Mean Numeric Rating Scale Pain Score Research Articles

Remifentanil at a Relatively Elevated Dose in Active Phase is Safe and More Suitable Than Fixed Lower Dose for Intravenous Labor Analgesia.

Intravenous labor analgesia is recommended as an alternative for parturients who have contraindications to epidural analgesia. There are several opioid analgesics and different administering regimens used in the clinic. This study aimed to compare the effectiveness and safety of two intravenous remifentanil dosage regimens in the first labor stage. One hundred and fifteen parturients with a contraindication to epidural analgesia but were willing to receive systemic labor analgesia were randomized into group A received a fixed dose of remifentanil throughout the first stage of labor, and group B received an elevated dose of remifentanil during the active phase of the first stage both by patient-controlled analgesia (PCA). Maternal numerical rating scale (NRS) pain score and oxygen desaturation, sedation efficacy, satisfaction, as well as maternal and fetal adverse reactions were recorded and compared. The mean NRS pain scores before analgesia and in the latent phase showed no statistically significant difference between the two groups (P > 0.05). However, during the active phase, group B demonstrated significantly lower mean NRS pain scores and lowest pain score compared to group A (P < 0.05). Furthermore, group B exhibited higher overall sedation scores and satisfaction scores in comparison to group A (P < 0.05). The incidence of adverse reactions between the two groups was similar (P > 0.05). Relatively elevated intravenous dosage of remifentanil with PCA during the active phase in the first stage of labor is safe and more effective than a fixed-dosage regimen for labor analgesia. This study was registered with ChiCTR on 24/08/2021 with trial identification number: ChiCTR2100050247. First participant was recruited on 31/08/2021. The last patient was recruited on 12/08/2022.

Efficacy of analgesic and sub-dissociative dose ketamine for acute pain in the emergency department

BackgroundAcute pain accounts for over 70% of Emergency Department (ED) visits. Sub-dissociative dose ketamine (0.1–0.6 mg/kg) is safe and effective for the management of acute pain in the ED. However, the optimal dose of intravenous ketamine that provides effective analgesia and minimizes the risk of adverse effects has yet to be identified. The objective of this study was to describe an effective analgesia dose range of IV ketamine for acute pain in the ED. MethodsThis multi-center, retrospective cohort study evaluated adult patients who received analgesic and sub-dissociative dose ketamine for the management of acute pain between May 5, 2018, and August 30, 2021, in 21 emergency departments at academic, community, and critical access hospitals across four states. Patients were excluded if they received ketamine for an indication other than pain, such as procedural sedation or intubation, or for whom there was incomplete documentation for the primary outcome. Patients who received a ketamine dose <0.3 mg/kg were stratified into the low-dose group, and those who received a dose of 0.3 mg/kg or higher to the high-dose group. The primary outcome was change in pain scores within 60 min using a standard 11-point numeric rating scale (NRS). Secondary outcomes included incidence of adverse effects and use of rescue analgesics. Continuous variables were compared between dose groups using student t-test or Wilcoxon Rank-Sum test. Linear regression was used to assess the association between the change in NRS pain scores within 60 min and dose after adjusting for baseline pain, requiring an additional dose of ketamine, and receiving an opioid. ResultsFrom 3796 patient encounters screened for receipt of ketamine, 384 patients met inclusion criteria including 258 in the low-dose group, and 126 in the high-dose group. The primary reason for exclusion was incomplete documentation of pain scores, or ketamine used for sedation. Median baseline pain scores were 8.2 in the low-dose group and 7.8 in the high-dose group (difference 0.5; 95% CI 0 to 1, p = 0.04). Both groups demonstrated significant reductions in their mean NRS pain scores within 60 min following the first administration of IV ketamine. There were no differences in the change in pain scores between both groups (−2.2 vs −2.6, mean difference 0.4, 95% CI -0.4 to 1.1, p = 0.34). Use of rescue analgesics (40.7% vs 36.5%, p = 0.43) and adverse effects were similar between groups, including early discontinuation of the ketamine infusion (37.2% vs. 37.3%, p = 0.99). Overall, the most common adverse effects were agitation (7.3%) and nausea (7.0%). ConclusionThe analgesic efficacy and safety of high-dose sub-dissociative ketamine (≥0.3 mg/kg) was not superior to low-dose (< 0.3 mg/kg) for the management of acute pain in the ED. Low-dose ketamine <0.3 mg/kg is an effective and safe pain management strategy in this population.

Assessment of Pain in Glaucoma Patients Undergoing Micropulse Transscleral Laser Therapy

This study aimed to assess the pain experienced during micropulse transscleral laser therapy (MPTLT) and overnight thereafter and explore the factors associated with the pain. This prospective study included 100 eyes of 81 glaucoma patients undergoing MPTLT under retrobulbar anesthesia. All patients were asked to rate both types of pain using a numerical rating scale (NRS). The risk factors were explored using multivariable mixed-effects ordinal logistic regression. The mean (SD) NRS pain score during the procedure was 3.57 (3.41) (range 0-10), which included no, mild, moderate, and severe pain in 30 (30%), 33 (33%), 17 (17%), and 20 (20%) eyes, respectively. The mean (SD) NRS score of overnight pain was 2.99 (2.28) (range 0-9), which included no, mild, moderate, and severe pain in 17 (17%), 59 (59%), 17 (17%), and 7 (7%) eyes, respectively. Twenty-seven (27%) eyes reported worse pain overnight than during the procedure. Increased age, initial intraocular pressure, and pain during the procedure were significantly associated with increased overnight pain (p < 0.05). Up to a fourth of eyes had worse pain after discharge. Older age, initial intraocular pressure, and pain during the procedure were risk factors for higher levels of overnight pain.

Efficacy and Safety of Cervical and High-Thoracic Dorsal Root Ganglion Stimulation Therapy for Complex Regional Pain Syndrome of the Upper Extremities

ObjectivesThe purpose of this study was to evaluate analgesic and safety considerations for high thoracic and cervical dorsal root ganglion (DRG) neuromodulation for complex regional pain syndrome (CRPS). We hypothesized that DRG neuromodulation would provide sustained analgesia with complications like that of low thoracic or lumbar electrode implantation. Materials and MethodsA single-center, retrospective study was conducted of patients with CRPS I or II of the upper extremities, refractory to previous therapies, who were treated with DRG neuromodulation in the upper thoracic and cervical spine. The primary outcome was successful DRG therapy, defined as ≥ 50% pain relief on a Numeric Rating Scale (NRS) 0 to 10 pain scale at six months after implantation. A secondary outcome was a reduction in daily opioid use after DRG therapy. ResultsAfter a DRG stimulation trial, 17 of 20 patients (85%) had ≥ 50% improvement in NRS pain and underwent a permanent pulse generator implant, with 100% endorsing ≥ 50% pain relief at six months. Mean NRS pain scores before DRG neuromodulation were 9.3 ± 1.1, with a mean reduction of 5.5 (95% CI, 4.5–6.6; p < 0.001) at six months. Ten patients were taking opioids at baseline; the median (interquartile range) dose was 45 mg (23 to 120) morphine equivalents (MME), which was reduced to 20 MME (15 to 40) at six months. The median reduction in daily MME use was −25 (95% CI, −100 to 20; p = 0.099). Six of 20 patients (30%) experienced a complication: three had lead migration; two experienced paresthesias; and one had a reduction in shoulder mobility. One patient had symptoms of a reversible spinal cord compression immediately after implant, requiring emergent electrode removal. ConclusionsDRG neuromodulation for patients with CRPS of the upper extremities produced clinically important analgesia and reduced opioid use for ≥ six months but was associated with one serious complication.

Cooled and traditional thermal radiofrequency ablation of genicular nerves in patients with chronic knee pain: a comparative outcomes analysis

IntroductionGenicular nerve radiofrequency ablation (GNRFA) is a minimally invasive intervention for patients with chronic knee pain (CKP) not responding to conservative treatments. Few investigations have compared treatment outcomes of cooled-RFA...

Spinal versus general anesthesia for minimally invasive transforaminal lumbar interbody fusion: implications on operating room time, pain, and ambulation.

There has been increasing interest in the use of spinal anesthesia (SA) for spine surgery, especially within Enhanced Recovery After Surgery (ERAS) protocols. Despite the wide adoption of SA by the orthopedic practices, it has not gained wide acceptance in lumbar spine surgery. Studies investigating SA versus general anesthesia (GA) in lumbar laminectomy and discectomy have found that SA reduces perioperative costs and leads to a reduction in analgesic use, as well as to shorter anesthesia and surgery time. The aim of this retrospective, case-control study was to compare the perioperative outcomes of patients who underwent minimally invasive surgery (MIS)-transforaminal lumbar interbody fusion (TLIF) after administration of SA with those who underwent MIS-TLIF under GA. Overall, 40 consecutive patients who underwent MIS-TLIF by a single surgeon were analyzed; 20 patients received SA and 20 patients received GA. Procedure time, intraoperative adverse events, postoperative adverse events, postoperative length of stay, 3-hour postanesthesia care unit (PACU) numeric rating scale (NRS) pain score, opioid medication, and time to first ambulation were collected for each patient. The two groups were homogeneous for clinical characteristics. A decrease in total operating room (OR) time was found for patients who underwent MIS-TLIF after administration of SA, with a mean OR time of 156.5 ± 18.9 minutes versus 213.6 ± 47.4 minutes for patients who underwent MIS-TLIF under GA (p < 0.0001), a reduction of 27%. A decrease in total procedure time was also observed for SA versus GA (122 ± 16.7 minutes vs 175.2 ± 10 minutes; p < 0.0001). No significant differences were found in intraoperative and postoperative adverse events. There was a difference in the mean maximum NRS pain score during the first 3 hours in the PACU as patients who received SA reported a lower pain score compared with those who received GA (4.8 ± 3.5 vs 7.3 ± 2.7; p = 0.018). No significant difference was observed in morphine equivalents received by the two groups. A difference was also observed in the mean overall NRS pain score, with 2.4 ± 2.1 for the SA group versus 4.9 ± 2.3 for the GA group (p = 0.001). Patients who received SA had a shorter time to first ambulation compared with those who received GA (385.8 ± 353.8 minutes vs 855.9 ± 337.4 minutes; p < 0.0001). The results of this study have pointed to some important observations in this patient population. SA offers unique advantages in comparison with GA for performing MIS-TLIF, including reduced OR time and postoperative pain, and faster postoperative mobilization.

A Safety Study for Long-Time Use of a Novel Pain Management Device, AT-04

Abstract Fibromyalgia is a common chronic pain disorder characterized by widespread pain and tenderness in mostly tendon attachments with unknown etiology. Treatment of fibromyalgia is mainly drug and other treatments, especially cognitive behavioral therapy and exercise therapy combined. However, drugs for fibromyalgia have, in general, broad adverse effects. Thus, an unmet medical need remains for effective therapeutic modalities for fibromyalgia. We have recently developed a new magnetic medical device (project code “AT”) that has alternating magnetic fields and stimulates the affected area for pain relief. In the pilot study, AT treatment (twice daily for 10 min) tended to reduce the mean NRS (Numerical Rating Scale) pain score. Moreover, we demonstrated long treatment (30 min) suppressed LPS-induced (Lipopolysaccharide-induced) mRNA IL-6 expression compared with 10-min treatment in vitro. These results assumed that long treatment has high efficiency. To evaluate the safety of long time (120 min/day) AT treatment for 12 weeks. Single center, prospective, open-label, single-arm, intervention study to demonstrate the safety of long-time use of AT in 5 healthy Japanese volunteers to 12 weeks. During the intervention period, all of the adverse events were measured. The represents of AT treatment was 99.8 % in 5 subjects. The average and median exposure time of the study device was 135 min per day and 132 min per day, respectively. There were 3 nonserious adverse events and no serious adverse events during this study. This study tested long-time use of AT among 5 healthy subjects in Japan and showed that it did not pose any significant safety concerns. Because there are in-house in vitro data suggesting that the longer exposure of AT achieves a greater effect, the result of this study may allow us to conduct further studies to confirm more effectiveness and safety of long-time use of AT in a larger scale of clinical trial.

Adjuvant use of melatonin for relieving symptoms of painful diabetic neuropathy: results of a randomized, double-blinded, controlled trial.

The trial aimed to investigate the effectiveness of exogenous melatonin as an adjuvant to pregabalin for relief of pain in patients suffering from painful diabetic neuropathy (PDN). This randomized, double-blind, placebo-controlled trial was carried out between October 2019 and December 2020 in an outpatient specialty clinic in Iran. One-hundred-three type 2 diabetic patients suffering from PDN were randomized into either the melatonin group (n = 52) or the placebo group (n = 51). Besides pregabalin at a dose of 150mg per day, patients started with melatonin or an identical placebo, at a dose of 3mg/day at bedtime for 1week, which was augmented to 6mg/day for further 7weeks. The primary outcomes were changes in mean NRS (numerical rating scale) pain score from baseline to endpoint and responder rate (patients with a reduction of 50% and higher in average pain score compared with baseline). Secondary endpoints were changes in mean NRS pain-related sleep-interference score, overall improvement evaluated by Patient and Clinical Global Impressions of Change (PGIC, CGIC), and impact of the intervention on patient's Health-related quality of life (QOL). All analyses were conducted on an Intention-to-Treat (ITT) analysis data set. At the study endpoint, treatment with melatonin resulted in a considerably higher reduction in the mean NRS pain score in comparison with placebo (4.2 ± 1.83 vs. 2.9 ± 1.56; P-value < 0.001). In terms of treatment responders, a greater proportion of melatonin-treated patients satisfied the responder criterion than placebo-treated patients (63.5% vs. 43.1%). Melatonin also reduced pain-related sleep interference scores more than did placebo (3.38 ± 1.49 vs. 2.25 ± 1.26; P-value < 0.001). Further, at the endpoint, more improvement was also seen in terms of PGIC, CGIC, and Health-related QOL in patients treated with melatonin than placebo. Melatonin was also well tolerated. The present results showed that melatonin as an adjunct therapy to pregabalin might be helpful for use in patients with PDN. However, confirmation of these results requires further studies.

Effectiveness of Focused Shockwave Therapy versus Radial Shockwave Therapy for Noncalcific Rotator Cuff Tendinopathies: A Randomized Clinical Trial.

Background The superiority of focused shockwave therapy (F-SWT) versus radial shockwave therapy (R-SWT) for treating noncalcific rotator cuff tendinopathies remains controversial. This study is aimed at comparing the effectiveness of F-SWT versus R-SWT for the management of noncalcific rotator cuff tendinopathies. Methods A total of 46 patients affected by noncalcific rotator cuff tendinopathies were randomly divided into 2 groups of 23 individuals. Patients in group A received 4 sessions of F-SWT, while patients in group B were treated by 4 sessions of R-SWT. In each session, mean energy flux density (EFD) for F-SW 3000 shots was 0.09 ± 0.018 mJ/mm2 with 5.1 ± 0.5 Hz, while average pressure for R-SW 3000 shots was 4.0 ± 0.35 bar with 3.2 ± 0.0 Hz. Pain level and shoulder function were assessed with the numerical rating scale (NRS) and Constant-Murley Scale (CMS). The primary endpoint was the change in the mean NRS pain score from baseline to 24 weeks after the intervention. Secondary endpoints were changes in the mean NRS pain scores at all other follow-up points, changes in the mean CMS scores, and radiographic findings. Results There were no significant differences between the two groups regarding NRS pain score and CMS score within 24 weeks after intervention (all p > 0.05). However, F-SWT resulted in significantly lower NRS compared with R-SWT at 24 weeks and 48 weeks after treatment (2.7 ± 1.0 vs. 4.5 ± 1.2 and 1.4 ± 1.0 vs. 3.0 ± 0.8, respectively, all p < 0.001). Similar results were found in CMS changes and radiographic findings. Conclusions Both F-SWT and R-SWT are effective in patients with noncalcific rotator cuff tendinopathy. F-SWT proved to be significantly superior to R-SWT at long-term follow-up (more than 24 weeks). This trial is registered with ChiCTR1900022932.

Analgesic efficacy of morphine sulfate immediate release vs. oxycodone/acetaminophen for acute pain in the emergency department.

Previous research demonstrated that administration of Morphine Sulfate Immediate Release (MSIR) results in similar analgesic efficacy to Oxycodone but with significantly lesser degrees of euphoria and reward. The purpose of this study sit to investigate if MSIR combined with Acetaminophen can serve as an opioid analgesic alternative to Oxycodone combined with acetaminophen (Percocet) for acute pain in the Emergency Department (ED). A prospective, randomized, double-blind trial of ED patients aged 18 to 64years presenting with moderate to severe acute pain as defined by an 11-point numeric rating scale (NRS) with an initial score of ≥5 (0=no pain and 10=very severe pain). Patients were randomized to receive either 15mg MSIR combined with 650mg of Acetaminophen or 10mg Oxycodone combined with 650mg Acetaminophen. Patients were assessed at baseline, 30, 45 and 60min. The primary outcome was reduction in pain at 60min. Secondary outcomes include drug likeability and adverse events. 80 patients were enrolled in the study (40 per group). Demographic characteristics were similar between the groups (P>0.05). Mean NRS pain scores at baseline were 8.44 for the MSIR group and 8.53 for the Percocet group (P=0.788). Mean pain scores decreased over time but remained similar between the groups: 30min (6.03 vs. 6.43; P=0.453), 45min (5.31 vs. 5.48; P=0.779), and 60min (4.22 vs. 4.87; P=0.346). Reduction in mean NRS pain scores were statistically significant from baseline to 30, 45 and 60min within each group (P<0.0001 at each time point for both groups). The largest NRS mean difference was from baseline to 60min: 4.2 (95% CI: 3.43 to 5.01) for MSIR group and 3.61 (95% CI: 2.79 to 4.43) for Percocet group. No clinically significant changes or any serious adverse events were observed in either group. MSIR provides similar analgesic efficacy as Percocet for short-term pain relief in the ED, similar rates of nausea/vomiting, and lower rates of likeability of the drug.

Sublingual Sufentanil Tablet System Versus Continuous Morphine Infusion for Postoperative Analgesia in Cardiac Surgery Patients

To assess the effectiveness and side effects of a patient-controlled sublingual sufentanil tablet system for postoperative analgesia after cardiac surgery and to compare it to a nurse-controlled continuous morphine infusion. Prospective, open-label, randomized controlled trial. Single university academic center. Adult patients undergoing cardiac surgery, which included a sternotomy. Sublingual sufentanil tablet system versus nurse-controlled continuous morphine infusion. A total of 483 cardiac surgery patients were screened for eligibility, of whom 64 patients completed the study. No statistically significant differences were found for baseline characteristics between both groups. All mean numeric rating scale (NRS) pain scores from after extubation until intensive care unit discharge were ≤3 in both groups. The cumulative mean NRS pain score from 24 hours after extubation (primary outcome) (t = hours after extubation) was significantly different in favor of the morphine group: (t = 0-24) (0.8 [0.7] v 1.3 [0.8]; p = 0.006). Later cumulative mean pain scores were also in favor of the morphine group: (t = 24-48) (0.2 [0.3] v 0.6 [0.5]; p = 0.001) and (t = 48-63) (0.0 [0.0] v 0.1 [0.2]; p = 0.013). The cumulative opioid dose (in milligrams intravenous morphine equivalents) was significantly higher in the morphine group compared with the sublingual sufentanil group (241.94 [218.73] v 39.84 [21.96]; p = 0.0001). No differences were found for the incidences of postoperative nausea and vomiting, sedation, hypoventilation, bradycardia, or hypotension between both groups (secondary outcomes). Despite resulting in statistically significantly higher pain scores, a patient-controlled sublingual sufentanil tablet system offers adequate analgesia after cardiac surgery and reduces opioid consumption when compared with continuous morphine infusion.

Postoperative Pain Is Correlated with Scaphoid Dorsal Translation following Scapholunate Interosseous Ligament Reconstruction.

Background Dorsal scaphoid translation (DST) has been demonstrated to occur in patients with complete scapholunate interosseous ligament (SLIL) tears. Radiographs and magnetic resonance imaging (MRI) have demonstrated ability to detect DST in patients with documented complete scapholunate (SL) disruption, but the relevance of this parameter to outcomes of reconstruction has not been determined. Purpose The purpose of this article is to determine how radiographic parameters of SL dissociation correlate with postoperative pain and functional outcomes of SLIL reconstruction. Methods We performed a retrospective review of prospectively collected data on a cohort of 14 patients who underwent SLIL repair or reconstruction. Preoperative data included radiographic measurements of carpal posture and alignment (SL angle, radiolunate [RL] angle, SL gap, and DST), self-reported measure of average pain on a numerical rating scale (NRS) of 0 to 10, and the patient rated wrist evaluation (PRWE) survey. Postoperatively, the same data were collected at each follow-up visit. Radiographic parameters were statistically compared with postoperative NRS pain score and PRWE scores. Statistical correlations were calculated using Spearman's correlation coefficient, and mean NRS pain scores were compared using Wilcoxon's rank-sum tests, with an α value of p = 0.05. Results Mean NRS pain scores improved significantly after surgery. Mean DST improved significantly after surgery. The presence of postoperative dorsal scaphoid translation (DST) correlated strongly with postoperative pain. SL angle, RL angle, and SL gap showed no correlation with patient reported pain. There was no correlation with any radiographic parameter and PRWE. Conclusions Our study demonstrates that the presence of DST in postoperative radiographs has a strong correlation with patient reported pain following SLIL reconstruction. We conclude that correction of dorsal translation of the scaphoid is a more sensitive predictor of postoperative pain relief than SL gap, RL angle, or SL angle. Level of evidence This is a Level IV study.

A very early clinical response to treatment with the Janus kinase inhibitor tofacitinib in patients with active rheumatoid arthritis: the dynamics of pain and central sensitization elements

Janus kinase (JK) inhibitors block the intracellular signaling pathways that are responsible for the synthesis of proinflammatory cytokines and mediators, which in turn cause the activation of pain receptors and central sensitization (CS). It is suggested that JK inhibitors can rapidly eliminate pain and reduce the severity of CS.Objective: to evaluate the effect of the JK inhibitor tofacitinib (TOFA) on the intensity of pain and the signs of CS in patients with active rheumatoid arthritis (RA) at 7 and 28 days after therapy initiation.Patients and methods. A study group consisted of 39 patients (79.5% female) (mean age 50.9±11.1 years) with RA (DAS28 5.8±0.6). Of these, 89.7% were seropositive for rheumatoid factor; 82.0% took methotrexate and 18.0% received leflunomide. All the patients were prescribed TOFA 5 mg twice daily due to the inefficacy or intolerance of biological agents. The investigators estimated pain intensity using a Brief Pain Inventory (BPI), rated the presence of a neuropathic pain component (NPC) with the PainDETECT questionnaire, and assessed the signs of CS with the Central Sensitization Inventory (CSI) during the first 4 weeks after TOFA administration.Results and discussion. The patients initially experienced moderate or severe pain (the mean scores of 5.33±2.51 on the numerical rating scale (NRS) included in BPI); 53.8% had signs of CS (CSI scores of ≥40); 17.9% had signs of a NPC (PainDETECT scores of &gt;18). Already on day 7 after the start of TOFA administration, there was a statistically significant decrease in the mean NRS pain intensity scores to 4.06±2.2 (p=0.01) and by 29.4±17.9%, as shown by the patient's assessment of the analgesic effect of therapy (BPI), as well as the severity of CS, namely a decrease in the mean NRS pain score to 35.9±11.2 (p=0.01). On 28 days, the effect became better: there was a reduction in the level of NRS pain to 2.32±1.57 (p&lt;0.001), in pain according to the patient's assessment of the analgesic effect of therapy to 43.6±29.6%; in the median PainDETECT score to 2.5 [0; 8.7] (p&lt;0.001); and in CSI scores to an average of 26.4±13.9 (p &lt;0.001). No serious adverse reactions were noted.TOFA has a rapid analgesic effect, which allows it to be considered as a chooser for pathogenetic therapy in patients with active RA and severe pain, especially in the presence of CS signs and secondary fibromyalgia. Undoubtedly, large-scale, long-term controlled studies with a wider range of estimated parameters are required to clarify the therapeutic potential of TOFA in this patient category. The limitation of this investigation was its open observer design pattern.Conclusion. The use of the JK inhibitor TOFA can achieve a rapid analgesic effect, inter alia due to its effect on CS and NPC.

MP81-11 A MULTICENTER PROSPECTIVE STUDY OF 1008 PATIENTS UNDERGOING MPMRI FUSION-TARGETED BIOPSIES UNDER LOCAL ANESTHESIA: OUTCOMES AND PREDICTORS OF PAIN

You have accessJournal of UrologyProstate Cancer: Detection & Screening VIII (MP81)1 Apr 2020MP81-11 A MULTICENTER PROSPECTIVE STUDY OF 1008 PATIENTS UNDERGOING MPMRI FUSION-TARGETED BIOPSIES UNDER LOCAL ANESTHESIA: OUTCOMES AND PREDICTORS OF PAIN Giancarlo Marra*, Junlong Zhuang, Mattia Beltrami, Alessandro Marquis, Xiaozhi Zhao, Giorgio Calleris, Yansheng Kan, Marco Oderda, Haifeng Huang, Riccardo Faletti, Qing Zhang, Luca Molinaro, Wei Wang, Laura Bergamasco, Hongqian Guo, and Paolo Gontero Giancarlo Marra*Giancarlo Marra* More articles by this author , Junlong ZhuangJunlong Zhuang More articles by this author , Mattia BeltramiMattia Beltrami More articles by this author , Alessandro MarquisAlessandro Marquis More articles by this author , Xiaozhi ZhaoXiaozhi Zhao More articles by this author , Giorgio CallerisGiorgio Calleris More articles by this author , Yansheng KanYansheng Kan More articles by this author , Marco OderdaMarco Oderda More articles by this author , Haifeng HuangHaifeng Huang More articles by this author , Riccardo FalettiRiccardo Faletti More articles by this author , Qing ZhangQing Zhang More articles by this author , Luca MolinaroLuca Molinaro More articles by this author , Wei WangWei Wang More articles by this author , Laura BergamascoLaura Bergamasco More articles by this author , Hongqian GuoHongqian Guo More articles by this author , and Paolo GonteroPaolo Gontero More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000973.011AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Low tolerability due to peri-procedural pain experimented during transperineal (TP) biopsy in an in-office setting using local anesthesia (LA) is considered as one of its major weakness. Nevertheless, no large cohorts analyzed pain outcomes and factors influencing pain of mpMRI-TP fusion biopsies (TPFBx). METHODS: From 2016 to 2019 we included 1008 men undergoing TPFBx under LA in a multicenter prospective study. To evaluate pain scores in different procedural phases (i) and to identify factors associated with severe pain (ii) were the primary outcomes. To develop a model capable of identifying men at higher risk of experiencing severe pain based on most relevant pre-procedural factors was the secondary outcome. We recorded pain scores using a numeric rating scale (NRS) at the time of: i) transrectal US probe insertion; ii) local anesthesia; iii) prostate biopsy. We used the cut-off of NRS>6 to defined severe pain and pre-procedural anxiety. RESULTS: 1008 men undergoing TPFBx under LA were enlisted in our study. Mean NRS pain scores: 3.9±2.1 for LA, 3.1±2.3 for Bx; maximum mean experienced pain was 4.7±2.1. Age and severe anxiety were a protective and risk factor respectively on multivariate analysis, both for severe maximum (age OR 0.96, 95% CI 0.94-0.98; anxiety>6 OR 2.82, 95% CI 1.87-4.27) and for severe biopsy pain (age OR 0.96, 95% CI 0.94-0.99; anxiety>6 OR 2.99, 95% CI 1.83-4.89). Procedural time was also combined with an increased risk of experiencing severe maximum (OR 1.03, 95% CI 1.01-1.06) and severe biopsy pain (OR 1.04, 95% CI 1.00-1.08). The best anxiety cut-off to predict severe pain, selected amongst different anxiety cut offs, was 5 (SEN 65%, SPE 79.45%). Nonetheless, from a clinical perspective, if aiming to test possible anxiety preventive measures effects on pain, an anxiety cut off >6 NRS would decrease to 13% the number of patients being treated whilst identifying 56% of those experiencing severe pain. CONCLUSIONS: TPFBx under LA are tolerable, with highest pain scores recorded in LA-phase. Anesthesia, biopsy and maximum severe pain levels are predicted by severe anxiety thus it may be used to identify those at higher risk of experiencing severe pain and to test the effect of possible anxiety preventive measures to reduce pain in these patients. Our findings need future studies to be validated. Source of Funding: No funding. © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1240-e1240 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Giancarlo Marra* More articles by this author Junlong Zhuang More articles by this author Mattia Beltrami More articles by this author Alessandro Marquis More articles by this author Xiaozhi Zhao More articles by this author Giorgio Calleris More articles by this author Yansheng Kan More articles by this author Marco Oderda More articles by this author Haifeng Huang More articles by this author Riccardo Faletti More articles by this author Qing Zhang More articles by this author Luca Molinaro More articles by this author Wei Wang More articles by this author Laura Bergamasco More articles by this author Hongqian Guo More articles by this author Paolo Gontero More articles by this author Expand All Advertisement PDF downloadLoading ...

Wide Awake Local Anesthesia No Tourniquet (WALANT) - Turkish Patients Perspective

Objectives Recently, wide awake local anesthesia no tourniquet (WALANT) technique has been rapidly increasing in popularity because of its benefits for surgeons, patients, and institutions. In this study, we wanted to evaluate Turkish patients’ operative experiences with different hand surgery procedures under WALANT. Methods There were 138 patients included in this study who were operated under WALANT and accepted to fill a questionnaire during telephone interview. Patients were asked to quantify their pain levels on a numerical rating scale (NRS) and compare the operation to a dental procedure. They were also asked about their expectations and their feelings about re-operation with the same anesthesia method. Results The mean age was 43.5 years, and the mean follow-up was 11.2 months. The mean NRS pain score was 2.3 during local anesthetic administration, and it was 1.2 during surgery. Seventy-six percent of responders reported a better operative experience when compared with dental procedures, and 77.5% of them reported a better operative experience than they had expected. Eighty-eight percent of the patients wished to be operated on with the same anesthesia method for any possible operations in the future. Conclusions We observed that Turkish patients readily adopted the WALANT technique and were satisfied with their operative experience. We advise WALANT technique for a variety of hand surgery procedures.

Anatomic Lead Placement Without Paresthesia Mapping Provides Effective and Predictable Therapy During the Trial Evaluation Period: Results From the Prospective, Multicenter, Randomized, DELIVERY Study

The purpose of this study was to compare the trial success rate between anatomic lead placement (AP) and paresthesia-mapped (PM) lead placement techniques for spinal cord stimulation (SCS) using a nonlinear burst stimulation pattern. Eligible patients with back and/or leg pain with a Numeric Rating Scale (NRS) score of ≥6 who had not undergone previous SCS were enrolled in the study. A total of 270 patients were randomized in a 1:1 ratio to each treatment arm. In the AP group, one lead tip was placed at the mid-body of T8, and the other at the superior endplate of T9. In the PM group, physicians confirmed coverage of the patient's primary pain location. Trial success was a composite of the following: ≥50% patient-reported pain relief at the end of the minimum three-day trial period, physician's recommendation, and patient's interest in a permanent implant. Trial success for AP vs. PM groups was equivalent to 84.4% and 82.3%, respectively. Physicians who performed both techniques preferred AP technique (70% vs. 30%). Procedure times for placement of two leads were 31% shorter in the AP group (p < 0.0001). Decrease in the mean NRS pain score was similar between groups (53.2%, AP group; 53.8%, PM group, p = 0.79). Trial success for patients who went on to an extended trial with tonic stimulation was 50% (5/10) vs. 79% (11/14) for AP group and PM group, respectively (p = 0.2). A total of 13 adverse events were observed (4.5%), most commonly lead migrations and pain around implant site, with no difference between groups. When using a nonlinear burst stimulation pattern, anatomic or PM lead placement technique may be used. Nonresponders to subthreshold stimulation had a higher conversion rate when a PM technique was used. AP resulted in shorter procedure times with a similar safety profile and was strongly preferred by trialing physicians.

90. Impact of patient-controlled analgesia on clinical outcomes after posterior lumbar spinal fusion surgery

BACKGROUND CONTEXT Optimal postoperative pain control is critical after spinal fusion surgery. Significant variability remains in the use of postoperative intravenous opioid patient-controlled analgesia (PCA) and very little data evaluating its utility compared to nurse-controlled analgesia (NCA) in lumbar fusion patients. PURPOSE We performed a retrospective evaluation of posterior lumbar spinal fusion patients being treated postoperatively with patient-controlled analgesia (PCA) and compared their pain-related outcomes to nurse-controlled analgesia (NCA). PCA utilization was independently associated with increased opioid prescription in the postoperative period. After controlling for preoperative opioid use, we found that opioid naive patients have worse pain control with PCA than NCA, and patients with very high opioid consumption (>90 MME/day) had greater rates of opioid-related adverse events with PCA. STUDY DESIGN/SETTING Retrospective clinical study, single institution. PATIENT SAMPLE A retrospective review from a single institution was conducted in consecutive patients treated with posterior lumbar spinal fusion for degenerative pathology. Patients with scoliosis, traumatic, neoplastic, infectious and minimally invasive treatments were excluded. OUTCOME MEASURES Postoperative numerical rating scale (NRS) pain scores, length of stay, and total opioid consumption were collected and compared. Opioid-related adverse events for each patient were also measured. METHODS Patients were divided into two cohorts: those treated postoperatively with PCA or NCA. Outcome measures were compared for patients in groups. Patients were stratified according to preoperative opioid consumption as naive, low (60 morphine milligram equivalents (MME) daily), high (61-90 MME) or very high (>90 MME) for analysis. RESULTS A total of 240 patients were identified: 62 and 178 patients in PCA and NCA groups, respectively. PCA patients had higher mean preoperative opioid consumption compared to the NCA group (49.2 vs 24.3 MME, p=0.009). PCA patients had higher mean opioid consumption in first 72 hours in all preoperative opioid consumption categories. Pain control and adverse event rates were similar between PCA and traditional opioid therapy in the low to high preoperative opioid consumption groups (>0 to 90 MME daily). Opioid naive patients had worse mean and highest NRS pain scores in the first 72 hours (all p 90 MME daily) had a greater rate of opioid-related adverse events (95% vs 70%, p CONCLUSIONS Postoperative PCA utilization is associated with significantly more opioid consumption and equal or worse postoperative pain scores compared to NCA after lumbar spinal fusion surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Intravenous Patient-controlled Analgesia Versus Thoracic Epidural Analgesia After Open Liver Surgery: A Prospective, Randomized, Controlled, Noninferiority Trial.

We conducted a randomized, controlled, noninferiority trial to investigate if intravenous, multimodal, patient-controlled analgesia (IV-PCA) could be noninferior to multimodal thoracic epidural analgesia (TEA) in patients undergoing open liver surgery. The increasing use of minimally invasive techniques and fast track protocols have questioned the position of epidural analgesia as the optimal method of pain management after abdominal surgery. Patients operated with open liver resection between February 2012 and February 2016 were randomly assigned to receive either IV-PCA enhanced with ketorolac/diclofenac (IV-PCA, n = 66) or TEA (n = 77) within an enhanced recovery after surgery protocol. Noninferiority would be declared if the mean pain score on the numeric rating scale (NRS) for postoperative days (PODs) 0 to 5 in the IV-PCA group was no worse than the mean pain score in the TEA group by a margin of <1 point on an 11-point scale (0-10). The primary endpoint, mean NRS pain score was 1.7 in the IV-PCA group and 1.6 in the TEA group, establishing noninferiority. Pain scores were lower in the TEA group on PODs 0 and 1, but higher or equal on PODs 2 and 5. Postoperative hospital stay was significantly shorter for patients in the IV-PCA group (74 vs 104 h, P < 0.001). The total opioid consumption during the first 3 days was significantly lower in the IV-PCA group. IV-PCA was noninferior to TEA for the treatment of postoperative pain in patients undergoing open liver resection.

Effectiveness of Genicular Nerve Cooled Radiofrequency Ablation on Chronic Knee Osteoarthritis Pain

Background: Outside of an invasive total knee arthroplasty, the available therapies for the treatment of pain secondary to knee osteoarthritis (OA) provide marginal and short-lived symptomatic relief. Genicular nerve radiofrequency ablation (RFA) serves as an alternative treatment modality for OA-associated knee pain and disability. Objectives: To quantify the effectiveness of cooled radiofrequency ablation (C-RFA) of the genicular nerves for chronic knee pain secondary to OA. Study Design: Retrospective chart review performed using Redcap, implementing current procedural terminology codes. Setting: An academic pain management center. Methods: Study population included patients treated with C-RFA from April 2015 through June 2017. Numeric Rating Scale (NRS) data were analyzed at 3 time points: 2 weeks, 4-6 weeks, and 7-33 weeks post-RFA (extended follow-up). Primary outcome for statistical analysis was NRS and the change in NRS from baseline at each of the 3 predetermined time points. Differences between the change in NRS and the number of diagnostic blocks performed (1 vs. 2) was evaluated. Correlation between the change in NRS and patient body mass index (BMI) was calculated. Results: Pre-RFA average NRS scores were available for 47 knees from 31 individuals, which were included in the analysis. The mean NRS score decreased by 50% at 2 weeks (n = 33; P &lt; 0.001), 55% at 4-6 weeks (n = 18; P &lt; 0.001), and 26% at 7-33 weeks (n = 18; P = 0.009). Eight patients (12 knees) provided specific data on the total duration of relief following RFA. The mean duration was 39 weeks or approximately 9 months. There were no statistically significant differences between groups receiving 1 versus 2 diagnostic blocks at 2 weeks or 4-6 weeks post- RFA. At 7-33 weeks, those who received 1 block had a decrease in NRS of –3.1, whereas those who received 2 blocks had an increase in NRS of +0.1 (P = 0.008). There was no correlation identified between BMI and change in NRS at any time point. Limitations: This study’s retrospective design inherently leads to a higher risk of selection bias. The sample size was relatively small as a high percentage of patients were lost to follow-up. The primary outcome measure for this study was the change in mean NRS pain score, and the mean of ordinal data with a nonnormal distribution lacks validity in statistical analysis. Conclusions: In this study population, C-RFA of the genicular nerves lead to 50% or greater pain relief at 2 weeks and 4-6 weeks postintervention. A 26% pain relief was achieved at 7-33 weeks, but this did not meet the established minimal clinically important difference cutoff. Two diagnostic genicular nerve blocks did not improve the rate of treatment success when compared to a single diagnostic block. BMI does not appear to correlate with outcomes. Key words: Genicular radiofrequency ablation, genicular RFA, cooled radiofrequency ablation, chronic knee pain, knee osteoarthritis

Transversus thoracis muscle plane block in cardiac surgery: a pilot feasibility study.

Cardiac surgery patients often experience significant pain after median sternotomy. The transversus thoracis muscle plane (TTP) block is a newly developed, single-shot nerve block technique that provides analgesia for the anterior chest wall. In this double-blind pilot study, we assessed the feasibility of performing this novel block as an analgesic adjunct. All patients aged 18-90 undergoing elective cardiac surgery were randomized to the block or standard care control group on admission to the intensive care unit after surgery. Under ultrasound guidance, patients in the block group received the TTP block with 20 mL of either 0.3% or 0.5% ropivacaine bilaterally, based on weight. The control group did not receive any injections. All blocks were performed by a single anesthesiologist, and data collection was performed by blinded assessors. The primary feasibility outcomes were rate of recruitment, adherence, and adverse events. The rate of recruitment was defined as the ratio of patients giving informed consent to the number of eligible patients who were approached to participate. Secondary outcomes included 12-hour and 24-hour Numeric Rating Scale (NRS) pain scores, 24-hour hydromorphone and acetaminophen requirements, time to extubation, time to first opioid administration, and patient satisfaction (on a yes/no questionnaire) at 24 hours. Twenty patients were approached for this study and 19 were enrolled. Eight patients received the intended intervention in each group. The recruitment rate was 95% of all approached eligible patients, and the adherence rate to treatment group was 94%. There were no block-related adverse events. The mean (SD) NRS pain scores at rest were 3.3 (3.2) in the block group vs 5.6 (3.2) in the control group at 12 hours. At 24 hours, the pain scores were 4.1 (3.9) vs 4.1 (3.3) in the block and control group, respectively. The mean (SD) 24-hour hydromorphone administration was 1.9 (1.1) mg in the block group vs 1.8 (0.9) mg in the control group. The TTP block is a novel pain management strategy poststernotomy. The results reveal a high patient recruitment, adherence, and satisfaction rate, and provide some preliminary data supporting safety. NCT03128346.