Analgesic Techniques Research Articles

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 > 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 < 0.05). While it was found that the first analgesic administration time was statistically longer in Group-I patients (p < 0.001), the amounts of paracetamol and tramadol consumed in the first 24 hours were found to be statistically lower (p < 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 postoperative analgesia effects between subcostal anterior quadratus lumborum block and transversus abdominis plane block in bariatric surgery: a prospective randomized controlled study

BackgroundCurrently, the prevalence of obesity is on the rise annually. Bariatric surgery stands out as the most efficacious approach for addressing obesity. Obese patients are more prone to experience moderate to severe pain after surgery due to lower pain thresholds. Regional block, as an important component of multimodal analgesia in bariatric surgery, is crucial in reducing opioid consumption and alleviating postoperative pain in patients undergoing bariatric surgery.Transversus abdominis plane block (TAPB) has gained widespread utilization in bariatric surgery; however, its limitation of inadequate reduction of visceral pain in obese patients remains a significant concern. Therefore, it is imperative to explore new and more efficient strategies for analgesia. Quadratus lumborum block (QLB) has emerged as a popular nerve block in recent years, frequently utilized in conjunction with general anesthesia for abdominal surgery. In the cadaver study of QLB, it was confirmed that the dye level could reach up to T6 when using the subcostal anterior quadratus lumborum muscle approach, which could effectively reduce the incision pain and visceral pain of bariatric surgery patients during the perioperative period.However, there is currently a lack of research on the use of subcostal anterior QLB in patients undergoing bariatric surgery. Our study aims to investigate whether subcostal anterior QLB can provide superior perioperative analgesic efficacy for bariatric surgery under general anesthesia compared to TAPB, leading to reduced postoperative opioid consumption and a lower incidence of postoperative nausea and vomiting (PONV).Methods and designThis study is a prospective, randomized controlled trial aiming to recruit 66 patients undergoing bariatric surgery. The participants will be randomly allocated into two groups in a 1:1 ratio: subcostal anterior QLB group (n = 33) and TAPB group (n = 33). The study aims to investigate the efficacy of subcostal anterior QLB and TAPB in obese patients who are scheduled to undergo bariatric surgery. Our primary outcome is to observe the amount of opioids used in the two groups 24 h after operation. The secondary outcomes included VAS of pain during rest/activity after operation, the type and dose of additional analgesics, the occurrence and severity of PONV, the type and dose of additional antiemetic drugs, postoperative anesthesia care unit (PACU) time, time of first postoperative exhaust, time to first out of bed activity, time to first liquid diet and postoperative admission days.DiscussionOpioid analgesics are prone to causing adverse reactions such as nausea, vomiting, and respiratory depression, especially in obese patients. Multimodal analgesia, including nerve block, can effectively reduce the dose of opioids and alleviate their adverse effects. Currently, TAPB is the most prevalent nerve block analgesia method for abdominal surgery. Recent studies have indicated that subcostal anterior QLB offers advantages over TAPB, including a wider block plane, faster onset, and longer maintenance time. It is not clear which of the two nerve block analgesia techniques is better for postoperative analgesia in patients undergoing bariatric surgery. Our objective in this investigation is to elucidate the superior method between TAPB and subcostal anterior QLB for postoperative pain management in bariatric surgery.Trial registrationChiCTR ChiCTR2300070556. Registered on 17 April 2023.

Postoperative Delirium and Neurocognitive Disorders: Updates for Providers Caring for Cancer Patients.

To provide up to date information on postoperative delirium and neurocognitive disorders in surgical cancer patients. Established risk factors such as age, psychosocial factors, comorbidities, frailty and preexisting cognitive decline continue to exhibit associations with perioperative neurocognitive disorders (PND); novel risk factors identified recently include microbiome composition and vitamin D deficiency. Prevention measures include cognitive prehabilitation, perioperative geriatric assessment and multidisciplinary care, dexmedetomidine and multimodal analgesic techniques. Studies investigating ciprofol, remimazolam, esketamine, ramelteon and suvorexant have shown encouraging results. Controversy remains regarding the use of inhalational versus intravenous general anesthesia. Innovative approaches to address PND are a rapidly developing area of research, but more studies are needed to identify effective prevention and management interventions. Despite challenges and controversy in the field, implementation of best practice can reduce the detrimental impact of PND on patients, caregivers, and society at large.

Postsurgical pain intensity in children on the VAS and FLACC scale across various analgesic techniques. Mathematical prediction as a component of justification

Nowadays, in pediatric practice, the Visual Analogue Scale (VAS) and the Face, Legs, Activity, Cry, Consolability (FLACC) scale are effective for assessing postsurgical pain. The modern concept of pain management includes a multimodal approach, including regional analgesia techniques. The aim of the study was to present a mathematical model to assess the efficacy of regional analgesia techniques in managing postsurgical pain intensity on the VAS and FLACC scale up to the fifth day of the study and predict the behaviour of the experimental data function up to day 87 following surgery using the autoregressive probability model. Materials and Methods. 89 patients operated on the anterior abdominal wall were divided into 3 groups depending on the type of anesthesia. The assessment of pain management quality and the presence of acute pain was conducted using the VAS and FLACC scale on days 1, 2, 3, and 5 post-operatively in all children. The ‘predict’ function in РТС MathCad Prime 7.0. software was used to automate calculating predictions based on the Burg method. Results. Studying the efficiency of the proposed treatment using regional analgesia techniques versus conventional analgesia enabled the prediction of varying postsurgical pain intensities on the VAS and FLACC scale based on their mathematical models, with coefficient of determination R2=0.9876, R2= 0, 9827, R2=0.9952 for the FLACC scale and R2=0.9868, R2=0,915, R2=0.9774 for the VAS. Conclusions. The use of regional analgesia techniques in children undergoing anterior abdominal wall surgery has been confirmed to be associated with a significant reduction in postsurgical pain intensity to the fifth day of observation and predicted to remain so up to day 87

Long-Term Outcome and Predictors of Transversus Abdominis Plane Block for Chronic Post-Hernioplasty Pain.

Background/Objectives: Different analgesic techniques have been used in the clinical management of chronic post-hernioplasty pain (CPHP), with variable results. This study aimed to investigate clinical factors associated with long-term outcome of the transversus abdominal plane (TAP) block for CPHP. Methods: We retrospectively analyzed 26 patients with CPHP who were treated with single or multiple TAP blocks with local anesthetic and steroid. Patients were evaluated for pain and neuropathic pain intensity by a Numerical Rating Scale (NRS) and the painDETECT questionnaire (PDQ), for anxiety and depression by the Hospital Anxiety and Depression Scale, and for quality of life by the 12-item Short Form Health Survey (SF12). Results: At 6 months post-treatment, 20 patients (77%) presented substantial (>50%) or moderate (30-50%) CPHP relief and were considered responders. In responders, the 24-h average and maximum NRS pain significantly declined (p < 0.01) from 7.3 ± 1.3 to 2.6 ± 2.1 and from 8.8 ± 1.5 to 5.1 ± 2.0, and the neuropathic PDQ score from 9.1 ± 3.2 to 6.1 ± 1.3; the physical SF12 score improved from 36.5 ± 5.8 to 44.3 ± 7.5 (p < 0.01). Six patients failed to achieve a significant CPHP improvement and were considered non-responders. Non-responders presented a significantly (p < 0.05) longer CPHP, higher body mass index and neuropathic symptoms, and more frequent anxiety, depression, diabetes, and fibromyalgia. Conclusions: The TAP block with local anesthetic and steroid should be considered as a therapeutic option for CPHP. However, medical and psychiatric comorbidities negatively impact the TAP block effectiveness for CPHP.

Efficacy and Safety of Intrathecal Morphine for Cesarean Delivery: A Narrative Review.

Pain management is a critical aspect of care during and following a cesarean delivery. Without proper control of pain, individuals can experience poor mobility, increased thromboembolic events, and difficulty caring for the neonate in the postpartum period. There have been multiple methods for pain management for cesarean delivery and intrathecal morphine (ITM) has emerged as a prominent option for post-operative analgesia due to its efficacy, safety, and potential benefits over other treatments. This review analyzes data on efficacy, side effects, and safety of ITM and the pain control alternatives. A comprehensive literature review was conducted to compare ITM with other analgesic techniques in post-cesarean patients. ITM was found to be as effective or better than other analgesic options, including bilateral quadratus lumborum block (QLB), opioid-free epidural analgesia (CSEA-EDA), and intravenous fentanyl. One study found that both ITM and oral analgesia were effective in pain control and that ITM caused fewer breakthrough pain events but had a longer duration and a greater rate of side effects than oral opioid analgesia. Commonly observed side effects of intrathecal opioids include nausea, vomiting, pruritus, and urinary retention, and it is thought that the adverse effects from intrathecal administration of opioids are short-lived. ITM may provide a decreased risk of DVT and coagulation by decreasing lower extremity weakness and numbness, thereby decreasing recovery time and increasing mobility. ITM is a safe and effective option for post-cesarean analgesia, with comparable pain relief to alternative forms of pain control, and side effects that are generally manageable. Further research is warranted to explore beneficial combinations with other methods of pain management and optimal dosing strategies.

Ultrasound-Guided Pudendal Nerve Block versus Caudal Block for Post-Operative Analgesia in Penile Surgeries in Children

Abstract Background Penile surgeries as hypospadias, urethroplasty and circumcision are of the most frequently performed surgical procedures in the pediatric male population. Using optimal analgesic regimen provide safe and effective analgesia, reduce postoperative stress response and accelerate recovery from surgery. This study was to compare the effectiveness and safety of ultrasound (US) guided pudendal nerve block (PNB) versus caudal block (CB) for postoperative analgesia in pediatric male patients undergoing penile surgeries. Methods The study was conducted on 40 randomly chosen patients in Ain Shams University Hospitals after approval of the medical ethical committee. Patients were divided randomly into two groups (20 each group) either receiving ultrasound-guided pudendal nerve block (PNB group) or caudal epidural block (CB group). In the PNB group, patients were injected with 0.3 mL/kg 0.25% bupivacaine and 1 ug/kg fentanyl. In the CB group, patients were injected with 1 mL/kg 0.25% bupivacaine and 1 ug/kg fentanyl. The two groups were adequately monitored and assessed pre, intra and post-operatively and they were compared regarding demographic data, pre, intra and postoperative hemodynamics, postoperative pain control using objective pain scale (OPS) score, consumption of paracetamol in the 1st 24 hours postoperatively and complications of both anesthetic techniques. Results This prospective randomized controlled single-blind clinical study was performed on total 40 patients of age 3 to 10 years scheduled for penile surgeries. For the primary outcome, there was a statistically significant increase in time to first analgesia in PNB group than CB group with p value &amp;lt; 0.001 while there was a statistically significant increase in total dose of paracetamol in CB group than PNB group with p value &amp;lt; 0.001. For OPS score, there was a statistically significant increase in pain score in CB group than PNB group at 6 h, 12 h and 24 h with p value = 0.02, 0.005 and 0.01, respectively. Conclusion From our study we can conclude that US guided PNB provided significantly prolonged postoperative analgesia and reduced the postoperative analgesic requirements as compared with caudal block in pediatric patients undergoing penile surgeries and also demonstrated that both analgesic techniques are safe.

Comparitive Study between the Analgesic Effect of Erector Spinae Plane Block and Transversus Abdominis Plane Block After inguinal hernia repair

Abstract Background Multimodal analgesia is used to control postoperative pain in inguinal hernia repair. Transversus Abdominis plane block is an effective regional anesthesia technique for postoperative analgesia in inguinal hernia repairs. The Erector Spinae plane block applied to the low thoracic region was also reported to provide effective analgesia in these surgeries. Aim and Objectives To assess and compare the analgesic efficacy of Erector Spinae plane block with that of Transversus Abdominis plane block after inguinal hernia surgeries. Subjects and Methods A prospective randomized clinical study, conducted at Ain Shams University hospitals, Cairo, Egypt on 56 patients divided into 2 groups: (Group 1) (ESP group); 28 patients received unilateral ultrasound guided ESP block, (Group2) (TAP group); 28 patients received unilateral ultrasound guided TAP block during a period of 6 months. Result There was high statistically significant difference between the studied groups as regard first analgesic request and total analgesic consumption. Conclusion ESPB is a more effective regional block technique for postoperative pain relief in patients undergoing inguinal hernia repair than TAPB. In which The ESP block has a longer duration of analgesia, delays the time to first requirement for analgesia, and reduces analgesic consumption when compared with the TAP block and can be used in multimodal analgesia and opioid-sparing regimens

Comparative Study between Ultrasound Guided Serratus Anterior Plane Block versus Thoracic Epidural as Postoperative Pain Management in Modified Radical Mastectomy

Abstract Background Surgery is one of the mainstays of treatment of breast cancer, and modified radical mastectomy (MRM) is one of the standard treatments for multi-centric disease or tumors with extensive coexistent ductal carcinoma in situ, where achieving a clear surgical margin becomes difficult with a segmental mastectomy. Aim of the Work to compare between Serratus Anterior plane block and thoracic epidural as efficacy of postoperative analgesia in Modified Radical Mastectomy. Patients and Methods This study was prospective controlled single blinded randomized clinical study, carried out in Ain Shams University hospitals, Cairo, Egypt over a period of 6 months. The study included adult female patients undergoing modified radical mastectomy was randomly assigned into two equal groups by computer generated: Group A: Included 15 patients received general anaesthesia preceded by Thoracic Epidural 9 ml of 0.25% Bupivacaine at T4-T5 level. Group B: Included 15patients received general anaesthesia followed by SAP block using only bupivacaine 0.25% (safety dose 3 mg /kg). Results The haemodynamic data including heart rate and mean arterial blood pressure show a significant decrease in SAP group less than the TE group. The pain scale (VAS) showed a significant decrease in SAP group less than the TE group. The total opioids consumption was significantly less in SAP than TE group. The first rescue morphine analgesia (min.) was significantly higher in SAP group more than TE group. Conclusion The SAP was effective and safe technique which provides better pain relief compared with the TE and reduced post-operative opioid consumption. Also, SAP was effective analgesic technique showing greater hemodynamics stability and less stress response to surgery compared with TE.

A Comparative Study between Ultrasound Guided Pectoral Nerve Block Type II versus Intravenous Patient Controlled Analgesia for Intra-Operative and Post-Operative Analgesia in Patients Undergoing Modified Radical Mastectomy

Abstract Background Breast surgery is becoming more and more common. Patients are often middle-aged women and with high public awareness around issues of breast cancer. The numbers are increasing. Breast surgery is an exceedingly common procedure and associated with an increased incidence of acute and chronic pain. Regional anaesthesia techniques may improve post-operative analgesia for patients undergoing breast surgery. Aim of the Work The primary aim of this study is to compare the efficacy of PECS block versus PCA with iv morphine to provide prolonged post-operative analgesia. The secondary objective is to identify the side effects of both techniques as post-operative analgesic techniques. Patients and Methods This study is a randomized clinical trial study conducted in Ain-shams University Hospitals, Cairo, Egypt for 6 months after medical ethical committee approval. The participants were allocated randomly into two groups of 25 patients each: group A: Patients received general anaesthesia followed by PECS block at the end of the operation before extubation, group B: Patients received general anaesthesia followed by the PCA at the end of surgery after extubation. Results The VAS score in the PECS group was statistically significantly lower at the 1st, 2nd and 4th hours. In this case, the use of PECS for postoperative analgesia is as effective as intravenous Morphine PCA in pain treatment, but with less systemic side effect as the nausea and vomiting is significantly higher in the PCA group than the PECS group at the 6th hour, however, the need of intra operative opioids in PCA group is significant. Conclusion In modified radical mastectomy, PECS block is as effective as intravenous Morphine PCA in pain treatment. Compared with intravenous PCA, PECS block can be considered as a more preferable method because it can avoid the systemic actions of morphine used for PCA, and can decrease the need of analgesia intra-operative, however PCA analgesic effect last longer, less invasive technique and easier to be used while PECS block require hand skills and limited to 24 hours analgesia only.

Ultrasound-Guided Quadratus Lumborum Block Using Bupivacaine versus Bupivacaine – Dexamethasone as Postoperative Analgesia in Laparoscopic Cholecystectomy

Abstract Background The QLB is an effective analgesic technique for various abdominal wall incisions. The QLB covers T7 to L2 dermatomes by the spread of LA drugs either into the paravertebral space or in the thoracolumbar plane, through iliohypogastric and ilioinguinal nerves, A and C fiber nociceptors, mechanoreceptors and high-density network of lumbar sympathetic fibers. Objective To assess the analgesic sparing effect of adding Dexamethasone to Bupivacaine in Quadratus lumborum block in patients undergoing Laparoscopic cholecystectomy under general anesthesia. Patients and Methods Sixty patients scheduled for elective Laparoscopic cholecystectomy surgeries under general anesthesia were included in this study, they were divided into two groups. Group A (perineural dexamethasone and bupivacaine group) [n = 30] Those cases will receive 2ml volume of dexamethasone (8mg) combined with 18 ml of bupivacaine of 0.25% concentration. Group B (perineural bupivacaine group) [n = 30] Those cases will receive perineural 18 ml bupivacaine (0.25%) combined with 2 ml normal saline. Results At the end of this study we found that The addition of dexamethasone to bupivacaine in QLB in Laparoscopic cholecystectomy surgeries provides a prolonged duration of postoperative analgesia, with reduced analgesic requirements, a better quality of analgesia in terms of NRS compared to bupivacaine alone group. Conclusion The addition of dexamethasone to Bupivacaine in lateral QLB in Laparoscopic cholecystectomy surgery provides a prolonged duration of postoperative analgesia, with reduced analgesic requirements, a better quality of analgesia in terms of NRS compared to bupivacaine alone group.

Effect of pericapsular nerve group block and suprainguinal fascia iliaca block on postoperative analgesia and stress response in elderly patients undergoing hip arthroplasty: a prospective randomized controlled double-blind trial

BackgroundAs a novel regional analgesic technique, ultrasound-guided pericapsular nerve group (PENG) block has some potential advantages, and we designed a randomized clinical trial (RCT) to investigate whether the ultrasound-guided PENG block combined with general anesthesia can better reduce stress response, maintain intraoperative hemodynamic stability, and reduce postoperative analgesia in elderly hip arthroplasty compared with ultrasound-guided suprainguinal fascia iliaca block (SIFIB) combined with general anesthesia.MethodsSeventy-four subjects were enrolled over an 8-month period (20 April 2023 to 31 December 2023). All patients were divided into the test group (group P) and the control group (group S) using the envelope as the randomization method. The test group was treated with preoperative ultrasound-guided PENG block analgesia combined with general anesthesia and the control group was treated with preoperative ultrasound-guided SIFIB analgesia combined with general anesthesia. The primary outcome selected was the patient Visual Analogue Scale (VAS) score at 12 h postoperatively.ResultsAfter generalized estimating equations (GEE) analysis, there was a statistically significant difference in the main effect of postoperative VAS score in group P compared with group S (P = 0.009), the time effect of VAS score in each group was significantly different (P < 0.001), and there was no statistically significant difference in the group-time interaction effect (P = 0.069). There was no statistically significant difference in the main effect of intraoperative mean arterial pressure (MAP) change (P = 0.911), there were statistically significant differences in the time effect of MAP in each group (P < 0.001), and there were statistically significant differences in the interaction effect (P < 0.001).ConclusionsIn summary, we can conclude that in elderly patients undergoing hip fracture surgery, postoperative analgesia is more pronounced, intraoperative hemodynamic parameters are more stable, and intraoperative stress is less induced in patients receiving SIFIB than in patients receiving PENG block.

Efficacy of quadratus lumborum block as a relatively new analgesic technique in patients undergoing open inguinal hernia surgical repair

Study objective To determine the analgesic efficacy of ultrasonographic guided transmuscular graduatus lumborum block (QLB) in patients undergoing open inguinal hernia surgery. Design Prospective randomized double-blinded study. Methodology and interventions This prospective randomized double-blinded study was carried out at Sohag University hospital, after local research ethical committee approval and obtaining informed written consent from all patients participating in the study or their guardians. A total of 50 patients (ASA grade I to II) were posted for open inguinal hernia surgery. All patients underwent the operation under general anesthesia. Then patients were randomly divided into two equal groups: group A (QLB group, N=25): were underwent a transmuscular QLB approach, after wound dressing with a single shot of a total volume of 20 ml of mixture (10 ml bupivacaine 0.5% and10 ml normal saline). Group B (control group N=2): patients received only general anesthesia with conventional intravenous analgesia. Measurements Pain intensity between groups was compared using the Visual Analog Score (VAS), furthermore, analgesic consumption (morphine and ketorolac) and additional rescue analgesic requirements were also calculated. Results Postoperative VAS scores at rest and during movement were significantly lower in group (QLB) A than the control group B at 1, 5, 7, 8, 9, 10, and 12 h, the time of first rescue analgesia was significantly delayed in QLB group (15.8±3.94 h) than the control group (8.5±4.29 h). Number of patients required morphine was significantly different between both groups. Number of patients required ketorolac was significantly lower in QLB group than in the control group. Total morphine and ketorolac requirements were significantly lower in group A (2.5±0.71 mg, 75±25.1), respectively than those consumed by the control group B (4.7±0.49, 126±23.24), respectively. Conclusions QLB significantly improves the analgesic quality in patients undergoing inguinal hernia repair compared to the standard intravenous analgesia regimen.

A Cross-Sectional Study of Labor Analgesia Practices Across India

Introduction: Labour analgesia practices have evolved significantly over the past years, with most of the current practices being evidence-based. Labour analgesia is considered a standard of care in resource-rich countries. However, in resource-limited countries such as India, there is a lack of awareness, and round the clock availability of labour analgesia services across the country. This raises significant challenges in establishing successful labour analgesia programs. Methods: This survey was conducted using multi-question Google Form@, so as to improve our understanding of labour analgesia practices in India. Our primary objective was to study the prevalence of labour analgesia practices amongst anaesthesiologists across India. Our secondary objectives included the work profile of anaesthesiologists providing labour analgesia, common techniques of labour analgesia practised, drugs used and common complications as well as side-effects encountered. Results: The results of our survey showed that 72.9% of the respondents practised labour analgesia in one form or the other. Practitioners in non-government facilities such as private hospitals, private medical colleges, and nursing homes accounted for more than 60% of the total labour analgesia delivered. Government medical colleges fared the best among practitioners at government-owned facilities. Approximately 85% of those polled agreed that the most common way of pain relief in a labouring patient was regional analgesia. The most prevalent was labour epidural (59.4%), followed by a single shot spinal analgesic, while 29% of anaesthesiologists used systemic analgesia. Conclusion: The impediments to delivering widespread labour analgesia services across India were poor infrastructure and high costs.

Use of Muscle Relaxants for Acute Postoperative Pain: A Practical Review.

Skeletal muscle relaxants have emerged as a broad category of analgesic adjuncts, aiming to improve pain relief and reduce opioid reliance. These drugs induce muscle relaxation and reduce muscle spasms, and therefore, they are commonly used in surgical procedures involving muscle manipulation, such as abdominal surgery, breast surgery, and spine surgery. However, their analgesic efficacy and opioid-sparing effects are poorly explored. A scoping review of literature was performed with several electronic databases. We used a search string with a sequence of text words and word variants related to central muscle relaxants, pain management, postoperative pain, and specific muscle relaxants. Review of literature shows significant heterogeneity among the studies in terms of surgical procedures, patient populations, choice of muscle relaxant, and timing and duration of administration, potentially limiting the generalizability of the findings and the ability for pooled analysis. Given the lack of evidence, we recommend that the use of skeletal muscle relaxants be reserved for patients in whom an optimal multimodal analgesic technique is not adequate. Also, there may be a limited role for these drugs in patients at high risk of postoperative pain undergoing surgical procedures with expected high opioid requirements. Due to the concerns of potential adverse effects, the decision to use muscle relaxants in vulnerable populations should be made carefully, weighing the benefits against the risks.

Modified Thoracoabdominal Nerves Block Through Perichondral Approach: A Systematic Review and Meta-analysis

PurposeThis systematic review and meta-analysis aimed to investigate the postoperative analgesic efficacy and safety of the modified thoracoabdominal nerve block through the perichondral approach (M-TAPA) in abdominal surgeries. DesignSystematic review and meta-analysis. MethodsWe searched electronic databases to identify relevant studies comparing M-TAPA with conventional analgesic techniques. The primary outcome was the requirement for rescue analgesia at 12 and 24 hours postsurgery. Secondary outcomes included the 11-point numerical rating scale pain scores at 0, 1, 2, 4, 6, 8, 12, and 24 hours following surgery, global quality of recovery scores, and postoperative adverse events. FindingsFive randomized controlled trials involving 308 patients were analyzed. M-TAPA showed no significant difference in the requirement for rescue analgesia at 12 hours (relative risk [RR]: 0.87; 95% confidence interval [CI]: 0.62, 1.22; P = .424; I2 = 40.7%; Ph = .185) and 24 hours (RR: 0.67; 95% CI: 0.22, 1.99; P = .252; I2 = 90.3%; Ph < .001) postsurgery compared to non-M-TAPA. No significant differences in numerical rating scale pain scores or global quality of recovery scores were found between the two groups (all P < .05). However, M-TAPA was associated with a lower occurrence of nausea (RR: 0.37; 95% CI: 0.22, 0.68; P < .001; I2 = 0%; Ph = .834), vomiting (RR: 0.32; 95% CI: 0.17, 0.62; P < .001; I2 = 0%; Ph = .884), and itching (RR: 0.38; 95% CI: 0.21, 0.70; P = .002; I2 = 0%; Ph = .826). ConclusionsThere was no significant difference in analgesic efficacy and safety between M-TAPA and non-M-TAPA techniques.

Challenges of the Regional Anesthetic Techniques in Intensive Care Units - A Narrative Review.

Effective pain management is vital for critically ill patients, particularly post-surgery or trauma, as it can mitigate the stress response and positively influence morbidity and mortality rates. The suboptimal treatment of pain in Intensive Care Unit (ICU) patients is often due to a lack of education, apprehensions about side effects, and improper use of medications. Hence, the engagement of pain management and anesthesiology experts is often necessary. While opioids have been traditionally used in pain management, their side effects make them less appealing. Local anesthetics, typically used for anesthesia and analgesia in surgical procedures, have carved out a unique and crucial role in managing pain and other conditions in critically ill patients. This work aims to offer a comprehensive overview of the role, advantages, challenges, and evolving practices related to the use of local anesthetics in ICUs. The ability to administer local anesthetics continuously makes them a suitable choice for controlling pain in the upper and lower extremities, with fewer side effects. Epidural analgesia is likely the most used regional analgesic technique in the ICU setting. It is primarily indicated for major abdominal and thoracic surgeries, trauma, and oncology patients. However, it has contraindications and complications, so its use must be carefully weighed. Numerous challenges exist regarding critically ill patients, including renal and hepatic failure, sepsis, uremia, and the use of anticoagulation therapy, which affect the use of regional anesthesia for pain management. Appropriate timing and indication are crucial to maximizing the benefits of these methods. The advent of new technologies, such as ultrasonography, has improved the safety and effectiveness of neuraxial and peripheral nerve blocks, making them feasible options even for heavily sedated patients in ICUs.

Fisiología de dolor y analgesia multimodal en el paciente crítico

Pain in the Intensive Care Unit is a frequent entity, although very little evaluated and incorrectly treated by professionals in this area of medicine, despite being considered the fifth vital sign and its presence directly impacts the evolution of the critically ill patient. . Much of the incorrect interpretation of this phenomenon is due to lack of knowledge in its objective evaluation since less than 50% of intensive care professionals evaluate pain, mainly due to little training in this regard. Understanding the mechanisms of generation of the painful stimulus, the assessment methods and knowing different analgesic treatment strategies could allow us to offer our patients appropriate interventions and not only limit ourselves to analgesics such as opioids or routes of administration such as intravenous, since the approach Multimodal offers different useful alternatives in the intensive care unit, improving the quality of analgesia and the adverse effects of different analgesics due to their overdose. A review of the current literature on this topic was carried out in search engines such as PubMed and databases such as UpToDate, Clinikal Key, SpringerLink, ScienceDirect, with the main search titles being analgesia in critically ill patients, multimodal analgesia and regional analgesia and anesthesia techniques in the critical patient resulting in the following article with great evidence compiled.

Morphine synovial fluid concentrations after intravenous regional limb perfusion in horses during standing sedation.

Addition of morphine to the perfusate while performing intravenous regional limb perfusion (IVRLP) may be helpful in treating painful infectious orthopaedic conditions of the distal limb. The main objective of this study was to determine synovial morphine concentrations following IVRLP with morphine alone or in combination with amikacin. Randomised cross-over in vivo experiment. Six horses underwent IVRLP with 0.1 mg/kg morphine sulphate diluted to 60 mL using 0.9% NaCl (M group) or combined with 2 g amikacin and 0.9% NaCl (MA group) with a 2-week washout period between treatments. Synovial fluid was collected from the radiocarpal joint (RCJ) at 10, 20, 30, 120, 240, 480, 720 and 1440 min after IVRLP. The tourniquet was removed after the 30-min sample was collected. Synovial concentrations of morphine and major metabolites were measured using liquid chromatography-tandem mass spectrometry. Amikacin concentrations were quantified by a fluorescence polarisation immunoassay. Measurable concentrations of morphine were apparent in the RCJ of all horses. Median CMAX of morphine in the M group was 4753.1 (2115.7-14 934.5) ng/mL and 4477 (3434.3-7363) ng/mL in the MA group (p = 0.5). Median CMAX of synovial amikacin was 322.6 (157.5-1371.6 μg/mL). Limitations include small sample size. Investigators were not blinded to the treatments and a third treatment group where amikacin alone was administered via IVRLP to the study population was not included. IVRLP using morphine is a feasible technique and synovial morphine concentrations were measurable following IVRLP and were not affected when used concurrently with amikacin. Administration of morphine via IVRLP may be beneficial as an analgesic technique for orthopaedic conditions of the distal limb while limiting potential serious systemic side-effects.

The influence of epidural analgesic techniques on obstetrical outcomes

PurposeThe aim of this study is to compare and evaluate the obstetrical differences between three techniques, including the programmed intermittent epidural bolus (PIEB), the patient-controlled epidural analgesia (PCEA), and the continuous epidural analgesia (CEA).MethodsThis is a retrospective cohort study that investigates the obstetrical outcomes of 2240 patients who received EA during labor in a tertiary maternal unit over the course of 9 years (2011–2018). The only inclusion criterion was the use of epidural analgesia during childbirth and the only exclusion criteria were multiplets’ gestation. Multivariate logistic regression, Kruskal–Wallis test, and the log-rank test were utilized to compare the differences between the three EA techniques in terms of cesarean section rate, the incidence of perineal tears, the use of Oxytocin, the duration of labor, and the incidence of paresthesia.ResultsOut of the 2240 included deliveries; 1084 utilized PIEB, 1086 PCEA, and 70 CEA techniques. The incidence of Cesarean section was the highest in the CEA group (45.7%) compared to PIEB (24.8%) and PCEA (24.4%) P < 0.001. A significantly shorter duration of labor (vaginal delivery) was observed in the PCEA group (n: 821, 336.7 min) compared to the PIEB group (n: 814, 368.8 min) P < 0.001. There were no statistically significant differences in the incidence of perineal tears, the need of uterotonics, and the incidence of paresthesia.ConclusionThe results of this study indicate that the PIEB and PCEA techniques are superior to the CEA technique when it comes to analgesia during childbirth. In this study, the PCEA technique seems to be the best-suited technique for childbirth, since it had a significantly shorter duration of labor than the PIEB technique.