Adjuvant Analgesics Research Articles

Factors Influencing the Initiation of Strong Opioids in Cancer Patients on Palliative Care: An Audit from a Tertiary Cancer Center in India.

Aim:This audit was done to analyze the factors influencing the use of strong opioids in cancer patients receiving comprehensive palliative care from a tertiary institute.Materials and Methods:Case records of patients registered for palliative care at our center in 3 months were retrospectively reviewed and followed up throughout the course of their illness. Demographic factors, prior treatments, social support system, analgesic use at registration, and use of radiation and adjuvant analgesics were recorded. Strong opioid use and their time of initiation were evaluated, and multivariate analysis was used to identify the factors correlating with the above.Results:After registration, strong opioids were initiated in 16% of the patients. It was observed that patients younger than 55 years and those with visceral metastases and history of use of weak opioids at the time of registration had a higher probability of being started on strong opioids. Factors associated with a significantly longer strong opioid-free interval were having spouse as primary caregiver, presence of skeletal metastases, use of palliative radiotherapy, and low socioeconomic status.Conclusion:It is certain that the use of strong opioids for adequate analgesia is a necessity for palliative-care patients. However, optimal utilization of adjunctive analgesic modalities, coupled with good supportive care, can minimize the requirement and duration of strong opioid use, especially in developing countries with limited access to specialist palliative care.

Pain in dementia.

The ageing revolution is changing the composition of our society with more people becoming very old with higher risks for developing both pain and dementia. Pain is normally signaled by verbal communication, which becomes more and more deteriorated in people with dementia. Thus, these individuals unnecessarily suffer from manageable but unrecognized pain. Pain assessment in patients with dementia is a challenging endeavor, with scientific advancements quickly developing. Pain assessment tools and protocols (mainly observational scales) have been incorporated into national and international guidelines of pain assessment in aged individuals. To effectively assess pain, interdisciplinary collaboration (nurses, physicians, psychologists, computer scientists, and engineers) is essential. Pain management in this vulnerable population is also preferably done in an interdisciplinary setting. Nonpharmacological management programs have been predominantly tested in younger populations without dementia. However, many of them are relatively safe, have proven their efficacy, and therefore deserve a first place in pain management programs. Paracetamol is a relatively safe and effective first-choice analgesic. There are many safety issues regarding nonsteroidal anti-inflammatory drugs, opioids, and adjuvant analgesics in dementia patients. It is therefore recommended to monitor both pain and potential side effects regularly. More research is necessary to provide better guidance for pain management in dementia.

Pediatric pain treatment and prevention for hospitalized children.

Introduction:Prevention and treatment of pain in pediatric patients compared with adults is often not only inadequate but also less often implemented the younger the children are. Children 0 to 17 years are a vulnerable population.Objectives:To address the prevention and treatment of acute and chronic pain in children, including pain caused by needles, with recommended analgesic starting doses.Methods:This Clinical Update elaborates on the 2019 IASP Global Year Against Pain in the Vulnerable “Factsheet Pain in Children: Management” and reviews best evidence and practice.Results:Multimodal analgesia may include pharmacology (eg, basic analgesics, opioids, and adjuvant analgesia), regional anesthesia, rehabilitation, psychological approaches, spirituality, and integrative modalities, which act synergistically for more effective acute pediatric pain control with fewer side effects than any single analgesic or modality. For chronic pain, an interdisciplinary rehabilitative approach, including physical therapy, psychological treatment, integrative mind–body techniques, and normalizing life, has been shown most effective. For elective needle procedures, such as blood draws, intravenous access, injections, or vaccination, overwhelming evidence now mandates that a bundle of 4 modalities to eliminate or decrease pain should be offered to every child every time: (1) topical anesthesia, eg, lidocaine 4% cream, (2) comfort positioning, eg, skin-to-skin contact for infants, not restraining children, (3) sucrose or breastfeeding for infants, and (4) age-appropriate distraction. A deferral process (Plan B) may include nitrous gas analgesia and sedation.Conclusion:Failure to implement evidence-based pain prevention and treatment for children in medical facilities is now considered inadmissible and poor standard of care.

Opioid Free Anesthesia in Laparoscopic Cholecystectomy (Comparative Clinical Study)

Background: Opioid Free Anesthesia aims to avoid perioperative opioids, instead uses adjuvant agents for their opioid-sparing effect which could also affect recovery rates and hospital length of stay (LOS). Patients and Methods: This prospective, randomized, single-blinded clinical study included 62 patients aged between 21 to 50 years, scheduled for LC. Group OA (n=31) received OA with fentanyl as the main anesthetic adjuvant and peri-operative analgesic. Group OFA (n=31) received OFA with dexmedetomidine, ketamine, and paracetamol as an anesthetic adjuvant and peri-operative analgesics. The intraoperative assessment included HR, systolic, diastolic and mean BP, the need for rescue analgesia or ephedrine. The postoperative assessment included the same values plus VAS score, Aldrete score, duration of stay in PACU, the incidence of side effects and complications and hospital LOS. Results: No significant difference between both groups regarding intraoperative hemodynamic values. In the group, OA 22 patients (70.9%) required intraoperative rescue analgesia (with mean dose 55.6 ± 37.4µg, median 70µg and highest dose of 100µg) compared to none in group OFA. In the group, OA 10 (32.3%) patients had PONV compared to 3 (9.7%) patients from group OFA which was statistically significant (P-value 0.033). No significant difference between both groups regarding postoperative VAS score, analgesic requirement, discharge time from PACU or LOS. Conclusions: The study showed that OFA was as effective as OA in maintaining intraoperative hemodynamic stability although group OFA showed the lower need for intraoperative analgesia. OFA also showed a significant reduction of incidence of PONV compared to group OA.

Recent Advances in Ketamine Research: An Update

Ketamine is a sedative N-methyl-D-aspartate receptor antagonist, considered as a dissociative anesthetic medication. Ketamine inhibits the voltage-gated Na+ & K+ channels and serotonin and dopamine re-uptake and affects specific receptors, such as α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA), kainate and aminobutyric acid A receptors. It is commonly administered by a parenteral route. On administration, ketamine has particular properties that are potentially involved during anesthetic induction including the enhancement of descending inhibition and anti-inflammatory effects. Recent literature reviews report that ketamine possesses various clinically beneficial properties. Sub-dissociative dose/Lower dose of ketamine (LDK) has potential as well as safe effects in clinical practice for the management of acute and chronic pain in postoperative room as well as Emergency Department (ED), along with cognitive function and depression in Psychiatric Department. Moreover, pharmacology of ketamine includes bronchodilators, neuro-protective actions, anti-shock, anti-suicide, and anti-tumor action immune system disorder. The purpose of this review is to illustrate recent advances in mechanism of action, mode of administration and indication of clinical uses of ketamine. In this article various new uses of ketamine have been shown, mainly related to its NMDAR antagonism and the clinical implementation and significance of low dose/sub dissociative dose of ketamine. In future, beyond being used as the adjuvant general anesthesia, it also can be used as a rapid acting antidepressant and anti-suicidal agent for mental disorders, and adjuvant analgesia to avoid potential risk and side effects of opioids in emergency department and in post-operative care.

Comparison of Post-Caesarean Section Wound Healing Methods Based on Reeda Scale and Platelet Lymphocyte Ratio

To evaluate post-caesarean section wound healing on patient given standard analgesia compared with Tranversus Abdominis plane Block (TAP Block) and wound site infiltration based on REEDA scale and platelet Lymphocyte Ratio 72 hours post-caesarean section. A randomized clinical controlled trial study was conducted on 30 post-caesarean section women under spinal anesthesia. Participants were randomly divided into the groups: Standard Analgesia groups (SA), TAP Block groups (TAP), and Wound Site Infiltration groups (Infiltration). Each group received standard analgesia (ketorolac and tramadol) and adjuvant analgesia Ropivacain 0.2% on transversus abdominis space (TAP block group) and wound site infiltration in infiltration group. Wound healing was evaluated based on REEDA Scale and Platelet Lymphocite Ratio (PLR) 72 hours post-operation. There were significant differences on REEDA scale and PLR value between the three groups 72 hours post-caesarean section (P < 0.001). TAP groups had the lowest REEDA Scale (0,2 ±0.422) and PLR value (134.2±18.57) Tranversus abdominis plane block showed the best healing process compared to standard analgesia only and wound site infiltration.

Analgesics and analgesic adjuvants inhibiting nerve conduction in the frog sciatic nerve —local anesthetics, opioids, α&lt;sub&gt;2&lt;/sub&gt; adrenoceptor agonists, antiepileptics, antidepressants and NSAIDs

Analgesics and analgesic adjuvants inhibiting nerve conduction in the frog sciatic nerve —local anesthetics, opioids, α&lt;sub&gt;2&lt;/sub&gt; adrenoceptor agonists, antiepileptics, antidepressants and NSAIDs

Collaborating With a Spinal Interventionalist in the Management of Low Back Pain

Low back pain is the primary cause of adult disability worldwide and if poorly managed can precipitate the unnecessary use of opioids, diminish physical functioning, and lead to comorbid conditions interfering with patient quality of life. Providers who collaborate with a spinal interventionalist can effectively manage acute and chronic low back pain, improve physical functioning, and reduce the use of opioid analgesics. The implementation of specific spinal interventions, adjuvant analgesics, and collaboration with a multidisciplinary team can promote health and wellness for 1 of the most prevalent and debilitating global health conditions.

A Stepped-Wedge Randomized Controlled Trial: Effects of eHealth Interventions for Pain Control Among Adults With Cancer in Hospice

ContextUnrelieved cancer pain at the end of life interferes with achieving patient-centered goals. ObjectiveTo compare effects of usual hospice care and PAINRelieveIt® on pain outcomes in patients and their lay caregivers. MethodsIn a five-step, stepped-wedge randomized, controlled study, 234 patients (49% male, 18% Hispanic, 51% racial minorities) and 231 lay caregivers (26% male, 20% Hispanic, 54% racial minorities) completed pre-pain/post-pain measures. They received usual hospice care with intervention components that included a summary of the patient's pain data, decision support for hospice nurses, and multimedia education tailored to the patient's and lay caregiver's misconceptions about pain. ResultsThe intervention effect on analgesic adherence (primary outcome) was not significant. Post-test worst pain intensity was significantly higher for the experimental group, but the difference (0.70; CI = [0.12, 1.27]) was not clinically meaningful. There was nearly universal availability of prescriptions for strong opioids and adjuvant analgesics for neuropathic pain in both groups. Lay caregivers' pain misconceptions (0-5 scale) were significantly lower in the experimental group than the usual care group (mean difference controlling for baseline is 0.38; CI = [0.08, 0.67]; P = 0.01). ConclusionThis randomized controlled trial was a negative trial for the primary study outcomes but positive for a secondary outcome. The trial is important for clearly demonstrating the feasibility of implementing the innovative set of interventions.

Implementación de la dexmedetomidina en el manejo del dolor en el postoperatorio inmediato de cirugía cardíaca

BackgroundThis study arose from the need to improve all tasks related to monitoring pain in post cardiac surgery patients. ObjectivesChecking and quantifying the pain suffered by patients undergoing cardiac surgery in the first 24hours of their stay in the intensive care unit (ICU), treated with Dexmedetomidine (Dex) as analgesic adjuvant, as well as their degree of sedation and the need for opiates such as rescue analgesia. Material and methodsUnicentric study, observational, descriptive, from April 2016 to September 2017. Both genders, all adult, undergoing cardiac surgery, operating theatre-extubated and Dex continuous infusion carriers. Pain degree level was evaluated by the Visual analogue Scale of Pain (VAS), from immediately post-surgery until 24hours from ICU entry and sedation degree, by the Richmond Sedation Agitation Scale (RASS), only while the Dex infusion lasted. Results109 patients were included. The results obtained showed that the average pain suffered by patients during the first 24hours was .47 with standard deviation (SD) of 1.25; the average maximum pain experienced was 3.58 with a range of 0 to 8 and the RASS average was −.68 (SD: 0,80). In addition, 44.04% of the patients needed rescue opiates, although only 7.32% showed severe pain greater than 6. ConclusionsThe Dex infusion patients showed mild levels of pain, however, a small percentage, who must be taken into account, suffered severe pain.

Dexmedetomidine ameliorates memory impairment in sleep-deprived mice

ABSTRACT The selective α2-adrenergic receptor agonist dexmedetomidine acts as an analgesic, sedative, and anesthetic adjuvant. The most common consequence of sleep deprivation is memory impairment. We investigated whether dexmedetomidine can counteract memory impairment caused by sleep deprivation and suppress the production of inflammatory factors. For inducing sleep deprivation, adult male mice were placed inside a water cage containing 15 platforms immersed in water up to 1 cm for 7 days. One day after sleep deprivation, dexmedetomidine at the respective dosage (5, 10, and 20 μg/kg) and α2-adrenoceptor antagonist atipamezole (250 μg/kg) were intraperitoneally injected into the mice, once per day for six days. The step-down avoidance task and the Morris water maze test were performed. Western blot analysis was performed to determine the levels of tumor necrosis factor-α (TNF-α), interleukin (IL)-6, brain-derived neurotrophic factor (BDNF), tyrosine kinase B (TrkB), nuclear transcription factor-κB (NF-κB), inhibitor of κBα (IκBα), and ionized calcium binding adapter molecule I (Iba-1) in the hippocampus. Immunohistochemistry was performed for the determination of Ki-67 and glial fibrillary acidic protein (GFAP) expression in the hippocampal dentate gyrus. Dexmedetomidine ameliorated sleep deprivation-induced deterioration of short-term memory and spatial learning ability. Dexmedetomidine inhibited production of inflammatory mediators caused by sleep deprivation. Dexmedetomidine also prevented the decrease in BDNF, TrkB expression, and cell proliferation induced by sleep deprivation. Dexmedetomidine could be used to counteract the neuropathological effects of sleep deprivation.

Association of preoperative pain in knee and external to knee with postoperative pain outcome after total knee arthroplasty.

BackgroundPreoperative pain in the symptomatic knee may predict postoperative pain severity in patients undergoing total knee arthroplasty (TKA). However, the effect of preoperative pain external to the knee on postoperative pain is unclear. This study evaluated postoperative pain outcomes in TKA patients according to the presence of preoperative pain in the knee only or in the knee and external to the knee.MethodsWe retrospectively assessed medical records of patients who underwent unilateral TKA. The relationship between reported preoperative pain characteristics and morphine equivalent consumption or numerical rating scale (NRS) pain scores on postoperative day (POD) 0–3 was assessed using a multivariable generalized linear model.ResultsIn total, 3,429 adult patients who underwent their first TKA were included; 2,864 (83.5%) patients preoperatively experienced only knee pain and 565 (16.5%) knee pain with external to knee pain. Preoperative pain in the knee and external to the knee was associated with 5% higher morphine equivalent consumption on POD 0–3 compared to preoperative knee pain only (exponentiated regression coefficient: 1.05; 95% confidence interval: 1.02 to 1.09; P = 0.004). However, the NRS pain scores on POD 0, 1, 2, and 3 and adjuvant analgesics consumption (acetaminophen and ketorolac) on POD 0–3 were not significantly different between the two groups (P > 0.05).ConclusionsThis study showed that there was an increase of morphine equivalent consumption during POD 0–3 in patients with preoperative knee pain with external to knee pain than in patients with preoperative only knee pain.

The intraoperative use of non-opioid adjuvant analgesic agents: a survey of anaesthetists in Australia and New Zealand

BackgroundOpioids have long been the mainstay of drugs used for intra-operative analgesia. Due to their well-known short and long term side effects, the use of non-opioid analgesics has often been encouraged to decrease the dose of opioid required and minimise these side effects. The trends in using non-opioid adjuvants among Australian Anaesthetists have not been examined before. This study has attempted to determine the use of non-opioid analgesics as part of an opioid sparing practice among anaesthetists across Australia and New Zealand.MethodsA survey was distributed to 985 anaesthetists in Australia and New Zealand. The questions focused on frequency of use of different adjuvants and any reasons for not using individual agents. The agents surveyed were paracetamol, dexamethasone, non-steroidal anti-inflammatory agents (NSAIDs), tramadol, ketamine, anticonvulsants, intravenous lidocaine, systemic alpha 2 agonists, magnesium sulphate, and beta blockers. Descriptive statistics were used and data are expressed as a percentage of response for each drug.ResultsThe response rate was 33.4%. Paracetamol was the most frequently used; with 72% of the respondents describing frequent usage (defined as usage above 70% of the time); followed by parecoxib (42% reported frequent usage) and dexamethasone (35% reported frequent usage). Other adjuvants were used much less commonly, with anaesthetists reporting their frequent usage at less than 10%. The majority of respondents suggested that they would never consider dexmedetomidine, magnesium, esmolol, pregabalin or gabapentin. Perceived disincentives for the use of analgesic adjuvants varied. The main concerns were side effects, lack of evidence for benefit, and anaesthetists’ experience. The latter two were the major factors for magnesium, dexmedetomidine and esmolol.ConclusionThe uptake of tramadol, lidocaine and magnesium amongst respondents from anaesthetists in Australia and New Zealand was poor. Gabapentin, pregabalin, dexmedetomidine and esmolol use was relatively rare. Most anaesthetists need substantial evidence before introducing a non-opioid adjuvant into their routine practice. Future trials should focus on assessing the opioid sparing benefits and relative risk of using individual non-opioid adjuvants in the perioperative period for specific procedures and patient populations.

Improvement of Anxiety, Coughing, Breathlessness and Pain Control in The Management of Bronchoscopy by Adding Alprazolam

Background: Anxiolytic premedication can reduce anxiety, improving procedural tolerance, and reduce postbronchoscopic complications. There was ongoing debate about the safety of bronchoscopist-administered sedation. Alprazolam as a surgical premedication can reduce anxiety. Alprazolam can be used as an adjuvant analgesic, to reduce anxiety-related breathlessness, and to reduce coughing as adjuvant antitussive. The study aimed to evaluate the effectiveness of alprazolam in patients undergoing bronchoscopy.&#x0D; Methods: A clinical study with experimental quasi pre-post test control group design, using consecutive sampling was performed in patients with lung tumor undergoing bronchoscopy in dr.Moewardi Hospital from February to March 2019. The study subjects were divided in experimental (alprazolam) and control groups (without alprazolam). The Hospital Anxiety and Depression Scale (HADS), VAS for pain score, modified Borg score, and VAS for cough were measured in baseline, before, and after bronchoscopy. &#x0D; Results: Thirty two lung subjects were included in this study. The intervention groups showed decreased HADS score pre and post bronchoscopy (6.56±2.83 and 6.88±2.63), pain VAS scores (15.00±10.95 and 9.69±11.61), cough VAS score (11.56±8.89 and 27.19±17.89), and these were different significantly compared to control group. We found decreased mean of modified Borg in the study group though they were not significant compared to the control group. &#x0D; Conclusion: Alprazolam controlled anxiety, coughing, and pain in patients undergoing bronchoscopy. Alprazolam minimized breathlessness after bronchoscopy. (J Respir Indo. 2019; 39(4): 245-55)

Benefit of subcutaneous patient controlled analgesia after total knee arthroplasty

PurposeSubcutaneous patient-controlled analgesia (PCA) has been widely used for orthopedic surgeries including total knee arthroplasty (TKA). This study aims to clarify the usefulness of subcutaneous PCA in the early phase after TKA. MethodsOur subjects consisted of 88 osteoarthritis knee patients who underwent primary TKA, and were classified into two groups: 42 patients received a subcutaneous PCA (containing fentanyl and droleptan) after operation (PCA group), and 46 patients were managed without a subcutaneous PCA (control group). We compared the incidence of side effects for 3 days postoperatively, measuring the number of times patients used adjuvant analgesia and range of motion on day 7 between the two groups. 34 of 42 patients in the PCA group tolerated PCA use until POD 3 (continuation sub-group), while 8 patients could not continue PCA (interruption sub-group). Demographic data of the two sub-groups were compared. ResultsThe mean number of times adjunctive analgesics were used by the PCA group (3.7 ± 2.2) was significantly less than in the control group (5.4 ± 2.8) (p = 0.0049). There were no significant differences in the frequency of side effects between the two groups. There was no significant difference in range of motion between the two groups. Comparing the continuation and interruption sub-groups, patients over 80 years old were at risk to discontinue a subcutaneous PCA (p = 0.0319, odds ratio 5.4). ConclusionThese findings demonstrate that subcutaneous PCA would be a safe postoperative pain regimen for TKA patients, but the effect was not enough to promote early functional recovery. Levels of evidenceTherapeutic, Level Ⅱ.

Evaluation of Ultrasound-guided Genitofemoral Nerve Block Combined with Ilioinguinal/iliohypogastric Nerve Block during Inguinal Hernia Repair in the Elderly.

To evaluate the anesthetic effect of ultrasound-guided (USG) ilioinguinal/iliohypogastric nerve (II/IHN) block combined with genital branch of genitofemoral nerve (GFN) block in the elderly undergoing inguinal hernia repair, 54 old patients (aged 60-96years, ASA I-III) with indirect hernia were enrolled and scheduled for unilateral tension-free herniorrhaphy. Patients were grouped randomly to receive either USG II/IHN plus GFN block (Group G) or USG II/IHN block alone (Group I). The intraoperative visual analogue scale (VAS) scores were recorded at skin incision, at spermatic cord/round ligament traction and at sac ligation. The resting and dynamic VAS scores were recorded postoperatively. The requirements of extra sedatives and analgesics for intra- and postoperative analgesia were assessed. Occurrence of complications of the block, postoperative nausea and vomiting and femoral nerve palsy was also reported. Both groups showed similar sensory block. When stretching spermatic cord/round ligament, the patients in group G had significantly lower VAS scores than in group I. And group G used much fewer adjuvant sedatives and analgesics to achieve adequate anaesthesia. In addition, group G was presented with better intraoperative anaesthesia and lower postoperative dynamic VAS scores at all time points tested. No significant difference was found in the postoperative requirement of rescue medication. Both groups showed no complications related to the block and group G reported no femoral nerve palsy. The addition of GFN block to II/IHN block improves the quality of perioperative anesthesia and analgesia in the elderly and reduces the consumption of extra sedatives and analgesics during the surgery.

Evaluation of Percutaneous Electrical Nerve Stimulation of the Auricle for Relief of Postoperative Pain Following Cesarean Section.

Objective: Percutaneous electrical nerve stimulation is a nonpharmacologic modality of analgesia. This study was conducted to evaluate such a technology (ANSiStim™, DyAnsys Inc., San Mateo, CA) prospectively, in conjunction with standard analgesia per patient demand, for managing postoperative pain following lower-segment cesarean section. Materials and Methods: One hundred parturients were randomized into 2 equal groups (controls and study cases). The latter cohort consisted of parturients for whom nerve stimulation was exerted on the pinna. Pain scores were compared across subjects at corresponding time points with 17 intervals in 48 hours, and, in totality, using estimated area under the curves of numerical scores. Conditional inference analysis was also performed. Results: Ninety-six parturients were finally included. The device was well-tolerated by a majority of parturients. Pain scores were significantly lower in the study group, both at corresponding time intervals and in totality. (H - 15)*(0.74 - H)*(H2 - 17H + 110)/440, where H was the corresponding hour, fit the pain scores in the control group. Controls could be detected at the 11 hour with greater pain scores (≥ 4), whereas smaller scores (≤ 2) at the 42nd hour mostly revealed that electrical stimulation was performed (p < 0.001). Requirements for supplementary analgesics were lower for subjects who were given the electroanalgesia. Conclusions: Neurostimulation via the ANSiStim™ is a safe and reasonably effective ambulatory analgesic adjuvant following abdominal delivery. There are no serious adverse effects.

Trends in prior receipt of prescription opioid or adjuvant analgesics among patients with incident opioid use disorder or opioid-related overdose from 2006 to 2016

BackgroundWith increasing efforts to scrutinize and reduce opioid prescribing, limited data exist on the recent trend in receipt of prescription pain medications before diagnosis of opioid use disorder (OUD) or opioid-related overdose (OD). MethodsUsing 2005–2016 Truven MarketScan Commercial Claims databases, we assessed trends in annual 1) incidence of OUD or OD and 2) prevalence of receipt of prescription opioids or four commonly-prescribed adjuvant analgesics among patients newly diagnosed with OUD/OD. Trends were examined in the overall sample and by 3 age groups, including youths (≤18 years), adults (19–64 years), and older adults (≥65 years). ResultsThe incidence of diagnosed OUD or OD increased more than 3-fold from 4.99 to 23.81 per 10,000 persons from 2006 to 2016, with the highest increase (14.18-fold) seen in older adults, followed by adults (3.53-fold), and youths (0.16-fold). Between 2006 and 2016, the proportion of patients with incident OUD/OD who received anticonvulsant adjuvant analgesics in the year before diagnosis increased (from 23.4% to 34.3% [P-trend = .005]) whereas the proportion receiving high-dose prescriptions opioids decreased (from 45.5% to 34.8% [P-trend =< .001]). A decreasing trend was observed in general for tricyclic antidepressants and serotonin and norepinephrine reuptake inhibitors. DiscussionIn US commercially insured patients newly diagnosed with OUD/OD, receipt of high-dose opioid prescriptions preceding the diagnosis decreased over time, paralleled by increased use of anticonvulsants commonly prescribed for pain conditions. Further investigations are warranted to understand how prescribed and anticonvulsants contribute to the development of OUD/OD.

Physicians Prescribe More Opioid Than Needed to Treat Pain in Children After Outpatient Urological Procedures: An Observational Cohort Study.

The epidemic of nonmedical use of prescription opioids (NMUPOs) has been fueled in part by the availability of leftover, legitimately prescribed opioids. In children, outpatient urological procedures are among the most common surgeries performed, but data are lacking to guide appropriate postoperative opioid prescribing. The aim of this study was to compare the amount of prescribed opioid medication to the amount taken for acute pain after minor pediatric urological surgery and to determine the disposition of excess opioid. In addition, we explored whether distinct patient characteristics and procedure type influenced opioid prescribing and consumption. Of the 139 families of pediatric patients enrolled, 115 were interviewed within 48 hours and/or 10-14 days of discharge to determine the amount of opioid prescribed and consumed, duration of treatment, and disposition of unconsumed opioid. The most common procedures performed were circumcision (n = 58) and orchiopexy (n = 40). Most patients (98%) were male, and 77% were <8 years of age. All opioid prescriptions were for oxycodone dosed every 4 hours as needed (PRN). Median number of doses prescribed was 30 (interquartile range [IQR], 23-31; n = 138) for both respondents who reported doses remaining (IQR, 29-31; n = 83) and those who did not (IQR, 22-32; n = 55). Among those reporting doses remaining, median number of doses consumed was 4.2 (IQR, 0-14). Multivariable linear regression showed no significant association between doses consumed and patient age, type of procedure, discharge pain score, or use of adjuvant analgesics. Median duration of opioid therapy was 2 days (IQR, 0-5; n = 83) with each additional day of opioid use corresponding to an average increase in consumption of 2.3 doses (95% confidence interval [CI], 1.8-2.8). An estimated 75% (95% CI, 69%-81%) of opioid dispensed was not consumed, and 86% (72/83) of patients took ≤18 doses. Forty-four of 65 (68%) families reported receiving no disposal instructions for leftover opioid, and only 7 families disposed of leftover medication. For minor pediatric urological surgeries in young boys, a 3-day supply (18 doses) of opioid was sufficient to adequately treat acute postoperative pain in most patients. Adjusting opioid dispensing to align with consumption and better educating patients and families on opioid disposal can be used to potentially decrease availability of leftover opioids in homes and communities.

Spontaneous ventilation in thoracoscopic surgeries(VATS), early experience

Introduction Thoracoscopic surgery (VATS) has been an important minimally invasive tool in the hands of experienced surgeons. On a natural progress, anaesthetic support has evolved and become equally less invasive1. Thoracoscopic surgery without tracheal intubation is an emerging treatment modality for a wide variety of thoracic procedures.2 The Key advantage is to avoid the use of muscle relaxants and its related complications in a wide range of patients as well as it can reduce the need for endotracheal intubation and hence airway instrumentation. Methods This audit was a retrospective review of 26 patients underwent VATS with spontaneous breathing general anaesthesia (between March and November 2018). Inclusion criteria:BMI Anaesthetic perspective: All patients received General anaesthesia with induction with Propofol 10 patients, PropofolM 2 single-port techniques). Pain management modalities: 23/ 26 received pre-incision paravertebral block, using anatomical landmark with 2 level single shot of total of 40 ml 0,25% Levobubivacaine provided by anaesthetic team. Additionally, pre-incision wound block and surgical ports with 20 ml Lidocaine 1% Provided by Surgeon. Adjuvant analgesics were used in the form of Morphine i.v, Paracetamol & if not contraindicated Ketorolac i.v. Patients received Morphine IV PCA in the recovery. Results 18 males and 8 females were studied with a mean age of 41 years. Average operative time was 101.3 minutes. Average values of oxygen saturation peak end-tidal carbon dioxide & respiratory rate were 97% and 6.1 KPa and 15 cycles/min respectively. Average recovery Period was 79.9 minutes. Average pain score in the recovery was 3.9, with an average use of 5.2 mg of morphine PCA.Average reocvery PaCo2 of 6.4 KPa. Mean postoperative stay was 4.8 days. Discussion Our initial experience in Glenfield Hospital showed that Spontaneously Breathing Thoracic Surgical procedure is feasible and safe with Careful patient selection and Multi-disciplinary collaboration between anaesthetists, surgeons and theatre team.