Effective Pain Control Research Articles

HPB SO34 - Inter-fascial/Wound Catheter with Local Anaesthetic Infusion vs Thoracic Epidural Analgesia in Hepato-biliary Surgery (HILA) – A Retrospective Cohort Study

Abstract Background Thoracic epidural analgesia (TEA) offers effective pain control after open hepato-biliary surgery, however it is associated with several limitations that delay post-operative recovery. This study compared outcomes between inter-fascial/wound catheter with local anaesthetic infusion (IF/WC) and thoracic epidural analgesia (TEA) following open liver and biliary surgery in an enhanced recovery after surgery (ERAS) setting. Method Retrospective cohort data of all open liver and biliary surgery between August 2023 to February 2024 that used inter-fascial/wound catheter with local anaesthetic infusion (IF/WC) or thoracic epidural analgesia (TEA). Baseline characteristics were similar in the combined IF (n=17) and WC (n=7) group vs TEA (n=39) group. Technical failure rates were 12.5% in the IF/WC group vs 20.5% in the TEA group, p=0.509. Results Vasopressor requirement immediately post-surgery decreased by 32.7% in IF/WC vs TEA group [8.3% vs 41.0%, p=0.005], whereas none in the IF/WC group required vasopressor beyond 24 hours [0 vs 25.6%, p=0.010]. Length of critical care stay reduced by 1.5 days [1.79 vs 3.28 days; 95% CI 0.28-2.70, p=0.016] while length of hospital stay reduced by 2.6 days [5.79 vs 8.41 days; 95% CI 0.72-4.52, p=0.022] in the IF/WC vs TEA group. Admission cost reduced by £3941 per patient in the IF/WC vs TEA group [£10323 vs £14265; 95% CI 661-7222, p=0.019]. Conclusion Inter-fascial/wound catheter with local anaesthetic infusion (IF/WC) is an effective, safe and cost-saving alternative to thoracic epidural analgesia (TEA) with significant decrease in post-operative vasopressor requirements, and length of critical care and hospital stay.

VS 02 - HPB Inter-fascial Catheter with Local Anaesthetic Infusion in Hepato-biliary Surgery (HILA) – A Video Guide to Catheter Placement

Abstract Background Thoracic epidural analgesia (TEA) offers effective pain control after open hepato-biliary surgery, however it is associated with several limitations that delay post-operative recovery. Inter-fascial catheter with local anaesthetic infusion (IF) is an effective, safe and cost-saving alternative to thoracic epidural analgesia (TEA) following open liver and biliary surgery, with significant decrease in post-operative vasopressor requirements, and length of critical care and hospital stay. Method This video presentation outlines current clinical evidence with local data from Nottingham University Hospital, relevant clinical anatomy of the inter-fascial plane, intra-operative placement techniques, tips and tricks as well as troubleshooting in the event of a catheter related complication. Results The inter-fascial catheters can be placed in the transversus abdominis or posterior rectus plane based on the type of skin incision to achieve optimal post-operative pain control. It is associated with a low technical failure rate. Conclusion Inter-fascial catheter with local anaesthetic infusion is an effective, safe and cost-saving technique associated with significant decrease in post-operative vasopressor requirement, and length of critical care and hospital stay.

RADT-08. THIRD RECURRENT WHO 1 SPINAL MENINGIOMAS. CASE SERIES AND CLINICAL OUTCOMES FOLLOWING SURGERY OR DEFINITIVE RADIOTHERAPY

Abstract INTRODUCTION Spinal meningiomas (SM) account for approximately 1.2–12.7% of all meningiomas and 25% of spinal cord tumors. Most are benign (WHO grade 1), but a small percentage are atypical (WHO grade 2) or anaplastic (WHO grade 3). These tumors are typically solitary and non-invasive with low recurrence rates post-surgery. This study aims to compare the efficacy of definitive radiotherapy (RT) versus third surgery for recurrent SM WHO grade 1, focusing on local control, progression-free survival (PFS), and toxicity. METHODS A retrospective review approved by the Institutional Review Board included patients diagnosed with recurrent SM WHO grade 1 who underwent second surgery between 2008-2020. Patients who received radiation after the first surgery or upgraded to WHO grade 2 or 3 were excluded. Data on demographics, tumor characteristics, surgical techniques, and radiation therapy details were analyzed using descriptive and inferential statistics. RESULTS The study included 48 cases of third progression SM WHO grade 1. The median age was 53 years, and 70.8% were female. Tumor locations were primarily thoracic (75%). There was no significant difference in PFS between the third surgery and RT groups, with 36-month PFS rates of 77.4% and 76.4%, respectively. RT-related toxicities were manageable, and neurological improvements were noted in both groups, with more pronounced improvements in the surgical group. RT showed better pain control outcomes. CONCLUSION Both definitive RT and third surgery are effective for managing recurrent SM WHO grade 1, with comparable PFS. RT is a viable alternative, especially for high-risk surgical patients, providing effective pain control and manageable toxicities. Further studies with larger cohorts and longer follow-ups are recommended to validate these findings and refine treatment protocols for recurrent SM, ultimately improving patient outcomes and quality of life.

Perioperative Management of Opioid-Tolerant Patients: A Comprehensive Guide

The perioperative management of opioid-tolerant patients presents significant challenges, necessitating a tailored approach to pain management and the prevention of opioid-related complications. This review discusses the essential aspects of preoperative assessment, intraoperative strategies, and postoperative care for opioid-tolerant patients. Emphasis is placed on the continuation of baseline opioid therapy, the use of multimodal analgesia, and the importance of individualized opioid dosing to achieve effective pain control while minimizing the risk of withdrawal, respiratory depression, and opioid-induced hyperalgesia. The role of a multidisciplinary team in optimizing patient outcomes and the necessity of thorough discharge planning and follow-up are also highlighted. By addressing these critical factors, healthcare providers can ensure safe and effective perioperative care for opioid-tolerant patients.

The Effect of Ultrasound-Guided Erector Spinae Plane Block on Postoperative Opioid Consumption and Respiratory Recovery in Laparoscopic Sleeve Gastrectomy: A Randomized Controlled Study.

The aim of this prospective, randomized, controlled study was to evaluate the effect of ultrasound (US)-guided bilateral erector spinae plane (ESP) block on postoperative opioid consumption and respiratory recovery in patients with obesity undergoing laparoscopic sleeve gastrectomy (LSG). The study was conducted on 40 patients scheduled for LSG. The patients were randomly allocated into either the ESP block group or the control group. The US-guided bilateral ESP block was performed preoperatively. The control group received no intervention. Postoperative median [IQR] tramadol consumption was significantly lower in the ESP block group [150.0 [100-200] mg vs 450.0 [400-500] mg, p < 0.0001]. Postoperative spirometric variables were significantly impaired in both groups, compared with preoperative variables (p < 0.0001). Intraoperative median [IQR] fentanyl consumption was 200.0 [200-200] µg in the ESP block group, and 350.0 [300-400] µg in the control group (p < 0.0001). Postoperative mean pain scores at rest and during movement were significantly lower in the ESP block group, at all time points (p < 0.05). In terms of mean arterial PH, Horowitz ratio, and PaCO2, there was no statistically significant difference between the groups (p > 0.05). None of the patients experienced postoperative respiratory adverse events and/or block-related complications. US-guided bilateral ESP block significantly reduced both intraoperative and postoperative analgesic consumptions and provided effective postoperative pain control for patients with obesity undergoing bariatric surgery. Following bariatric surgery, all patients' postoperative pulmonary functions deteriorated. The effect of US-guided bilateral ESP block on postoperative respiratory recovery could not be clearly demonstrated. Randomized controlled studies with a larger patient population are necessary.

Comparison of ultrasound-guided fascia iliaca compartment block versus the combined obturator nerve and adductor canal block application in postoperative analgesia for patients undergoing arthroscopic knee surgery

Background: Arthroscopic knee surgery is a surgical intervention that is frequently performed by orthopedic clinics and new studies are constantly carried out by anesthetists to ensure effective pain control. This study aimed to compare the efficacy of ultrasound-guided suprainguinal fascia iliaca compartment block (FICB) versus the combined adductor canal and obturator nerve block application in terms of postoperative analgesia in patients undergoing arthroscopic knee surgery under spinal anesthesia.Materials and Method: Sixty patients, who underwent arthroscopic knee surgery under elective conditions were included in the study. They were randomly divided into two groups, Group 1 (n=30) and Group 2 (n=30), using a lottery method. Patients operated under spinal anesthesia received ultrasound-guided suprainguinal fascia iliaca compartment block (FICB) for Group 1. The combined adductor canal and obturator nerve block for Group 2 at the end of the surgery. Intravenous patient-controlled analgesia (PCA) device containing tramadol was connected to all patients in both groups, and they were evaluated for Visual Analog Scale (VAS) scores at 0, 2, 4, 12, and 24 hours of ward follow-up. The amount of PCA used at 24 hours, additional analgesic use, development of side effects, mobilization capabilities, and satisfaction levels were assessed at the end of 24 hours.Results: There were no significant differences between the groups in terms of demographic characteristics and the type of surgery performed (p&gt;0.05). In Group 1, where fascia iliaca block was applied the block administration time was observed to be significantly shorter compared to Group 2 (p&lt;0.05). No significant differences were observed between the two groups in terms of postoperative VAS scores, PCA usage amounts, incidence of side effects, postoperative mobilization abilities, and satisfaction measures (p&gt;0.05).Conclusions: Ultrasound-guided fascia iliaca compartment block alone can be effectively applied for postoperative analgesia in patients undergoing arthroscopic knee surgery, instead of combined adductor canal and obturator nerve block.

Is the Use of a Buprenorphine Transdermal Patch More Effective Than Oral Medications for Postoperative Analgesia After Arthroscopic Rotator Cuff Repair? A Randomized Clinical Trial.

Appropriate analgesic protocols for patients following arthroscopic rotator cuff repair remain controversial. Although transdermal buprenorphine patches might potentially provide better pain control and fewer side effects, it is worth noting that there is limited evidence for this given a lack of direct comparisons with oral pain regimens. Among patients undergoing arthroscopic rotator cuff repair, and compared with an analgesic approach using oral tramadol plus celecoxib: (1) Does perioperative use of buprenorphine patches provide better pain relief by a clinically important margin? (2) Does perioperative use of buprenorphine patches improve shoulder joint function recovery? (3) Does perioperative use of buprenorphine patches have a lower frequency of adverse reactions? This was a prospective, single-center, randomized controlled trial. We included patients who underwent arthroscopic rotator cuff repair for partial- or full-thickness rotator cuff tears < 3 cm in size in the anterior to posterior direction as estimated by preoperative MRI and excluded those who had obesity, were pregnant, had opioid dependence, had history of cardiac bypass surgery or ipsilateral rotator cuff repair, had allergies to trial medications, were taking anticoagulants or antidepressants, were being treated with other postsurgical pain management methods, or had severe liver or kidney dysfunction. Based on these criteria, 64% (72 of 112) of patients were eligible. The patients were randomly assigned into either the control group (oral tramadol and celecoxib) or the experimental group (buprenorphine patches). The control group received 100 mg of tramadol and 200 mg of celecoxib every 12 hours for 2 weeks after surgery. The experimental group received buprenorphine patches about 48 hours before surgery without any oral medication. A medication journal was given to the patients to self-report their compliance in taking the drugs. The dosage regimen adhered strictly to protocol. After enrollment, 11% (4 of 36) of patients in the control group and 17% (6 of 36) of patients in the experimental group could not be fully analyzed because of loss to follow-up or missing data. The surveillance period was 3 months, and there was no crossover between groups. The groups did not differ at baseline in terms of demographic parameters and relevant clinical characteristics, including age, gender, BMI, American Society of Anesthesiologists classification, tear size, concomitant procedures, and number of anchors. The outcomes were (1) numeric rating scale (NRS) for pain score at rest or with movement, which ranges from 0 to 10, where 0 indicates no pain, and 10 indicates the worst pain; (2) the American Shoulder and Elbow Surgeons (ASES) score for joint function, which ranges from 0 to 100, with higher scores indicating better shoulder joint function; and (3) the incidence of postoperative adverse reactions. We defined the minimum clinically important difference on the NRS as 2 of 10 points and on the ASES score as 15 of 100 points, based on anchor-based approaches reported in other studies. We found no clinically important between-group differences in NRS pain scores at any time point, either at rest or with movement. Likewise, we found no clinically important between-group differences in ASES scores at any time point. Postoperative dizziness or drowsiness (20% [6 of 30 patients] versus 44% [14 of 32 patients]; p = 0.04) and nausea (10% [3 of 30 patients] versus 34% [11 of 32 patients]; p = 0.02) during the hospital stay were slightly lower in the experimental group compared with the control group. In this randomized trial, we found no clinically important advantages in pain or function to the use of buprenorphine patches after arthroscopic rotator cuff repair, and insufficient evidence exists to confirm whether the minor differences in transient side effects could justify the use of a new and largely untested analgesic approach in this context. That being so, we recommend against the routine use of buprenorphine patches for this indication. In general, we found that pain levels were low after the procedure in both groups. Future studies, therefore, should focus on the efficacy of buprenorphine patches for more invasive or more painful procedures. Level I, therapeutic study.

Evaluation of Cold and Electric Pulp Tests for Assessing the Success of Inferior Alveolar Nerve Block for Mandibular First Molars diagnosed with Symptomatic Irreversible Pulpitis

IntroductionFear of dentistry, often due to past painful experiences, is a significant barrier preventing patients from visiting dentists. Achieving effective pain control, especially during root canal treatments, is crucial. However, inferior alveolar nerve blocks (IANB) have a low success rate, influenced by factors such as anxiety, anatomical variations, and technique limitations, leading to anesthesia failure. Although numerous studies have examined the cold test and EPT in assessing the success of local anesthesia, no standardized method has been established. This study evaluated the effectiveness of electric pulp test (EPT) and cold tests in assessing the depth of anesthesia in patients with symptomatic irreversible pulpitis (SIP) in the mandibular first molar teeth. MethodsA cross-sectional study was conducted on 50 patients with SIP who met the inclusion criteria and exhibited lip numbness. Following the administration of the IANB and confirmation of lip numbness, cold tests and EPT were performed on all patients. Subsequently, the preparation of the access cavity (gold standard test) was initiated, and patients' responses during cavity preparation were recorded as either "presence of pain or discomfort" or "absence of pain or discomfort," indicating IANB failure and success, respectively. Sensitivity (SN), specificity (SP), positive predictive value (PPV), negative predictive value (NPV), positive and negative likelihood ratios (LR-/+), and accuracy (AC) with 95% confidence intervals (CI) were calculated for each test separately as well as for sequential testing. ResultsIANB failure was determined in 56% of the patients. A comparative analysis of diagnostic tests (cold test and EPT) showed no significant difference in SN, NPV, and AC; however, the cold test had higher SP, PPV, and LR+. Combining cold test and EPT evaluations improved SN, NPV, PPV, and LR-, but SP and AC were similar to EPT alone. No correlation was found between IANB success and patient age, sex, or initial pain. ConclusionsDespite evidence of lip numbness, a significant number of IANBs failed in cases of painful pulpitis. A positive result from the cold test strongly indicated anesthesia failure. The findings of the current study suggested that when the cold test yielded a negative result, further evaluation with EPT was necessary to confirm anesthetic success and ensure complete pain control.

Efficacy of Quadratus Lumborum Block Compared to Paravertebral Block on Pediatric Patients Undergoing Abdominal Surgery

Background: Abdominal surgery is a major procedure associated with severe postoperative pain in pediatric patients. Quadratus lumborum block (QLB) is considered an effective pain control in such cases. Paraverterbral block (PVB) is another option for postoperative pain management. The aim of this study was to compare the effectiveness of quadratus lumborum block with paravertebral block. Methods: This single-blind randomized controlled trial included 22 pediatric patients who underwent abdominal surgery at Sanglah Hospital, Denpasar between August – October 2022. Research subjects were divided into 2 treatment groups; group A consisted of general anesthesia combined with quadratus lumborum block and group B consisted of general anesthesia combined with paravertebral block. Duration of analgesia was recorded based on the time to analgesic rescue, FLACC pain scale at 0, 2, 4, 6, 12 and 24 hours and total opioid consumption 24 hours after surgery. Statistical analyses were performed using SPSS. Results: Eleven patients received QLB and PVB respectively. There was a significant difference in mean analgesia duration of 1287 ± 129.69 minutes compared to 750 ± 122.22 minutes (p &lt; 0.001) (CI 95%: 425.18 – 649.36), median FLACC pain scale at 12 (1 (IQR 2) vs 4 (IQR 1)) and 24 hours postoperative (1 (IQR 2) vs 3 (IQR 1)) between QLB and PVB (p &lt; 0.001 and p &lt; 0.007). Mean 24-hour postoperative opioid consumption was significantly lower in the QLB compared to the PVB. Conclusion: QLB has better effectiveness than PVB in pediatrics undergoing abdominal surgery.

Family caregivers’ administration of medications at the end-of-life in China: a qualitative study

BackgroundEffective medication management is crucial for ensuring timely pain and symptom control at the end of life. Dying in pain is a major concern for patients, yet some find less effective pain control at home. Family caregivers (FCGs) play a vital role in managing pain and symptom control for dying patients. However, the experience of administering medications at home for terminal-stage patients has not been widely recognized or understood. Our study aimed to explore the experiences of FCGs in administering medications to adult dying patients.MethodsWe conducted a directed content analysis of data from 73 semi-structured interviews with FCGs across 19 Chinese provinces from 2021 to 2023. FCGs were recruited through the Voluntary Cooperative Network Research. We asked, “Could you recall the end-of-life care process for the patients?” We aligned the themes with the five issues identified by Wilson et al. (2018): administration, organizational skills, empowerment, relationships, and support.ResultsFCGs in China exhibit concerns about over-engagement and empowerment in medication administration, concealing medication information from the patient, and medication accessibility. FCGs faced significant challenges in accurately identifying and addressing pain and symptoms, determining appropriate dosages, accessing effective medications, and managing the emotional stress associated with potential medication errors. Financial burden, medication regulatory restrictions, geographical inequality, and travel restrictions during COVID impeded patients and FCGs from accessing medication. A culturally specific finding is the use of alternative medicine at the end of life.ConclusionOur findings build upon Wilson et al.‘s framework and extend their insights on empowerment, highlighting the need for policies to support home-based palliative care professionals in training FCGs for effective medication administration.

Pain Management Methods and Techniques in Lumbar Disc Surgery: A Narrative Review Study

Background and Aim: This study examines the complex field of pain treatment related to lumbar disc disorders in a narrative review. Methods and Materials/Patients: Our search strategy involved utilizing specific terms, including ‘pain management,’ ‘lumbar disc surgery,’ ‘methods,’ and ‘techniques.’ We formulated a search query using Boolean operators: (‘Pain management’ OR ‘analgesia’) AND (‘lumbar disc surgery’ OR ‘spinal surgery’) AND (‘techniques’ OR ‘procedures’ OR ‘approaches’ OR ‘methods’) AND ‘narrative review.’ A systematic search was conducted across reputable medical databases including PubMed, MEDLINE, and Cochrane Library. Filters were applied to refine search results based on publication type and date, with a focus on material published within the past two decades to ensure the inclusion of current, high-quality literature. Results: This study synthesized information from several sources, demonstrating the changing methods used to address pain in lumbar disc disorders. The article explored the historical background of medical treatments, emphasized both contemporary surgical and non-surgical methods, and investigated the predicted factors that affect the results. The study investigated the range of surgical incidents and examined the clinical factors to be taken into account for treatments. The value of efficient pain treatment in alleviating chronic back pain and maximizing patient results was emphasized. Conclusion: In conclusion, this review underscores the paramount importance of comprehensive management of lumbar disc pain. It stresses that effective pain control not only alleviates immediate suffering but also plays a pivotal role in ensuring positive surgical experiences, enhancing patient outcomes, and promoting long-term well-being.

Celecoxib in rheumatic diseases: possibilities and prospects. Brief descriptive survey

Chronic pain is the main manifestation of rheumatic diseases (RD), it determines the main complaints and worsens the quality of life of patients. The problem of effective control of chronic pain in rheumatology remains a current issue despite the successes in the development of new drugs for pathogenetic therapy, especially in immunoinflammatory RD. For example, 40-50% of patients with rheumatoid arthritis (RA), even those receiving biologic disease-modifying antirheumatic drugs and Janus kinase inhibitors, require analgesics. According to several population studies, about 50% of patients with the most common RD, osteoarthritis (OA) are forced to take various analgesics on a regular basis.The most popular class of analgesics with proven efficacy in RA, spondyloarthritis (SpA) and OA are non-steroidal anti-inflammatory drugs (NSAIDs). As has been shown in several meta-analyses, NSAIDs are superior to placebo and paracetamol in their therapeutic effect, are not inferior to opioids and are better tolerated overall. However, the use of NSAIDs can be associated with the development of dangerous adverse events (AEs), which requires careful monitoring of the patient's condition, considering comorbid diseases and risk factors. It is very important to choose a drug with a balanced ratio of efficacy and low risk of gastrointestinal and cardiovascular AEs. One such drug is celecoxib, whose therapeutic potential and relative safety have been confirmed in RA, SpA and OA. A differentiated approach to celecoxib prescription makes it possible to achieve a maximum therapeutic result with a minimum risk of AEs. For severe pain, treatment starts with a dose of 400 mg/day, followed by a switch to a maintenance dose of 200 mg/day.

Safe and Effective Augmentation Mastopexy with Tumescent Local Anesthesia: A Decade of Experience.

Background: Tumescent local anesthesia (TLA) is widely used in esthetic surgery due to its ability to reduce complications, eliminate the need for general anesthesia, provide effective pain control, and shorten hospitalization times. Methods: This study evaluates the use of TLA in 80 patients who underwent augmentation mastopexy between 2010 and 2022. A tumescent solution containing 500 mg lidocaine, 672 mg sodium bicarbonate, and 1 mg epinephrine in 1000 mL of saline was infiltrated, with an average of 300 mL per breast. The surgical technique involved creating a subpectoral pocket for textured round implants (250-400 cc), followed by careful hemostasis. Results: No patients required conversion to general anesthesia, and there were no signs of toxicity or major complications. Minor complications included wound dehiscence (6.2%), hematoma (2.5%), and capsular contracture (2.5%). Pain management satisfaction at 3 months post-surgery was rated as "outstanding" by 12.5% of patients, "excellent" by 67.5%, and "good" by 20%. The longest follow-up was 6 years, with no implant ruptures except one (1.2%). Conclusions: While the study did not include a control group or statistical analysis, the findings suggest that TLA is a safe and effective alternative to general anesthesia for augmentation mastopexy, providing excellent pain control and a low rate of complications.

Conceptual Study on the Effect of Palasha Gudavarti in Post-operative Pain Management of Anorectal Surgeries

Post-operative pain management is a crucial component of recovery, particularly following anorectal surgeries, where pain can significantly hinder healing. The prevalence of postoperative pain after 24 hours of surgery is 55.3%, after 48 hours is 34.7 % and of moderate to severe post-operative pain is 13 % after 24 hours, and 11.7% after 48 hours1 .Ano rectal pathology amenable to ambulatory surgery includes anal fissures, warts, fistulas, hemorrhoids,abscess and small neoplasms. Quick recovery after ano rectal surgery can be successful only with effective post-operative pain control. Acharya Sushruta recommends the use of Yashtimadhu siddha ghritha application over the operated area2 . Additionally , he advocates the application of shoolahara dravyas and vatahara dravyas processed with ghritha to the surgical site for effective pain relief. Planning a cost effective, reliable, time tested and technically simple management is the need of this modem era. The present study explores the possible analgesic, anti-inflammatory, and wound-healing properties of Palasha Gudavarti, offering an alternative approach to conventional pain management techniques.

The effectiveness of parenteral agents to mitigate relapses after severe acute migraine headache presentations: A systematic review and network analysis.

To compare the effectiveness of parenteral agents to reduce relapse in patients with acute migraine and identify factors that predict relapse. Following discharge from emergency settings, many patients with acute migraine will experience a relapse in pain; severe relapses may result in re-visits to emergency settings. A comprehensive literature search, updated to 2023, was conducted to identify randomized controlled trials assessing the effectiveness of parenteral agents on relapse outcomes in patients with acute migraine discharged from emergency settings. Two independent reviewers completed study selection, quality assessment, and data extraction. A traditional meta-analysis compared parenteral corticosteroids to placebo; a frequentist network analysis assessed direct and indirect comparisons. Results are reported as risk ratios (RRs) and 95% confidence intervals (CIs). The review protocol was registered with the International Prospective Register of Systematic Reviews (identifier: CRD42018099493). From 8949 citations, a total of 53 unique studies were included involving 6167 patients. Most studies had a high or unclear risk of bias. Corticosteroids significantly reduced relapses compared to placebo (RR 0.67, 95% CI 0.52-0.88; I2 = 0%). Patients receiving lidocaine (RR 0.10, 95% CI 0.01-0.82), sedatives/hypnotics (RR 0.33, 95% CI 0.14-0.75), ergot agents (RR 0.44, 95% CI 0.25-0.75), neuroleptics (RR 0.47, 95% CI 0.31-0.71), opioids (RR 0.58; 95% CI 0.35-0.94), or corticosteroids (RR 0.64, 95% CI 0.47-0.86) were significantly less likely to relapse. Lidocaine (RR 0.09, 95% CI 0.01-0.71), combination therapy (RR 0.12, 95% CI 0.02-0.74), or adding corticosteroids (RR 0.61, 95% CI 0.44-0.84) were more likely to reduce severe relapses. Longer duration of headache and residual pain at discharge were significantly associated with higher relapses. Corticosteroids remain the recommended first-line option to reduce relapse outcomes. Some parenteral agents typically provided for pain relief including ergot agents, neuroleptics, or combination therapy may effectively reduce relapse; however, opioids are not recommended due to safety concerns. Additional research is needed for some lesser studied, albeit promising, agents including lidocaine and propofol. Effective pain control in emergency settings prior to discharge and duration of headache may play a role in the success of such treatments and further investigations could provide further insight regarding how and why some parenteral agents are effective in mitigating relapse events.

Safety and efficacy of high thoracic epidural analgesia for chest wall surgery in young adolescents: A retrospective cohort analysis and a new standardised definition for success rate.

Chest wall surgery for the correction of pectus excavatum or pectus carinatum has gained increased interest in recent years. Adequate pain treatment, respiratory physiotherapy and early ambulation are key to improving the outcomes. Although thoracic epidural analgesia is highly effective, its safety is controversial, leading to extensive scrutiny and questioning of its role. We hypothesise that thoracic epidural analgesia is effective and well tolerated to use in adolescents, with a high success rate and low pain scores. Observational retrospective cohort study. All adolescent cases in a high-volume academic tertiary chest wall surgery centre between March 1993 and December 2017 were included. A total of 1117 patients aged from 12 to 19 years of age and receiving either Ravvitch, Nuss or Abramson chest wall reconstruction for pectus excavatum were identified in our institutional chest wall surgery database. After applying selection and exclusion criteria, 532 patients were included in the current analysis. The primary endpoint of this study was the safety of epidural analgesia, assessed by the incidence of acute adverse events. Secondary endpoints were block success rates using a specific novel definition, and analgesic efficacy using recorded postoperative pain scores. More than 60% of patients experienced one or more adverse events. However, all events were minor and without consequences. No serious or long-term adverse events were detected. The success rate of thoracic epidural placement was 81%. Low postoperative pain scores were observed. Thoracic epidural analgesia is an extremely effective pain control technique, with a surprisingly high number of minor adverse events but safe with regard to serious adverse events. The local research ethics committee approved and registered this study on 16 May 2022 (registration number: S66594).

Intravenous Lidocaine Compared with Quadratus Lumborum Block on Postoperative Analgesia Following Laparoscopic Renal Surgery: Protocol for a Randomized Noninferiority Trial.

Patients undergoing laparoscopic renal surgery often experience significant postoperative pain. Quadratus lumborum block (QLB) provides effective postoperative pain control after laparoscopic procedures, while lidocaine administered intravenously also exerts analgesic effects for surgical patients. We design this trial to compare the effects of i.v. lidocaine infusion with QLB on postoperative analgesia in patients undergoing laparoscopic renal surgery. In this randomized noninferiority trial, a total of 120 adult patients undergoing laparoscopic renal surgery will be randomized to receive either i.v. lidocaine or unilateral QLB for postoperative pain management. Lidocaine will be i.v. administered at 1.5 mg/kg (ideal body weight) over 10min during anesthesia induction, followed by an infusion of 1.5 mg/kg/h intraoperatively and in a post-anesthesia care unit. Ultrasound-guided anterior QLB with 0.375% ropivacaine 30 mL will be conducted before the start of surgery. Patient-controlled i.v. sufentanil will be used for pain relief during the first 48h after surgery. The primary outcome is the cumulative sufentanil consumption during 0-24h postoperatively, with a noninferiority margin of 5μg. Secondary outcomes include pain intensity at rest and on coughing at 1, 6, 24, and 48h postoperatively; sufentanil consumption within 24-48h after surgery; rescue analgesic use within 0-48h after surgery; nausea and vomiting within 0-48h postoperatively; and quality of recovery at 24 and 48h after surgery. The results of this trial will add to the clinical evidence for improving postoperative pain management in patients who undergo laparoscopic renal surgery. Chinese Clinical Trial Registry (ChiCTR2400082974).

Posterior Hip Pericapsular Block (PHPB) with pericapsular nerve group (PENG) block for hip fracture: a case series

BackgroundPain after total hip arthroplasty (THA) for femoral neck fracture (FNF) can be severe, potentially leading to serious complications. PENG block has become an optional local analgesic strategy in hip fracture surgery, but it cannot provide effective pain relief for the posterior capsule of the hip joint. Therefore, we modified the traditional sacral plexus nerve block and named it Posterior Hip Pericapsule Block (PHPB) to complement the blockade of the relevant nerves innervating the posterior hip capsule region. Thereby, we detail the analgesic effect of PHPB combined with PENG block on five hip fracture patients and the effect on their hip motor function.MethodsThis case series was conducted from December 2023 to February 2024. We performed ultrasound-guided PHPB combined with PENG block on five patients with hip fractures. Numerical Rating Scale (NRS) pain scores at rest and maximum NRS pain scores during limb movement of the five patients were recorded within 48 h after surgery. Their hip flexion, abduction, adduction, keen flexion and quadriceps muscle strength were also recorded. Serious postoperative complications, including wound infection, hematoma formation, or nerve injury, were recorded.ResultsThey experienced effective pain control within 48 h postoperatively, with NRS pain scores at rest decreasing from 3.0 (3.0, 4.5) to 0.0 (0.0, 1.0) and maximum NRS pain scores during limb movement from 8.0 (7.5, 8.5) to 1.0 (0.5, 2.0). They can autonomously perform hip flexion, abduction, adduction, and knee flexion within 48 h postoperatively without any signs of movement disorders or quadriceps muscle weakness. No severe postoperative complications, such as wound infections, hematoma formation or nerve damage, were observed in any of the patients.ConclusionsUltrasound-guided PENG block combined with PHPB provided effective analgesia for hip fracture patients in the perioperative period. It maintained hip joint motor function and quadriceps muscle strength within 24 h after THA.

Pain control during intrauterine device insertion: Transcutaneous electrical nerve stimulation.

Current practice lacks effective periprocedural pain management during common gynecological procedures such as intrauterine device insertion, increasing the possibility of significant pain and adverse reaction to such procedures. Because of this, pain can often be a barrier for a patient in choosing a form of contraception that best serves them. Transcutaneous electrical nerve stimulation offers an option for effective pain control during intrauterine device insertion. This case review characterizes five cases where patients were offered transcutaneous electrical nerve stimulation for pain control during intrauterine device insertion. The patients reported a range of no pain to moderate pain during intrauterine device insertion and rated their pain experience as better compared with prior insertions. Although limited to a case review, our findings suggest a promising clinical indication for transcutaneous electrical nerve stimulation as a pain management strategy for intrauterine device insertion.

Comparison of nerve block and spinal anesthesia in second toe pulp free flap surgery for fingertip reconstruction.

Toe pulp flap surgery is a viable option for soft tissue defects of the fingertips, effectively addressing patient needs and fingertip characteristics. The preferred anesthesia for lower-extremity surgery includes spinal and regional anesthesia. However, the choice between these methods depends on patient safety and surgical efficacy. In this retrospective study, we aimed to ascertain the optimal anesthetic technique by examining the efficacy, safety, pain control, and potential side effects of spinal and peripheral nerve block anesthetics. We included 40 patients aged 18-60 years who underwent partial second toe pulp free flap surgery for fingertip reconstruction. Twenty patients received spinal anesthesia (SA), while the remaining 20 received peripheral nerve block anesthesia. We conducted a comparative analysis of postoperative pain scores, adverse effects, analgesic usage, and patient satisfaction scores associated with each anesthesia method. Independent t-test, Mann-Whitney U test, and chi-squared test were performed. The SA group exhibited hypotension, bradycardia, urinary retention, and postdural puncture headache rates of 10%, 10%, 5%, and 5%, respectively. A significant difference in the timing of first analgesic use was observed (spinal, 3.7 ± 0.8 vs. peripheral nerve block, 13.2 ± 6.6; P = 0.006). Visual analog scale (VAS) scores of the patients at the 2nd, 4th, and 6th h were significantly lower in the peripheral nerve block group (P < 0.001, P < 0.001, P < 0.001, respectively). VAS scores at 12 and 24 h were similar between the groups (P = 0.07, P = 0.135, respectively). Peripheral nerve block anesthesia is superior to SA for partial second toe pulp free flap surgery, offering lower complication rates, reduced postoperative pain, and improved patient comfort.