Minimal important difference in postoperative morphine consumption after hip and knee arthroplasty using nausea, vomiting, sedation and dizziness as anchors

BACKGROUND

Morphine-sparing effects are often used to evaluate non-opioid analgesic interventions. The exact effect that would warrant the implementation of these interventions in clinical practice (a minimally important difference) remains unclear. We aimed to determine this with anchor-based methods.

METHODS

This was a post hoc analysis of three studies investigating pain management after hip or knee arthroplasty (PANSAID [NCT02571361], DEX-2-TKA [NCT03506789] and Pain Map [NCT02340052]). The overall population was median aged 70, median ASA 2, 54% female. We examined the correlation between 0 and 24 h postoperative iv morphine equivalent consumption and the severity of nausea, vomiting, sedation and dizziness. The anchor was different severity degrees of these opioid-related adverse events. The primary outcome was the difference in morphine consumption between patients experiencing no versus only mild events. Secondary outcomes included the difference in morphine consumption between patients with mild versus moderate and moderate versus severe events. We used Hodges-Lehmann median differences, exact Wilcoxon-Mann-Whitney tests and quantile regression.

RESULTS

The difference in iv morphine consumption was 6 mg (95% confidence interval: 4-8) between patients with no versus only mild events, 5 mg (2-8) between patients with mild versus moderate events and 0 mg (-4 to 4) between patients with moderate versus severe events.

CONCLUSIONS

In populations comparable to this post-hoc analysis (orthopaedic surgery, median age 70 and ASA 2), we suggest a minimally important difference of 5 mg for 0-24 h postoperative iv morphine consumption.

Intraoperative methadone for day-case gynaecological laparoscopy: A double-blind, randomised controlled trial

Optimal pain relief in day-case surgery is imperative to patient comfort and timely discharge from hospital. Short-acting opioids are commonly used for analgesia in modern anaesthesia, allowing rapid recovery after surgery. Plasma concentration fluctuations from repeated dosing of short-acting opioids can cause patients to oscillate between analgesia with potential adverse effects, and inadequate analgesia requiring rescue dosing. Methadone's unique pharmacology may offer effective and sustained analgesia with less opioid consumption, potentially reducing adverse effects. Using a double-blind, randomised controlled trial, we compared post-anaesthesia care unit opioid consumption between day-case gynaecological laparoscopy patients who received either intravenous methadone (10 mg), or short-acting opioids intraoperatively. The primary outcome was post-anaesthesia care unit opioid consumption in oral morphine equivalents. Secondary outcomes included total opioid consumption, discharge opioid consumption, pain scores (0-10) until discharge, adverse effects (respiratory depression, postoperative nausea and vomiting, excess sedation), and rate of admission. Seventy patients were randomly assigned. Patients who received methadone consumed on average 9.44 mg fewer oral morphine equivalents in the post-anaesthesia care unit than the short-acting group (18.02 mg vs 27.46 mg, respectively, 95% confidence interval 0.003 to 18.88, P = 0.050) and experienced lower postoperative pain scores at every time point, although absolute differences were small. There was no evidence of lower hospital or discharge opioid consumption. No significant differences between the methadone and short-acting groups in other outcomes were identified: respiratory depression 41.2% versus 31.4%, Padjusted >0.99; postoperative nausea and vomiting 29.4% versus 42.9%, Padjusted >0.99; overnight admission 17.7% versus 11.4%, Padjusted >0.99; excess sedation 8.82% versus 8.57%, Padjusted >0.99. This study provides evidence that, although modestly, methadone can reduce post-anaesthesia care unit opioid consumption and postoperative pain scores after day-case gynaecological laparoscopy. There were no significant differences in any secondary outcomes.

Management of an Entrapped Epidural Catheter

Epidural catheters are seldom challenging to remove from patients. The occurrence of knotting in an epidural catheter, resulting in entrapment, is an uncommon complication of epidural catheterization. There is the risk of significant morbidity with a retained catheter, with the potential for infection or nerve injury. This report describes the techniques used in a case where surgical removal of an entrapped epidural was required and discusses other potential strategies for the successful management of this type of complication. In this case, a low thoracic epidural catheter that was inserted into a 68-year-old male for post-operative analgesia proved challenging to remove. After multiple attempts to remove the catheter, a lumbar CT scan and neurosurgical evaluation were obtained. The neurosurgical team decided to perform a right thoracic hemilaminectomy to remove the entrapped catheter. This surgery revealed a knot near the distal tip of the catheter, which likely caused the entrapment of the catheter in the epidural space.

Postoperative pain management using an intravenous combination of ibuprofen and acetaminophen compared with acetaminophen alone after thyroidectomy: A prospective randomized controlled trial

BACKGROUND

Multiple medications are more effective than single agents for postoperative pain management. We investigated the analgesic effects of an intravenous combination of acetaminophen and ibuprofen immediately after thyroidectomy.

METHODS

In this double-blind clinical trial, 62 patients who underwent thyroidectomies were randomized to either the treatment (1000 mg acetaminophen, 300 mg ibuprofen) or control (1000 mg acetaminophen) group. Postoperative pain intensity was assessed using the visual analog scale (VAS) 0, 15, and 30 min after recovery room admission. Opioid rescue consumption was also recorded.

RESULTS

The VAS scores were significantly lower in the treatment than in the control group 15 [3 (2-4.3) vs. 5 (3-6); p = 0.015] and 30 [3 (2-4.3) vs. 4 (3-5); p = 0.018] min after recovery room admission, as were the opioid rescue dose requirements (p = 0.033).

CONCLUSIONS

Combined intravenous acetaminophen and ibuprofen may be better than acetaminophen alone for immediately acute postoperative pain after thyroidectomy.

Analgesic efficacy of local infiltration anaesthesia versus femoral nerve block in alleviating postoperative wound pain following total knee arthroplasty: A systematic review and meta-analysis

Total knee arthroplasty (TKA) often involves significant postoperative pain, necessitating effective analgesia. This meta-analysis compares the analgesic efficacy of local infiltration anaesthesia (LIA) and femoral nerve block (FNB) in managing postoperative wound pain following TKA. Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, this meta-analysis was structured around the PICO framework, assessing studies that directly compared LIA and FNB in TKA patients. A comprehensive search across PubMed, Embase, Web of Science and the Cochrane Library was conducted without time restrictions. Studies were included based on specific criteria such as participant demographics, study design and outcomes like pain scores and opioid consumption. Quality assessment utilized the Cochrane Collaboration's risk of bias tool. The statistical approach was determined based on heterogeneity, with the choice of fixed- or random-effects models guided by the I2 statistic. Sensitivity analysis and evaluation of publication bias using funnel plots and Egger's linear regression test were also conducted. From an initial pool of 1275 articles, eight studies met the inclusion criteria. These studies conducted in various countries from 2007 to 2016. The meta-analysis showed no significant difference in resting and movement-related Visual Analogue Scale scores post-TKA between the LIA and FNB groups. However, LIA was associated with significantly lower opioid consumption. The quality assessment revealed a low risk of bias in most studies, and the sensitivity analysis confirmed the stability of these findings. There was no significant publication bias detected. Both LIA and FNB are effective in controlling postoperative pain in TKA patients, but LIA offers the advantage of lower opioid consumption. Its simplicity, cost-effectiveness and opioid-sparing nature make LIA the recommended choice for postoperative analgesia in knee replacement surgeries.

Tumeszenz-Lokalanästhesie bei geriatrischen Patienten mit Hauttumoren im Kopf-Hals-Bereich - Eine retrospektive Studie an 782 Patienten: Tumescent local anesthesia in geriatric patients with head and neck skin cancer - a retrospective study of 782 patients

Hintergrund und Zielsetzung

Aufgrund ihrer Morbidität werden dermatochirurgische Eingriffe bei älteren Patienten vorzugsweise in Tumeszenz‐Lokalanästhesie durchgeführt. Allerdings ist die Datenlage hierzu begrenzt. Ziel der Arbeit war es, die Tumeszenz‐Lokalanästhesie für Hautkrebsoperationen bei älteren Patienten mit dem Fokus auf klinische Vorteile (Behandlungsprozesse, Schmerzmanagement) und dem lokalen postoperativen Komplikationsrisiko zu evaluieren.

Patienten und Methodik

Untersuchung von Patienten ≥75 Jahren mit stationär durchgeführten Hautkrebsoperationen im Kopf‐Hals‐Bereich unter Tumeszenz‐Lokalanästhesie.

Ergebnisse

2940 Eingriffe bei 782 Patienten (Durchschnittsalter 83,3 Jahre) mit dem Ziel einer vollständigen Tumorresektion während des stationären Aufenthaltes wurden durchgeführt. 3,8 (Bereich: 1–20) Eingriffe erfolgten über einen Zeitraum von durchschnittlich 4,9 Tagen (Bereich: 1–28). 43,2% benötigten keine postoperative Analgesie. 53,5% erhielten NSAID, 3,3% Opioide. Wundinfektionen (13,6%) waren die häufigste lokale postoperative Komplikation. Chirurgische Interventionen aufgrund von Nachblutungen waren in 2,8% der Fälle erforderlich. Keine der Blutungen waren hämoglobinrelevant oder lebensbedrohlich. Nahtdehiszenzen und Nekrosen waren selten (0,6%).

Schlussfolgerungen

Die Tumeszenz‐Lokalanästhesie ist für Hautkrebsoperationen bei älteren Menschen eine effektive Anästhesiemethode. Durch den Verzicht auf eine Vollnarkose können die Behandlungsabläufe optimiert und anästhesiologische Risiken minimiert werden. Lokale postoperative Komplikationen treten eher selten auf und sind gut behandelbar. Die langanhaltende Analgesie führt zu einem geringeren Analgetikabedarf und selteneren Medikamenteninteraktionen.

Tumescent local anesthesia in geriatric patients with head and neck skin cancer - a retrospective study of 782 patients

BACKGROUND AND OBJECTIVES

Due to frailty, dermatosurgery in the elderly is preferably performed under tumescent local anesthesia, but data is limited. The aim was to evaluate tumescent local anesthesia for skin cancer surgery in the elderly with focus on clinical benefits (treatment processes, pain management) and local postoperative complication risk.

PATIENTS AND METHODS

Investigation of patients ≥ 75 years with inpatient head and neck skin cancer surgery under tumescent local anesthesia.

RESULTS

2,940 procedures in 782 patients (mean age 83.3 years) were performed with the aim of complete tumor resection during the inpatient stay. 3.8 (range: 1-20) interventions were done over an average of 4.9 days (range: 1-28). 43.2% did not require any postoperative analgesia. 53.5% received NSAIDs, 3.3% opioids. Infection (13.6%) was the most common local postoperative complication. Surgical intervention due to bleeding was required in 2.8%. None was hemoglobin relevant or life-threatening. Suture dehiscence and necrosis were rare (0.6%).

CONCLUSIONS

Tumescent local anesthesia is an effective method for skin cancer surgery in the elderly. By avoiding general anesthesia, treatment processes can be optimized and anesthesiologic risks minimized. Local postoperative complications are still low and well treatable. The long-lasting analgesia results in a reduced need for analgesics and drug interactions.

A Retrospective Comparison of Clinical Efficacy between Multimodal Analgesia and Patient-Controlled Epidural Analgesia in Patients Undergoing Total Knee Arthroplasty

Background and Objectives: Adequate pain management during early rehabilitation is mandatory for improving the outcomes of patients undergoing total knee arthroplasty (TKA). Conventional pain management, mainly comprising opioids and epidural analgesia, may result in certain adverse effects such as dizziness, nausea, and motor blockade. We proposed a multimodal analgesic (MA) strategy involving the use of peripheral nerve block (NB), periarticular injection (PAI), and intravenous patient-controlled analgesia (IVPCA). This study compared the clinical efficacy and adverse effects of the proposed MA strategy and patient-controlled epidural analgesia (PCEA). Materials and Methods: We enrolled 118 patients who underwent TKA under spinal anesthesia. The patients followed either the MA protocol or received PCEA after surgery. The analgesic effect was examined using a numerical rating scale (NRS). The adverse effects experienced by the patients were recorded. Results: A lower proportion of patients in the MA group experienced motor blockade (6.45% vs. 22.98%) compared to those in the PCEA group on the first postoperative day. Furthermore, a lower proportion of patients in the MA group experienced numbness (18.52% vs. 43.33%) than those in the PCEA group on the first postoperative day. Conclusions: The MA strategy can be recommended for reducing the occurrence of motor blockade and numbness in patients following TKA. Therefore, the MA strategy ensures early rehabilitation while maintaining adequate pain relief.

Developing and Implementing Postoperative Pain Management Guidelines for Breast Cancer Surgery: A Leadership Perspective

Introduction Persistent postoperative pain significantly diminishes the quality of life in breast cancer patients. Effective pain management post-surgery is critical for patient satisfaction, reducing complications, and facilitating quick recovery and hospital discharge. This study addresses the lack of patient-centered postoperative pain management guidelines for breast cancer patients. Aim The primary goal of this study was to develop tailored postoperative pain management guidelines for the local community in the United Arab Emirates, integrating these into a broader network of oncology facilities. Methods and Materials Employing a mixed-methods approach with a qualitative emphasis, the study gathered data from 10 female breast cancer patients (aged 39-65 years) with postoperative satisfaction surveys. Additionally, semi-structured interviews with six healthcare professionals involved in guideline development were conducted. Results A significant 90% of patients reported experiencing moderate-to-extreme pain post-surgery, indicating a need for improved pain management. Key factors identified included the need for enhanced nurse training and patient education on pain management preoperatively. The study team unanimously recognized the necessity for dedicated postoperative guidelines. Conclusion The study underscores the critical need for adequate postoperative pain management in breast cancer care. The findings advocate for creating multidisciplinary, evidence-based guidelines focused on patient-centered care. Furthermore, the study highlights the importance of international collaboration and continuous quality improvement measures, such as the Plan-Do-Study-Act (PDSA) cycle, for developing and refining these guidelines.

Development of multidisciplinary, evidenced-based protocol recommendations and implementation strategies for anterior lumbar interbody fusion surgery following a literature review

The anterior lumbar interbody fusion (ALIF) procedure involves several surgical specialties, including general, vascular, and spinal surgery due to its unique approach and anatomy involved. It also carries its own set of complications that differentiate it from posterior lumbar fusion surgeries. The demonstrated benefits of treatment guidelines, such as Enhanced Recovery after Surgery in other surgical procedures, and the lack of current recommendations regarding the anterior approach, underscores the need to develop protocols that specifically address the complexities of ALIF. We aimed to create an evidence-based protocol for pre-, intra-, and postoperative care of ALIF patients and implementation strategies for our health system. A 12-member multidisciplinary workgroup convened to develop an evidence-based treatment protocol for ALIF using a Delphi consensus methodology and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system for rating the quality of evidence and strength of protocol recommendations. The quality of evidence, strength of the recommendation and specific implementation strategies for Methodist Health System for each recommendation were described. The literature search resulted in 295 articles that were included in the development of protocol recommendations. No disagreements remained once the authors reviewed the final GRADE assessment of the quality of evidence and strength of the recommendations. Ultimately, there were 39 protocol recommendations, with 16 appropriate preoperative protocol recommendations (out of 17 proposed), 9 appropriate intraoperative recommendations, and 14 appropriate postoperative recommendations. This novel set of evidence-based recommendations is designed to optimize the patient's ALIF experience from the preoperative to the postoperative period.

Analgesic efficacy of continuous wound infiltration compared with continuous intravenous fentanyl after gynaecological surgery: a non-inferiority, randomised controlled trial

OBJECTIVE

The present trial aimed to prove the non-inferiority of the analgesic efficacy of continuous wound infiltration (CWI) to that of continuous intravenous fentanyl (IV) and to compare the safety of the two methods.

METHODS

This trial was a prospective, single-centre, two-arm, non-inferiority, randomised controlled trial. Patients participating in the trial were randomised to a CWI group or an IV group. The VAS (visual analogue scale), additional analgesic usage and side effects were then compared between the groups.

RESULTS

In total, 61 patients were enrolled; two in CWI were excluded, leaving 59 (30 in the CWI group and 29 in the IV group) for analysis. The difference in the VAS score at 24 h (CWI group - IV group) was -3.2 (95% confidence interval [CI] -14.7 to 8.2), which was less than the non-inferiority margin of 15. The mean amount of total fentanyl use at postoperative hour 48 was 1395 (95% CI 886-1903) µg in the CWI group and 3186 (95% CI 2716-3658) µg in the IV group. The amount of other analgesics and the incidence of adverse effects did not differ significantly between the groups.

CONCLUSION

CWI was non-inferior to IV in terms of its analgesic effect, and has an opioid sparing effect in open gynaecological surgery.

Effective Postoperative Pain Management in Thoracic Outlet Syndrome Surgery: The Role of the Erector Spinae Plane Block

Thoracic outlet syndrome (TOS) often necessitates surgical intervention to alleviate neurovascular bundle compression, which can result in severe postoperative pain. The myriad of surgical techniques available for TOS treatment, the intricate involvement of diverse sensory pathways, and the limited literature on effective analgesic methods for these specific cases underscore the need for successful approaches. This report introduces an efficacious multimodal analgesic strategy that incorporates the erector spinae plane (ESP) block to enhance postoperative pain management after a supraclavicular surgical approach. By combining this fascial block with a comprehensive rationale for its implementation, this case offers valuable insights into improving the postoperative care of TOS patients, ultimately aiming to enhance their comfort and recovery.

The analgesic efficacy of ultrasound-guided transversus abdominis plane block vs. local anesthetic infiltration technique in major gynecologic surgery: A randomized controlled trial

Background and Aim

Transversus abdominis plane (TAP) block and local anesthetic infiltration (LAI) technique are used as part of the multimodal analgesic regimen after abdominal surgery. Postoperative opioid consumption and analgesic efficacy was compared using TAP and LAI techniques in patients undergoing gynecologic surgery in a randomized, controlled clinical trial.

Material and Methods

Total of 135 patients scheduled for major gynecological surgeries were allocated into three groups: group T received bilateral TAP block with bupivacaine 0.25%; group I received LAI with 0.25% bupivacaine with epinephrine 5 μ/mL in the peritoneum and abdominal wall, and group C was control group. Anesthesia and postoperative analgesia were standardized. Outcome measures were cumulative and rescue tramadol consumption, numerical rating score (NRS) for pain and side effects in post-anesthesia care unit (PACU) at 4, 8, 12 hours postoperatively.

Results

Tramadol consumption, need for rescue analgesia, and NRS for pain between three groups at 4, 8, and 12 hours postoperatively had no statistically significant difference (P < 0.05). In PACU, median tramadol consumption used for rescue analgesia between group T (15 (15-30)) and group C (30 (15-45)) (P = 0.035), and between group T (15 (15-30)) and group I (30 (15-52)) was statistically significant (P = 0.034). In PACU, the percentage of patients having NRS >4 on movement in group C (72%) compared to group T (46.5%) and group I (46.5%) was significant (P = 0.034). No statistically significant difference was observed in the incidence of side effects among study groups (P > 0.05).

Conclusion

Except for the immediate postoperative period, neither TAP block nor LAI had added benefit to the multimodal analgesia regimen in patients undergoing gynecological surgeries.

Pain Management in the Postoperative Period for People With Dementia: An Integrative Review

Objective

With the increased global prevalence of older people with dementia, more will present for surgery over the coming decades. Therefore, the objective of this study was to synthesize the existing research about how pain in managed for people with dementia in the postoperative period and discuss the implications for clinical practice.

Methods

For this integrative review, the Cumulative Index to Nursing and Allied Health literature, Medline/Pubmed, ProQuest, ERIC, and Health Source Nursing were searched to identify original empirical research published between 2000 and 2021. Tasks were divided between reviewers to ensure independent study selection, data extraction, and risk of bias assessment.

Results

Eleven articles were eligible. The evidence is incompletely developed therefore the review focused on pain assessment, the types and amount of pain relief, that people with dementia receive less analgesia than people without dementia and the challenges for effective pain management. Most studies were surgery for hip fracture so there is scope to look at outcomes for other types of surgery. Analgesia was administered but it was noted that even over a 20-year period, people with dementia received less than cognitively intact people. Pain management could have a stronger evidence-base with more psychometric development of pain assessment tools. Challenges are due to the impaired ability of the person with dementia to communicate pain and that clinicians have difficulty understanding pain behavior in people with dementia.

Conclusion

Adequate pain management for people with dementia in the postoperative period is important for a faster and better recovery.

No Success without Effort: Follow-Up at Six Years after Implementing a Benchmarking and Feedback Concept for Postoperative Pain after Total Hip Arthroplasty

BACKGROUND

Total hip arthroplasty (THA) is still ranked among the operations with the highest postoperative pain scores. Uncontrolled postsurgical pain leads to prolongated hospital stays, causes more frequent adverse reactions and can induce chronical pain syndromes. In 2014, we implemented a standardized, multidisciplinary pain management concept with continuous benchmarking at our tertiary referral center by using the "Quality Improvement in Postoperative Pain Management" (QUIPS) program with excellent results over a period of two years. The initial study ended in 2016 and we aimed to evaluate if it was possible to obtain the excellent short-term results over a period of six years without any extra effort within the daily clinical routine.

MATERIALS AND METHODS

In a retrospective study design, we compared postoperative pain, side effects and functional outcome after primary THA for 2015 and 2021, using validated questionnaires from the QUIPS project. In contrast to the implementation of the pain management concept in 2014, the weekly meetings of the multidisciplinary health care team and special education for nurses were stopped in 2021. Data assessment was performed by an independent pain nurse who was not involved in pain management.

RESULTS

Altogether, 491 patients received primary THA in 2015 and 2021 at our tertiary referral center. Collected data revealed significantly worse maximum and activity-related pain (both p < 0.001) in combination with significantly higher opioid consumption in comparison to implementation in 2015. Though the patients reported to be less involved in pain management (p < 0.001), the worse pain scores were not reflected by patient satisfaction which remained high. While the participation rate in this benchmarking program dropped, we still fell behind in terms of maximum and activity-related pain in comparison to 24 clinics.

CONCLUSION

Significantly worse pain scores in combination with higher opioid usage and a lower hospital participation rate resemble a reduced awareness in postoperative pain management. The significantly lower patient participation in pain management is in line with the worse pain scores and indirectly highlights the need for special education in pain management. The fact patient satisfaction appeared to remain high and did not differ significantly from 2015, as well as the fact we still achieved an acceptable ranking in comparison to other clinics, highlight the value of the implemented multidisciplinary pain management concept.

Intrathecal Adjuvant Midazolam Versus Fentanyl With Hyperbaric Bupivacaine for Post-operative Analgesia in Women Undergoing Total Abdominal Hysterectomy

Background The administration of adequate analgesia post-operatively has been associated with fewer cardiopulmonary complications, lower morbidity and mortality, lower healthcare costs, and higher patient satisfaction. One of the most effective ways to raise the standard of healthcare would be standardization of multimodal analgesia with enhanced recovery after surgery. Adjuncts to spinal anesthetists can achieve a better post-operative pain relief with less doses of rescue analgesia. Methods This was a prospective, randomized trial conducted on 60 women undergoing abdominal hysterectomy under spinal anesthesia. We evaluated the impact of adding 0.5 mL (2.5 mg) of intrathecal midazolam versus 25 mcg of intrathecal fentanyl (0.5 mL) with 2.5 mL injection of 0.5% bupivacaine (hyperbaric) (12.5 mg). The outcomes were prolongation of analgesia in the post-operative period, onset and duration of sensory and motor blockade, stable hemodynamics, and any adverse reactions to the study drugs. Results The two groups, group M (midazolam + hyperbaric bupivacaine) and group F (fentanyl + hyperbaric bupivacaine), had similar distribution for age, weight, and type and duration of surgical procedure. Both groups had stable vital parameters and experienced a similar onset of sensory and motor blockade. Intraoperative modified Ramsay sedation score was better in group M in comparison to group F. However, mean of elapsed time of two-segment regression of sensory block, from T12 to L1 level, and mean time to regression, from Bromage score 3 to 2, were longer in group F. Group F also had a better visual analogue scale (VAS) score in the post-operative period than group M, and group F experienced a longer average post-operative analgesic duration (lasting for 367.73 minutes) as compared to group M (lasting for 254.9 minutes), having a difference that was of statistical significance (p < 0.001). No substantial adverse reactions were seen in either group. Conclusion The duration of post-operative analgesia is significantly prolonged when 25 mcg of adjuvant intrathecal fentanyl is used with 0.5% bupivacaine (hyperbaric) as compared to intrathecal midazolam 0.5 mL (2.5 mg) in women undergoing abdominal hysterectomy under spinal anesthesia. Both fentanyl and midazolam have minimal adverse reactions and are safe to use as adjuvants to 0.5% of bupivacaine (hyperbaric) in surgeries conducted in the lower abdomen.

Laparoscopic versus ultrasound-guided transversus abdominis plane block for postoperative pain management in minimally invasive colorectal surgery: a meta-analysis protocol

Introduction

Transversus abdominis plane block (TAPB) is now commonly administered for postoperative pain control and reduced opioid consumption in patients undergoing major colorectal surgeries, such as colorectal cancer, diverticular disease, and inflammatory bowel disease resection. However, there remain several controversies about the effectiveness and safety of laparoscopic TAPB compared to ultrasound-guided TAPB. Therefore, the aim of this study is to integrate both direct and indirect comparisons to identify a more effective and safer TAPB approach.

Materials and methods

Systematic electronic literature surveillance will be performed in the PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov databases for eligible studies through July 31, 2023. The Cochrane Risk of Bias version 2 (RoB 2) and Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tools will be applied to scrutinize the methodological quality of the selected studies. The primary outcomes will include (1) opioid consumption at 24 hours postoperatively and (2) pain scores at 24 hours postoperatively both at rest and at coughing and movement according to the numerical rating scale (NRS). Additionally, the probability of TAPB-related adverse events, overall postoperative 30-day complications, postoperative 30-day ileus, postoperative 30-day surgical site infection, postoperative 7-day nausea and vomiting, and length of stay will be analyzed as secondary outcome measures. The findings will be assessed for robustness through subgroup analyses and sensitivity analyses. Data analyses will be performed using RevMan 5.4.1 and Stata 17.0. P value of less than 0.05 will be defined as statistically significant. The certainty of evidence will be examined via the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) working group approach.

Ethics and dissemination

Owing to the nature of the secondary analysis of existing data, no ethical approval will be required. Our meta-analysis will summarize all the available evidence for the effectiveness and safety of TAPB approaches for minimally invasive colorectal surgery. High-quality peer-reviewed publications and presentations at international conferences will facilitate disseminating the results of this study, which are expected to inform future clinical trials and help anesthesiologists and surgeons determine the optimal tailored clinical practice for perioperative pain management.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=281720, identifier (CRD42021281720).

Reducing Opioid Exposure Following Common Ambulatory Hand Surgery: A Systematic Review

BACKGROUND

The opioid epidemic is a health crisis in the United States. Physicians contribute to this problem by overprescribing opioids. Ambulatory hand surgery (AHS) is common in the United States and associated with overprescribing of opioids. Education and guidance regarding the effectiveness of nonopioid compared with opioid interventions for pain management following ambulatory hand procedures are lacking. We assessed the current literature to suggest evidence-based protocols for postoperative analgesia.

METHODS

A systematic review was performed using PubMed, Web of Science, and Cochrane Library. Studies comparing nonopioid with opioid treatments for pain management following AHS were identified. Studies investigating opioid-sparing strategies after AHS were also identified. Evidence was examined to determine efficacy of nonopioid interventions and to provide recommendations for optimal nonopioid protocols and opioid-sparing strategies.

RESULTS

A total of 510 studies were identified in the search with 18 meeting inclusion criteria. High-level evidence demonstrated efficacy of nonopioid interventions for pain management following AHS (levels I and II evidence). Results provided evidence-based guidelines for recommendations of nonopioid treatment protocols and opioid-sparing strategies (levels I and II evidence).

CONCLUSIONS

Our review demonstrated nonopioid interventions are adequate in multiple aspects of pain management compared with opioid treatments. Recommendations were established for two nonopioid treatment protocols, and for an opioid-sparing intervention (levels I and II evidence). The evidence provided in this review should be strongly considered for pain management guidance following AHS and provides a means to decrease opioid overprescribing in the United States.

A Comprehensive Review on the Efficacy of Nerve Blocks in Reducing Postoperative Anesthetic and Analgesic Requirements

The purpose of this article review is to investigate whether or not nerve blocks are beneficial in minimizing the amount of postoperative anesthetic and analgesic medication required, hence improving patient outcomes and reducing healthcare costs. This review investigates several different kinds of nerve blocks, their administration techniques, and the anatomical and physiological aspects that influence nerve block effectiveness. It analyzes the impact of nerve blocks on opioid use, postoperative pain scores, and the incidence of opioid-related adverse effects by compiling the findings of numerous large-scale, randomized, controlled trials. Infection, hematoma, nerve injury, and systemic toxicity are some potential complications of nerve blocks discussed in the article. It concludes with recommendations for optimizing nerve block techniques in clinical practice and identifies areas that require further research, such as the development of new anesthetics and the identification of patient subgroups that would benefit the most from nerve blocks. In addition, it provides recommendations for optimizing nerve block techniques in clinical practice.

Is intravenous magnesium sulphate a suitable adjuvant in postoperative pain management? - A critical and systematic review of methodology in randomized controlled trials

A growing worldwide focus on opioid-free anaesthesia entails multimodal analgesic strategies involving non-opioids such as magnesium sulphate (MgSO4). Several systematic reviews have concluded there is beneficial analgesic effect of MgSO4 administration but do not take considerable heterogeneity among the studies into consideration. Medical literature published until June 2021 was searched in PubMed/Medline, Embase, Central and Web of Science: The final search yielded a total of 5,672 articles. We included only randomised controlled trials assessing the effect of intravenous MgSO4 on opioid consumption and acute postoperative pain when compared to either placebo or standardized analgesic treatment. The primary aim was to compare the homogeneity of essential variables and confounders. A post-hoc meta-analysis demonstrated a reduction in both postoperative morphine consumption (-6.12 mg) and pain score (-12.32 VAS points) in favour of the MgSO4-groups. Data for meta-analysis was missing from 19 studies (45%) on morphine consumption and 29 studies (69%) for pain score, the majority of which reports no effect for either morphine consumption or pain score. The calculated heterogeneity among the included studies was considerable for both outcomes; I 2=91% for morphine consumption and I 2=96% for pain score. Although we found a per se reduction in opioid consumption and pain score, methodological heterogeneity and clinical shortcomings of pre-, intra-, and post anaesthetic data precludes conclusions on clinical importance of intraoperative intravenous MgSO4. In addition, the reduction is likely less than what can be gained from using standardized analgesic treatment.

Evaluation of continuous wound infusion with local analgesics in postoperative renal transplantation patients: A retrospective study

Objectives

The objective is to evaluate the efficacy of the continuous wound infusion (CWI) with Ropivacaine (naropeine 2 mg/ml) on postoperative pain, analgesics consumption, and bowel function in renal transplantation patients.

Materials and Methods

A retrospective study trial including 79 patients who underwent renal transplantation. Patients were separated into two groups (catheter or without catheter). We identified 52 (65.8%) patients who received catheter wound infusion during the first 48 h postoperatively. On the other hand, 27 (34.1%) patients received standard without catheter anesthetic technique. Catheter wound infusion was achieved through a 12 cm catheter, inserted subcutaneously after abdominal closure. The catheter was placed above the external oblique aponeurosis. All postoperative data were examined to evaluate the first postoperative 48 h. This study aims to assess three variables: postoperative pain analysis through a visual analog scale, analgesics consumption, and bowel function.

Results

The overall score of the three variables was studied. Regarding pain assessment, we have determined that the group of patients with catheter scored better than patients without catheter with borderline significance (66.3 vs. 61.2 consecutively; P = 0.0843). An early bowel function was noted in patients with catheters on the 2nd postoperative day (P = 0.0209). Moreover, patients without catheter consumed more painkillers with nonsignificant difference (P = 0.2499).

Conclusion

Patients with catheter showed earlier bowel function than the noncatheter group on the 2nd postoperative day. The catheter group had better pain evaluation.

Minimal important difference in opioid consumption based on adverse event reduction-A study protocol

BACKGROUND

The patient-relevant minimal important difference for opioid consumption remains undetermined, despite its frequent use as primary outcome in trials on postoperative pain management. A minimal important difference is necessary to evaluate whether significant trial results are clinically relevant. Further, it can be used as effect size to ensure that trials are powered to find clinically relevant effects. By exploring the dose-response relationship between postoperative opioid consumption and opioid-related adverse effects, we aim to approximate the minimal important difference in opioid consumption anchored to opioid-related adverse effects.

METHODS

This is a post-hoc analysis of aggregated data from two clinical trials (PANSAID NCT02571361 and DEX2TKA NCT03506789) and one observational cohort study (Pain Map NCT02340052) on pain management after total hip and knee arthroplasty. The primary outcome is the Hodges-Lehmann median difference in opioid consumption between patients with no opioid-related adverse effects and patients experiencing the mildest degree of one or more opioid-related adverse effects (i.e., mild nausea, sedation and/or dizziness or vomiting). Secondary outcomes include the Hodges-Lehmann median difference in opioid consumption that corresponds to one point on a cumulated opioid-related adverse event 0-10 scale. Further, we will explore the proportion of patients that experience opioid-related adverse effects for consecutive opioid dose intervals of 2 mg iv morphine equivalents. Quantile regression will be used to assess any significant interactions with patient baseline characteristics.

CONCLUSIONS

This study will hopefully bring us one step closer to determining relevant opioid reductions and thereby improve our understanding of intervention effects and planning of future trials.

A Safe Number of Perioperative Opioids to Reduce the Risk of New Persistent Usage Among Opioid-Naïve Patients Following Total Joint Arthroplasty

BACKGROUND

Higher initial opioid dosing increases the risk of prolonged opioid use following total joint arthroplasty (TJA), and the safe amounts to prescribe are unknown. We examined the relationship between perioperative opioid exposure and new persistent usage among opioid-naïve patients after total knee and hip arthroplasty.

METHODS

In this retrospective cohort study, 22,310 opioid-naïve patients undergoing primary TJA between 2018 and 2019 were identified within a commercial claims database. Perioperative opioid exposure was defined as total dose of opioid prescription in morphine milligram equivalents (MME) between 1 month prior to and 2 weeks after TJA. New persistent usage was defined as at least one opioid prescription between 90 and 180 days postoperatively. Multivariate regression analyses were performed to examine the relationship between the perioperative dosage group and the development of new persistent usage.

RESULTS

For the total patient cohort, 8.1% developed new persistent usage. Compared to patients who received <300 MME, patients who received 600-900 MME perioperatively had a 77% increased risk of developing new persistent usage (odds ratio 1.77, 95% CI, 1.44-2.17), and patients who received ≥1,200 MME perioperatively had a 285% increased risk (odds ratio 3.85, 95% CI, 3.13-4.74).

CONCLUSION

We found a dose-dependent association between perioperative MME and the risk of developing new persistent usage among opioid-naïve patients following TJA. We recommend prescribing <600 MME (equivalent to 80 pills of 5 mg oxycodone) during the perioperative period to reduce the risk of new persistent usage.

LEVEL OF EVIDENCE

Level III.

An Observational Study to Assess Postoperative Pain Control and Formulate a Comprehensive Approach to the Implementation of Policy Change for Pain Control in Postoperative Units

Background Postoperative pain control irrespective of the magnitude of surgery has always remained a challenge for clinicians and healthcare workers. Good postoperative pain control is pivotal for unremarkable recovery and shorter hospital stays. Unfortunately, there is no uniform approach across the globe to address postoperative pain control. This provoked our thought to conduct a prospective observational study in our center to assess the already existing efficacy of pain management. Materials and methods This is a prospective observational study conducted in a tertiary care center in Coimbatore, India. The aim of this study is to assess the efficacy of an ongoing pain management system to compare it with standards in the literature to introduce changes and re-examine the results. A total of 100 patients who underwent major surgical procedures from various specialities were included after satisfying the inclusion criteria. The study was conducted over a period of four months to collect data from patients in the postoperative ward. Data were collected, pain-related variables were tabulated, and deficits were identified. Standardized pain assessment tools were not used. The results suggested the need for a policy change for quality improvement. This article gives reports on initial study results and plans to address the deficits in the current pain management system. A systematic and schematic approach for the implementation of the policy change and the framework for the new acute pain service team aiming at quality improvement have been discussed in detail. Results The results show that 28 patients were prescribed only routine paracetamol and rescue nonsteroidal anti-inflammatory drugs (NSAIDs). At rest, 56 patients had some pain, and 29 complained of moderate to severe pain. On movement, only seven patients had no pain, 48 had mild pain, and 45 had moderate to severe pain. Only 12 patients out of 100 had good sleep, 27 had moderate, and 43 had little sleep. Twelve patients had no sleep due to continuous ongoing pain in spite of ongoing pain control modalities. Sixteen patients complained of undue delay in receiving their analgesics. Twenty-two patients were dissatisfied, and 44 suggested the need for improvement of current pain control strategies. These data clearly suggest that the pain control strategies are inadequate and need improvement undoubtedly for quality improvement. The Wendy Hirsch model is chosen to create a framework for implementing a new change, and a detailed report is done to present to the hospital quality control department. These changes will be done after the approval, and a post-implementation outcome will be studied. Conclusion Good postoperative pain control is of paramount significance for both patients and healthcare professionals. With the current availability of various pain relief modalities, one should consider establishing a pain control pathway, if possible an acute pain team with a systematic approach. These measures not only improve patient satisfaction but also improve postoperative outcomes and better ways of utilizing healthcare resources.

Effectiveness and safety of path-based analgesic regimens designed by clinical pharmacists based on the type of biliary and pancreatic surgery

WHAT IS KNOWN AND OBJECTIVE

As the incidence of postoperative pain in patients with biliary and pancreatic diseases has gradually increased, how to control postoperative pain has received increasing research attention. By reading pain management guidelines and multidisciplinary communication and cooperation, clinical pharmacists designed multi-mode analgesia regimens based on surgical types, in order to provide strong evidence for the effectiveness and safety of postoperative analgesia regimens and better serve patients.

METHODS

Data from biliary or pancreatic surgery performed at Nanjing Drum Tower Hospital from 2019 to 2021 were collected. Take October 2020 as the time point to compare the outcomes before and after the implementation of the path-based postoperative analgesic regimens. The primary outcomes were NRS pain scores, sleep quality, and incidence of adverse reactions. Length of stay was a secondary outcome.

RESULTS AND DISCUSSION

A total of 268 and 239 patients were enrolled in the study and control groups, respectively. Four path-based postoperative analgesic management regimens significantly reduced patients' static and dynamic NRS scores in the 24 h (p < 0.05). The patients' sleep quality were better than controls (p > 0.05). The incidence of adverse reactions and the length of stay in the study group were numerically lower than controls. Moderate analysis indicated that four analgesia regimens are more precise and better meet actual clinical needs.

WHAT IS NEW AND CONCLUSION

Effective and safe postoperative pain management is particularly important for clinical purposes. Path-based postoperative analgesia regimens based on different types of surgery overcome the disadvantages of overly broad and generalized traditional guidelines, which play an important role in providing personalized and precise clinical services. Further, study findings provide evidence that four path-based analgesic regimens can reduce postoperative pain and reduce the length of hospital stay, which may provide a better direction for clinical postoperative pain management.

Pain Management and Analgesics Used in Small Mammals during Post-Operative Period with an Emphasis on Metamizole (Dipyrone) as an Alternative Medication

Metamizole (dipyrone) is a widely used non-opioid analgesic in both human and animal medicine. Metamizole's safety has been the topic of numerous opposing debates, given the fact that in certain countries metamizole is frequently used as an over-the-counter (OTC) medicine, while in others it is banned due to the risk of agranulocytosis. Further, small mammals such as rabbits, ferrets, rodents, and hedgehogs have become some of the most common pets present in veterinary practice, and each of these species has specific analgesic needs due to their anatomy and physiology. The key to providing appropriate medical care is in finding a substance that has minimal negative effects. In small mammals, analgesia is an important factor and, it happens frequently that, pain in these patients is not well managed. Post-operative pain management is an important topic in the welfare of animals. The objectives of this review, thus, were to provide a concise overview of analgesics that are used in the treatment of postoperative pain in small mammals (e.g., rabbits and rodents) and to highlight the importance of this product, metamizole, in veterinary medicine, as well as the potential of this substance as an alternative analgesic for the treatment of postoperative pain in small mammals.

Peripheral Nerve Blocks Associated With Shorter Length of Stay Without Increasing Readmission Rate for Ankle Open Reduction Internal Fixation in the Outpatient Setting: A Propensity-Matched Analysis

Peripheral nerve blocks (PNB) have become an important modality for pain management in ankle fracture surgery. Previous studies have reported their efficacy, but concerns with rebound pain and readmissions have been cited as possible deterrents. The purpose of this study was to evaluate the effects of PNB on hospital length of stay (LOS), narcotic intake, visual analog scale (VAS) for pain, and associated complications in patients undergoing outpatient ankle open reduction internal fixation (ORIF). Adult patients undergoing ankle ORIF were matched 2:1 (no block:block) using propensity-score matching. Preoperative patient characteristics and postoperative outcomes were compared between cohorts. VAS and total narcotic intake were evaluated for each of the first 3 postoperative 8-hour shifts. Narcotic medication was converted to morphine milligram equivalents (MME). Thirty-two patients who received PNB were matched to 64 patients who did not. The PNB group had lower VAS and MME during each of the 8-hour shifts after surgery: 0 to 8 hours (VAS 1.8 vs 6.3; MME 10.6 vs 77.9; p < .001), 8 to 16 hours (VAS 1.2 vs 5.9; MME 9.2 vs 28.2; p < .001), 16 to 24 hours (VAS 3.7 vs 6.2; MME 13.2 vs 24.2; p = .006 and 0.019). PNB had a shorter LOS (average 16.7 hours vs 26.8 hours; p < .001). There were no differences in rates of ED presentations after discharge, hospital readmissions, or complications between cohorts. Peripheral nerve blocks after ankle ORIF are associated with shorter hospital LOS, lower VAS, and reduced narcotic intake without increasing rates of ED visits, hospital readmissions, or complications.

The Effect of Dexamethasone on Postoperative Pain in Patients After Laparoscopic Cholecystectomy

Objectives The objective of the study was to determine the effect of a single dose of IV dexamethasone on postoperative pain in patients after laparoscopic cholecystectomy. The outcome will be measured in the terms of mean pain score. Study design and setting This is a prospective study. We did a randomized control trial to compare the outcome in two groups. This study was conducted in the Department of Surgery, Benazir Bhutto Hospital, Rawalpindi, from December 2021 to May 2022. The total duration of the study was six months. Methodology A total of 160 patients were randomly divided into group A and group B. We performed laparoscopic cholecystectomies on all the patients under standard general anesthesia. In group A (control group), 5 mL of normal saline was injected intravenously at the time of induction of anesthesia. In group B, the dexamethasone group, the inj. dexamethasone with a dose of 0.1 mg/kg diluted in 5 mL normal saline was given intravenously at the time of induction of anesthesia. Postoperatively, the median pain score was measured using visual analog scale (VAS) at 2, 6, 12, and 24 h on a specially made proforma. The results were further stratified according to gender and age. Results The postoperative VAS in group B was significantly low compared with group A when measured at 2, 6, 12, and 24 h. It means that the median pain score was markedly less in the study group than in the placebo one, and it was statistically significant (p<0.05). Conclusion Administration of a single dose of dexamethasone preoperatively in laparoscopic cholecystectomy patients is effective to control postoperative pain.

Fascial plane blocks for breast surgery - current state of knowledge

Breast surgeries belong to the most frequently performed procedures and are often associated with a high intensity of pain in the postoperative period. Regional anesthesia techniques, and paravertebral block, have been the gold standard of postoperative pain management for major breast cancer surgeries. In recent years, the development of new techniques of regional anesthesiology, which is due to the extensive implementation of ultrasound imaging, has enabled the use of a number of new blockades. The "new players" in regional anesthesiology include numerous fascial plane blocks. Fascial plane blocks are often technically easier and less invasive compared to, for example, paravertebral blockade. The core mechanism of action in fascial blocks consists in blocking the nerve structures that supply a certain area of the trunk after deposition of local anesthetic (LA) within the fascial and fasciomuscular compartments. In addition to direct nerve blockade, there are other potential mechanisms of analgesia such as systemic effects. This idea differs from the traditional concept of nerve and plexus blocks, but it should be remembered that the final effect of a fascial plane block and its extent can be extremely variable across individual cases. According to the current state of knowledge, an alternative to paravertebral blockade may be PECS blockade. The available options also include erector spinae plane block (ESPB) and serratus plane block (SPB), however their recommendation in breast surgery requires more extensive scientific evidence.

Erector Spinae Plane Block versus Transversus Abdominis Plane Block for Postoperative Analgesia in Abdominal Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Regional anesthesia technique has been reported to exert excellent analgesic efficacy for various surgeries. Erector spinae plane block (ESPB) and transversus abdominis plane (TAP) block are good ways to relieve postoperative pain after abdominal surgery. However, the analgesic efficacy between them remains controversial. This meta-analysis evaluated the analgesic effect between these two blocks in abdominal surgery with statistical and clinical interpretation.

METHODS

PubMed, Web of Science, the Cochrane Library, ClinicalTrials.gov register, and Embase databases were systematically searched by two independent investigators from the inception to December 2021.

RESULTS

10 randomized controlled trials (RCTs) comprising 570 patients were included in the final meta-analysis. Meta-analysis revealed that ESPB decreased the opioid consumption and improved the pain scores during the first 24 postoperative hours compared with TAP groups statistically, while the magnitude of this difference did not reach the clinically significant threshold (10 mg of intravenous morphine consumption and 1.3 cm on the VAS scale). In addition, ESPB prolonged blockade duration and decreased the occurrence of postoperative nausea and vomiting (PONV). However, it did not improve the patients' satisfaction.

CONCLUSIONS

Although ESPB does not provide better clinical analgesia than the TAP block, it could be a comparable nerve block technique for abdominal wall analgesia.

Surgeon-Placed Erector Spinae Plane Catheters for Multilevel Lumbar Spine Fusion: Technique and Outcomes Compared With Single-Shot Blocks

BACKGROUND

Postoperative pain management of multilevel lumbar fusion remains challenging. There are few reports of opioid-sparing regional analgesia for spine surgery. We present a novel method for surgeon-placed erector spinae plane (ESP) catheters for multilevel lumbar spine fusion and compare pain- and opioid-related outcomes in a matched cohort who received anesthesiologist-placed ESP blocks.

METHODS

A retrospective matched pilot study of 18 patients: 6 received intraoperative, bilateral ESP catheters. Tunneled catheters were placed under the intact ESP at the proximal end of the incision. Continuous infusions of ropivacaine (0.2%) were started in the postanesthesia care unit (PACU) after emergence from anesthesia and maintained for 48 hours. Catheter patients were matched 1:2 with 12 patients who received preincision single-shot ESP blocks administered by an anesthesiologist, according to age, gender, American Society of Anesthesiologists class, body mass index, and number of spinal levels fused. All patients were provided opioid intravenous patient-controlled analgesia (IV-PCA). Numeric rating scale pain scores (NRS, 0-10), length of stay (LOS), opioid consumption (oral morphine equivalents, mg), opioid side effects, and complications (motor weakness, local anesthetic toxicity, infection, technical issues, and failure), were compared in the PACU and on the nursing floor.

RESULTS

Only 1/6 patients with ESP catheter used opioid IV-PCA, compared with 11/12 who received ESP blocks. There were no differences in total opioid consumption (catheters: 135 ± 141 mg; blocks: 183 ± 112 mg; P = 0.448) or median (interquartile range) LOS (catheters: 73 [50,107] hours; blocks: 90 [72,116] hours, P = 0.708). NRS pain was significantly higher in the PACU after ESP catheters (5.9 ± 1.7) vs ESP blocks (3.3 ± 2.4; P = 0.036), but no differences were found at later timepoints (5.0 ± 1.6 vs 4.3 ± 1.1, respectively; P = 0.383). No catheter-related complications were found.

CONCLUSION

Surgeon-placed ESP catheters represent a simple technique to provide regional analgesia, particularly in centers lacking regional anesthesiology services. Risks, benefits, and efficacy compared to other techniques require prospective study.

LEVEL OF EVIDENCE: 3

Effectiveness of continuous femoral nerve block for pain relief after total knee arthroplasty: comparison with epidural patient-controlled analgesia and periarticular injection

OBJECTIVE

To compare the clinical outcomes among three analgesic techniques, continuous femoral nerve block (CFNB), epidural patient-controlled analgesia (EPCA) and periarticular injection (PAI), in patients undergoing total knee arthroplasty (TKA).

METHODS

This retrospective case-control study enrolled patients that underwent TKA. Visual analogue scale (VAS) pain scores, sleep disturbance, additional opioid consumption and incidence of opioid-related side-effects were assessed.

RESULTS

A total of 120 patients were categorized into three groups: EPCA (group A, n = 40), PAI (group B, n = 40) and CFNB (group C, n = 40). Group C had significantly lower VAS pain scores than groups A and B at 8, 12 and 24 h after TKA. There were no significant differences in VAS pain scores among the three groups from 48 h after TKA. Sleep quality on the first day after surgery was significantly better in group C than in groups A and B. Additional opioid consumption was significantly lower in the group C than in the groups A and B. Group C showed a lower rate of opioid-related side-effects than groups A and B.

CONCLUSION

CFNB was a more effective additional analgesic technique than EPCA or PAI for acute postoperative pain control within 24 h of TKA.

Association Between Opioid Use and Diabetes in Patients With Ankle Fracture Repair

BACKGROUND

Ankle fractures in patients with diabetes mellitus have long been recognized as a challenge to practicing clinicians. Ankle fracture patients with diabetes may experience prolonged healing, higher risk of hardware failure, an increased risk of wound dehiscence and infection, and higher pain scores pre- and postoperatively, compared to patients without diabetes. However, the duration of opioid use among this patient cohort has not been previously evaluated. The purpose of this study is to retrospectively compare the time span of opioid utilization between ankle fracture patients with and without diabetes mellitus.

METHODS

We conducted a retrospective cohort study using our institution's TriNetX database. A total of 640 ankle fracture patients were included in the analysis, of whom 73 had diabetes. All dates of opioid use for each patient were extracted from the data set, including the first and last date of opioid prescription. Descriptive analysis and logistic regression models were employed to explore the differences in opioid use between patients with and without diabetes after ankle fracture repair. A 2-tailed P value of .05 was set as the threshold for statistical significance.

RESULTS

Logistic regression models revealed that patients with diabetes are less likely to stop using opioids within 90 days, or within 180 days, after repair compared to patients without diabetes. Female sex, neuropathy, and prefracture opioid use are also associated with prolonged opioid use after ankle fracture repair.

CONCLUSION

In our study cohort, ankle fracture patients with diabetes were more likely to require prolonged opioid use after fracture repair.

LEVEL OF EVIDENCE

Level III, prognostic.

Transversus Abdominis Plane Block in Colorectal Surgery: A Meta-Analysis

Acute postoperative pain is one of the most common concerns during the early postoperative period in colorectal surgery. Opioids still represent the cornerstone of postoperative pain management, yet they often result in significant side effects such as nausea and/or vomiting, sedation, urinary retention, delayed recovery of colonic motility, respiratory depression, and postoperative ileus. Transversus abdominis plane (TAP) block has been widely used for postoperative analgesia in various abdominal surgeries. The primary aim of this meta-analysis was to compare the postoperative opioid requirements of patients in the TAP block group and the control group (placebo). The secondary aims included evaluation of the efficacy of TAP blocks in postoperative pain management, the measurement of time to first request for opioids, the measurement of length of hospital stay (LoS), and the documentation of postoperative nausea and/or vomiting. We searched for articles reporting the results of randomized controlled trials (RCTs) on the application of TAP block in colorectal surgery published before September 2021. Eight RCTs involving 615 patients were included in the meta-analysis. Seven articles reported the results of TAP blocks in laparoscopic surgery and eight in both laparoscopic and open surgery. The need for opioids and the intensity of pain at rest within 24 h after laparoscopic and combined (laparoscopic and open) surgeries were significantly lower in the TAP block group compared with the “no block” group. The intensity of pain during coughing within 24 hours after laparoscopic surgery was significantly lower in the TAP block groups compared to the groups without block. There were no statistically significant differences between the TAP block and “no block” groups in overall (over the entire hospital stay) postoperative opioid consumption and length of hospital stay after laparoscopic surgery, as well as in postoperative nausea and vomiting after laparoscopic and combined surgeries.

Analgesic Efficacy of Spinal Morphine in Comparison With Transversus Abdominis Plane Block for Postoperative Pain Management in Patients Undergoing Cesarean Section Under Spinal Anesthesia: A Randomized Controlled Trial

Background

Cesarean section (CS) has been one of the most frequently performed major surgical interventions and causes severe postoperative pain. Spinal opioid and abdominal field block have been investigated as effective analgesia for postoperative pain and reduce the need for systemic medications and associated side effects. The aim of the current study is to compare spinal morphine (SM) and bilateral landmark oriented transversus abdominis plane (TAP) block for postoperative pain management.

Method

In this randomized controlled trial, 114 pregnant mothers scheduled for CS under spinal anesthesia were allocated randomly to receive either SM 0.1 mg (group SM; n = 56) or bilateral landmark-oriented TAP block with 20 ml of 0.25% of bupivacaine (group TAP; n = 52). A comparison of numerical variables between study groups was done using unpaired student t-test and Mann–Whitney test for symmetric and asymmetric data, respectively. Time to event variable was analyzed by using Kaplan–Meir's survival function. A p-value of < 0.05 was considered statistically significant.

Result

A total of 114 patients were recruited and randomly assigned and received interventions. Among them, 108 patients completed this study. Time to first analgesic request was significantly shorter in the TAP block compared to SM. Twenty-four-hour median morphine consumption was reduced in the SM group compared to the TAP block (p < 0.001). Median postoperative pain score during movement and rest shows statistically significant differences between groups (p < 0.001).

Conclusion

The addition of preservative-free 100 μg SM provides prolonged postoperative analgesia time, superior postoperative analgesia, and less postoperative opioid consumption compared to the TAP block.

Trust and Distrust in Opioid Decision-Making: A Qualitative Assessment of Patient-Doctor Relationship

PURPOSE

Surgeons often prescribe opioid analgesics for pain management after surgery. However, we understand little about how patients perceive opioid prescribing and make decisions to use opioids for postoperative pain management. In this study, we aimed to gain an understanding of patients' decision-making process on postoperative opioid use.

METHODS

We conducted semi-structured interviews with 30 adult patients undergoing elective surgery at our institution. The interviews were content-coded for thematic analysis. We used trust in the medical setting as a conceptual framework to interpret and find the inherent theory in the data.

RESULTS

We found that participants based their opioid decisions on their trust or distrust toward various elements of their postoperative pain management. Participants believed that the surgeons "know," thereby, reinforcing their trust in surgeons' postoperative opioid prescribing to be in the participants' best interest. Moreover, the positive reputation of the institution strengthened the participants' trust. However, participants conveyed nuanced trust because of their distrust toward the opioid medications themselves, which were viewed as "suspicious," and the pharmaceutical companies, that were "despised." Despite this distrust, participants had confidence in their inherent ability to protect themselves from opioid use disorders.

CONCLUSIONS

Understanding how patients perceive and form decisions on postoperative opioid use based on their trust and distrust toward various factors involved in their care highlights the importance of the patient-doctor relationship and building trust to effectively address postoperative pain and reduce opioid-related harms.

CLINICAL RELEVANCE

Through a strengthened therapeutic alliance between patients and surgeons, we can improve our strategies to overcome the ongoing opioid epidemic through patient-centered approaches.

α2-Adrenergic Receptor Agonist, an Attractive but Underused ERAS Component in Improving Fast-Track Recovery and Surgical Outcomes

Enhanced Recovery After Surgery (ERAS) protocols have been implemented in many institutions to attenuate the stress of surgery and facilitate early recovery. Careful selection of multimodal analgesic medication plays an essential role in achieving the goals of ERAS protocols. Clonidine and dexmedetomidine are α₂-adrenergic receptor (α₂-AR) agonists that can greatly enhance various ERAS components owing to their unique pharmacologic properties: antinociception, anxiolysis, anti-inflammation, and renal protection. The α₂-AR agonists exert supraspinal and spinal antinociceptive effects by potentiating descending pain modulatory pathways and inhibiting peripheral C fibers. These antinociceptive effects of α₂-AR agonists are independent of opioid receptors and result in analgesic synergy with opioid agonists. Several meta-analyses and systematic reviews have reported that α₂-AR agonists decrease opioid consumption and side effects in adult and pediatric surgical patients. Given the wide distribution of α₂-ARs in the body, α₂-AR agonists have been associated with a reduction in anxiety, perioperative stress, inflammation, postoperative nausea and vomiting, shivering, and cognitive dysfunction. This course describes the basic and applied pharmacology of the α₂-AR agonists and provides emerging evidence to support their utility in acute pain management and ERAS protocols. Perioperative administration of α₂-AR agonists can enhance pain management, decrease adverse effects, and promote surgical recovery.

Improving Pain Management After Cesarean Birth Using Transversus Abdominis Plane Block With Liposomal Bupivacaine as Part of a Multimodal Regimen

As educators, advocates, and champions for women's health, nurses play pivotal roles throughout a woman's pregnancy and childbirth journey. Most women experience postsurgical pain after cesarean birth and are prescribed opioids. Caution around opioid use warrants opioid-reducing strategies, particularly because exposure to opioids exacerbates risk for developing persistent postsurgical opioid use. Multimodal approaches can help address this concern. Regional anesthesia using transversus abdominis plane blocks with aqueous formulations of local anesthetics can reduce opioid consumption and pain but has a short duration of action. Liposomal formulation of bupivacaine prolongs its release, overcoming this obstacle. Transversus abdominis plane blocks with liposomal bupivacaine can reduce opioid use and pain after cesarean birth, improving recovery. These findings represent numerous implications for nursing practice to improve postcesarean pain management.

Do local liposomal bupivacaine and interscalene nerve block provide similar pain control after shoulder arthroplasty? A dual-center randomized controlled trial

BACKGROUND

Interscalene nerve block (INB) has become a popular technique for shoulder anesthesia. However, INB is associated with complication rates as high as 20%. Local liposomal bupivacaine (LLB) is an alternative to INB that potentially offers extended pain control with fewer adverse effects.

METHODS

We conducted a dual-center randomized controlled trial of 108 participants who were treated with LLB (n = 54) or INB (n = 54) to control pain after shoulder arthroplasty. We assessed visual analog scale pain scores at 6-hour intervals from 6 to 96 hours postoperatively and at the first postoperative visit. We assessed opioid medication consumption intraoperatively and on days 1, 2, 3, and 4 postoperatively, as well as the duration of hospital and postanesthesia care unit (PACU) stays.

RESULTS

At 6 hours postoperatively, the mean visual analog scale pain score was lower in the INB group (2.9 ± 3.1) than in the LLB group (5.1 ± 2.9, P < .01). The INB group consumed less opioid medication during the first 24 hours postoperatively (18 ± 12 morphine milligram equivalents) than did the LLB group (36 ± 48 morphine milligram equivalents, P = .01). The PACU stay was shorter in the INB group (102 ± 53 minutes) compared with the LLB group (139 ± 77 minutes, P < .01).

CONCLUSIONS

Compared with LLB, INB provides better pain control immediately after shoulder arthroplasty as evidenced by shorter PACU stays, lower pain scores at 6 hours postoperatively, and less opioid medication consumption during the first 24 hours postoperatively. However, no differences in outcomes were observed between groups beyond 24 hours.

Comparison of local infiltration analgesia and interscalene block for postoperative pain management in shoulder arthroscopy: a prospective randomized controlled trial

Background/aim

The aim of this study was to compare the effects of local infiltration analgesia and interscalene brachial plexus block techniques on postoperative pain control and shoulder functional scores in patients undergoing arthroscopic rotator cuff repair.

Materials and methods

Sixty patients who underwent arthroscopic rotator cuff repair were prospectively included in the study. Patients were randomly divided into two groups. Group 1 was comprised of patients who had interscalene brachial plexus block, while group 2 was comprised of patients who had local infiltration analgesia. In group 1, interscalene block was applied with 20 mL 0.5% bupivacaine. In group 2, the Ranawat cocktail was used for local infiltration analgesia. Sixty milliliters of Ranawat cocktail was applied to the subacromial space and glenohumeral joint in equal amounts. Postoperative pain was assessed by the VAS score. Functional scores of the shoulder were also evaluated by Constant–Murley and UCLA scores. The time of first analgesic requirement and total analgesic consumption in the postoperative period were assessed.

Results

The first analgesic requirement was significantly late in the interscalene brachial plexus block group (p = 0.000). There was no statistically significant difference between the groups in terms of total analgesic consumption (p = 0.204). In the postoperative 6th h, the VAS score was 2.43 in the interscalene brachial plexus block group, whereas 2.86 in the local infiltration analgesia group (p = 0.323). There was no statistically significant difference between the groups in terms of Constant–Murley shoulder and UCLA scores in the 3rd postoperative month (respectively, p = 0.929, p = 0.671). Besides, postoperative VAS scores and functional scores were negatively correlated (p < 0.01).

Conclusion

Local infiltration analgesia is an effective alternative to interscalene brachial plexus block for postoperative pain management and total analgesic consumption in arthroscopic rotator cuff repair. However, the interscalene brachial plexus block provides a longer postoperative painless period.

Perioperative pain management and opioid-reduction in head and neck endocrine surgery: An American Head and Neck Society Endocrine Surgery Section consensus statement

BACKGROUND

This American Head and Neck Society (AHNS) consensus statement focuses on evidence-based comprehensive pain management practices for thyroid and parathyroid surgery. Overutilization of opioids for postoperative pain management is a major contributing factor to the opioid addiction epidemic however evidence-based guidelines for pain management after routine head and neck endocrine procedures are lacking.

METHODS

An expert panel was convened from the membership of the AHNS, its Endocrine Surgical Section, and ThyCa. An extensive literature review was performed, and recommendations addressing several pain management subtopics were constructed based on best available evidence. A modified Delphi survey was then utilized to evaluate group consensus of these statements.

CONCLUSIONS

This expert consensus provides evidence-based recommendations for effective postoperative pain management following head and neck endocrine procedures with a focus on limiting unnecessary use of opioid analgesics.

Establishment of resilience in a challenging recovery at home after pediatric tonsil surgery-Children's and caregivers' perspectives

The objective of this study was to explore children's and caregivers’ experiences and management of postoperative recovery at home after tonsil surgery. The study had an explorative qualitative design with an inductive approach. Twenty children (5‐12 years of age) undergoing tonsillectomy or tonsillotomy with or without adenoidectomy participated along with their caregivers in semi‐structured interviews at a mean time of 28 days after surgery. The interviews were analyzed with content analysis. One main category emerged from the interviews: children and caregivers struggle to establish resilience in a challenging recovery. The families’ resilience relied on their situational awareness and capacity to act, which in turn formed a basis for the ability to return to normal daily life. Children and caregivers described the recovery as an evident interruption of daily life which had an impact on the children's physical and psychological well‐being. Both children and caregivers described the pain as a central concern. The families used different pharmacological and complementary strategies to manage the pain, which in some cases were complex. Some families said that the analgesics were insufficient in preventing breakthrough pain, and spoke about a lack of support as well as inadequate and contradictory information from healthcare staff. Caregivers also expressed uncertainty, ambivalence, or anxiety about the responsibility associated with their child's recovery. To optimize and support the recovery after tonsil surgery, it is crucial to obtain knowledge of children's and caregivers’ perspectives of postoperative recovery at home. The results indicate that the postoperative period included several troublesome experiences for which neither the children nor the caregivers were informed or prepared. The experience of pain was significant, and often complex to manage. To increase families’ resilience, the information provided by healthcare professionals needs to be broadened. Multidisciplinary teamwork is necessary to achieve this goal.

Liposomal Bupivacaine Versus Bupivacaine/Epinephrine Intercostal Nerve Block as Part of an Enhanced Recovery After Thoracic Surgery (ERATS) Care Pathway for Robotic Thoracic Surgery

OBJECTIVES

To examine how postoperative pain control after robotic thoracoscopic surgery varies with liposomal bupivacaine (LipoB) versus 0.5% bupivacaine/1:200,000 epinephrine (Bupi/Epi) intercostal nerve blocks within the context of an enhanced recovery after thoracic surgery (ERATS) protocol.

DESIGN

A retrospective analysis of a prospectively maintained database of patients undergoing robotic thoracoscopic procedures between September 1, 2018 and October 31, 2019 was conducted.

SETTING

University of Miami, single-institutional.

PARTICIPANTS

Patients.

INTERVENTIONS

Two hundred fifty-two patients had either LipoB intercostal nerve blocks (n = 129) or Bupi/Epi intercostal nerve blocks (n = 123) when undergoing robotic thoracic surgery.

MEASUREMENTS AND MAIN RESULTS

Comparative analysis of patient-reported pain levels, in-hospital and post-discharge opioid requirements, 90-day operative complications, length of hospital stay, and hospital costs was performed. Data were stratified to either anatomic lung resection or pulmonary wedge resection/mediastinal-pleural procedures. Bupi/Epi patients reported significantly more acute postoperative pain than LipoB patients, which correlated with higher in-hospital and post-discharge opioid requirements. There were no differences in postoperative complications, length of hospital stay, or hospital costs between the two groups.

CONCLUSIONS

As part of an ERATS protocol, infiltration of intercostal spaces and surgical wounds with LipoB for robotic thoracoscopic procedures afforded better postoperative subjective pain control and decreased opioid requirements without an increase in hospital costs as compared with use of Bupi/Epi.

The effect of postoperative serratus anterior plane block on postoperative analgesia in patients undergoing breast surgery

Objectives

This study aimed to evaluate the effect of serratus anterior plane block (SAP) on postoperative morphine consumption. We aimed to determine the differences between both similar blocks and evaluate the effect of the methods of application of this block on patients' postoperative pain scores and morphine consumption.

Material and Methods

This study is a single-center, prospective and observational study performed with 40 volunteer patients with American Society of Anesthesiologists (ASA) I-III, who were 18-70 years of age, scheduled for breast surgery. A total of 40 patients who underwent general anesthesia were divided into two groups each with 20 patients. While SAP block was applied to the study group, no block was applied to the control group. SAP block was made by injecting a total of 40 ml of 0.25% bupivacaine between 2 muscles after the test dose was injected with saline. All patients were followed up for 12 hours postoperatively with patient-controlled analgesia (PCA) pump. Morphine consumption, visual analogue score (VAS) values and side effects were recorded at the postoperative 1st, 6th and 12th hours.

Results

There was no significant difference between the two groups in terms of hemodynamic parameters and demographic data. Postoperative morphine consumption and postoperative analgesic requirement were significantly lower in the SAP block group (p <0.001). Postoperative VAS values were significantly lower in the SAP block group (p <0.001). No complication was observed related to the block.

Conclusion

It was found that the SAP block reduced morphine consumption, significantly decreased VAS values, and reduced side effects due to opioids postoperatively.

Standardized Order Set Exhibits Surgeon Adherence to Pain Protocol in Pediatric Adenotonsillectomy

OBJECTIVES/HYPOTHESIS

To produce a sustained reduction in opioid prescriptions in patients <5 years of age undergoing T&A through utilization of standardized algorithms and electronic health record (EHR) automation tools.

STUDY DESIGN

Prospective quality improvement initiative.

METHODS

Plan-do-study-act (PDSA) methodology was used to design an age-based postoperative pain regimen in which children <5 years of age received a non-opioid pain regimen, and option to prescribe oxycodone for additional pain relief was given for children >5 years of age. Standardized discharge instructions and automated, age-specific order sets were created to facilitate adherence. Rate of discharge opioid prescription was monitored and balanced against post-discharge opioid prescriptions and returns to the emergency department (ED).

RESULTS

In children <5 years of age undergoing T&A, reduction in opioid prescription rates from 65.9% to 30.9% after initial implementation of the order set was noted. Ultimately, reduction of opioid prescribing rates to 3.7% of patients was noted after pain-regimen consensus and EHR order set implementation. Opioid prescriptions in patients >5 years of age decreased from 90.6% to 58.1% initially, and then down 35.9% by the last time point analyzed. Requests for outpatient opioid prescriptions did not increase. There was no significant change in returns to the emergency ED for pain management, or in the number opioids prescribed when patients returned to the ED.

CONCLUSIONS

Iterative cycles of improvement utilizing standardized pain management algorithms and EHR tools were effective means of producing a sustained reduction in opioid prescriptions in postoperative T&A patients. Such findings suggest a framework for similar interventions in other pediatric otolaryngology settings.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2337-E2343, 2021.

Epidural analgesia for postoperative pain: Improving outcomes or adding risks?

Current evidence shows that the benefits of epidural analgesia (EA) are not as impressive as believed in the past, while the risks of adverse effects and serious complications are greater than previously estimated. There are many reasons for the decreasing role of epidural technique in clinical practice (table). Indeed, EA can cause harm and hinder early mobilization in enhanced recovery after surgery (ERAS) programmes. Some ERAS interventions are complex, confusing, sometimes contradictory and apparently unimplementable. In spite of much hype and after almost 25 years, the originator of the concept has described the current status of ERAS as 'far from good'. Outpatient surgery setup has been a remarkable success for many major surgical procedures, and it predates ERAS and appears to be a simpler and better model for reducing postoperative morbidity and hospitalization times. Systematic reviews of comparative studies have shown that less invasive and safer but equally effective alternatives to EA are available for almost all major surgical procedures. These include: paravertebral block, peripheral nerve blocks, catheter wound infusion, periarticular local infiltration analgesia, preperitoneal catheters and transversus abdominis plane block. Increasingly, these non-EA methods are being used as surgeon-delivered regional analgesia (RA) techniques. This encouraging trend of active surgeon participation, with anaesthesiologist collaboration, will undoubtedly improve the decades-old twin problems of underused RA techniques and undertreated postoperative pain. The continued use of EA at any institution can only be justified by results from its own audits; however, regrettably only very few institutions perform such regular audits.

An interdisciplinary approach to safe opioid prescribing and administration for surgical patients at an academic medical center

AIM AND OBJECTIVES

To explore and understand the current practice, perceptions, and knowledge of general surgery trainees, advanced practice providers, and surgical nurses regarding opioid prescribing and administration. To this end, a novel opioid education and training was introduced to educate these practitioners on safe opioid practices in surgical patients.

BACKGROUND

National awareness of the opioid epidemic has increased significantly in the last several years. However, there remain a disturbingly high number of opioid prescriptions written in the US indicating a need for improved provider and nurse education. This involves increasing awareness and understanding of national guidelines as well as implementing multi-modal therapy to treat pain.

DESIGN

Pre-post-intervention quality improvement project.

METHODS

An opioid education and training involving a morphine equivalent daily dosing calculator in the electronic medical record was provided to 26 surgical trainees, eight advanced practice providers and 97 surgical nurses in November 2019. Perceptions, current practice and knowledge were measured using a pre- and post-intervention survey (SQUIRE checklist).

RESULTS

The survey results showed a positive clinical change in perception of opioid use in surgical patients following the intervention and a modest decrease in the average morphine equivalent daily dosing at discharge in general and transplant surgery patients.

CONCLUSIONS

Effective pain management for surgical patients must be individualised. Safe opioid prescribing should involve an interdisciplinary approach with all members of the team undergoing assessment of their opioid knowledge and prescribing habits, easily accessible training tools and opioid calculators in the electronic medical record.

RELEVANCE TO CLINICAL PRACTICE

Our initiative may provide useful information to settings that replicate use of a morphine equivalent daily dosing calculator in the electronic medical record. Utilisation of safe opioid prescribing tools in the electronic medical record and continuing education for providers and nurses can help ensure the safety of surgical patients.

Factors affecting the incidence of chronic pain following breast cancer surgery: Preoperative history, anesthetic management, and surgical technique

BACKGROUND OR OBJECTIVES

Breast cancer is the most frequent cancer in women. Chronic pain following mastectomy remains a significant problem. This study aimed to evaluate risk factors associated with postoperative chronic pain.

METHODS

Medical records were analyzed retrospectively for 147 consecutive patients with breast cancer who underwent mastectomy between July 2016 and February 2018 with one-year follow-up. All patients received a paravertebral block pre-operatively and then general anesthesia for the surgery.

RESULTS

The median postoperative pain score was 1.3 on the verbal analgesic score. The average total dose of opioids administered postoperatively was 10.4 mg, expressed in morphine milligram equivalents. The incidence of chronic pain after mastectomy was 16.7% at 6 months and 13.3% at 1 year. The satisfaction rate for anesthesia and surgery was 95.7%.

CONCLUSIONS

The data suggested that preoperative paravertebral nerve blocks, appropriate adjuvants, and a balanced general anesthetic may contribute to better postoperative pain control and decreased the incidence of chronic pain. A history of preoperative use of opioids and/or a history of alcohol consumption were both associated with significant increased levels of postoperative pain, and this subgroup warrants attention to diminish the risk of developing chronic pain.

Outpatient Opioid Use After Cesarean Delivery

OBJECTIVES

With a goal of informing opioid prescribing after cesarean delivery, we compared inpatient, prescribed, and outpatient Morphine Equivalent Doses (MED) and patient characteristics.

METHODS

Patients were enrolled after cesarean delivery and followed for 2-5 weeks with demographic, opioid use, and clinical characteristics collected from participants and the medical record. T-test, ANOVA, linear regression, and Pearson correlation coefficients were used in analyses.

RESULTS

Among 76 women, 21% used all opioids prescribed and 20% used none. History of psychiatric comorbidities was associated with higher outpatient opiate use (172 MED vs 103 MED; p = 0.046). There was no difference in opiates consumed inpatient and amount prescribed at discharge (p = 0.502). However, low, medium, and high inpatient consumers used 53 (SD 76), 111 (SD 96), and 195 (SD 132) MEDs outpatient, respectively (p < 0.001).

CONCLUSIONS

Outpatient opioid prescribing based on inpatient needs may facilitate judicious opioid use after cesarean delivery. Significance What Is Already Known: Opioid abuse is a growing problem in this country, and excess prescribing contributes to the availability of opioids. Limited data exist regarding the amount of opioids patients need after cesarean delivery, or what factors are predictive of an individual patient's opioid needs.

WHAT THIS STUDY ADDS

This study further supports the growing literature demonstrating that providers frequently over-prescribe opioids following cesarean delivery. It uniquely adds associations of patient-specific factors and outpatient opioid needs.

Effect of cocktail therapy after arthroscopic rotator cuff repair: a randomized, double-blind trial

BACKGROUND

We investigated the effectiveness of cocktail therapy after arthroscopic rotator cuff repair (ARCR).

METHODS

We evaluated 128 shoulders undergoing ARCR and used block randomization to divide patients into 2 groups in this double-blind trial: The cocktail group received 20 mL of 0.75% ropivacaine, 5 mg of morphine, 0.3 mg of epinephrine, 2 mg of betamethasone, and saline solution to a total of 42 mL, whereas the control group received 20 mL of 0.75% ropivacaine and saline solution to a total of 42 mL. Postoperatively, one of the drug mixtures was injected into the glenohumeral joint, subacromial bursa, suprascapular nerve, and anterior, middle, and posterior parts of the deltoid muscle according to the treatment group. We recorded patients' visual analog scale scores preoperatively and at 4, 8, 16, 24, and 48 hours postoperatively; the number of patients using postoperative diclofenac suppositories and buprenorphine hydrochloride; the number of patients experiencing nausea; the number of patients with infection and delayed wound healing as adverse effects; the surgery time; the retear rate; and passive shoulder range of motion.

RESULTS

The cocktail group constituted 64 shoulders (50.0%), with 39 men (60.9%) and 25 women (39.1%); the mean age was 64.2 ± 10.2 years. The control group constituted 64 shoulders (50.0%), with 41 men (64.1%) and 23 women (35.9%); the mean age was 65.2 ± 7.5 years. We found no significant difference in age or sex between the 2 groups. There was also no significant difference in rotator cuff tear size or surgery time between the 2 groups. The visual analog scale scores at 8, 16, and 24 hours postoperatively were significantly lower in the cocktail group. The number of patients using suppositories was also significantly lower in the cocktail group. The number of patients receiving buprenorphine injections tended to be lower in the cocktail group, but the difference was not significant. Nausea occurred in 6.3% of patients in the cocktail group and 15.6% in the control group, but the difference was not significant. No infection or delayed wound healing occurred in either group. There was no significant difference in the retear rate between the 2 groups. Passive anterior elevation at 3 months postoperatively was significantly better in the cocktail group than in the control group.

CONCLUSION

We compared cocktail therapy and ropivacaine after ARCR and found no difference in results except for VAS score at 8, 16, and 24 hours postoperatively and frequency of postoperative suppository use without an apparent risk of infection or a detrimental effect on tendon healing.