PCA Morphine Research Articles

Comparison of Ultrasound Guided Transversus Abdominis Plane Block versus Intravenous Patient Controlled Analgesia for Post-Operative Analgesia in Patients Undergoing Lower Abdominal Surgeries under Spinal Anesthesia

Abstract Background poorly controlled acute pain after abdominal surgery is related to somatic pain signals derived from the abdominal wall and is associated with a variety of unwanted postoperative consequences, including patient suffering, distress, respiratory complications, delirium, myocardial ischemia, prolonged hospital stay, an increased likelihood of chronic pain, increased consumption of analgesics, delayed bowel function and increase the requirement for rescue analgesics. Aim of the Work to compare the efficacy of TAP block versus PCA with IV morphine to provide prolonged post-operative analgesia; secondary objective is to identify the side effects of both techniques as post-operative analgesia Patients and Methods The study was conducted on 40 randomly chosen patients aged 21 to 70 years in both sexes, American Society of Anesthesiologists (ASA) class I or II scheduled for elective lower abdominal surgeries under spinal anesthesia in Ain Shams University Hospitals after approval of the medical ethical committee. Results TAP block is given in the volume of 20 mL bilaterally, it is as effective as intravenous Morphine PCA in pain treatment, but with less systemic side effect Also TAP block delay using of postoperative additional analgesia, however PCA analgesic effect last longer, less invasive technique and easier to be used while TAP require hand skills and limited to 24 hours analgesia only. Conclusion In lower abdominal surgery, when TAP block is given in the volume of 40 mL, it is as effective as intravenous PCA in pain treatment. Compared with intravenous PCA, TAP block can be considered as a more preferable method because it can avoid the systemic actions of morphine.

A Comparative Study between Ultrasound Guided Pectoral Nerve Block Type II versus Intravenous Patient Controlled Analgesia for Intra-Operative and Post-Operative Analgesia in Patients Undergoing Modified Radical Mastectomy

Abstract Background Breast surgery is becoming more and more common. Patients are often middle-aged women and with high public awareness around issues of breast cancer. The numbers are increasing. Breast surgery is an exceedingly common procedure and associated with an increased incidence of acute and chronic pain. Regional anaesthesia techniques may improve post-operative analgesia for patients undergoing breast surgery. Aim of the Work The primary aim of this study is to compare the efficacy of PECS block versus PCA with iv morphine to provide prolonged post-operative analgesia. The secondary objective is to identify the side effects of both techniques as post-operative analgesic techniques. Patients and Methods This study is a randomized clinical trial study conducted in Ain-shams University Hospitals, Cairo, Egypt for 6 months after medical ethical committee approval. The participants were allocated randomly into two groups of 25 patients each: group A: Patients received general anaesthesia followed by PECS block at the end of the operation before extubation, group B: Patients received general anaesthesia followed by the PCA at the end of surgery after extubation. Results The VAS score in the PECS group was statistically significantly lower at the 1st, 2nd and 4th hours. In this case, the use of PECS for postoperative analgesia is as effective as intravenous Morphine PCA in pain treatment, but with less systemic side effect as the nausea and vomiting is significantly higher in the PCA group than the PECS group at the 6th hour, however, the need of intra operative opioids in PCA group is significant. Conclusion In modified radical mastectomy, PECS block is as effective as intravenous Morphine PCA in pain treatment. Compared with intravenous PCA, PECS block can be considered as a more preferable method because it can avoid the systemic actions of morphine used for PCA, and can decrease the need of analgesia intra-operative, however PCA analgesic effect last longer, less invasive technique and easier to be used while PECS block require hand skills and limited to 24 hours analgesia only.

Morphine Consumption and/or Numerical Scale in Pain Studies: Silverman Integrating Approach (SIA SCORE)

Introduction: Ligamentoplasty pain management is dynamic performance, demanding constant vigilance and adaptation. The aim of this prospective study was to compare the analgesic efficacy of three techniques for knee ligamentoplasty using an integration score, the SIA score.
 Methods: The study included 165 patients undergoing primary reconstruction of the anterior cruciate ligament of the knee. The first group, systemic analgesia (SA), received balanced systemic analgesia postoperatively for a minimum of five days, based on Paracetamol, Diclofenac, and a morphine PCA. In addition to the systemic analgesia already described, the second group, femoral analgesia (FA), will benefit from a femoral peri-nervous catheter in the crural position. The third intra-articular analgesia (IAA) group received, in addition to the same systemic analgesia, an infusion through an epidural catheter of 20 ml of 0.125% bupivacaine, followed by maintenance with 8 ml/h of the same local anesthetic via an electric syringe pump for 36 h. Cumulative morphine consumption was assessed, as well as pain at rest, using a numerical scale (EN) from 1 to 10 and an integration of these two parameters.
 Results: Morphine consumption was lower in the AF group. The lowest mean rank was in the AF group, followed by the AIA group, and the difference was statistically significant with an H = 6.89 and a p= 0.032. The difference was significant between the AS group and the AF group (p = 0.09); the other inter-group differences were not significant. 23.2% of patients had an AIS score between [-100, -200], and were in little pain and consumed little morphine (effective treatment); 14.2% of patients had an AIS score between [100, 200] and were in great pain and consumed a lot of morphine (morphine-resistant or very sensitive to pain).
 Conclusion: Analgesia in the femoral peri-nerve group was more effective, with a reduction in mean EN compared with the other two groups.

Continuous Intra-Incisional Bupivacaine for Postoperative Analgesia after Hip Nailing Surgery: A Randomized Clinical Trial.

The effectiveness of continuous wound infiltration (CWI) as a postoperative pain-control technique has been shown in many surgical procedures. This study investigates the effect of CWI of local anesthetic on postoperative pain control in intertrochanteric fracture patients undergoing hip nailing surgery. In this randomized clinical trial, 48 patients who were scheduled for hip nailing surgery were randomly assigned to receive (n = 24) or not receive (n = 24) bupivacaine infusion through a catheter inside the surgical wound, postoperatively. Pain intensity (NRS), required dose of morphine, and drug-related complications within 24 hours of the intervention were assessed and compared. Pain intensity was significantly lower in the bupivacaine group both during the recovery room stay and in the ward in the first 24 hours after the procedure (P < 0.001). In the recovery room, the control group patients had a higher morphine consumption compared to the bupivacaine group (P < 0.001) and requested it earlier than the bupivacaine group (60 (45-60) vs. 360 (195-480) minutes) (P < 0.001). In the ward, all control group patients used the PCA morphine pump, while only 54% of the bupivacaine group self-administered morphine through the pump, with a significantly lower total morphine consumption (1 (0-2) vs. 10 (5-14) mg, P < 0.001). None of the patients in the bupivacaine group required additional morphine, while 37.5% of the control requested additional morphine (P=0.002). Altogether, the control group had a higher total morphine consumption compared to the bupivacaine group in the first 24 hours (10.5 (6-15.5) vs. 1 (0-2) mg, P < 0.001). CWI of bupivacaine helps better pain reduction during the early postoperative hours while it reduces opioid consumption, minimizes nausea and vomiting, and improves patient satisfaction.

Analgesia for Knee Ligamentoplasty: Comparisons of Three Techniques using the Silverman Integrating Approach (SIA Score)

The aim of this prospective study was to compare the analgesic efficacy of three techniques for knee ligamentoplasty using an integration score, the SIA score. Hypothesis. The use of a statistical approach to integrate data from pain scores and morphine consumption will identify four patient subgroups that may hamper the accuracy of the comparative study Material. - We included 165 patients undergoing primary reconstruction of the anterior cruciate ligament of the knee. All patients underwent spinal anaesthesia. The first group, systemic analgesia (SA), received balanced systemic analgesia postoperatively for a minimum of five days, based on Paracetamol, Diclofenac and a morphine PCA. In addition to the systemic analgesia already described, the second group, femoral analgesia (FA), will benefit from a femoral peri-nervous catheter in the crural position. 20 ml of bupivacaine at 0.125% concentration is injected; maintenance is set up immediately with a continuous flow of 8 ml/h for 36 h. The third intra-articular analgesia (IAA) group received, in addition to the same systemic analgesia, an infusion through an epidural catheter of 20 ml of 0.125% bupivacaine, followed by maintenance with 8 ml/h of the same local anesthetic via an electric syringe pump for 36 h. We evaluated cumulative morphine consumption, pain estimation at rest using a numerical scale (EN) from 1 to 10, and an integration of these two parameters. Results. - The mean age was identical for all three groups, at around 30 years. Analgesia in the femoral peri-nerve group was more effective, with a reduction in mean EN compared with the other two groups. Morphine consumption was lower in the AF group. The lowest mean rank was in the AF group, followed by the AIA group, and the difference was statistically significant with an H = 6.89 and a p= 0.032. The difference was significant between the AS group and the AF group (p = 0.09); the other inter-group differences were not significant. 23.2% of patients had an AIS score between [-100, -200], and were in little pain and consumed little morphine (effective treatment); 14.2% of patients had an AIS score between [100, 200] and were in great pain and consumed a lot of morphine (morphine-resistant or very sensitive to pain). For the difference (ranked pain score - ranked morphine), 4.5% of cases had values between [- 100, - 200] and were therefore not very painful but consumed a lot of morphine (propensity), while 3.9% had values between [100, 200] and were therefore very painful but consumed little morphine (intolerant). Discussion. - This study suggests that the use of a statistical approach to integrating data from pain scores and morphine consumption, such as the Silverman Integrating Approach (SIA), will yield four patient subgroups that may hamper the accuracy of the comparative study, including the morphine-resistant subgroup and the propensity subgroup. Comparison of the means of the therapeutic efficacy group will eventually be more precise. Continuous femoral block really does provide added analgesia and morphine sparing, and should therefore be preferred wherever possible to intra-articular or systemic therapy.

Comparative Study Between Systemic Balanced Analgesia, Continuous Femoral Perineural Analgesia and Continuous Intra-articular Analgesia for Primary Reconstruction Surgery of the Anterior Cruciate Ligament of the Knee

Introduction. The aim of this prospective study was to compare the analgesic efficacy of three techniques for knee ligamentoplasty and quadricipital deficit with a view to early physiotherapy. Hypothesis. Continuous intra-articular analgesia and well-managed systemic analgesia could replace continuous femoral peri-nerve analgesia in resource-limited countries. Material. - We included 165 patients undergoing primary reconstruction of the anterior cruciate ligament of the knee. All patients underwent spinal anaesthesia. The first group, systemic analgesia (SA), received balanced systemic analgesia postoperatively for a minimum of five days, based on Paracetamol, Diclofenac and a morphine PCA. In addition to the systemic analgesia already described, the second group, femoral analgesia (FA), will benefit from a femoral peri-nervous catheter in the crural position. 20 ml of bupivacaine at 0.125% concentration is injected; maintenance is set up immediately with a continuous flow of 8 ml/h for 36 h. The third intra-articular analgesia (IAA) group received, in addition to the same systemic analgesia, an infusion through an epidural catheter of 20 ml of 0.125% bupivacaine, followed by maintenance with 8 ml/h of the same local anesthetic via an electric syringe pump for 36 h. Cumulative morphine consumption, pain estimation at rest and on mobilization using a numerical scale (EN) from 1 to 10, and quadriceps deficit were evaluated. Results. - Morphine consumption was lower in the AF group and the difference was statistically significant with an F = 3.539(2) and a p = 0.031. A mean difference of 6.12 ± 2.41 between the AS and AF groups with a significant p = 0.012, a mean difference of 1.67 ± 2.41 with a non-significant p = 0.49 between the AF and AIA groups and a mean difference of 4.45 ± 2.31 with a p = 0.056 at the limit of significance between the AS and AIA groups. Analgesia in the femoral peri-nerve group was more effective, with a reduction in mean EN compared with the other two groups. Efficacy was statistically significant at H4, then from H24 to H36 compared with systemic analgesia, but not significant compared with intra-articular analgésia. Intra-articular analgesia was only significantly effective compared with systemic analgesia at H36. Quadriceps muscle deficit is an incident specific to femoral blocks. Discussion. - This study suggests that a continuous intra-articular or even a well-conducted systemic analgesia provides satisfactory analgesia for knee ligamentoplasty, compared with a more effective femoral peri-nerve. The quadricipital lock absent in intra-articular treatment could be an advantage in speeding up functional recovery.

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

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

Infiltration Between Popliteal Artery and Capsule of the Knee Combined with Adductor Canal Block as Analgesic Adjuvant During and Postoperative in Total Knee Replacement Surgery

Background: Infiltration between the popliteal artery and capsule of the knee (iPACK) is one method that has been proposed in recent years as a potential alternative to peripheral nerve block as analgesia in total knee replacement (TKR) procedures. This study presents anesthetic management using spinal anesthesia combined with iPACK and adductor canal block (ACB) in patients with grade IV osteoarthritis who underwent TKR of the right knee.&#x0D; Case presentation: A woman, a housewife aged 50 years, was planning to undergo TKR surgery. The patient came with complaints of pain in the right knee 1 year before entering the hospital. The patient was given supplemental oxygen with a nasal cannula at 3 liters per minute. Prior to spinal anesthesia, the patient was given fentanyl 25 mcg iv, ketamine 10 mg iv, and midazolam 1.5 mg IV as premedication. The patient was positioned on the right side, and a 27G Quincke needle was inserted at the level of L3-L4 and given bupivacaine heavy 0.5% 7.5 mg, then lateralized for 15 minutes. After lateralization, the patient was positioned supine and used ultrasound to direct ACB action with a regimen of ropivacaine 0.25% + dexamethasone 5 mg a volume of 20 ml, then iPACK was performed with a regimen of Ropivacaine 0.375% + dexamethasone 5 mg a volume of 20 ml. After surgery, the patient is treated in the recovery room for 1 hour until bromage score is 0. The patient received the PCA Morphine analgesic demand only 1 mg/mL, 1 mg per dose, max 5 mg over 4 hours, lockout interval 6 minutes; Paracetamol 500 mg every 6 hours PO; Ibuprofen 400 mg every 8 hours PO.&#x0D; Conclusion: TKR patients who were given analgesia using the ACB peripheral nerve block technique combined with iPACK experienced a decrease in pain levels and lower use of postoperative morphine so that patient mobilization was faster and reduced the patient's length of stay.

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

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

329: A PERFECT STORM OF SICKLE CELL HEPATOPATHY

Introduction: Intrahepatic cholestasis (SCIC) an uncommon but serious complication of vaso-occlusive crisis in sickle cell disease (SCD). Presenting with abdominal pain, hyperbilirubinemia, and transaminitis, and in severe cases with renal failure, encephalopathy, and coagulopathy. Early diagnosis is challenging but essential to improving outcomes. Herein, we report a case of a young patient with SCD who presented with SCIC requiring exchange transfusion which resulted in an eventual favorable outcome. Description: 18-year-old man with history of SCD presented for generalized abdominal pain. He complained of severe diffuse body pain. On admission, he had a total bilirubin (T.Bili) of 5.5 mg/dL, hemoglobin of 9.1 g/dL (baseline 8-9) and a clear chest x-ray. He was started on morphine PCA due to increasing pain and transfused one unit of packed red cells (pRBC). He subsequently developed a fever and had a chest x-ray concerning for acute chest syndrome. On day 2, hemoglobin dropped to 5.1 g/dL and he was transfused a further 2 units of pRBC. Over the course of day 2, he developed worsening kidney function and metabolic acidosis, so he was transferred to the medical intensive care unit. Overnight, he became increasingly encephalopathic and developed acute liver failure with AST 2317 IU/L, ALT of 1976 IU/L, INR of 4.7 and T.Bili of 13.3 mg/dL. An exchange transfusion was urgently arranged and initiated by morning of Day 3. His hospital course was complicated by ongoing encephalopathy, respiratory failure requiring mechanical ventilation and renal failure requiring hemodialysis. His total bilirubin, direct bilirubin and alkaline phosphatase peaked at 32.0 mg/dL, 30.0 mg/dL, 1024 IU/L, respectively. With further supportive care, he had recovery of liver function, was extubated, weaned off dialysis, and eventually discharged home. Discussion: This case illustrates the rapid and life threatening nature of SCIC and the importance of prompt initiation of exchange transfusion therapy. While SCIC is a challenging given its non-specific constellation of symptoms with significant overlap with several other hepatic processes, nevertheless it should be high on the differential in patients with SCD who develop hepatic abnormalities during vaso-occulsive crisis.

OGC P49 Case report: Ivor Lewis oesophagectomy requiring one lung ventilation in a patient with a previous laryngectomy

Abstract Background A 68 year old patient with squamous cell carcinoma (SCC) of lower oesophagus (T3N0M0) presented for Ivor Lewis oesopphagectomy (ILO) following neoadjuvant chemoradiotherapy. Four years previously the patient had undergone total laryngectomy, radical right neck dissection with right pectoralis major flap and bilateral adjuvant radiotherapy for hypopharyngeal SCC (pT3N2bM0). A tracheal stoma was present with speaking valve in-situ. An ILO was planned requiring one lung ventilation (OLV) to facilitate surgical access. In our institution, OLV is routinely achieved via double lumen endotracheal tube (DLT), although endobronchial blocker through single lumen endotracheal tube or laryngeal mask airway and endobronchial intubation with a single lumen tube are potential options. Post laryngectomy the method used for lung isolation is limited and care must be taken not to traumatise the stoma site or surrounding tissue. Additionally, the angulation formed by the trachea and stoma mean a DLT is often not suitable while specific double lumen tracheostomy tubes may have too great a diameter for a small stoma. Surgically, close relations of the tumour to gastro-oesophageal junction, left diaphragmatic crus and descending thoracic aorta made suitability for resection uncertain, despite two negative staging laparoscopies. We describe the anaesthetic and surgical management of this interesting case. Methods General anaesthesia was delivered via an intravenous induction and maintenance was with sevoflurane. Airway management included bag mask ventilation with a neonatal facemask followed by placement of an 8mm reinforced endotracheal tube through the tracheal stoma. Prior to right thoracotomy a right sided 9Fr VivaSight endobronchial blocker (Ambu) was placed under direct vision using a single use Ambu aScope™ 4 Broncho Slim fibreoptic bronchoscope. OLV was successful using this method; SpO2 ≥96% (FiO2 0.6) and peak inspiratory pressure 18–20cmH2O-1. Analgesia comprised intrathecal morphine, right erector spinae plane local anaesthetic block and infusion catheter and morphine PCA. Abdominal phase was undertaken laparoscopically. The hiatus was noted to be fibrotic following chemoradiotherapy and a small capsular breach of the left lobe of liver occurred, controlled with Surgiflo (Ethicon). A right thoracotomy was performed through the 6th intercostal space. Right lung was deflated and surgical access was adequate. OrVil (Covidien – Medtronic) anastomosis was attempted but the anvil was unable to pass through the pharynx, therefore a purse string applicator was applied and OrVil staple used. The left pleura was also breached during dissection. One left and two right chest drains were placed. Results Postoperatively, analgesia was adequate and the patient did not require any cardiovascular or respiratory support. However, on first postoperative day it was noted that the speaking valve was not functioning causing significantly hoarse voice. A valve leak was detected and though hard to know the precise cause, it was assumed that it had become dislodged via either anaesthetic procedures, surgical handling or a combination. Despite some improvement in the symptoms over the first post-operative week, the patient also experienced airway soiling on commencing oral intake and after review by ENT a new valve was successfully sited and all symptoms resolved. Although a minor and easily rectifiable complication, the ‘loss of voice’ was very distressing for the patient. The patient had an otherwise uneventful postoperative course and was discharged home on day-11. Clinic review at six weeks revealed the patient had made a complete recovery and had resumed all normal activities. Histology showed scattered small foci of moderately differentiated SCC infiltrating the muscularis propria (stage ypT2). Longitudinal margins were clear of both dysplasia and malignancy. There was no evidence of lymphatic, venous or perineural invasion. One of 12 lymph nodes showed metastatic SCC. Adjuvant course of Nivolumab immunotherapy is currently planned. Conclusions We have presented an unusual case of previous laryngectomy plus requirement for OLV for ILO. The use of an endobronchial blocker via a reinforced endotracheal tube has been shown to be a successful airway management strategy. Speaking valve displacement and/or malfunction is a potential complication in such cases and should form part of preoperative counselling. Close liaison between surgical, anaesthetic and ENT teams is essential in the management of complex and unusual cases and, as we have demonstrated, strong teamwork leads to successful outcomes for patients.

The effects of a short-term perioperative duloxetine treatment on post-colectomy pain: A randomized, controlled clinical trial

Study objectiveTo test the hypothesis that duloxetine reduces postoperative morphine consumption and pain intensity in patients undergoing major colonic surgeries. DesignSingle-center, prospective, double-blinded, randomized, controlled trial. SettingTertiary university hospital, from December 2019 to September 2021. PatientsSixty 18–85 years old, ASA I – III patients undergoing elective open major colonic surgeries were randomly allocated into duloxetine (duloxetine) or placebo (placebo) groups (n = 30 per group). InterventionsDuloxetine 60 mg or placebo was administered orally 2 h before and 24 h after surgery. MeasurementsPCA morphine consumption, surgical pain at rest, and movement measured on 10-cm visual analog scales (VAS), Ramsay sedation scores, and the incidence of adverse effects potentially associated with duloxetine were assessed at patients' admission to the post-anesthesia care unit (PACU), 6, 24, and 48 h postoperatively (PO). Main resultsAfter adjusting for age, BMI, ASA physical status, education level, and incision type, no differences were found between groups in PCA morphine consumption 24 PO h (duloxetine = 5.44 ± 2.06 mg; placebo = 10.33 ± 2.06 mg, p = 0.62) or 48 h PO (duloxetine = 9.18 ± 2.06 mg, placebo = 12.93 ± 2.06, p = 1). Pain at rest also did not differ between groups at 24 h PO (duloxetine = 1.76 ± 0.67 cm; placebo = 1 ± 0.67 cm, p = 1) or at 48 h PO (duloxetine = 0.84 ± 0.67 cm; placebo = 0.49 ± 0.67 cm, p = 1). Similarly, groups did not differ regarding pain on movement at 24 h PO (duloxetine = 2.09 ± 0.68 cm; placebo = 1.80 ± 0.68, p = 1) or at 48 h PO (duloxetine = 1.16 ± 0.68 cm; placebo = 0.88 ± 0.68 cm, p = 1). Sedation scores and adverse effects also did not differ between groups. ConclusionUnder this study's conditions, short-term duloxetine did not reduce total opioid consumption or pain intensity during the initial 48 h following major colon surgery.

Sublingual Sufentanil versus Standard-of-Care (Patient-Controlled Analgesia with Epidural Ropivacaine/Sufentanil or Intravenous Morphine) for Postoperative Pain Following Pancreatoduodenectomy: A Randomized Trial.

BackgroundThe optimal treatment strategy for postoperative pain following pancreatoduodenectomy remains unknown. The aim of this study was to investigate whether sublingual sufentanil tablet (SST) is a non-inferior analgesic compared to our standard-of-care (patient-controlled epidural analgesia [PCEA] or PCA morphine) in the treatment of pain following pancreatoduodenectomy.MethodsThis was a pragmatic, strategy, open-label, non-inferiority, parallel group, randomized (1:1) trial. The primary outcome was an overall mean pain score (Numerical Rating Scale: 0–10) on postoperative days 1 to 3 combined. The non-inferiority margin was −1.5 since this difference was considered clinically relevant.ResultsBetween October 2018 and July 2021, 190 patients were assessed for eligibility and 36 patients were included in the final analysis: 17 patients were randomized to SST and 19 patients to standard-of-care. Early treatment failure in the SST group occurred in 2 patients (12%) due to inability to operate the SST system and in 2 patients (12%) due to severe nausea despite antiemetics. Early treatment failure in the standard-of-care group occurred in 2 patients (11%) due to preoperative PCEA placement failure and in 1 patient (5%) due to hemodynamic instability caused by PCEA. The mean difference in pain score on postoperative day 1 to 3 was −0.10 (95% CI −0.72–0.52), and therefore the non-inferiority of SST compared to standard-of-care was demonstrated. The mean pain score, number of patients reporting unacceptable pain (pain score >4), Overall Benefit of Analgesia Score, and patient satisfaction per postoperative day, perioperative hemodynamics and postoperative outcomes did not differ significantly between groups.ConclusionThis first randomized study investigating the use of SST in 36 patients following pancreatoduodenectomy showed that SST is non-inferior compared to our standard-of-care in the treatment of pain on postoperative days 1 to 3. Future research is needed to confirm that these findings are applicable to other settings.

P.130 Morphine PCA use after CS under general anaesthesia: a review of practice

P.130 Morphine PCA use after CS under general anaesthesia: a review of practice

Continuous Unilateral Erector Spinae Plane Block versus Intravenous Analgesia in Minimally Invasive Cardiac Surgery: A Randomized Controlled Trial

Objectives: the study was conducted to assess the safety and efficacy of anesthesia under the erector spinae plane block (ESPB) in minimally invasive cardiac surgery (MICS). Methods: a prospective, randomized controlled trial was carried out in 56 adult patients who underwent MICS via a right thoracic incision at Vietnam National Heart Institute, Bach Mai hospital, Vietnam. Patients were randomly allocated into two groups: ESPB and conventional analgesia (intravenousmorphine patient-controlled analgesia, PCA). Patients in ESPB group received ultrasound-guided unilateral ESPB at the T4/T5 transverse process level, and the tip of the catheter was advanced 5cm beyond the tip of the needle; injected with 20 ml ropivacaine 0.5%. At the cardiac ICU, patients received paracetamol (1g every 6 hours), continuous infusion ropivacaine 0.1% 0.2ml/kg/hour. Patients in the PCA group received paracetamol (1g every 6 hours) and intravenous morphine PCA. All patients were followed for 72 hours after being extubated. Results: the resting VAS score was significantly lower in ESPB group at the time H4, H8, H12, H16, H36, H42, H48, H54, H60, H66 after extubated compared to that of the PCA group (p&lt; 0.05). The dynamic VAS score at was also significantly lower in the ESPB group at all measured time points (p&lt;0.05). Only 4 patients in the ESPB group required intravenous morphine PCA with the mean amount morphine were statistically lower in the ESPB group compared to the PCA group at 24 hours, 48 ​​hours, 72 hours postoperative. No serious adverse events such as neurological complications, bleeding or infection were observed in both groups. Conclusion: ESPB is an effective analgesic for MICS via thoracic incision in reducing the VAS score and the morphine required. It is also a safe method with no severe ESPB-related complications.

Effect of Magnesium Sulfate on the Total Anesthetic and Analgesic Requirements in Neurosurgery

Introduction: The intraoperative anesthetic and postoperative analgesic requirements are of great importance especially in neurosurgical anesthesia. This requires balancing a deep and effective anesthesia and postoperative analgesia versus the risks of delayed recovery and postoperative respiratory depression from excessive analgesics. Magnesium sulfate is an antagonist of the N-Methyl-D-Aspartate (NMDA) receptors in a voltage-dependent fashion. Propofol also inhibits the NMDA subtype of the glutamate receptor. Therefore, magnesium sulfate when coadministered with propofol potentiates anesthetic effect and NMDA antagonism of propofol. Majority of the studies that evaluated the anesthetic and analgesic requirement in patients receiving magnesium sulfate depended on the clinical parameters, for example, hemodynamic parameters and measurement of pain scores. In this study, we added bispectral index (BIS) and neuromuscular monitoring using train-of-four (TOF) to adjust intraoperative anesthetic requirements in addition to the clinical parameters.&#x0D; Methodology: This randomized controlled double-blind study included 50 adult ASA I and II male and female patients undergoing neurosurgical maneuvers. Patients were randomly divided into two equal groups. Routine intraoperative monitoring including invasive BP and in addition TOF and BIS were applied. In a blind fashion, patient in group I (Magnesium group) received magnesium sulfate 20 mg/kg as bolus dose over 5 min followed by 0.1 ml/kg/hr of 10% solution as infusion, while patient in group II (Control group) received saline with the same bolus and infusion rates after the induction of anesthesia. Anesthesia was induced in both groups by fentanyl 2 µg/kg, propofol 1.5–2 mg/kg, and rocuronium in a dose of 0.6 mg/kg to facilitate ETT insertion. This is followed by continuous infusion of propofol 6–10 mg/kg/hr and fentanyl 1–2 mic/kg/hr. The parameters which were assessed included hemodynamic parameters (HR and BP), TOF, and BIS. Total consumptions of propofol, fentanyl, rocuronium, and postoperative analgesic requirements (PCA morphine) were recorded. In addition, recovery time and postoperative pain score by visual analog scale (VAS) were recorded.&#x0D; Result: There was no significant difference in patient characteristics between the two groups. As regard the hemodynamic changes and BIS, no significant difference was seen between the two groups except the HR change which was significantly reduced (p = 0.005) with surgical stimulation in group I compared to the other group. Results also showed that the mean fentanyl, propofol, and rocuronium consumption, recovery time, degree of postoperative pain, and postoperative analgesic requirements were significantly less in patients that received magnesium sulfate infusion compared to those in the control group.&#x0D; Conclusion: Magnesium sulfate is most likely a safe and cost-effective supplement to the general anesthesia in neurosurgery as it reduces the total anesthetic and analgesic requirements and postoperative pain.

Impact of Intra-Articular Local Anesthesia Infiltration versus Femoral Nerve Block for Postoperative Pain Management in Total Knee Arthroplasty.

Background:Postoperative pain relief after total knee arthroplasty (TKA) can be attained by using several techniques such as intravenous analgesia, epidural analgesia, and peripheral nerve blocks that include femoral nerve and saphenous nerve. Several authors recommended intra-articular injection of local anesthetic (IALA) as a part of multimodal analgesia regimens for TKA instead of other techniques.Aims:The present study compares IALA technique efficacy with single-shot femoral nerve block (FNB) as part of multimodal analgesia regimen in TKA patients for postoperative pain management.Setting and Design:Perioperative care, randomized double-blind comparative study.Subjects and Methods:We recruited a total of 60 patients scheduled for unilateral total knee replacement under spinal anesthesia. Subjects were allocated randomly into two groups FNB and IALA receiving ultrasound-guided FNB and Intra-articular local anesthesia and morphine mix infiltration, respectively. Twenty-four hour postoperative morphine consumption through patient-controlled analgesia was the primary outcome measure in our study. Secondary outcome measures were pain scores, nausea and vomiting.Statistical Analysis:Chi-square test, Mann–Whitney test.Results:The amount of morphine consumed at the end of 24 h was noted to be higher in IALA group as compared to FNB (FNB − 16.03 ± 9.37 mgs; IALA − 23.60 ± 13.73 mgs P = 0.03). Visual analog score at 24 h with knee flexion was better in FNB group (FNB − 1.27 ± 1.43; IALA 2.42 ± 2.54, P = 0.04).Conclusion:FNB technique provides better analgesia in comparison to IALA for postoperative pain management in terms of PCA morphine consumption.

Bilateral posterior Quadratus Lumborum block for pain relief after cesarean delivery: a randomized controlled trial

BackgroundAchieving optimal analgesia with few side effects is the goal of pain management after cesarean delivery. Intrathecal (IT) morphine is the current standard but ultrasound-guided quadratus lumborum block (QLB) may offer superior pain control with fewer side effects. This study compared the pain-free period after cesarean delivery among parturients who received spinal block with IT morphine, with IT morphine and bilateral QLB, or only bilateral QLB.MethodsParturients having elective cesarean delivery under spinal block were randomized and allocated into IT morphine 0.2 mg with sham QLB (Group IT), IT morphine 0.2 mg and bilateral QLB with 0.25% bupivacaine 25 ml in each side (Group IT+QLB), or bilateral QLB with 0.25% bupivacaine 25 ml in each side (Group QLB). A PCA pump was connected after completion of the QLB or sham block. The first time to PCA morphine requirement was recorded and compared.ResultsEighty parturients were included. Analysis of Group QLB was terminated early because at the second interim analysis, median pain-free period was significantly shorter in Group QLB [hours (95%CI): 2.50 (1.04–3.96) in Group IT vs. 7.75 (5.67–9.83) in IT+QLB vs. 1.75 (0.75–2.75) in QLB (p < 0.001)]. The median (min, max) amount of morphine required during 24 h was 5.5 (0–25) in Group IT vs. 5.0 (0–36) in IT+QLB vs. 17.5 (1–40) mg in Group QLB (p < 0.001). In the final analysis the median pain-free period was 2.50 (1.23–3.77) hours (95%CI) in Group IT (n = 27) vs. 8.02 (5.96–10.07) in IT+QLB (n = 28). (p = 0.027).ConclusionUS-QLB used in conjunction with IT morphine yielded a statistically significant longer median pain-free period compared with standard IT morphine alone. However, QLB alone provided inferior pain control compared with standard IT morphine. When combined with IT morphine, QLB could provide additional analgesic benefit as a part of multimodal analgesic regimen, especially during the early postoperative period.Trial registrationClinicalTrials.gov no. NCT03199170 Date registered on June 22, 2017. Prospectively registered.

Perioperative analgesia for the prolepsis of persistence of post-thoracotomy chronic neuropathic pain

Abstract: Proper perioperative analgesic management of Thoracic surgery cases constitutes a primary factor for the successful outcome of the surgery, having created the ideal conditions for both the thoracic surgeon and the anesthesiologist, but mainly for the avoidance of postoperative pain for the patient. 5%-67% of thoracic surgery cases reports post thoracotomy pain syndrome that can persist for up to 20 years. Purpose: To give prominence to the benefits of analgesics for the patient undergoing thoracic surgery after having received appropriate perioperative treatment and starts analgesic protection from the time preceding surgical incision to the patient’s complete recovery, as far as prevention of chronic neuropathic pain is concerned. Complete analgesic protection presupposes the interdisciplinary collaboration of the surgeon and the anesthesiologist with the patient. Materials & methods: Thorough review of scientific literature in scientific databases (PubMed, Scopus, SignaVitae) concerning perioperative analgesia in thoracotomies. Results: In our effort to prevent the persistence of Chronic Neuropathic Pain, we always take into consideration the fact that thoracotomy patients suffer from respiratory complications/uneasy breathing with invasive analgesia techniques. Therefore, we remain alert to reduce the use of opioids and their adverse effects on those patients. Major analgesic outcomes and avoidance of persistence of chronic neuropathic pain can be achieved with the following procedure: (1) Intravenous administration of non-steroidal anti-inflammatories, paracetamol, dexamethasone 8 mg, NMDA receptor antagonist (Ketamine 30 mg) before incision as well as local infusion of Ropivacaine 2% solution. (2) Intravenous infusion of lidocaine, fentanyl, remifentanil, morphine, tramadol, Mg, ketamine, during surgery by adjusting doses per patient and operative time. (3) Particular caution is suggested in the immediate postoperative period so as to avoid transition from acute postoperative pain to chronic neuropathic pain. Our armamentarium includes paracetamol, tramadol, dexketoprofen, oxycodone per os, PCA morphine, pain busters (paired drainage catheters with elastomeric pumps) of ropivacaine 2%, patch lidocaine and thoracic epidural analgesia with ropivacaine pumps and intercostal block nerve conduction. A medical record of the postoperative analgesic course of our patients is kept and completed by our medical and nursing staff. Conclusions: Perioperative analgesia is our key concern in all thoracic surgeries, so as to prevent post thoracotomy pain syndrome. For the purpose of this concern, we administer analgesic treatment on all surgery stages as well as keep postoperative analgesic record.

Perioperative Analgesia in Major Oncology operations for the prolepsis of persistence of Chronic Neuropathic Pain

Abstract: Perioperative Analgesia in Major Oncology operations for the prolepsis of persistence of Chronic Neuropathic Pain might include intravenous infusion of analgesics, concomitant drugs as well as invasive techniques in all surgical stages. Achieving highly effective analgesia presupposes the interdisciplinary collaboration of the surgeon and the anesthesiologist with the patient. Purpose: To give prominence to the benefits of analgetics for the oncology patient undergoing surgery after having received appropriate perioperative treatment and starts analgesic protection from the time preceding surgical incision to the patient’s complete recovery, as far as prevention of chronic neuropathic pain is concerned. Materials & methods: Thorough review of scientific literature in scientific databases (PubMed, Scopus, hesmo.org, uicc.org, Signa Vitae) which are consistent with the way our department functions and in compliance with the protocols concerning the prolepsis of persistence of Chronic Neuropathic Pain in major oncology operation patients. Results: Major analgesic outcomes and avoidance of persistence of chronic neuropathic pain, by taking into consideration the fact that postoperative oncology patients suffer from respiratory depression after invasive analgesia techniques. Also, we are prepared to reduce the use of opioids and their adverse effects, following the procedure below: (1) Choose, when allowed, a combination of general and epidural anesthesia to achieve maximum intraoperative and postoperative analgesia. (2) Intravenous administration of non-steroidal anti-inflammatories, paracetamol, dexamethasone 8mg, NMDA receptor antagonist (Ketamine 30 mg) before incision as well as local infusion of Ropivacaine 2% solution. (3) Intravenous infusion of lidocaine, fentanyl, remifentanil, morphine, tramadol, Mg, ketamine, during surgery by adjusting doses per patient and operative time. (4) Particular caution is suggested in the immediate postoperative period so as to avoid transition from acute postoperative pain to chronic neuropathic pain. Continue drop by drop administration of ropivacaine 2% from epidural catheter. Our armamentarium includes paracetamol, tramadol, dexketoprofen, oxycodone per os, PCA morphine, pain busters (paired drainage catheters with elastomeric pumps) of ropivacaine 2%, patch lidocaine and block nerve conduction. A medical record of the postoperative analgesic course of our patients is kept and completed by our medical and nursing staff.Conclusions: Perioperative analgesia is our key concern in all oncology patients undergoing major surgeries, so as to prevent persistence of chronic neuropathic pain, taking into consideration the impaired health status of patients with acute pain conditions.