Method Of Pain Control Research Articles

Postoperative pain control modalities for pectus excavatum repair: A prospective observational study of cryoablation compared to results of a randomized trial of epidural vs patient-controlled analgesia

BackgroundPain following bar placement for pectus excavatum is the dominant factor post-operatively and determines length of stay (LOS). We recently adopted intercostal cryoablation as our preferred method of pain control following minimally invasive pectus excavatum repair. We compared the outcomes of cryoablation to results of a recently concluded trial of epidural (EPI) and patient-controlled analgesia (PCA) protocols. MethodsWe conducted a prospective observational study of patients undergoing bar placement for pectus excavatum using intercostal cryoablation. Results are reported and compared with those of a randomized trial comparing EPI with PCA. Comparisons of medians were performed using Kruskal-Wallis H tests with alpha 0.05. ResultsThirty-five patients were treated with cryoablation compared to 32 epidural and 33 PCA patients from the trial. Cryoablation was associated with longer operating time (101 min, versus 58 and 57 min for epidural and PCA groups, p < 0.01), resulted in less time to pain control with oral medication (21 h, versus 72 and 67 h, p < 0.01), and decreased LOS (1 day, versus 4.3 and 4.2 days, p < 0.01). ConclusionIntercostal cryoablation during minimally invasive pectus excavatum repair reduces LOS and perioperative opioid consumption compared with both EPI and PCA. Level of EvidenceII.

Can Combination of Peripheral Nerve Block and Non-opioidal Patient Controlled Analgesia Be an Effective Postoperative Pain Control Method?

Category:Ankle, Pain medicineIntroduction/Purpose:Even though bone surgery is very painful after operation, there is no established method to control postoperative pain due to efficacy and side effects. Ultrasound-guided peripheral nerve block (PNB) and nonsteroidal anti- inflammatory drugs (NSAIDs) patient controlled analgesia (PCA) can effectively control pain and reduce side effects.Methods:We conducted a prospective study of 150 patients over 18 years of age who underwent bone surgery from June 2018 to December 2018. All operations were performed under anesthetic ultrasound-guided PNB and additional PNB was performed to control postoperative pain. Among the 120 patients who participated in the final study, NSAIDs PCA was used in group A (65 patients) and NSAIDs PCA was not used in group B (55 patients) for pain control. Postoperative management except PCA was same in both groups. Pain scores are measured at 6, 12, 18, 24, 36, 48, and 72 hours after the operation and they were compared using visual analogue scale (VAS) pain scores. Survey was done on satisfaction of patients, and their willingness to reconsider same method of pain control when they undergo same surgery next time. Also, we evaluated possible side effects that might happen during process of controlling pain.Results:VAS pain score were significantly different only at 24 h postoperatively (p=0.004). In Group A, three patients were prescribed 3 amples of pethidine intramuscular injection as rescue analgesic. In group B, 35 patients were prescribed 50 amples of pethidine and 12 patients of them were received additional 18 amples of ketorolac intramuscular injection as rescue analgesic(p=0.000). In group A, all patients were satisfied with the pain control method, but 5 of the group B patients were dissatisfied (p=0.001). 3 patients responded to severe pain after operation and 2 of them due to postoperative nausea and vomiting (PONV). In group A, there were no patients complaining of PONV, but in group B, 5 patients complained of symptoms (p=0.018), and 3 of them were prescribed additional antiemetics (p=0.093).Conclusion:Combined use of ultrasound-guided PNB and NSAIDs PCA seems to be an effective postoperative pain control method in foot and ankle surgery. Because, pain can be effectively controlled and PONV can be reduced.

Effect of Pregabalin on Postcraniotomy Pain in Patients Undergoing Supratentorial Tumor Surgery: A Randomized, Double-Blind, Placebo-Controlled Trial.

Background and Objectives Suboptimal management of postcraniotomy pain causes sympathetic and hemodynamic perturbations, leading to deleterious effects on the neurological system and overall patient outcome. Opioids are the mainstay of postoperative pain management but have various problems when given in high doses, or for prolonged durations in neurosurgical patients. The ideal method of pain control following craniotomy generally relies on a combination of various drugs. Oral pregabalin may be an attractive alternative in these patients. Materials and Methods Sixty, American Society of Anesthesiologists class I and II patients posted for elective supratentorial craniotomy, aged 18 and 60 years, were randomly assigned into three groups of 20 each to receive oral placebo (Group A), pregabalin 75 mg (Group B), or pregabalin 150 mg (Group C) before the induction of anesthesia. At the end of the surgery, patient-controlled analgesia was started with intravenous fentanyl. Visual analog scale (VAS) score was recorded every 2 hours for 24 hours, along with total postoperative fentanyl requirement. Results There were no differences in sex, duration of surgery or anesthesia and total intraoperative fentanyl administered among the three groups. The median postoperative VAS score (Group A—18.0, Group B—20, and Group C—22.0; p = 0.63) was similar in all the groups. However, postoperative fentanyl requirement over 24 hours was least in the group that received 150 mg pregabalin (Group A—190 μg, Group B—240 μg, and Group C—100 μg; p = 0.03). Conclusions Even though pain scores were not significantly different, patients receiving 150 mg oral pregabalin required the least amount of postoperative opioids.

A novel method for pain control: infiltration free local anesthesia technique (INFLATE) for transrectal prostatic biopsy using transcutaneous electrical nerve stimulation (TENS).

To describe a novel method for the control of pain during prostate biopsies, infiltration free local anesthesia technique (INFLATE) for transrectal prostatic biopsies with no further needle insertions for local anesthetic infiltration. A total of 138 men with elevated prostate-specific antigen levels and/or abnormal digital rectal examination findings were included in the study. Of the patients, 73 were assigned to the INFLATE group and 65 to the TRUS-PNB group. Demographic data, PSA levels, findings of digital rectal examinations, and multiparametric prostatic magnetic resonance imaging were recorded. In the INFLATE group, a two-channel TENStem eco basic device with two electrodes was used for pain control during the biopsy. For the TRUS-PNB group, 60mg lidocaine gel was given intrarectally in addition to infiltration of a prilocaine and bupivacaine mixture (5mL of 2% prilocaine + 5mL of 0.25% bupivacaine). Pain perception was assessed using a linear numeric rating scale. The mean ages, BMIs, prostate volumes, and PSA levels were similar between the two groups (p > 0.05). Of the 56 participants with prostate adenocarcinoma, 28 were in the INFLATE group, and 28 were in the TRUS-PNB group with a 40.6% overall cancer detection rate. The mean preoperative and post-operative pain scores during probe insertion, biopsy and post-biopsy were similar between the groups (p > 0.05). The results of the study confirmed that INFLATE for transrectal prostate biopsy using a TENS device could safely and effectively be used for pain control with the advantage of two fewer needle attempts with no increase in significant complications.

Transversus abdominis plan bloğu için ultrason eşliğinde farklı bölgelerden yapılan ölçümler

Amaç: Analjeziklerin yetersiz veya yüksek doz kullanımı giderek önem kazanmaktadır; bu yüzden analjezi yöntemleri her gün geçtikçe gelişmektedir. Transversus abdominis plan (TAP) bloğu ultrason eşliğinde batın cerrahilerinde ağrı kontrolü için yapılan bir yöntemdir. Çalışmamızda Ultrason eşliğinde farklı bölgelerden ölçümler alarak TAP bloğunun hangi bölgeden uygulanması gerektiğini araştırmayı amaçladık.Materyal ve Metot: Çalışmaya 18-65 yaş arası 30 hasta çalışmaya alındı. Ön karın bölgesinden ultrason’nun lineer probu subkostal bölgeden ve krista iliyakanın üstünden anterior aksiler bölge ve mediyal aksiler hatta denk gelecek bölgeden internal oblık kas, eksternal oblik kas, ve transversus abdominal plan kılıf genişliği kaydedildi. Yine bu bölgelerin görüntü netliği (kötü, iyi ve çok iyi olarak ) değerlendirilip kaydedildi.Bulgular: Krista iliyaka üzerinden anterior aksiler hattın (A1) median aksiler hat (A2) ile karşılaştırılmasında alınan ölçümlerde internal oblik kas, eksternal oblik kas, transversus abdominus kası genişlikleri ve transversus abdominus fasiya daha düşük çıkmış ve istatistiksel olarak olarak anlamlı bulunmuştur (P&amp;lt;0,05). Kostal kenar altından anterior aksiler hattın (B1) median aksiler hat (B2) ile karşılaştırılmasında alınan ölçümlerde internal oblık kas ile transversus abdominus fasiya daha düşük çıkmış ve istatistiksel olarak anlamlı bulunmuştur (P&amp;lt;0,05).Sonuç: Medial aksiler hatta anterior aksiler hatta göre ölçümlerin daha yüksek çıkması ve görüntü netliğinin daha iyi olması nedeniyle TAP blok uygulanırken probun mediyal aksiler hat üzerinden yapılması gerektiği kanatindeyiz. Anahtar Kelimeler: Transversus abdominis plan bloğu, Ultrason, Analjezi.

Assessing the Impact of Epidural Analgesia Early Pain Management and Functional Outcomes Following Deformity Surgery: A Retrospective Review

Abstract INTRODUCTION ERAS is a multifaceted, multidisciplinary approach for patients undergoing surgery with the aim of improving patient functional recovery while shortening postop hospital length of stay and reducing readmission rates. ERAS has emerged as an instrumental strategy for improving the quality and value of surgical care and has been shown to reduce healthcare costs and improve patients’ overall satisfaction. ERAS achieves its goals through a multidisciplinary approach, integrating the best practices from multiple healthcare fields into a standardized protocol. These protocols form an integrated continuum of care with 3 broad stages: preparing patients for surgery, reducing the impact of surgery, and enabling faster recovery for patients. Importantly, an essential component of ERAS is effective pain management. Here, we retrospectively assessed the efficacy of ERAS implementation for spinal deformity correction surgery patients at UT Southwestern. METHODS The records of 59 patients who had undergone corrective deformity surgery and were given epidural analgesia as the primary method of early pain control were reviewed. Baseline characteristics such as age, body mass index (BMI), and number of segments fused were evenly matched. Postoperative parameters including distance in physical therapy, length of hospital stay, visual analog scale (VAS) pain scores, number of readmissions, and postoperative complications were compared and contrasted. RESULTS Pain scores were significantly reduced by POD 5 following implementation of ERAS (4.15 vs 2.08, P = .021). Furthermore, ERAS patients achieved higher average ambulatory distance on PODs 5 (259 vs 273), 6 (426.2 vs 528.2), and 7 (424.9 vs 577.5). The amount of blood loss was significantly lower in the ERAS group when compared to the non-ERAS group (1772.73 vs 11168.36, P-value = .007). The ERAS group required less supplemental opioids when compared to the non-ERAS group. CONCLUSION Implementation of a standardized ERAS protocol for spinal-corrective deformity surgery reduced postoperative pain, improved early patient functional recovery, and decreased patient opioid usage.

Multimodal pain management strategies in penile implant recipients

Penile prosthesis insertion can cause significant pain and discomfort. Traditional methods of pain control using narcotics alone have been shown to contribute to drug abuse and/or potential lethal overdose. Multimodal therapies are often used to reduce both pain and narcotic usage following surgery but until recently have been poorly characterized in prosthetic urology. Common medications used as part of an enhanced recovery after surgery are discussed. A prior novel investigation on multimodal therapy that spans the entire peri-operative and post-operative recovery period following penile implantation is also reviewed. Additionally, techniques for performing penile blocks are described with video demonstration of pudendal and penile nerve blocks.

The effect of sacral massage on labor pain and anxiety: A randomized controlled trial.

Nonpharmacologic pain control methods, which are increasingly becoming widespread in coping with labor pain, are the methods that allow women to completely relax without using any medication and direct them to perceive the pain at the lowest level. This study was conducted to determine the effect of sacral massage on labor pain and anxiety. This study was conducted as a randomized controlled experimental study at Bağcılar Hospital, Obstetrics and Gynecology Clinic between March and October 2016. In all, 60 women, 30 of whom were in the control group and 30 of whom were in the experimental group, constituted the research sample. The women in the experimental group were administered a massage to the sacral region for 30 min. The questionnaire form, birth action follow-up form, postpartum interview form, visual analog scale (VAS) and state-trait anxiety inventory were used to collect data in the study. The latent phase VAS averages (3.57 ± 1.43), active phase VAS averages (7.03 ± 1.5) and transition phase VAS averages (8.83 ± 1.78) of the experimental group were found to be statistically significantly lower than those of the control group (P < .05). It was concluded that sacral massage applied during labor reduced women's labor pain, lowered the levels of concern and anxiety, led to greater feelings of satisfaction among pregnant women in terms of labor, positively affected the perception of labor and had no fetal side effects.

Effect of Regular Smooth Breathing on the Intensity of Pain Caused by Dressing Change in Patients with Second-Degree Burns: A Clinical Trial

Background: The pain caused by wound dressing is common in burn patients. Using respiratory techniques is one of the non-pharmacological methods of pain control that has remained understudied in burn patients. Objectives: The aim of this study was to probe the effect of regular smooth breathing on the pain induced by dressing change in patients with second-degree burns. Methods: This clinical trial was performed on 30 qualified patients with second-degree burns. The subjects were chosen through random sampling and assigned to experimental (n = 15) and control (n = 15) groups. The respiratory intervention was carried out in four dressing change sessions for the experimental group while the control group received only the routine care. The data were collected using a demographic questionnaire and a visual analog scale (VAS) for measuring pain intensity. The results were subsequently analyzed in SPSS 23 using the chi-square test, Fisher-exact test, and independent t-test. Results: Pain intensity after dressing was significantly lower in experimental group than control group in all four dressing sessions (P < 0.05). Conclusions: Regular smooth breathing reduces the pain caused by dressing burn injuries. Therefore, this intervention is recommended for burn patients.

Opioids for cancer pain: A growing quandary: Opioid prescriptions for cancer-related pain are facing greater scrutiny amid the nation's spiraling epidemic.

Opioids for cancer pain: A growing quandary: Opioid prescriptions for cancer-related pain are facing greater scrutiny amid the nation's spiraling epidemic.

Multimodal Strategy to Improve Comfort and Reduce Opioid Use After Cesarean Births

Opioids are regularly prescribed as a method of pain control after a cesarean. One in 300 opioid-naïve women become addicted after cesareans. Although nurses strive to ensure appropriate postoperative pain control, we should be responsible in our delivery of opioids. Research has shown that after cesarean, women are often prescribed more opiates at discharge than necessary, which results in increased opportunity for diversion. Therefore, it is necessary for health care providers to address prescribing practices as well as comfort strategies used in managing postoperative pain. To improve use of comfort strategies and nonopiate medications to decrease the amount of opioids required postoperatively as well as to decrease the number of opioids prescribed at discharge for women who underwent cesareans. An interdisciplinary workgroup was convened to assess data on opioid use, provider prescribing practices at discharge, and nursing use of alternative pain relief strategies between January and March 2018. A literature review was performed to identify strategies that had reduced opioid consumption postcesarean and to improve comfort. Nursing staff and health care providers were educated on the initiative. A comfort-measures band was added to the electronic medical record system to increase ease of documentation. Several new strategies for improving comfort and reducing opioid use were incorporated into our multimodal approach. Data were reevaluated August 2018 and compared with preintervention data to assess improvement: preoperative administration of acetominophen (0% vs. 33.3%), education on postoperative comfort strategies (0% vs. 100%), regular use of simethicone (45% vs. 100%), postoperative gum chewing (0% vs. 25%), abdominal binder use (50.7% vs. 58.3%), and lower prescribed opioid dose at discharge (28% ≤ 20 tablets at discharge vs. 100% ≤ 20 tablets at discharge). Although we noted modest improvement in some areas, we believe the new documentation process may have hampered our improvements, because many nurses reported being unaware of where to document their efforts. Nurses have an important role in intervening and educating patients about the use of nonopioid pain-relief strategies. This, in turn, may affect patients’ opiate consumption, both inpatient and after returning home.

Clinical and imaging characteristics of patients with extreme low back pain or sciatica referred for spinal injection.

To analyze the causes of pain, imaging characteristics, and therapeutic effect of spinal injection in patients with extreme low back pain or sciatica. We analyzed 381 consecutive patients with extreme low back pain or sciatica visiting our spinal intervention center between January and December 2017. Clinical and imaging characteristics were analyzed. The treatment response, defined as a numerical pain rating scale decrease of ≥ 30%, was measured. Fisher's exact test was performed to identify the association between the injection response and subsequent lumbar surgery rate. The most frequent cause of pain was spinal stenosis, followed by herniated intervertebral disc, facet osteoarthritis, and osteoporotic compression fracture. A herniated intervertebral disc was the most common disorder in patients < 50years of age, while spinal stenosis was the most common in patients ≥ 50years of age. Women comprised 66.4% of the study population. The majority of lumbar pathologies occurred below L3/4. Spinal injection was found to be effective in 44.2% of cases. Those who responded to the injection showed a significantly lower rate of lumbar surgery within 6months (P = 0.004). Those with extreme low back pain or sciatica had clinical and imaging characteristics similar to those with typical low back pain referred for spinal injection. Spinal injection could be an effective method of pain control for patients with extreme low back pain or sciatica.

Associated factors with the knowledge of nurses of a high complexity oncology centre in Brazil, on the management of cancer pain

Pain is one of the most prevalent symptoms in cancer patients and may be directly related to cancer or to the procedures needed for its diagnosis and treatment. It is estimated that about 40% of cancer patients receive inadequate treatment for painful conditions. Among the barriers to adequate pain management are inadequate knowledge and the dysfunctional beliefs of healthcare professionals. Therefore, the present study aims to assess the knowledge of oncology nurses on the management of pain, as well as the factors associated with it. It is a cross-sectional study with 126 nurses working at a High Complexity Oncology Centre in Brazil. Knowledge about the management of cancer pain was evaluated through the instrument ‘Nurses’ Knowledge on Cancer Pain Management—World Health Organization—developed by Ramos (1994). In the analysis of the association between knowledge about pain management and the independent variables, Poisson regression was used with robust variance, and values of p ≤ 0.05 were considered statistically significant. Adequate knowledge prevalence was 54.1% confidence intervals (CI 5.40%–62.80%). These nurses differed in relation to those with inadequate knowledge regarding the source of knowledge about pain, the ethical aspects in the treatment of the patient with oncologic pain, and non-pharmacological methods (coeliac plexus neuroleptic block) for pain control. Also, the factors associated with adequate knowledge were longer professional experience time ([10–19 years (ratio prevalence (RP) = 1.72, 95% CI: 1.05–2.81), 20–29 years (RP = 2.56, 95% CI: 1.63–4.02), 30–39 years (RP = 3.45, 95% CI: 2.25–5.29]), and not believing that the use of opioids causes harm to patients corresponded with a greater chance prevalence ratio (PR = 1.20, 95% CI: 1.12–1.20) of having adequate knowledge. The findings of the study point to the need for continuing education, updated education, and reflection, especially for nurses with less professional experience.

Utilizing Ultrasound-Guided Femoral Nerve Blocks and Fascia Iliaca Compartment Blocks for Proximal Femur Fractures in the Emergency Department

Proximal femur fractures (PFF) are one of the many common injuries that present to the emergency department (ED). The current practice for pain management utilizes systemic opioid analgesics. The use of opioids is an excellent analgesic choice, but they carry a significant burden for potential adverse effects. It is vital that providers have a variety of approaches to acute pain control. The use of femoral nerve blocks (FNBs) and fascia iliaca compartment blocks (FICB) are an alternative method of pain control in the ED. They have advantages over systemic opiates in that they do not require hemodynamic monitoring, have less adverse effects, and more importantly they induce rapid pain control with longer duration than systemic analgesics (). This manuscript examines a review of literature and identifies the efficacy, patient safety, indications, contraindications, patient satisfaction, and ultrasound-guided FNB and FICB techniques.

Contemporary concepts of pain surgery.

Pain surgery is one of the historic foundations of neurological surgery. The authors present a review of contemporary concepts in surgical pain management, with reference to past successes and failures, what has been learned as a subspecialty over the past 50 years, as well as a vision for current and future practice. This subspecialty confronts problems of cancer pain, nociceptive pain, and neuropathic pain. For noncancer pain, ablative procedures such as dorsal root entry zone lesions and rhizolysis for trigeminal neuralgia (TN) should continue to be practiced. Other procedures, such as medial thalamotomy, have not been proven effective and require continued study. Dorsal rhizotomy, dorsal root ganglionectomy, and neurotomy should probably be abandoned. For cancer pain, cordotomy is an important and underutilized method for pain control. Intrathecal opiate administration via an implantable system remains an important option for cancer pain management. While there are encouraging results in small case series, cingulotomy, hypophysectomy, and mesencephalotomy deserve further detailed analysis. Electrical neuromodulation is a rapidly changing discipline, and new methods such as high-frequency spinal cord stimulation (SCS), burst SCS, and dorsal root ganglion stimulation may or may not prove to be more effective than conventional SCS. Despite a history of failure, deep brain stimulation for pain may yet prove to be an effective therapy for specific pain conditions. Peripheral nerve stimulation for conditions such as occipital neuralgia and trigeminal neuropathic pain remains an option, although the quality of outcomes data is a challenge to these applications. Based on the evidence, motor cortex stimulation should be abandoned. TN is a mainstay of the surgical treatment of pain, particularly as new evidence and insights into TN emerge. Pain surgery will continue to build on this heritage, and restorative procedures will likely find a role in the armamentarium. The challenge for the future will be to acquire higher-level evidence to support the practice of surgical pain management.

Efficacy and cost savings with the use of a\xa0minimal sedation / anxiolysis protocol for intra-articular corticosteroid injections in children with juvenile idiopathic arthritis: a retrospective review of prospectively collected data

BackgroundIntra-articular corticosteroid injections (IACI) are frequently used in the treatment of juvenile idiopathic arthritis. There is a paucity of evidence-based research describing methods of pain and anxiety control for this procedure. IACI were mostly performed under general anesthesia for children younger than 13 years old in our institution as of 2014. We started to integrate sedation services more commonly in our institution with the minimal sedation/anxiolysis (MSA) protocol outlined as an alternative to general anesthesia for IACI in 2015. The purpose of this study was to evaluate the effectiveness and cost savings of a minimal sedation protocol for intra-articular corticosteroid injections in juvenile idiopathic arthritis patients after instituting this protocol at our institution.MethodsThe MSA protocol included nitrous oxide, intranasal fentanyl, a topical numbing agent, acetaminophen, ibuprofen, ondansetron and child life intervention. A retrospective review of prospectively collected data was performed on a total of 80 consecutive patients with juvenile idiopathic arthritis who underwent joint injections using the protocol.ResultsThe procedure was successfully completed in greater than 95% of the patients. The median pain score (measured on a verbal numeric scale of 0–10) reported by the patient was 1 (IQR 0–2.5), by the parent 1 (IQR 0–2), by the rheumatologist 1 (IQR 0–1), and by the sedationist 1 (IQR 0–1). Degree of motion during the procedure was reported by the rheumatologist and the sedationist as none in 68% of the patients, mild in 36% and moderate in 6%. Patient, parent, rheumatologist and sedationist rated satisfaction as very high in the vast majority (94%). Emesis was reported in only 2 (2.5%) patients, no significant adverse events were reported, and no patients progressed to a deeper level of sedation than intended. Financial analysis revealed a 33% cost reduction compared with the use of general anesthesia in the operating room.ConclusionsA minimal sedation/anxiolysis protocol (including nitrous oxide, intranasal fentanyl, a topical numbing agent, acetaminophen, ibuprofen, ondansetron and child life intervention), provides safe and effective analgesia for intra-articular corticosteroid injection in a subset of patients with juvenile idiopathic arthritis and offers a lower cost alternative to general anesthesia.

What is the most effective local anesthesia for transrectal ultrasonography-guided biopsy of the prostate? A systematic review and network meta-analysis of 47 randomized clinical trials

We aimed to compare the effectiveness of various local anesthetic methods for controlling prostate biopsy (PBx) related pain using network meta-analysis. Literature searches were performed on PubMed/Medline, Embase, and Cochrane Library up to March 2018. Forty-seven randomized controlled trials, in which the effectiveness of PBx-related pain was investigated using a visual analogue scale after various local anesthetic methods, were included. The local anesthetic methods included intraprostatic local anesthesia (IPLA), intrarectal local anesthesia (IRLA), intravenous sedation (IVS), periprostatic nerve block (PNB), pelvic plexus block (PPB), and spinal anesthesia (SPA). Eight pairwise meta-analyses and network meta-analyses with 21 comparisons were performed. All modalities, except single use of IPLA and IRLA, were more effective than placebo. Our results demonstrate that PNB + IVS (rank 1) and SPA (rank 2) were the most effective methods for pain control. The followings are in order of PPB + IRLA, PNB + IPLA, PPB, PNB + IRLA, IVS, and PNB. In conclusion, the most effective way to alleviate PBx-related pain appears to be PNB + IVS and SPA. However, a potential increase in medical cost and additional risk of morbidities should be considered. In the current outpatient setting, PPB + IRLA, PNB + IPLA, PPB, PNB + IRLA, and PNB methods are potentially more acceptable options.

The Efficacy and Safety of Combined Adductor Canal Block with Periarticular Anesthetic Injection Following Primary Total Knee Arthroplasty: A Meta-Analysis

Objective: Recently, there has been an increasing interest in combined adductor canal block (ACB) with periarticular anesthetic injection (PAI) as a technique to control postoperative pain in total knee arthroplasty (TKA). This study evaluated the analgesic efficacy and safety of the combined therapy for early postoperative pain treatment after TKA. Methods: From the inception to July 2018, two independent investigators used the following electronic databases to search existing literature: PubMed, Embase, Medline, and Web of Science. The primary outcome was pain scores, while secondary outcome measures included opioid consumption, distance walked, length of stay (LOS), and opioid-related adverse effects. Results: A total of 10 studies were included. In the outcomes of ACB + PAI versus PAI, ACB + PAI was associated with statistically significant lower pain scores on POD 0-1 (whether at rest or during movement), lower opioid consumption on POD 0-1, more distance walked on POD 1. In the outcomes of ACB + PAI versus ACB, ACB + PAI was associated with statistically significant lower pain scores on POD 0 and 1 (whether at rest or during movement), lower opioid consumption on POD 1, more distance walked on POD 1. No significant benefits of combined therapy in pain scores, opioid consumption, and distance walked were observed on POD 2. Similarly, there were no significant differences between groups in opioid-related adverse effects, and LOS. Conclusions: There is evidence that combined therapy is more effective than single therapy within 48 h following primary TKA. Applying combined therapy appears to be an effective and safe method for pain control.

Open reduction and internal fixation of ankle fracture using wide-awake local anaesthesia no tourniquet technique

IntroductionAnkle fractures frequently occur and must be treated with open reduction for long-term stability. The existing anaesthesia methods include general anaesthesia, spinal and epidural anaesthesia, peripheral nerve block and local anaesthesia with IV sedation. However, each method has its inherent risks and potential costs, and the use of a tourniquet is inevitable. Therefore, the wide-awake local anaesthesia no tourniquet (WALANT) technique provides an alternative method for equivalent haemostasis and pain control without the use of a tourniquet. Patients and methodsWe prospectively enrolled 13 consecutive patients (9 males and 4 females) who presented ankle fractures and required ORIF from January 2017 to December 2017. The fracture types of the 13 patients included lateral malleolar fracture (three patients), bimalleolar fracture (two patients), bimalleolar equivalent fracture (three patients), medial malleolar fracture (two patients) and trimalleolar fracture (three patients; articular surface involvement <25%). We used a solution of 1% lidocaine mixed with 1:40,000 epinephrine for WALANT. ResultsAll patients underwent surgery if they exhibited an initial numerical pain rating scale (NPRS) score of 0 without using a tourniquet. Only two patients required an additional 5 ml of local anaesthesia due to NPRS score elevation during the surgery; no dose exceeded the safe limit of 7 mg/kg. No local complications occurred, and no shifts to other anaesthesia methods were required due to the failure of WALANT. ConclusionsWALANT simplified surgical preparations and provided a safe and reliable method for ankle fracture management. Because the use of a tourniquet was not required, reduced postsurgical pain was observed. Moreover, the use of local anaesthesia resulted in more satisfied patients and facilitated easier recovery.

Intravenous vs Oral Acetaminophen as a Component of Multimodal Analgesia After Total Hip Arthroplasty: A Randomized, Blinded Trial

BackgroundMultimodal analgesia including acetaminophen is increasingly popular for analgesia after total hip arthroplasty (THA). Intravenous (IV) administration of acetaminophen has pharmacokinetic benefits, but unclear clinical advantages. The authors hypothesized that IV acetaminophen would reduce pain with activity, opioid usage, or opioid-related side effects, compared to oral acetaminophen. MethodsIn this double-blinded, randomized, controlled trial, 154 THA patients received either IV or oral acetaminophen as part of a comprehensive opioid-sparing multimodal analgesia strategy. Primary outcomes were pain with physical therapy on postoperative day (POD) 1, opioid side effects (POD 1), and cumulative opioid use. ResultsThere was no difference in opioid side effects, pain scores, or opioid use between the groups. ConclusionPatients in both groups had low pain scores, minimal opioid side effects, and limited opioid usage (corresponding to 6 doses of tramadol 100 mg over 3 days). This highlights multimodal analgesia as an effective method of pain control for THA.