Difference In Opioid Consumption Research Articles

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What's New in Sports Medicine.

Pectoral Nerve Blocks for Breast Augmentation Surgery: Comment

By a randomized, double-blind, dual-centered controlled trial in 73 adult female patients undergoing aesthetic breast augmentation surgery under general anesthesia, Aarab et al.1 showed that compared to multimodal analgesic regimen alone, pectoral nerve blocks combined with multimodal analgesia significantly improved postoperative pain control and decreased total opioid consumption over the first 5 postoperative days. In addition to the limitations described by the authors in the discussion, however, we note several issues in the results of this study that deserve further clarification.First, a numerical rating scale score of 3 or less is generally considered as satisfied pain control.2 In this study, other than 0.5 h after extubation, the mean numerical rating scale scores at other time points in the early postoperative period were 3 or less, indicating that most of patients have a satisfied pain control. Patient satisfaction was very good in both groups. In this case, it is difficult for readers to determine whether early postoperative pain control improved by adding pectoral nerve blocks to multimodal analgesia should be considered clinically important.Second, between-group differences in opioid consumption were of questionable clinical significance. Differences in milligram oral morphine equivalents were 3 mg in the first 6 h after extubation and 10.5 mg from 6 to 24 h postoperatively (total, 13.5 mg 0 to 24 h postoperatively, equivalent to about 4.5 mg of intravenous morphine).3 Although the recommendation of 10 mg of intravenous morphine equivalents per 24 h as the minimal clinically important difference was published4 well after the study by Aarab et al.1 was designed and performed, the 4.5-mg difference is nonetheless much less. In addition, the total between-group difference from postoperative days 1 through 5 was 21-mg oral morphine equivalents. Given that duration of pectoral nerve block is limited and the total between-group difference in oral morphine consumption was very small, we question the clinical value of this opioid sparing.Support was provided solely from institutional and/or departmental sources.The authors declare no competing interests.

Optimizing the use of liposomal bupivacaine in shoulder arthroplasty

BackgroundShoulder arthroplasty (SA) is the fastest growing joint replacement surgery in the United States, and it has been estimated that postoperative pain management is not adequately controlled in up to 80% of patients. Liposomal bupivacaine (LB) has been included as part of the multimodal pain management that has shown promise in reducing pain, narcotic consumption, and hospital length of stay in SAs, but there has been some controversy regarding its efficacy in the literature. This may be due to lack of standardization across studies in the utilization of LB or the lack of efficacy of local LB infiltration. The purpose of this study was to identify whether there is an optimal dilution of LB required for maximal analgesia after SA in order to direct future literature and increase the strength of evidence for recommendations in clinical practice. MethodsA retrospective review of prospectively collected data was conducted with patients undergoing primary SA categorized into 40 mL, 60 mL, or 80 mL dilutions of 20 mg of LB with 0.9% normal saline. Patient-reported pain scores and opioid consumption were collected at days 1, 3, 7, and 30 postoperatively. Dependence rates were reported and defined as three months of continuous opioid use. Opioid consumption was calculated using total morphine equivalents (TME), and an analysis of variance was performed to compare outcomes between groups. ResultsSeventy-four patients were identified and divided into one of three groups based on the dilution of LB received intraoperatively. There were significant differences in pain scores between the groups on day 7 postoperatively with the 80 mL group having significantly lowest pain scores (P = .012). No significant difference in opioid consumption was found between the groups during any time point. There was a trend toward fewer opioids over the study period in the 80 mL group relative to other groups. Overall, all dilution groups resulted in low TME and postoperative pain after the 30-day study period. ConclusionAll three dilution groups achieved excellent pain control and minimal opioid usage following SA. The 80 mL dilution group showed lower pain scores at day 7 postoperatively and trended toward less opioid consumption in the first 30 days. Our study suggests that, overall, orthopedic surgeons can consider using all three LB dilutions as an effective and safe option for pain management after an SA.

Thoracic Interfascial Plane Blocks and Outcomes After Minithoracotomy for Valve Surgery.

Introduction. Thoracic interfascial plane blocks are increasingly used for pain management after minimally invasive thoracotomy for valve repair and replacement procedures. We hypothesized that the addition of these blocks to the intercostal nerve block injected by the surgeon would further reduce pain scores and opioid utilization. Methods. In this retrospective cohort study, 400 consecutive patients who underwent minimally invasive thoracotomy for mitral or aortic valve replacement and were extubated within 2hours of surgery were enrolled. The maximum pain score and opioid utilization on the day of surgery and other outcome variables were compared between patients who received interfascial plane blocks and those who did not. Results.193 (48%) received at least one interfascial plane block while 207 (52%) received no interfascial plane block. Patients who received a thoracic interfascial plane block had a maximum VAS score on the day of surgery (mean 7.4 ± 2.5) after the block was administered which was significantly lower than patients in the control group who did not receive the block (mean 7.9 ± 2.2) (P = .02). Opioid consumption in the interfascial plane block group on the day of surgery was not significantly different from the control group. Conclusion. Compared to intercostal blocks alone, the addition of thoracic interfascial plane blocks was associated with a modest reduction in maximum VAS score on the day of surgery. However, no difference in opioid consumption was noted. Patients who received interfascial plane blocks also had decreased blood transfusion requirements and a shorter hospital length of stay.

Opioid consumption and pain in patients with gynecological cancer who underwent spinal anesthesia vs. general anesthesia for interstitial brachytherapy

AIMSInterstitial brachytherapy (ISBT) is an effective option for delivering conformal high dose radiation to the target volume with better organ-at risk sparing but is thought to be more invasive and painful than other methods. This study investigated pain levels and opioid consumption in patients who received spinal anesthesia (SA) or general anesthesia (GA) for their ISBT. MATERIALS AND METHODSPatients that underwent ISBT from April 2014 to September 2018 were analyzed from a prospective institutional database. The most prevalent malignancies were cervical (45%), recurrent endometrial (27%) and vaginal (20%) cancers. Baseline patient characteristics, radiation treatment details, anesthesia records, and inpatient charts were obtained. Opioid consumption was quantified as oral morphine equivalent per day (OMEq/day) from implantation until removal. Pain score levels were collected by using an 11-point scoring system. RESULTSNinety nine patients received GA and 40 patients received SA as their anesthesia for ISBT. During their first admission, 76 patients (55%) required intravenous opioids. Patients receiving SA had significantly lower mean pain scores on the morning of their procedure 6 (Interquartile range [IQR] 2–8) vs. 0 (IQR: 0–1); p < 0.001]. Pain did not significantly differ between cohorts at any other time. During the first admission, SA patients had a lower median opioid usage of 23 (IQR: 9–47) mg/day compared to GA patients at 38 (IQR: 21–71) mg/day (p = 0.011). No difference in opioid consumption was seen during subsequent admissions. CONCLUSIONSIn patients undergoing ISBT, SA provides better immediate pain control post insertion compared to GA. Patients who received SA used lower amounts of opioids during their first ISBT insertion.

Patient outcomes and adherence to an enhanced recovery pathway for open gynecologic surgery: a 6-year single-center experience

ObjectivesTo evaluate compliance with an Enhanced Recovery After Surgery (ERAS) protocol for open gynecologic surgery at a tertiary center and the relationship between levels of compliance and peri-operative outcomes.MethodsThis retrospective...

Lumbar Erector Spinae Plane Block for Total Hip Arthroplasty Comparing 24-Hour Opioid Requirements: A Randomized Controlled Study.

Design Prospective, randomized, controlled trial. Patients. Sixty-three adult patients with an American Society of Anesthesiologists Status I–III who are undergoing elective primary total hip arthroplasty. Interventions. Patients were randomized to the control group (no block) or the ESPB group (preoperative ultrasound-guided lumbar ESPB). Intraoperatively, all patients received spinal anesthesia with moderate sedation. Postoperatively, patients received a standardized multimodal analgesia protocol. Measurements. The primary outcome was cumulative opioid consumption at 24 hours postoperatively. Secondary outcomes included cumulative opioid consumption at 8 hours and through 48 hours postoperatively and pain scores at 24 and 48 hours post surgery. Main Results. Thirty-one patients were randomized to the control group (spinal alone) and 32 patients to the ESPB group. The median opioid requirement in the first 8 hours after surgery was higher in the control group (28 mg of oral morphine equivalents (OME) versus 5 mg of OME in the ESPB group) (p = 0.013). There was no statistically significant difference in opioid consumption between the groups at 24 hours (p = 0.153) or 48 hours (p = 0.357) postoperatively. There was no statistically significant difference in pain scores between the two groups through 24 hours (p = 0.143) or 48 hours (p = 0.617) after surgery. Conclusion Lumbar ESPB reduces opioid utilization during the first 8 hours postoperatively after total hip arthroplasty but not thereafter. Evaluating the use of either adding a local anesthetic adjunct to the ESPB or using longer-acting local anesthetic warrants further investigation.

Effect of introduction of routine single shot adductor canal block in primary total knee arthroplasty in a rural Australian setting.

There is a growing demand for quality osteoarthritis management available in Australia. There has been increasing emphasis on post-total knee replacement pain relief as a significant issue, especially in the context of postoperative recovery protocols which focus on early mobility. The aim of this study was to assess if the addition of adductor canal blocks (ACB) reduced postoperative pain and affected mobility post primary total knee arthroplasty (TKR) at Armidale Rural Referral Hospital (ARRH). A retrospective cohort study was performed of unilateral TKR patients before and after the addition of adductor canal blocks to the TKR protocol at ARRH. Forty-seven patients were included in the study who are matched for age and radiographic disease severity. All patients were prescribed post-operative analgesia per the protocol. Patients who received an ACB had a significant difference in opioid consumption in the first 24 h post-operative compared with those who did not, 115.90 mg oral morphine compared to 66.07 mg (P= 0.0001). This was also supported by a significant difference in patient self-rated numerical pain score between groups, no ACB group 3.09/10 and ACB group 1.05/10 (P= 0.0001). The ACB group were able to mobilize further on post-op days 1 and 2 than those who did not receive an ACB with the ACB group (P= 0.0001 and 0.0008). This adds to the evidence supporting the use of Adductor Canal Blocks in patients undergoing total knee arthroplasty, of especial significance in a rural population.

Bipolar Sealers and Tourniquet Use Have Similar Outcomes in Total Knee Arthroplasty.

The use of tourniquets and bipolar sealers are effective methods of hemostasis during total knee arthroplasty (TKA). However, their effect on perioperative patient outcomes is unknown. The purpose of this study is to compare the efficacy of tourniquet-less, tourniquet-less with use of a bipolar sealer, and tourniquet use on postoperative pain and surgical outcomes following TKA. A retrospective study of prospectively collected data of 120 primary TKA cases was conducted at an urban academic hospital. Primary outcomes were visual analog scale (VAS) scores and opioid consumption (in morphine milligram equivalents). Demographics, length of stay (LOS), perioperative complications, and change in Knee Injury and Osteoarthritis Outcome Score (ΔKOOS) were also collected. Patients were divided into cohorts based on the use of tourniquet-less with bipolar sealer (TRLB) (n = 40), tourniquet (TR) (n = 40), or tourniquet-less (TRL) (n = 40). There were no differences in demographic data between each cohort. TRLB, TR and TRL had similar LOS (2.68 ± 1.63 vs 2.29 ± 1.27 vs 2.36 ± 1.42days; p = 0.472) and VAS pain score on postoperative day 1 (4.68 vs 3.74 vs 3.63; p = 0.209). There were also no differences in opioid consumption at 2weeks (p = 0.903), 1month (p = 0.973), 3months (p = 0.983), or 5months (p = 0.983) post-operatively. TRLB and TR had comparable improvement in ΔKOOS from baseline to 12weeks post-operatively (Δ16.58 ± 8.47 vs Δ23.92 ± 14.60; p = 0.254). Compared to the ΔKOOS of TRL (Δ5.19 ± 2.59), TRLB and TR had clinically and statistically greater ΔKOOS improvements (p = 0.009; p = 0.001). The TRL cohort also had a higher readmission rate than TRLB and TR (15% vs 0% vs 5%, p = 0.025). Our findings demonstrate that both bipolar sealer and tourniquet use in TKA are associated with similar postoperative pain levels and LOS in comparison to tourniquet-less only TKA. However, bipolar sealer and tourniquet use may lead to better longer term improvement such as greater PRO score improvement and fewer readmissions.

Buccally Absorbed Cannabidiol Shows Significantly Superior Pain Control and Improved Satisfaction Immediately After Arthroscopic Rotator Cuff Repair: A Placebo-Controlled, Double-Blinded, Randomized Trial

Background: Despite the widespread use and sales of cannabidiol (CBD) products in the United States, there is a paucity of literature to evaluate its effectiveness, safety, or ideal route of administration for postoperative pain. Purpose: To evaluate the potential analgesic effects of buccally absorbed CBD in patients who have undergone arthroscopic rotator cuff repair (ARCR). Study Design: Randomized controlled trial; Level of evidence, 1. Methods: This was a US Food and Drug Administration–sanctioned, multicenter, placebo-controlled, randomized, double-blinded trial conducted in patients undergoing ARCR. Patients aged from 18 to 75 years undergoing ARCR were prospectively enrolled and randomized to the control and experimental groups. The experimental group received an oral, buccally absorbed tablet containing 25 mg of CBD 3 times a day if <80 kg, or 50 mg of CBD 3 times a day if >80 kg, for 14 days postoperatively, while the control group received an identical placebo. Patients were followed up on days 1, 2, 7, and 14, and visual analog scale (VAS) for pain scores, opioid consumption, and satisfaction with pain control were recorded. Additionally, liver function tests were conducted on days 7 and 14 to assess safety, and nausea was monitored. P < .05 was considered to be statistically significant. Results: Overall, 100 patients were recruited, with 1 patient being excluded, for a total of 99 patients. There were no significant differences in patient demographics between the 2 groups. On day 1, the VAS pain score was significantly lower in the CBD group than in the control group (4.4 ± 3.1 vs 5.7 ± 3.2, respectively; P = .04), although this difference was no longer present on day 2 (4.7 ± 2.8 vs 5.3 ± 2.6, respectively; P = .32). On both days 1 and 2, patient satisfaction with pain control was significantly higher in the CBD group than in the control group (day 1: 7.0 ± 3.0 vs 5.6 ± 3.7, respectively [P = .04]; day 2: 7.3 ± 2.5 vs 6.0 ± 3.3, respectively [P = .03]). The quantity of opioids consumed was low in both groups, and there were no statistically significant differences in opioid consumption (P > .05). On days 7 and 14, there were no statistically significant differences in VAS scores, opioid consumption, or patient satisfaction with pain control between the CBD and control groups (P > .05 for all). There were no significant differences in liver function test results postoperatively (P > .05). Conclusion: Buccally absorbed CBD demonstrated an acceptable safety profile and showed significant promise in the reduction of pain in the immediate perioperative period after ARCR compared with the control. Further studies are currently ongoing to confirm dosing and effectiveness in other orthopaedic conditions. Registration: NCT04672252 (ClinicalTrials.gov identifier).

The Effect of Preoperative Marijuana Use on Surgical Outcomes, Patient-Reported Outcomes, and Opioid Consumption Following Lumbar Fusion.

Retrospective Cohort Study. To (1) investigate the effect of marijuana use on surgical outcomes following lumbar fusion, (2) determine how marijuana use affects patient-reported outcomes measures (PROMs), and (3) determine if marijuana use impacts the quantity of opioids prescribed. Patients > 18years of age who underwent primary one- or two-level lumbar fusion with preoperative marijuana use at our institution were identified. A 3:1 propensity match incorporating patient demographics and procedure type was conducted to compare preoperative marijuana users to non-marijuana users. Patient demographics, surgical characteristics, surgical outcomes (90-day all-cause and 90-day surgical readmissions, reoperations, and revision surgeries), pre- and postoperative narcotic usage, and PROMs were compared between groups. Multivariate regression models were created to determine the effect of marijuana on surgical reoperations patient-reported outcomes (PROMs) 1-year postoperatively. Of the 259 included patients, 65 used marijuana preoperatively. Multivariate logistic regression analysis demonstrated that marijuana use (OR = 2.28, P = .041) significantly increased the likelihood of having a spine reoperation. No other surgical outcome was found to be significantly different between groups. Multivariate linear regression analysis showed that marijuana use was not significantly associated with changes in 1-year postoperative PROMs (all, P > .05). The quantity of pre- and postoperative opioids prescriptions was not significantly different between groups (all, P > .05). Preoperative marijuana use increased the likelihood of a spine reoperation for any indication following lumbar fusion, but it was not associated with 90-day all cause readmission, surgical readmission, the magnitude of improvement in PROMs, or differences in opioid consumption. III.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Impact of Timing of Targeted Muscle Reinnervation on Pain and Opioid Intake Following Major Limb Amputation.

Targeted muscle reinnervation (TMR) has been shown to play an important role in managing neuromas. However, the impact of the timing of TMR on pain visual analogue scale (VAS) scores or patient opioid use has not been thoroughly explored. We hypothesized that TMR performed acutely would lead to lower VAS scores and decreased opioid intake. Prospectively collected data from an amputation registry at a single institution were utilized to identify patients who underwent TMR. Acute TMR was defined as TMR performed within 1 month of the major limb amputation. Primary outcomes included VAS pain scores and patient-reported opioid consumption. In all, 25 patients (26 limbs) were identified in the acute group, and 18 patients (18 limbs) were identified in the delayed group. At intermediate follow-up (between 4 and 8 months postoperatively) and at final follow-up, the average pain VAS score in the delayed TMR group was significantly higher than that in the acute group (5.2 vs. 1.9 at intermediate P = .01 and 6.2 vs. 1.9 at final P = .002). In all, 84% of the amputees overall were not consuming opioid medications at the time of final follow-up (79% acute, 88% delayed, P = .72). There were no statistically significant differences in opioid consumption between the acute and delayed group at intermediate follow-up (P = .35) or at final follow-up (P = .68). TMR is an effective procedure to reduce pain following major limb amputation. Patients with TMR performed acutely had significantly lower VAS pain scores at both intermediate and final follow-up than patients with TMR performed in a delayed setting. Therapeutic II.

Paper 68: Cannabidiol is Effective in Improving Immediate Post-operative Pain and Patient Satisfaction Following Arthroscopic Rotator Cuff Repair: A Placebo-Controlled, Randomized, Double-Blinded Study

Objectives:The purpose of this study is to evaluate the potential analgesic effects of buccal-absorbed cannabidiol (CBD) in patients that have undergone arthroscopic rotator cuff repair (ARCR).Methods:This is an FDA sanctioned, multi-center, placebo-controlled, randomized, double-blinded trial conducted in patients undergoing ARCR. Patients from 18 to 75 years of age undergoing an ARCR were prospectively enrolled. Patients were equally randomized to the control and experimental groups. The experimental group post-operatively received 25mg of CBD (Oravexx, Orcosa Pharmaceuticals, USA) TID if < 80kg and 50mg of CBD TID if > 80kg for 14 days, with control groups receiving an identical placebo. Patients were followed-up on Day 1, 2, 7, and 14, and Visual Analog Scale (VAS) for pain, opioid consumption, and satisfaction with pain control were recorded. Additionally, liver function tests (LFT) were done on Days 7 and 14 to assess safety, and nausea was monitored. A priori power analysis was performed based on the VAS score as primary endpoint, which revealed that a minimum of 39 patients would be required in each group to detect a clinically important difference in the VAS score (1.4) with a power of 0.8. A value of p < 0.05 was considered to be statistically significant.Results:Overall, 80 patients were recruited. There were no significant differences in age, sex, or BMI between the two groups. On Day 1, VAS pain score was significantly lower in those receiving CBD (4.1 ± 3.0 vs 6.0 ± 3.1, p = 0.01), which also meets VAS MCID for shoulder arthroscopy (1.2-1.4). Patient satisfaction with pain control trended towards significance favoring the CBD group (72% vs 60%, p = 0.072). However, there were no statistically significant differences in opioid consumption (16.4mme ± 12.7 vs 20.6mme ± 14.4, p = 0.186), which was relatively small in both groups. Notably, patients receiving 50 mg of CBD reported lower VAS scores at day 1 (3.9 ± 3.3 vs 4.6 ±2.5 ± 6.0 ± 3.1, p = 0.0394) and higher satisfaction with pain control at day 1 and 2 (8.1 ± 2.3, 5.8 ± 3.3, 5.9 vs 3.6, p = 0.0175 | 7.8 ± 1.8 vs 6.3 ± 3.0 6.0 ± 3.2, p = 0.05) compared to those receiving 25 mg of CBD and control group respectively. On Day 7 and Day 14, there were no statistically significant differences in VAS score, opioid consumption, or patient satisfaction with pain control (p>0.05 for all). There were no significant differences in nausea or LFTs post-operatively (p > 0.05).Conclusions:CBD is safe and effective in reducing pain in the immediate peri-operative period following ARCR and should be considered in post-operative multimodal pain control.Table 1.Summary of Major Kinematic Effects for LMORT Lesions and Repairs

Local Infiltration Analgesia Versus Interscalene Block for Pain Management Following Shoulder Arthroplasty: A Prospective Randomized Clinical Trial.

While providing effective analgesia following shoulder arthroplasty, an interscalene block has known complications. Local infiltration analgesia (LIA) using ropivacaine has been successfully employed in other joint arthroplasties, but its efficacy in shoulder arthroplasty has not been studied extensively. The purpose of this study was to compare pain and opioid consumption between LIA and an interscalene block following shoulder arthroplasty. Patients undergoing primary shoulder arthroplasty were prospectively randomized into 2 groups: the block group received an interscalene block using liposomal bupivacaine, and the injection group received an LIA injection intraoperatively. The LIA injection included ropivacaine, epinephrine, ketorolac, and normal saline solution. Postoperative visual analog scale pain scores, opioid consumption in morphine milligram equivalents, and complications were compared between the groups. The mean pain scores during the first 24 hours postoperatively were used to test noninferiority of LIA compared with an interscalene block. The study included 74 patients (52 men and 22 women with a mean age of 69 years; 37 were in the injection group and 37 in the block group). There was no significant difference between the groups with respect to pain scores at any postoperative time points (p > 0.05), except for the 8-hour time point, when the injection group had a significantly higher pain score than the block group (p = 0.01). There was no significant difference in opioid consumption between the groups at any time points postoperatively (p > 0.05). The amount of intraoperative opioid consumption was significantly higher in the injection group (p < 0.001). In noninferiority testing for the mean pain scores during the first 24 hours, the injection group was found to be noninferior to the block group. One patient in the block group developed transient phrenic nerve palsy. One patient in the injection group developed dislocation after reverse arthroplasty related to noncompliance. The mean procedure hospital charge was $1,718 for an interscalene block and $157 for LIA. LIA and an interscalene block provided similar analgesia during the first 24 hours after primary shoulder arthroplasty. LIA was associated with worse pain at 8 hours postoperatively and more intraoperative opioid consumption but was also substantially less costly. Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Evaluation of Analgesic Efficacy and Opioid-sparing Effect of Duloxetine After Arthroscopic Rotator Cuff Repair: A Randomized Clinical Trial.

This study aimed to evaluate the analgesic efficacy and opioid-sparing effect of duloxetine in adults having arthroscopic rotator cuff repair, as well as its clinical safety. In this randomized trial, 120 adults having arthroscopic rotator repair were randomized to receive perioperative oral duloxetine or placebo. The primary outcome was patient self-reported pain score (Visual Analog Scale: 0 to 10) at rest and opioid consumption within postoperative 2 days. Other outcomes included adverse effects, changes of thromboelastogram, and hemoglobin indicators before and after the operation. A total of 120 patients were included in the intention-to-treat analysis, of which 60 received duloxetine and 60 received placebo. Groups were similar on the demographic, baseline, and intraoperative variables. There were significant differences in pain scores at rest at postoperative 3, 6, 12, 24, and 48 hours (3 h: P=0.001; 6 h: P=0.001; 12 h: P=0.001; 24 h: P=0.005; 48 h: P=0.034) and at movement at postoperative 6, 12, and 48 hours (6 h: P=0.004; 12 h: P=0.002; 48 h: P=0.033), while none of the differences met the minimum clinically important difference. There were no significant differences in opioid consumption and in hemoglobin and thromboelastogram before and after operation between the duloxetine group and the placebo group (all P>0.05). For adverse effects, the incidence of nausea and vomiting in the duloxetine group was significantly higher than that in the placebo group (P=0.018). For patients undergoing arthroscopic rotator cuff repairs, duloxetine resulted in a significant reduction in pain within postoperative 2 days, but the reduction was not clinically meaningful. Duloxetine did not decrease the opioid consumption within postoperative 2 days and did not increase the risk of bleeding within postoperative 2 days. The incidence of nausea and vomiting in the duloxetine group was significantly greater than that in the placebo group.

Impact on Postoperative Pain and Recovery of a Regional Analgesia Strategy Based on the Surgical Approach for Lung Resection: A Prospective Observational Study.

Various regional anesthesia (RA) techniques were shown to reduce pain after lung surgery, but controversies remain regarding the best technique to use to improve recovery. In this observational prospective study, the aim was to assess the efficacy of an RA strategy depending on the surgical approach. Patients who underwent lung surgery were included if an RA was planned following our unit procedure (erector spinae plane block (ESP) for video-assisted thoracic surgery (VATS) and thoracic epidural analgesia (TEA) or intrathecal analgesia (IA) for thoracotomy). Patients were compared according to the RA used. In total, 116 patients were included, 70 (60%), 32 (28%), 14 (12%) in the ESP, TEA and IA groups, respectively. Between Day 1 and Day 3, median NRS values were ≤4 at rest, and <50% patients experienced moderate-to-severe pain in each group. There were no significant differences in opioid consumption and in pain at rest or during chest physiotherapy on Days 1 and 2 between groups. However, patients who received an IA had lower NRS than other groups on Day 0 and 3 and a shorter length of hospital stay in comparison with those who received a TEA. Thus, in our institution, a strategy combining ESP for VATS and TEA, or IA for thoracotomy, allowed for effective analgesia after a lung resection. Interestingly, IA appeared to be more effective than TEA in reducing the length of hospital stay and pain on Day 0 and 3.

Clinical Efficacy of Perioperative Intravenous Dexmedetomidine and Lidocaine Combined Infusion for Thyroidectomy: A Prospective, Randomized, Double-Blind, Placebo-Controlled Trial.

The aim of this study was to evaluate the efficacy of perioperative dexmedetomidine (DEX) combined with lidocaine intravenous infusion on relieving postoperative pain and improving recovery for patients undergoing thyroidectomy. A total of 138 patients undergoing thyroidectomy with general anesthesia were randomly divided into 4 groups: lidocaine (1.5 mg/kg bolus followed by 2 mg/kg/h infusion) in the group L, DEX (0.5 µg/kg) in the group D, lidocaine (same as the group L) with DEX (0.5 µg/kg) in the group L+D, and placebo as normal saline in the group C. All drugs were infused until the end of the surgery. The visual analog scale (VAS) scores of patients at 1, 4, 8, 12, and 24 hours following surgery, opioid requirement, propofol consumption, incidence of postoperative nausea and vomiting, awaking time, hemodynamic variables, and any adverse effects were assessed. Compared with the group C, the VAS scores in the group L+D were significantly lower until 8 hours after surgery (P<0.05), while the VAS scores were significantly decreased just until 4 hours in the group L and 1 hour in the group D after surgery (P<0.05). There was no significant difference in opioid consumption between 4 groups. Propofol consumption in the group L+D was significantly lower than other groups (P<0.05). Compared with the group C, the incidence of postoperative nausea and vomiting in the group L+D was lower (P<0.05), and awaking time in the group L+D and the group L was shorter (P<0.05). DEX combined with lidocaine infusion can effectively attenuate the postoperative pain without any serious adverse events, which may improve postoperative recovery in patients undergoing thyroidectomy.

Glucocorticoid minimizes local anesthetic infusion requirement through adductor canal block and improves perioperative prosthetic joint range of motion in total knee arthroplasty.

IntroductionThe use of glucocorticoid as local anesthetic adjuvant in single-injection adductor canal block (ACB) is well-documented but its effects in the presence of an indwelling catheter is unclear. The purpose of this study was to determine the impacts of one-time perineural glucocorticoid injection on continuous adductor canal block in patients undergoing total knee arthroplasty.MethodsA single center retrospective study of 95 patients undergoing unilateral total knee arthroplasty (TKA) was performed. Patients were divided into three groups based on adjuvant received through ACB before continuous catheter placement: a control group with no adjuvant (N = 41), a treatment group with dexamethasone (DEX) as adjuvant (N = 33) and another treatment group with DEX/ Methylprednisolone acetate (MPA) as adjuvant (N = 21). The primary outcome was the amount of ropivacaine administered via patient controlled ACB catheter. Secondary outcomes included numeric pain score, perioperative opioid usage, immediately postoperative prosthetic knee joint active range of motion (AROM), opioid usage at 6 weeks and 3 months, length of stay and discharge disposition.ResultsPatients in both treatment groups demonstrated a statistically significant decrease in the requirement of self-administered ropivacaine than the control group on postoperative day (POD) 1 (p<0.001) and POD 2 (p<0.001). There was no significant difference in opioid consumption and pain scores between either treatment group vs. control. Compared to control (66%), more home disposition was observed in the DEX (88%, p = 0.028) and DEX/MPA group (95%, p = 0.011).ConclusionThis study suggested that single dose perineural glucocorticoid injection with DEX or DEX/MPA significantly decreased the dose of local anesthetic ropivacaine infusion required through continuous ACB for TKA while maintaining comparable level of pain score and opioid consumption, and significantly more patients were discharged home.

Comparison of Ultrasound Guided Interscalene Block vs Multimodal Analgesia in Shoulder Arthroscopic Surgeries- Prospective, Randomized Controlled Study

Introduction: Arthroscopic shoulder surgery is common and associated with severe postoperative pain. Interscalene block is recommended as a most effective method to relieve pain but it is also associated with some serious complications and expertise is required. This study assesses the efficacy, quality of analgesia postoperatively and overall satisfaction of patients undergoing shoulder arthroscopy by comparing ultrasound guided interscalene block with intraarticular morphine and local anaesthesia. Methods: This is prospective, single blind, randomized controlled study involving 46 patients randomized in ratio of 1:1 undergoing elective shoulder arthroscopy where GA was given in all patients out of which 23 received ISB before GA and 23 patients received intra articular injection of morphine and lignocaine at end of surgery. VAS score for postoperative pain, opioid consumption, PONV, patient satisfaction and readiness to discharge criteria was observed at 1, 4, 6, 12 and 24 hours post operatively in both groups. Results: In block group patient, VAS score was significantly low at 1 h and 6 h compared to non-block group. At 12 h both the group had a similar VAS score while at 24 h significantly high VAS score found in Block group patient. There was significant difference in opioid consumption in both groups. PONV, Complication rates, Satisfaction score and ready to discharge criteria were comparable in both groups. Conclusion: ISB provides effective analgesia in early postoperative period and it reduces the overall opioid requirement but the rebound pain which occurs after wearing off the block can reduce its overall benefit and satisfaction as compared to other modalities of multimodal analgesia. So, intra articular LA and opioid infiltration provides equivalent benefits in terms of post op analgesia and satisfaction.