Morphine In Postanesthesia Care Unit Research Articles

Battle of the Blocks: Which Pain Management Technique Triumphs in Gender-Affirming Bilateral Mastectomies?

Gender-affirming mastectomy, performed on transgender men and non-binary individuals, frequently leads to considerable postoperative pain. This pain can significantly affect both patient satisfaction and the overall recovery process. The study examines the efficacy of four analgesic techniques pectoral nerve (PECS) 2 block, erector spinae plane (ESP) block, thoracic wall local anesthesia infiltration (TWI), and systemic multimodal analgesia (SMA) in managing perioperative pain, with special consideration for the effects of chronic testosterone therapy on pain thresholds. A retrospective analysis was conducted on patients aged 18 - 45 who underwent gender-affirming bilateral mastectomies at a New York City community hospital. The study compared intraoperative and post-anesthesia care unit (PACU) opioid consumption, postoperative pain scores, the interval to first rescue analgesia, and total PACU duration among the four analgesic techniques. The study found significant differences in intraoperative and PACU opioid consumption across the groups, with the PECS 2 block group showing the least opioid requirement. The PACU morphine milligram equivalent (MME) consumption was highest in the SMA group. Postoperative pain scores were significantly lower in the PECS and ESP groups at earlier time points post-surgery. However, by postoperative day 2, pain scores did not significantly differ among the groups. Chronic testosterone therapy did not significantly impact intraoperative opioid requirements. The PECS 2 block is superior in reducing overall opioid consumption and providing effective postoperative pain control in gender-affirming mastectomies. The study underscores the importance of tailoring pain management strategies to the unique physiological responses of the transgender and non-binary community. Future research should focus on prospective designs, standardized block techniques, and the complex relationship between hormonal therapy and pain perception.

Pudendal nerve block decreases narcotic requirements and time spent in post-anesthesia care units in patients undergoing primary inflatable penile prosthesis implantation.

Efforts to minimize narcotic usage following inflatable penile prosthesis (IPP) implantation are vital, considering the current opioid epidemic in the United States. We aimed to determine whether pudendal nerve block (PNB) utilization in a multiethnic population undergoing primary IPP implantation can decrease rates of post-operative opiate usage. A single-institution, retrospective study was conducted on patients who underwent primary IPP implantation between December 2015 and June 2022. PNB usage and intra- and post-operative outcomes were analyzed using multivariate binary logistic regression. 449 patients were included, with 373 (83.1%) in the PNB group. Median time (minutes) spent in the post-anesthesia care unit (PACU) (1499 [119-198] vs. 235 [169-322], p < 0.001) was significantly lower in the PNB group. There were no significant differences in intra-operative and PACU morphine milligram equivalents or post-operative safety outcomes between groups. However, fewer patients in the PNB group called for pain medications post-operatively (10.2% vs 19.7%, p = 0.019). Multivariate analysis revealed a significantly decreased operative time (B -6.23; 95%CI -11.28, -1.17; p = 0.016) and decreased time in recovery (B: -81.62; 95%CI: -106.49, -56.76, p < 0.001) in the PNB group. PNB decreases post-operative opioid analgesic requirements and time spent in PACU in patients undergoing a primary IPP implantation and thus may represent an attractive, non-opioid adjunct.

Impact of Dexamethasone on Length of Stay and Early Pain Control in Direct Anterior Approach Total Hip Arthroplasty With Neuraxial Anesthesia

BackgroundDexamethasone has been shown to reduce postoperative pain and opioid consumption for total joint arthroplasty patients; however, its impact on patients who received neuraxial anesthesia (NA) is not well described. We examined the impact of perioperative dexamethasone on outcomes for patients undergoing direct anterior approach total hip arthroplasty (THA) under NA. MethodsA retrospective review was conducted for 376 THA patients from a single institution. Univariate analysis was used to compare postoperative outcomes for 164 THA patients receiving dexamethasone compared to 212 who did not receive dexamethasone. ResultsNo differences in age, gender, body mass index, or American Society of Anesthesiologists (ASA) Score were observed between the groups. Patients receiving perioperative dexamethasone reported statistically significantly lower postanesthesia care unit (PACU) pain numeric rating scale (Dexamethasone 1.6 vs No dexamethasone 2.3, P = .014) and received lower PACU morphine milligram equivalents (MME) (Dexamethasone 8.57 vs No dexamethasone 11.44, P < .001). Patients receiving dexamethasone had significantly shorter LOS (Dexamethasone 29.40 vs No dexamethasone 35.26 hrs., P < .001). ConclusionPerioperative dexamethasone is associated with decreased postoperative pain and narcotic consumption, and shorter length of stay for patients undergoing primary direct anterior approach THA with NA.

Prospective Single-Blinded Randomized Controlled Trial Comparing Pericapsular Injection Versus Lumbar Plexus Peripheral Nerve Block for Hip Arthroscopy

Background: Hip arthroscopy has become the standard for the operative treatment of symptomatic femoroacetabular impingement. Given the high levels of postoperative pain associated with hip arthroscopy, optimal analgesia is critical to ensure patient comfort and safety after discharge. Purpose/Hypothesis: Our purpose was to perform a single-blinded randomized controlled trial comparing the use of pericapsular injection versus lumbar plexus blockade for postoperative pain control after arthroscopic surgery on the hip. We hypothesized that pericapsular injection would provide equivalent pain relief to that of lumbar plexus blockade while minimizing adverse effects and alleviating the dependence on a qualified individual to administer. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 64 consecutive patients undergoing hip arthroscopy were prospectively assessed over a 6-month period between 2017 and 2018. Patients were randomly allocated to 1 of 2 groups: 32 patients received a lumbar plexus blockade by a single anesthesiologist, while 32 patients received a pericapsular injection of 30 mL of ropivacaine and 12 mg of morphine. Postoperative pain in the postanesthesia care unit (PACU) as measured using the numeric rating scale, time to discharge, PACU morphine equivalents, and adverse effects were collected by PACU staff. Postoperative day 1 and 2 narcotic use was obtained through a telephone call with the patient on postoperative day 3. Results: We found no statistically significant difference in PACU pain scores at all time points, although there was a trend toward lower pain for patients receiving a pericapsular injection. PACU and short-term narcotic demand did not vary across the 2 arms. Time to discharge from the PACU did not differ. There were no major adverse events reported for either intervention. Conclusion: Pericapsular injection provides equivalent analgesia when compared with lumbar plexus blockade. It is a safe intervention that allows for efficient postoperative analgesia for patients undergoing hip arthroscopy. Registration: ClinicalTrials.gov ID: NCT03244631.

The pudendal nerve block for ambulatory urology: What's old is new again. A quality improvement project

Caudal epidural analgesia (CEA) is a common analgesic technique performed for pediatric penile surgeries; however, it has associated morbidity. The pudendal nerve block (PNB) has been described as an effective analgesic alternative to CEA. In this quality improvement study, we aim to assess the efficacy of PNB as compared to CEA within our ambulatory surgery center (ASC). We demonstrate our initial experience employing PNB for ambulatory pediatric urology procedures. Using retrospective, non-randomized, time-series, observational data, a comparative effectiveness study of CEA and PNB was performed. Patients less than three years old, who underwent circumcision, hypospadias repair, congenital chordee repair, correction of penile angulation/torsion, and buried penis repair with or without scrotoplasty, between January 1, 2015-September 9, 2019 with either CEA or PNB in an ASC at a single institution were included. Standard protocols for local and postoperative analgesia were used. Outcome measures were post anesthesia care unit (PACU) pain scores, morphine rescue rates, and PACU length of stay (LOS). These were analyzed using statistical process control (SPC) charts; standard SPC rules were used to detect special cause variation. A total of 999 patients were identified; 746 (74.7%), 172 (17.2%) and 81 (8.1%) received CEA, ultrasound guided PNB (US-PNB) and landmark directed PNB (LD-PNB), respectively. Demographic data was comparable between the three cohorts. There was no special cause variation in the outcome measures between the CEA, US-PNB and LD-PNB cohorts for maximum pain score, morphine rescue rates and PACU LOS. Pain outcomes and PACU LOS were similar between the CEA, US-PNB and LD-PNB cohorts, suggesting equivalent postoperative pain control between these techniques within our cohort. Previous published data has reported lower postoperative pain scores with PNB as compared to CEA for patients undergoing circumcision and hypospadias repair. PNB is non-inferior to CEA for analgesia for pediatric penile surgery, with LD-PNB being as effective as US-PNB. Given the simplicity and documented lower risk profile, PNB may be preferred to CEA for ambulatory pediatric urology procedures.

Lumbar Plexus Block versus Peri-capsular Injection for Hip Arthroscopy: A Single-Blinded Randomized Controlled Trial

Objectives:To perform a single-blinded, randomized controlled trial comparing pericapsular injection versus lumbar plexus blockade for post-operative pain control following arthroscopic surgery on the hip.Methods:70 consecutive patients undergoing hip arthroscopy were prospectively assessed over a six-month period from 2017 to 2018. Patients were randomly allocated to 1 of 2 groups. 35 patients received a lumbar plexus blockade by a single anesthesiologist, while 35 patients received a pericapsular injection of 30cc of ropivacaine and 12mg of morphine. Post-operative pain in the post-anesthesia care unit (PACU) as measured by the numeric rating scale (NRS), time to discharge, PACU morphine equivalents and adverse effects were collected by PACU staff. Post-operative day (POD) 1 and POD 2 narcotic use was obtained through a phone call with the patient on post-operative day 2.Results:We found no statistically significant difference in PACU pain scores at all time-points, although there was a trend towards lower pain for patients receiving a pericapsular injection. PACU and short-term narcotic demand did not differ significantly between the two arms. Time to discharge from the PACU did not differ. There were no major adverse events reported for either intervention.Conclusion:Pericapsular injection provides equivalent analgesia when compared to lumbar plexus injection. It is a safe, time-saving intervention that allows for efficient post-operative analgesia for patients undergoing hip arthroscopy.

MP63-15 DOES SIZE MATTER? PAIN SCORES AND NARCOTIC USAGE AMONGST SHEATH SIZES IN AMBULATORY PERCUTANEOUS NEPHROLITHOTOMY (PCNL) PROCEDURES

INTRODUCTION AND OBJECTIVE: Smaller PCNL tracts are becoming popular due to an increasing ability to clear even large stones as well as decreasing tissue trauma. We postulate that smaller tracts may decrease post-operative pain and narcotic usage in the post-anesthesia care unit (PACU). METHODS: All mini-PCNL (mPCNL, n=32) and standard tract PCNLs (sPCNL, n=67) performed by a single surgeon at an ambulatory surgery center within the last 6 months were analyzed. mPCNL procedures were performed with a 16.5/17.5 French dilator/sheath metal set. sPCNL procedures were performed with a 24/28-30/34 French sheath with balloon dilation. Patient demographics, stone characteristics, and operative room (OR) times were recorded. Pain scores (Numerical Rating Scale, 0-10) on arrival, 15, 60 minutes, and at discharge were recorded. Aldrete scores (Oxygenation, Respiration, Circulation, Consciousness, Activity scores ranked 0-2 for a total score from 0-10) after surgery were recorded. Post-operative PACU morphine equivalents were tracked. RESULTS: mPCNL patients tended to be younger (51 vs 57, p=0.04), had lower stone burdens (17.5 vs 36.4 mm, p=0.0001), and shorter procedures (OR time 84 vs 93, p=0.03 and intracorporeal time 36 vs 44 min, p=0.04). Despite this, mPCNL patients tended to have higher pain scores at 15 (1.78 vs 0.7, p=0.04) and 60 minutes (2.56 vs 1.33, p=0.03). This was not correlated with changes in Aldrete scores or PACU time. Finally, PACU morphine equivalent usage was almost triple in the mPCNL cohort (2.94 vs 1.03, p=0.02). CONCLUSIONS: mPCNL patients tended to have higher pain scores and require higher doses of narcotics in the PACU. Plans for a prospective matched study with single step metal dilation vs balloon dilation are underway. Increased intra-renal pressures are known to occur in mPCNL procedures; however, it is not clear if these increased pressures account for the increased need for pain control or if the dilation technique (metal dilation for mPCNL versus radial dilation for sPCNL) contribute to the increased pain noted post-procedure.Source of Funding: NA

Perioperative analgesic profile of dexmedetomidine infusions in morbidly obese undergoing bariatric surgery: a meta-analysis and trial sequential analysis

BackgroundOpioid-sparing analgesia for bariatric surgery in morbidly obese can potentially prevent catastrophic airway complications. Our meta-analysis attempts to consolidate the evidence on dexmedetomidine evaluating its analgesic and safety profile. MethodsTrails comparing perioperative dexmedetomidine infusion to conventional analgesic regimens for bariatric surgery were searched. Comparisons were made for 24-hour and postanesthesia care unit (PACU) morphine consumed, PACU pain scores, postoperative nausea and vomiting pain scores, and heartrate. Meta-regression was performed for length of stay to evaluate various analgesic control subgroups. ResultsSix trials were included in the final analysis. Dexmedetomidine infusion (reported in 5 intraoperative subgroups and 2 postoperative subgroups) decreased 24-hour morphine by 18.13±6.11 mg (random effects: P<.001, I2 = 95.48%). Despite the small number of included studies, the sample size for avoiding a false positive result was adequate as the trial sequential analysis found the present sample size (362) to be well past the required “sample size” (n = 312) for 85% power. Meta-regression for infusion dose on morphine consumption difference found a predictability of 49% (coefficient = 39.93, random-effects, Tau2 = 396.08), and predictability of the model improved to 68% on inclusion of time of initiation of infusion. The dexmedetomidine group had lower PACU morphine consumption (by 6.91±1.19, I2 = 34.37%), lower pain scores (scale of 0–10±2.27, I2 = 88.14%), lower postoperative nausea and vomiting incidence (odds ratio =±0.26, I2 = 0%), and lower heart rate (73.25 versus. 83.50) (mean difference =±10.15 I2 = 94.04%). No adverse events were reported across trials. ConclusionPerioperative dexmedetomidine infusion in obese patients undergoing bariatric surgery is a promising and safe alternative. Both intraoperative or postoperative infusions lead to significant opioid sparing in early and extend postoperative recovery phase. Morbidly obese patients receiving perioperative dexmedetomidine infusions have overall better pain control and lower incidence of postoperative nausea-vomiting. All the aforementioned merits come with a stable hemodynamic profile and without any reported major adverse events.

Managing Postoperative Analgesic Failure: Tramadol Versus Morphine for Refractory Pain in the Post-Operative Recovery Unit.

This study aimed to discover whether co-analgesia with tramadol or additional morphine was more effective for patients who still had severe pain despite being given 10 mg intravenous morphine in the post-anesthesia care unit (PACU). All eligible patients were consented and recruited to the trial pre-operatively, but only a small subgroup – whose pain was not successfully controlled (pain score 6/10 or more) after receiving 10 mg of morphine in the PACU—were then randomized to enter the trial and receive, in a double blinded fashion, the analgesic study drug; which consisted of either a further 10 mg of morphine, or 100 mg of tramadol, titrated intravenously to control their pain. The groups were compared as to: the time to readiness for discharge, the patient’s pain scores over time, and the presence of side effects. There was no statistically significant difference in any of the outcomes measured. The time to readiness for discharge from PACU was 119 minutes in the morphine group and 120 minutes in the tramadol group. However in approximately half the cases who entered the trial (i.e., where pain had not been controlled with the pre-enrollment baseline 10 mg of morphine in PACU) neither a further 10 mg of morphine nor 100 mg of tramadol effectively relieved the patient’s pain. We found no difference between additional morphine and co-analgesia with tramadol in this study. Patients who don’t respond to reasonable doses of opioids in PACU are very likely to be unresponsive to further opioids, and other non-opioid analgesic techniques (such as regional anesthesia) should be considered early in this group of patients.

Ultrasound-guided rectus sheath and transversus abdominis plane blocks for perioperative analgesia in upper abdominal surgery: A randomized controlled study.

Background:Regional anesthetic techniques can be used to alleviate postoperative pain in patients undergoing major upper abdominal surgery. Our aim was to evaluate the efficacy of bilateral ultrasound (US)-guided rectus sheath (RS) and transversus abdominis plane (TAP) blocks for better perioperative analgesia.Patients and Methods:It is a prospective, observer-blinded, randomized clinical study. 40 eligible patients undergoing elective liver resection or Whipple procedure were included. All patients received a standardized anesthetic technique. Group 1 (n = 20) received preincisional US-guided bilateral RS and TAP blocks using 20 ml volume of bupivacaine 0.25% for each, and group 2 (n = 20) received local wound infiltration at end of surgery with 40 ml of bupivacaine 0.25%. A standardized postoperative analgesic regimen composed of intravenous paracetamol and a morphine patient-controlled analgesia (PCA). The use of intraoperative fentanyl and recovery room morphine boluses, PCA-administered morphine, pain scores as well as number of patients’ experienced postoperative nausea and vomiting in the ward at 6 and 24 h were recorded.Results:Group 1 patients received a significantly lower cumulative intraoperative fentanyl, significantly lesser boluses of morphine in postanesthesia care unit, as well, significantly lower cumulative 24 h postoperative morphine dosage than the group 2 patients. Pain visual analog scale scores were significantly lower at both 6 and 24 h postoperatively in TAP group when compared with the no-TAP group. There were no complications related to the TAP block procedures. No signs or symptoms of local anesthetic systemic toxicity were detected.Conclusion:The combination of bilateral US-guided RS and TAP blocks provides excellent perioperative analgesia for major upper abdominal surgery.

Effectiveness of ultrasound-guided transversus abdominis plane block for intraoperative and postoperative analgesia in kidney transplantation

Background The transversus abdominis plane (TAP) exists between the internal oblique and transversus abdominis muscles, and encompasses an intersected plexus of nerves. The TAP block has been the subject of multiple clinical trials to determine its analgesic efficacy. Patients and methods A total of 60 patients were randomized into one of two groups: TAP block group (group 1) or no-TAP block group (group 2). All patients underwent a standardized anesthetic technique. The TAP block group received preincisional ultrasound-guided TAP block on the side of surgery with a 20-ml volume of 0.5% of bupivacaine, and the no-TAP group received equivalent amounts of saline. A standardized postoperative analgesic regimen composed of intravenous paracetamol and a morphine patient-controlled analgesia (PCA). The amounts of intraoperative fentanyl and post-anesthesia care unit (PACU) morphine and PCA-administered morphine, pain scores, as well as number of patients experienced postoperative nausea and vomiting in the ward at 6 and 24 h were recorded. Results TAP block group patients received a significantly lower cumulative intraoperative fentanyl, significantly less boluses of morphine in postanesthesia care unit, and significantly lower cumulative 24-h postoperative morphine dosage than the no-TAP block patients. Pain visual analog scale scores were significantly lower at both 6 and 24 h postoperatively in the TAP group when compared with the no-TAP group. There were no complications related to the TAP block procedures. No signs or symptoms of local anesthetic systemic toxicity were detected. Conclusion On the basis of our current results, preincisional ultrasound-guided TAP blocks confer analgesic benefit when added to the multimodel analgesia regimen during and after kidney transplantation.

Reducing postoperative opioid consumption by adding an ultrasound-guided rectus sheath block to multimodal analgesia for abdominal cancer surgery with midline incision.

Background:Many multimodal analgesia techniques have been tried to provide adequate analgesia for midline incisions extending above and below the umbilicus aiming at limiting the perioperative use of morphine thus limiting side effects. Ultrasound (US) guidance made the anesthesiologist reconsider old techniques for wider clinical use. The rectus sheath block (RSB) is a useful technique under-utilized in the adult population.Objectives:Our study examined the efficacy of a preemptive single-injection rectus sheath block in providing better early postoperative pain scores compared to general anesthesia alone.Patients and Methods:Sixty patients were recruited in this randomized controlled trial. These patients were divided into two groups: RSB group had an RSB after induction of anesthesia and before surgical incision, and GA (general anesthesia) group had general anesthesia alone. Both groups were compared for verbal analogue scale (VAS) score, opioid consumption and hemodynamic variables in the post-anesthesia care unit (PACU). Analgesic requirements in surgical wards were recorded in postoperative days (POD) 0, 1 and 2.Results:The median VAS score was significantly lower in RSB group compared with GA group in all 5 time points in the PACU (P ˂ 0.05). Also PACU morphine consumption was lower in RSB group than GA group patients (95% confidence interval [CI] of the difference in means between groups, −4.59 to −2.23 mg). Morphine consumption was also less in the first 2 postoperative days (POD0 and POD1).Conclusions:Ultrasound-guided rectus sheath block is an easy technique to learn. This technique, when it is used with general anesthesia, will be more effective in reducing pain scores and opioid consumption compared with general anesthesia alone.

The effect of topical tetracaine eye drops on emergence behavior and pain relief after strabismus surgery

Pediatric strabismus surgery may be associated with postoperative nausea, vomiting, and emergence agitation (restlessness, thrashing, crying, moaning, disorientation). We hypothesize that emergence agitation after strabismus surgery is in part related to pain and that topical tetracaine ophthalmic drops can decrease the intensity and incidence of postoperative pain and emergence agitation. Eighty-eight subjects aged 1 to 12 years scheduled for strabismus surgery were enrolled in a double-masked randomized control trial. The patients were randomized to one of three groups: Group A received normal saline drops before and after surgery; Group B received normal saline drops before and tetracaine 1% drops after surgery; Group C received tetracaine 1% drops before and after surgery. An observer masked to group assignment assessed each patient in the postanesthesia care unit (PACU) using both a behavior scale and a modified behavioral pain scale. Patients in Group A were found to be in significantly more pain than Groups B or C at 5 minutes after arrival to the PACU (p < 0.013). Using the behavior scale, a significantly greater proportion of patients in Group A were crying or crying and thrashing at 5, 15, and 30 minutes after arrival to the PACU (5 minutes, p < 0.019; 15 minutes, p < 0.041; 30 minutes, p < 0.021). There was no significant difference between groups in total PACU time, PACU vomiting, PACU morphine use, or pain at home. Postoperative strabismus surgery pain was improved by the use of preoperative, and pre- and postoperative, tetracaine drops. Emergence agitation was not fully evaluated by the behavioral scale, and therefore, the effect of tetracaine drops on emergence agitation was not clarified. This study suggests that tetracaine drops can lead to a less stressful early postoperative experience for the patient.