Analgesic Administration Research Articles

EP467 - Bowel obstruction due to colonic lithobezoar in a patient with PICA

Abstract A 16-year-old girl was admitted with complaints of abdominal distension, severe pain, vomiting, chest discomfort, and an inability to pass gas. She disclosed a history of PICA, regularly consuming brick and cement. She had no significant medical history but reported suffering from constipation for over two years. Physical examination revealed a markedly distended, tender abdomen with hyper-resonance. Digital rectal examination detected soft, breakable stool in the rectum. A chest X-ray demonstrated massive bowel distension, causing lung compression. Clinical impression was of bowel obstruction secondary to constipation, leading to NG tube insertion, NBM status, and analgesia administration. A CT abdomen and pelvis confirmed a markedly distended rectum with impacted faeces, proximal faecal loading, and colon dilatation consistent with severe pseudo-obstruction. Other abdominal organs were compressed but otherwise normal, with no signs of ischemia, free air, or free fluid. Patient was taken to emergency theatre for examination under anaesthesia and manual evacuation. Six litres of stool were manually evacuated, along with removal of ingested stone-like substances, leading to suspicion of lithobezoar. This was followed by a four-litre saline washout. Postoperatively, patient received regular enemas, laxatives, and monitoring. She spent three days in the Intensive Care Unit due to persistent metabolic acidosis, necessitating ventilatory support. Afterward, she was transferred to the surgical ward, where she was monitored overnight before being discharged with laxatives and dietary advice. Patient was referred to dietitians for addressing her PICA and eating habits, with plans for psychiatric follow-up initiated through a referral from her GP.

Avoiding Invasive Measures: Sphenopalatine Ganglion Block as a Substitute for Epidural Blood Patch in Post-dural Puncture Headache: A Case Report

Introduction: Post-dural puncture headache (PDPH) is a well-known consequence of neuraxial anesthesia that can impede patient recovery and delay early discharge. Traditional remedies include hydration and the administration of simple analgesics for symptom relief. When symptoms persist despite conservative interventions, an epidural blood patch (EBP) is typically recommended. However, this invasive procedure carries risks and complications. Our case report aims to explore a potential alternative treatment for PDPH. Case Presentation: We present the case of a 22-year-old female who experienced PDPH following spinal anesthesia. Despite initial attempts at conservative management, her symptoms persisted. She then opted for a trans-nasal sphenopalatine ganglion (SPG) block, which resulted in remarkable pain relief and eliminated the need for an EBP. Conclusions: The SPG block emerges as a minimally invasive option for treating PDPH. Multiple studies have demonstrated that patients undergoing SPG block therapy did not require EBP.

Rapidly progressive malignant glomus tumor of the breast: a case report and review of the literature.

The glomus tumor is a rare neoplasm that is typically found subungually in the extremities and functions as a specialized neurovascular organ. An extremely rare site for glomus tumors is the breast, with only a few reported cases. Breast glomus tumors present with three typical clinical signs: dull pain, focal tenderness, and cold sensitivity. Less than 10% of all glomus tumors are malignant. We herein present a case of a malignant glomus tumor originating in the breast. Distant metastasis was ruled out, and the tumor was completely resected. However, the patient unexpectedly developed rapid systemic metastasis, detected 5 weeks after tumor removal. Despite the administration of analgesics and targeted therapy, the patient died 1 month later. When treating patients with undiagnosed breast tumors, clinicians should pay attention to unexplained and repeatedly reported symptoms and consider the possibility of a rare disease. Our literature search revealed no cases of malignant glomus tumors originating in the breast, making this case the first of its kind.

Video-based compilation of acute pain behaviours in cats.

The aim of this work was to create a video-based compilation of acute pain behaviours in cats as an open-access online resource for training of veterinary health professionals. A database comprising 60 h of video recordings of cats was used. Videos were previously recorded after ethical approval and written client consent forms, and involved cats with different types (eg, medical, surgical, trauma, orofacial) and degrees (eg, from no pain to severe pain) of acute pain, before and after surgery or the administration of analgesia. The database included videos of cats of different coat colours, ages, sex and breeds. Video selection was based on a published ethogram of acute pain behaviours in cats. Videos were selected by one observer (SM) according to their definition and quality, followed by a second round of screening by two observers (SM and PVS). Video editing included a standardised template (ie, watermark and titles). A total of 24 videos (mean length 33 ± 17 s) with each acute pain-related behaviour described in the ethogram were uploaded to an open-access online video-sharing platform (http://www.youtube.com/@Steagalllaboratory) with an individual hyperlink. Videos were provided with a short description of the behaviour for the public. This video-based compilation may promote better training of veterinary health professionals on acute pain assessment while improving feline health and welfare and the understanding of cat behaviours.

Improving Pain Management in the Intensive Care Unit by Assessment

PurposePatients in the intensive care unit suffer from pain caused by life-threatening illness or injury but also treatments such as surgery and nursing procedures such as venipuncture. Unconsciousness following head trauma or sedation stage complicates self-report, and both under- and over-management of pain can occur. Inadequate assessment and treatment might follow from unsuitable pain assessment practices. The aim of this study was to evaluate the effect of the implementation of a pain assessment tool on nurses` documentation of pain and the administration of analgesia and sedation. DesignQuantitative pre-post design. MethodsThe study was conducted at one intensive care unit at a university hospital and involved 60 patient records and 30 pre-implementations and 30 post-implementations of the Critical-Care Pain Observation Tool (CPOT). ResultsAfter implementation, a 38% adherence rate was found. The frequency of nurses’ pain evaluations increased significantly from 1.3 to 2.3 per nursing shift. The implementation of CPOT also improved how often nurses identified pain by use of facial expressions, muscle tension, and cooperation with the mechanical ventilator, whereas focus on vital signs dropped (p = .014). A larger proportion of patients (17%) received paracetamol after the CPOT implementation compared with before (8%). Findings were statistically significant at p < .01. ConclusionsImplementation of CPOT increased the frequency of pain evaluations, and the observable patient behavior was more often interpreted as pain-related. Nurses’ adherence rate to sustained patient behavior focus being modest highlights the essential need for ongoing improvements in practice. Implementation of a new tool must be followed by non-pharmacological and pharmacological pain management steps. Clinical ImplicationsImplementing the CPOT as a pain assessment tool has the potential to enhance assessment practices. However, it is important to note that simply increasing assessment frequency does not guarantee nursing interventions to alleviate pain. This indicates the need for additional steps to be taken in order for nurses to complete the pain assessment cycle and effectively address interventions and reassessments.

Enhanced Recovery After Surgery (ERAS) cardiac turnkey order set for perioperative pain management in cardiac surgery: Proceedings from the American Association for Thoracic Surgery (AATS) ERAS Conclave 2023

ObjectiveOptimal perioperative pain management is an essential component of perioperative care for the cardiac surgical patient. This turnkey order set is part of a series created by the Enhanced Recovery After Surgery Cardiac Society, first presented at the Annual Meeting of The American Association for Thoracic Surgery in 2023. Several guidelines and expert consensus documents have been published to provide guidance on pain management and opioid reduction in cardiac surgery. Our objective is to consolidate that guidance into an evidence-based order set that will assist in the implementation of a comprehensive multimodal approach to pain management. MethodsSubject matter experts were consulted to translate existing guidelines and peer-reviewed literature into a sample turnkey order set for pain management. Orders derived from consistent Class I, IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the order set in bold type. Selected orders that were inconsistently Class I or IIA, Class IIB, or supported by published evidence, were also included in italicized type. ResultsOpioid-based analgesia is associated with delayed recovery and opioid-related adverse events. Several multimodal medications have been shown to reduce reliance upon opioids. These include the scheduled use of acetaminophen, gabapentinoids, and nonsteroidal anti-inflammatory drugs. In addition, intravenous analgesics such as dexmedetomidine, ketamine, magnesium, and lidocaine have been shown to both complement the maintenance of anesthesia as well as optimize pain control postoperatively. Long-acting opioids remain a key component of pain management when provided to reduce the overall use of short-acting synthetic opioids or in direct response to break though pain after exhausting other alternatives. When applied in a bundled fashion, several studies have demonstrated a reduction in overall opioid administration and improved rates of postoperative recovery. ConclusionsThere has been increased awareness regarding the potential short- and long-term adverse effects of both inadequate analgesia and excessive opioid administration after cardiac surgery. This turnkey order set aims to facilitate implementation of a comprehensive approach toward provision of multimodal, opioid-sparing medications to optimize pain management in cardiac surgery.

Non-operating Room Anesthesia (NORA): A Comprehensive Review of Monitored Anesthesia Care.

Monitored anesthesia care (MAC) is being increasingly employed in non-operative environments, particularly in the realms of endoscopy and magnetic resonance imaging (MRI) procedures. This in-depth analysis delves into the essential components of MAC within these specific contexts, with a primary focus on ensuring patient safety, evaluating efficacy, and assessing procedural outcomes. It is a common practice in endoscopic procedures to necessitate sedation for the purpose of alleviating discomfort and anxiety, ultimately ensuring patient cooperation and the successful completion of the procedure. MAC, which entails the administration of sedatives and analgesics under the close supervision of an anesthesia professional, offers a personalized approach that carefully balances the depth of sedation with maintaining optimal patient safety standards. Within the domain of MRI procedures, where challenges such as claustrophobia and motion artifacts can significantly impact the process, MAC plays a crucial role in providing a controlled setting that not only enhances image quality but also improves patient compliance throughout the procedure. The review extensively investigates the various pharmacological agents commonly utilized in these scenarios, including but not limited tomidazolamand fentanyl, shedding light on their pharmacokinetic and pharmacodynamic properties specific to these contexts. Furthermore, the critical role of the anesthesia provider in effectively managing potential complications, such as respiratory depression, hemodynamic instability, and allergic reactions, is thoroughly examined and discussed. The analysis extends to the implementation of MAC protocols, encompassing pre-procedural assessments, continuous intra-procedural monitoring, and comprehensive post-procedural care, all aimed at ensuring the best possible outcomes for patients. Additionally, the review delves into the economic considerations associated with MAC, taking into account its impact on procedural efficiency, healthcare costs, and patient throughput within these settings. By exploring current guidelines and recommendations established by professional societies such as the American Society of Anesthesiologists (ASA), this review aims to provide a holistic understanding of the best practices in MAC for both endoscopy and MRI procedures. Through the synthesis of available evidence, the primary objective of this review is to contribute to informing clinical practices, enhancing patient safety measures, improving procedural success rates, and ultimately advocating for the broader adoption of monitored anesthesia care in diverse non-operative medical settings.

Morphological and morphometric analysis of the Sacral Hiatus using lumbosacral spine CT scans: clinical relevance in Caudal Epidural Analgesia.

To conduct a morphological and morphometric analysis of the sacral hiatus (SH) using lumbosacral spine CT scans and to evaluate its clinical relevance in caudal epidural analgesia (CEA). This retrospective study analyzed 77 lumbosacral spine CT scans from a diverse patient population. The shape of the SH was classified into common types: inverted U, inverted V, irregular, and bilobed. Morphometric measurements included the length, width, and depth at the apex of the SH. The apex level of the SH was also determined in relation to the sacral vertebrae, and statistical analysis was performed to identify any correlation between the apex level and the morphometric dimensions. The most frequent SH shape was inverted U (68.83%), followed by inverted V (20.77%), irregular (9%), and a single instance of a bilobed shape (1.29%). The apex of the SH was most commonly located at the level of the S4 vertebra (75.32%), followed by the S3 vertebra (20.77%), S5 in two (2.59) and S2 in one (1.29%). No significant correlation was found between the level of the apex and the length, width, or depth of the SH. These findings indicate a high degree of anatomical variability in the SH, independent of the apex level. The anatomical variability of the SH, as observed in this study, underscores the need for individualized assessment during CEA. The lack of correlation between the apex level and the morphometric dimensions of the SH highlights the importance of imaging modalities such as ultrasound or fluoroscopy to ensure precise localization and effective analgesia administration. These insights can improve clinical outcomes by enhancing the accuracy and safety of caudal epidural procedures.

Effects of opioid-sparing general anesthesia on postoperative nausea and vomiting in laparoscopic gynecological surgery.

In this study, we aimed to investigate whether opioid-sparing anesthesia (OSA) reduces postoperative nausea and vomiting (PONV) in patients undergoing laparoscopic gynecological surgery. Adult patients undergoing elective laparoscopic gynecological surgery were randomly assigned to either the opioid-using anesthesia (OUA) or the OSA groups. In the OUA group, remifentanil was administered as an opioid during general anesthesia. In the OSA group, apart from a single dose of 5 μg/kg of alfentanil for tracheal intubation, no other opioids were used. In both groups, a multimodal intravenous non-opioid analgesic regimen was used preferentially in the post-anesthesia care unit (PACU). The primary outcome was the incidence of PONV, assessed by symptoms until the postoperative day (POD) 1. A total of 120 patients were included in this study. The incidence of nausea in the PACU was significantly lower in the OSA group compared to in the OUA group (31.7% in the OSA group vs. 51.7% in the OUA group, P = 0.026). Pain scores and the incidence of opioid analgesic administration were lower in the OSA group during PACU stay, resulting in a significantly lower number of patients requiring rescue opioid analgesics (3.3% vs. 18.3%, P = 0.008). There were no significant differences in intraoperative vital signs, hemodynamic interventions, or duration of PACU and hospital stay between the two groups. OSA significantly reduced postoperative nausea, pain scores, and the need for rescue analgesics in the PACU without increasing hemodynamic instability in patients undergoing laparoscopic gynecological surgery.

Evaluating potential unexpected adverse events and mortality after oral analgesics administration in fracture care-A cohort study.

Analgesic selection per individual's tolerance is essential to avoid risks. The study evaluated current oral analgesic prescription practice, analgesic adverse effects-related factors, unexpected events, and mortality post-fracture surgery. Present prospective cohort study from June 2022 to July 2023 enrolled a total of 198 proximal femoral, ankle, and hindfoot trauma fracture patients. Stratification was done for oral analgesics prescribed at hospital discharge and 1 week with their accompanying toxicity assessed for 2 weeks. Analyzed Kaplan-Meier curve and the absolute risk for possible analgesics-related deaths. Following oral analgesics administration, 122 (62%) patients experienced adverse events. In seven expiries, five were possibly due to acetaminophen added tramadol combined with any of pregabalin, diclofenac, etoricoxib, or gabapentin (absolute risk 2.5%, 97.5% proportion 2 weeks survival). Three (2% of 122) patients taking acetaminophen added tramadol or diclofenac experienced unexpected serious adverse events. Elderly diabetic and hypertensive hip fracture patients expired or experienced unexpected events. Data suggest that oral acetaminophen added tramadol combined with any of pregabalin, diclofenac, etoricoxib, or gabapentin might increase the death risk or unexpected serious adverse events in elderly diabetic and hypertensives suffering from intertrochanteric/femoral neck fracture. Safe analgesic selection is necessitated for at-risk patients.

Feasibility and safety of ultrasound-guided supra-clavicular block in children

BackgroundUltrasound-guided supra-clavicular nerve block (SCNB) has regained interest in adults but remains underutilized in pediatrics. This case series aims to evaluate the efficacy and safety of ultrasound-guided SCNB in children undergoing upper-extremity surgery. MethodsProspective observational case series, the inclusion criteria were children over one year old who were scheduled for elective upper-extremity surgery. After induction of general anesthesia, an ultrasound-guided SCNB was performed. A dose of 0.2–0.5 ml/kg of bupivacaine 0.25 % or ropivacaine 0.2 % was administered all around the brachial plexus. In case of postoperative pain, 15 mg kg-1 of paracetamol + 10 mg kg-1 of ibuprofen were administered. The primary outcome measure was the success and safety of the block. Secondary outcomes were time to first analgesia administration and duration of motor blockade. ResultsThirty-three patients were included. Median age and weight were 6 [2.75,9.75] years and 24 [16,35] kg, respectively with a sex ratio of 3.1. Bupivacaine 0.25 % was used in the majority of cases (N = 24). The overall duration to complete block performance was 170 [120,300] seconds. A single attempt was sufficient for the majority of children, with a block success rate of 100 %. No incidents were reported during block performance. Postoperatively, time to the first analgesic request was 10 [8,12.5] hours. Twenty-five patients developed a motor block, with a duration of 4 [0.5,5] hours. Bupivacaine 0.25 % was associated with higher incidence of motor blockade (p = 0.002). ConclusionsUltrasound-guided SCNB appears to be an effective and safe technique in children. Further studies using lower doses of bupivacaine could help reduce the incidence of motor block.

Effect of pericapsular nerve group block on perioperative analgesia characteristics for hip fracture operations

Aims: Pericapsular nerve group (PENG) block is a new regional analgesia technique that has recently been used for perioperative analgesia for hip fracture operations. The purpose of this research was to examine the perioperative analgesic characteristics of PENG block in patients who were going to undergo spinal anesthesia for a hip fracture procedure. Methods: The study was conducted as a prospective randomized controlled study between February 2021 and May 2021 after ethics committee approval. Patients with consent were included in the study. The patients were randomly divided into two groups (Group-I and Group-II). Patients in Group I underwent a PENG block with a 0.25% concentration of 20 cc bupivacaine in the preoperative waiting room 30 minutes before the operation. Afterward, spinal anesthesia was applied in the operating room. The patients in Group II received only spinal anesthesia. Preoperative visual analog scale (VAS) scores were recorded for both groups in the preoperative period. ECG, arterial blood pressure, pulse, and oxygen saturation measurements were performed in all patients preoperatively, intraoperatively, and postoperatively. Pulse, arterial blood pressure, oxygen saturation measurements, and VAS scores were recorded in the lateral decubitus position before and at the 5th minute after spinal anesthesia. In addition, the comfort of the anesthetist who will administer the spinal anesthesia during the application was questioned (0: poor, 1: moderate, 2: good, 3: very good). All patients 5 min after spinal anesthesia It remained in the lateral position for the duration. VAS scores were recorded during the postoperative phase at the 0th, 2nd, 8th, 16th, and 24th hours, along with the time of the first analgesic administration. The total amount of tramadol and paracetamol taken during the first 24 hours following surgery was noted. Results: Patients; gender, age, body weight, height, BMI, and ASA values were statistically similar (p &gt; 0.05). In comparisons between the groups; During position, postoperative 2nd, 8th, 16th, 24th hours, and their sum, VAS values were found to be statistically lower in Group-I (p &lt; 0.05). While it was found that the first analgesic administration time was statistically longer in Group-I patients (p &lt; 0.001), the amounts of paracetamol and tramadol consumed in the first 24 hours were found to be statistically lower (p &lt; 0.001). In addition, the comfort of the anesthetist during spinal anesthesia was found to be better in Group-I (p: 0.014). Conclusion: PENG block can be used effectively as a part of perioperative multimodal analgesia in hip fracture surgery. PENG can reduce the pain levels of patients with hip fractures as well as reduce the need for additional analgesia. It also increases the comfort of the anesthetist who will administer regional anesthesia.

Comparison of the preclinical quality of analgesia of emergency physicians and paramedics based on trauma patients

Adequate prehospital pain management is acritical component of emergency medical services. With the introduction of the paramedic profession and the Paramedics Act in Germany, the basis for more extensive competencies of paramedics was established. In many emergency medical service areas it is thus possible for paramedics to perform analgesia and sedation with esketamine/midazolam according to pre-established instructions and/or standard operating procedures. This study assessed the quality of analgesia administered to trauma patients by paramedics compared to emergency medical service physicians. The study included trauma patients who received prehospital administration of analgesia by either emergency medical service physicians or paramedics and were subsequently admitted to the central emergency department of the Saarland University Hospital. Astandardized data collection form was used to collect information from the emergency service protocol and initial emergency department assessment. The evaluation employed descriptive statistical methods and a total of 207 completed records were analyzed. Both professional groups achieved significant pain reduction and fulfilled the criteria for effective pain management (pain reduction: emergency medical service physicians 5.5 ± 2.0/paramedic 4.4 ± 2.1, p < 0.001). Emergency medical service physicians, however, more frequently attained ahigher reduction in numerical rating scale scores and administered oxygen. Notable differences were observed in the range of medications used and the dosages. This study could show that prehospital analgesia is comparable between emergency medical service physicians and paramedics in terms of effectiveness for trauma patients if the indications are correctly set, while observing pre-existing instructions. With their competencies paramedics are able to perform an effective and safe analgesic treatment within the framework of preformulated procedural instructions, which can be equal to that of an emergency medical service physician.

WHO/INRUD Drug Prescribing Indicators in the Emergency Ward of a Teaching Hospital, South East of Iran

Background: Rational drug use is an important issue in all healthcare settings. Core drug use indicators have been developed by World Health Organization/ International Network for Rational Use of Drugs (WHO/INRUD). The prescribing indicators measure healthcare providers’ performance in five key areas of drug usage. The aim of this study was to evaluate WHO/INRUD indicators of prescribing in emergency ward of a teaching hospital. Methods: This descriptive cross-sectional study was carried out in Emergency Ward of teaching hospital from March 2022 – March 2023. A standard prescribing indicators form was utilized to collect the required data using WHO drug prescribing indicators. Besides the rate of intravenous fluids and narcotic analgesics administration was evaluated. Index of rational drug prescribing (IRDP) was also calculated for each month and the mean of 12 IRDPs represent the emergency ward IRDP. Descriptive statistics were used for analysis. Results: Antibiotics were prescribed in 34% of studied prescriptions and ceftriaxone was the most widely used antibiotic (33.8%). Index of rational drug prescribing (IRDP) was 0.73 for polypharmacy, 0.93 for generic name prescribing, 0.88 for antibiotic prescribing, 0.1 for injectable drug use and 1 for formulary-based drug prescription. Total IRDP for the emergency ward was 3.64 (from optimal value of 5). IV fluids and narcotics were prescribed in 61.1% and 8.3% of studied prescription respectively. Conclusion: We concluded that although our overall IRDP value is below the WHO standard but it is about other neighbor countries. Our condition regarding IV drug administration showed a huge difference with WHO standards. It shows we need more input and regulations in this regard.

Equity in the Early Pain Management of Long Bone Fractures in Black vs White Patients: We Have Closed the Gap.

Patients with long bone fractures often present to the emergency department (ED) with severe pain and are typically treated with opioid and non-opioid analgesics. Historical data reveals racial disparities in analgesic administration, with White patients more likely to receive analgesics. With the diversifying US population, health equity is increasingly crucial. In this study we aimed to evaluate the early administration of opioid and non-opioid analgesia among Black and White patients with long bone and femur fractures in EDs over different time frames using a substantial database. We retrospectively extracted Information from 57 US healthcare organizations within the TriNetX database, encompassing 95 million patients. The ED records from 2003-2023 were subjected to propensity score matching for age and gender. We focused on four cohorts: two comprising Black and White patients diagnosed with long bone fractures, and another two with Black and White patients diagnosed solely with femur fractures. We examined analgesic administration rates over 20years (2003-2023) at five-year intervals (2003-2008; 2008-2013; 2013-2018; 2018-2023), and further analyzed the rates for the most recent two-year period (2021-2023). Disparities in analgesic administration significantly diminished over the study period. For patients with long bone fractures (1,095,052), the opioid administration gap narrowed from 6.3% to 1.1%, while non-opioid administration disparities reduced from 4.4% to 0.3%. Similar trends were noted for femur fractures (265,181). By 2021-2023, no significant differences in analgesic administration were observed between racial groups. Over the past 20years, the gap in early administration of opioid and non-opioid analgesics for Black and White patients presenting with long bone fractures or femur fractures has been disappearing.

Effect of dexmedetomidine constant rate infusion on the analgesic duration of peripheral nerve blocks in dogs: a randomized clinical study

The aim of this study was to evaluate whether a constant rate infusion of dexmedetomidine could prolong the analgesic effect of peripheral nerve blocks. Twenty client-owned dogs were enrolled and randomly divided into 2 groups. The DEX group received dexmedetomidine infusion at 1 mcg kg−1 h−1, and the NaCl group received an equivalent volume infusion of saline. Infusions were started after securing vascular access and continued for 10 min, after which intravenous (IV) methadone at 0.2 mg kg−1 and propofol to effect were administered. All animals were maintained with isoflurane in 70% oxygen. Sciatic, saphenous and obturator nerve blocks were performed using 0.1 mL kg−1 0.5% ropivacaine/block. Intraoperative fentanyl was administered if the heart rate and/or mean arterial pressure (MAP) increased > 15% from the previous measurement, and vasopressors were administered if MAP was ≤ 70 mmHg. Postoperative pain was assessed every hour using the Glasgow Composite Pain Scale (GCPS) until the first rescue analgesia administration. Postoperative rescue analgesia (methadone (0.2 mg kg−1 IV) and carprofen (2 mg kg−1 IV)) was administered if the pain score was higher than 6/24 or 5/20. Duration of analgesia was defined as the time between the nerve block procedure and initial postoperative rescue analgesia. Ambulation, proprioception, and skin sensitivity were evaluated to assess the duration of the motor and sensory block. A Student T and chi-square test were used to compare groups for duration of postoperative analgesia and intraoperative fentanyl and vasopressor use, respectively (p values ≤ 0.5 considered significant). A greater number of dogs in the NaCl group required fentanyl (5/10 p = 0.03) and vasopressors (8/10, p = 0.02) than did those in the DEX group (0/10 and 2/10, respectively). The duration of postoperative analgesia was significantly longer (604 ± 130 min) in the DEX group than in the NaCl group (400 ± 81 min, p = 0.0005).Dexmedetomidine infusion at 1 mcg kg−1 h−1 delays the time to first administration of rescue analgesia and reduces intraoperative analgesic and vasopressor requirements during Tibial Tuberosity Advancement surgery.

Time budgets and weight shifting as indicators of pain in hospitalized horses.

Pain assessment in horses presents a significant challenge due to their nonverbal nature and their tendency to conceal signs of discomfort in the presence of potential threats, including humans. Therefore, this study aimed to identify pain-associated behaviors amenable to automated AI-based detection in video recordings. Additionally, it sought to determine correlations between pain intensity and behavioral and postural parameters by analyzing factors such as time budgets, weight shifting, and unstable resting. The ultimate goal is to facilitate the development of AI-based quantitative tools for pain assessment in horses. A cohort of 20 horses (mean age 15 ± 8) admitted to a university equine hospital underwent 24-h video recording. Behaviors were manually scored and retrospectively analyzed using Loopy® software. Three pain groups were established based on the Pain Score Vetmeduni Vienna : pain-free (P0), mild to moderate pain (P1), and severe pain (P2). Weight shifting emerged as a reliable indicator for discriminating between painful and pain-free horses, with significant differences observed between pain groups (p < 0.001) and before and after administration of analgesia. Additionally, severely painful horses (P2 group) exhibited lower frequencies of feeding and resting standing per hour compared to pain-free horses, while displaying a higher frequency of unstable resting per hour. The significant differences observed in these parameters between pain groups offer promising prospects for AI-based analysis and automated pain assessment in equine medicine. Further investigation is imperative to establish precise thresholds. Leveraging such technology has the potential to enable more effective pain detection and management in horses, ultimately enhancing welfare and informing clinical decision-making in equine medicine.

Anesthetic recovery outcomes after 2 methods of nasal mucosal preparation for endoscopic sinus surgery

PurposeOur institution uses two approaches for nasal mucosal preparation during endoscopic sinus surgery (ESS) to improve surgical field visualization: topical epinephrine (TE) versus topical cocaine with injection of lidocaine containing epinephrine (TCLE). We aimed to compare anesthetic outcomes after ESS using these techniques. Methods and materialsWe retrospectively identified adult patients at our institution who underwent ESS from May 2018 through January 2023 under general anesthesia with propofol and remifentanil infusions. Postoperative anesthetic outcomes, including pain and recovery time, were compared between patients who had mucosal preparation with TE versus TCLE using inverse probability of treatment weighting (IPTW) to adjust for potential confounders. ResultsAmong 1449 patients who underwent ESS, 585 had TE, and 864 had TCLE. Compared with TE, during anesthetic recovery, the TCLE group had fewer episodes of severe pain (numeric pain score ≥ 7) (IPTW-adjusted odds ratio, 0.65; 95 % CI, 0.49–0.85; P = .002), less opioid analgesic administration (IPTW-adjusted odds ratio, 0.55; 95 % CI, 0.44–0.69; P < .001), and shorter recovery room stay (IPTW-adjusted ratio of the geometric mean, 0.90; 95 % CI, 0.85–0.96; P = .002). Postoperative nausea and vomiting and postoperative sedation were similar between groups. ConclusionsPatients who received preparation of the nasal mucosa with TCLE, compared with TE, were less likely to report severe pain or receive an opioid analgesic in the postanesthesia recovery room and had faster anesthetic recovery. This observation from our large clinical practice indicates that use topical and local anesthetic during endoscopic sinus surgery may have benefit for ambulatory ESS patients.

Investigating the Effect of Enterally Administered Capromorelin on Body Weight in Mice (Mus musculus).

Significant weight loss in mice (Mus musculus) is a welfare concern and can alter physiology and behavior in ways that may confound research aims. In this study, factorial design was used to investigate the effect of enterally administered capromorelin on changes in mouse body weight overall and with various research-related interventions, such as administration of analgesics, anesthesia, or surgery. BALB/c mice (n = 61 [27 males/34 females] for analysis) were randomized into 8 intervention-treatment groups with 2 treatment allocations: capromorelin (10 mg/kg) or control, and 4 intervention allocations: no intervention; buprenorphine extended-release (XR) alone; buprenorphine XR, meloxicam, and anesthesia; or surgery under anesthesia with buprenorphine XR, meloxicam, and bupivacaine administered. Mice were habituated to handling, weighing, and voluntary consumption of condensed milk, which was used as the control solution and later a vehicle for capromorelin delivery, for 5 d (days 0 to 4). Then, mice received their interventions followed by 3 days of daily treatment or control administration (days 7 to 9). Body weights were measured daily (days 8 to 11 and day 14) to compare with baseline weights (days 0 to 4 and day 7) and evaluate for treatment and intervention effects on body weight. The interventions resulted in a decrease in group body weights 3 and 4 d after the interventions were conducted. Overall, body weights increased more in mice given capromorelin compared with control, and mice treated with capromorelin returned to, or exceeded, baseline weights faster. The weight loss was mitigated by capromorelin administration in all interventions except for the buprenorphine XR-only group. It is recommended to clinically consider enterally administered capromorelin to mitigate research-induced weight loss in mice.

Risk Factor Targeted Perioperative Care Reduces Anastomotic Leakage after Colorectal Surgery: The DoubleCheck study.

The DoubleCheck study aimed to introduce pre- and perioperative interventions minimizing exposure to modifiable risk factors and determine its effect on CAL. Colorectal anastomotic leakage (CAL) is a severe complication. In order to predict and prevent its occurrence, the LekCheck study identified intraoperative modifiable risk factors for CAL: anemia, hyperglycemia, hypothermia, incorrect timing of antibiotic prophylaxis, administration of vasopressors and epidural analgesia. This international open-labelled interventional study was performed between September 2021 and December 2023. An enhanced care bundle consisting of anemia correction, glucose measurement, attaining normothermia, antibiotics administration within 60 to 15 minutes preoperatively, refraining from vasopressors and epidural analgesia was introduced. Primary outcome was the occurrence of intraoperative risk factors just prior to the anastomosis creation. Secondary outcomes were CAL and mortality. Univariate and multivariate regression analysis were performed to establish the relationship between the enhanced care bundle, exposure to the six factors and CAL. The historical LekCheck group consisted of 1572 patients versus 902 in the DoubleCheck. The LekCheck group had a mean of 1.84 risk factors versus 1.63 in DoubleCheck ( P <0.001). In the DoubleCheck significantly less patients had ≥3 risk factors ( P <0.001). CAL was significantly lower in the DoubleCheck group (8.6% vs. 6.2%, P =0.039). The reduction of CAL was associated with the enhanced care bundle in multivariate regression analysis (OR 1.521, 95% CI 1.01-2.29, P =0.045). The mortality rate did not differ significantly (1.3%, vs. 0.8%, P =0.237). The DoubleCheck study showed that optimization of modifiable risk factors reduced CAL in colorectal surgery.