Inadequate Postoperative Pain Control Research Articles

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.

Analgesic and hemodynamic effects of intravenous magnesium sulfate infusion versus lidocaine infusion in patients undergoing thyroid surgery for toxic goiter resection: a randomized controlled study

Background Anesthesia for toxic goiter resection is challenging as manipulation of the thyroid gland and inadequate postoperative pain control could lead to hemodynamic instability due to stress and a neurohormonal response. Both magnesium sulfate and lidocaine are known for their analgesic effects and decreasing stress response. Herein, we compared the previous two medications regarding intraoperative hemodynamics and postoperative analgesia. Patients and methods 57 patients who underwent toxic goiter resection were enrolled in this prospective randomized trial (group M received magnesium sulfate, group L received lidocaine, and group C received normal saline). Intraoperative hemodynamics and postoperative analgesic profiles were assessed. Results Both injection groups expressed significantly lower pain scores compared with control group at Post anaesthesia care unit (PACU) and one-hour postoperative. Postoperative fentanyl consumption was significantly lower, and the time to first analgesic request was significantly prolonged in Magnesium and Lidocaine groups than in the control group. The previous beneficial effects were more prominent in the Magnesium Group compared with the Lidocaine Group. There was no significant difference in mean arterial pressure (MAP) and heart rate (HR) among the three study groups at the baseline, after the end of infusion, and after induction. Nonetheless, there was a significant rise in mean arterial pressure and heart rate values in the control group compared with the Magnesium and Lidocaine Groups with intubation and during the first hour of surgery. Conclusion Both magnesium sulfate and lidocaine have beneficial hemodynamic stabilizing and analgesic effects in patients undergoing thyroid surgery for toxic goiter, with a slight superiority for magnesium.

Prescribing pattern of analgesics used for postoperative pain and its correlate with patient and doctor satisfaction

Background: Post operative pain is difficult to assessment and its management has been neglected at times. Moreover, the drug treatment involves administration of drug on as and when basis which leads to inadequate control. Methods: This observational, prospective study was conducted in 100 post-operative patients i.e., 50 each from surgery and orthopedics departments. Investigator enrolled post-operative patients within 24 hours of surgery and followed them for next 5 days or till hospital discharge, whichever was earlier. Analgesic prescribing pattern, self-assessment of pain, patient and doctor satisfaction using ASSIST questionnaire were recorded in Case Record Form and analysed. Results: Out of 100 patients, average number of analgesics prescribed post-operatively was 1.49±0.5 (baseline and all follow-up). 76.5% patients received NSAIDs which included diclofenac (44.29%) and paracetamol (30.87%). Opioids in the form of tramadol were prescribed in 23.49% patients. Mean least pain experienced by patients on day 1 was 2±0.75 which decreased to 1.32±0.63 on day 5. Mean worst pain decreased from 6.64±1.43 on day 1 to 3.38±1.17 on day 5. Average percentage of duration of severe pain was 35.2%±16.48 on day 1 which successively decreased to 16.32±8.26 on day 5. Average pain relief observed in 62.3% patients on day one increased to 80.88% on day 5. Patient satisfaction increased as pain score decreased (r=-0.73) and a strong positive correlation was observed between doctor satisfaction and patient satisfaction (r=0.91). Conclusions: Inadequate control of post-operative pain affects effective patient management and recovery. Incorporation of effective pain assessment scores in pain management is desirable.

Unscheduled Healthcare Contact after Outpatient Surgical Fixation of Distal Radius Fractures: A Retrospective Cohort Study

Background: Distal radius fractures (DRFs) commonly require surgical fixation. Unscheduled healthcare contact (UHC) after surgery represents an area of quality improvement in surgical care. We hypothesize that UHC after outpatient surgical fixation of DRFs is more common in patients undergoing treatment at a safety-net hospital versus those treated at a university-affiliated facility. Methods: An IRB-approved retrospective review studied patients who underwent outpatient surgical treatment of DRFs from January 2017 to May 2021. Surgery was performed either at a local safety-net hospital or at a university-affiliated hospital. UHC was defined as telephone calls, emergency room visits, and/or readmissions to the hospital within 30 days of surgery. Demographic factors, medical comorbidities, and injury and surgery details were analyzed. Results: In total, 442 patients met inclusion criteria. An estimated 257 patients (58.1%) were treated at a university-affiliated facility, whereas 185 patients (41.9%) had surgery at the safety-net hospital. The overall rate of UHC within thirty-days of surgery was 14.0%, with the most common reason being uncontrolled pain. Rates of UHC were higher at the safety-net hospital compared with those at a university-affiliated facility (26.5% versus 5.1%, P < 0.05). Conclusions: UHC was significantly greater for patients undergoing surgery in a safety-net hospital setting compared with those in a university setting. UHC after surgery is often related to inadequate postoperative pain control. Improved pain control and patient education may alleviate unnecessary healthcare contact.

Sustained release of levobupivacaine from temperature-sensitive injectable hydrogel for long-term local anesthesia in postoperative pain management

Postoperative pain is a major concern for most of the surgical patients, and an inadequate postoperative pain control may cause a series of complications. With an effective pain control and lesser side effects, local anesthetics are preferred for use in postoperative pain management. However, the action duration of current local anesthetics is too short to meet the requirements of postoperative analgesia. In this study, an injectable levobupivacaine (LB)-loaded thermo-sensitive hydrogel system based on biodegradable poly(D,L-lactide)-poly(ethylene glycol)-poly(D,L-lactide) (PLEL) was developed for long-acting local anesthetic, in which the soluble charged cation form of LB (LB HCl) was partly alkalified to the poorly soluble base form (LB base). This hybrid LB loaded PLEL system (hLB/PLEL) is a free flowable liquid at room temperature and changes into a semi-solid hydrogel once injection in response to the physiological temperature. Then, the dissolved LB HCl could release firstly from the hydrogel contributing to a quick work, and the insoluble LB base dissolved and released gradually as the decrease of the pH during the biodegradation of PLEL hydrogel, resulting in a long-term LB release in local. The drug release behavior, pharmacokinetic, and biocompatibility of the thermo-sensitive hLB/PLEL were studied in vitro and in vivo. The anesthetic effects of hLB/PLEL system were evaluated in the rat models of sciatic nerve block, subcutaneous infiltration anesthesia and postoperative pain as well. This hLB/PLEL system generated a significantly prolonged analgesic effect in rat models, which produced approximately 7 times longer duration than 0.75% LB HCl and effectively relieved the spontaneous pain for 3 days. In general, the presented hLB/PLEL system can not only achieve a fast-acting but also sustainably release LB to block the nerve and significantly extend the effect of local analgesia, which means a promising candidate for long-acting postoperative pain management.

Bones, groans and sending patients home: Perioperative opioid-related harm reduction strategy utilisation in a regional New South Wales (NSW) hospital.

Perioperative initiation of opioids continues to be a major contributor to chronic use, misuse and diversion in regional areas. There is considerable effort to mitigate harm through avoiding excessive prescribing and reducing the risk of persistent postoperative opioid use. Improving perioperative documentation practices has been reported to ensure appropriate opioid initiation and de-escalation. It has not been established whether these strategies are utilised in regional hospitals. A retrospective observational study of perioperative opioid prescribing and documentation practices in Goulburn Base Hospital, a regional centre in the Southern New South Wales (NSW) Local Health District. Data were collected from 110 records and validated for adult patients undergoing elective total knee replacement (TKR) or total hip replacement (THR) from 12 January 2020 to 13 January 2021. To observe perioperative opioid prescribing and utilisation of harm reduction strategies in a regional hospital. 65% of patients were opioid naïve (ON). Preoperative pain assessments and patient education were completed in 23% and 15% of records, respectively. Postoperative opioids were prescribed for 99% of patients, with 74% prescribed a slow-release (SR) formulation. 50% of patients were discharged with an SR prescription. Inadequate postoperative pain control was reported in 21% of patients. Of the 103 patients prescribed opioids on discharge, only 20% included a de-escalation plan and only 35% of discharge summaries included dose and quantity of opioids supplies. This study has identified underutilisation of perioperative harm reduction strategies despite the potential to improve appropriate initiation and de-escalation of opioids. These findings highlight opportunities for improvement in regional hospitals.

Clinical trial to assess role of ketamine in post operative analgesia after laparoscopic cholecystectomy

Background: The physiological consequences of post-operative pain including Stress response to surgery, Respiratory complications, cardiovascular complications, Thromboembolic complications, Gastrointestinal complications, Musculoskeletal complications and Psychological complications, all of which could delay or impair postoperative recovery and increase the economic cost of surgery as a result of the longer period of hospitalization. Inadequate post-operative pain control may also lead to the development of chronic pain after surgery .Aim of This study: is to evaluate the preemptive analgesic effect of intravenous ketamine in laparoscopic cholecystectomy. Patients and Methods: double blinded randomized clinical trial conducted at Al-Yarmouk teaching hospital, over a period of one year from March 2013 to March 2014 on a total of 120 adult patients scheduled for elective laparoscopic cholecystectomy, Patients were divided in to three groups of 40 patients each, the study drug administered intravenously during induction. Groups A and B received ketamine in a dose of 1 and 0.5 mg/kg, respectively, whereas group C received isotonic saline. The degree of pain at rest and deep breathing postoperatively were estimated using VAS, time of first analgesic dose, total opioid consumption, nausea, vomiting and hallucination were recorded for 24 h postoperatively. Results: postoperative pain scores were significantly low in group A when compared with the other groups at most times in the first 24 hours. Highest pain score was in group C at 0 h. Postoperative analgesic consumption was minimum in group A then group B and highest in group C. There was little significant difference in the pain scores between groups B and C. Group A had a significantly higher blood MAP than group B at 0, 0.5 and 1 h. 7.5% incidence of hallucinations were in group A. Conclusion: According to this study we conclude that preemptive ketamine in a dose of 1 mg/kg has a definitive role in reducing postoperative pain and analgesic requirement in patients undergoing laparoscopic cholecystectomy. A low dose of 0.5 mg/kg had little significant in preemptive analgesic effect and in reducing analgesic requirement.

Postoperativna analgezija kod dece

In many centres for pediatric surgery too many children still experience intense postoperative pain. Factors that contribute to inadequate postoperative pain control in children are: lack of the experience, inadequate use of pain scales, interpatient variability in pain perception and analgesic requirements, differences in pharmacodynamics and pharmacokinetics, age restricted drug licensing and a relative paucity of researches. The proper pain estimation scales are dependent on the child's age and their understanding of pain and of the scale. Most commonly used drugs in pediatric postoperative pain relief are opioid and nonopioid analgesics (nonsteroidal anti-inflammatory drugs, paracetamol, metamizole, ketamine, Dexamethasone and Alpha-2-agonists). The use of regional anesthesia techniques is becoming increasingly popular in postoperative analgesia following pediatric surgery. Severe acute postoperative pain in children can have significant long term effects such as chronic pain. Of great importance is that acute postoperative pain in children is optimally managed from the outset.

Erector Spinae Plane Block Decreases Pain and Opioid Consumption in Breast Surgery: Systematic Review.

Background:Adequate control of acute postoperative pain is crucial in breast surgeries, as it is a significant factor in the development of persistent chronic pain. Inadequate postoperative pain control increases length of hospital stays and risk of severe complications. Erector spinae plane block (ESPB) is a novel regional block that has the ability to sufficiently block unilateral multidermatomal sensation from T1 to L3. By reviewing the literature on ESPB, this paper aimed to elucidate its efficacy in breast surgery analgesia and its role in addressing the opioid crisis in North America.Methods:PUBMED, EMBASE, and Cochrane databases were systematically searched for relevant articles according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Inclusion criteria included any articles that described ESPB in breast surgery. Exclusion criteria composed of articles that exclusively discussed other kinds of regional blocks.Results:Thirty-two articles including 6 randomized controlled trials were included in this review. ESPB demonstrated superior pain control and less opioid consumption compared with tumescent anesthesia or using no block. However, ESPB showed lower efficacy in pain control compared with pectoral nerve block. Patients experienced less nausea and vomiting and were overall more satisfied with ESPB compared with other pain control modalities. The vast majority of the studies reported the ease of ESPB administration, and only 1 case presented with a complication.Conclusions:ESPB is a promising form of regional anesthesia that can decrease postoperative pain and opioid consumption when used as part of multimodal pain analgesia for patients undergoing breast surgery.

Implementation of a Multimodal Analgesic Strategy Including Continuous Femoral Nerve Block in Patients Undergoing Total Knee Arthroplasty

Total knee replacement is a painful surgical procedure. The inadequate control of postoperative pain is associated with adverse outcomes in the short and long term. Continuous femoral block has been shown to be effective and efficient as part of multimodal analgesia. This series of 48 patients who underwent total knee replacement, who received multimodal analgesic treatment including continuous femoral nerve block, documents the pain control profile during the first 48 hours. This is a successful experience of implementing regional techniques as part of perioperative pain relief, as documented in the literature. We emphasize that each institution must know its technical and human resource and characterize its patients, in order to implement multimodal analgesia protocols that include this regional technique. We also suggest to monitor and implement continuous improvement processes.

Selective Epidurography for the Assessment of Epidural Catheter Placement After Esophagectomy

Adequate pain control immediately after esophagostomy is critical to patient recovery and may be compromised by uncertainty regarding correct epidural catheter placement. The aim of the current study was to determine the role of performing an epidurogram in selective patients to assess epidural placement after esophagectomy. Patients undergoing esophagectomy in a high-volume center were retrospectively reviewed to identify those in whom an epidurogram was performed less than 24 hours after surgery. Since 2012 epidurograms have been selectively performed in patients and have demonstrated features concerning for incorrect epidural catheter placement, including difficult/complicated insertion, negative sensory test, nonreassuring intraoperative hemodyamic response, and inadequate postoperative pain control. Fifty-two of 192 patients (27%; 43 men; age 65 ± 11 years) who underwent esophagostomy since 2012 had an epidurogram. Epidurograms were not associated with any adverse events. In 21 patients (40%) epidurogram findings led to a direct change in patient management, prompting either removal/replacement of an incorrectly sited catheter (n= 9), partial withdrawal of a catheter associated with unilateral contrast distribution (n= 2), or by endorsing a clinical decision to modify the analgesic regimen in a patient with a correctly sited epidural catheter (n= 10). Identifying and rescuing incorrect epidural catheter placement was not associated with longer intensive care unit/hospital stay or postoperative morbidity (p > 0.05) CONCLUSIONS: We reviewed selective epidurogram use in esophagectomy patients to determine its role in "rescuing" inadequate pain control through expediting clinical decision-making. Findings confirm that in selected patients epidurography is feasible and has the potential to directly contribute to patient care.

P.121 Preoperative predictors of poor postoperative pain control: systematic review and meta-analysis

Background: Inadequate postoperative pain control is common and is associated with negative clinical outcomes. The objective is to identify preoperative predictors of poor postoperative pain control in the adult population undergoing inpatient surgery. Methods: Meta-analysis was performed according to MOOSE guidelines. Studies were included if they evaluated postoperative pain using a validated instrument in adults undergoing inpatient surgery and reported a measure of association between poor postoperative pain control and at least one preoperative predictor. Measures of association were pooled using random effects models. Results: A total of 33 studies representing 59,259 patients were included. Significant preoperative predictors of poor postoperative pain included sleeping difficulties (OR 2.32 [95% CI 1.46-3.69]), history of depressive symptoms (OR 1.71 [95% CI 1.32-2.22]), use of preoperative analgesia (OR 1.54 [95% CI 1.18-2.03]), smoking (OR 1.33 [95% CI 1.09-1.61]), -female sex (OR 1.29 [95% CI 1.17-1.43]), presence of preoperative pain (OR 1.21 [95% CI 1.10-1.32]], history of anxiety symptoms (OR 1.22 [95% CI 1.09-1.36)], younger age (OR 1.18 [95% CI 1.05-1.32)], and higher BMI (OR 1.02 [95% CI 1.01-1.03]). Conclusions: Nine significant predictors of poor postoperative pain control were identified and these should be recognized as important factors when developing pre- and peri-operative strategies to improve pain outcomes.

Preoperative Pain Management Education: An Evidence-Based Practice Project

The purpose of this evidence-based practice project was to evaluate the effectiveness of a preoperative pain management patient education intervention on improving patients' pain management outcomes. The project was conducted in an outpatient general surgery service at a teaching institution for patients undergoing same-day surgery. Intervention patients received one-on-one education on postoperative pain management including how to take medications, managing medication side effects, using nonpharmacologic methods, and reporting inadequate postoperative pain control. Comparison patients received general education from multiple health care providers, and this information may not have been consistent. Intervention patients received education at the first preoperative clinic visit. Patients in the intervention and comparison groups completed the Revised American Pain Society Patient Outcome Questionnaire during their first postoperative clinic visit. Results were analyzed by the Mann-Whitney U test/Wilcoxon rank sum test. A 12-month project (N = 99) showed statistically significant results (P = .020 and P=.001, respectively) in questions about side effects and whether the patient was encouraged to use nonpharmacologic methods to reduce pain. The intervention group reported the effects of pain on mood (P = .067) and use of nonpharmacologic methods (P=.052); however, these results were not statistically significant. More intervention patients than comparison patients reported medication side effects and were encouraged to use nonpharmacologic methods for reducing postoperative pain. Intervention patients also reported the effects of pain on mood and the use of nonpharmacologic methods more frequently than comparison patients. Preoperative pain management education may increase patients' knowledge in key areas of postoperative pain management to prevent negative outcomes.

A Comparison between office and other ambulatory practices: Analysis from the National Anesthesia Clinical Outcomes Registry.

Ambulatory and office-based surgery is expanding rapidly. While growth continues, there are lingering patient safety concerns. To this end, the American Society of Anesthesiologists (ASA) created the Anesthesia Quality Institute (AQI), which collected patient and procedural characteristics on 23,341,130 anesthetics from all health care settings from 2010 to 2014. Of these, 179,618 office and 4,627,379 ambulatory cases were isolated and compared. Our findings show that although both settings are often grouped together, there are statistically significant differences in patient demographics, procedure types, and reported adverse events. Among these reports, inadequate postoperative pain control and nausea/vomiting are the most common issue. More serious events such as death, cardiac arrest, and vision loss occurred but were rare.

IV Acetaminophen

Inadequate control of postoperative pain after orthopedic procedures may trigger complications that increase morbidity. Multimodal analgesia is used to manage pain effectively after surgical procedures and reduce the need for rescue analgesia. Intravenous (IV) acetaminophen (OFIRMEV; Cadence Pharmaceuticals, Inc.), an analgesic that has been studied and used in the multimodal management of acute pain after major orthopedic procedures, combines the safety seen with oral and rectal formulations with a preferred route of administration. Two double-blind, randomized, placebo-controlled clinical trials were conducted (total 130 patients) to determine the efficacy and safety of single-dose IV acetaminophen in patients following total hip arthroplasty. Although both studies were stopped prematurely, overlap in patient populations, study design, and methodologies in the single-dose phase of these studies allowed for analysis of their results to be presented concurrently. Both trials demonstrated IV acetaminophen having greater efficacy than placebo in terms of primary endpoints [pain intensity differences from T0.5 to T3 (P < 0.05 in both studies)]. The use of IV acetaminophen also reduced the need for rescue opioid consumption, with patients receiving IV acetaminophen consuming, on average, less than half the amount of rescue medication as those receiving placebo. IV acetaminophen was effective in treating moderate-to-severe pain after total hip arthroplasty and reduced the need for rescue opioid consumption.

Preoperative Femoral Nerve Block in Hip Arthroscopic Surgery

Background: The utility of a femoral nerve block as an adjunct for pain management has been recognized for various surgical techniques but has yet to be examined in the preoperative setting as an adjunct to general anesthesia for improved postoperative pain control in hip arthroscopic surgery. Purpose: To evaluate the safety and efficacy of a preoperative femoral nerve block for postoperative pain control in patients undergoing hip arthroscopic surgery. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective chart review of 108 consecutive hip arthroscopic surgery cases (in 103 patients) was carried out. All patients underwent arthroscopic surgery under a general anesthetic with or without a preoperative femoral nerve block. Groups were compared with respect to patient sex, age, and body mass index (BMI); physical status classification according to the American Society of Anesthesiologists (ASA); procedure performed; operative time; total intraoperative morphine-equivalent dose; pain scores (0-10 scale) recorded at 0, 15, 30, 45, and 60 minutes postoperatively in the post-anesthesia care unit (PACU); total morphine-equivalent dose in the PACU; presence of nausea or vomiting in the PACU; time to discharge from the PACU; oxycodone consumption in the surgical day care unit (SDCU); and maximal patient-reported pain score in the SDCU. Results: Twelve cases were excluded from the analysis for a total of 96 cases (in 92 patients). Forty patients had general anesthesia alone (group A), and 56 patients had a preoperative femoral nerve block before the induction of general anesthesia (group B). There was no significant difference between the groups with regard to sex, age, weight, height, BMI, ASA classification, or type of procedure performed. Patients who received a femoral nerve block also received a significantly lower total intraoperative morphine-equivalent dose than did those patients who did not receive a block. Postoperative patient-reported pain scores were lower at all time points for the femoral nerve block group; however, a statistical significance was seen only at the 60-minute postoperative time point. Patients who did not receive a block had significantly higher morphine-equivalent doses in the PACU. There was no difference in the rates of nausea and vomiting and time to discharge from the PACU between the 2 groups. Oxycodone consumption in the SDCU was similar between the groups, but the femoral nerve block group had significantly lower maximal patient-reported pain scores in the SDCU. Two patients in the general anesthesia group were admitted to the hospital postoperatively because of inadequate postoperative pain control. No complications were noted in any patient with regard to the femoral nerve block. Conclusion: A preoperative femoral nerve block is a relatively safe procedure that may decrease the requirement for intraoperative morphine while providing effective postoperative pain control in patients undergoing hip arthroscopic surgery.

Ketamine Decreases Postoperative Pain Scores in Patients Taking Opioids for Chronic Pain: Results of a Prospective, Randomized, Double-Blind Study

Patients prescribed opioids for chronic pain may suffer from inadequate postoperative pain control. Ketamine is an adjuvant demonstrating analgesic and opioid-sparing effects. We hypothesize that an intravenous ketamine infusion in addition to opioid-based patient-controlled analgesia (PCA) improves postoperative pain relief in this patient population. We evaluated 64 patients with chronic pain taking opioids undergoing nononcologic surgery. Patients were randomized to receive either postoperative hydromorphone PCA and continuous ketamine (0.2 mg/kg/hour), or hydromorphone PCA and saline. Patients provided numeric rating scale (NRS) pain scores for "worst," "average," and "least" pain following surgery. The primary outcome measure was change in patients' postoperative NRS scores compared with baseline NRS. Secondary and tertiary outcomes included postoperative day one 24-hour opioid use and the amount of opioid used 24 hours prior to hospital discharge. Fifty-nine patients were included in the analysis. Baseline patient characteristics were similar with the exception of age. Patients using ketamine had decreased "average" pain scores (percent change between postoperative and preoperative NRS) after surgery (13.5% decrease in the ketamine group vs 15.5% increase in NRS in the placebo group, P = 0.0057). There were no differences in "worst" or "least" pain scores or postoperative opioid use. Side effects between groups were similar. Our study demonstrates that a postoperative ketamine infusion at 0.2 mg/kg/hour in addition to opioids results in a statistically significant reduction of "average" pain scores in patients undergoing surgery who take opioids for chronic pain. However, "least" and "worst" pain scores and the amount of opioid used postoperatively did not differ between groups. Thus, the use of a postoperative ketamine infusion at 0.2 mg/kg/hour provides limited benefit in improving pain management for this challenging population.

Pre-operative Femoral Nerve Block in Hip Arthroscopy—A Retrospective Review of 108 Consecutive Cases

Objectives:To evaluate the safety and efficacy of pre-operative femoral nerve block for post-operative pain control in patients undergoing hip arthroscopy.Methods:A retrospective chart review of 108 consecutive hip arthroscopy cases (in 103 patients) was carried out. All patients underwent hip arthroscopy at a single academic centre by two orthpaedic surgeons with advanced fellowship training in hip arthroscopy. All patients underwent arthroscopy under general anaesthetic with our without pre-operative femoral nerve block. Patients were separated into two groups based on the presence or absence of a pre-operative femoral nerve block prior to induction of general anesthesia. Groups were compared with respect to patient gender, age, body mass index (BMI), ASA Physical Status classification, procedure performed, operative time, total intra-operative morphine-equivalent dose, post-anesthesia care unit (PACU) pain scores (0 to 10) recorded at 0, 15, 30, 45, and 60 minutes post-operatively, total PACU morphine-equivalent dose, presence of nausea or vomiting in the PACU, time to discharge from PACU, oxycodone consumption in the surgical day care unit (SDCU), and highest pain score (0 to 10) in the SDCU prior to discharge.Results:Twelve cases were excluded from analysis for a total of 96 cases (in 92 patients). Forty patients had general anesthesia alone (Group A) and 56 patients had a pre-operative femoral nerve block prior to the induction of general anesthesia (Group B). There was no significant difference between the groups with regard to gender, age, weight, height, BMI, ASA classification, or type of procedure performed. Patients who received a femoral nerve block had a significantly shorter operative time and received a significantly lower total intra-operative morphine-equivalent dose than those patients who did not receive a block. Post-operative pain scores were lower at all time points for the femoral nerve block group, however statistical significance was seen only at the 60 minute post-operative time point (p < 0.05). Patients who did not receive a block had significantly higher morphine-equivalent doses in the PACU. There was no difference in rates of nausea and vomiting and time to discharge from the PACU between the two groups. Oxycodone consumption in the surgical day care unit (SDCU) was similar between groups, but the femoral nerve block patients had significantly lower pain scores prior to discharge from the SDCU. Two patients in Group A group were admitted to hospital post-operatively due to inadequate post-operative pain control. No complications were noted in any patient with regard to the femoral nerve block.Conclusion:A pre-operative femoral nerve block is a safe procedure that may decrease the requirement for intra-operative morphine while providing effective post-operative pain control in patients undergoing hip arthroscopy.

Effect of continuous psoas compartment block and intravenous patient controlled analgesia on postoperative pain control after total knee arthroplasty

BackgroundTotal knee arthroplasty (TKA) generates severe postoperative pain in 60% of patients and moderate pain in 30% of patients. Because inadequate postoperative pain control can hinder early physiotherapy and rehabilitation, it is the most influential factor dictating a good outcome. The purpose of this study was to evaluate the effectiveness of continuous psoas compartment block (PCB) in comparison to intravenous patient-controlled analgesia (IVPCA) in TKA patients.Methods40 TKA patients were randomly divided into 2 groups. Group IVPCA (n = 20) received intravenous patient controlled analgesia (IVPCA) for 48 hours. Group PCB (n = 20) received continuous PCB for 48 hours at the fourth intertransverse process of the lumbar using the C-arm. Pain scores, side effects, satisfaction, the length of hospital stay, rescue antiemetics, and analgesics were recorded.ResultsPain scores (VNRS 0-100) were higher in Group IVPCA than in Group PCB. Nausea and sedation occurred more frequently in Group IVPCA than in Group PCB. There were no differences between the groups in the length of the hospital stay, satisfaction scores, and the use of rescue antiemetics and analgesics.ConclusionsContinuous PCB seemed to be an appropriate and reliable technique for TKA patients, because it provided better analgesia and fewer side effects such as nausea and sedation when compared to IVPCA.

Efficacy and safety of fentanyl HCl iontophoretic transdermal system compared with morphine intravenous patient-controlled analgesia for postoperative pain management for patient subgroups

Inadequate postoperative pain control remains a problem for many patients undergoing surgery. This study presents subgroup analyses from a large, randomized, multicentre, European study comparing the efficacy and safety of the fentanyl HCl iontophoretic transdermal system and morphine intravenous patient-controlled analgesia for postoperative pain management. The efficacy and safety of the fentanyl iontophoretic transdermal system and morphine intravenous patient-controlled analgesia were evaluated for patients divided by surgery type, sex, American Society of Anesthesiologists physical status and type of anaesthesia used during surgery. Efficacy measures included a patient global assessment of the method of pain control (a rating of 'good' or 'excellent' was considered as a success rating) and mean last pain intensity scores in the first 24 h. Discontinuation rates and the incidence of adverse events were also evaluated. Numerically similar percentages of patients in most subgroups reported success on the last patient global assessment in the first 24 h for both the fentanyl iontophoretic transdermal system and morphine intravenous patient-controlled analgesia. Similar percentages of investigators reported success ratings on the investigator global assessment at the last assessment for both treatment groups regardless of surgery type, except for the knee surgery subgroup (fentanyl iontophoretic transdermal system, 75%; morphine intravenous patient-controlled analgesia, 95%). Mean last pain intensity scores in the first 24 h after surgery were similar in all subgroups. Rates of patient withdrawals and the incidence of adverse events were generally similar between treatment groups in the patient subgroups. The fentanyl iontophoretic transdermal system and morphine intravenous patient-controlled analgesia are comparably well tolerated and effective methods of pain control, regardless of sex, American Society of Anesthesiologists physical status or the type of anaesthesia used for surgery, and following most surgery types.