Intravenous Morphine Research Articles

Efficacy of iliopsoas plane block for patients undergoing hip arthroscopy: a prospective, triple-blind, randomized, placebo-controlled trial

BackgroundIntraoperative stretching of the hip joint capsule often generates severe pain during the first 3 hours after hip arthroscopy. The short-lived severe pain mandates high opioid consumption, which may result...

Knowledge and Attitudes of Anesthesia Staff on Pain in the Hospitals of Niamey

Aim of the study: To assess the knowledge and attitudes of anesthesia staff on the management of pain in the hospitals of Niamey. Patients an method: This was a multicenter descriptive cross-sectional study carried out in five hospitals in Niamey (Republic of Niger) from July 3rd to December 3rd, 2021. Were been included in the study, all the anesthesia staff who agreed to answer the questionnaire. The variables studied were: age, gender, seniority, sector of activity and qualification, definition of pain, different types of pain, the impact of pain on the body, tools used for assessment of pain, difference between acute and chronic pain, knowledge about analgesics, the practical attitudes of pain management. The data were intered and processed with Epi info 7.2 software and the Microsoft Office 2019 pack. Results: Our study concerned 106 agents from the anesthesia and resuscitation department of the hospitals that served as our study framework. There is a female predominance of 55.42% with a sex ratio of 0.80. The 45-54 age group was the most represented with 40.07% of cases. The average age of respondents was 44.95 ± 8.9 years. Anesthesia nurses were the most represented with 90.36%. The operating theatre unit was the most represented sector of activity with 85.54%. All the respondents knew the definition of pain. The different types of pains were known by 45.78% of respondents. The most used pain scales were visual analog scale (VAS) and verbal descriptor scale (VDS) respectively in 53.01 % and 12.05 % of cases. Tramadol and paracetamol were the mostly used analgesics respectively in 98.80 % and 97.59%. Intravenous morphine titration was known to 67.47% of the respondents. Only 18.07% of the respondents benefited from a training on the management of pain. Conclusion: The knowledge and attitudes of anesthetists on pain deserve to be updated through theorical and practical training to improve the management of pain in our hospitals.

Erector spinae plane block for post-operative analgesia in thoracolumbar spine surgery: A randomised controlled trial

Background and Aims: Thoracolumbar spine surgery is one of the most painful surgical procedures. This study's primary objective was to evaluate the effect of erector spinae plane (ESP) block on post-operative cumulative morphine consumption at 24 h in patients undergoing thoracolumbar spine surgery. Methods: Seventy adults posted for thoracolumbar spine surgery were randomised into the control group [Number of patients (n)=35], who received general anaesthesia without any nerve block, and the intervention group (n = 35), who received bilateral ultrasound (US)-guided ESP block at the level of spine surgery with 0.25% bupivacaine 20 mL after standard general anaesthesia. Along with intravenous patient-controlled analgesia morphine, post-operative analgesia was standardised for both groups. Total morphine consumption, visual analogue scale (VAS) score to evaluate pain, overall patient satisfaction, and any side effects were compared at 24 h. The statistical analysis was done using Statistical Package for Social Sciences (SPSS Inc., Chicago, IL). Results: Post-operative total morphine consumption at 24 h was significantly decreased in the intervention group compared to the control group [5.69 (1.549) versus 9.51 (1.634) mg; P < 0.001]. Post-operative VAS scores were also significantly decreased in the intervention group at rest (P < 0.001) and on movement (P < 0.001). Patient satisfaction scores were more favourable in the intervention group [3.8 (0.4) versus 3.2 (0.6); P < 0.001]. Post-operative nausea and vomiting were found more in the control group but were not significant (n = 14 versus 8; P = 0.127). Conclusion: US-guided ESP block significantly reduces post-operative morphine consumption and improves analgesia and patient satisfaction without adverse effects in patients undergoing thoracolumbar spine surgery.

Effect of nociception level index-guided intra-operative analgesia on early postoperative pain and opioid consumption: a systematic review and meta-analysis.

Acute postoperative pain remains a critical treatment priority and has prompted a search for technologies and techniques to assist with intra-operative analgesic monitoring and management. Anaesthetists traditionally rely on clinical judgement to guide intra-operative analgesia, but several emerging technologies such as the nociception level index herald the possibility of routine intra-operative analgesia monitoring. However, the impact of devices like nociception level index on postoperative outcomes has not been proven. We undertook a systematic review and meta-analysis of articles which compared nociception level index-guided analgesia to standard care. The primary outcomes were pain intensity and opioid consumption during the first 60-120 min after surgery. Secondary outcomes were the incidence of postoperative nausea and vomiting and duration of stay in the post-anaesthesia care unit. Ten studies, collectively including 662 patients and published between 2019 and 2023, met inclusion criteria for both the qualitative systematic review and quantitative meta-analysis. Risk of methodological bias was generally low or unclear, and six studies reported a significant conflict of interest relevant to their findings. Our meta-analysis was performed using a random-effects model. It found statistically significant benefits of nociception level index-guided analgesia for early postoperative pain (mean (95%CI) difference -0.46 (-0.88 to -0.03) on an 11-point scale, p = 0.03), and opioid requirement (mean (95%CI) difference -1.04 (-1.94 to -0.15) mg intravenous morphine equivalent, p = 0.02). Our meta-analysis of the current literature finds that nociception level index-guided analgesia statistically significantly reduces reported postoperative pain intensity and opioid consumption but fails to show clinically relevant outcomes. We found no evidence that nociception level index-guided analgesia affected postoperative nausea and vomiting nor duration of stay in the post-anaesthesia care unit.

Sufentanil Sublingual Tablet System vs. Intravenous Patient-Controlled Analgesia with Morphine: Postoperative Pain Control and Its Impact in Quality of Recovery.

Patient-controlled analgesia (PCA) is commonly used for postoperative pain control. Although widely used, intravenous (IV) morphine PCA may not be suitable for all patients. Sufentanil sublingual tablet system (SSTS) PCA is a recent technique that has had success as a safe and effective alternative for acute pain management. This study aims to compare both the efficacy and safety of SSTS PCA versus IV morphine PCA in postoperative pain control and the quality of recovery in adult patients following scheduled gynecological or orthopedic surgery. Open-label, parallel-group, randomized controlled trial with 54 patients. The primary outcome was postoperative pain control, while the secondary outcomes included adverse effects associated with two analgesic modalities, total opioid dose required, patient satisfaction, and impact on the quality of postoperative recovery. Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 26.0 (Released 2019; IBM Corp., Armonk, New York, United States). The chi-squared test was used in categorical variables. When distribution was normal, T-student (mean ± standard deviation) was used in continuous variables. In contrast, when distribution was not normal, the Mann-Whitney test (median (minimal-maximal)) was used. The results showed that there was a statistically significant difference in the total dose of opioid used by patients at 24 hours postoperatively, with patients receiving SSTS PCA requiring a higher total dose when compared to those receiving IV morphine PCA. However, there were no statistically significant differences in pain scores, adverse events, or patient satisfaction. The study suggests that both IV morphine and sublingual sufentanil are safe and effective for postoperative pain management.

Long-term, continuous infusion of single-agent dinutuximab beta for relapsed/refractory neuroblastoma: an open-label, single-arm, Phase 2 study

BackgroundShort-term infusions of dinutuximab beta plus isotretinoin and cytokines administered in previous immunotherapy studies in neuroblastoma were associated with severe pain. Here, long-term, continuous infusion of single-agent dinutuximab beta was evaluated in patients with relapsed/refractory neuroblastoma.MethodsIn this open-label, single-arm, Phase 2 study, patients with either refractory or relapsed high-risk neuroblastoma received dinutuximab beta by continuous infusion over 10 days of each cycle, for up to five cycles. The primary endpoint was objective response rate 24 weeks after the end of cycle 5. Secondary endpoints included adverse events, intravenous morphine use, best response, duration of response, and three-year progression-free and overall survival.ResultsOf the 40 patients included, 38 had evaluable response. Objective response rate was 26% and best response rate 37%. Median duration of response was 238 days (IQR 108–290). Three-year progression-free and overall survival rates were 31% (95% CI 17–47) and 66% (95% CI 47–79), respectively. Prophylactic intravenous morphine use and duration of use decreased with increasing cycles. The most common grade 3 treatment-related adverse events were pain, diarrhea, and hypokalemia.ConclusionLong-term continuous infusion of single-agent dinutuximab beta is tolerable and associated with clinically meaningful responses in patients with relapsed/refractory high-risk neuroblastoma.Clinical trial registrationThe study is registered with ClinicalTrials.gov (NCT02743429) and EudraCT (2014-000588-42).

Environmental impact of low-dose methoxyflurane versus nitrous oxide for analgesia: how green is the ‘green whistle’?

BackgroundThe NHS has the target of reducing its carbon emission by 80% by 2032. Part of its strategy is using pharmaceuticals with a less harmful impact on the environment. Nitrous...

Effects of MIdazolam versus MOrphine in acute cardiogenic pulmonary edema and chronic obstructive pulmonary disease: An analysis of MIMO trial

AimsChronic obstructive pulmonary disease (COPD) is an important comorbidity in heart failure. The MIMO trial showed that patients with acute cardiogenic pulmonary edema (ACPE) treated with midazolam had fewer serious adverse events than those treated with morphine. In this post hoc analysis, we examined whether the presence/ absence of COPD modifies the reduced risk of midazolam over morphine. MethodsPatients >18 years old clinically diagnosed with ACPE and with dyspnea and anxiety were randomized (1:1) at emergency department arrival to receive either intravenous midazolam or morphine. In this post hoc analysis, we calculated the relative risk (RR) of serious adverse events in patients with and without COPD. Calculating the CochranMantel-Haenszel interaction test, we evaluated if COPD modified the reduced risk of serious adverse events in the midazolam arm compared to morphine. ResultsOverall, 25 (22.5%) of the 111 patients randomized had a history of COPD. Patients with COPD were more commonly men with a history of previous episodes of heart failure, than participants without COPD. In the COPD group, the RR for the incidence of serious adverse events in the midazolam versus morphine arm was 0.36 (95%CI, 0.1–1.46). In the group without COPD, the RR was 0.44 (95%CI, 0.22–0.91). The presence of COPD did not modify the reduced risk of serious adverse events in the midazolam arm compared to morphine (p for interaction =0.79). ConclusionsThe reduced risk of serious adverse events in the midazolam group compared with morphine is similar in patients with and without COPD.

Comparison of three regimens with inhalational methoxyflurane versus intranasal fentanyl versus intravenous morphine in pre-hospital acute pain management: study protocol for a randomized controlled trial (PreMeFen)

BackgroundPre-hospital pain management has traditionally been performed with intravenous (IV) morphine, but oligoanalgesia remain a recognized problem. Pain reduction is essential for patient satisfaction and is regarded as a measure of successful treatment. We aim to establish whether non-invasive methods such as inhalation of methoxyflurane is non-inferior to intranasal fentanyl or non-inferior to the well-known IV morphine in the pre-hospital treatment of acute pain.Method/designThe PreMeFen study is a phase three, three-armed, randomized, controlled, non-inferiority trial to compare three regimens of analgesics: inhalation of methoxyflurane and intranasal (IN) fentanyl versus IV morphine. It is an open-label trial with a 1:1:1 randomization to the three treatment groups. The primary endpoint is the change in pain numeric rating scale (NRS) (0–10) from baseline to 10 min after start of investigational medicinal product administration (IMP). The non-inferiority margin was set to 1.3, and a sample size of 270 patients per protocol (90 in each treatment arm) will detect this difference with 90% power.DiscussionWe chose a study design with comparison of analgesic regimens rather than fixed doses because of the substantial differences in drug characteristics and for the results to be relevant to inform policymakers in the pre-hospital setting. We recognize that easier administration of analgesics will lead to better pain management for many patients if the regimens are as good as the existing, and hence, we chose a non-inferiority design. The primary endpoint, the change in pain (NRS) after 10 min, is set to address the immediate need of pain reduction for patients with acute prehospital pain. On a later stage, more analgesic methods are often available.SummaryPreMeFen is a non-inferiority randomized controlled trial comparing three analgesic regimens aiming to establish whether inhalation of methoxyflurane or intranasal fentanyl is as good as IV morphine for fast reduction of acute pain in the prehospital setting.

The impact of PECS II blockade in patients undergoing minimally invasive cardiac surgery—a prospective, randomized, controlled, and triple-blinded trial

BackgroundClassic neuraxial techniques, such as thoracic epidural anesthesia, or alternative approaches like the paravertebral block, are not indicated in cardiac surgery due to increased bleeding risk. To provide satisfactory analgesia without the need for excessive opioid use, novel ultrasound techniques gained popularity and are of growing interest. The pectoralis nerve block II (PECS II) has been shown to provide good postoperative analgesia in modified radical mastectomy and might also be suitable for minimally invasive cardiac surgery.MethodsIn a single center, prospective, triple-blinded, two-group randomized trial, 60 patients undergoing elective, unilateral minimal invasive cardiac surgery will be randomized to receive a PECS II with 30 ml of ropivacaine 0.5% (intervention group) or sodium chloride 0.9% (placebo group). The primary outcome parameter is the overall opioid demand given as intravenous morphine milligram equivalents (MME) during the first 24 h after extubation. Secondary endpoints are the visual analog scale (VAS) 2, 4, 6, 8, 12, and 24 h after extubation, the Overall Benefit of Analgesia Score (OBAS) after 24 h, the interval until extubation, and intensive care unit (ICU) discharge within 24 h, as well as the length of hospital stay (LOS).DiscussionThis prospective randomized, controlled, and triple-blinded trial aims to assess if a PECS II with ropivacaine 0.5% helps to decrease the opioid demand in the first 24 h and increases postoperative pain control after minimally invasive cardiac surgery.Trial registrationwww.clinicaltrialsregister.eu; EudraCT Nr: 2021–005452-11; Lukas Gasteiger MD, November 18, 2021.

Neurocognitive effect of biased µ-opioid receptor agonist oliceridine, a utility function analysis and comparison with morphine.

Oliceridine (Olinvyk®) is a μ-opioid receptor agonist that in contrast to conventional opioids preferentially engages the G-protein-coupled signaling pathway. We determined the utility function of oliceridine versus morphine based on neurocognitive tests and cold pressor test. The study had a randomized, double-blind, placebo-controlled, partial block 3-way crossover design. Experiments were performed in 20 male and female volunteers. Subjects received intravenous oliceridine (1 or 3 mg; cohorts of 10 subjects/dose), morphine (5 or 10 mg; cohorts of 10 subjects/dose) or placebo on three separate occasions. Prior to and following dosing, neurocognitive tests, cold pressor test and plasma drug concentrations were obtained at regular intervals. Population pharmacokinetic-pharmacodynamic analyses served as basis for construction of a utility function, which is an objective function of probability of benefit minus probability of harm. Antinociception served as measure of benefit, slowing of saccadic peak velocity and increased body sway as measures of neurocognitive harm. The oliceridine and morphine C50's, i.e. the effect-site concentrations causing 50% effect, were: antinociception 13±2 and 23±7 ng/mL, saccadic peak velocity 90±14 and 54±15 ng/mL, and body sway 10±2 and 5.6±0.8 ng/mL, respectively. The ratio oliceridine/morphine of the therapeutic indices, C50(benefit)/C50(harm), were 0.34 (95% CI 0.17-0.7; p<0.01) for saccadic peak velocity and 0.33 (0.16-0.50; p<0.01) for body sway. The oliceridine utility was positive across the effect-site concentration 5-77 ng/mL, indicative of a greater probability of benefit than harm. The morphine utility was not significantly different from zero from 0-100 ng/mL. Over the concentration range 15-50 ng/mL the oliceridine utility was superior to that of morphine (p < 0.01). Similar observations were made for body sway. These data indicate that over the clinical concentration range, oliceridine is an analgesic with a favorable safety profile over morphine when considering analgesia and neurocognitive function.

Comparison of Ultrasound Guided Transversus Abdominis Plane Block versus Intravenous Patient Controlled Analgesia for Post Operative Analgesia in Parturients Undergoing Cesarean Delivery under General Anesthesia

Abstract Background Cesarean delivery rates are rising, and efficient postoperative pain management is a key priority of women undergoing cesarean delivery. Inadequate pain management in the acute postoperative period is associated with persistent pain, greater opioid use, delayed functional recovery, and increased postpartum depression. In addition to pain relief, optimal management of patients after cesarean delivery should address the goals of unrestricted maternal mobility, minimal maternal and neonatal side effects, rapid recovery to baseline functionality, and early discharge home. Aim of the Work The Primary aim is to compare the efficacy of TAP block versus PCA with IV morphine to Provide Prolonged Post-operative analgesia. Secondary objective is to identify the side effects of both techniques as post operative analgesia. Patients and Methods 74 patients were randomly allocated to one of 2 groups (n=37; each); group A received general anesthesia followed by US-guided TAB block at the end of the operation before extubation using 20 ml bupivacaine 0.25% bilaterally. Group B: received general anesthesia followed by PCA at the end of operation after extubation via dedicated 20 G canula woth disposable PCA pump of 100 ml volume, through continuous infusion of 2 ml/hr &amp; bolus application of 1 ml with 15 min lock time using 50 mg morphine, 60 mg ketorolac, 2 mg granisetrone &amp; filled with 0.9% normal saline. Conclusion when TAP block is given in the volume of 20 mL bilaterally, it is as effective as intravenous Morphine PCA in pain treatment. Compared with intravenous PCA, TAP block can be considered as a more preferable method because it can avoid the systemic actions of morphine used for PCA, and its analgesic effect begins earlier.

Comparison of acetaminophen, ketamine, or ketorolac versus morphine in the treatment of acute renal colic: A network meta-analysis

BackgroundRenal colic is a disease in which a calculus obstructs the urinary tract, resulting in severe pain do ureteric peristaltic movements. Other symptoms, such as hematuria, nausea, and vomiting, may accompany the pain. This network meta-analysis aimed to compare the efficacy and safety of different analgesic agents for the treatment of acute renal colic. MethodsMedline, Embase, and CENTRAL databases were searched. Randomized controlled trials (RCTs) that compared different analgesic agents, either alone or in combination were included. For the management of acute renal colic, analgesic agents were selected based on the current standard medical practice. The medications included intravenous acetaminophen, ketamine, ketorolac, and morphine. This study sought to evaluate the pain score on the visual analog scale (VAS) at 15, 30, and 60 min; adverse events; and the utilization of rescue therapy. The efficacy of different analgesic agents was explored through a frequentist network meta-analysis using the Netmeta statistical package in R software. All treatments were ranked using the Netrank function, yielding P-scores. ResultsTwelve RCTs were deemed eligible. As per the P-scores, acetaminophen was the most effective in reducing pain score at 15 min (P-score = 0.74). Ketorolac was the most effective in reducing the pain score at 30 and 60 min (P-score = 0.84) (P-score = 0.99), whereas morphine was the least effective (P-score = 0.07). Moreover, morphine was correlated with the highest odds of adverse events after treatment (P-score = 0.89). Morphine was the most frequently required rescue therapy in cases of suboptimal pain relief (P-score = 0.96). ConclusionThis network meta-analysis demonstrated that ketorolac and acetaminophen were the most effective analgesic agents according to the pain score. Morphine showed the highest adverse event profile and the highest rate at which rescue therapy was required for the management of acute renal colic.

Nocturnal Hypoventilation in the Patients Submitted to Thoracic Surgery.

Nocturnal hypoventilation may occur due to obesity, concomitant chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, and/or the use of narcotic analgesics. The aim of the study was to evaluate the risk and severity of nocturnal hypoventilation as assessed by transcutaneous continuous capnography in the patients submitted to thoracic surgery. The material of the study consisted of 45 obese (BMI 34.8 ± 3.7 kg/m2) and 23 nonobese (25.5 ± 3.6 kg/m2) patients, who underwent thoracic surgery because of malignant (57 patients) and nonmalignant tumors. All the patients received routine analgesic treatment after surgery including intravenous morphine sulfate. Overnight transcutaneous measurements of CO2 partial pressure (tcpCO2) were performed before and after surgery in search of nocturnal hypoventilation, i.e., the periods lasting at least 10 minutes with tcpCO2 above 55 mmHg. Nocturnal hypoventilation during the first night after thoracic surgery was detected in 10 patients (15%), all obese, three of them with COPD, four with high suspicion of moderate-to-severe OSA syndrome, and one with chronic daytime hypercapnia. In the patients with nocturnal hypoventilation, the mean tcpCO2 was 53.4 ± 6.1 mmHg, maximal tcpCO2 was 59.9 ± 8.4 mmHg, and minimal tcpCO2 was 46.4 ± 6.7 mmHg during the first night after surgery. In these patients, there were higher values of minimal, mean, and maximal tcpCO2 in the preoperative period. Nocturnal hypoventilation in the postoperative period did not influence the duration of hospitalization. Among 12 patients with primary lung cancer who died during the first two years of observation, there were 11 patients without nocturnal hypoventilation in the early postoperative period. Nocturnal hypoventilation may occur in the patients after thoracic surgery, especially in obese patients with bronchial obstruction, obstructive sleep apnea, or chronic daytime hypercapnia, and does not influence the duration of hospitalization.

RETRACTED ARTICLE: The effects of intermittent bolus paravertebral block on analgesia and recovery in open hepatectomy: a randomized, double-blinded, controlled study

BackgroundWe aimed to investigate the effects of intermittent bolus paravertebral block on analgesia and recovery in open hepatectomy.MethodsEighty 18–70 years old, American Society of Anesthesiologists level I-III patients scheduled for hepatectomy with a J-shaped subcostal incision were enrolled and randomized to receive either intermittent bolus paravertebral ropivacaine (0.5% loading, 0.2% infusion) or 0.9% saline infusion at 1:1 ratio (25 ml loading before surgery, 0.125 ml/kg/h bolus for postoperative 48 h). The primary outcome was set as postoperative 48 h cumulative intravenous morphine consumption recorded by a patient-controlled analgesic pump.ResultsThirty-eight patients in each group completed the study. The cumulative morphine consumptions were lower in the paravertebral block than control group at postoperative 24 (difference -10.5 mg, 95%CI -16 mg to -6 mg, P < 0.001) and 48 (difference -12 mg, 95%CI -19.5 mg to -5 mg, P = 0.001) hours. The pain numerical rating scales at rest were lower in the paravertebral block than control group at postoperative 4 h (difference -2, 95%CI -3 to -1, P < 0.001). The active pain numerical rating scales were lower in the paravertebral block than control group at postoperative 12 h (difference -1, 95%CI -2 to 0, P = 0.005). Three months postoperatively, the paravertebral block group had lower rates of hypoesthesia (OR 0.28, 95%CI 0.11 to 0.75, P = 0.009) and numbness (OR 0.26, 95%CI 0.07 to 0.88, P = 0.024) than the control group.ConclusionsIntermittent bolus paravertebral block provided an opioid-sparing effect and enhanced recovery both in hospital and after discharge in patients undergoing hepatectomy. Trial registrationclinicaltrials.gov (NCT04304274), date: 11/03/2020.

The Effectiveness of Intraoperative Thoracic Epidural Analgesia in Major Abdominal and Thoracic Surgery and Its Prediction of Severe Pain at Discharge from the Post-Anesthetic Care Unit: A Prospective Cohort Study

Objective: To assess the factors associated with ineffective thoracic epidural analgesia (iTEA) in the post-anesthesia care unit (PACU) among patients requiring TEA. Material and Methods: This prospective cohort was conducted on 146 patients requiring post-operative TEA. The verbal numeric rating scale (VNRS) was employed to assess TEA effectiveness on PACU arrival at 10, 20, and 30 minutes after surgery; iTEA was determined if the VNRS score was more than 3 and 4 at rest and during activity, respectively. The patient characteristics, and intra- and post-operative epidural management were collected. The risk factors of iTEA were evaluated using mixed-effects models. Moreover, factors associated with severe pain at PACU discharge were evaluated using logistic regression analyses. Results: The incidence of iTEA on PACU arrival, and at 10, 20, and 30 minutes after PACU arrival were 53.4%, 51.4%, 50.7%, and 36.3%, respectively. Intra-operative intravenous morphine supplementation and the cumulative fentanyl equivalent dose (every 10 mcg) were significantly associated with preventing the risk of iTEA on PACU arrival (OR 0.27; 95% CI=0.07-0.92) and during PACU stay (OR 0.87; 95% CI=0.77-0.97) compared to those who did not receive opioids. Moreover, iTEA on PACU arrival was a significant risk for severe pain at 30 minutes (adjusted OR 4.77; 95% CI=1.57-18.10). Conclusion: This study demonstrates a high incidence of iTEA immediately after surgery, and that intravenous opioid supplementation during and after surgery reduces the risk of iTEA. Lastly, iTEA on PACU arrival is a strong predictor of severe pain at discharge from PACU.

Analgesic effectiveness of serratus anterior plane block in patients undergoing video-assisted thoracoscopic surgery: a systematic review and updated meta-analysis of randomized controlled trials

BackgroundSerratus anterior plane block (SAPB) is a promising regional technique for analgesia in thoracic surgery. Till now, several randomized controlled trials (RCTs) have explored the effectiveness of SAPB for postoperative pain control in patients undergoing video-assisted thoracoscopic surgery (VATS), but the sample sizes were small and conclusions remained in controversy. Therefore, we conducted the present systematic review and meta-analysis.MethodsRCTs evaluating the analgesic performance of SAPB, comparing to control methods (no block, placebo or local infiltration anesthesia), in patients undergoing VATS were searched in PubMed, EMBASE, Web of Science and Cochrane Library from inception to December 31, 2022. Mean difference (MD) and corresponding 95% confidence interval (95%CI) were calculated for postoperative pain scores at various time points, postoperative opioid consumption and length of hospital stay. Pooled relative risk (RR) with 95%CI were calculated for the risk of postoperative nausea and vomiting (PONV) and dizziness. A random-effect model was applied.ResultsA total of 12 RCTs (837 participants) were finally included. Compared to control group, SAPB had significant reductions of postoperative pain scores at 2 h (MD = -1.58, 95%CI: -1.86 to -1.31, P < 0.001), 6 h (MD = -2.06, 95%CI: -2.74 to -1.38, P < 0.001), 12 h (MD = -1.72, 95%CI: -2.30 to -1.14, P < 0.001) and 24 h (MD = -1.03, 95%CI: -1.55 to -0.52, P < 0.001), respectively. Moreover, SAPB conferred a fewer postoperative opioid consumption (MD = -7.3 mg of intravenous morphine equivalent, 95%CI: -10.16 to -4.44, P < 0.001) and lower incidence of PONV (RR = 0.56, 95%CI: 0.41 to 0.77, P < 0.001). There was no difference between both groups regarding length of hospital stay and risk of dizziness.ConclusionSAPB shows an excellent performance in postoperative pain management in patients undergoing VATS by reducing pains scores, postoperative opioid consumption and incidence of PONV. However, due to huge heterogeneity, more well-designed, large-scale RCTs are needed to verify these findings in the future.

Perioperative Intravenous Nefopam on Pain Management and Ambulation after Open Spine Surgery: A Randomized Double-Blind Controlled Study.

This was a randomized double-blind controlled study. This study was designed to evaluate the effects of intravenous nefopam regarding its ability to reduce morphine consumption and postoperative pain and improve recovery in patients undergoing open spine surgery. Multimodal analgesia, including nonopioid medications, is essential for pain management in spine surgery. Evidence regarding the use of intravenous nefopam in open spine surgery as part of enhanced recovery after surgery is lacking. In this study, 100 patients undergoing lumbar decompressive laminectomy with fusion were randomized into two groups. The nefopam group received 20-mg intravenous nefopam diluted in 100-mL normal saline intraoperatively, followed by 80-mg nefopam diluted in 500-mL normal saline, administered as a continuous infusion postoperatively for 24 hours. The control group received an identical volume of normal saline. Postoperative pain was managed using intravenous morphine via patient-controlled analgesia. Morphine consumption in the first 24 hours was recorded as the primary outcome. Secondary outcomes, including postoperative pain score, postoperative function, and length of hospital stay (LOS), were assessed. No statistically significant differences in the total morphine consumption and postoperative pain score in the first 24 hours postoperatively between the two groups. At the post-anesthesia care unit (PACU), the nefopam group demonstrated lower pain scores while at rest (p =0.03) and upon movement (p =0.02) than the normal saline group. However, the severity of postoperative pain between the two groups was similar from postoperative day 1 to day 3. LOS was significantly shorter in the nefopam group than in the control group (p <0.01). The time to first sitting and walking and PACU discharge between the two groups were comparable. Perioperative intravenous nefopam demonstrated significant pain reduction during the early postoperative period and shortened LOS. Nefopam is considered safe and effective as a part of multimodal analgesia in open spine surgery.

Combined erector spinae plane block with surgical intercostal nerve cryoablation for Nuss procedure is associated with decreased opioid use and length of stay

Background and objectivesPain management for patients undergoing the Nuss procedure for treatment of pectus excavatum can be challenging. In an effort to improve pain management, our institution added bilateral single...

Comparative Study Between Intravenous Patient-Controlled Analgesia Morphine and Computerized Ambulatory Delivery Device Epidural Morphine for Post Operative Analgesia for Nuss Procedure in Pectus Excavatum: A Retrospective Analysis.

Pectus deformities are commonly seen in chest wall deformities among the pediatric age group. Pectus deformities occur due to defective growth of the sternum and its surrounding cartilage. The Nuss procedure is the technique of choice for correcting the deformity surgically which includes placing a convex bar under the sternum without resection or injury to costal cartilages. Adequate pain control is utmost to improve wound healing, patient satisfaction, short hospital stays, and decrease the financial burden on attendants. Therefore, it is necessary to investigate which analgesic method is more advantageous for the Nuss procedure. To compare the analgesic effects of intravenous patient-controlled analgesia (IVPCA) morphine versus computerized ambulatory delivery device (CADD) epidural morphine on acute post-operative pain management in Nuss procedures. A retrospective study was done at Rajiv Gandhi Cancer and Research Hospital, New Delhi from 2015 to 2020 to assess the efficacy and safety between IVPCA morphine and CADD epidural for post-operative analgesia following pectus excavatum repair. A total of 34 cases of Nuss procedures were taken with 17 cases in each group. Group 1 (intravenous PCA morphine) was given 39 ml normal saline + 6 ml morphine (total 45 ml, 2 mg/ml morphine), set at demand dose 0.5 ml, i.e. 1 mg, lockout interval 7 minutes, doses per hour was six and Group 2 (CADD epidural morphine) was given 42 ml normal saline + 3 ml morphine (1 mg/ml morphine) with continuous infusion at the rate of 0.5 ml/hr. Demand dose 0, lockout interval nil. Visual analog pain scores using a scale of 0-10 and Ramsay Sedation Score (RSS) scores were obtained on arrival at the post-anesthesia care unit, at 12, 24, 48, and 72 hours throughout the subsequent hospital stay. This study yielded positive information about our experience with the pectus post-operative pain management. The mean visual analogscale (VAS) score was lower in Group 1 compared to Group 2 but significantly different at 12 and 72 hours only. The mean RSS score was comparable between groups. The mean hospital stay (days) and requirement of rescue analgesia doses were 3.47±0.51 and 0.12±0.33 in Group 1 and 4.76±0.44, 0.59±1.12 in Group 2. Both IVPCA morphine and CADD morphine were effective in controlling post-surgical pain in the Nuss procedure, but IVPCA morphine was better as compared to CADD morphine in this regard because it was noninvasive, safe, and cost-effectivewith non-significant complications.