Average Postoperative Pain Score Research Articles

Use of Vascularized, Denervated Muscle Targets for Prevention and Treatment of Upper-Extremity Neuromas

Neuroma formation following upper-extremity peripheral nerve injury often results in persistent, debilitating neuropathic pain with a limited response to medical management. Vascularized, denervated muscle targets (VDMTs) offer a newly described surgical approach to address this challenging problem. Like targeted muscle reinnervation and regenerative peripheral nerve targets, VDMTs are used to redirect regenerating axons from an injured nerve into denervated muscle to prevent neuroma formation. By providing a vascularized muscle target that is reinnervated via direct neurotization, VDMTs offer some theoretical advantages in comparison with the other contemporary surgical options. In this study, we followed the short-term pain outcomes of patients who underwent VDMT surgery for neuroma prevention or treatment. We performed a retrospective chart review of 9 patients (2 pediatric and 7 adult) who underwent VDMTs either for symptomatic upper-extremity neuromas or as a prophylactic measure to prevent primary neuroma formation. In-person and/or telephone interviews were conducted to assess their postoperative clinical outcomes, including the visual analog pain scale simple pain score. Of the 9 patients included in this study, 7 underwent VDMT surgery as a prophylactic measure against neuroma formation, and 2 presented with symptomatic neuromas that were treated with VDMTs. The average follow-up was 5.6 ± 4.1 months (range, 0.5-13.2 months). The average postoperative pain score of the 7 adult patients was 1.1 (range, 0-8). This study demonstrated favorable short-term outcomes in a small cohort of patients treated with VDMTs in the upper extremity. Larger, prospective, and comparative studies with validated patient-reported and objective outcome measures and longer-term follow-ups are needed to further evaluate the benefits of VDMTs in upper-extremity neuroma management and prevention. Therapeutic III.

Quadratus Lumborum Block for Upper Tract Urological Surgery in Pediatric Patients

Abstract Objective Among regional blocks, the quadratus lumborum fascial plane block (QLB) has been well described, but the description of its use and efficacy for pediatric patients undergoing upper abdominal urologic surgery is limited. We present a case series examining the use of the QLB for postoperative pain management in children undergoing upper tract surgery. Methods From August 2019 to August 2020, through a chart review, we identified 5 patients who had undergone a QLB for upper urinary tract surgery via a flank incision. Posterior QLB was performed after induction of general anesthesia. A single injection of 0.5mL/kg of either 0.25% or 0.5% ropivacaine with 1mcg/kg of clonidine was administered. Patients received fentanyl IV (1 mcg/kg), and acetaminophen IV (15mg/kg) as adjuvants during the operation. Postoperative pain was managed with oral acetaminophen and ibuprofen. Results The average postoperative pain score during the entire admission was 1, with the lowest being 0 and highest, 3. No administration of rescue narcotics was required in the postanesthesia care unit or on the floor. The average length of stay ranged from 0 to 1 day. No complications associated with the regional QLB were identified. Conclusions Our series suggests the QLB may be considered as a regional anesthetic option to minimize narcotic requirements for children undergoing upper abdominal urological surgery via flank incision. Additional studies are needed to compare the efficacy of the QLB versus alternate regional anesthetic blocks for upper tract urological surgery via flank incision in children and to determine effective dosing and use of adjuvants.

Application of Vagus Nerve Branch Preservation in Thoracoscopic Surgery for Early-Stage Lung Cancer.

Background In this study, we introduced a novel surgical strategy to protect vagal nerve branches during radical thoracoscopic surgery in right lung cancer and explored the effects of vagal nerve branch preservation. Methods We retrospectively studied 53 patients with right-sided lung cancer with clinically staged T1N0M0 between 2019 and 2020. All 53 patients were treated with total thoracoscopic lobectomy and mediastinal lymph node dissection in the same number of lymph node stations. Of these, 22 patients adopted a vagus nerve branch protection strategy during lymph node dissection. Another 31 patients were treated with traditional lymph node dissection as the control group. Results The characteristics of the patients were similar between the two groups. The operation time and intraoperative bleeding in the protection group were longer than those in the control group. However, the protection group had a lower average postoperative pain score and average postoperative hospital stay. The above difference was not statistically significant. Three cases of arrhythmia occurred in the protection group, including 1 case of tachycardia and 2 cases of atrial fibrillation. In the control group, 13 cases of arrhythmia occurred after the operation, including 8 cases of tachycardia and 5 cases of atrial fibrillation. We also tracked changes in the patients' heart rates throughout the treatment process (excluding patients with arrhythmias). An increased heart rate was observed postoperatively in both groups, but the increase of heart rate of the protection group was smaller than that of the control group; however, the difference was not statistically significant. Conclusions A vagus nerve branch preservation-based approach to radical surgery is a safe and feasible strategy for right lung cancer treatment, which could significantly reduce the risk of postoperative arrhythmia in patients and may also have a potential role in reducing the length of hospital stay and maintaining heart rate stability in the postoperative period.

Nerve transfers for femoral nerve palsy: an updated approach and surgical technique.

Femoral nerve palsy results in significant impairment of lower extremity function due to the loss of quadriceps muscle function. The authors have previously described their techniques utilizing the anterior obturator and sartorius nerves for transfer in cases of femoral nerve palsy presenting within 1 year of injury. In the current study, the authors discuss their updated techniques, results, and approach to partial and complete femoral nerve palsies using femoral nerve decompression and nerve transfers. They conducted a retrospective review of patients with femoral nerve palsies treated with their technique at the Washington University School of Medicine in 2008-2019. Primary outcomes were active knee extension Medical Research Council (MRC) grades and visual analog scale (VAS) pain scores. Fourteen patients with femoral nerve palsy were treated with femoral nerve decompression and nerve transfer: 4 with end-to-end (ETE) nerve transfers, 6 with supercharged end-to-side (SETS) transfers, and 4 with ETE and SETS transfers, using the anterior branch of the obturator nerve, the sartorius branches, or a combination of both. The median preoperative knee extension MRC grade was 2 (range 0-3). The average preoperative VAS pain score was 5.2 (range 1-9). Postoperatively, all patients attained an MRC grade 4 or greater and subjectively noted improved strength and muscle bulk and more natural gait. The average postoperative pain score was 2.3 (range 0-6), a statistically significant improvement (p = 0.001). Until recently, few treatments were available for high femoral nerve palsy. A treatment strategy involving femoral nerve decompression and nerve transfers allows for meaningful functional recovery and pain relief in cases of partial and total femoral nerve palsy. An algorithm for the management of partial and complete femoral nerve palsies and a detailed description of surgical techniques are presented.

283 Creating an ERAS for Living Donors for Renal Transplant

Abstract Aim To design and facilitate an enhanced recovery after surgery (ERAS) protocol for the Wessex Kidney Centre (WKC) for live donors for renal transplants. This audit focussed on the post-operative analgesia guidelines and average length of hospital stay post the ERAS protocol implementation. Method An enhanced recovery after surgery (ERAS) protocol was created for renal living donors. The protocol incorporated pre, peri and post-operative guidelines to optimise patient care. The protocol was based on a survey sent to all transplant units in the UK regarding their own pathways for live donors(13/23 units responded). The ERAS protocol was then trialled on all live donors throughout 2020 and into 2021 at WKC. For this audit, data was collected on length of stay, analgesia used post-operatively and the VAS scores recorded by patients to grade their pain levels. Results There were a total of 11 renal live donors from September 2020 to January 2021 during which data was collected on all donors. National average length of stay for live donors is 3.9 days. Post ERAS, the average length of stay at WKC is 2.1 days, reduced from an average of 6 days pre-protocol. There was a minimal change in VAS score at 6 hours post-operatively: 3.9 (pre-ERAS average 4.2). However, at 24 hours post-operatively, average VAS score was 2.6 (pre-ERAS average 3.7). Conclusions The introduction of a specific ERAS protocol for live donors for renal transplant notably improved the average post-operative pain scores and reduced the average length of stay to below the national average.

Next day discharge after the Nuss procedure using intercostal nerve cryoablation, intercostal nerve blocks, and a perioperative ERAS pain protocol

BackgroundThe Nuss procedure for pectus excavatum has historically been associated with significant postoperative pain, which has been the major factor contributing to hospital length of stay (LOS). MethodsA single-institution, prospective study of 40 consecutive patients undergoing Nuss bar placement for pectus excavatum between November 2019 and January 2021 was conducted to assess the effectiveness of a multimodality pain management protocol. All patients received T3-T8 intercostal nerve cryoablation (INC), T3-T8 bupivacaine intercostal nerve blocks, Exparel at the skin incisions, and management with a perioperative analgesia regimen that minimized narcotic usage. The primary outcome was LOS. Secondary outcomes included opioid use, pain scores, and time to sensory recovery. Results37/40 patients (92.5%) were discharged home on postoperative day (POD) 1, and 3/40 (7.5%) were discharged on POD 2 (mean LOS = 1.1 days). The median average postoperative pain score was 2/10. After eliminating IVPCA from our protocol, total oral morphine equivalent (OME) decreased by 73% (55.5 mg to 15 mg) with no change in pain scores or discharge timing. ConclusionsINC combined with bupivacaine intercostal nerve blocks and a pre- and post-hospital analgesia protocol facilitated discharge one day after the Nuss procedure, achieved excellent pain control, and eliminated the need for intravenous opioids.

Endoscopic Spinal Decompression: A Retrospective Review of Pain Outcomes at an Academic Medical Center.

Introduction: Spinal stenosis is a chronic, debilitating condition that is expected to affect an increasing number of people as the population ages. Symptomatic spinal stenosis, like other spine pathologies, including disc herniation and degenerative disc disease, traditionally required an open decompressive surgical approach if more conservative approaches failed. An emerging alternative has been developed to address the needs of this population of patients in the form of endoscopic spine surgery (ESS). Advantages of ESS include minimal tissue trauma, decreased risk of damage to the neurovascular structures, minimal epidural fibrosis/scarring, reduced hospital stay, early functional recovery, and improved cosmetic outcomes. The purpose of this study was to review the outcomes of patients undergoing transforaminal endoscopic spinal decompression at an academic pain program.Methods: We conducted a retrospective review of electronic medical records with approval from the University of Florida Institutional Review Board (IRB #202001529). Twenty patients underwent successful transforaminal endoscopic lumbar spinal decompression surgery at UF Health Pain Medicine from July 1, 2019, to June 1, 2020. The majority of cases were performed at L4-5 (n = 14), followed by an equal number (n = 3) of cases at L3-4 and L5-S1. Preoperative and postoperative visual analog scale (VAS) pain scores from patients' pain clinic appointments were obtained from the electronic health records system to assess the intervention as a pain relief strategy.Results: Patients had an average pain reduction of 82% (SD = 31%), resulting in an average postoperative pain score of 1.8 (SD = 2.8) on a 10-point VAS.Conclusion: This study highlights the benefits of endoscopic spine surgery for patients, including pain reduction and reduced scarring.

Comparing post-operative pain between single bundle and double bundle anterior cruciate ligament reconstruction: a retrospective study

BackgroundIn anterior cruciate ligament (ACL) reconstruction, the clinical outcome and level of post-operative pain are important factors. To date there have been no studies evaluating differences in post-operative pain between single bundle and double bundle ACL reconstruction with a hamstring graft.Hypothesis/purposeWe hypothesized that post-operative pain in single bundle ACL reconstruction would be less than in double bundle ACL reconstruction. This study was to compare post-operative pain between patients undergoing single bundle versus double bundle ACL reconstruction.Study designCohort study.MethodsThis was a retrospective study comparing post-operative pain scores between single bundle and double bundle ACL reconstruction. Each patient was given our standard regimen of oral diclofenac (25 mg/tab) three times per day and paracetamol (500 mg/tab) six times per day for 1 day post-operatively. If the patient complained of moderate to severe pain (pain numeric rating scale (PNRS) > 3), 3 mg of morphine was injected intravenously every 3 h for 24 h and 1 mg of morphine as a rescue medication every 1 h for 24 h. PNRS and morphine consumption were recorded at 4-h intervals for 24 h.Results209 patients were included in this study of whom 102 and 107 patients received single bundle and double bundle ACL reconstruction, respectively. The average post-operative pain scores of the single bundle group were lower at all time points. Linear mixed effect regression analyses showed that the single bungle group had lower post-operative pain than the double bundle group after adjusting for confounders (beta = − 0.45; 95% CI = − 0.838, − 0.062) but there was no statistically significant difference between numbers of bundle ACL reconstruction with regard to morphine consumption.ConclusionSingle bundle ACL reconstruction had significantly lower post-operative pain scores than double bundle ACL reconstruction.Clinical relevanceDouble bundle ACL reconstruction results in higher post-operative pain, which may slow the start of rehabilitation and reduce patient satisfaction. In middle-aged adult patients with low-demand activities, we suggest performing a single bundle ACL reconstruction.

Opioid-Free Anesthesia for Craniotomy.

Perioperative opioids are problematic following craniotomy as they can impede neurological examination because of excessive sedation and mask surgical complications. Multimodal anesthetic techniques including nerve blocks have been used successfully to deliver opioid-free anesthesia in other surgical populations; however, no clinical data evaluating opioid-free anesthesia for craniotomy exists within the current body of literature. Six prospectively identified patients underwent supratentorial craniotomy at Emory University Hospital using a multimodal opioid-free anesthetic (OFA) technique consisting of preoperative scalp block, dexmedetomidine and intravenous acetaminophen. These opioid-free patients were matched by age, sex, incision length, and incision location to 18 retrospectively identified control patients who underwent craniotomy using conventional, opioid-based anesthetic techniques. Postoperative opioid consumption and pain scores were compared and analyzed for noninferiority. Noninferiority of the OFA technique was demonstrated for opioid consumption at all measured intervals from postanesthesia care unit arrival to 24 hours postoperatively. Noninferiority was also demonstrated with respect to average postoperative pain scores from 0 to 12 hours, 0 to 24 hours, as well as length of postanesthesia care unit stay. Noninferiority was not shown for time to first rescue opioid postoperatively, pain scores for the 12 to 24 hours postoperative period, or time to emergence from anesthesia. This pilot study demonstrates the feasibility of an OFA technique for patients undergoing supratentorial craniotomy and suggests that larger prospective randomized controlled trials are indicated to examine the role of multimodal anesthetic techniques for craniotomy.

Safety and Efficacy of Achilles Repair Using the Mini-Open Approach in Supine Versus Prone Position: A Retrospective Study.

PurposeSurgical repair of the Achilles tendon is a common procedure in cases of acute rupture. Open Achilles tendon surgery with a traditional extensile approach is most often performed in the prone position, but this can lead to numerous complications. The mini-open approach for repair in the supine position may avoid the risks of the prone position. The purpose of this study is to compare perioperative outcomes and differences in cost between patients undergoing acute Achilles rupture repair with mini-open approach, incision of approximately 3 cm, in the supine position versus traditional approach in the prone position.MethodsPatients who underwent surgical repair of acute Achilles rupture at a single institution were retrospectively identified using Current Procedural Terminology (CPT) code 27650. Complication rates and the total cost charged to the insurance companies of both the supine and prone groups were calculated.ResultsA total of 80 patients were included for analysis, 26 supine and 54 prone. The difference in average total time in the operating room was statistically significant. The prone position took approximately 15% more time (118.7 minutes) compared to the supine position (100 minutes) (p = 0.001). While not statistically significant, the total cost for the supine group ($19,889) was less than the for the prone group ($21,722) (p = 0.153) Average postoperative pain score, infection rate, dehiscence rate, sepsis rate, and deep vein thrombosis (DVT) rate were also similar between the two groups. No patient in either group experienced re-rupture of the Achilles tendon within the first year of primary repair.ConclusionThe mini-open approach in the supine position may be advantageous in the repair of acute Achilles rupture in that it reduces total time in the operating room and total cost while maintaining positive patient outcomes. Prospective clinical studies are warranted to validate these assessments.

Effect of abdominal binder after laparoscopic cholecystectomy on enhanced recovery: a randomized controlled trial.

PurposeThe purpose of this randomized controlled trial was to compare the effects of abdominal binder after laparoscopic cholecystectomy.MethodsFrom August to December 2020, 66 patients who were set to undergo cholecystectomy were selected for a prospective trial at Kangbuk Samsung Hospital, Seoul, Republic of Korea, and their clinical characteristics and postoperative surgical outcomes were evaluated. Among 66 patients, 33 patients belong to the abdominal binder group and the other 33 patients belong to the control group.ResultsThe average hospital stay was 2.46 ± 1.29 days, and was not significantly different between the two groups. The average postoperative pain score (visual analogue scale, 0–10) 12, 24, and 48 hours after surgery were not significantly different. However, the degree of comfort score was significantly higher for the control group patients (2.56 vs. 3.33, p < 0.001). Time to the first ambulation, walking ability, return of bowel function, time to full diet resumption, and the numbers of analgesics and antiemetics administered were not significantly different between the two groups.ConclusionNo postoperative recovery benefit and no reduction in hospital stay was found in patients who used an abdominal binder while undergoing laparoscopic cholecystectomy. Statistically, between the group that used the binder and the one that did not, no significant differences in surgical outcome nor postoperative outcome were observed. The only exception was that the degree of comfort score was significantly higher in the control group. Therefore, in terms of patient benefit and convenience, wearing an abdominal binder after laparoscopic cholecystectomy is not recommended.

Analgesic effects of a retrobulbar block with 0.75% ropivacaine in dogs undergoing enucleation

ObjectiveTo assess the analgesic effects of a retrobulbar block with ropivacaine in dogs undergoing enucleation. Study designProspective, randomized, masked placebo-controlled trial. AnimalsA total of 23 client-owned dogs. MethodsDogs were randomized to be administered a preoperative inferior-temporal palpebral retrobulbar injection of either ropivacaine 0.75% (1 mL 10 kg–1; group RG) or equivalent volume of 0.9% saline (control; group CG). Intraoperative variables recorded to detect a response to noxious stimuli included heart rate (HR) and mean arterial pressure (MAP). Three observers assessed and recorded pain using a numerical rating pain scale and visual analog scale (VAS) before anesthesia (baseline) and postoperatively at 0, 0.5, 1, 2, 3, 4, 5, 6 and 24 hours after extubation. Rescue analgesia was administered if intraoperative HR or MAP increased by ≥ 20% from the previously recorded surgical time point, average postoperative pain scores totaled ≥ 9/20, scored ≥ 3/4 in any one category with VAS ≥ 35/100, or if VAS was ≥ 35/100 with a palpation score > 0/4. ResultsIntraoperatively, there was no significant difference in HR or MAP between groups. Rescue analgesia was administered intraoperatively to four and one dogs and postoperatively to five and seven dogs in groups CG and RG, respectively, with no significant difference between groups. VAS scores were significantly lower in ropivacaine dogs at extubation (p = 0.02), but not at other postoperative time points. Adverse events were not observed in either group. Conclusions and clinical relevancePreoperative retrobulbar 0.75% ropivacaine injection (1 mL 10 kg−1) provided analgesia in dogs following enucleation at extubation; however, intraoperative and postoperative pain control did not differ from a placebo injection with saline. Lack of differences between groups may have been influenced by sample size limitations.

Multimodal Analgesia Decreases Postoperative Opioid Consumption in Living Liver Donation.

ObjectiveTo evaluate the effects of multimodal analgesia on postoperative opioid consumption and perioperative pain management in patients undergoing living liver donation.MethodsA retrospective study was conducted of 129 patients who underwent living liver donation between 2006 and 2015. Patients were separated into 2 cohorts, pre–multimodal analgesia and multimodal analgesia, to allow intergroup analysis. All patients received an intrathecal opioid injection and underwent donor hepatectomy. Primary outcome data compared opioid consumption in oral morphine equivalents for postoperative days (PODs) 0 to 4 between the cohorts. Secondary outcomes compared yearly averaged cumulative opioid consumption on PODs 0 to 4 in oral morphine equivalents; yearly averaged numeric rating scale pain scores; hospital length of stay; and percentage of patients receiving intravenous ketorolac, ketamine, or transversus abdominis plane blocks.ResultsFor PODs 0 to 4, a 50% reduction in overall opioids administered postoperatively (359 mg vs 179 mg; P<.01) was observed in the multimodal analgesia cohort, whereas no significant difference was found in year-to-year average postoperative pain scores (4.5 vs 3.6). The proportion of patients receiving ketorolac increased to more than 90% by 2013. More than 40% of all patients in the multimodal analgesia group received a perioperative regimen of acetaminophen, gabapentin, ketamine, and transverse abdominal plane blocks (0% in pre–multimodal analgesia). Mean hospital length of stay was reduced from 7.7 to 6.6 days (P<.01).ConclusionImplementation of multimodal analgesia to manage perioperative pain in living liver donation resulted in a 50% reduction of postoperative opioid consumption. Clinically satisfactory average pain scores were maintained for PODs 0 to 4.

Liposomal bupivacaine interscalene nerve block in shoulder arthroplasty is not superior to plain bupivacaine: a double-blinded prospective randomized control trial

Interscalene brachial plexus blocks are a common modality used to provide adjunctive pain relief with shoulder replacement surgery. In 2018, the Federal Drug Administration approved the use of liposomal bupivacaine (LB) for such nerve blocks. We sought to evaluate whether this formulation of bupivacaine would provide superior pain relief for shoulder replacement patients over standard bupivacaine alone. Our hypotheses were that in the LB cohort the average postoperative pain score over the first 72 hours would be significantly lower, time to block cessation would be longer, total opioid consumption would be lower, and the average patient satisfaction score regarding their pain management would be higher. A randomized, double-blinded study was designed comparing primary shoulder replacement surgery after an interscalene block with 25 mL of 0.5% plain bupivacaine vs. 133 mg of LB with 7.5 mL of 0.5% and 7.5 mL of 0.25% plain bupivacaine. A total of 104 patients were included in the study, with an equal number in each study arm. Patients' visual analog pain scores (VAPS) were followed for their inpatient stay, first 3 full outpatient days, and at a 3-week follow-up. Use of opioid medication was recorded for the same intervals and converted to morphine milligram equivalents. The time to first opioid rescue was documented, as well as the patients' satisfaction with their pain management at both the 3-day and 3-week intervals. No clinically relevant advantage to the use of LB over plain bupivacaine was found. During the second postoperative day, the mean VAPS was 2.4 with LB vs. 3.3 in the standard cohort (P = .0409). The only other statistically significant finding was a higher VAPS with LB during the third full day home compared with standard bupivacaine (4.0 vs. 2.8, respectively, P = .0197). Both of these differences were less than the minimal clinically important difference of 2 for the VAPS. Analysis of the VAPS for the first and third postoperative days, the first and second full days home, and at 3 weeks revealed no significant difference. Similarly, there was no significant difference in time to first opioid rescue, total morphine milligram equivalent use, and patient satisfaction with pain management. When used for an interscalene block to provide adjunctive pain relief in shoulder replacement surgery, the addition of LB to plain bupivacaine provides no additional clinically important benefit to the patient's pain experience over standard bupivacaine.

Opioid Consumption Following Breast Reconstruction Decreases With a Brief Educational Intervention: A Randomized, Controlled Trial

PURPOSE: There has been a focus on opioid consumption and overprescribing, but the utility of patient education in reducing opioid consumption has only recently been explored. This randomized trial aimed to evaluate the effectiveness of a brief patient educational intervention in reducing pain and opioid consumption in patients undergoing mastectomy and breast reconstruction. We hypothesized that implementation of an educational intervention on pain control would decrease postoperative opioid consumption. METHODS AND MATERIALS: A parallel, randomized, single-center controlled trial of women undergoing mastectomy and immediate, implant-based breast reconstruction was completed to evaluate the utility of a patient educational instrument. The control group received standard patient counseling, and the treatment group received an additional single-paged handout intervention. Goals of the educational instrument were to normalize the pain experience, set expectations for pain after surgery, and inform patients of alternative (nonopioid) methods of pain control. A questionnaire was administered postoperatively to collect data on pain control and opioid consumption. RESULTS: Over a 12-month time period, 100 patients were randomized. A total of 46 participants from the control group (92%) and 39 participants from the intervention group (78%) completed the postoperative questionnaire. Postoperative questionnaires were completed a median of 13.0 days after surgery in both groups. Review of the electronic medical record showed similar demographics and comorbidities between the control and intervention groups; however, participants in the control group were statistically more likely to be a current tobacco user (P = 0.04). There were no statistical differences in surgical characteristics or postoperative prescriptions between the 2 groups. All outcome analysis was performed according to intended treatment groups. A statistically significant reduction in the number of opioid tablets consumed was seen in the intervention group (control 24.3, SD 21.8; intervention 16.2, SD 16.4; P = 0.05). Although immediate postoperative prescriptions were equivalent between the 2 groups, more participants in the control group required a prescription refill compared to the intervention group (control n = 10, 21%; intervention n = 6, 12%; χ2 = 1.3; P = 0.3). Due to the differences in need for prescription refill, the total average number of opioid tablets prescribed to the control group was statistically higher than the intervention group (control 46.6, SD 21.8; intervention 39.2, SD 11.9; P = 0.04). There was a marginal trend toward lower average postoperative pain scores reported by the intervention group (control 3.6/10, SD 1.6; intervention 3.0/10, SD = 1.8; P = 0.06). CONCLUSIONS: This study was successful in trialing an easily implemented, brief intervention. When tested in a randomized population of breast reconstruction patients, the instrument was found to reduce opioid consumption, while maintaining noninferior pain control and need for opioid refills. The effectiveness of a brief patient education tool on patient opioid consumption has been shown, and implementation of similar protocols in this patient population is recommended.

Pediatric Endoscopic Pilonidal Sinus Treatment (PEPSiT) in Children With Pilonidal Sinus Disease: Tips and Tricks and New Structurated Protocol.

Background: The advent of pediatric endoscopic pilonidal sinus treatment (PEPSiT) has dramatically changed the surgical management of pilonidal sinus disease (PSD) in children and adolescents. This study aimed to report the outcome of our new structurated protocol, including PEPSiT, laser epilation, and oxygen-enriched oil-based gel dressing, for treatment of PSD in pediatric patients and describe tips and tricks of the technique.Methods: We retrospectively reviewed the data of 127 pediatric patients, who underwent PEPSiT for PSD in our institutions over a 36-month period. All patients received laser epilation (LE) before and after surgery. Post-operative dressing was performed using silver sulfadiazine spray and in the last 18 months oxygen-enriched oil-based gel. We divided the patients in two groups according to the protocol adopted: G1 (laser + oxygen-enriched oil-based gel dressing) included 72 patients and G2 (laser + silver sulfadiazine spray dressing) included 55 patients. The two groups were compared regarding success rate, recurrence, wound infection rate, wound healing time, post-operative outcome, time to full daily activities and patient satisfaction.Results: No difference emerged between the two groups regarding the average operative time, the average post-operative pain score, the average analgesic requirement, the average hospitalization and the average time to full daily activities (p = 0.33). No intra- or post-operative complications including wound infection occurred in both groups. The patients required an average number of 7 LE sessions (range 4–10) to achieve complete hair removal. The overall success rate was significantly higher in G1 (n = 71, 98.6%) compared with G2 (n = 50, 90.9%) [p = 0.001]. The recurrence rate was also significantly lower in G1 (n = 1, 1.4%) compared with G2 (n = 5, 9%) [p = 0.001]. Furthermore, G1 reported a faster wound healing (average 21 days) compared with G2 (average 29 days) [p = 0.001] and a higher patient satisfaction score (average 4.9) compared with G2 (average 4.2) [p = 0.001].Conclusions: Based upon our experience, PEPSiT may be considered the standard of care for surgical treatment of PSD in children and adolescents. Our new structurated protocol consisting of pre-operative LE, PEPSiT, and post-operative wound management with oxygen-enriched oil-based gel dressing and LE, allowed to achieve an excellent outcome, with a success rate > 98%.

Medium-term results after treatment of percutaneous tennis elbow release under local anaesthesia.

Background:The purpose of this study was to evaluate the results of the technique of percutaneous release of common extensor procedure under local anesthesia for lateral epicondylitis and to emphasize its simplicity.Methods:Forty seven elbows (41 patients) were treated surgically for lateral epicondylitis in the outpatient minor procedure room under local anaesthesia. The indication for surgery was continuation of sypmtoms (such as pain, movement and power loss) despite conservative treatment lasting more than six months The treatment results were assessed using the visual analogue scale (VAS) and Mayo Elbow Performance Score (MEPS).Results:Twentysix right elbows and fifteen left elbows were treated surgically. Dominate elbow rate was 74%. The follow-up period was 36 to 72 months (mean 52 months). All patients had full range of motion. The average post operative pain score was 2.6(range 0 to 9). The average post operative MEPS score was 82 (range 40 to 100). ). Sixteen patients had excellent, twenty patients had good, two patients had fair and three patients had poor outcomes (repetitive problems).Conclusion:The percutaneous release of the common extensor origin is an important treatment option with minimal morbidity, safety, simplicity and good to excellent results in most patients. The procedure can be performed under local anaesthetic and leave a rarely visible scar. (www.actabiomedica.it)

Acute postcesarean pain is associated with in-hospital exclusive breastfeeding, length of stay and post-partum depression

Study objectiveThe primary aim of the proposed study was to determine the association between postoperative pain and breastfeeding after cesarean delivery during hospital stay. DesignRetrospective cohort study. SettingPostoperative recovery area and operating room. PatientsData was obtained on singleton pregnancies undergoing scheduled cesarean deliveries under spinal anesthesia between 2013 and 2016. InterventionsDetermine the association between postoperative pain and breastfeeding after cesarean delivery. MeasurementsPostoperative pain score, breastfeeding, LATCH score post-partum depression and length of stay values collected. Main resultsThe dataset consisted of electronic medical records from 5350 patients. We found that the pain score is negatively associated with the LATCH score; higher pain was associated with lower LATCH scores, −0.01 [−0.01,-0.00], p < .0402. Every one-point increase in average pain score was associated with a 21% reduction in the odds of in-hospital exclusive breast-feeding relative to exclusive formula-feeding, OR = 0.79 [0.70–0.90], p < .0002. We observed that the post-partum depression status was associated with the average postoperative pain score, F (1, 5347) = 41.51, p < .0001. We also found a significant positive association between the average pain score and the duration of hospital stay (p < .0001); every one-point increase in the average pain-score was associated with a 7.98 [6.28, 9.68] hour increase in length of stay. ConclusionsOur results demonstrate significant association between the increase in post-cesarean pain scores and deterioration of breastfeeding initiation while also exposing slight reductions in the quality of breastfeeding. Additionally, we found that increases in post-cesarean pain scores also positively associate with postpartum depression and duration of stay, with each increase in pain score resulted in an almost one-day increase in the length of stay.

Retrospective cohort-based comparison of intraoperative liposomal bupivacaine versus bupivacaine for donor site iliac crest analgesia during alveolar bone grafting

Bone grafting of alveolar clefts is routinely performed with cancellous bone harvested from the iliac crest. Graft site morbidity is frequently seen, with early postoperative pain being one of the most common complaints. Liposomal bupivacaine (LB) has been demonstrated to provide improvement in postoperative pain for patients undergoing bunionectomy or hemorrhoidectomy, which may translate to patients requiring iliac crest bone graft harvest. Thirty-eight patients undergoing iliac crest bone harvest were included in the study. Twenty-one patients underwent open iliac crest bone graft harvest with administration of 0.25% bupivacaine at the hip donor site, while 17 patients received local infiltration of 1.3% liposomal bupivacaine. Patient-reported pain scores, total narcotic use, length of stay, and postoperative steps were monitored. There were no significant differences in age, weight, distribution of clefts, or choice of donor hip between the two groups. There were no significant differences in length of hospitalization stay. However, differences were noted in average postoperative pain scores at five of six time points in the first 24h, total oral morphine equivalents administered (4.7 ± 5.3 vs. 14.3 ± 12.0), and steps at postoperative days one to three (p<0.001, for all three days) for patients receiving 1.3% LB versus 0.25% bupivacaine, respectively. Reduced pain scores and increased postoperative activity highlight the potential of LB to improve postoperative pain management in children undergoing iliac crest bone harvest for alveolar bone grafting.

Safety of Achilles Repair Using the Mini-Open Approach in Supine Position vs Prone Position: A Retrospective Study

Category:SportsIntroduction/Purpose:Surgical repair of the Achilles tendon is a commonly-performed procedure in cases of acute tendon rupture. Open Achilles tendon surgery with traditional extensile approach is most often performed with the patient in prone position, but this can interfere with airway access, put increased pressure on the abdomen, and subject to increase perioperative period and comorbidities. Mini-open approach in supine repair may potentially avoid the risks of the prone position, but the safety and utility of this approach have not been established. The purpose of this study is to compare perioperative outcomes between patients undergoing acute Achilles rupture repair with mini-open approach in the supine position versus traditional approach in the prone position.Methods:Patients who underwent surgical repair of acute Achilles rupture between the years 2011 and 2018 at a single institution were retrospectively identified using CPT code 27650. Patients who underwent concurrent procedures for additional injuries were excluded. Charts of included patients were retrospectively reviewed for demographic information, intraoperative characteristics, and postoperative outcomes. Statistical analysis was conducted and p-values =0.05 were considered significant.Results:A total of 81 patients were included for analysis, 26 supine and 55 prone. Baseline characteristics were statistically similar between the two groups. Average total time in the operating room was significantly greater among patients in the prone position (118.7 minutes) than those in the supine position (100 minutes) (p = 0.0011). Average surgery time, blood loss, and time in PACU were greater among the prone group than the supine group, although these differences were not statistically significant. Average postoperative pain score, infection rate, dehiscence rate, sepsis rate, and DVT rate were also similar between the two groups.Conclusion:The mini open approach in supine position may be advantageous in repair of acute Achilles rupture in that it significantly reduces total time in the operating room while maintaining positive patient outcomes. Prospective clinical studies are warranted to validate these assessments.