthesiologists (ASA) score, injury mechanism, additional injuries, open injury, and additional inpatient surgery were recorded. Unadjusted and adjusted multivariable models were used to evaluate the impact of RA on inpatient opioid consumption and outpatient opioid demand. RESULTS Adjusted models demonstrated increases in inpatient opioid consumption in patients with RA (6.9 estimated OE's without RA vs 8.8 OE's with RA from 48-72 hours post-op, p<0.05) but no significant differences at other timepoints (10.3 estimated OE's without RA vs 9.2 OE's with RA from 0-24 hours post-op, 8.2 vs 8.8 from 24-48 hours post-op, p>0.05). Estimated cumulative outpatient opioid demand did not differ significantly in patients with RA (82.3 OE's without RA vs 94.8 with RA from discharge to two-weeks, 105.4 vs 116.3 OE's to 6-weeks, and 124.5 vs 137.9 OE's to 90-days, all p>0.05). Late opioid refills were significantly more common in patients with RA (1.57 odds at 2-weeks to 6-weeks, 1.69 odds at 6-weeks to 90-days, p<0.05) DISCUSSION: In femoral shaft fracture surgery, RA was not associated with decreased opioid demand after adjusting for baseline patient and treatment characteristics. These results provide a real-world estimate of the impact of RA on opioid demand in femoral shaft fracture surgery and encourage providers to seek alternative analgesic modalities. LEVEL OF EVIDENCE Level III, retrospective, therapeutic cohort study.
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Affiliation(s)
- Daniel J Cunningham
- Duke University Medical Center, Department of Orthopaedic Surgery, 200 Trent Drive, Durham, NC 27710, United States.
| | - Micaela A LaRose
- Duke University School of Medicine, Duke University Medical Center 3710, Durham, NC 27710, United States
| | - Isabel F DeLaura
- Duke University School of Medicine, Duke University Medical Center 3710, Durham, NC 27710, United States
| | - Gloria X Zhang
- Duke University School of Medicine, Duke University Medical Center 3710, Durham, NC 27710, United States
| | - Ariana R Paniagua
- Duke University School of Medicine, Duke University Medical Center 3710, Durham, NC 27710, United States
| | - Mark J Gage
- Duke University Medical Center, Department of Orthopaedic Surgery, 200 Trent Drive, Durham, NC 27710, United States
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Woo JH, Lee HJ, Oh HW, Lee JW, Baik HJ, Kim YJ. Perineural dexamethasone reduces rebound pain after ropivacaine single injection interscalene block for arthroscopic shoulder surgery: a randomized controlled trial. Reg Anesth Pain Med 2021; 46:965-970. [PMID: 34535548 DOI: 10.1136/rapm-2021-102795] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 08/25/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND OBJECTIVES A single injection interscalene block (ISB) is a common regional analgesic technique in patients undergoing arthroscopic shoulder surgery. However, rebound pain after ISB resolution may reduce its overall benefit. Our primary aim was to assess whether perineural dexamethasone reduces the intensity and incidence of rebound pain in patients undergoing arthroscopic shoulder surgery under general anesthesia combined with a preoperative single injection ISB. METHODS The patients were randomly assigned to receive single injection ISB using either 0.5% ropivacaine (control) or 0.5% ropivacaine containing 5 mg of dexamethasone. The primary outcomes were the pain score difference before and after ISB resolution, and the incidence of rebound pain. The secondary outcomes were the onset and duration of rebound pain, the presence of sleep disturbances due to postoperative pain, the first time when an analgesic was requested, and pain scores at various predefined time points. RESULTS Pain increase following ISB resolution was lower in the dexamethasone group compared with the control group (4.5±2.4 and 6.9±2.2, respectively, p<0.001). The incidence of rebound pain was significantly lower in the dexamethasone group compared with the control group (37.1% and 82.9%, respectively, p<0.001). The controls experienced greater sleep disturbance during the postoperative period compared with those who received ISB with perineural dexamethasone. CONCLUSIONS Perineural dexamethasone added to ISB using ropivacaine led to a much smoother resolution of ISB, reflected in a significantly smaller increase in pain after block resolution, a lower incidence of rebound pain and a lower sleep disturbance during the first postoperative week. TRIAL REGISTRATION NUMBER Clinical Trial Registry of Korea (KCT0004418).
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Affiliation(s)
- Jae Hee Woo
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Hyun Jung Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Hye-Won Oh
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Jong Wha Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Hee Jung Baik
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Youn Jin Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
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Grape S, Kirkham KR, Akiki L, Albrecht E. Transversus abdominis plane block versus local anesthetic wound infiltration for optimal analgesia after laparoscopic cholecystectomy: A systematic review and meta-analysis with trial sequential analysis. J Clin Anesth 2021; 75:110450. [PMID: 34243030 DOI: 10.1016/j.jclinane.2021.110450] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/30/2021] [Accepted: 07/01/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Both transversus abdominis plane (TAP) block and local anesthetic wound infiltration have been used to relieve pain after laparoscopic cholecystectomy. We undertook this systematic review and meta-analysis with trial sequential analysis to determine the best analgesic technique. METHODS We systematically searched the literature for trials comparing TAP block with wound infiltration after laparoscopic cholecystectomy. The primary outcome was pain score during rest (analogue scale, 0-10) at 2 postoperative hours. Secondary pain-related outcomes included pain scores during rest at 12 and 24 h, pain scores during movement and intravenous morphine consumption at 2, 12 and 24 h, and postoperative nausea and vomiting. Other secondary outcomes sought were block-related complications such as rates of postoperative infection, hematoma, visceral injury and local anesthetic systemic toxicity. RESULTS Ten trials including 668 patients were identified. There was a significant difference in pain score during rest at 2 postoperative hours in favour of TAP block when compared with wound infiltration (mean difference [95%CI]: -0.7 [-1.2, -0.2]; I2 = 71%; p = 0.008). Pain scores during rest at 12 and 24 h and pain scores during movement at 24 h were also significantly lower with TAP block than wound infiltration. Postoperative morphine consumption and the incidence of postoperative nausea and vomiting were significantly lower in patients who received a TAP block. Data were insufficient to compare block-related complications. The overall quality of evidence was moderate-to-high. CONCLUSIONS There is moderate-to-high level evidence that the TAP block provides superior analgesia when compared with wound infiltration in patients undergoing laparoscopic cholecystectomy. Trial registry number: PROSPERO CRD42020208057.
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Affiliation(s)
- Sina Grape
- Department of Anesthesia, Valais Hospital, Sion, and University of Lausanne, Lausanne, Switzerland.
| | - Kyle Robert Kirkham
- Department of Anesthesia, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - Liliane Akiki
- Department of Anesthesia, Valais Hospital, Sion, Switzerland
| | - Eric Albrecht
- Program Director of Regional Anaesthesia, Department of Anesthesia, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
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Hamilton DL. Rebound pain: distinct pain phenomenon or nonentity? Br J Anaesth 2021; 126:761-763. [PMID: 33551124 DOI: 10.1016/j.bja.2020.12.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/31/2020] [Indexed: 11/26/2022] Open
Affiliation(s)
- Duncan L Hamilton
- Department of Anaesthesia, James Cook University Hospital, Middlesbrough, UK; School of Medicine, University of Sunderland, Sunderland, UK.
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Shim JH. Multimodal analgesia or balanced analgesia: the better choice? Korean J Anesthesiol 2020; 73:361-362. [PMID: 32951409 PMCID: PMC7533177 DOI: 10.4097/kja.20505] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 09/09/2020] [Indexed: 12/23/2022] Open
Affiliation(s)
- Jae Hang Shim
- Department of Anesthesiology and Pain Medicine, Hanyang University School of Medicine, Seoul, Korea
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