Background Infusion Research Articles

The impact of pre-rehydration guided by carotid corrected flow time on hypotension prevention following general anesthesia induction in patients undergoing gastrointestinal surgery: a prospective randomized controlled trial.

Patients undergoing gastrointestinal surgery often experience hypotension following general anesthesia induction due to insufficient volume. This study aimed to assess whether pre-rehydration guided by carotid corrected flow time (FTc) could mitigate post-induction hypotension induced by general anesthesia. Patients undergoing resection of gastrointestinal tumors were assigned to either the conventional treatment group (Group C) or the fluid treatment group based on FTc (Group F). Within Group F, patients were further divided into Group A (carotid FTc <340.7 ms) and Group B (carotid FTc ≥340.7 ms) based on pre-rehydration carotid FTc values. Group A patients received pre-rehydration with 250 mL of colloids (hydroxyethyl starch-HES) administered within 15 min until carotid FTc reached ≥340.7 ms to counteract hypovolemia prior to induction. Patients in Group B and Group C received a continuous HES infusion at a rate of 6 mL/kg/h 30 min before induction to compensate for physiological fluid loss. All patients received a perioperative background infusion of 3 mL/kg/h compound sodium chloride, with infusion rates optimized based on mean arterial pressure (MAP) and heart rate (HR). The incidence of post-induction hypotension was compared between Group C and Group F, as well as between Group A and Group B. The incidence of hypotension after induction was significantly lower in Group F compared to Group C (26.4% vs. 46.7%, respectively; p < 0.001). Patients in Group A received significantly more pre-rehydration, leading to a greater increase in carotid FTc values compared to Group B (336.5 ± 64.5 vs. 174.3 ± 34.1 ms, p = 0.002). However, no significant difference in carotid FTc values after pre-rehydration was observed between the groups. There was no significant difference in the incidence of hypotension after general anesthesia induction between Group A and Group B (22.9% vs. 28.8%, p = 0.535). Pre-rehydration based on FTc can effectively reduce the occurrence of post-induction hypotension in patients undergoing gastrointestinal surgery who present with insufficient volume. https://www.chictr.org.cn/showprojEN.html?proj=201481.

A double-blinded randomised controlled study of fluid restriction versus liberal fluid during induction of labour: A pilot study.

Excess intravenous fluid for women requiring an induction of labour may adversely affect the duration of labour and maternal/neonatal outcomes. This study aimed to determine the difference in duration of labour and outcomes with a low background infusion rate, compared to liberal background intravenous fluid management. A double blind randomised controlled pilot study was performed on 200 women who underwent induction of labour at a single institution. Women were randomised to an intravenous rate of 40 mL/h versus 250 mL/h of Hartmann's solution. Fluid boluses were strictly controlled to limit bias. This trial was registered with the Australian clinical trial registry: ACTRN12621001298808. Analysis of the total amount of fluid received showed good separation with Group 1 (40 mL/h) receiving 1,736 mL less than Group 2 (250 mL/h), median (interquartile range) 841 mL (458, 1691) versus 2,577 mL (1620, 4326) (P < 0.001). Median duration of labour was shorter in Group 1 by 24 min (P = ns). Subset analysis of nulliparous women showed that duration of labour was shorter in Group 1 by 83.5 min (P = ns). As this was a pilot study, a significant difference in duration of labour or secondary outcomes was not seen. Given the increasing numbers of nulliparous women having an induction of labour, potential for adverse maternal and neonatal outcomes and the associated higher rate of operative birth, this study guides power calculations and supports proof of concept for future research into optimum fluid management during induction of labour for these women.

Enhancing pain control in elbow rehabilitation; A case report of variable ropivacaine dosages through Brachial Plexus Catheter

Managing postoperative pain and discomfort during physiotherapy for upper arm injuries, including complex fractures or traumatic amputations, is crucial. Challenges include severe pain, stiffness, and limited range of motion. Physiotherapy is vital for preventing muscle atrophy, promoting joint mobility, and facilitating functional recovery.The successful management of postoperative pain and pain during physiotherapy in a 27-year-old female, who sustained multiple injuries including a displaced distal humerus fracture and a traumatic right-hand amputation, was achieved through the utilization of a continuous brachial plexus block with variable doses of ropivacaine. The patient’s history revealed a complex array of injuries, including a displaced distal humerus fracture and traumatic right-hand amputation, necessitating open reduction and internal fixation for the fracture and subsequent hand debridement. Despite addressing stiffness through capsulectomy, persistent concerns arose regarding postoperative pain and discomfort during physiotherapy sessions. To address these concerns, a continuous supraclavicular catheter was placed under ultrasound guidance, providing effective pain relief and facilitating physiotherapy interventions for optimal recovery. The patient underwent open reduction and internal fixation for the humerus fracture which was subsequently managed with amputation of several fingers and a hand debridement procedure. Following the surgeries, the patient complained of a stiff elbow, which was addressed through capsulectomy. However, concerns persisted regarding postoperative pain and pain during physiotherapy sessions, leading to the decision to place a continuous supraclavicular catheter. The catheter was accurately positioned under ultrasound guidance and tunneled under the skin, providing effective pain relief for seven days. Ropivacaine was administered as per the patient’s requirements, with a background infusion of 0.2% ropivacaine at 8-hour intervals, a 10 ml bolus of 0.2% ropivacaine administered half an hour before physiotherapy, and 10 ml of 0.5% ropivacaine during physiotherapy sessions if pain levels exceeded 4 on the numerical rating scale. This case highlights the utility of continuous brachial plexus blockade for prolonged postoperative analgesia and pain management during physiotherapy in patients with upper extremity injuries.

Safety and Efficacy of Ultrasound-Guided Combined Segmental Thoracic Spinal Epidural Anesthesia in Abdominal Surgeries and Laparoscopic Procedures: A Prospective Randomized Clinical Study.

Thoracic segmental spinal anesthesia (SA) may be a good alternative to general anesthesia (GA) for abdominal operations and laparoscopic procedures, especially in high-risk patients. The aim of this study was to investigate the safety and efficacy of thoracic segmental SA vs GA during abdominal operations and laparoscopic procedures. This study was conducted at our university hospital and involved a total of 46 patients who underwent abdominal operations and laparoscopic procedures. The study period spanned from January 15, 2022, to October 15, 2022. Patients were divided into 2 groups: Group 1 (n = 23) received standard GA, and group 2 (n = 23) received thoracic segmental SA. A combination of 10 mg of hyperbaric bupivacaine 0.5% and 25 μg of fentanyl was injected through the spinal needle. The epidural catheter was then threaded through the Tuohy needle after withdrawal of the spinal needle to keep only 4 cm up in the epidural space. Demographic data, both intra and postoperative hemodynamic parameters, were monitored. Postoperatively, pain in both groups was treated with intravenous (IV) morphine by patient controlled analgesia (PCA), PCA settings were 1 mg morphine/mL, no background infusion, bolus dose 2 mL and lockout interval 15 min. Postoperative, both resting VAS and VAS during cough were measured for all patients at fixed intervals, and all patients were followed up for postoperative complications. No significant variation was found in demographic data. Intra and postoperative mean arterial pressure (MAP) and heart rate (HR) measurements were higher in group 1 than in group 2 but without a statistically significant difference (P < 0.029). Early postoperative VAS values and discharge time from the postanesthesia care unit (PACU) were significantly reduced in group 2 than in group 1 (P < 0.001). The number of patients asked for analgesia and total opioid consumption were substantially reduced in group 2 than in group 1. Also, the time of the first analgesia request and patient satisfaction were substantially greater in group 2 than in group 1. Combined thoracic spinal/epidural block results in stable hemodynamics, longer postoperative analgesia with fewer side effects, and greater surgeon and patient satisfaction in patients undergoing abdominal operations and laparoscopic procedures.

Incidence of Hemidiaphragmatic Paralysis After Ultrasound Guided Low Dose Interscalene Brachial Plexus Block

Background and Aims: Hemidiaphragmatic paralysis is a complication of single shot and continuous interscalene brachial plexus block that can be minimised by ultrasound guided extra fascial catheter placements and by limiting the amount of local anaesthetic administered. In this study, we report incidence of hemidiaphragmatic paralysis with patient-controlled infusion of low volume of ropivacaine after ultrasound guided low dose interscalene brachial plexus block (LD-ISB). Methods: Patients aged 18-65 years undergoing surgery for shoulder dislocation or proximal humerus fracture were recruited and administered general anaesthesia. Before extubation ultrasound guided LD-ISB (10 ml of 0.5% ropivacaine) was administered and a catheter tunneled so that patient controlled interscalene analgesia (PCIA) could be given with low volume ropivacaine. PCIA was initiated after four hours in the post operative recovery to deliver background infusion of 2 ml/h, bolus of 5ml (0.2% of ropivacaine) with lockout interval of 30 minutes for a total duration of 24 hours. Incidence of hemidiaphragmatic paralysis was recorded at extubation using M-mode ultrasonography. Before start of PCIA i.e. at 4 hours and after start of PCIA i.e. 6,12 and 24 h after extubation. Results: PCIA after LD-ISB was administered to 29 patients. Subsequently, two patients were excluded due to catheter dislodgement. The incidence of complete and partial paresis of diaphragm after extubation was 85% and 3.7% with LD-ISB respectively but was resolved before start of PCIA i.e., at 4 hours. Thus, at time of commencement of PCIA all patients had normal diaphragmatic excursions and subsequently at 6,12 and 24 h no paresis/paralysis was reported in patients administered only the background infusion or an additional single bolus dose of ropivacaine with the background infusion. Partial paresis was noted in all patients in which two bolus doses/h were administered. All patients with paresis had diaphragmatic excursion normalised in the next recording made at 4 hours and no complication was reported in any patient. VAS (Visual Analog Scale) was below 3 at all time points. Conclusion: Partial/complete paresis after a single shot injection of 10 ml of 0.5% ropivacaine resolves in 4 hours. PCIA initiated after it for subsequent 20 hours with a single bolus dose of 5ml of 0.2% ropivacaine and background infusion at 2 ml/h does not cause phrenic paresis. Partial paresis is reported with two bolus doses/h, but it is clinically asymptomatic. Thus, the above dose regimes are safe and effective in managing post-operative pain. Keywords: Interscalene block, Diaphragmatic paresis, Ropivacaine, continuous infusion, Analgesic efficacy

The Efficacy of Low-Dose Esketamine and Butorphanol in Treating Depression and Pain After Cesarean Section

Objective: To explore the efficacy of combining low-dose esketamine with butorphanol in treating depression and pain following cesarean section. Methods: 100 cases of elective cesarean section were selected and randomly assigned into two groups in a 1:1 ratio. All parturients who fulfilled the inclusion criteria received spinal anesthesia, maintaining the anesthesia level at T6. In the esketamine group, the dosage regimen comprised esketamine 0.5 mg/kg and butorphanol 10 mg, diluted with 0.9% sodium chloride injection to 100 mL. The control group received butorphanol 10 mg, diluted similarly. Analgesia in both groups commenced after cutting the umbilical cord, with a loading volume of 2 mL, a background infusion dose set to 2 mL/h, and patient-controlled analgesia at 2 mL with an effective interval time of 30 minutes. The main indicators included the maternal burnout scale (MBS) and numerical rating scale (NRS) for pain to assess postpartum depression and pain after surgery. Results: No significant differences were observed in MBS scores between the two groups on postoperative days 1 to 9 (P &gt; 0.05). Postpartum depression was not detected in either group. Pain NRS scores at 24 and 48 hours after surgery, including incision and uterine contraction pain, showed no significant differences between the two groups (P &gt; 0.05). Tramadol rescue was not administered to any patients in either group. Additionally, no adverse reactions requiring drug intervention occurred in either group. Conclusion: This study concluded that the combination of low-dose esketamine with butorphanol did not further optimize the analgesic effect of butorphanol but significantly improved postpartum depression after cesarean section. Further research is needed to investigate the impact of the ketamine postoperative analgesia regimen on postpartum analgesia and depression.

Risk factors for discontinuation of intravenous patient-controlled analgesia after general surgery: a retrospective cohort study

Identifying patients at risk for developing side effects secondary to intravenous patient-controlled analgesia (IV PCA) and making the necessary adjustments in pain management are crucial. We investigated the risk factors of discontinuing IV PCA due to side effects following general surgery; adult patients who received IV PCA after general surgery (2020–2022) were included. Data on postoperative pain intensity, PCA pain relief, side effects, continuity of PCA use, and PCA pump settings were collected from the records of the acute pain management team. The primary outcome was identifying the risk factors associated with PCA discontinuation due to side effects. Of the 8745 patients included, 94.95% used opioid-containing PCA, and 5.05% used non-steroidal anti-inflammatory drug (NSAID)-only PCA; 600 patients discontinued PCA due to side effects. Female sex (adjusted odds ratio [aOR] 3.31, 95% confidence interval [CI] 2.74–4.01), hepato-pancreatic-biliary surgery (aOR 1.43, 95% CI 1.06–1.94) and background infusion of PCA (aOR 1.42, 95% CI 1.04, 1.94) were associated with an increased likelihood of PCA discontinuation. Preoperative opioid use (aOR 0.49, 95% CI 0.28–0.85) was linked with a decreased likelihood of PCA discontinuation. These findings highlight the importance of individualized pain management, considering patient characteristics and surgical procedures.

Effect of oxycodone combined with ultrasound-guided thoracic paravertebral nerve block on postoperative analgesia in patients with lung cancer undergoing thoracoscopic surgery: protocol for a randomised controlled study

IntroductionPostoperative pain is a main component influencing the recovery of patients with lung cancer. The combination of patient-controlled intravenous analgesia (PCIA) and paravertebral nerve block for postoperative analgesia in patients...

Effect of postoperative application of esketamine on postoperative depression and postoperative analgesia in patients undergoing pancreatoduodenectomy: a randomized controlled trial protocol

BackgroundPancreatoduodenectomy (PD) is traumatic, difficult to perform, and has a high incidence of postoperative complications and perioperative mortality. Postoperative complications and pain occur frequently and seriously affect the psychological status of patients. Esketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, has analgesic and antidepressant effects. In this study, we aim to investigate the effect of esketamine on postoperative depression and pain in patients undergoing PD.Methods/designThis prospective, single-center, randomized control trial will include 80 patients who will undergo elective PD. The patients will be randomly assigned to two groups: the experimental group that will receive esketamine (n = 40) and the control group (n = 40). In the esketamine group, the analgesic pump will be connected immediately after surgery. A solution of esketamine 1.5 mg/kg + sufentanil 2 µg/kg, diluted to 150 mL, will be administered continuously for 72 h at the background infusion and impact doses of 1 mL/h and 2 mL/time, respectively; the locking time will be 10 min. The control group will receive sufentanil 2 µg/kg that will be administered as per the esketamine group. The primary outcome will be the Hamilton Depression Scale (HAMD-17) score on the third day post-surgery (POD3). Secondary study indicators will include (1) visual analog scale (VAS) score and HAMD-17 score prior to surgery, immediately after entering the postanesthesia care unit (PACU) and 1, 2, 3, 4, and 5 days after surgery; (2) Richmond Agitation-Sedation Scale (RASS) score at 1, 2, 3, 4, and 5 days after surgery; (3) consumed doses of sufentanil and esketamine after surgery; (4) postoperative analgesia pump effective press times, rescue analgesia times, and rescue drug dosage, recording the number of rescue analgesia and rescue drug dosage at 6, 24, 48, and 72 h after the patient enters the PACU; (5) postoperative complications and adverse events; (6) postoperative hospital stay; (7) concentrations of brain-derived neurotrophic factor (BDNP), 5-hydroxytryptamine (5-HT), tumor necrosis factor (TNF-α) and interleukin-6, at 1, 3, and, 5 days post-surgery; and (8) the patient survival rate at 6 and 12 months post-surgery.DiscussionThe study hypothesis is that the postoperative HAMD-17 and VAS scores, incidence of postoperative adverse reactions, and concentration of serum markers BDNP, 5-HT, TNF-α, and IL-6 in the experimental group will be lower than those in the control group.Trial registrationClinicalTrials.gov ChiCTR2200066303. Registered on November 30, 2022.Protocol version: 1.0

Postoperative infusion of dexmedetomidine via intravenous patient-controlled analgesia for prevention of postoperative delirium in elderly patients undergoing surgery

BackgroundPostoperative delirium (POD) is a common clinical complication in elderly patients after surgery and predicts poor outcomes.AimWe researched whether postoperative infusion of dexmedetomidine (DEX) had prophylactic effect on POD in elderly patients.MethodsA total of 236 patients over the age of 60 years undergoing thoracoabdominal tumor surgery were enrolled in Zhejiang Cancer Hospital from November 2016 to October 2020. The patients were randomly assigned into DEX group (group D) and control group (Group C). DEX was provided via PCIA pump 1–3 days after surgery, which consisted of 3 ug/kg sufentanil and 3 ug/kg DEX in group D, and 3 ug/kg sufentanil without DEX in group C. The PCIA parameters were programmed as follows: total amount 150 ml, 2 ml bolus dose with a lock-out of 10 min and background infusion rate 2 ml/h. The primary endpoint was the incidence of POD, assessed twice daily within 7 days after surgery by Richmond Agitation-Sedation Scale (RASS) and the Confusion Assessment Method–Intensive Care Unit (CAM-ICU). The secondary endpoint was postoperative hospitalization days, ICU stay time, adverse events and non-delirium complications.ResultsThe incidence of POD in all patients was 7%. The incidence of POD in group C was significantly higher than that in group D (10.1% vs 3.4%, P = 0.042). There were no significant differences in length of hospital stay after operation, ICU stay time, the percentage of patients discharged within 7 days after surgery, non-delirium complications, and 30-day all-cause deaths between the two groups. The incidence of hypertension in group D was lower than that in group C (P = 0.003), and there were no differences in other adverse events.ConclusionPatients aged over 60 years received DEX in addition to intravenous patient-controlled analgesia (PCIA) for major thoracoabdominal surgery experienced less delirium.

High-volume patient-controlled epidural vs. programmed intermittent epidural bolus for labour analgesia: a randomised controlled study.

The aim of neuraxial analgesia is to achieve excellent pain relief with the fewest adverse effects. The most recently introduced technique for epidural analgesia maintenance is the programmed intermittent epidural bolus. In a recent study, we compared this with patient-controlled epidural analgesia without a background infusion and found that a programmed intermittent epidural bolus was associated with less breakthrough pain, lower pain scores, higher local anaesthetic consumption and comparable motor block. However, we had compared 10 ml programmed intermittent epidural boluses with 5 ml patient-controlled epidural analgesia boluses. To overcome this potential limitation, we designed a randomised, multicentre non-inferiority trial using 10 ml boluses in each group. The primary outcome was the incidence of breakthrough pain and total analgesic intake. Secondary outcomes included motor block; pain scores; patient satisfaction; and obstetric and neonatal outcomes. The trial was considered positive if two endpoints were met: non-inferiority of patient-controlled epidural analgesia with respect to breakthrough pain; and superiority of patient-controlled epidural analgesia with respect to local anaesthetic consumption. A total of 360 nulliparous women were allocated randomly to patient-controlled epidural analgesia-only or programmed intermittent epidural bolus groups. The patient-controlled group received 10 ml boluses of ropivacaine 0.12% with sufentanil 0.75 μg.ml-1 ; the programmed intermittent group received 10 ml boluses supplemented by 5 ml patient-controlled boluses. The lockout period was 30 min in each group and the maximum allowed hourly local anaesthetic/opioid consumption was identical between the groups.Breakthrough pain was similar between groups (11.2% patient controlled vs. 10.8% programmed intermittent, p = 0.003 for non-inferiority). Total ropivacaine consumption was lower in the PCEA-group (mean difference 15.3 mg, p < 0.001). Motor block, patient satisfaction scores and maternal and neonatal outcomes were similar across both groups. In conclusion, patient-controlled epidural analgesia is non-inferior to programmed intermittent epidural bolus if equal volumes of patient-controlled epidural analgesia are used to maintain labour analgesia and superior with respect to local anaesthetic consumption.

Influence of fentanyl-based Patient-Controlled Intravenous Analgesia (PCIA) with and without background infusion on postoperative pain intensity in patients following total hip replacement

ABSTRACT Objective The goal of this trial was to determine if fentanyl PCIA and background infusion are effective for post-total hip replacement analgesia. Methods This trial examined two groups of patients receiving PCIA who had total hip replacements: group A (n = 35) with no background infusion, lockout time of 6 min; group B (n = 35) with background infusion 2 mL/h infusion, lockout time of 10 min. The fentanyl dose in each group was diluted with 100 mL normal saline. Primary outcome was VAS scores at rest after 24 hr. The secondary outcomes included VAS scores at rest at 6, 12, and 18 hr, fentanyl consumption, injection to attempt ratio, blood pressure, and heart rate. Results Neither background infusion nor no background infusion showed significant differences in VAS scores at 24 hr. Background infusion groups exhibited lower VAS pain levels at 6, 12, and 18 hr. At 24 hr after surgery, attempts, injections, and fentanyl consumption were significantly different between the two groups (P < 0.001). While BP and HR did not differ significantly between groups, pain control effectiveness showed statistically significant differences between groups. Conclusion Background infusion increased the overall quantity of fentanyl consumed within 24 hr after total hip replacement. The background infusion considerably decreased the pain at 6, 12, and 18 hr, but it had little effect on hip replacement pain at 24 hr. Importantly, it did not increase the incidence of BP, and HR. However, there were no significant differences in BP or HR between both groups, Fentanyl Background infusion was effective for post-total hip replacement analgesia.

Algorithm for evaluating ophthalmic artery pseudo-occlusion during intra-arterial chemotherapy for retinoblastoma.

Intra-arterial chemotherapy infusion for retinoblastoma is typically performed via selective catheterization of the ophthalmic artery. Anastomoses between the external carotid and the ophthalmic arteries have also been utilized when the ophthalmic artery cannot be catheterized directly. However, these are not present in every patient. A 10-month-old boy presented with bilateral retinoblastoma and underwent one round of intra-arterial chemotherapy (IAC) via direct catheterization of the ophthalmic arteries. Combined with adjuvant laser therapy, they experienced symptomatic improvement and tumour regression. However, during subsequent treatment sessions both ophthalmic arteries did not have anterograde flow and attempts to catheterize their origin were unsuccessful. Unfortunately, no targetable anastomoses between the external carotid and ophthalmic arteries were identified for drug delivery. Due to the patient's anatomy, balloon occlusion of the ECA was felt to be unsafe. As a salvage technique, a balloon was inflated in the left internal carotid artery (ICA) distal to the ophthalmic take-off to redirect flow into the ophthalmic. Repeat angiography with the distal ICA occluded showed improved flow into the ipsilateral ophthalmic artery. IAC was then successfully delivered through the left ICA. This case illustrates the importance of utilizing creative endovascular techniques for targeted intra-arterial drug delivery when other conventional measures fail as these patients often have limited, and potentially higher risk, therapeutic alternatives.

High Dosage of Patient-Controlled Epidural Analgesia (PCEA) with Low Background Infusion during Labor: A Randomized Controlled Trial.

Patient-controlled epidural analgesia (PCEA) is well documented; however, it is unclear whether a high dosage of PCEA with a low dosage of background infusion during labor can be a safe and effective application. Group LH was administered a continuous infusion (CI) of 0.084 mL/kg/h with PCEA of 5 mL every 40 min. Group HL was given a CI of 0.028 mL/kg/h and PCEA of 10 mL every 40 min; Group HH was given a CI of 0.084 mL/kg/h and PCEA of 10 mL every 40 min. The primary outcomes were VAS pain score, the number of supplemental boluses, incidence of pain outbreaks, drug dose for pain outbreaks, PCA times, effective PCA times, anesthetic consumption, duration of analgesia, duration of labor and delivery outcome. Secondary outcomes included adverse reactions such as itching, nausea and vomiting during analgesia and neonatal Apgar scores 1 min and 5 min after birth. A total of 180 patients, 60 in each group were randomly assigned to one of three groups included group LH, group HL or group HH. The VAS scores were obviously decreased in HL group and HH group in comparison with LL group at 2 h after analgesia and the time point of full cervical dilation and delivery of baby. The time for third stage of labor in HH group was increased compared with LH group and HL group. Incidence of pain outbreaks in LH group was obviously increased compared with HL and HH group. The effective PCA times in HL group and HH group were remarkably reduced compared with those in LH group. High dose of PCEA with a low background infusion can reduce effective PCA times, incidence of outbreak pain and the total amount of anesthetics without diminishing analgesia effects. However, high dose of PCEA with a high background infusion can enhance analgesia effect but increase the third stage of labor, instrumental delivery ratio and the total amount of anesthetics.

The optimal dose of oxycodone in PCIA after laparoscopic surgery for gastrointestinal cancer in elderly patients: A randomized controlled trial.

To explore the optimal bolus dose of oxycodone for patient controlled intravenous analgesia (PCIA) without background dose in elderly patients after laparoscopic surgery for gastrointestinal cancer. In this prospective, randomized, double-blind, parallel-controlled study, we recruited patients aged 65 years or older. They underwent laparoscopic resection for gastrointestinal cancer and received PCIA after surgery. Eligible patients were randomly divided into 0.01, 0.02, or 0.03 mg/kg group according to the bolus dose of oxycodone in PCIA. The primary outcome was VAS scores of pain on mobilization at 48 h after surgery. Secondary endpoints included the VAS scores of rest pain, the total and effective numbers of press in PCIA, cumulative dose of oxycodone used in PCIA, the incidence of nausea, vomiting and dizziness, as well as patients' satisfaction at 48 h after surgery. A total of 166 patients were recruited and randomly assigned to receive a bolus dose of 0.01 mg/kg (n = 55), 0.02 mg/kg (n = 56) or 0.03 mg/kg (n = 55) of oxycodone in PCIA. The VAS scores of pain on mobilization, the total and effective numbers of press in PCIA in 0.02 mg/kg group and 0.03 mg/kg group were lower than those in 0.01 mg/kg group (P < 0.05). Cumulative dose of oxycodone used in PCIA and patients' satisfaction in 0.02 and 0.03 mg/kg groups were more than those in 0.01 mg/kg group (P < 0.01). The incidence of dizziness in 0.01 and 0.02 mg/kg groups was lower than that in 0.03 mg/kg group (P < 0.01). There were no significant differences in VAS scores of rest pain, the incidence of nausea and vomiting among three groups (P > 0.05). For elderly patients undergoing laparoscopic surgery for gastrointestinal cancer, 0.02 mg/kg bolus dose of oxycodone in PCIA without background infusion may be a better choice.

Intravenous Low Dose (4 mg) Dexamethasone as an Adjunct to Epidural Labour Analgesia with 0.125% Ropivacaine in Parturients: A Randomised Controlled Study

Introduction: Labour pain is one of the most severe pains, and the mother’s demand is reason enough for the induction of labour analgesia, provided that no contraindications exist. Labour analgesia must be safe for both the mother and the child. Aim: To assess the impact of a low dose (4 mg) of intravenous (IV) dexamethasone used in conjunction with neuraxial labour analgesia with 0.125% Ropivacaine. Materials and Methods: The present study was a doubleblinded randomised controlled study conducted at tertiary care hospital on 80 parturients classified as American Society of Anaesthesiologists (ASA) II. The parturients were over 18 years old, in their third trimester, carrying a single live foetus that was cephalic at 36 weeks of gestation, and whose cervical dilation was greater than 3 cm and who requested epidural analgesia. All parturients were randomly divided into two equal groups. Before receiving epidural analgesia, the dexamethasone group received 4 mg of IV dexamethasone in 50 mL of normal saline. Patients in the control group received only 50 mL of normal saline. After an initial bolus of 0.125% ropivacaine (8 mL given gradually over 5 minutes), all expectant mothers received a continuous background infusion of 0.125% ropivacaine at a rate of 5 mL/h, along with patient-controlled boluses of 5 mL of the same medication given with a lockout interval of 12 minutes using a Patient Controlled Epidural labour Analgesia (PCEA) pump through the epidural route. Yates continuity correction test (Chi-square test), Fisher’s exact test, and Fisher Freeman Halton were used to compare qualitative data. For categorical data, numbers and percentages were used to summarise all continuous variables as mean±SD. Results: Demographics such as age, height, weight, and preprocedure obstetric-related details were comparable in both groups. There was no statistically significant difference in the average hourly medication intake between the dexamethasone group and the control group (Group D-7.64±0.88 mL/hr and Group C-8.04±1.24 mL/hr, p-value=0.09). Other factors, including pain scores, haemodynamics, administration method, and side effects, did not differ significantly between the two groups. Conclusion: Despite having modest analgesic properties, IV dexamethasone could not significantly reduce the hourly average medication consumption of ropivacaine during epidural labour analgesia.

Patient-controlled analgesia in palliative care - Concepts and practical aspects

Patient-Controlled Analgesia (PCA) involving the use of on-demand subcutaneous or intravenous opioids offers patients greater autonomy in managing pain. In palliative situations, this method allows a continuous background infusion rate of opioids and allows a patient to self-administer a pre-set bolus dose of opioids. Indications for PCA are moderate to severe pain that is not relieved by 3rd level analgesics administered in oral ore transdermal route or by intermittent injections. PCA prescription, programming, initiation, and safety monitoring require the vigilance of a trained interdisciplinary team. PCA is safe and effective on hospice inpatients and outpatients and encourage their return or their stay at home.

Adjunctive use of Ketorolac for Postoperative Pain Management in Elective Cardiac Surgery Patients: A Randomized Control Trial

Objective: To compare between the efficacy of Ketorolac and Paracetamol in the management of post-operative pain following elective cardiac surgery.&#x0D; Study Design: Randomized (single-blind) Control Trial (RCT NCT05361824.) &#x0D; Place and Duration of Study: This study was conducted in the Surgical Intensive Care Unit (SICU) at the National Institute of Cardiovascular Diseases Hospital, Karachi Pakistan, From 1st Jan to 30th Jun 2021.&#x0D; Methodology: Randomization of 60 patients undergoing elective cardiac surgery into either Paracetamol (30 control patients) or Ketorolac (30 treatment patients) was done.In addition, to a low dose, short duration background infusion of Nalbuphine, the control group was administered. Injection Paracetamol 1gm every six-hours. Whereas the treatment group was administered injection Ketorolac 30mg every eight-hours. Assessment of pain was done at 6, 12, 18 and 24 hours post-extubation, using a Visual analog scale (VAS). For the purpose of this study, a score of 4 or less was taken as a cut-off for adequate pain control.&#x0D; Results: VAS score was significantly lower in Ketorolac group as compared to the Paracetamol group at all four-time points with an average rating of 3.2±1.9 vs. 5.3±1.7; p&lt;0.001, 3.5±1.5 vs. 5±1.7; p&lt;0.001, 3.3±1 vs. 5.0±1.4; p&lt;0.001, and 3.0±1.4 vs. 4.3±1.6; p&lt;0.001 at 6, 12, 18, and 24 hours respectively. The total dose of Nalbuphine administered (infusion + bolus doses) over 48 hours post-operatively was 15.3±5.2 vs 25.7±6.8 ml; p&lt;0.001 in the Ketorolac and Paracetamol groups, respectively.&#x0D; Conclusion: The use of Ketorolac in conjunction with Nalbuphine gives better control over post-operative pain in elective cardiac surgeries than Paracetamol and Nalbuphine.

Bilateral ultrasound-guided erector spinae plane block versus wound infiltration for postoperative analgesia in lumbar spinal fusion surgery: a randomized controlled trial

PurposeBoth erector spinae plane block and wound infiltration are used to improve analgesia following spinal fusion surgery. Herein, we compared the analgesic effect of bilateral erector spinae plane block with wound infiltration in this patient population.MethodsIn this randomized trial, 60 patients scheduled for elective open posterior lumbar interbody fusion surgery were randomized to receive either ultrasound-guided bilateral erector spinae plane block before incision (n = 30) or wound infiltration at the end of surgery (n = 30). Both groups received standardized general anesthesia and postoperative analgesia, including patient-controlled analgesia with sufentanil and no background infusion. Opioid consumption and pain intensity were assessed at 2, 6, 12, 24, and 48 h after surgery. The primary outcome was cumulative opioid consumption within 24 h after surgery.ResultsAll 60 patients were included in the intention-to-treat analysis. The equivalent dose of sufentanil consumption within 24 h was significantly lower in patients given erector spinae plane block (median 11 μg, interquartile range 5–16) than in those given wound infiltration (20 μg, 10 to 43; median difference − 10 μg, 95% CI − 18 to − 3, P = 0.007). The cumulative number of demanded PCA boluses was significantly lower with erector spinae plane block at 6 h (median difference − 2, 95% CI − 3 to 0, P = 0.006), 12 h (− 3, 95% CI − 6 to − 1, P = 0.002), and 24 h (− 5, 95% CI − 8 to − 2, P = 0.005) postoperatively. The proportion given rescue analgesia was also significantly lower in patients given erector spinae plane block group within 48 h (relative risk 0.27, 95% CI 0.07 to 0.96, P = 0.037). There were no statistical differences in pain intensity at any timepoints between groups. No procedure-related adverse events occurred.ConclusionsCompared with wound infiltration, bilateral ultrasound-guided erector spinae plane block decreases short-term opioid consumption while providing similar analgesia in patients following lumbar spinal fusion surgery.Chinese Clinical Trial Registry: ChiCTR2100053008.

Transplantation of Hematopoietic Stem and Progenitor Cells from Cadaveric Organ Donors Leads to Long-Term Multilineage Engraftment in NSG Mice

Background Infusion of Hematopoietic Stem and Progenitor Cells (HSPC) from cadaveric organ donors (CD) has been used anecdotally in the setting of allogeneic Hematopoietic Stem Cell transplants (HSCT) most commonly with the intention for induction of mixed hematopoietic chimerism and subsequent immunological tolerance. No systematic study has addressed the functional capacity of these cells for inducing long-term multi-lineage engraftment. Since the introduction of post-transplant Cyclophosphamide (PTCy) it has been possible to reliably overcome HLA barriers and achieve stable engraftment across extensively HLA-mismatched donor and recipient pairs. Banked HSPC from cadaveric donors may provide a new approach to expand the number of donors for HSCT. Usage of HSPC from bone marrow (BM) of banked cadaveric donors is viewed as no different than live donor aspirated marrow by the FDA but is not yet available on the registry. This emerging source could be of high importance to allow rapid on-demand access to transplants for patients who lack HSPC donors or induce stable mixed chimerism and immune tolerance in patients undergoing combined organ and BM transplantation. The objective of our studies was to investigate whether hCD34⁺HSC selected from cadaveric BM retain their capacity for long-term multi-lineage engraftment. Methods and Results We compared CD34⁺-selected HSPC obtained from CD and living donors (LD) regarding their in vitro and in vivo function and with particular focus on their ability to achieve long-term multi-lineage engraftment following transplantation into NSG mice. Bone marrow was recovered from vertebral bodies of CD and CD34⁺ selected. 5x10⁵ hCD34⁺ cells from 24 different CD were transplanted i.v. in to NSG or SGM3 mice (n=5 per donor) following 1Gy total body irradiation (TBI). Blood was drawn every two weeks, starting week 4 and human CD45⁺ chimerism was analyzed via flow cytometry. All donors engrafted successfully and robust long-term multi-lineage engraftment >16 weeks was seen in 19 out of 22 donors. To further investigate the long-term repopulating capacity, we performed secondary transplants. BM of 15 primary engrafted donors was harvested, hCD45⁺ were selected with immunobeads and transplanted into 1Gy irradiated NSG mice. Successful multi-lineage engraftment after secondary transfer was observed in 12 out of 15 donors in the peripheral blood (PB). Results of tissue engraftment are still outstanding for most experiments. So far they showed mean engraftment of human CD45⁺ cells of 6.16%+/-2.4% for donor 1 and 8.48%+/-0.74% for donor 2 in the BM. To compare CD and LD we set up two side-by-side transplantation experiments and intra-mouse competitive engraftment studies using HLA-mismatched donors. Using side-by-side experiments no significant difference in human CD45⁺ chimerism was detected in blood measured at weeks 6, 12 and 16 pos-transplant. The tissues showed a mean engraftment of human CD45⁺ cells of 87% +/- 9.6% vs 71% +/- 9.5% in spleen and 76% +/- 5.3% vs 78% +/- 4% (NS) in BM upon takedown 20 weeks post-transplant. For our competitive assays, we transplanted 2.5x10⁵ hCD34⁺ i.v. from LD and CD simultaneously into NSG mice (n=5 per donor pair) following 1Gy TBI. In total 8 CD and 3 LD were used, out of whom 4 CD reached higher engraftment than the LD. Conclusion Our data suggest that CD34+HSPC from CD retain their long-term multi-lineage engraftment capacity, reaching at least equipotent levels as HSPC from living donors. Based on our findings cadaveric bone marrow should be considered as HSPC source for HSCT.