A Comparative Study for Post Operative Analgesia in the Emergency Laparotomies: Thoracic Epidural Ropivacaine with Nalbuphine and Ropivacaine with Butorphanol

Ultrasound‑guided erector spinae plane block in posterior lumbar surgery (Review)

The erector spinae plane block (ESPB) is a novel fascial planar block technique, which is used to reduce postoperative pain in several surgical procedures, including breast, thoracic, spine and hip surgery. Due to its recognizable anatomy and low complication rate, the application of ESPB has been significantly increased. However, it is rarely used in clinical practice for postoperative analgesia after posterior lumbar spine surgery, while the choice of adjuvant drugs, block levels and drug doses remain controversial. Based on the current literature review, ropivacaine and dexmedetomidine could be considered as the best available drug combination. The present review aimed to analyze the currently available clinical evidence and summarize the benefits and challenges of ESPB in spinal surgery, thus providing novel insights into the application of ESPB in the postoperative management of posterior lumbar surgery.

Analgesic Efficacy of Nalbuphine as an Adjuvant to Ropivacaine in Erector Spinae Plane Block for Percutaneous Nephrolithotomy: A Randomized, Double-Blinded, Clinical Trial

Background

Erector spinae plane block (ESPB) is an easy and safe method for postoperative analgesia. However its effect lasts only for several hours. This trial was to investigate the effectiveness of different doses of nalbuphine as an adjuvant to ropivacaine in ESPB for patients undergoing percutaneous nephrolithotomy (PCNL).

Methods

Patients scheduled for PCNL were randomized into three groups and received ultrasound-guided ESPB at T10 level for postoperative analgesia. Each subject received 28 mL of 100 mg ropivacaine solution mixed with 2 mL of normal saline (Group R), 2 mL of 10 mg nalbuphine (Group RNL), or 2 mL of 20 mg nalbuphine (Group RNH). Primary outcome was the time to first opioid demand. Secondary outcomes were morphine consumption, VAS scores within 24 h postoperatively, rescue analgesic requirements, and length of hospital stay.

Results

The median [interquartile range, IQR] time to first opioid demand was significantly longer in group RNH (8.70 [6.90,14.85] h) than that of group R and group RNL (2.90 [2.00,6.30] h and 5.80 [2.95,7.00] h, respectively). VAS scores (either resting or active) within 24 h postoperatively were comparable between the three groups, with the most significant differences especially at 4, 6, 8 h. Morphine consumption at 24 h postoperatively was significant for R group vs RNH group (median difference, 9; 95% confidence interval [CI], 1.57 to 16.43; p = 0.02).

Conclusions

Adding 20mg nalbuphine to ropivacaine in ESPB could significantly improve the effect of analgesia and prolong the duration of nerve blocks for PCNL.

A meta‐analysis showing the quantitative evidence base of perineural nalbuphine for wound pain from upper‐limb orthopaedic trauma surgery

The adjuvant effectiveness of nalbuphine in context of brachial plexus block (BPB) in patients undergoing upper-limb orthopaedic trauma surgery has remained uncertain. The purpose of this meta-analysis was to evaluate the analgesic benefit of mixing nalbuphine into local anaesthetics in BPB for wound pain from upper-limb trauma surgery. Primary outcome was the duration of analgesia. Seventeen trials (1104 patients) were analysed. Patients receiving nalbuphine have an increased weighted mean difference (WMD) 95% confidence interval of the duration of analgesia by 186.91 minutes (133.67 to 240.16) (P < 0.001). Compared to placebo, nalbuphine shorten the onset time of sensory and motor block by WMD of 2.59 (1.27 to 3.92) and 3.06 minutes (1.65 to 4.48) (P < 0.001), respectively. Meanwhile, nalbuphine prolonged the durations of sensory and motor block (P < 0.001). Qualitative and quantitative synthesis revealed no differences with regard to the outcomes related to side-effects. There is moderate-quality evidence that the addition of nalbuphine to local anaesthetics for BPB in patients undergoing upper-limb orthopaedic trauma surgery significantly prolongs the duration of analgesia, while preserving a similar safety-profile compared with local anaesthetics alone. However, these benefits should be further weighed against nalbuphine-related neurological safety in future studies.

Postoperative pain management in non-traumatic emergency general surgery: WSES-GAIS-SIAARTI-AAST guidelines

BACKGROUND

Non-traumatic emergency general surgery involves a heterogeneous population that may present with several underlying diseases. Timeous emergency surgical treatment should be supplemented with high-quality perioperative care, ideally performed by multidisciplinary teams trained to identify and handle complex postoperative courses. Uncontrolled or poorly controlled acute postoperative pain may result in significant complications. While pain management after elective surgery has been standardized in perioperative pathways, the traditional perioperative treatment of patients undergoing emergency surgery is often a haphazard practice. The present recommended pain management guidelines are for pain management after non-traumatic emergency surgical intervention. It is meant to provide clinicians a list of indications to prescribe the optimal analgesics even in the absence of a multidisciplinary pain team.

MATERIAL AND METHODS

An international expert panel discussed the different issues in subsequent rounds. Four international recognized scientific societies: World Society of Emergency Surgery (WSES), Global Alliance for Infection in Surgery (GAIS), Italian Society of Anesthesia, Analgesia Intensive Care (SIAARTI), and American Association for the Surgery of Trauma (AAST), endorsed the project and approved the final manuscript.

CONCLUSION

Dealing with acute postoperative pain in the emergency abdominal surgery setting is complex, requires special attention, and should be multidisciplinary. Several tools are available, and their combination is mandatory whenever is possible. Analgesic approach to the various situations and conditions should be patient based and tailored according to procedure, pathology, age, response, and available expertise. A better understanding of the patho-mechanisms of postoperative pain for short- and long-term outcomes is necessary to improve prophylactic and treatment strategies.

Efficacy of Nalbuphine as an Adjuvant to Ropivacaine in Ultrasound-guided Supraclavicular Brachial Block: A Prospective Randomized Controlled Study

BACKGROUND

A brachial plexus block (BPB) provides anesthesia and analgesia with limited duration. Various opioids have been used as adjuvants of local anesthetics to improve the effects.

OBJECTIVE

The objective of this study was to evaluate the safety and effectiveness of nalbuphine used as an adjuvant to local anesthetic during the supraclavicular BPB.

MATERIALS AND METHODS

In this prospective, double-blinded, randomized controlled study, 90 American Society of Anesthesiology (ASA) Physical Status I and II patients (aged 20 to 65 y) of either sex undergoing upper limb orthopedic surgeries under ultrasound-guided supraclavicular BPB were randomly allocated into 3 groups: group C (n=30), group NL (n=30), and group NH (n=30) for analyses. Each patient received 18 mL of 100 mg ropivacaine solution combined with 2 mL of normal saline, 2 mL of 10 mg nalbuphine, or 2 mL of 20 mg nalbuphine. The time of onset and block duration of sensory block (SB) and motor block (MB), duration of analgesia, hemodynamic variables, and any adverse effects were assessed.

RESULTS

Compared with group C, the onset time of both SB and MB were significantly shortened. The SB and MB duration were significantly prolonged in group NL and group NH. There was no significant difference between the duration of analgesia in group NL and NH although the analgesia duration of both groups was longer than group C. But the incidence of side effects in group NH such as vomiting was significantly higher than group NL.

CONCLUSIONS

Nalbuphine is an effective adjuvant to 0.5% ropivacaine in ultrasound-guided supraclavicular BPB. The dosage of 10 mg improves the quality of the anesthesia with less incidence of side effects.