Additional Opioid Analgesia Research Articles

Short-term outcome of totally minimally invasive versus hybrid minimally invasive Ivor-Lewis esophagectomy.

For resectable esophageal cancer, the choice of total minimally invasive esophagectomy (TMIE) or hybrid minimally invasive esophagectomy (HMIE) remains controversial. The purpose of this study was to evaluate the short-term clinical outcomes of TMIE and HMIE under the Ivor-Lewis procedure. The data of 145 patients diagnosed with middle or lower esophageal cancer who underwent radical Ivor-Lewis esophagectomy in the Affiliated Hospital of Qingdao University between January 2018 and December 2019 were retrospectively analyzed. The short-term outcomes such as complications during surgery or within 30 days after surgery and postoperative pain were analyzed. All patients were divided into TMIE group (75 patients) and HMIE group (70 patients). No significant difference was observed in the baseline characteristics of the two groups. TMIE was associated with less blood loss than the HMIE group (p<0.05). A total of 54 (37.2%) patients had postoperative complications. Although the two groups were statistically similar in the incidence of major complications, patients in the HMIE group were more likely to have pneumonia compared with those in the TMIE group. The numeric rating scale for pain was significantly higher in the HMIE group (p=0.002) and more patients required an additional opioid analgesia after esophagectomy (p=0.282). In conclusion, according to perioperative outcomes, TMIE can benefit patients better than HMIE.

Can gabapentinoids decrease perioperative opioid requirements in orthopaedic trauma patients? A single-centre retrospective analysis.

Perioperative pain control in patients with orthopaedic trauma/extremity fractures has gained a lot of attraction from the scientific community in the last two decades. In addition to multimodal analgesia, the use of non-opioid drugs like gabapentinoids for pain relief is gradually finding its place in several orthopaedic subspecialties like spinal surgery, arthroplasty, and arthroscopic procedures. We envisage investigating the effectiveness of gabapentin in perioperative pain control in patients with extremity fractures undergoing surgical fixation. This was a retrospective comparative study conducted between January 2020 and January 2022. Patients with isolated fractures of the extremity involving long bones who were treated at our trauma centre, during the study period were divided into two groups based on the analgesics they received. Patients who received gabapentin and paracetamol were placed in group GP and those who received only paracetamol were assigned group NGP. Gabapentin was given in a single dose of 300mg 4h before surgery. Postoperatively, they were given 300mg 12 hourly for 2days. All patients in our trauma centre are usually managed with parenteral paracetamol administration pre and postoperatively. VAS score was calculated postoperatively at 2, 6, 12, 24 and 48h. Patients requiring additional analgesics for pain relief were administered intravenous tramadol or a buprenorphine patch was applied. Patients in both groups were compared in terms of pain control, the additional requirement of opioid analgesics, and any adverse event related to medications. One hundred and nineteen patients were enrolled in the study. Out of 65 patients in the NGP group (non-gabapentin group), 74% of patients received additional opioid analgesics apart from paracetamol. Out of the 54 patients in the GP group (gabapentin group), only 41% required additional opioid analgesia for pain control. There was a significant difference in opioid consumption between the two groups (p < 0.01). VAS scores were not significantly different between the two groups at 2, 4, 6, 12, 24 and 48h. Gender and fracture morphology did not affect opioid intake in the GP group. However, in the non-gabapentin group, there was a significant difference in opioid requirement in patients with intraarticular fractures (p < 0.01). Analgesic requirements vary from patient to patient depending on the injury's severity and surgery duration. However, there are no strict guidelines for pain relief in limb trauma surgeries which often leads to overuse and opioid-related complications or underuse and chronic pain. Gabapentinoids can supplement the analgesic effect of paracetamol in trauma patients during the perioperative period, decreasing the need for opioids.

Combination of Femoral and Parasacral Sciatic Nerve Block as Multimodal Pain Management in Post Hemiarthroplasty Surgery Patient

Background: The prevalence of femoral neck fractures is high in geriatric patients with a high mortality rate. Many geriatric patients have comorbidities and find it difficult to tolerate general or neuraxial anesthesia during hip hemiarthroplasty. A more safe technique in lower extremities using peripheral nerve blocks is preferred. The combination of sciatic nerve blocks and psoas compartments can supply adequate anesthesia for hip surgery thus reducing mortality. Femoral nerve blocks decrease the incidence of complications than psoas compartment blocks. Case: A 88-year-old female patient, 70 kg, with distal femoral subtrochanteric fracture accompanied by dislocation, hypertension emergency, hyperplasia heart disease (HHD), and heart failure stage B Fc II were undergoing hemiarthroplasty with regional anesthesia sciatic nerve block and femoral block. After surgery, a block was performed using regional anesthesia sub-arachnoid block bupivacaine 0,5% 7mg + fentanyl 25 µg + Morphin 0,1 µg, post-operative pain with ultrasound, the patient received 0.375% naropin and 50 mg trilac total volume 20 cm3. Then femoral block was done with 0.375% and 50 mg trilac total volume 20 cm3. Patients were observed for pain scale during hospitalization, time of mobilization, and length of stay. Post-operative hemodynamic was stable, the pain scale using VAS assessment was 0-1 during hospitalization without additional opioid analgesia, active mobilization began on the 2nd day, and the length of stay was 3 days. Conclusion: The combination of a femoral and sciatic nerve block to the proximal part of the skin incision can supply adequate pain compliance for hip hemiarthroplasty.

Postoperative analgesic effects of Reiki therapy in bitches undergoing ovariohysterectomy

ABSTRACT: This study aimed to evaluate the effects of Reiki therapy on postoperative pain in bitches undergoing elective minimally invasive ovariohysterectomy (OVH). Thirty bitches were randomly assigned to three groups: Control, Placebo, or Reiki. All dogs received methadone as preanesthetic medication (PAM), meloxicam in the preoperative period, propofol for anesthetic induction, and isoflurane for anesthetic maintenance. Immediately after OVH, the dogs in the Reiki were submitted to a single session of Reiki therapy, dogs in the Placebo received simulated Reiki therapy from a non-therapist, and dogs in the Control received no treatment. All dogs were evaluated for pain using short-form Glasgow composite measure pain scale (CMPS-SF) and visual analog scale (VAS) before (M0) and 2 (M2), 4 (M4), 8 (M8), 12 (M12), and 24 hours (M24) after administration of PAM. Comparing the CMPS-SF scores between the groups, at M2 Reiki scores were lower than those of the Placebo and at M4 those in the Reiki were lower than those of the Control or Placebo groups. Comparing the VAS scores, at M4 and M8, Reiki scores were lower than those of the Control or Placebo groups. Additional analgesia (morphine 0.2 mg.kg-1 intramuscularly) was administered to three bitches in Control and to four bitches of the Placebo. Reiki did not require additional opioid analgesia in the postoperative period. It was concluded that Reiki therapy provided analgesic effect and contributed to improve postoperative comfort of bitches submitted to elective OVH.

The Effects of Infiltration of Liposomal Bupivacaine for Pain Control After Cesarean Delivery: A Randomized Trial [19T

INTRODUCTION: In response to the growing opioid epidemic, we determine whether the addition of liposomal bupivacaine infiltration administered above and below the fascial layer and within the subcutaneous tissue at the time of closure post cesarean delivery would reduce pain scores compared to the use of intra-thecal morphine alone. METHODS: Randomized, placebo-controlled, single-blinded study. Eligible women over 17 years of age and at least 34 weeks gestation, non-emergent cesarean delivery under spinal anesthesia. Random assignment to receive either intrathecal Astramorph® and saline wound infiltration or intrathecal Astramorph® and wound infiltration with liposomal bupivacaine (Exparel®). Primary outcome was post-operative pain scores measured via visual analog scale until discharge. Secondary outcomes included side effects and patient satisfaction. A t-test was used to assess differences between groups for continuous variables, and a chi-square test was used to assess differences for categorical variables. Informed consent and IRB approval obtained. RESULTS: Of the 22 eligible subjects identified during the study interval, 18 were randomized and completed the study. The groups were similar in regards to demographic parameters. As compared to the placebo group, the mean daily pain scores were significantly lower in the Exparel® group on post-operative days 1 and 2 (P < 0.05) and required less opioids. No significant differences between groups in satisfaction scores or the presence of side effects. No patients required additional opioid analgesia after discharge. CONCLUSION: Wound infiltration with liposomal bupivacaine during cesarean delivery reduced post-operative pain scores without increasing side effects. Supports the effectiveness of this multimodal approach to post cesarean delivery analgesia.

Ultrasound guided supra-inguinal Fascia Iliaca Compartment Blocks in hip fracture patients: An alternative technique

IntroductionIn the Emergency Department, regional anesthesia is increasingly used in elderly patients with hip fractures. An example is a Fascia Iliaca Compartment Block (FICB). Traditionally, this block is administered below the inguinal ligament. There is no Emergency Department data regarding effectivity of an alternative, more cranial approach above the inguinal ligament. The objective was to determine analgesic effects of an ultrasound-guided supra-inguinal FICB in hip fracture patients in the Emergency Department. MethodsThis case series included all Emergency Department hip fracture patients who were treated with a supra-inguinal FICB during a period of 10 months. All data were recorded prospectively. Primary study outcome was decrease in Numerical Rating Scale (NRS) pain scores 60 min after the FICB. Secondary outcomes included the proportion of patients achieving 1.5 NRS points decrease at 60 min; NRS differences at 30 and 120 min compared to baseline; need for additional analgesia and occurrence of adverse events. ResultsA total of 22 patients were included in the study. At 60 min median NRS pain scores decreased from 6.0 to 3.0 (p < 0.001). Of all patients, a total of 59% achieved a decrease in 1.5 NRS points after 60 min. Median pain scores at 30 and 120 min were 4.0 (Interquartile Range (IQR) 2.0–5.0) and 2.5 (IQR 0.8–3.0). Seven patients (31.8%) required additional opioid analgesia after the FICB. No adverse events were recorded. ConclusionAn ultrasound-guided supra-inguinal FICB decreases NRS pain scores in hip fracture patients both clinically relevant and statistically significantly after 60 min. Clinical trial registrationThe study was registered in the ISRCTN database (ISRCTN74920258).

Ketamine as an Adjunct to Opioids for Acute Pain in the Emergency Department: A Randomized Controlled Trial.

This study had five objectives: 1) to measure and compare total opioid use and number of opioid doses in patients treated with opioids versus ketamine in conjunction with opioids; 2) to measure pain scores up to 2 hours after presentation in the ED patient with pain, comparing standard opioid pain control to ketamine in conjunction with opioids; 3) to compare patient satisfaction with pain control using opioids alone versus ketamine in conjunction with opioids; 4) to monitor and compare side effects in patients treated with opioids versus ketamine in conjunction with opioids; and 5) to identify effect variation between different subgroups of patients, with the purpose of focusing future research. We hypothesized that low-dose ketamine, compared to placebo, as an adjunctive treatment to opioids would result in better pain control over 2 hours and greater patient satisfaction with pain control; further, this protocol will result in a lower opioid dosage over 2 hours. This was a randomized, double-blinded, placebo-controlled trial at a single academic emergency department evaluating the use of ketamine versus placebo in conjunction with opioids for moderate to severe pain. Subjects with a continued high level of pain after an initial dose of opioid analgesia were randomized to receive either 0.1 mg/kg ketamine or placebo prior to protocol-based dosing of additional opioid analgesia, if required. Over 120 minutes, subjects were assessed for pain level (0-10), satisfaction with pain control (0-4), side effects, sedation level, and need for additional pain medication. Total opioid dose, including the initial dose, was compared between groups. Sixty-three subjects were randomized to the placebo group and 53 to the ketamine group. No significant differences were found in demographics between the groups. Patients receiving ketamine reported lower pain scores over 120 minutes than patients receiving placebo (p=0.015). Total opioid dose was lower in the ketamine group (mean ± SD= 9.95±4.83 mg) compared to placebo (mean±SD=12.81±6.81 mg; p=0.02). Satisfaction did not differ between groups. Fewer patients in the ketamine group required additional opioid doses. More patients reported light-headedness and dizziness in the ketamine group. Ketamine, as an adjunct to opioid therapy, was more effective at reducing pain over 120 minutes and resulted in a lower total opioid dose as well as fewer repeat doses of analgesia. More side effects were reported in the ketamine group (51% vs. 19%), but the side effect profile appears tolerable.

Effects of preincisional analgesia with surgical site infiltration of ketamine or levobupivacaine in patients undergoing abdominal hysterectomy under general anesthesia; A randomized double blind study.

Context:Postoperative pain management remains a cornerstone in patient's management to ensure a better quality of life. Preemptive analgesia is reported to inhibit the persistence of postoperative pain.Aims:The aim of this study is to assess the analgesic effectiveness of preincisional infiltration of ketamine following elective abdominal hysterectomy as compared to levobupivacaine.Settings and Design:This was a prospective, randomized, double-blind study.Subjects and Methods:This study included 48 patients undergoing abdominal hysterectomy under general anesthesia. They were randomized into two equal groups; Group K received subcutaneous infiltration of 20 ml containing ketamine 2 mg/kg and Group L received subcutaneous infiltration of 20 ml of levobupivacaine 0.25% along the Pfannenstiel incision 5 min before incision. Postoperative pain was assessed using visual analog scale (VAS) at rest and on coughing with evaluation of additional opioid analgesic requirements.Statistical Analysis Used:Numerical variables were presented as mean and standard deviation or median and range as appropriate. The intergroup differences were compared using the independent-sample Student's t-test or Mann–Whitney test for numerical variables.Results:VAS score decreased significantly in Group L from 10 to 24 h and in Group K from 8 to 24 h as compared to the immediate postoperative reading. VAS score in ketamine group was significantly lower than that in the levobupivacaine group 8, 10, and 24 h postoperatively. Ketamine group showed delayed request of additional opioid analgesia (P < 0.001) with significantly less opioid consumption (P < 0.001) as compared to levobupivacaine. The total dose of meperidine consumed during the 24 postoperative h was significantly smaller in ketamine group (P < 0.001).Conclusion:Surgical site infiltration of ketamine is a promising preemptive analgesic method in the lower abdominal surgery with minimal sedation and adverse effects.

Standard Preoperative Analgesia with or without Fascia Iliaca Compartment Block for Femoral Neck Fractures

To compare the visual analogue score (VAS) for pain in patients with femoral neck fracture who received standard preoperative analgesia with or without fascia iliaca compartment block (FICB). In patients with femoral neck fracture, 69 patients who received standard preoperative analgesia (regular paracetamol 1g 4 times a day, codeine 60 mg 4 times a day, and opioid 10 mg 2 hourly as required) were compared with 50 patients who received standard preoperative analgesia plus FICB. VAS for pain at rest and on movement (hip flexion) was assessed before FICB and 15 minutes, 2 and 8 hours after FICB. The amount of additional opioid required and the incidence of opioid overdose (necessitating administration of naloxone) were determined. VAS for pain was significantly lower after standard analgesia plus FICB than standard analgesia alone (p=0.001). The analgesic effect (pre-score minus post-score) of standard analgesia plus FICB did not differ between genders (p=0.57) or fracture patterns (p=0.79). 19 (38%) patients with standard analgesia plus FICB required no additional opioid analgesia. Compared with standard analgesia alone, addition of FICB reduced the mean dose of opioid from 6.2 to 2.0 (p=0.001) and the number of opioid overdose from 7.2% to 0% (p=0.001). No patient had any complication following FICB. In patients with femoral neck fracture, FICB reduced the need for additional opioid analgesia and avoided the risk of opioid overdose and respiratory depression.

Sub‐dissociative dose intranasal ketamine for limb injury pain in children in the emergency department: A pilot study

The present study aims to conduct a pilot study examining the effectiveness of intranasal (IN) ketamine as an analgesic for children in the ED. The present study used an observational study on a convenience sample of paediatric ED patients aged 3-13 years, with moderate to severe (≥6/10) pain from isolated limb injury. IN ketamine was administered at enrolment, with a supplementary dose after 15 min, if required. Primary outcome was change in median pain rating at 30 min. Secondary outcomes included change in median pain rating at 60 min, patient/parent satisfaction, need for additional analgesia and adverse events being reported. For the 28 children included in the primary analysis, median age was 9 years (interquartile range [IQR] 6-10). Twenty-three (82.1%) were male. Eighteen (64%) received only one dose of IN ketamine (mean dose 0.84 mg/kg), whereas 10 (36%) required a second dose at 15 min (mean for second dose 0.54 mg/kg). The total mean dose for all patients was 1.0 mg/kg (95% CI: 0.92-1.14). The median pain rating decreased from 74.5 mm (IQR 60-85) to 30 mm (IQR 12-51.5) at 30 min (P < 0.001, Mann-Whitney). For the 24 children who contributed data at 60 min, the median pain rating was 25 mm (IQR 4-44). Twenty (83%) subjects were satisfied with their analgesia. Eight (33%) were given additional opioid analgesia and the 28 reported adverse events were all transient and mild. In this population, an average dose of 1.0 mg/kg IN ketamine provided adequate analgesia by 30 min for most patients.

Effect of Sedation on Pain Perception

Sedation or anesthesia is used to facilitate many cases of an estimated 45 million diagnostic and therapeutic medical procedures in the United States. Preclinical studies have called attention to the possibility that sedative-hypnotic drugs can increase pain perception, but whether this observation holds true in humans and whether pain-modulating effects are agent-specific or characteristic of IV sedation in general remain unclear. To study this important clinical question, the authors recruited 86 healthy volunteers and randomly assigned them to receive one of three sedative drugs: midazolam, propofol, or dexmedetomidine. The authors asked participants to rate their pain in response to four experimental pain tasks (i.e., cold, heat, ischemic, or electrical pain) before and during moderate sedation. Midazolam increased cold, heat, and electrical pain perception significantly (10-point pain rating scale change, 0.82 ± 0.29, mean ± SEM). Propofol reduced ischemic pain and dexmedetomidine reduced both cold and ischemic pain significantly (-1.58 ± 0.28, mean ± SEM). The authors observed a gender-by-race interaction for dexmedetomidine. In addition to these drug-specific effects, the authors observed gender effects on pain perception; female subjects rated identical experimental pain stimuli higher than male subjects. The authors also noted race-drug interaction effects for dexmedetomidine, with higher doses of drug needed to sedate Caucasians compared with African Americans. The results of the authors' study call attention to the fact that IV sedatives may increase pain perception. The effect of sedation on pain perception is agent- and pain type-specific. Knowledge of these effects provides a rational basis for analgesia and sedation to facilitate medical procedures.

Reduction in Opioid-Related Adverse Events and Improvement in Function with Parecoxib followed by Valdecoxib Treatment after Non-Cardiac Surgery

Multimodal pain therapy including cyclo-oxygenase-2 inhibitors can result in optimal pain management with decreased opioid use and fewer opioid-related adverse events. Patient reported outcomes (PROs) help identify benefits in reduced opioid use and increased pain control. In this randomized, double-blind trial, patients (n = 1062) undergoing major non-cardiac elective surgery received either parenteral parecoxib for 3 days or placebo then oral valdecoxib or placebo for a total of 10 days, with both arms being allowed additional opioid analgesia. Clinically meaningful opioid-related adverse events were assessed daily using the Opioid-Related Symptom Distress Scale (OR-SDS). Pain severity and interference with function were evaluated daily using the modified Brief Pain Inventory exploratory form (mBPI-e). Additional validation work was undertaken to understand the psychometric properties of the two PROs. Detailed clinical results were reported elsewhere. Patients receiving parecoxib/valdecoxib achieved significantly better pain control and consumed 37% and 28% less opioid medication than the placebo group on day 2 and day 3, respectively. Over the 10-day treatment period, patients receiving parecoxib/valdecoxib consumed 31% less opioid medication. This coincided with significantly fewer (p < 0.0001) OR-SDS clinically meaningful events (CMEs) and lower mBPI-e scores from days 2-10 in the parecoxib/valdecoxib group compared with the placebo group. On day 3, the percentage of patients reporting one, two or three CMEs in the parecoxib/valdecoxib versus placebo group was 11.6% versus 13.0%, 2.3% versus 5.1%, and 0.8% versus 2.3%, respectively. The mean (+/- standard error) mBPI-e pain severity scores over days 2-10 were 2.47 +/- 0.04 for the parecoxib/valdecoxib group and 3.01 +/- 0.04 for the placebo group, and the mean mBPI-e pain interference scores were 1.73 +/- 0.04 and 2.19 +/- 0.04, respectively. Patients receiving parecoxib/valdecoxib had less pain interference on physical functioning, required less opioid medication and experienced fewer clinically meaningful opioid-related adverse events than patients receiving placebo.

The effective duration of analgesia after intrathecal morphine in patients without additional opioid analgesia: a randomized double-blind multicentre study on orthopaedic patients

To know whether the application of patient-controlled analgesia devices could be avoided if intrathecal morphine is given in combination with spinal anaesthesia. In a randomized, double-blind multicentre study, 188 orthopaedic patients were randomized to receive intrathecally placebo, 0.1 mg morphine or 0.2 mg morphine in addition to 15 mg bupivacaine. The primary outcome parameter was the number of patients without any additional request for opioid during a period of 72 h after surgery. Patients with 0.1 or 0.2 mg morphine showed a significant reduction in opioid requests compared with placebo during 72 h after surgery (P = 0.0001). At 24 h after surgery, the rate of patients who required additional opioid analgesia was 71% in the placebo group, 51% in the 0.1 mg morphine group and 31% of the patients in the 0.2 mg morphine group. After 0.2 mg morphine, systemic opioid requirements at 24 h were significantly lower than those in patients with 0.1 mg morphine (P < 0.05). Intrathecal morphine was not associated with an increased frequency of respiratory depression. Forty per cent of patients with intrathecal morphine did not ask for systemic opioids. Intrathecal morphine in a dose of 0.1 and 0.2 mg provides effective analgesia for up to 48 h without any need for systemic opioids at all in many patients.

POSTOPERATIVE ANALGESIA AFTER PAEDIATRIC ORCHIDOPEXY: EVALUATION OF A BUPIVACAINE-MORPHINE MIXTURE

The value of combining morphine with bupivacaine for caudal analgesia was investigated. Thirty children, undergoing orchidopexy, received a caudal block of 0.125% bupivacaine with or without morphine 0.05 mg kg-1. Analgesia, side-effects, ventilatory frequency and oxygen saturation (SaO2) were recorded after operation. None of the 15 patients receiving the bupivacaine-morphine mixture required post-operative opioids, whereas eight of 15 patients receiving bupivacaine alone needed additional opioid analgesia. The incidence of side effects after surgery was similar for the two groups and there was no detectable difference in ventilatory frequency or SaO2.