On-demand (SOS) analgesia through Transversus Abdominis Plane (TAP) catheter route for post-operative pain relief in Emergency Laparotomies-a non-randomised interventional study (STAPLE trial)

INTRODUCTION

This study aimed to compare the efficacy and safety of on-demand bupivacaine infusion via transversus abdominis plane (TAP) catheter in emergency laparotomy patients.

METHODS

A non-randomised interventional study was conducted on patients undergoing emergency midline laparotomy. The intervention group received an on-demand infusion of 10 ml 0.5% bupivacaine through TAP catheters, whilst the control group received standard analgesic care. The primary outcome was the amount of rescue analgesic consumption. Secondary outcomes included the post-operative, measured by visual analogue scores (VAS), side effects, time to first flatus, post-operative nausea and vomiting, and pulmonary complications.

RESULTS

One-hundred-twenty patients (58 in the TAP-SOS group, 62 in the control group) were included in the final analysis. The TAP-SOS group showed significantly reduced rescue analgesic requirement by 91% (p < 0.001) and lower VAS scores at 3, 6, 12, and 24 h (adjusted p < 0.00). Time to out-of-bed mobilisation was significantly shorter in the TAP-SOS group by 12.47 h (p < 0.001), and post-operative pulmonary complications were lower by 75% (p < 0.05). There were no significant differences in bowel recovery, catheter-related complications, or post-operative morbidity. No incidences of catheter-site infection were reported on follow-up; however, the catheter tip-culture was positive in 3 (5.17%) patients.

CONCLUSION

On-demand bupivacaine infusion through a TAP catheter effectively reduced post-operative pain and opioid requirements in emergency laparotomy patients without complications. If an epidural is not an option, the TAP-SOS approach can be a helpful adjunct in implementing the ERAS protocol in an emergency since it allows for early ambulation and better pain management.

Optimum dose of spinal ropivacaine with or without single intravenous bolus of S-ketamine during elective cesarean delivery: a randomized, double-blind, sequential dose-finding study

Background

Maternal hypotension after spinal anaesthesia occurs at a high rate during caesarean delivery and can lead to adverse maternal or foetal outcomes. The aim of this study was to determine the optimal dose of spinal ropivacaine for caesarean section with or without intravenous single bolus of S-ketamine and to observe the rates of hypotension associated with both methods.

Methods

Eighty women undergoing elective caesarean delivery were randomly allocated into either a ropivacaine only or ropivacaine with intravenous S-ketamine group. If the upper sensory level of the patient reached T6 and the visual analogue scale (VAS) scores remained below 3 points before delivery, the next patient had a 1/9th chance of receiving a lower dose or an 8/9th chance of receiving the same dose as the previous patient. If the patient had VAS scores of more than 2 points or needed an extra epidural rescue bolus before delivery, a higher dose was used for the next patient. The primary outcome was the successful use of spinal ropivacaine to maintain patient VAS score of < 3 points before delivery and the incidence of post-spinal hypotension in both groups. Secondary outcomes included the rates of hypotension-related symptoms and interventions, upper sensory level of anaesthesia, level of sedation, neonatal outcomes, Edinburgh Postnatal Depression Scale scores at admission and discharge, and post-operative analgesic effect. The 90% effective dose (ED90) and 95% confidence interval (95% CI) were estimated by isotonic regression.

Results

The estimated ED90 of ropivacaine was 11.8 mg (95% CI: 11.7–12.7) with and 14.7 mg (95% CI: 14.6–16.0) without intravenous S-ketamine, using biased coin up-down sequential dose-finding method. The rates of hypotension and associated symptoms were significantly lower in S-ketamine group than in the ropivacaine only group.

Conclusions

A spinal dose of ropivacaine 12 mg with a single intravenous 0.15 mg/kg bolus dose of S-ketamine may significantly reduce the risk of hypotension and induce sedation before delivery. This method may be used with appropriate caution for women undergoing elective caesarean delivery and at a high risk of hypotension or experiencing extreme nervousness.

Trial registration

http://www.chictr.org.cn (ChiCTR2000040375; 28/11/2020).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04229-y.

A comparison of ultrasound guided bilateral single injection shot Erector Spinae Plane blocks versus wound infiltration for post-operative analgesia in laparoscopic assisted colonic surgery- a prospective randomised study

Background

Both wound infiltration (WI) with local anaesthetic and Erector Spinae Plane block (ESPB) have been described for post-operative analgesia after abdominal surgery. This study compared the efficacy of WI versus ESPB for post-operative analgesia after laparoscopic assisted colonic surgery.

Methods

Seventy-two patients between 18 and 85 years of age undergoing elective surgery were randomised to receive either WI or ESPB. In the WI group a 40 ml bolus of 0.5% Ropivacaine, infiltrated at the ports and minimally invasive wound at subcutaneous and fascia layers. In the ESPB group at T8 level, under ultrasound guidance, a 22-gauge nerve block needle was passed through the Erector Spinae muscle to reach its fascia. A dose up to 40 ml of 0.5% Ropivacaine, divided into two equal volumes, was injected at each side. Both groups had a multimodal analgesic regime, including regular Paracetamol, dexamethasone and patient-controlled analgesia (PCA) with Fentanyl. The primary end point was a post-operative pain score utilising a verbal Numerical Rating Score (NRS, 0–10) on rest and coughing in the post anaesthetic care unit (PACU) and in the first 24 h. Secondary outcomes measured were: opioid usage, length of stay and any clinical adverse events.

Results

There was no significant treatment difference in PACU NRS at rest and coughing (p-values 0. 382 and 0.595respectively). Similarly, there were no significant differences in first 24 h NRS at rest and coughing (p-values 0.285 and 0.431 respectively). There was no significant difference in Fentanyl use in PACU or in the first 24 h (p- values 0.900 and 0.783 respectively). Neither was there a significant difference found in mean total Fentanyl use between ESPB and WI groups (p-value 0.787).

Conclusion

Our observations found both interventions had an overall similar efficacy.

Trial registration

The study was registered with the Australian New Zealand Clinical Trial Registry (ACTRN: 12619000113156).

The safety and efficacy of intrathecal morphine in pediatric spinal deformity surgery: a 25-year single-center experience

PURPOSE

Pre-incision intrathecal morphine (IM) is a popular adjunct in adolescent idiopathic spinal deformity surgery. This study represents our 25-year experience with IM in all diagnostic groups undergoing posterior spinal fusion (PSF) and segmental instrumentation (SI).

METHODS

Our prospective Pediatric Orthopaedic Spine Database (1992-2018) identified all patients undergoing PSF and SI. We included patients 21 years of age or less, had a PSF with SSI, and received the recommended IM dose of 9-19 mcg/kg (up to 1 mg) or no IM. We assessed demographics, pain scores, duration of surgery, time to first dose of narcotics, pediatric intensive care unit (PICU) admission, length of hospital stay, and IM complications (respiratory depression, pruritus, nausea/vomiting).

RESULTS

There were 984 patients who met inclusion criteria: 760 patients received IM, 224 did not (non-IM). They were divided into 5 diagnostic groups: idiopathic, neuromuscular, syndromic, and congenital scoliosis and kyphosis. The mean first post-operative opioid following IM administration was at 16.1 h in the IM group compared to 8.7 h in the non-IM group (p =  < 0.001). The post-operative pain scores in the IM groups were significantly lower (p =  < 0.001). Sixteen patients (2%) in the IM group were admitted to the PICU for observation secondary to respiratory depression, none requiring re-intubation. There were no other complications related to IM.

CONCLUSION

Pre-incision IM is a safe adjunct for pain management in select children in all diagnostic groups undergoing spinal deformity surgery. There were no serious complications.

LEVEL OF EVIDENCE

III.

Ultrasound-guided adductor canal block combined with lateral femoral cutaneous nerve block for post-operative analgesia following total knee arthroplasty: a prospective, double-blind, randomized controlled study

PURPOSE

The purpose of this study was to investigate whether adductor canal block (ACB) combined with lateral femoral cutaneous nerve block (LFCNB) could improve the efficacy of post-operative analgesia in a comparison with a standard peri-articular infiltration analgesia (PIA) after a total knee arthroplasty (TKA).

METHODS

One hundred and sixty patients of scheduled unilateral primary TKA were randomly allocated into two groups for post-operative analgesia. Eighty cases were treated with ACB combined with LFCNB and the other eighty treated with PIA. The primary outcomes were pain visual analogue scale (VAS) and rescue pain killer consumption, and the secondary outcomes were knee active range of motion (ROM), quadriceps strength, patients' ambulation ability, Knee Society Score (KSS), length of hospital stay, and adverse events.

RESULTS

We found that ACB combined with LFCNB was better on decreasing the post-operative pain score within 12 hours at rest and 8 h with activity (p < 0.05) and provided longer duration of analgesia (19.91 ± 5.09 VS 12.06 ± 3.67 h, p < 0.01) and less rescue morphine consumption (13.63 ± 9.84 vs 18.00 ± 11.52 mg, p = 0.011) than the PIA. There was no significant difference between the two groups (p > 0.05) in terms of knee ROM, quadriceps strength, daily mobilization distance, KSS, and complication occurrence.

CONCLUSIONS

ACB combined with LFCNB provides a significantly better pain control, less opioid consumption, and longer duration of analgesia than peri-articular infiltration while preserving muscle function without affecting knee functional recovery nor the length of stay or side effects occurrence.

Extended-Release Dinalbuphine Sebacate Versus Intravenous Patient-Controlled Analgesia with Fentanyl for Postoperative Moderate-to-Severe Pain: A Randomized Controlled Trial

INTRODUCTION

Post-operative pain control remains unsatisfactory in patients after laparotomy. This study aimed to evaluate the efficacy, safety, and quality of life with a single dose of extended-release dinalbuphine sebacate (ERDS) pre-operatively to intravenous patient-controlled analgesia (PCA) with fentanyl in patients undergoing laparotomy.

METHODS

This was a prospective, open-label, randomized controlled study. Of 110 randomized patients, 107 completed all assessments. The area under the curve (AUC) of visual analogue scale (VAS) from baseline to 48 h after surgery, VAS throughout 7 days after surgery, post-operative analgesics use, quality of life, satisfaction, and safety were evaluated.

RESULTS

The AUC of VAS from baseline to 48 h after surgery were 118.6 [97.5% confidence interval (CI) 95.6-141.6] in ERDS group and 176.13 (97.5% CI 150.8-201.4) in PCA group, which showed the non-inferiority because the upper limit of the 97.5% CIs of ERDS group was lower than the lower limit of PCA group (P < 0.001), but also had superiority in favor of ERDS group (P < 0.001). ERDS group reported a significant reduction in VAS pain intensity at 4, 24, 32, 72, 120, and 144 h after surgery, and better quality of life (P < 0.05). The safety profile was comparable between ERDS and PCA groups.

CONCLUSIONS

In patients undergoing laparotomy, a single dose of dinalbuphine sebacate was superior to intravenous PCA with fentanyl on lower pain intensity and better quality of life.

TRIAL REGISTRATION

NCT03296488.

Predictors of long-term opioid dependence in transforaminal lumbar interbody fusion with a focus on pre-operative opioid usage

PURPOSE

Predictors of long-term opioid usage in TLIF patients have not been previously explored in the literature. We examined the effect of pre-operative narcotic use in addition to other predictors of the pattern and duration of post-operative narcotic usage.

METHODS

We conducted a retrospective cohort study at a single academic institution of patients undergoing a one- or two-level primary TLIF between 2014 and 2017. Total oral morphine milligram equivalents (MMEs) for inpatient use were calculated and used as the common unit of comparison.

RESULTS

A multivariate binary logistic regression (R² = 0.547, specificity 95%, sensitivity 58%) demonstrated that a psychiatric or chronic pain diagnosis (OR 3.95, p = 0.013, 95% CI 1.34-11.6), pre-operative opioid use (OR 8.65, p < 0.001, 95% CI 2.59-29.0), ASA class (OR 2.95, p = 0.025, 95% CI 1.14-7.63), and inpatient total MME (1.002, p < 0.001, 95% CI 1.001-1.003) were positive predictors of prolonged opioid use at 6-month follow-up, while inpatient muscle relaxant use (OR 0.327, p = 0.049, 95% CI 0.108-0.994) decreased the probability of prolonged opioid use. Patients in the pre-operative opioid use group had a significantly higher rate of opioid usage at 6 weeks (79% vs. 46%, p < 0.001), 3 months (51% vs. 14%, p < 0.001), and 6 months (40% vs. 5%, p < 0.001).

CONCLUSIONS

Pre-operative opioid usage is associated with higher total inpatient opioid use and a significantly higher risk of long-term opiate usage at 6 months. Approximately 40% of pre-operative narcotic users will continue to consume narcotics at 6-month follow-up, compared with 5% of narcotic-naïve patients. These slides can be retrieved under Electronic Supplementary Material.

Comparison of Efficacy of Bupivacaine with Dexmedetomidine Versus Bupivacaine Alone for Transversus Abdominis Plane Block for Post-operative Analgesia in Patients Undergoing Elective Caesarean Section

Background

Increasing rate of Caesarean sections and inadequate pain relief following Caesarean section is seen in almost all parts of the world. Transversus abdominis plane block is gaining popularity as a part of multimodal analgesia for post-operative pain relief following abdominal surgeries.

Aim

To compare bupivacaine and bupivacaine with dexmedetomidine in transversus abdominis plane block for pain relief after Caesarean section.

Method

American Society of Anaesthesiologists I and II parturients with no comorbidities admitted for elective Caesarean section were included in the study. Thirty-five patients were in each study (with dex) and control (without dex) groups. At the end of Caesarean section done under spinal anaesthesia, transversus abdominis plane block was done bilaterally under ultrasound guidance using in-plane technique of needle insertion. 20 ml of 0.25% bupivacaine with 0.5 mcg/kg of dexmedetomidine in the study group and 20 ml of 0.25% bupivacaine in the control group were injected in the neurovascular plane.

Results

Eight patients from the study group and 15 from the control group were given opioids as rescue analgesia. The average time at which rescue analgesia was first sought was 14.25 and 7.73 h in the study and control groups, respectively. The P value of this difference was 0.0136 and was found to be statistically significant.

Conclusion

The addition of dexmedetomidine to bupivacaine in TAP block prolonged the duration of time at which first dose of rescue analgesia was sought and also reduced the total dose of opioid requirement in the first 24-h post-Caesarean section.

Dexamethasone as an Adjuvant to Bupivacaine in Supraclavicular Brachial Plexus Block in Paediatrics for Post-operative Analgesia

INTRODUCTION

Sensory blockade of the brachial plexus with local anaesthetics for perioperative analgesia leads to stable haemodynamics intraoperatively, smoother emergence from general anaesthesia and decreased need for supplemental analgesics or suppositories in the Post-operative period. However, increasing the duration of local anaesthetic action is often desirable because it prolongs surgical anaesthesia and analgesia. Various studies in adults prove that steroids increase the duration of action of local anaesthetics when used as adjuncts.

AIM

The study aimed at determining the efficacy of dexame-thasone as an adjuvant to bupivacaine for Post-operative analgesia following sensory blockade of the brachial plexus in paediatrics.

MATERIALS AND METHODS

The study was divided into two groups of 15 each, group BD receiving dexamethasone (0.1mg/kg) as an adjunct to bupivacaine 0.125% and group B receiving bupivacaine alone. The duration of analgesia was taken as time from completion of the block to the patient receiving rescue analgesia, the haemodynamics were measured until 180 minutes after surgery, the incidence of Post-operative Nausea and Vomiting (PONV) was measured.

RESULTS

The duration of analgesia in the group BD was 27.1±13.4 hours and was significantly higher as compared to the group B, in which it was 13.9±11.3 hours (p<0.05). The pulse rate measured Post-operatively between both groups at 20 minutes (p-value 0.634), 60 minutes (p-value 0.888), 120 minutes (p-value 0.904) and 180 minutes (p-value 0.528) showed no statistical significance. Likewise the mean blood pressure measured between the two groups at 20 minutes, 60 minutes, 120 minutes and 180 minutes Post-operatively showed no significance. There was no significant difference in incidence of PONV in both groups with p-value of 0.624.

CONCLUSION

Dexamethasone as an adjuvant to local anaesthetic in brachial plexus blocks significantly, prolongs duration of analgesia in children undergoing upper limb surgeries.

A Study on the Efficacy of the Addition of Low Dose Dexmedetomidine as an Adjuvant to Lignocaine in Intravenous Regional Anaesthesia (IVRA)

INTRODUCTION

Intravenous Regional Anaesthesia (IVRA) is a simple, effective method of providing anaesthesia for short duration surgical procedures on the extremities, its chief drawbacks are tourniquet pain, short duration of block and absence of post-operative analgesia. Dexmedetomidine is known to reduce anaesthetic requirements and also provide analgesia to the patient.

AIM

To evaluate the efficacy of dexmedetomidine as an adjuvant to lignocaine in IVRA with respect to the quality of the block, tourniquet pain and post-operative analgesia.

MATERIALS AND METHODS

A prospective, randomized, double-blinded study was conducted on 60 patients scheduled for orthopaedic surgery of the upper limb, of American Society of Anaesthesiologist's physical status grades I and II. They were divided into two groups of 30 each. The control group C received 40ml of 0.5% lignocaine with saline and Group D received dexmedetomidine 0.5μg/kg added to 40ml of 0.5% lignocaine. The time taken for the onset and recovery of sensory and motor block, incidence of tourniquet pain, intra-operative and post-operative Visual Analogue Scale (VAS) scores, duration of post-operative analgesia and any side effects were noted. Student t-test was used for evaluation of the demographic data, haemodynamic variables, the onset and recovery times of block, duration of analgesia and intra-operative analgesic consumption and tourniquet pain. Friedman's test was used for intra-operative and post-operative VAS and sedation scores.

RESULTS

The onset time of both sensory and motor block were significantly shortened, the recovery of sensory and motor block was prolonged, the incidence of tourniquet pain was comparatively lesser and there was significantly increased duration of post-operative analgesia in the dexmedetomidine group. Haemodynamic parameters were similar in both groups.

CONCLUSION

The addition of 0.5μg/kg of dexmedetomidine as an adjuvant to IVRA effectively enhances the anaesthesia and post-operative analgesia obtained with lignocaine. The low dose of dexmedetomidine was effective and did not cause any major side effects.

Clinical evaluation of post-operative analgesia comparing suprascapular nerve block and interscalene brachial plexus block in patients undergoing shoulder arthroscopic surgery

BACKGROUND

Shoulder arthroscopic surgeries have a high incidence of severe post-operative pain significant enough to interfere with recovery and rehabilitation. A regional anaesthetic technique combined with general anaesthesia reduces intra-operative requirements of anaesthesia and provides a better post-operative pain relief. As the commonly employed technique of interscalene brachial plexus block (ISB) is associated with potential serious complications, suprascapular nerve block (SSB) can be used as a safer alternative.

METHODS AND MATERIAL

In this prospective study, 60 ASA 1 or 2 adult patients undergoing shoulder arthroscopic surgery were randomised into two groups - ISB and SSB. In group ISB, ISB with 20 ml of 0.5% bupivacaine mixed with 75 μg clonidine was given. In the SSB group SSB was given with 15 ml of 0.5% bupivacaine with 75 μg clonidine. Pain was assessed using visual analogue scale and verbal pain scale scores and time to first rescue analgesia was noted. We used Student's t test and Chi-square/Fisher Exact test and used a statistical software to compare data.

RESULTS

In the present study, the mean duration of analgesia was 2.53 ± 2.26 h in SSB group compared to 7.23 ± 6.83 h in group ISB (p value < 0.05). Overall rescue analgesic requirements were higher in SSB group compared to ISB group (63.3% versus 40.0%) but this was statistically not significant (p value > 0.05).

CONCLUSION

Both interscalene and SSB can be used to provide intra-operative and post-operative analgesia in patients undergoing shoulder arthroscopy.

Postarthroscopy analgesia using intraarticular levobupivacaine and intravenous dexketoprofen trometamol

PURPOSE

The aim of this prospective study was to determine the efficacy of intraarticular levobupivacaine with and without intravenous dexketoprofen trometamol for postarthroscopy analgesia.

METHODS

Sixty patients who underwent arthroscopic knee surgery were randomly assigned to three treatment groups. When the surgical procedure was completed, patients received the following treatments: group I (n = 20) patients received 20 mL intraarticular normal saline and 2 mL intravenous dexketoprofen trometamol (50 mg); group II (n = 20) patients received 20 mL intraarticular 0.5 % levobupivacaine (100 mg) and 2 mL intravenous normal saline; and group III (n = 20) patients received 20 mL intraarticular 0.5 % levobupivacaine (100 mg) and 2 mL intravenous dexketoprofen trometamol (50 mg). The visual analogue scale (VAS) was used, and the total analgesic consumption was assessed at 1, 2, 4, 6, 12, and 24 h post-operatively.

RESULTS

The VAS scores at 1, 2, 4, 6, 12, and 24 h post-operatively were significantly increased in group I and group II compared with group III (p < 0.05). The average VAS score during the first 24 h post-operatively was significantly lower in group III than in group I and group II (p < 0.001). Total meperidine consumption was significantly lower in group III than in groups I and II (p < 0.001).

CONCLUSION

Intraarticular levobupivacaine with adjuvant intravenous dexketoprofen trometamol administration provided better pain relief and less analgesic requirement after arthroscopic knee surgery during the first 24 h than that induced by dexketoprofen alone or levobupivacaine intraarticular alone.

LEVEL OF EVIDENCE

II.

Intrathecal morphine for postoperative analgesia: Current trends

The practice of anesthesiology has always been governed by evidence-based medicine. The quick turnover rate of patients in the operating room and patient safety and satisfaction, have also further changed the way we practice anesthesia. The use of intrathecal (IT) opiates as an effective form of postoperative pain relief has been established for many years. Morphine was the first opioid used by IT route. In clinical practice, morphine is regarded as the gold standard, or benchmark, of analgesics used to relieve intense pain. Perhaps for this reason, IT morphine has been used for over 100 years for pain relief. IT morphine is one of the easiest, cost-effective and reliable techniques for postoperative analgesia and technical failures are rare. And yet there is no consensus amongst anesthesiologists regarding the dose of IT morphine. Like all other methods of pain relief, IT morphine also has some side effects and some of them are serious though not very common. This review article looks into some of the key aspects of the use of IT morphine for post-operative analgesia and various doses for different procedures are discussed. This article also describes the side effects of IT morphine and how to treat and prevent them.

Pain management following myringotomy and tube placement: intranasal dexmedetomidine versus intranasal fentanyl

PURPOSE

Despite the brevity of the procedure, bilateral myringotomy and tympanostomy tube placement (BMT) can result in significant postoperative pain and discomfort. As the procedure is frequently performed without intravenous access, non-parenteral routes of administration are frequently used for analgesia. The current study prospectively compares the efficacy of intranasal (IN) dexmedetomidine with IN fentanyl for children undergoing BMT.

METHODS

This prospective, double-blinded, randomized clinical trial included pediatric patients undergoing BMT. The patients were randomized to receive either IN dexmedetomidine (1 μg/kg) or fentanyl (2 μg/kg) after the induction of general anesthesia with sevoflurane. All patients received rectal acetaminophen (40 mg/kg) and the first 50 patients also received premedication with oral midazolam. Postoperative pain and recovery were assessed using pediatric pain and recovery scales, and any adverse effects were monitored for.

RESULTS

The study cohort included 100 patients who ranged in age from 1 to 7.7 years and in weight from 8.6 to 37.4 kg. They were divided into 4 groups with 25 patients in each group: (1) midazolam premedication+IN dexmedetomidine; (2) midazolam premedication+IN fentanyl; (3) no premedication+IN dexmedetomidine; and (4) no premedication+IN fentanyl. Pain scores were comparable when comparing groups 2, 3 and 4, but were higher in group 1 (midazolam premedication with IN dexmedetomidine). There was no difference in total time in the post-anesthesia care unit (PACU) or time from arrival in the PACU until hospital discharge between the 4 groups. The heart rate (HR) was significantly lower in group 3 when compared to the other groups at several different times after arrival to the PACU. No clinically significant difference was noted in blood pressure.

CONCLUSION

Following BMT, when no premedication is administered, there was no clinical advantage when comparing IN dexmedetomidine (1 μg/kg) to IN fentanyl (2 μg/kg). The addition of oral midazolam as a premedication worsened the outcome measures particularly for children receiving IN dexmedetomidine.