Intraoperative Pain Management Research Articles

Perioperative Pain Management Simulation Course: Improving Anesthesia Trainees' Confidence in the Management of Perioperative Pain and the Associated Critical Incidents.

Introduction Pain management is a crucial aspect of patients' perioperative journey and a fundamental duty of every anesthetist. Throughout anesthesia training, there is an emphasis on the management of critical incidents, several of which surround pain management. With changes to the anesthesia curriculum over recent years, variable exposure to training opportunities, and a reduction in clinical hours during training, many trainees report feeling underprepared for their future roles as consultants. However, pain management remains a small fragment of the core anesthesia curriculum with no pain-focused simulation courses currently available across the UK.Simulation has proven to aid learning transfer in complicated and stressful scenarios with a substantial improvement in knowledge retention and prevention of skill loss while eliminating the risk of harm to patients. Aim A novel perioperative pain management simulation course was designed and implemented in the East of England to equip junioranesthesia traineeswith the knowledge, skills, and confidence to manage perioperative pain and the associated critical incidents. Methods A multidisciplinary team (MDT) was involved in the course design. The faculty consisted of anesthesia consultants, trainees, pain nurses, and simulation technicians. The course ran twice over a six-month period both locally and regionally. A blended learning approach was adopted where 17 trainees attended PowerPoint presentations providing an overview of basic pain theories, perioperativepain management, regional anesthesia, and labor analgesia. Trainees then underwent telecasted simulation training using replicated patient notes, imaging, blood gas analysis, and a high-fidelity SimMan®. A debriefing period followed each scenariousing Pendleton'smodel. An anonymized questionnaire was completed by all trainees before and after the course to assess improvement in theirknowledge and confidence levels across fourdomains covering the management of perioperative pain. Results All 17 trainees completed the questionnaire; therefore, the entire dataset was analyzed. The pre-course questionnaire showedthat usinga scale of zero to 10, the vast majority of trainees reported low levels of confidence (<6/10) in the management of chronic pain during the perioperative period (82%), intraoperative pain management (76%),regional anesthesia(88%), and labor analgesia (65%). Following thesimulation training, the results showed an overwhelmingly positive improvement in all 17 trainees' knowledge and confidence across all four tested domains. All 17 trainees (100%) also showed an improvement in their understanding of local pain protocols. The subjective feedback was positive, highlighting the overall usefulness of the course andthat thetailored complexity of each simulation scenario was appropriateto each candidate's prior level of experience. Trainees also reported feeling more confident in starting their anesthesia on-calls. Conclusion This novel simulation course is the first of its kind in pain management. It has shown great improvements in trainee confidence in managing perioperative pain and the associated critical incidents. Subjective feedback has also been positively reassuring. Its inclusion into the East of England anesthesia training programand national training curriculum would greatly enhance trainee's knowledge and experience in pain management in the perioperative setting.

Delayed awakening and its associated factor following general anesthesia service, 2022: a cross-sectional study.

The time to emerge from anesthesia is affected by patient factors, anesthetic factors, the duration of surgery, and preoperative and intraoperative pain management. This study aimed to determine the prevalence and contributing factors of delayed awakening following general anesthesia. A cross-sectional study was conducted from January to June 2022. After getting ethical approval with the permission number S/C/R 37/01/2022, willing patients participate with written informed consent. Chart reviews in the preoperative and postoperative recovery rooms were used to collect data. Frequency and percentage with cross-tabulation were used to provide the descriptive statistics. To determine the predictive variables that were associated with the outcome variable, bivariable, and multivariable logistic regression models were fitted. The statistical significance was evaluated using P-values of 0.05 for multivariable regression. In the current study, a normal emergency occurred in 91.7% of surgical patients receiving general anesthesia, while delayed awakening, emergence with hypoactive, and emergence with delirium occurred in 2.6, 3.9, and 1.8% of cases, respectively. Patients older than 64 years [adjusted odds ratio (AOR): 1.33, 95% CI: 0.83-7.191], being diploma anesthesia providers (AOR: 2.38, 95% CI: 2.05-7.15), opioids (AOR: 2.3, 95% CI: 2.20-5.76), surgery lasting longer than 2h (AOR: 1.91, 95% CI: 1.83-6.14), estimated blood loss of more than 1500ml (AOR: 1.20, 95% CI: 0.62-11.30), crystalloid administration of more than 3000ml (AOR: 3.12, 95% CI: 2.19-7.32), intraoperative hypotension (AOR: 3.37, 95% CI: 2.93-9.41) and extreme body weight, were significantly linked to delayed awakening after general anesthesia. Although delayed emergence is an uncommon condition with a number of contributing causes, it is preventable, and once it has occurred, it presents a challenge for anesthetists.

Incidence of postoperative administration of opioids in dogs undergoing a tibial plateau leveling osteotomy after intra-operative liposomal bupivacaine administration with or without morphine epidural

ObjectiveTo determine the influence of two intraoperative pain management protocols on the need for additional opioids in patients receiving an epidural and periarticular liposomal bupivacaine (PLB) vs. PLB alone in the 12–24 h period after undergoing a TPLO.Study designRetrospective study.AnimalsOne hundred seventy-four dogs with cranial cruciate ligament tears presenting for TPLO.MethodsMedical records of dogs presenting for a unilateral or bilateral cranial cruciate ligament tear who had a TPLO performed were reviewed for signalment, weight, body condition score, and peri-operative pain management protocol. Dogs were divided into two groups: those who received an epidural and PLB, and those who received only PLB. Post-operative opioid administration was recorded for each group.ResultsPatients who received an epidural and PLB received fewer postoperative opioids. There were 36% fewer opioid injections administered to dogs who received epidurals compared to dogs who did not receive epidurals (IRR) (95% CI) = 0.64 (0.45–0.92), P = 0.02). BCS was not a significant predictor of the post-operative opioid requirement (IRR (95% CI) = 1.3 (0.75–2.4), P = 0.38). When adjusting for BCS as a possible confounder, there were 39% fewer opioid injections in dogs who received epidurals than dogs without (IRR (95% CI) = 0.61 (0.42–0.88), P = 0.009).ConclusionsThe incidence of postoperative opioid administration was significantly diminished in patients receiving both an epidural and PLB.Clinical significanceAdministration of an epidural in addition to infiltration of PLB significantly decreased the incidence of postoperative opioid administration in dogs undergoing a TPLO.

V11-10 ANATOMIC TRANSPERINEAL PUDENDAL NERVE BLOCK BEFORE PENILE PROSTHESIS PLACEMENT TO REDUCE IMMEDIATE POSTOPERATIVE PAIN - DESCRIPTION AND OUTCOMES

You have accessJournal of UrologyCME1 Apr 2023V11-10 ANATOMIC TRANSPERINEAL PUDENDAL NERVE BLOCK BEFORE PENILE PROSTHESIS PLACEMENT TO REDUCE IMMEDIATE POSTOPERATIVE PAIN - DESCRIPTION AND OUTCOMES Kieran Lewis, Raevti Bole, Jacquelyn Booher, Lydia Deangelo, Gwendolyn Fuller, Ly Hoang Roberts, Petar Bajic, and Scott Lundy Kieran LewisKieran Lewis More articles by this author , Raevti BoleRaevti Bole More articles by this author , Jacquelyn BooherJacquelyn Booher More articles by this author , Lydia DeangeloLydia Deangelo More articles by this author , Gwendolyn FullerGwendolyn Fuller More articles by this author , Ly Hoang RobertsLy Hoang Roberts More articles by this author , Petar BajicPetar Bajic More articles by this author , and Scott LundyScott Lundy More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003337.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Inflatable penile prosthesis (IPP) is the gold standard surgery for refractory erectile dysfunction, though patients can experience significant pain in the postoperative period. Historically, this pain has been managed with opioid medication, which presents additional risk to patients. Pudendal nerve block (PNB) has long been used for intraoperative pain management in IPP, though knowledge of its impact in the postoperative period is limited. Recently, a multimodal analgesic regimen that included a PNB was shown to reduce pain and opioid use following IPP when compared to opioid medication alone. In this video abstract, we describe a simple and safe pudendal nerve block to reduce postoperative pain in patients undergoing IPP. METHODS: We retrospectively reviewed 10 patients who underwent a transperineal PNB prior to IPP at our institution. To explore its safety, we documented intraoperative complications and 90-day postop complications. We also documented immediate postop pain using the visual analog scale (VAS), immediate postop opioid administration, and patient-reported pain at the first follow-up visit. Our PNB is a single component of an ERAS protocol, which utilizes pre and postoperative gabapentin, meloxicam, and acetaminophen, in addition to intracavernosal lidocaine. RESULTS: Of the 10 patients we reviewed, 0/10 experienced intraoperative complications and in the 90-day period following surgery 0/10 experienced postop complications. The median VAS pain score in the immediate postop period was 2 (IQR=0 – 3), with 5/10 patients receiving fentanyl for pain control in the PACU. Patients that received fentanyl were on average given two 50mcg doses and had a median VAS pain score of 5 prior to the first dose. 9/10 patients reported no pain at first follow-up, with just a single patient reporting mild pain along the scrotum. CONCLUSIONS: In this video abstract, we demonstrate a safe and effective transperineal pudendal nerve block to minimize pain and reduce opioid use in patients following IPP implantation. Our PNB adds minimal pre-op time, does not require ultrasound, and has a low risk of possible complications. For quality control, we reviewed 10 patients who received a PNB before IPP. None of these patients experienced intraoperative or postop complications, demonstrating the safety of the procedure. Additionally, patients reported minimal pain in the immediate postop period and at first follow-up, once again demonstrating the safety and potential efficacy of the nerve block. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1001 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kieran Lewis More articles by this author Raevti Bole More articles by this author Jacquelyn Booher More articles by this author Lydia Deangelo More articles by this author Gwendolyn Fuller More articles by this author Ly Hoang Roberts More articles by this author Petar Bajic More articles by this author Scott Lundy More articles by this author Expand All Advertisement PDF downloadLoading ...

1019: SURGICAL PHARMACISTS PERI-OP[EN] THE DOOR TO IMPROVED TRANSITIONS OF CARE

Introduction: Surgical patients pass through a myriad of transitions of care during their hospitalization. Often in elective procedures, patients will undergo surgery and immediate post-operative care prior to pharmacist profile review. Many patients, however, may be on high-risk medications per the Institute for Safe Medication Practices (ISMP) that need immediate attention in the perioperative setting. Additionally, intensive care units (ICU) are consistently at capacity, and therefore ways to decrease this burden should be optimized. Recognizing this, subspecialty surgical pharmacists began preoperatively reviewing patients. Methods: A pilot process of preemptive patient review of 412 elective surgical patients was established to assess home medications and pertinent past medical history. The goal was to prevent intra- and post-operative medication-related complications that may translate to poor surgical outcomes, admission to the ICU, or increased length of stay. The service line pharmacist would work with the perioperative pharmacist, surgeons, and anesthesiologists to optimize care, discuss potential barriers, and develop a plan. Results: 295 patients (71.6%) were identified to have 1 or more high-risk medications, with a range of 0-6 medications per patient, that required intervention or coordination of care. Some examples of interventions include: reducing missed doses of seizure mediations, identifying patients that may need intra-operative insulin drips to prevent DKA, identifying the need for stress dose steroids perioperatively to avoid shock, preventing post-operative atrial fibrillation by resuming home beta blockers, identifying intrathecal baclofen pumps, facilitating initiation of heart rate and blood pressure lowering medications in patients with strict hemodynamic goals, and coordinating with anesthesiologists and surgeons regarding intraoperative pain management for chronic pain patients. Conclusions: Preoperative review of elective surgical patients’ home medications and pertinent past medical history by a pharmacist can aid in improved transitions of care. Developing care plans and facilitating these transitions has the potential to decrease poor surgical outcomes, avoid unnecessary admission to the ICU, and decrease length of stay.

A national Israeli survey of neuraxial anesthesia for cesarean delivery: pre-operative block assessment and intra-operative pain management

BackgroundNeuraxial protocols for cesarean delivery differ among institutions, with various means of assessing the block prior to incision and managing breakthrough intra-operative pain. The different approaches used to deal with these issues in Israel have not been assessed. MethodsQuestionnaires were distributed to all anesthesiologists working in obstetric units in Israeli hospitals. The survey included several non-identifying respondent details intended to allow a description of the study population as a whole and multiple-choice questions addressing neuraxial techniques, method of pre-operative block assessment and medications used to treat intra-operative pain. ResultsThree hundred and sixty-one doctors completed the survey in 24 medical centers, an 81.1% response rate. Thirteen different protocols for spinal anesthesia and 20 different protocols for epidural anesthesia were described. Nine different protocols for assessment of the block prior to incision were identified, with significant inter-institutional differences (P <0.001). For treatment of intra-operative pain prior to delivery, 35.7% of spinals given and 40% of epidurals given were converted to general anesthesia whereas, after delivery, conversion of spinal to general anesthesia was 18% and epidural to general anesthesia was 18.6%. ConclusionsThere were a variety of spinal and epidural regimens used as well as different methods for assessing the block and managing intra-operative pain. Further studies should be performed to identify optimal techniques for neuraxial anesthesia for pre-operative block assessment and for management of intra-operative pain.

Persistent opioid use in cataract surgery pain management and the role of nonopioid alternatives.

Cataracts are a leading cause of preventable blindness globally. Although care varies between developing and industrialized countries, surgery is the single effective approach to treating cataracts. From the earliest documented primitive cataract removals to today's advanced techniques, cataract surgery has evolved dramatically. As surgical techniques have developed, so have approaches to surgical pain management. With current cataract surgical procedures and advanced technology, anesthesia and intraoperative pain management have shifted to topical/intracameral anesthetics, with or without low-dose systemic analgesia and anxiolysis. Despite this, pain and discomfort persist in some patients and are underappreciated in modern cataract surgery. Although pain management has progressed, opioids remain a mainstay intraoperatively and, to a lesser extent, postoperatively. This article discusses the evolution of pain management in cataract surgery, particularly the use of opioids and the associated risks as well as how ophthalmology can have a positive impact on the opioid crisis.

Regional Anesthesia Use in Pediatric Burn Surgery: A Descriptive Retrospective Series.

Pediatric burns are a common and often devastating injury. Treatment, reconstruction, and rehabilitation are painful experiences. For some, the experience triggers post-traumatic stress disorder and/or a chronic pain syndrome. Given the role pain plays as a major secondary disease, it must be addressed to achieve optimal healing. Regional anesthesia has been used extensively to manage postoperative pain and reduce the need for opioids following other surgical procedures in children. However, regional anesthesia is not widely used in pediatric burn care. We present a descriptive, retrospective case series of 15 pediatric burn patients who received regional anesthesia as part of their intra-operative pain management. In our patient population, we saw low levels of anesthetic as well as opioid usage with well-controlled pain. In this cohort, 93% of patients scored a 0/10 on the Face, Legs, Activity, Cry and Consolability (FLACC) scale for pain by post-anesthesia care unit (PACU) discharge, with an average PACU stay of 70 minutes. Thirty-three percent of patients received no opioids, with the average opioid dose being 0.06mg/kg morphine equivalents. This case series serves to make clinicians aware of the feasibility of use and benefits of regional anesthesia in pediatric burn patients requiring operative repair.

Ultrasound-guided Multiple Nerve Blocks: A Safe and Effective Anesthetic Modality in Geriatric Hip Fracture Patients.

The aim was to compare the feasibility of ultrasound-guided multiple nerve blocks (fascia iliaca compartment block+sacral plexus block+superior cluneal nerve block) with general anesthesia in geriatric hip fracture patients. Ninety-four patients were randomly divided into 2 groups: group N received ultrasound-guided multiple nerve blocks and group G received general anesthesia. Primary outcome measures included perioperative Pain Threshold Index (PTI) and Numerical Rating Scale. Secondary outcome measures comprised the following: (1) perioperative Delirium Index and Short Portable Mental Status Questionnaire; (2) perioperative Comfort Index; (3) perioperative opioid consumption (within 72 hours postoperatively); and (4) postoperative side effects (within 72 h postoperatively). Eighty-seven patients completed the study. Baseline PTI was comparable between the groups. However, intraoperative PTI was significantly lower in group N than in group G. Preoperative and postoperative Comfort Index scores were comparable between the groups. Moderate delirium (24 to 72 h postoperatively) was significantly higher than the baseline in group G. Early moderate delirium (24 h postoperatively) was significantly higher in group G than in group N. Severe delirium was comparable between the groups and within each group. High intraoperative PTI was associated with high opioid consumption. The intravenous sufentanil dose in group G was twice of that in group N. Incidence of nausea and vomiting was similar between the groups. Ultrasound-guided multiple nerve blockade may be an alternative to the common anesthetic procedures used for geriatric hip fracture patients. It provided satisfactory intraoperative pain management and reduced early postoperative cognitive disorders.

Cochlear implantation under local anesthesia in 117 cases: patients’ subjective experience and outcomes

PurposeTo report the outcomes and the patients’ subjective experience of cochlear implantation (CI) performed under local anesthesia (LA). To describe a new form of intraoperative cochlear monitoring based on the patients subjective sound perception during CI.MethodsIn this retrospective case–cohort study, 117 patients underwent CI under LA with (n = 58) or without conscious sedation (n = 59). Included were primarily elderly patients with elevated risks for general anesthesia and recently patients with residual hearing eligible for electro-acoustic stimulation (EAS) (n = 27), in whom hearing could be monitored during the electrode insertion. A 500 Hz test tone was presented and the patient reported of subjective changes in loudness, leading to a modification of the insertion. A questionnaire was sent to all patients in which they assessed their subjective experience.ResultsAll patients were successfully operated under LA without the need to intraoperatively convert to general anesthesia. 90% of the patients reported that the surgery was a positive experience. The vast majority, 90% of patients were satisfied with the overall treatment and with intraoperative pain management and 84% of the patients would opt for local anesthesia again. Cochlear monitoring by the patients’ subjective sound perception enabled for atraumatic insertions as all EAS patients could hear the test tone up to the end of the surgery.ConclusionsCI under LA was well tolerated and recommended by the vast majority of patients. In addition, it offers the possibility to monitor the patients’ hearing during the electrode insertion, which may help to prevent insertion trauma.

A Comparison between Intrathecal Nalbuphine and Fentanyl for Intraoperative Pain Management during Uterine Exteriorization in Cesarean Section: A Randomized Controlled Trial

BACKGROUND: Uterine exteriorization during cesarean section is linked to an increased incidence of visceral pain. AIM: This study explored the ability of intrathecal nalbuphine to alleviate this accompanied pain to be used as an effective safer alternative to fentanyl, as there is almost no study compared between these agents to alleviate visceral pain induced by uterine exteriorization. METHODS: This double-blinded randomized controlled research was done on 135 cases subjected to cesarean section with exteriorization of the uterus. Patients were randomized equally into F, N, and C groups which received 25 μg fentanyl, 800 μg nalbuphine, and 0.5 ml saline, respectively, added to intrathecal 0.5% hyperbaric bupivacaine. The occurrence of visceral and shoulder pain and their VAS, the need for rescue IV fentanyl, adverse events, hemodynamics, and Apgar scores were evaluated. RESULTS: The incidence of visceral pain was 22.2%, 24.4%, and 66.7% for Groups F, N, and C, respectively. Patients who needed rescue IV fentanyl were 6.7%, 11.1%, and 60% for Groups F, N, and C, respectively. The statistical difference regarding these parameters was highly significant (p &lt; 0.0001) between C group and both F and N groups but insignificant between F and N groups. Nausea, shivering, itching, and bradycardia were significantly lower (p &lt; 0.05) in N group in comparison to F and C. HR had a significant difference between F group and both N and C groups. CONCLUSION: Intrathecal nalbuphine is an effective safer alternative to fentanyl to control visceral pain induced by uterine exteriorization during cesarean delivery.

The role of local anaesthesia in intra-operative pain management in dental practice

Intra-operative pain management with the means of local anaesthesia is an important of dental practice. Local anaesthetics are drugs the most commonly used drugs in dentistry, being, at the same time, the safest and most effective pain preventing and pain relieving agents known to medicine.The mechanism of action of local anaesthetics involves interruption of the conduction of nerve impulses. These agents show high affinity for the voltage-dependent sodium channels (Nav), they block them, thus preventing the influx of sodium cations through the membranes of the neuron. The potential threshold is not reached and the potential itself is not present. The potency of local anaesthetic drugs depends primarily on the concentration of the solutions used, while possible side effects depend on the dose. In this paper the characteristics of local anaesthetics used in dental practice were presented as well as characteristics of vasoconstrictors added to anaesthetic solutions. The historical outline, the mechanism of action of local anaesthetics and the currently used both basic and additional methods of anaesthesia are discussed. Possible strategies for improving the effectiveness of anaesthesia by the means of physical and chemical methods were explained. General and local adverse reactions of dental anaesthetics were also discussed, along with ways to prevent and treat them.

Anesthesia For Total Arthroplasty Of The Joints Of The Lower Extremities In Patients With A High Anesthetic Risk

Purpose: to determine the effect of unilateral spinal anesthesia on systemic and central hemodynamics, to identify its side effects in the elderly and senile, with total hip replacement.&#x0D; Materials and methods: 60 patients of geriatric age operated on under unilateral spinal anesthesia were examined. 44 patients underwent total hip arthroplasty (THA), 16 - total knee arthroplasty (TKA). Inclusion criteria: elderly (from 60 to 75 years). For continuous monitoring of the vital functions of the patient, they used the "resuscitation and surgical" monitor UM 300 (LLC UTAS Company Ukraine).&#x0D; Conclusion: Unilateral spinal anesthesia is a safe and highly effective technique that can provide full intraoperative pain management for patients with total hip replacement in a high-risk group of patients.

To Compare the Effectiveness of Non-Opioid Analgesics over Opioids in the Intraoperative Pain Management

To Compare the Effectiveness of Non-Opioid Analgesics over Opioids in the Intraoperative Pain Management

Abstract P1-20-23: Eliminating postoperative opioids for outpatient breast surgery in a large integrated healthcare system

Abstract Introduction: The epidemic of opioid addiction and overdose has become a public health emergency in the United States. Opioids prescribed for postoperative pain management have contributed significantly to this epidemic. At the Permanente Medical Group (TPMG), reducing postoperative opioid prescriptions has become a priority. A pilot study in 2016 led by TPMG breast surgeons showed that pain after lumpectomy can be managed effectively without opioids. The results of this study were disseminated to all TPMG breast surgeons via a February 2017 webinar. In November 2018, TPMG implemented an outpatient Enhanced Recovery After Surgery (ERAS) initiative that included reducing postoperative opioid prescriptions. The objective of our study was to evaluate self-reported changes in TPMG breast surgeon opioid-prescribing practices after these interventions. Methods: An online survey was created to assess perioperative and postoperative practices. This survey was distributed to TPMG breast surgeons before the 2017 educational webinar about non-opioid regimens, and again in June 2019, more than 6 months after the implementation of the outpatient ERAS initiative. Questions included how surgeons manage patient expectations during the initial consultation, surgeons’ preoperative pain medication regimens, intraoperative pain management including nerve blocks, local anesthetics, ketorolac use, and postoperative pain management. We used a chi-square test to compare differences between the two surveys. Results: We received 13 responses from a group of over 100 TPMG breast surgeons in 2017 and 29 responses from 59 surgeons in 2019. Overall, self-reported non-opioid regimens increased between 2017 and 2019, with only 23% of surgeons using these regimens for lumpectomy in 2017 and 79% in 2019 (p&amp;lt;0.001). TPMG Self-Reported Opioid Prescribing Patterns After Lumpectomy, 2017 vs 2019# Opioid Tablets Prescribed After Lumpectomy% of Surgeons Prescribingp-value2017201902379&amp;lt;0.0011 to 10870.9311 to 201570.3921 to 302330.045&amp;gt;30150NAUnspecified153NA Notably, non-opioid regimens were also reported by 66% of surgeons for lumpectomy with sentinel lymph node biopsy (SLNbx), 41% for mastectomy without reconstruction, and 14% for mastectomy with implant-based reconstruction. 2019 Self-Reported Opioid Prescribing Patterns After Different Types of Breast Operations% of Surgeons Prescribing# Opioid Tablets Prescribed, by Type of OperationLumpectomyLumpectomy With Sentinel Lymph Node BiopsyMastectomy Without ReconstructionMastectomy With Reconstruction0796641141 to 1071021311 to 20717282821-3033710&amp;gt;310007Unspecified3333Per plastics00034 Conclusion: Self-reported postoperative opioid prescribing practices for breast surgery have changed significantly after implementation of TPMG initiatives, with the majority of TPMG breast surgeons prescribing no opioids after lumpectomy with or without SLNbx, and many prescribing no opioids after mastectomy. In future work, we aim to validate the self-reported data using pharmacy prescription data from 2017-2019. We also plan to identify perioperative factors that are predictive of successful non-opioid postoperative pain management such as the use of nerve blocks, non-steroidal anti-inflammatory drugs (NSAIDs), gabapentin, and acetaminophen. Citation Format: Avani R Patel, Gillian E Kuehner, Sharon B. Chang. Eliminating postoperative opioids for outpatient breast surgery in a large integrated healthcare system [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-20-23.

P207 COMPARISON OF OPIOID vs OPIOID PLUS LOCAL ANESTHETIC EPIDURAL ADMINISTRATION IN IVOR LEWIS ESOPHAGECTOMY

Abstract Aim of the study was the comparison of single morphine vs morphine plus ropivacaine epidural administration for intraoperative pain management in Ivor Lewis esophagectomy. Background &amp; Methods In a randomized prospective clinical trial, after informed consent, 20 patients were assigned to groups A (n=10): Morphine, and B (n=10=): Morphine and ropivacaine combination, according to the medication they were administered epidurally (ed), when submitted to Ivor Lewis esophagectomy. In both groups’ patients a thoracic epidural (T5-7) was inserted preoperative, and anesthetic protocol was the same, apart from opioid analgesics, that were titrated according to patients’ requirements. In group A morphine 1.5-3mg in 10-12ml normal saline volume, while in group B morphine 1.5-3mg plus ropivacaine 0.25% in a total volume of 10-12 ml were ed administered at least 20min before surgical incision. Opioids requirement, heart rate, arterial blood pressure, increments of muscle relaxant (rocuronium bromide) repetitive doses intraoperatively, and rescue analgesics need and side effects such as nausea, vomiting, drowsiness, respiratory depression and patients’distress in case of leg movement inability were recorded postoperatively. Results Patients’ demographics were similar in both groups. Intraoperatively, group A received significantly higher (p&lt;0.001) fentanyl doses (4-6mcg/kg initially and 2hrs repetitive increments of 1-2mcg) vs group B (2-2.5mcg/kg initially, 4 (40%) patients didn’t require any supplementary dose and the rest 2-3mcg/kg in 1-2 increment doses until the end of operation). Vital signs were stable in both groups. Rocuronium requirement was significantly lower (p&lt;0.001) in group B (apart from initial dose 1mg/kg, which was the same in both groups, group B demanded repetitive dose only before single to two-lumen endotracheal tube replacement, while group A required 0.2-0.3mg increment doses hourly). All patients were transferred awake postoperatively in ICU. None of any group patients demonstrated any side effects, but 3 (30%) group A patients required rescue analgesic (pain score &gt; 4). Conclusion Morphine plus ropivacaine combination administered epidurally seems to provide lower pain scores and reduces the need for extra opioids intra- and postoperatively, and reduces muscle relaxants requirement during operation. Further studies are required to support these findings.

Chronic pain patient and anaesthesia.

Severe chronic pain is often devastating for the affected individuals causing substantial suffering, health impairment, and a very low quality of life, including significant negative consequences for the patient and for society. Patients with complex pain disorders are seen often in relation to anaesthesia. They deserve special attention and require long time hospitalization and multiple contacts with health-care providers after discharge from hospital. A wider adoption of best perioperative and intraoperative pain management practice is required. This paper reviews current knowledge of perioperative and intraoperative pain management and anaesthetic care of the chronic pain patient. The individual topics covered include the magnitude of the problem created by chronic pain, the management of the patients taking various types of opioids, tolerance and opioid induced hyperalgesia and the multidisciplinary approach to pain management. The preventive and preemptive strategies for reducing the opioid needs and chronic pain after surgery are reviewed. The last section includes the role of acute pain services and an example of the implementation of a transitional pain service with the various benefits it offers; for example, the decrease of the opioid dose after discharge from the hospital. Patients also receive the continuity of care, with not only pain relief but also improvements in physical functioning, quality of life and emotional stress.

The Role of Thoracolumbar Fascia in Planar Spread of Quadratus Lumborum Blocks

Injections of local anesthetic in the fascial planes around the quadratus lumborum muscle (QL blocks) are performed for postoperative pain control after abdominal surgeries. Multiple approaches of injecting anesthetic in and around the QL have been reported (anterior, posterior, transmuscular, intramuscular and lateral QL blocks). These techniques vary in terms of ease of administration and extent of analgesia. The extent of the anesthetic spread from this ultrasound‐guided procedure is influenced by the fascial layers surrounding the QL. A limited number of studies on small samples using varying amounts of anesthetic have left open questions regarding the extent of spread of local anesthetic and the best approach. This study evaluates the local anesthetic spread of two ultrasound‐guided lateral QL block approaches that have proven effective in controlling postoperative pain. A methylene blue‐dyed saline solution (40mL per QL block) is injected into fresh frozen cadavers (n=10). With the patient in supine position, the needle tip is placed at either (1) the anterolateral border of the QL deep to the transversalis fascia or (2) anterior to the transversus abdominus muscle superficial to its aponeurosis. Anatomic dissection of the injection plane is then performed to determine the extent of spread of the dyed saline. We hypothesize that the continuity between the transversalis fascia and the anterior layer of the thoracolumbar fascia (anterior to the QL) facilitates the cranial spread of the anesthetic under the lateral arcuate ligament to the endothoracic fascia. This would explain our observed analgesic effect past the umbilical region to dermatomes in the epigastric region (T7–T8). Understanding how QL fascial planes facilitate anesthetic spread will enable intraoperative administration of these blocks to be tailored to specific procedures and facilitate post‐operative recovery after abdominal operations. Improved methods of intraoperative pain management may reduce post‐operative opioid use and support the medical community in addressing the opioid epidemic in the United States.This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Practice and bias in intraoperative pain management: results of a cross-sectional patient study and a survey of anesthesiologists.

BackgroundPerioperative pain carries a considerable risk of becoming persistent; hence aggressive preventive approaches are advocated. Persistently high prevalence of postoperative pain, however, suggests anesthesiologists underuse these strategies. A prospective cross-sectional study of patients in the postanesthetic care unit (PACU) and a survey of anesthesiologists were thus conducted to evaluate practice and uncover bias in intraoperative pain management.MethodsNotes of PACU patients were reviewed and information regarding surgical context, comorbidities, and analgesic administration was retrieved. Variables were analyzed for their predictive properties on pain and intraoperative analgesic management. Furthermore, clinical dose–effect estimates for intraoperative morphine were determined. Finally, anesthesiologists completed a questionnaire comprising statements regarding pain relating to surgical context and morphine administration.ResultsData of 200 patients and 55 anesthesiologists were analyzed. Prevalence of pain in PACU was 28% and was predicted by local anesthetic (LA) and low-dose morphine administration. Additionally, when LA was used, little coanalgesics were employed. These results suggest a restrained approach by anesthesiologists toward intraoperative pain management. It is supported by their reluctance to administer more than 10 mg morphine, despite these individuals regarding this practice as insufficient. The hesitancy toward morphine also transpired in the dose–effect estimates with the average applied dose operating on an ED63 instead of an ED95 level.ConclusionThis study confirmed a high prevalence of pain in PACU. It also indicated conservative intraoperative analgesic administration by anesthesiologists. The modest morphine usage and overreliance on LA application, which are not supported by published evidence, additionally suggest bias in current intraoperative pain management.

Gabapentinoids as a part of multi-modal drug regime for pain relief following laproscopic cholecystectomy: A randomized study

Background:Gabapentinoids have been used as preemptive analgesics for pain management following laparoscopic cholecystectomy. Recently, multimodal analgesic techniques have been found superior to preemptive analgesia alone.Aim:The aim of this study is to evaluate and compare a single preoperative dose of pregabalin 150 mg and gabapentin 300 mg for pain relief following laparoscopic cholecystectomy as a part of multimodal drug regime.Settings and Design:This randomized, single-blind study was conducted after Ethical Committee approval and written informed consent from the patients.Materials and Methods:Fifty patients undergoing laparoscopic cholecystectomy under general anesthesia were randomly allocated to receive either 150 mg pregabalin (Group PG), or 300 mg gabapentin (Group GB) orally, 2 h before surgery. Standard anesthesia induction and maintenance were done. For intraoperative pain management, injection fentanyl 2 μg.kg-1 intravenous (IV) along with injection voveran 75 mg IV and port site infiltration was used. Postoperatively, injection diclofenac 75 mg intramuscular TDS was continued. Severity of postoperative pain (visual analog scale [VAS]), postoperative fentanyl requirement and incidence, and severity of side effects were assessed. When VAS >40 mm or on patient's request, a Fentanyl bolus at an increment of 25–50 μg IV was given as rescue analgesia.Results:Intraoperative fentanyl requirement was 135 ± 14 μg in Group PG and 140 ± 14 μg in Group GB (P = 0.21). Postoperative, fentanyl requirement was 123 ± 18 μg in Group PG and 131 ± 23 μg in Group GB (P = 0.17) There was no statistically significant difference in the VAS score for static and dynamic pain. Time to the first requirement of analgesic was 5.4 ± 1.1 h in Group PG and 4.6 ± 1.6 h in Group GB (P = 0.015). No side effects were observed.Conclusion:We conclude that a single preoperative dose of pregabalin (150 mg) or gabapentin (300 mg) are equally efficacious in providing pain relief following laparoscopic cholecystectomy as a part of multimodal regime without any side effects.