Analgesic Administration Research Articles

Randomised controlled trial of intramuscular tramadol versus transdermal buprenorphine patch for early postoperative surgical pain.

This study assesses the efficiency of the buprenorphine patch system compared to the routine use of tramadol intramuscular injections in the context of the South African public healthcare sector. Patients were randomised into two groups, who received routine tramadol injections 100 mg every 8 hours intramuscular and buprenorphine patches 5 mcg every hour. The study assessed the first 48 hours postoperatively. A visual discrete pain scale was used to assess the level of postoperative pain as well as all complications associated with insufficient analgesic administration. The sample size included 75 patients in the tramadol group and 75 patients in the buprenorphine patch group. Nine patients (12%, p-value < 0.0001) who received the buprenorphine patch subsequently required additional analgesia. The pain score was found to be significantly less in the buprenorphine patch group on both day 1 and day 2, as were complications such as vomiting, nausea, nightmares, sweating and insomnia. The pain score in the buprenorphine group as significantly lower compared to the tramadol group. The use of the buprenorphine patch showed a slight increase in costs compared to the tramadol group (R7 800.75 vs R7 537.50; p-value 0.483) in the whole study. The study showed that the use of the buprenorphine patch is a reliable and effective method of postoperative analgesia, although it is slightly more expensive compared to the routine use of tramadol. The buprenorphine patch showed significantly better results in all assessed parameters; thus, it may be recommended for use at the Dr George Mukhari Academic Hospital (DGMAH).

Epidural Analgesia as a Part of Combined Anesthesia during Abdominal Oncological Surgeries (Results of the Survey among the Russian Anesthesiologists and Resuscitators)

The objective: to analyze the contemporary specific parameters of intraoperative management of epidural analgesia (EA) in combined anesthesia in abdominal oncological surgeries in different medical organizations of Russia.Subjects and Methods. The data necessary for analysis and statistical processing were obtained by developing a formalized questionnaire (21 questions, some of which with the possibility of choosing several answers at the same time – multiple choice), published on the official website of the Association of Anesthesiologists-Resuscitators (https://association-ar.ru/). The survey lasted for 16 days (from May 23, 2022 to June 7, 2022). The survey results were collected using the Google Forms online service and processed using the Google Spreadsheets. Multiple choice responses were processed as absolute numbers and presented as a percentage of the total number of responses to a particular question.Results. The total number of respondents who took part in the survey was 217 specialists from various medical organizations, mostly from the North-Western Federal District of the Russian Federation (34.1%) with more than 15 years of expertise in the specialty (44.7%). According to the survey results, the following specific features of EA during combined anesthesia practice in Russia have been identified: most participants perform EA in the sitting position (63.6%); ropivacaine is the drug of choice among local anesthetics (LA) (84.2%); as a rule, EA is initiated prior to incision (69.6%). During open surgical interventions, 44.7% use a combined EA method (continuous infusion and bolus injection – bolus-based mode), while during laparoscopic surgeries there is no preferred method (combined method – 33.1%; continuous infusion only – 35.5%; bolus injection only – 31.4%). Low concentrations of LA (0.2 ‒ 0.375%) combined with a low volume of administration (4‒10 ml for bolus, 4‒8 ml/h for infusion) are used more often both in open and laparoscopic surgeries. In most cases, achievement of effective EA is supported by lower doses of systemic opioid analgesics (65.4%). Insufficient degree of intraoperative analgesia is managed in different ways, such as using systemic opioids (68.7%), enhancing epidural analgesia (17.5%), and administration of non-opioid analgesics (13.8%).Conclusion. At present, there is no unified approach to the method of EA in combined anesthesia. The results of the survey showed the uncertainty of experts' opinions regarding the choice of LA concentrations for EA, the rate and volume of its administration into the epidural space. Finding the optimal method of intraoperative EA in abdominal oncological surgery is the most important clinical objective in terms of reducing perioperative complications.

Effect of Narcotic Analgesia on Decision to Operate in Acute Appendicitis

Aim: To study that narcotic analgesia administration in patients of acute appendicitis does not delay the diagnosis and does not interfere with the decision to operate in these patients. Study design: A randomized cross-over study. Setting and duration of study: Study was done at surgery department of Combined military hospital Lahore over a period of two years from March 2019-2021. Methodology: It was a double-blind randomized crossover study. A total of 100 patients, who were confirmed as acute appendicitis by clinical examination, were included. All the male and female patients of age 16 years and above were included in the study. The patients were divided in two groups each having 50 patients. The drugs were labelled as drug A and drug B. Drug A was morphine and drug B was placebo. Each drug was given to both the groups by crossover with an interval of 30 minutes and the components of physical examination were analyzed for both groups. The pain score was calculated by the visual analogue scale (VAS) for both the groups at both intervals. The p-value was calculated by using student’s t-test. The frequency and percentages of the decision to operate were calculated. The data was tabulated and then analyzed on SPSS version 23. Results: The pain score was calculated for both groups of male and females. The pain score difference was calculated in both groups and then p-value was calculated which came out to be significant. The frequencies of the decision to be operated were also calculated in both the groups and the results showed that there was no effect of narcotic analgesia on the decision to operate in patients with clinically diagnosed acute appendicitis Conclusion: The use of morphine analgesia in the patients of acute appendicitis does not alter the diagnostic efficacy of the patients of acute appendicitis. Keywords: Acute abdominal pain, acute appendicitis, Narcotic analgesia, Visual analog scale (VAS)

Analgesic Efficacy of Adjuvant Medications in the Pediatric Caudal Block for Infraumbilical Surgery: A Network Meta-Analysis of Randomized Controlled Trials.

Various adjuvants are added to local anesthetics in caudal block to improve analgesia. The comparative analgesic effectiveness and relative rankings of these adjuvants are unknown.This network meta-analysis (NMA) sought to evaluate the comparative analgesic efficacy and relative ranking of caudal adjuvants added to local anesthetics (versus local anesthetics alone) in pediatric infra-umbilical surgery. We searched the United States National Library of Medicine database (MEDLINE), PubMed, and Excerpta Medica database (Embase) for randomized controlled trials (RCTs) comparing caudal adjuvants (clonidine, dexmedetomidine, ketamine, magnesium, morphine, fentanyl, tramadol, dexamethasone, and neostigmine) among themselves, or to no adjuvant (control). We performed a frequentist NMA and employed Cochrane’s ‘Risk of Bias’ tool to evaluate study quality. We chose the duration of analgesia (defined as 'the time from caudal injection to the time of rescue analgesia') as our primary outcome. We also assessed the number of analgesic dose administrations and total dose of acetaminophen within 24 h.The duration of analgesia [87 randomized control trials (RCTs), 5285 patients] was most prolonged by neostigmine [mean difference: 513 min, (95% confidence interval, CI: 402, 625)]. Dexmedetomidine reduced the frequency of analgesic dose administrations within 24 h [29 RCTs, 1765 patients; -1.2 dose (95% CI: -1.6, -0.9)] and the total dose of acetaminophen within 24 h [18 RCTs, 1156 patients; -350 mg (95% CI: -467, -232)] the most. Among caudal adjuvants, neostigmine (moderate certainty), tramadol (low certainty), and dexmedetomidine (low certainty) prolonged the duration of analgesia the most. Dexmedetomidine also reduced the analgesic frequency and consumption more than other caudal adjuvants (moderate certainty).

NORMAL INDICATORS OF OXIDATIVE STRESS AND THE DYNAMICS OF THEIR CHANGES AT DIFFERENT TERMS OF EXPERIMENTAL OPIOID INFLUENCE

In the modern world, there are a large number of exogenous factors that contribute to the emergence of disorders associated with changes in biochemical data. One of these factors is the long-term usage of the opioid analgesics for therapeutic purposes, as well, as the use of opioid drugs without medical indications by people belonging to the category of drug addicts. More often, doctors of various specialties are faced with the problem of treating various nosology in people with opioid addiction. The process of correction of the main pathology makes it diffi cult due to the consequences arising from the chronic use of opioid drugs. The aim of the study is to fi nd out the dynamics of changes in the oxidative stress indicators of the blood of rats under normal conditions and during subchronic and chronic experimental opioid exposure. Material and methods. The research material was sexually mature, purebred male rats in the amount of 38 animals, weighing 160.0-270.0 g, aged 4.5-7.5 months. The animals were injected with nalbuphine intramuscularly, once a day at one time (10-11 am) per 70 days. The initial dose of nalbuphine during the fi rst 2 weeks was 0.212 mg/kg, the next 2 weeks (II-IV weeks) – 0.225 mg/kg, the next (IV-VI weeks) – 0.252 mg/kg, the next (VI-VIII weeks) – 0.260 mg/kg, and during (VIII-X weeks) – 0.283 mg/kg. Thus, conditions for chronic opioid exposure were created. Research results and their discussion. As a result of our experimental study, the eff ect of an opioid analgesic on the indicators of oxidative stress in the blood of rats, at the end of the 2nd week, we observed an unreliable increase in malondialdehyde and diene conjugates with a signifi cant decrease in the ceruloplasmin indicator. At the end of the 6th week administration of opioid analgesics, we observed a steady and continued growth of malondialdehyde and diene conjugates and a further decrease in ceruloplasmin. All indicators had a statistically proven diff erence compared with the control group. The animals of the experimental group, after 10 weeks of experimental opioid exposure have shown that all indicators continued the previously identifi ed dynamics and reached their maximum value of the diff erence compared to the control group. Conclusions. The conducted studies make it possible to clarify the peculiarities of changes in the oxidative stress indicators of the blood of rats in the subchronic and chronic periods of experimental opioid exposure.

Cross-species comparisons reveal resistance of human skeletal stem cells to inhibition by non-steroidal anti-inflammatory drugs.

Fracture healing is highly dependent on an early inflammatory response in which prostaglandin production by cyclo-oxygenases (COX) plays a crucial role. Current patient analgesia regimens favor opioids over Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) since the latter have been implicated in delayed fracture healing. While animal studies broadly support a deleterious role of NSAID treatment to bone-regenerative processes, data for human fracture healing remains contradictory. In this study, we prospectively isolated mouse and human skeletal stem cells (SSCs) from fractures and compared the effect of various NSAIDs on their function. We found that osteochondrogenic differentiation of COX2-expressing mouse SSCs was impaired by NSAID treatment. In contrast, human SSCs (hSSC) downregulated COX2 expression during differentiation and showed impaired osteogenic capacity if COX2 was lentivirally overexpressed. Accordingly, short- and long-term treatment of hSSCs with non-selective and selective COX2 inhibitors did not affect colony forming ability, chondrogenic, and osteogenic differentiation potential in vitro. When hSSCs were transplanted ectopically into NSG mice treated with Indomethacin, graft mineralization was unaltered compared to vehicle injected mice. Thus, our results might contribute to understanding species-specific differences in NSAID sensitivity during fracture healing and support emerging clinical data which conflicts with other earlier observations that NSAID administration for post-operative analgesia for treatment of bone fractures are unsafe for patients.

Multicenter Study Evaluating Nitrous Oxide Use for Labor Analgesia at High- and Low-altitude Institutions

(Anesth Analg. 2022;124:294–302) The United States has used nitrous oxide as a labor analgesia since the 1940s because it has no impact on uterine myometrial contractility, it has little impact on maternal hemodynamics and respiration, and it is a noninvasive procedure. However, most medical professionals still prefer neuraxial analgesia. Previous studies report that 40% nitrous oxide successfully decreased pain and increased maternal satisfaction during labor compared with a placebo at sea level, but there are no studies evaluating the effect of nitrous oxide on maternal pain relief or satisfaction in high altitudes. Because of the partial pressure gas law, as elevation increases, the study hypothesized gas analgesia administration had less of an effect than at sea level, both in pain relief and side effects. This study evaluated altitude's effect on nitrous oxide administration by comparing high altitude and low altitude births.

Evaluating Cancer Pain Characteristics and Treatment Factors in the Emergency Department: A Retrospective Cohort Study.

Objectives: To identify patient characteristics and treatment factors of patients presenting to the emergency department (ED) with cancer-related pain that may affect patient outcomes. Methods: We conducted a retrospective cohort study to evaluate adult patients with active cancer, who presented to the ED with a chief complaint of pain between June first, 2012 and January first, 2016. We utilized multivariable logistic regression to evaluate the association of several exposure variables, including disease and demographic characteristics, primary pain site, and treatment methods, on ED disposition and revisit rate. Results: We included 483 patients with active cancer with a chief complaint of pain. Patients with severe pain on arrival tended to be younger than those who did not present with severe pain (median: 58 vs 62 respectively, OR 8.0 p < 0.01). Patients with high ECOG scores (3-4) with severe pain on arrival (≥7 out of 10) had less improvement in their pain than the rest of our cohort (OR 8.4, p < 0.01). Also, those with musculoskeletal pain had significantly less improvement in reported pain than all other pain types (delta pain −2.1 vs −3.4, OR 2.3, p = 0.025) Long delays in initial analgesic administration were associated with increased rates of subsequent admission (OR 3.4) [p = 0.014]. Although opioid analgesics led to greater decreases in pain than non-opioid analgesics, patients treated with opioids were more likely to be admitted (43% vs 34.5% AOR 1.51, p = 0.048). Conclusion: Our study showed that delays in analgesic administration, poor functional status, and the presence of musculoskeletal (MSK) pain significantly influenced outcomes for this patient cohort. These findings suggest the development of specific protocols and tools to address cancer-related pain in the ED may be necessary.

Effect of Dexmedetomidine Compared to Remifentanil During Bariatric Surgery on Postoperative Nausea and Vomiting: a Retrospective Study.

Postoperative nausea and vomiting (PONV) occurs frequently after bariatric surgery and is a major cause of adverse outcomes. This retrospective study investigated whether opioid-restricted total intravenous anesthesia using dexmedetomidine as a substitute for remifentanil can reduce PONV in bariatric surgery. The electronic medical records of adult patients who underwent laparoscopic bariatric surgery between January and December 2019 were reviewed. The patients were divided into two groups according to the agents used for anesthesia: Group D, propofol and dexmedetomidine; Group R, propofol and remifentanil. A total of 134 patients were included in the analyses. The frequency of postoperative nausea was significantly lower in Group D than that in Group R until 2h after discharge from the postanesthesia care unit (PACU) (P = 0.005 in the PACU, P = 0.010 at 2h after PACU discharge) but failed to significantly reduce the overall high incidence rates of 60.5% and 65.5%, respectively (P = 0.592). Postoperative pain score was significantly lower in Group D until 6h after PACU discharge. The rates of rescue antiemetic and analgesic agent administration in the PACU were significantly lower in Group D than those in Group R. Opioid-restricted total intravenous anesthesia using dexmedetomidine reduces postoperative nausea, pain score, antiemetic, and analgesic requirements in the immediate postoperative period after bariatric surgery.

Comparative evaluation of fentanyl and magnesium sulphate as an adjuvant to 0.375% bupivacaine in ultrasound guided supraclavicular brachial plexus block

Supraclavicular block helps in achieving good anaesthesia along with complete muscle relaxation while providing hemodynamic stability and excellent post-operative analgesia. The addition of opioids to local anaesthetics injected during brachial plexus block has been shown to decrease the post-operative systemic analgesic requirements. This study was designed to compare the effectiveness of addition of MgSO (150 mg) and Fentanyl (50 micrograms) to 0.375% bupivacaine with placebo in supraclavicular brachial plexus block.A prospective double-blind randomised controlled study was conducted comprising of 75 patients undergoing upper limb surgeries under ultrasound guided supraclavicular brachial plexus block. Patients were randomized into one of the three groups (n=25) and designated as Group P (20ml of 0.375% Bupivacaine only), Group M (150 mg Magnesium sulphate with Bupivacaine) and Group F (50 micrograms Fentanyl with Bupivacaine). The primary purpose of the studywasto compare the onset and quality of sensory as well as motor blockade in all three groups. The onset time (in minutes) of sensory as well as motor blockade was significantly shorter in group P (p&amp;#60;0.001). Mean duration of sensory blockade (7.65±1.05 hours) and motor blockade (8.17±1.17 hours) was longest in group F when compared to group M and group P (p&amp;#60;0.001). Percentage of patients requiring rescue analgesia were significantly less in group F (16%) than group M (32%) and group P (80%) respectively (p&amp;#60;0.001). The mean time prior to administration of rescue analgesia in groups F, M and P were 14.21±4.29, 9.86±1.49 and 8.50 ±2.37 hours respectively (p&amp;#60;0.001).Although the additives delay the onset of action of local anaesthetic agents in brachial plexus block, Fentanyl as an adjuvant provided superior analgesia when compared to Magnesium sulphate as well as placebo with respect to duration of motor and sensory blockade. In addition, patients who received fentanyl as an adjuvant, required lesser rescue analgesia in the post-operative period.

WE8.8 Analgesia prescribing in a Surgical Assessment Unit

Abstract Aim Efficient analgesia administration is paramount to delivering good patient care and is an important factor in the safe assessment of patients. The aim of this audit was to assess analgesia prescribing and administration in the local Surgical Assessment Unit (SAU) and compare it with the standard of care set out by the Royal College of Emergency Medicine guidelines. Methods A retrospective audit was performed. Paper and electronic notes, including electronic prescribing data via HEPMA and pain scores were analysed for all patients referred with abdominal pain to SAU by GP's between the 21st of October and the 30th of October 2021. Data was compared with the RCEM best practice guidelines. Results A total of 33 patients were included. 39% of patients had a documented first pain score within 15 minutes of arrival, with a median time of 20 minutes. Of all patients presenting with moderate to severe pain, none received analgesia within 20 minutes. Earliest analgesia administration for this group was 1 hour 42 minutes. Overall median time to first analgesia prescription was 2 hours and 4 minutes and median time to administration was 4 hours and 8 minutes. Conclusion Since the COVID pandemic, NHS hospital staff- and bed shortages have put increased pressure on the delivery of safe patient care. This audit has found significant delays in both prescribing and administering analgesia for patients presenting to SAU. An electronic prescribing protocol was developed to increase efficiency in prescribing and another audit will be conducted to assess impact.

Opioid for in-hospital admitted patient analgesics; which demographics and psychiatric profiles need more pain drugs?

Introduction: The prevalence of substance use disorders is higher in patients receiving opioid analgesics, and pain management in these patients is more challenging. This study aimed to investigate the pattern of analgesic drug administration and evaluate the associated factors. Method: The cross-sectional study was performed on 230 patients admitted to General Hospital ( internal medicine, surgery, and cancer wards). Result: The most used analgesic drug was morphine (59.4%), and a mean dose of 27 mg, then pethidine and methadone. Most pain control methods were intravenous (68.1%) and PRN pattern (61.1%). Using analgesics in patients who do not have risk factors for drug abuse, or addiction, can be considered safe. In our subjects, 95.6% of analgesic users did not become addicted or had any misuse. Discussion and Conclusion: For effective and low-risk treatment of these patients, there is a need for clinical skills, knowledge of opioid administration, assessment, and risk management of substance abuse and addiction. In patients with substance abuse, analgesics should be prescribed in a particular setting, under supervision, and with careful monitoring. Structured and planned administration of opioid agonists (such as methadone or buprenorphine) seems appropriate according to a structured schedule. These plans are recommended: · Increasing the awareness of clinicians about prescribing narcotic analgesics. · Prescribing narcotic analgesics with a regular pattern against PRN. · Evaluating patients for a history of substance abuse. · Closely monitoring them, and if necessary. · Counseling. Identifying high-risk groups such as women, youth, and psychiatric patients are also recommended, and performing early interventions.

Quality by design approach for developing Emulgel of Diclofenac with central composite Design and Evaluation using in vitro release testing

Topical route of drug administration is more effective therapy for improving patient compliance and bioavailability. The topical administration of analgesics allows effective and painless deliverance of medicament with least side-effects. This investigation was aimed to develop and evaluate Diclofenac emulgel for topical drug delivery with enhanced anti-inflammatory and analgesic potential. Diclofenac is used as a first-line drug for acute and chronic pain and inflammation from a variety of causes. When applied topically the advantage of the drug is the avoidance of the first-pass metabolism, better patient compliance and site-specific for their action. Emulgel was prepared by using HPMC K4M as a gelling agent, light liquid paraffin as the oil base, Kollicream 3C and Kolliphor CS20 as emulsifiers via the QbD method. The emulgel formulation of diclofenac was optimized by central composite design and determines the effect of excipients on in vitro release. Emulgel formulation was evaluated for pH, drug content, viscosity, in vitro drug release and stability study. Optimized formulation showed pH, drug content and viscosity in an acceptable range. Based on the results of this investigation, it was summarized that diclofenac emulgel has a promising potential as an alternative to the conventional marketed dosage form.

Patient-controlled intravenous versus on-demand oral, intramuscular or mcs intravenous administration of oxycodone during medical induced abortion from 64 to 128 days of Gestation: A randomized controlled trial

ObjectiveTo compare oxycodone administration via intravenous patient-controlled analgesia (IVPCA) vs on-demand administration during late-first- and second-trimester medically induced abortion. Study designA prospective randomized controlled study. We enrolled women between 64 to 128 days of gestation in the study between June 2016 and August 2018. Participants were randomized to receive oxycodone either via IVPCA or given on-demand orally, intramuscularly, or intravenously. Pain intensity and satisfaction with care were measured using the visual analogue scale (VAS, 0–100mm). ResultsAltogether 99 participants were randomized: 48 in IVPCA group and 51 in on-demand group. Median gestational age was similar between groups (74 days [Interquartile range, IQR 69–81] in the IVPCA group vs 72 [69–80] in the control group, p = 0.587). Peak maximal pain was severe in both groups (median pain VAS was 62 [IQR 44–84] and 71 [IQR 56–90], p = 0.52). The odds for severe pain (highest pain VAS≥70) were similar between the groups (IVPCA group OR 0.51 [95% Confidence Interval 0.22–1.18], p = 0.118). In contrast, the odds for mild or tolerable pain (highest pain VAS≤40) were higher in the IVPCA group (OR 4.06 [95% CI 1.05–16.04], p = 0.043). Nevertheless, satisfaction with care was high (VAS 94 [89–100]) in both groups. Of those experiencing severe pain, 94.0% declared pain medication as adequate. ConclusionWomen often experience severe pain during medical abortion irrespective of the mode of opiate administration. Oxycodone administration via IVPCA permits women to self-administer analgesics when experiencing pain, raising the odds for mild or tolerable pain during abortion care. Satisfaction with care was high. ImplicationsMedical abortion in late-first- and second-trimester is often painful experience. IVPCA offers a good method of choice for analgesia and raises the odds for tolerable pain (pain VAS less than 40) experience when compared to on-demand administration of analgesics.

Analgesic efficacy of erector spinae plane block versus rectus sheath block in adults undergoing open para-umbilical hernia repair

Background: Rectus sheath block (RSB) is a popular technique for post-operative analgesia for patients undergoing abdominal surgeries with midline incisions. Ultrasound-guided erector spinae plane block (ESPB) is an interfacial plane block for the treatment of post-operative neuropathic pain. The aim of this study was to compare the analgesic efficacy of ESPB versus RSB in adult patients undergoing open para-umbilical hernia repair. Methods: This prospective randomized double-blinded study was carried out on seventy-four adult patients with ASA physical status I-II undergoing open paraumbilical hernia repair. Patients were divided into two equal groups: group I (ESPB): patients received bilateral ultrasound-guided ESPB using bupivacaine 0.25% (20 ml) on each side and group II (RSB): patients received bilateral ultrasound-guided RSB using bupivacaine 0.25% (20 ml) on each side. The following measurements was recorded: VAS score, intraoperative fentanyl consumption, the time to the first postoperative rescue analgesia administration, total dose of postoperative rescue analgesia (morphine) consumption, heart rate and mean arterial blood pressure.

Ultrasound-guided Transversus Abdominis Plane Block is Effective as Laparoscopic Trocar site infiltration in Postoperative Pain Management in Patients Undergoing Adrenal Surgery.

Pain management in patients undergoing laparoscopy is still a matter of debate as several techniques have been proposed to reduce postoperative analgesic consumption and improve recovery. Among these, transversus abdominis plane (TAP) block is considered as safe, effective, and easy to perform under ultrasound guidance; even so, recently laparoscopically guided trocar site anesthetic infiltration has been proposed as a "surgeon-dependent alternative to TAP block." The aim of this evaluation is to compare these analgesic techniques in the setting of laparoscopic adrenalectomy. This is a retrospective evaluation of a prospectively maintained database. Patients were divided into two groups: Group A patients received laparoscopic-assisted trocar site infiltration of ropivacaine; Group B patients received bilateral ultrasound-guided TAP block with ropivacaine. All patients received 24h infusion of 20mg morphine postoperatively; pain was checked at 6, 24 and 48h after surgery. A rescue analgesia was given if numerical rating scale (NRS) score was > 4 or on patient request. One hundred and three patients were enrolled in the evaluation (57 in group A and 46 in group B). There were no differences in operative time, complications and postoperative stay, and no complications related to trocar site infiltration. There were no differences in NRS at 6, 24, and 48hours as well as in patients requiring further analgesic administration. Laparoscopic-guided trocar site ropivacaine infiltration has similar pain outcomes compared to ultrasound-guided TAP block in the management of postoperative pain in patients undergoing laparoscopic adrenalectomy. Since there is no difference among these techniques, the decision can be based on surgeon or anesthesiologist preference.

Intranasal Fentanyl to Reduce Pain and Improve Oral Intake in the Management of Children With Painful Infectious Mouth Lesions.

Painful infectious mouth conditions such as herpangina, hand-foot-and-mouth disease, and herpetic gingivostomatitis can cause pain, dehydration, and hospitalization in young children. Treatment for these conditions is generally supportive and directed toward pain relief from ulcerative lesions, thus facilitating oral intake, and preventing dehydration. Attempts at oral therapy at home and in the emergency department are often refused and immediately spit back out. This study evaluated the efficacy of intranasal fentanyl (INF) compared with a commonly used oral (PO) acetaminophen/hydrocodone formulation for the treatment of children with painful infectious mouth conditions. This study was a prospective, nonblinded, randomized controlled noninferiority trial conducted in an academic tertiary care pediatric emergency department. The study enrolled children between the ages of 6 months and 18 years with painful infectious mouth lesions and poor oral intake. Patients were randomized to receive either INF (1.5 μg/kg, intervention) or PO acetaminophen/hydrocodone (0.15 mg/kg, control) based on the dose of hydrocodone. The primary outcome was volume of fluid intake per body weight (in milliliters per kilogram) 60 minutes after analgesic administration. Secondary outcomes included pain scores using a validated visual assessment scale (VAS; 1, no pain; 10, worst pain), hydration score (VAS; 1, well hydrated; 4, very dehydrated), admission rate and overall satisfaction score (VAS; 1, worst; 7, best). A priori power analysis indicated that 34 patients would achieve an 81% power with an α value of 0.05. Of the 34 patients enrolled, 17 were randomized to INF and 17 to PO. The demographics between both groups were similar in age, weight, sex, and race. There were no significant differences in parental perception of pain ( P = 0.69) or hydration status ( P = 0.78). Oral fluid intake at 60 minutes was 20 mL/kg for INF versus 18 mL/kg for PO ( P = 0.53). Pain scores at 15 and 30 minutes were 1.7 versus 2.9 ( P = 0.09) and 0.6 versus 1.6 ( P = 0.59). Parental perceptions of pain and hydration status at 60 minutes were 2.2 versus 2.4 ( P = 0.77) and 1.7 versus 1.5 ( P = 0.37). Overall parental satisfaction was 6.4 for INF versus 6.5 for PO ( P = 0.71), and admission rate was 0 vs 12% ( P = 0.49). There were no adverse events such as respiratory, cardiac, or central nervous system depression in either group. Intranasal fentanyl seems to be a safe and effective alternative to acetaminophen with hydrocodone in reducing pain and improving hydration status in children with painful infectious mouth lesions and poor oral intake.

The incidence of breakthrough pain associated with programmed intermittent bolus volumes for labor epidural analgesia: a randomized controlled trial

BackgroundIn this randomized, blinded study, we evaluated the effects of different programmed intermittent epidural bolus (PIEB) volumes for labor analgesia on the incidence of breakthrough pain and other analgesic outcomes. MethodsNulliparous women with term cephalic singleton pregnancies who requested labor analgesia had epidural analgesia initiated with 10 mL 0.1% ropivacaine with sufentanil 0.3 μg/mL. The pump was programmed to deliver a 4, 6 or 8 mL bolus every 45 min (groups 4, 6 or 8, respectively). The primary outcome was the incidence of breakthrough pain, defined as inadequate analgesia after two patient-controlled epidural analgesia administrations in a 20-min period. Secondary outcomes included ropivacaine consumption, time of the first patient-controlled epidural analgesia request, duration of the second stage of labor, and incidence of motor block. ResultsAmong 210 women randomly allocated the incidence of breakthrough pain was 34.9%, 19.7%, and 13.1%, for groups 4, 6 and 8, respectively (P=0.011). The incidence of breakthrough pain in group 8 was lower than in group 4 (P=0.006). The median (interquartile range) hourly ropivacaine consumption was 8.2 mg/h (7.1–11.3), 10.4 mg/h (9.2–13.0), and 12.0 mg/h (11.2–13.8) in groups 4, 6 and 8, respectively (P <0.001). Group 8 had a longer duration of effective analgesia and longer second stage of labor than group 4. There was no significant difference between groups in the incidence of motor block. ConclusionThe larger PIEB volumes were preferred for epidural labor analgesia compared with a smaller volume because of improved analgesia without clinically significant increases in adverse effects.

Inpatient administration of opioids and risk for post-operative ileus in older adults.

Post-operative ileus (POI) is a common and potentially serious complication after surgery. We assessed the incidence and identified predictors of POI in older surgical patients. A retrospective observational study. University of California-San Francisco electronic medical record data. Opioid-naïve, noncancer patients, aged 65 and older, who underwent elective surgery in the period 2017-2019. Administration of opioid analgesics per day of hospitalization in opioid naïve patients. Incidence of POI and likelihood of developing POI. In the study period, 3 percent of opioid naïve patients developed POI. Patients with POI used on average 197.1 oral morphine equivalents (OMEs) per day of hospitalization compared to 82.5 OME in patients without POI (p = 0.013). Yet, there were not statistically significant differences in post-operative pain scores between patients with and without POI. General surgery (p = 0.0031), length of surgery (p = 0.0031), and hospital length of stay (p < 0.0001) were significant predictors of the risk for developing POI. Adjusted inpatient administration of more than 90 OME per day of hospitalization was associated with a four times greater risk for developing POI (p = 0.016). Developing POI was associated with 6.5 (95 percent confidence interval: 5.2-7.8) additional days of hospitalization among patients who developed POI compared to patients who did not develop POI (p < 0.0001). Adjusted inpatient administration of more than 90 OME significantly increased the risk for developing POI in opioid-naïve older patients. Developing POI after surgery significantly increased the hospital length of stay. Optimizing inpatient administration of opioids may prevent opioid use-related POI and longer hospitalizations.

Pneumocephalus and headache following craniotomy during the immediate postoperative period

BackgroundPneumocephalus may be responsible for post-craniotomy headache but is easily overlooked in the clinical situation. In the present study, the relationship between the amount of intracranial air and post-craniotomy headache was investigated.MethodsA retrospective observational study was performed on 79 patients who underwent minimal invasive craniotomy for unruptured cerebral aneurysms. Those who had undergone previous neurosurgery, neurological deficit before and after surgery were excluded The amount of air in the cranial cavity was measured using brain computed tomography (CT) taken within 6 h after surgery. To measure the degree of pain due to intracranial air, daily and total analgesic administration amount were used as a pain index. Correlation between intracranial air volume and total consumption of analgesic during hospitalization was tested using Spearman rank correlation coefficients. Receiver operating characteristics (ROC) analysis was used to determine the amount of air associated with increased analgesic consumption over 72 h postoperatively.ResultsThe mean amount of intracranial air was 15.6 ± 9.1 mL. Total administration of parenteral and oral analgesics frequency were 6.5 ± 4.5, 13.2 ± 7.9 respectively. A statically significant correlation was observed between daily and total parenteral analgesic consumption after surgery and the amount of intracranial air at followed-up brain CT postoperatively within 24 h (r = 0.69, p < 0.001), within 48 h (r = 0.68, p < 0.001), and total duration after surgery (r = 0.84, p < 0.001). The optimal cut-off value of 12.14 mL of intracranial air predicts the use of parenteral analgesics over 72 h after surgery.ConclusionsPneumocephalus may be a causative factor for post-craniotomy pain and headache with surgical injuries.