Improved Pain Control Research Articles

Pain Outcomes Among Medical Centers With High vs Low Specialist Palliative Care Reach Among People With Heart Failure.

Background: Pain affects more than 60% of people with heart failure (HF), with increasing frequency and severity towards the end of life (EOL). We examined if family-rated pain near EOL was associated with rates of specialist palliative care (SPC) among patients with HF. Methods: We conducted a retrospective cohort study among 1095 decedents with advanced HF (aHF = ≥2 hospitalizations) from 83 Veterans Affairs Medical Centers (VAMCs) between 2018-2020. We used multilevel logistic regression to derive facility rates of predicted SPC for each VAMC adjusting for demographic and clinical characteristics. We examined associations between VAMCs in the top 20% (vs bottom 80%) of SPC rates and family-reported pain at the EOL from the Bereaved Family Survey and the interaction between receiving SPC and VAMC-level SPC rates on study outcomes. Analyses were conducted using generalized linear models, adjusting for demographic, clinical, and facility covariates. Results: The sample was 98% male, 73% White, and 20% Black, with a mean age of 79.7+/-10.3years. Over 77% of the sample had uncontrolled pain at the EOL. In adjusted models, there was no association between family-reported pain and VAMC rates of SPC (Odds Ratio = 1.082, 95% Confidence Interval = 0.706-1.659). Receipt of SPC did not change this relationship (p-interaction = .405). Conclusion: Families of people with aHF cared for in VAMCs with high rates of SPC were as likely to report uncontrolled pain relative to people cared for in VAMCs with lower SPC rates. Research is needed to identify delivery and organizational features associated with improved pain control at the EOL among this symptomatic population.

Long-Term Effects of Spinal Cord Stimulation on Pain in Postherpetic Neuralgia

Introduction: Postherpetic neuralgia (PHN) is a pain syndrome that develops within few months after the acute herpetic outbreak. The pain may be accompanied by specific cutaneous signs in the distribution of affected dermatomes and feel unbearable reaching up to 9–10/10 on visual analog scale (VAS). Despite the introduction of new medications, drug resistance develops in at least 50% of cases. Neuromodulation techniques such as spinal cord stimulation (SCS) and peripheral nerve stimulation (PNS) are considered as ones of the last resorts for PHN treatment, especially in pharmacoresistant patients. Recently, several studies with limited number of cases have shown high efficiency of neuromodulation (regression of pain syndrome in more than 82% of cases) after SCS in PHN patients, but these findings require further confirmation and have not been supported by large RCTs. Methods: Initially, 32 patients diagnosed with chronic drug-resistant PHN underwent a trial of SCS. Based on the trial results, a decision was made whether to implant a permanent SCS system. The condition of all patients implanted with SCS system was assessed using the VAS, SF-36, Patient Global Impression of Change (PGIC), and Medicine Quantification Scale, version III (MQS) questionnaires before the surgery and in the long-term follow-up. We also conducted systematic follow-up of patients who did not pass the test stimulation stage, using them as a control group to track the levels of pain. The hypothesis of normal distribution for quantitative values was tested using Shapiro-Wilk tests. Results: During the trial period, tonic spinal stimulation was effective in 16 out of 32 (50%) patients with drug-resistant PHN. Among 14 patients with implanted stimulators, a significant pain reduction (more than 50% from the baseline) was observed in 10 patients (71.4%). The pain level in patients with a tonic SCS was statistically lower than in patients receiving conservative therapy. For the entire group of patients with implanted SCS, a significant improvement was also observed in results of SF-36, PGIC, and MQS. Conclusion: Our clinical series demonstrates that tonic SCS was effective in 50% of patients with refractory PHN undergoing SCS trial. Significant improvement in pain control obtained during the long-term follow-up in patients treated with tonic SCS improves the quality of life and reduces the need for analgesic medications.

The effect of home exercises with kinesiotaping on pain, functionality, and work performance in bus drivers with non-specific neck pain.

Clinical research on the management and rehabilitation of work-related upper spinal pain in bus drivers is sparse, indicating a gap in knowledge and treatment strategies. This highlights the growing need for innovative approaches to rehabilitation programs in this area. To examine the effects of kinesio taping (KT) on pain, functionality, and work performance in bus drivers experiencing neck pain. The study involved 44 participants who were randomised into two different groups: the exercise group (n= 22) and the kinesio tape group (n= 22), with participants in both groups undertaking exercise interventions. Evaluations were made before and after 6 weeks of treatment. At the end of the 6-week, the participants' ROM, pain evaluations and functional scales were evaluated with disability, and work functionality. Neck pain severity decreased in both groups (p< 0.001 for each value), but there was no difference between the groups (p: 0.071). When disability scores were evaluated, improvement was noted in both groups (p: 0.001 for each value), but no statistically significant difference was found (p: 0.754). When the improvements in ROM values before and after the treatment were examined, the difference between the groups was recorded only in the neck extension ROM value (p: 0.011). Significant improvement was noted in all sub-steps of job performance in both groups (p< 0.05). KT added to ergonomic training and home exercise programmes is effective in controlling work-related musculoskeletal pain in drivers with neck pain. However, the addition of KT to exercise therapy was found to be no more effective than exercise therapy alone in improving pain control, functionality and work performance.

Phrenic nerve infiltration: A good practice to combine pulmonary expansion and pain control in patients with high risk of prolonged air leak

ObjectiveProlonged air leak due to residual air space after lung resection is a main challenge. To date, few surgical options have been described to prevent this complication. The aim of this study is to investigate the safety and the efficacy of intraoperative phrenic nerve infiltration with long-acting anesthetics in producing transient hemidiaphragm paralysis in patients at high risk for prolonged air leak, thus improving pulmonary expansion after surgery and reducing air leaks, while controlling postoperative pain. MethodsBetween January 2021 and 2023, 65 consecutive patients at risk for prolonged air leak (defined in accordance with “2019 Society of Thoracic Surgery score criteria of prolonged air leak”) who underwent lung resection (lobectomy or anatomic segmentectomy) for malignancy were prospectively included in the study. They were randomly (1:2 ratio) assigned to receive (group A, 22 patients) intraoperative phrenic nerve infiltration with ropivacaine 10 mg/mL in the peri-neurotic fat on the pericardium or not to receive intraoperative phrenic nerve infiltration (group B, 43 patients). Five patients in group B were excluded because they did not undergo anatomic resection. Data on pulmonary reexpansion, prolonged air leaks, pain at 24 and 72 hours postsurgery, referred shoulder pain, length of hospital stay, and length of chest tube permanence were collected and compared. ResultsHemidiaphragm elevation (P = .006) and pulmonary expansion (P = .000) were significantly higher in group A. Patients in group A showed lower pain at 24 and 72 hours compared with group B (P = .004). Shoulder pain (0.001) and prolonged air leak (0.000) were higher in group B. Length of chest tube was longer in group B. No difference in hospital stay length was observed. ConclusionsThis is the first study to investigate 2 combined effects of phrenic nerve anesthetic infiltration (hemidiaphragm elevation and pain control), with potential enhancement of a patient's recovery after surgery. Intraoperative phrenic nerve infiltration in patients with a risk for prolonged air leak appears to be a safe and effective clinical practice to improve pulmonary expansion in this set of patients, reducing postoperative air leak. This result is associated with an additional improvement in pain control, especially for shoulder pain.

Characterizing a Common Phenomenon: Why do Trauma Patients Re-present to the Emergency Department?

IntroductionTrauma patients return to the emergency department (ED) at alarmingly high rates, despite not all patients requiring hospital resources. Reasons for ED re-presentation and associated risk factors have not been fully investigated. MethodsRetrospective cohort study of adult trauma admissions at an urban safety net level 1 trauma center (1/12018-12/312021). Risk factors for ED re-presentation were identified using purposeful selection and modeled using multivariable logistic regression. ResultsOf 2491 patients, 19% returned within 30 d (N = 475). Most patients presented for uncontrolled pain (37%, N = 175), medical concerns (25%, N = 119), and infection (10%, N = 49). The readmission rates varied as follows: 18% for uncontrolled pain (N = 32), 42% for medical concerns (N = 50), and 67% for infection (N = 33). Risk factors for uncontrolled pain included depression/anxiety (adjusted odds ratio [aOR] 2.06, 95% confidence interval [CI] 1.39-3.05), substance use disorder (SUD) (aOR 1.65, 95% CI 1.12-2.43), and penetrating mechanism of injury (aOR 2.25, 95% CI 1.59-3.18). Risk factors for medical concerns included number of medical comorbidities (aOR 1.34, 95% CI 1.18-1.52), depression/anxiety (aOR 1.97, 95% CI 1.28-3.01), SUD (aOR 2.48, 95% CI 1.65-3.74), and nonhome discharge disposition (aOR 1.56, 95% CI 1.07-2.28). Risk factors for infection included non-English primary language (aOR 3.41, 95% CI 1.82-6.39), SUD (aOR 2.00, 95% CI 1.03-3.88), and nonhome discharge disposition (aOR 2.06, 95% CI 1.15-3.67). ConclusionsUncontrolled pain was the most common reason for re-presentation, although only a small fraction required readmission. Patients with penetrating injury may benefit from improved pain control. Primary care provider follow-up may help mitigate risk of medical disease exacerbation, and wound care instructions for non–English speaking patients may decrease re-presentation for infection.

The effectiveness of massage gun treatment combined with passive stretching in reducing non-specific lower back pain

Non-specific lower back pain is a common condition characterized by strain, muscle spasms, or weakness of the paraspinal muscles, particularly the multifidus muscle, which affects adjacent musculature such as the gluteus, hamstrings, and quadriceps. This study aimed to investigate whether massage gun treatment combined with passive stretching could reduce non-specific low back pain in patients experiencing subacute and chronic phases of this condition. This pseudo-experimental research employed a one-group pretest-posttest design with three treatments. Participants were selected using purposive sampling based on inclusion criteria: suffering from non-specific low back pain, willingness to participate, and age between 20 and 65 years. Exclusion criteria included anatomical abnormalities of the spine, fractures, open wounds, and specific spinal disorders. The visual analog scale (VAS) was used to measure pain intensity before and after each treatment session. Initial VAS scores averaged 65.6 units. Following the first treatment, scores decreased significantly to 52.1 units; subsequent reductions occurred at 42.1 units post-second treatment and 33.5 units post-third treatment. Statistical analysis revealed a significant difference across all three treatment sessions (p = 0.000 0.05), indicating a progressive improvement in pain control over time. Massage gun therapy coupled with passive stretching demonstrated efficacy in reducing non-specific lower back pain among participants. These findings suggest that repeated application of these interventions can lead to sustained improvements in pain management for individuals suffering from subacute and chronic non-specific low back pain conditions

Reducing Opioid Consumption and Length of Stay After Bariatric Surgery: A Nonpharmacologic ERAS Intervention Bundle

PurposeTo reduce opioid consumption and decrease length of stay (LOS) in bariatric surgical patients by implementing an evidence-based, nonpharmacologic enhanced recovery after surgery (ERAS) intervention bundle. DesignEvidence-based practice project. MethodsWe developed and implemented a nonpharmacologic ERAS bundle from existing American Society of PeriAnesthesia Nurses Standards and bariatric and subspecialty surgical ERAS protocols to standardize the postoperative nursing care of bariatric patients. The bundle consisted of early ambulation, immediate initiation and prolonged use of oxygenation, prevention of nausea and vomiting, frequent use of incentive spirometry, and application of ice packs to surgical sites. The two project outcomes were opioid consumption and patient LOS. We used descriptive statistics to summarize opioid consumption and LOS among surgical bariatric patients at baseline and post intervention and independent samples t tests to determine the statistical significance of pre- or post-LOS changes. FindingsAfter implementing the ERAS bundle in 31 bariatric surgical patients, we found that the percentage of patients given an opioid substantially decreased by 13.8%, with both fentanyl and hydromorphone (Dilaudid) consumption meaningfully decreasing by 11.0% and 25.6%, respectively. The average LOS significantly decreased (P = .015) by 23 minutes per patient following the intervention, from 1 hour and 58 minutes to 1 hour and 35 minutes, representing a 19.5% reduction in total patient time in the PACU. ConclusionsUse of a nonpharmacologic ERAS bundle and standardizing postoperative care decreased overall PACU bariatric surgical patient opioid consumption and significantly reduced PACU LOS. Optimizing pain management for bariatric patients in the PACU could lead to improved pain control and reduced reliance on opioids during their entire hospital stay, enhancing health care outcomes and improving patient safety. Perioperative leaders and educators can use our example to develop initiatives that decrease opioid use and LOS to improve care for the high-acuity bariatric patient population.

ID: 338464 Revision of 6-Year Implanted SCS Leads to Improved Pain Control

ID: 338464 Revision of 6-Year Implanted SCS Leads to Improved Pain Control

The effect of intraoperative methadone on postoperative opioid requirements in children undergoing orchiopexy: A randomized clinical trial.

Children undergoing outpatient surgery are at risk of inadequate postoperative pain control. Methadone has a long duration of action and an intraoperative dose may provide stable analgesia throughout the postoperative period. Intraoperative methadone has been shown to improve pain control in adolescents but its use for postoperative pain in pediatric patients undergoing outpatient surgery has not been studied before. Therefore, we conducted a double-blind randomized placebo-controlled trial to investigate the effects of a single dose of intraoperative methadone in children aged less than 5 years undergoing orchiopexy for undescended testis. A total of 68 children were randomized to receive either methadone (0.1 mg/kg) or isotonic saline following induction of anesthesia. Exclusion criteria included preterm birth, previous scrotal surgery, and parents' inability to consent. Primary outcomes were opioid requirements (first primary outcome) and pain intensity in the post-anesthesia care unit. Secondary outcomes included episodes of desaturation and time until readiness to discharge from the post-anesthesia care unit, sleep on the first postoperative night, pain intensity, and opioid requirements at home until the evening on the first postoperative day. Follow-up was 4 days. Sixty children completed the study (age, mean ± SD, 26.2 ± 13.9 months), 29 children received methadone, and 31 children received placebo. Eighteen children required opioids in the post-anesthesia care unit, five children in the methadone group (proportion = 0.17, 95% confidence interval (CI): 0.07, 0.36) compared to thirteen patients in the placebo group (0.42, 95% CI: 0.26, 0.60) (mean difference = -0.24 and 95% CI: -0.03, -0.47) (p = 0.037). Five children in the methadone group (0.17, 95% CI: 0.03, 0.31) versus ten in the placebo group (0.32, 95% CI: 0.16, 0.49) had a face, legs, activity, cry, consolability score of ≥5 in the post-anesthesia care unit (mean difference = -0.15, 95% CI: -0.36, 0.06) (p = .179). More children in the placebo group woke up due to pain the first night following surgery (seven children vs. one child). The methadone group had a longer stay in the post-anesthesia care unit. There were no differences between the two groups regarding the other secondary outcomes. A single dose of intraoperative methadone reduces short-term postoperative opioid requirements in children after orchiopexy for nondescended testes but prolongs the duration of their stay in the post-anesthesia care unit.

Effectiveness of Liposomal Bupivacaine Transversus Abdominis Plane Block in DIEP Flap Breast Reconstruction: A Randomized Controlled Trial.

Transversus abdominis plane (TAP) blocks improve pain control and reduce narcotic medication requirements in various surgical procedures. Liposomal bupivacaine may provide more sustained analgesia. This study compared pain-related outcomes between standard bupivacaine and liposomal bupivacaine TAP blocks after autologous breast reconstruction. The authors conducted a single-center, single-blinded randomized controlled trial between March of 2021 and December of 2022. Patients undergoing deep inferior epigastric perforator flap breast reconstruction in a standardized enhanced recovery after surgery pathway were randomized to receive intraoperative TAP blocks with either bupivacaine and epinephrine (control group) or liposomal bupivacaine, bupivacaine, and epinephrine (experimental group). Primary outcome was postoperative narcotic medication requirements, with secondary outcomes of pain scores, length of stay, and narcotic medication refills. A total of 117 patients met inclusion criteria (59 control patients and 58 experimental patients). Demographic characteristics, comorbidities, breast pathologic variables, surgery laterality, and immediate versus delayed reconstruction status were equivalent between groups. The control group had significantly higher average pain scores postoperatively (4.3 versus 3.6; P = 0.004). However, there were no significant differences in mean narcotic use (66.9 morphine milligram equivalents versus 60.2 morphine milligram equivalents; P = 0.47). Both length of stay and postoperative narcotic prescription refills were equivalent between groups (2.1 days versus 2.2 days, P = 0.55; 22% versus 17.2%, P = 0.52). The addition of liposomal bupivacaine to the standard bupivacaine TAP block mixture in a standardized enhanced recovery after surgery protocol did not demonstrate a significant reduction in postoperative narcotic requirements after deep inferior epigastric perforator flap breast reconstruction compared with standard bupivacaine alone. Patient-reported pain scores, however, were lower among liposomal bupivacaine patients after the initial 24 hours postoperatively and consistent with a longer duration of analgesia. Therapeutic, II.

Intraoperative magnesium sulfate is not associated with improved pain control after urologic procedures

ObjectiveTo evaluate effects of intraoperative magnesium sulfate infusion on pain control and analgesic use in the postanesthesia care unit (PACU).MethodsThis is a retrospective review of patients undergoing robot-assisted radical prostatectomy (RARP) and endoscopic procedures of the bladder, prostate, and urethra from 2/2021 to 12/2021. Patients receiving Mg infusion (Mg group) received an intravenous 2-g bolus of Mg at anesthesia induction, followed by infusion of 1 g/h until procedure end. Outcomes were compared with patients who underwent similar procedures during this timeframe without Mg (Control). Endpoints were use of anticholinergic (AC) and belladonna and opium suppositories (BO), maximum pain score, and morphine milligram equivalents (MME) in PACU.ResultsThere were 182 patients, with 89 (48.9%) patients in the Mg group and 93 (51.1%) in the Control. Significantly, fewer patients in the Mg group were given AC/BO in PACU (9.0% vs. 21.7%, p = 0.02), with odds of using AC/BO which was 0.36 (95% CI 0.14, 0.83). No differences were found in pain score (p = 0.62) or MME administration (p = 0.94). In subgroup univariate analysis, only those who underwent bladder procedures had a significant difference in use of AC/BO (9.5% vs. 30.2%; p = 0.02). Across all surgeries, Mg infusion was associated with decreased use of AC/BO in the PACU (OR 0.34, p = 0.02); however, stratifying by procedure type did not find a difference in AC/BO use postoperatively.ConclusionIntravenous infusion of magnesium was found to decrease use of AC/BO in the PACU; however, this significance was lost after multivariable analysis stratifying by procedure type.

Comparação de técnicas cirúrgicas para reparação de lesões SLAP no ombro

Introduction: SLAP (Anterior Posterior-Posterior Upper Labral) injuries in the shoulder are common in athletes and physically active individuals, often requiring surgical intervention to restore function and relieve pain. This systematic review compared different surgical techniques, such as tenodesis and labral repair, evaluating functional outcomes, postoperative complications, and rehabilitation efficacy. Methods: Randomized, observational studies, systematic reviews, and meta-analyses of patients with SLAP lesions submitted to various surgical techniques were included. Searches were conducted in databases such as PubMed, MEDLINE, Embase, and Cochrane. Methodological quality was assessed using the ROB 2 and ROBINS-I tools, and heterogeneity was analyzed using the I² index. Results: Patients under 40 years of age had better results with labral repair, while those over 40 years of age had superior outcomes with tenodesis. Arthroscopic techniques were associated with shorter recovery time and fewer complications compared with open techniques, especially in complex lesions. Rehabilitation, particularly hydrotherapy, has been shown to significantly improve pain control and range of motion. Heterogeneity between studies was moderate to high (I² = 65%), with the risk of bias being low in most included studies. Conclusion: The choice of surgical technique should be personalized, considering factors such as age, type of injury, and patient goals. Labral repair is recommended for younger patients, while tenodesis may be more suitable for older patients. Arthroscopic techniques offer advantages in terms of recovery and complications, and proper rehabilitation is crucial for postoperative success. Future studies should focus on high-quality randomised controlled trials to improve the available evidence.

Comparison of Dexamethasone at Three Doses Administered Postoperatively for Improving Pain Control and Sleep Quality in Patients Who Underwent Total Knee Arthroplasty: A Triple Blind Randomized Controlled Trial

BackgroundDexamethasone has been shown to alleviate pain, yet the optimal dosing and safety profiles remain unclear. This study aimed to evaluate the analgesic efficacy and impact on sleep quality of three different doses of intravenous dexamethasone in patients undergoing total knee arthroplasty (TKA). MethodsIn this randomized, triple-blind, clinical trial, we assessed the analgesic effects of three doses of intravenous dexamethasone (four, eight, and 16 mg) in adult patients who underwent TKA. Pain was measured using the visual analog scale at one, 12, 24, and 48 hours postoperatively, and sleep quality was assessed two weeks postsurgery. ResultsA total of 90 participants were enrolled in the study, with 30 participants in each dosing group. The mean visual analog scale scores at 12, 24, and 48 hours postoperatively showed significant improvement from baseline in all groups. Notably, the 16 mg and eight mg dexamethasone groups demonstrated significantly greater pain reduction compared to the four mg group (P < 0.05). Additionally, sleep quality significantly improved in the 16 mg and eight mg groups (P < 0.05). ConclusionsDexamethasone at doses of four, eight, and 16 mg effectively reduces pain and enhances sleep quality in patients undergoing TKA, with the 16 mg dose showing the most pronounced effects at 12, 24, and 48 hours postoperatively.

Is Next-day Discharge Safe After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis?

While the implementation of enhanced recovery after surgery protocols and improvements in pain control have decreased the length of stay (LOS) after scoliosis surgery, adolescents are typically hospitalized for several days after posterior spinal instrumented fusion (PSF). The purpose of this study was to determine whether next-day discharge after PSF for adolescent idiopathic scoliosis (AIS) had an equivalent safety profile compared with longer LOS. The secondary purpose was to examine perioperative factors associated with next-day discharge. We performed a retrospective study of all patients who underwent PSF for AIS at a single institution from 2017 to 2022. We compared patients based on postoperative LOS with an early discharge group consisting of those who were discharged on the first postoperative day 1 (POD1; n = 40) and a standard discharge group consisting of those who were discharged after POD1 (n = 71). We documented preoperative variables, including patient demographics and curve characteristics, intraoperative variables, including levels fused, implant density, operative time, and blood loss, and postoperative variables, including emergency department (ED) visits within 30 days and hospital readmissions within 90 days. One hundred eleven patients were included with a mean curve magnitude of 67 degrees. Forty patients (36%) were discharged on POD1. There were one (3%) ED visit and 2 (5%) readmissions in the early discharge group and 3 (4%) ED visits and 2 (3%) readmissions in the standard discharge group (P = 0.64 and 0.55, respectively). Patients in whom intravenous methadone was used intraoperatively were more likely to discharge POD1 (P = 0.02). There were no other significant differences in perioperative variables between the two groups including: BMI, distance from home to hospital, magnitude of main curve, curve flexibility, number of levels fused, estimated blood loss, implant density, operative time, or postoperative pain scores. Next-day discharge after PSF for AIS has an equivalent safety profile compared with longer LOS. Over one-third of patients were discharged on POD1, and there was no statistically significant difference in ED visits or hospital readmissions between the groups. Patients in whom intravenous methadone was used intraoperatively were more likely to discharge POD1. In a retrospective study of posterior spinal fusions for AIS, we found no increase in ED visits or hospital readmissions for those discharged the next day. Level III.

Bedside percutaneous cryoneurolysis technique for management of acute rib fracture pain in adult trauma patients

BackgroundAcute pain due to rib fractures causes significant in-hospital morbidity and impacts patients’ quality of life after discharge. Intraoperative transthoracic cryoneurolysis of the intercostal nerves can improve postoperative pain; however,...

Efficacy of a Multimodal Surgical Site Injection for Postoperative Pain Control in Pediatric Patients With Cerebral Palsy Undergoing Hip Reconstruction: A Randomized Controlled Trial.

One in 4 children with cerebral palsy (CP) will undergo orthopaedic surgery during their childhood. Despite its ubiquity, postoperative pain control has been poorly studied in this patient population. Moreover, poor pain management has been associated with adverse surgical outcomes. Multimodal analgesic injections have been well studied in the adult population, demonstrating safety and efficacy in reducing postoperative pain and narcotic consumption, but this modality has not been studied in pediatric patients undergoing similarly complex procedures. The objective of this study was to evaluate the efficacy of a multimodal surgical site injection for postoperative pain control following operative management of hip dysplasia in patients with CP. After obtaining IRB approval, a multicenter, randomized double-blind placebo control trial was completed. Patients below 18 years old with a diagnosis of CP who were scheduled for varus derotation osteotomy (VDRO) of the proximal femur were randomized to receive a surgical-site injection with either a combination of ropivacaine (3mg/kg), epinephrine (0.5mg), and ketorolac (0.5mg/kg) (experimental group) or normal saline (control). All included patients had identical postoperative care, including immobilization, physical therapy, and standardized, multimodal postoperative pain control. Pain scores and narcotic consumption were recorded at regular intervals and compared between groups utilizing two-tailed t test or a nonparametric Mann-Whitney test for quantitative variables and a Fischer exact test for categorical variables. Thirty-four patients were included, evenly divided between study arms. There were no significant differences in demographic variables, gross motor function classification system (GMFCS), comorbidities, preoperative radiographic parameters, or concomitant surgeries between groups. Patients in the experimental group required significantly lower narcotic medications at all postoperative time points from PACU until hospital discharge compared with controls (0.41 ± 0.42 vs. 1.87 ± 2.05 total morphine mEQ/kg, P =0.01). Similarly, patients in the experimental group were found to have significantly lower pain scores throughout their hospital stays compared with controls (1.0 ± 0.6 vs. 2.4 ± 1.1 mean pain score, P <0.001). There were no significant differences in operative time, OR time, blood transfusion requirements or hospital length of stay between groups. There were no adverse medication reactions or injection site complications in either group. In patients with CP undergoing hip reconstruction, surgical-site injection with a multimodal analgesic combination improves pain control and reduces narcotic consumption in the early postoperative period with no observed adverse effects. Local multimodal analgesic injections should be adopted as part of standard multimodal pain control in this patient population for all osseous surgeries. Level I-therapeutic.

Implementing a pragmatic clinical trial to tailor opioids for chronic pain on behalf of the IGNITE ADOPT PGx investigators.

Chronic pain is a prevalent condition with enormous economic burden. Opioids such as tramadol, codeine, and hydrocodone are commonly used to treat chronic pain; these drugs are activated to more potent opioid receptor agonists by the hepatic CYP2D6 enzyme. Results from clinical studies and mechanistic understandings suggest that CYP2D6-guided therapy will improve pain control and reduce adverse drug events. However, CYP2D6 is rarely used in clinical practice due in part to the demand for additional clinical trial evidence. Thus, we designed the ADOPT-PGx (A Depression and Opioid Pragmatic Trial in Pharmacogenetics) chronic pain study, a multicenter, pragmatic, randomized controlled clinical trial, to assess the effect of CYP2D6 testing on pain management. The study enrolled 1048 participants who are taking or being considered for treatment with CYP2D6-impacted opioids for their chronic pain. Participants were randomized to receive immediate or delayed (by 6 months) genotyping of CYP2D6 with clinical decision support (CDS). CDS encouraged the providers to follow the CYP2D6-guided trial recommendations. The primary study outcome is the 3-month absolute change in the composite pain intensity score assessed using Patient-Reported Outcomes Measurement Information System (PROMIS) measures. Follow-up will be completed in July 2024. Herein, we describe the design of this trial along with challenges encountered during enrollment.

Buprenorphine for acute pain in older adults: a systematic review with meta-analysis.

Buprenorphine, a partial opioid agonist, has emerging evidence as an alternative to full agonist opioids for treatment of acute pain. This systematic review aimed to evaluate the safety and efficacy of buprenorphine for acute pain in older adults. PubMed Medline, Embase, Cochrane Central Register of Controlled Trials, CINHAL, Web of Science database, and Google Scholar were searched. We included articles that reported buprenorphine as an intervention to treat acute pain among patients 60 years or older. Primary outcome was difference in pain scores for patients treated with buprenorphine compared to other analgesia. Secondary outcomes included adverse events, opioid consumption, and patient satisfaction. Meta-analysis was conducted on difference in pain scores and differences in nausea and vomiting. Twenty-two studies were included (n = 2610). Buprenorphine was administered as nerve blocks in six studies, transdermal in eight, intravenous or intramuscular in five, sublingual in two studies, and both intravenous and sublingual in one study. 10 out of 20 (50%) studies found improved pain control in buprenorphine groups. Meta-analysis found no significant difference in pain scores between buprenorphine and control analgesia at 24 hours (Cohen's d = -0.29 [95% CI -0.85 to 0.27]) and 7 days (Cohen's d = -0.89 [95% CI -2.66-0.88]). Six studies (54.5%) found reduced opioid consumption in patients receiving buprenorphine. There was no difference in adverse effects in most studies. This review did not find buprenorphine to be superior to alternative analgesia; however the mixed results provide scientific rationale for future studies testing buprenorphine in older populations.

A Review of Remote Monitoring in Neuromodulation for Chronic Pain Management.

Neuromodulation techniques have emerged as promising strategies for managing chronic pain. These techniques encompass various modalities of nerve stimulation, including Spinal Cord Stimulation (SCS), Dorsal Root Ganglion Stimulation (DRG-S), and Peripheral Nerve Stimulation (PNS). Studies consistently demonstrate significant improvements in pain intensity, quality of life, and reduced opioid usage among patients treated with these modalities. However, neuromodulation presents challenges, such as the need for frequent in-person follow-up visits to ensure proper functionality of the implanted device. Our review explored factors impacting compliance in current neuromodulation users and examined how remote monitoring can mitigate some of these challenges. We also discuss outcomes of recent studies related to remote monitoring of neuromodulation. While remote monitoring capabilities for neuromodulation devices is an emerging development, there are promising results supporting its role in improving outcomes for chronic pain patients. Higher patient satisfaction, improved pain control, and reduced caretaker burdens have been observed with the use of remote monitoring. This review discusses the current challenges with neuromodulation therapy and highlights the role of remote monitoring. As the field continues to evolve, understanding the importance of remote monitoring for neuromodulation is crucial for optimizing pain management outcomes.

Poster 191: Does Ischemic Preconditioning of the Operative Limb Reduce Pain after Hip Arthroscopy? A Prospective, Single Blind, Randomized Controlled Trial

Objectives: Improving pain control after hip arthroscopy is an important concern for surgeons and for optimizing the patient experience. Many surgeons use multimodal protocols including peripheral nerve blocks, oral medication, and intra-articular or local anesthetic. Identifying additional preoperative modalities for pain management is a promising way to improve pain and potentially decrease narcotic use. Ischemic preconditioning (IPC) involves the exposure of brief periods of circulatory occlusion and reperfusion which has protective effects on muscular and organ tissues. In addition, studies on the use of IPC prior to knee surgery have shown improvements in postoperative pain and decreased opioid consumption. The purpose of this study was to determine whether preoperative IPC of the operative limb affects postoperative pain scores or opioid consumption after hip arthroscopy. Methods: This is a prospective, single blind, randomized controlled trial. Patients were enrolled between October 2021 and April 2023. Inclusion criteria were patients age ≥ 18 years old undergoing hip arthroscopy by a single surgeon for hip pain in the setting of femoroacetabular impingement or labral tear. Exclusion criteria were history of venous thromboembolism or patients on medications known to increase the risk of blood clots. Following informed consent, patients were randomized to the IPC or control group and were blinded to their treatment group. Limb preconditioning was performed within 24 hours prior to surgery using the Delphi Personalized Tourniquet System (PTS) with the cuff placed on the proximal thigh of the operative limb. Patients in the IPC group received a 30-minute treatment consisting of 3 rounds of 5 minutes at limb occlusion pressure (LOP) alternating with 5 minutes of reperfusion. Patients in the control group received the same protocol at 20% LOP. Hip arthroscopy was then performed according to standard of care. All patients received a standardized preoperative and postoperative pain control regimen. Surveys were administered through RedCap daily from day of surgery through postoperative day 7. Patients were asked to rate their pain 0-10 according to the visual analog scale (VAS) for pain and to record pain medication utilization. Charts were reviewed for baseline characteristics and surgical procedures. Chi-square, independent t tests and paired t tests were used for statistical analysis. Results: A total of 64 patients (31 in the IPC group, 33 in the Control group) were enrolled. Demographics (age, sex, and body mass index) were similar between the IPC and Control groups. There was no significant difference in surgical procedures performed. Survey compliance was higher in the IPC group compared to the control group, 6.1 ± 2.8 days vs. 3.7 ± 3.4 days, respectively (p &lt; 0.05). Both groups reported significant reductions in their VAS for pain scores from day of surgery to postoperative day 6 or 7 (p &lt; 0.05). There was no significant difference between the IPC and control groups in VAS for pain scores at any of the time points from day of surgery to postoperative day 7 (Figure 1). There was also no significant difference between the groups in mean daily opioid consumption (expressed as morphine milligram equivalents) or in acetaminophen consumption at any time point. There were no early complications (within first 7 days postoperatively). Conclusions: Limb IPC does not appear to decrease pain or medication utilization after hip arthroscopy. It is possible that the pain modulating effects of IPC are not as effective when the surgical site is proximal to the site of occlusion. Other factors may have contributed to variability in the reported VAS scores, including differences in fluid extravasation, personal pain tolerances, and utilization of pain control regimen. [Figure: see text]