Multimodal Analgesia Protocol Research Articles

Erector spinae plane block (ESPB) enhances hemodynamic stability decreasing analgesic requirements in surgical stabilization of rib fractures (SSRFs)

ObjectiveTo evaluate the efficacy of erector spinae plane block (ESPB) on intraoperative hemodynamic stability, opioid and inhalation anesthetic requirements and postoperative analgesic effects in patients undergoing surgical stabilization of rib fractures (SSRFs).MethodsWe retrospectively reviewed 173 patients who underwent surgical stabilization of rib fractures between May 2020 and December 2023. The patients were allocated into the ESPB group or the control group. Demographic data, intraoperative hemodynamic parameters, total intraoperative opioid consumption, the average minimum alveolar concentration (MAC) of inhalational anesthetics, postoperative simple analgesics and opioid consumption and the length of hospital stay were included in the analysis.ResultsCompared with the control group, the ESPB group had a lower heart rate (HR) in the first 90 min after surgical incision and lower systolic blood pressure (SBP) and mean arterial pressure (MAP) at the beginning of surgery. Intraoperatively, a notable reduction in fentanyl consumption was observed in the ESPB group (p = 0.004), whereas no significant difference was observed in the average MAC of inhalational agents (p = 0.073). Postoperatively, the ESPB group required fewer doses of simple analgesics in the first 24 h (p < 0.001) and 48 h (p = 0.029). No statistically significant difference in the length of hospital stay (p = 0.608) was observed between the groups.ConclusionESPB was shown to enhance intraoperative hemodynamic stability, reduce opioid consumption and decrease postoperative analgesic consumption in patients who underwent SSRF. These results suggest that ESPB may serve as a valuable component of multimodal analgesia protocols for SSRF. Larger prospective studies are warranted to confirm the results and evaluate long-term outcomes.

Comparative study between effect of preoperative multimodal analgesia and pregabalin as unimodal analgesia in reduction of postoperative opioids consumption and postoperative pain in laparoscopic cholecystectomy

BackgroundLaparoscopic cholecystectomy is a popular abdominal surgery and the most common problem for patients undergoing laparoscopic cholecystectomy is the postoperative pain, and associated side effects due to opioids use for pain management and multimodal analgesia is suggested to reduce postoperative pain and need for postoperative opioids. This controlled clinical trial compares the effects of multimodal analgesia and pregabalin as unimodal analgesia on postoperative pain management, postoperative opioids consumption, and reduction of opioids accompanied adverse effects in patients undergoing laparoscopic cholecystectomy where large multicenter studies evaluating specific analgesic combinations are lacking.MethodThis comparison randomized controlled trial between multimodal analgesia approach and pregabalin as unimodal analgesia included 95 laparoscopic cholecystectomy patients that were randomly allocated to three groups using a simple randomization method where multimodal and pregabalin groups included 30 patients in each and the drugs was administered orally one hour before the incision and control group included 35 patients that did not receive any preoperative analgesia. Multimodal analgesic therapy included acetaminophen 1 g, pregabalin 150 mg and celecoxib 400 mg while pregabalin group received pregabalin 150 mg only.ResultsMultimodal group showed a significantly lower need for total opioid analgesics mean ± SD (1.33 ± 1.918) as compared to the control group mean ± SD (3.31 ± 2.784) with p-value 0.014. Pregabalin and multimodal groups showed significantly lower postoperative visual analogue scale used for pain assessment mean ± SD (3.50 ± 2.543) and mean ± SD (3.70 ± 2.231), respectively, compared to the control group mean ± SD (5.89 ± 2.857) with p-value 0.001.ConclusionMultimodal analgesia reduced postoperative opioids consumption more than pregabalin alone when used preoperatively in laparoscopic cholecystectomy and consequently reduced opioids associated adverse effects, but they have the same efficacy in reducing postoperative pain, so pregabalin can be used alone preoperatively in patients with contraindications for using some analgesics included in multimodal analgesia protocol. The study was registered retrospectively in clinical trials; Trial registration ID: NCT05547659.

No Difference in Postoperative Recovery Outcomes Between Opioid-Free and Opioid-Sparing Anesthesia Under Multimodal Analgesic Protocol for Video-Assisted Thoracoscopic Surgery: A Propensity Score Matching Cohort Study.

Background: With growing concerns about opioid-related risks, efforts to reduce opioid use throughout the perioperative period have increased. This study aimed to compare postoperative recovery outcomes between opioid-free anesthesia (OFA) and opioid-sparing anesthesia (OSA) under a multimodal analgesic protocol in video-assisted thoracoscopic surgery (VATS). Methods: A retrospective cohort study was conducted on 196 patients undergoing VATS from August 2019 to December 2021. Patients received either dexmedetomidine-based OFA or remifentanil-based OSA. Postoperative recovery was assessed using the Quality of Recovery-15 (QoR-15) score, opioid consumption, and pain intensity. Additionally, opioid-related complications and intraoperative hemodynamic changes were evaluated. Results: Both groups showed similar QoR-15 scores 24 h postoperatively (124.2 ± 7.0 vs. 123.0 ± 6.9, p = 0.227). Opioid consumption and pain intensity were comparable, and the incidence of opioid-related adverse events did not significantly differ between the groups. Intraoperative hypotension and bradycardia were more frequent in the OFA group, but the differences were not statistically significant. Conclusions: The study concluded that both OFA and OSA, when used under a multimodal analgesic protocol, provided effective postoperative recovery in patients undergoing VATS with no significant differences in outcomes.

Effectiveness of Ultrasound Guided Quadratus Lumborum Block versus Intravenous Analgesia for Postoperative Pain Management in Patients Undergoing Hip Surgeries

Abstract Background Orthopedic operations such as hip and femur fractures can lead to significant postoperative pain. In these patients, nonopioid analgesia techniques are especially important in aging populations when comorbidities are considered. Aim of the Work to compare the analgesic efficacy of ultrasound guided Quadratus Lumborum (QL) block versus intravenous analgesia for postoperative pain management in patients undergoing hip surgeries under spinal anesthesia. Patients and Methods This prospective interventional study was conducted at Anesthesiology, Intensive Care and Pain Management Department, Faculty of Medicine, Ain Shams University Maternity Hospitals from January until August 2023. During this study, 40 patients scheduled for hip surgery under spinal anaesthesia were enrolled and divided into two equal groups; quadratus lumborum and control groups, with the same inclusion and exclusion criteria. Total amount of opioid analgesics needed by patients in both groups, pain scores according to the Visual Analog Scale (VAS), first time the patient needed postoperative rescue analgesia, vital data, postoperative length of hospital stay and side effects of drugs were recorded and compared between both groups. Results In our study, no differences were noted between groups regarding demographic data “age, sex, ASA and type of operation”. Regarding hemodynamics, our study revealed that at 10, 20, 40 min, PACU at 30 and 1hr, mean arterial pressures and heart rate were statistically significant higher among control cases compared with quadratus lumborum group. Regarding analgesic efficacy, our study revealed that VAS score was statistically significant higher after 4, 6 and 12hrs, need of 1st rescue analgesic was statistically significant faster 3.60 ± 1.06 vs. 18.00 ± 8.49 hours and total narcotics “mg” was statistically significant higher 60.00 ± 16.16 vs. 40.00 ± 13.69 among control cases compared with quadratus lumborum group. Also, our study revealed that hospital stay “days” was statistically significant longer 2.75 ± 0.44 vs. 1.75 ± 0.64 and side effect respiratory depression and vomiting were statistically significant higher among control cases compared with quadratus lumborum group. Conclusion QL block is effective for analgesia in patients after hip surgery compared with placebo or no block. QLB as a part of multimodal analgesia protocol reduces opioid consumption and pain scores in patients undergoing hip surgeries. The certainty of evidence based on GRADE was moderate.

Updating Clinical Practice: Improving Perioperative Pain Management for Adeno-Tonsillectomy in Children.

Perioperative acute pain management in pediatric patients is essential to reduce complications. Adenoidectomy-Tonsillectomy are surgical procedures requiring pain control, and risk minimization for postoperative bleeding, nausea, and vomiting. Despite their known secondary effects, the use of opioid analgesics is still preponderant in pediatric perioperative management. We performed a comprehensive review on adeno-tonsillectomy perioperative pain management in children. We developed and implemented a multimodal analgesia protocol aimed to improve patients' pain management while consistently reducing opioids use. relevant Information was summarized, then compared to our clinical needs. Learnings were used to create and implement a multimodal analgesia protocol that we use in patients 3-9 years-old undergoing adenoidectomy/tonsillectomy. The full protocol is presented. Analgesic strategies have emerged to reduce or avoid the use of opioids. Among these strategies, combining different non-opioid analgesics (Ibuprofen, Paracetamol, Metamizole) has been shown to be an effective and safe pharmacological strategy when implemented as part of perioperative multimodal analgesia protocols. Considerable evidence associating the use of NSAIDs with a bigger risk of postoperative bleeding does not exist. Perioperative management of adenotonsillectomy pain should include preventive and multimodal analgesia, which have shown to provide significantly more effective analgesia than some opioid regimens. Ibuprofen offers highly effective analgesia for postoperative pain, particularly when combined with acetaminophen.

Ultrasound-guided bilateral anterior quadratus lumborum block at the lateral supra-arcuate ligament in patients undergoing laparoscopic radical gastrectomy: A randomised controlled study

Objective: Ultrasound-guided bilateral anterior quadratus lumborum block at the lateral supra-arcuate ligament has recently been proposed as an effective analgesia for abdominal surgery. To test the hypothesis that this novel technique was a viable alternative approach of conventional thoracic epidural analgesia for laparoscopic radical gastrectomy. Methods: Three hundred patients scheduled for laparoscopic radical gastrectomy were randomised 1:1 into the anterior quadratus lumborum block group: receiving the novel regional analgesia, and the thoracic epidural analgesia group: receiving thoracic epidural anaesthesia. The primary endpoint was intraoperative consumption of propofol and remifentanil. Intention-to-treat analysis was performed for all variables. Results: At five and ten minutes after block, anterior quadratus lumborum block group achieved more dermatomes coverage of the sensory block with both p &lt; 0.001. Intraoperative consumption of propofol and remifentanil was comparable between two groups (1116.21 ± 199.76 versus 1166.45 ± 125.31µg, p = 0.245 and remifentanil 1.83 ± 0.41 versus 1.81 ± 0.37ng, p = 0.988). However, anterior quadratus lumborum block group was associated with less intraoperative consumption of norepinephrine and atropine, shorter time to urinary catheter removal and out-of-bed activity than the thoracic epidural anaesthesia group. No significant difference in extubation time, pain scores at rest and exercising at all time points following surgery was observed between the two groups. Conclusions: Compared with conventional thoracic epidural anaesthesia, the novel technique was an equivalent effective component of multimodal analgesic protocol for laparoscopic radical gastrectomy. There were some advantages, including shorter procedure time, more reliable dermatomal coverage, shorter duration of urinary catheterisation and earlier time of out-of-bed activity to enhance recovery after surgery. Trial registration: The study was registered in the Chinese Clinical Trial Registry on 2 November 2022 (ChiCTR2200065325).

Effect of adductor canal block combined with infiltration between the popliteal artery and posterior capsular of the knee on chronic pain after total knee arthroplasty: a prospective, randomized, double-blind, placebo-controlled trial

IntroductionTotal knee arthroplasty (TKA) is accompanied by severe postoperative pain, which is reported to be an important cause of chronic pain. Ultrasound-guided adductor canal block (ACB) combined with infiltration between the popliteal artery and posterior capsular of the knee (IPACK) has been proven to have a better effect on relieving acute pain after TKA. However, whether it has a significant effect on the incidence of chronic pain after TKA has not been reported. This trial was designed to investigate the effect of ultrasound-guided ACB combined with IPACK on the incidence and intensity of chronic pain after TKA.MethodsIn this prospective, randomized, double-blind, placebo-controlled study, 100 subjects scheduled for TKA were randomly (1:1) divided into two groups: the ropivacaine group and the placebo group. Patients in each group received ultrasound-guided ACB + IPACK procedures with 0.25% ropivacaine or equal volume normal saline. All patients received multimodal analgesia. Pain intensity was assessed using the Numerical Rating Scale (NRS). The primary outcome was the incidence of chronic pain at 3 months after TKA by telephone follow-up. In addition, pain intensity in early resting and mobilized states, chronic pain intensity, the time to first rescue analgesia; opioid consumption; CRP and IL-6 after the operation; length of postoperative hospital stay; and cost of hospitalization and postoperative complications; as well as the function of the knee in the early stage after the operation, were recorded.ResultsNinety-one participants were included in the final analysis. At 3 months, the incidence of chronic pain was 30.4% in the ropivacaine group, significantly lower than 51.1% in the placebo group. Compared with the placebo group, the ACB + IPACK with ropivacaine group had significantly lower pain scores at 4 hours, 8 hours, 16 hours, and 24 hours after the operation; increased the knee range of motion at 8 hours and 24 hours after the operation; and a significantly decreased incidence of chronic pain at 3 months after the operation. During the follow-up period, there were no nerve block-related complications in either group.ConclusionIn the context of multimodal analgesia protocols, ACB combined with IPACK before surgery decreases the incidence and intensity of chronic pain 3 months after TKA compared with placebo injection. In addition, it reduces the NRS scores, whether at rest or during mobilization, and improves knee function within 24 hours after TKA.Trial registrationThis trial was registered in the China Clinical Trial Center (registration number ChiCTR2200065300) on November 1, 2022.

Эффективность применения Контрапаина-10® (нефопама гидрохлорида) при мультимодальной анальгезии собак

Purpose of the research: to estimate the effectiveness of nefopam hydrochloride (Contrapain-10®) as a part of multimodal analgesia in pre- and intraoperative period of dogs, and to find out whether this medicine will reduce the number of anesthetics used during the intraoperative period. Materials and methods: the study included 34 dogs; 2 groups (n = 17) were formed from patients with diagnosed herniated discs of varying severity in different departments. All animals were subject to surgical treatment: group A (control group with nefopam hydrochloride) and B (experimental group without nefopam hydrochloride). For group A dogs in the preoperative period a non-opioid analgesic of central action, nefopam hydrochloride, was introduced into the multimodal analgesia scheme at a dosage of 0.3…0.5 mg/kg of body weight intramuscularly with an assessment of the analgesic effect. For dogs of group B (control) A standard multimodal analgesia protocol was used without the nefopam hydrochloride. During the intraoperative period, patients' pain levels were assessed using numerical hardware parameters (the main components of monitoring are ECG, frequency of respiratory movements, heart rate, noninvasive blood pressure, pulse oximetry, thermometry), as well as visual monitoring. Physiological parameters, pain and degree of sedation were assessed during the whole surgical operation and intermediate results were recorded every 30, 60, 90, 120, 150, 180 minutes. Estimation of clinical effectiveness of the medicine was evaluated based on the results of the pain assessment (from 1 to 5), general condition and values of vital parameters recorded during surgery. Results: Contrapain-10® promotes high-quality and safe anesthesia of patients both during surgery and in the postoperative period. At the same time, the consumption of opioid and non-opioid analgesics is minimal.

Local Infiltration Analgesia Is Superior to Regional Nerve Blocks for Total Hip Arthroplasty: Less Falls, Better Mobility, and Same-Day Discharge.

Background: Multimodal analgesia in total hip arthroplasty (THA) provides better pain control, mobility, and reduced side effects compared to monotherapies. Local infiltration analgesia (LIA) and regional nerve blocks (RNBs) are commonly used throughout these protocols. This study aimed to compare these procedures as part of a multimodal analgesia protocol for patients undergoing THA. Materials and Methods: A retrospective review of 1100 consecutive elective primary THAs was performed in 996 patients between June 2018 and December 2021. The RNB consisted of a preoperative continuous femoral nerve catheter and single-shot obturator nerve block, and LIA consisted of the intraoperative infiltration of weight-based bupivacaine. Results: A total of 579 (52.6%) patients received RNB, and 521 (47.4%) received LIA. Mean oral morphine equivalents (OMEs) during the first four hours postoperatively were significantly lower for LIA group (p < 0.001). However, the numeric pain rating scale in the post-anesthesia care unit (PACU) was similar between groups. Patients with LIA had significantly greater first ambulation distance in the PACU (p < 0.001), higher successful same-day discharge rate (p = 0.029), fewer falls (p = 0.041), and less refill OMEs post-discharge (p < 0.001) than RNB. Conclusions: In the setting of similar pain management between groups and better functional outcomes for LIA, the use of minimally invasive procedures like LIA for pain control following THA is favorable.

Effects of Local Wound Infiltration Post-Mastectomy Using Bupivacaine Alone, Bupivacaine With Ketamine, and Bupivacaine With Dexmedetomidine: A Randomized Double-Blind Study.

Background and aim While the infiltration of surgical incisions with local anesthetics is not a new practice, it remains a crucial component of contemporary multimodal analgesia protocols. This study aimed to evaluate the efficacy and safety of using adjuvants in combination with local anesthetic wound infiltration for pain management in patients undergoing mastectomy surgery. Methods Eighty-one patients aged 18-60 years, classified as American Society of Anesthesiologists (ASA) grade I or II, were scheduled for unilateral mastectomy and randomly assigned to three groups of 27 each. The groups were designated as Group C (bupivacaine alone), Group D (bupivacaine with dexmedetomidine), and Group K (bupivacaine with ketamine). Group C received 0.25% bupivacaine alone, Group D received 0.25% bupivacaine with 1 mcg/kg dexmedetomidine, and Group K received 0.25% bupivacaine with 1 mg/kg ketamine. The time to achieve a Visual Analogue Scale (VAS) score of 3 following local wound infiltration was recorded for each group. Additionally, total postoperative fentanyl intake during the first 24 hours, as measured by the patient-controlled analgesia (PCA) pump, was compared among the groups. Sedation levels were assessed using the Ramsay Sedation Scale (RSS). Data were analyzed using the Chi-Square test and one-way ANOVA in IBM SPSS Statistics for Windows, Version 28.0 (Released 2021; IBM Corp., Armonk, NY, USA). Results Demographic factors were similar across the three groups. Analysis of the VAS scores revealed that the ketamine group provided better postoperative pain control than the dexmedetomidine group (p < 0.001). Groups D (71.72 ± 71.73) and K (3.53 ± 13.42) had significantly lower 24-hour fentanyl intake (in mcg) compared to Group C (the control group), as measured by PCA. Additionally, Group C had a significantly lower RSS at the sixth hour (p = 0.003) compared to both Groups D and K. Conclusion Ketamine, when used as an adjuvant to bupivacaine for local infiltration, enhances the effectiveness and prolongs postoperative analgesia more effectively than dexmedetomidine in patients undergoing mastectomy.

Strategy for the management of acute postoperative pain in day surgery centres in Spain. DUCMA 2.0. project

IntroductionAdequate treatment of acute postoperative pain is one of the quality requirements in ambulatory surgery and its suboptimal management is associated with delayed discharge, unplanned admissions and late admissions after home discharge. The aim of the present study was to learn about the organizational strategy for the management of postoperative pain in ambulatory surgery units (ASU) in Spain. MethodsA cross-sectional, multicenter study was carried out based on an electronic survey on aspects related to the management of acute postoperative pain in different ASUs in our country. ResultsWe recruited 133 ASUs of which 85 responded to the questions on the management of postoperative pain. Of the ASUs that responded, 80% had specific protocols for pain management and 37.6% provided preoperative information on the analgesic plan. The assessment of postoperative pain is carried out in 88.2% of the ASUs in the facility and only 56.5% at home. All ASUs use multimodal analgesia protocols; however, 68.2% report the use of opioids for the treatment of moderate to severe pain. Home invasive analgesia strategies are minimally used by the surveyed ASUs. ConclusionsThe DUCMA study highlights that the practice of pain treatment in day surgery remains a challenge in our country and is not always in agreement with national guidelines. The results suggest the need to establish strategies to improve clinical practice and homogenize pain management in ambulatory surgery.

Determination for the need for analgesics in day old calves following caustic paste disbudding

Caustic paste disbudding is practiced on 16.3% of U.S. opera­tions and 32.5% of calves, with a greater percentage usage as­sociated with larger farms. Only 5.6% of operations provide an­algesics/anesthetics for caustic paste disbudding heifers (USDA NAHMS, 2018). One standard operating procedure for caustic paste disbudding advises applying paste before calves are 2 days of age, and immediately after feeding to avoid scratching/ rubbing behavior. The author of one such protocol is adamant that no anesthetics or analgesics are needed with this protocol (Villarroel, 2011). There is increasing scientific evidence of pain experienced when caustic paste is used and supporting multi­modal analgesic protocols in association with this procedure. However, this data was not accumulated on calves &lt; 24 h of age at disbudding. The objective of this study is to examine effects of a multimodal analgesia protocol on nociceptive thresholds, behavior, and physiologic responses when caustic paste is ap­plied to calves &lt; 24 h of age. The following specific objectives were investigated.

Comparison of Ultrasound-guided Bilateral Anterior Quadratus Lumborum Block at the Lateral Supra-arcuate Ligament with Conventional Epidural Block in Patients Undergoing Laparoscopic Radical Gastrectomy: A Randomized Controlled Study

Abstract Background: To test the novel ultrasound (US)-guided bilateral anterior quadratus lumborum block (QLBA) at the lateral supra-arcuate ligament (supra-LAL) technique combined with postoperative intravenous analgesia was a viable alternative approach of conventional thoracic epidural analgesia (TEA) for laparoscopic radical gastrectomy (LRG). Methods: Three hundred and four patients scheduled for LRG were randomized 1:1 into QLBA group: receiving a novel pathway of US-guided bilateral QLBA at the supra-LAL before general anesthesia (GA) and patient-controlled intravenous analgesia (PCIA) after surgery, and TEA group: receiving TEA before GA and patient-controlled epidural analgesia following surgery. The difference in procedure time between the treatment groups was set as the primary endpoint. Results: Compared to TEA, procedure time was significantly shorter in the QLBA group (13.19 ± 0.78 vs. 15.65 ± 3.49, P = 0.001). At 5–10 min after block, QLBA group achieved more dermatomes coverage of cold sensory block with both P &lt; 0.001 and less influence on mean artery pressure. Intraoperative consumption of propofol and remifentanil were comparable between the two groups (1116.21 ± 199.76 vs. 1166.45 ± 125.31 ug, P = 0.245 and remifentanil 1.83 ± 0.41 vs. 1.81 ± 0.37 ng, P = 0.988). However, the QLBA group was associated with less intraoperative consumption of norepinephrine and atropine, shorter time to urinary catheter removal, and out-of-bed activity. No significant difference in extubation time, pain scores at rest and exercising across all time points postoperation was observed between two groups. Conclusion: Compared with conventional TEA, the novel technique combined with PCIA was an equivalent effective multimodal analgesic protocol for LRG. There were some advantages of technical simplicity with shorter procedure time, wider anesthetized dermatomes, less influence on intraoperative hemodynamic variables, fewer postoperative adverse events, and improved several sensible parameters of postoperative recovery. Trial Registration: The study was registered in the Chinese Clinical Trial Registry on November 02, 2022 (ChiCTR2200065325).

Cryoanalgesia as the Essential Element of Enhanced Recovery after Surgery (ERAS) in Children Undergoing Thoracic Surgery-Scoping Review.

This article aims to present cryoanalgesia as an inventive strategy for pain alleviation among pediatric patients. It underlines the tremendous need to align pain management with the principles of the enhanced recovery after surgery (ERAS) approach. The aim of the study was to review the patient outcomes of nerve cryoanalgesia during surgery reported with regard to ERAS in the literature. The literature search was performed using PubMed and Embase to identify articles on the use of cryoanalgesia in children. It excluded editorials, reviews, meta-analyses, and non-English articles. The analysis focused on the study methods, data analysis, patient selection, and patient follow-up. This review includes a total of 25 articles. Three of the articles report the results of cryoanalgesia implemented in ERAS protocol in children. The research outcome indicates shortened hospital stay, potential reduction in opioid dosage, and significant progress in physical rehabilitation. This paper also describes the first intraoperative utilization of intercostal nerve cryoanalgesia during the Nuss procedure in Poland, highlighting its effectiveness in pain management. Adding the cryoanalgesia procedure to multimodal analgesia protocol may facilitate the implementation of the ERAS protocol in pediatric patients.

Robot-assisted laparoscopic nephrectomy: early outcome measures with the implementation of multimodal analgesia and intrathecal morphine via the acute pain service

PurposeThe objective of this study was to perform a retrospective cohort analysis, in which we measured the association of an acute pain service (APS)-driven multimodal analgesia protocol that included preoperative intrathecal morphine (ITM) compared to historic controls (i.e., surgeon-driven analgesia protocol without ITM) with postoperative opioid use.MethodsThis was a retrospective cohort study in which the primary objective was to determine whether there was a decrease in median 24-h opioid consumption (intravenous morphine equivalents [MEQ]) among robotic nephrectomy patients whose pain was managed by the surgical team prior to the APS, versus pain managed by APS. Secondary outcomes included opioid consumption during the 24–48 h and 48–72 h period and hospital length of stay. To create matched cohorts, we performed 1:1 (APS:non-APS) propensity score matching. Due to the cohorts occurring at the different time periods, we performed a segmented regression analysis of an interrupted time series.ResultsThere were 76 patients in the propensity-matched cohorts, in which 38 (50.0%) were in the APS cohort. The median difference in 24-h opioid consumption in the pre-APS versus APS cohort was 23.0 mg [95% CI 15.0, 31.0] (p < 0.0001), in favor of APS. There were no differences in the secondary outcomes. On segmented regression, there was a statistically significant drop in 24-h opioid consumption in the APS cohort versus pre-APS cohort (p = 0.005).ConclusionsThe implementation of an APS-driven multimodal analgesia protocol with ITM demonstrated a beneficial association with postoperative 24-h opioid consumption following robot-assisted nephrectomy.

Perioperative intravenous lidocaine in thoracoscopic surgery for improved postoperative pain control: a randomized, placebo-controlled, double-blind, superiority trial.

Pain, including associated pain management, remains a burden on patients after thoracic surgery. Our objective was to investigate whether perioperative intravenous administration of lidocaine reduces postoperative morphine consumption and pain intensity after video-assisted thoracoscopic surgery (VATS). In this double-blind, placebo-controlled superiority trial, patients undergoing VATS with a planned duration of ≤90 minutes were randomized within an intention-to-treat setting. Patients received either intravenous lidocaine or placebo as a bolus of 1.5 mg/kg 30 minutes before incision, followed by a continuous infusion of 3.0 mg/kg/hour until 2 hours after skin closure. Pain and morphine consumption were evaluated when resting and when coughing 1, 2, 4, 8, 16, 24, and 48 hours after skin closure and in a follow-up 14, 90, and 180 days postoperatively. Twenty-eight patients were included in the lidocaine group, 24 in the placebo group. Patients' characteristics and preoperative pain scores were similar in both groups. When coughing, patients of the lidocaine group had less pain within 24 hours after skin closure than the placebo group (4.60±1.64 vs. 5.52±1.65; P=0.02). Morphine consumption was not statistically significantly lower in lidocaine group (18.22±12.87 vs. 21.26±9.39 mg; P=0.26). There were no significant differences between groups in secondary outcomes. Our results suggest that perioperative intravenous lidocaine administration reduces pain scores after VATS. The beneficial clinical effects are limited. Nevertheless, intravenous lidocaine may be helpful as part of a multimodal analgesia protocol or with patients in whom the use of other analgesics is contraindicated. ClinicalTrials.gov NCT03677817.

Decreased Opioid Prescription With Low Pain Scores After Urethroplasty: Using a Simplified, Multimodal, Opioid Minimization Pain Protocol

ObjectivesTo implement a simplified, opioid-minimized, multimodal pain management (MPM) protocol (Figure 1) and assess its effectiveness of reducing opioid dispersion while maintaining low postoperative complications, patient-reported pain, and patient-reported interference with quality of life (QOL) for men undergoing urethroplasty. Methods95 men at a single academic center from October 2020-October 2023 received a urethroplasty. We retrospectively reviewed the prior standard pain management (SPM) cohort before August 2021, then prospectively studied the MPM cohort after August 2021. For the SPM cohort, we collected postoperative day (POD) 1 pain scores from our EMR. For the MPM cohort, we obtained a validated pain and QOL assessment in the early postoperative period. The SPM cohort’s POD 1 pain scores were compared with the MPM cohort’s POD 2 pain scores. Opioid dispensation records were queried from the Prescription Monitoring Program. Results75 MME fewer opioids in the MPM cohort were prescribed than the SPM cohort (0 (interquartile range [IQR]: 0-0) vs. 75 (IQR:0-150), p<0.001, respectively). Patients with opioid discharge prescriptions fell from 50% in the SPM cohort to 11% in the MPM cohort (p<0.001). Early postoperative pain scores remained low and showed no significant difference between the cohorts. Pain’s interference with QOL measures remained low. Complications were rare across both cohorts. ConclusionThis simplified, multimodal analgesia protocol effectively decreases postoperative pain and opioid dispersion without affecting QOL outcomes after urethroplasty. This pain regimen can be easily adopted to decrease the use of postoperative opioids in men undergoing urethroplasty.

Use of subcostal and lateral transverse abdominal plane blocks as part of multimodal analgesia in a calf undergoing omphalitis surgical correction

AbstractThis report describes the combined use of the ultrasound‐guided subcostal and lateral transversus abdominis blocks as part of the multimodal analgesia in a 3‐month‐old calf, presented for omphalitis surgical repair. It was premedicated with xylazine, anaesthesia was induced with ketamine and maintained by isoflurane in oxygen. The block was performed with lidocaine 2%, and flunixin meglumine was administered pre‐ and postoperatively. Postoperative pain was scored, and rescue analgesia was not required intra‐ and postoperatively. Pain assessment and multimodal analgesia are crucial in food‐producing animals. Employing bilateral ultrasound‐guided lateral and subcostal transversus abdominis plane block can prove advantageous as part of the multimodal analgesia protocol for calves undergoing umbilical surgeries. Furthermore, it is essential to delv into the discussion of lidocaine's toxic dosage when applied in locoregional techniques.

What Is the Role of a Periarticular Injection for Knee Arthroplasty Patients Receiving a Multimodal Analgesia Regimen Incorporating Adductor Canal and Infiltration Between the Popliteal Artery and Capsule of the Knee Blocks? A Randomized Blinded Placebo-Controlled Noninferiority Trial.

Optimal analgesic protocols for total knee arthroplasty (TKA) patients remain controversial. Multimodal analgesia is advocated, often including peripheral nerve blocks and/or periarticular injections (PAIs). If 2 blocks (adductor canal block [ACB] plus infiltration between the popliteal artery and capsule of the knee [IPACK]) are used, also performing PAI may not be necessary. This noninferiority trial hypothesized that TKA patients with ACB + IPACK + saline PAI (sham infiltration) would have pain scores that were no worse than those of patients with ACB + IPACK + active PAI with local anesthetic. A multimodal analgesic protocol of spinal anesthesia, ACB and IPACK blocks, intraoperative ketamine and ketorolac, postoperative ketorolac followed by meloxicam, acetaminophen, duloxetine, and oral opioids was used. Patients undergoing primary unilateral TKA were randomized to receive either active PAI or control PAI. The active PAI included a deep injection, performed before cementation, of bupivacaine 0.25% with epinephrine, 30 mL; morphine; methylprednisolone; cefazolin; with normal saline to bring total volume to 64 mL. A superficial injection of 20 mL bupivacaine, 0.25%, was administered before closure. Control injections were normal saline injected with the same injection technique and volumes. The primary outcome was numeric rating scale pain with ambulation on postoperative day 1. A noninferiority margin of 1.0 was used. Ninety-four patients were randomized. NRS pain with ambulation at POD1 in the ACB + IPACK + saline PAI group was not found to be noninferior to that of the ACB + IPACK + active PAI group (difference = 0.3, 95% confidence interval [CI], [-0.9 to 1.5], P = .120). Pain scores at rest did not differ significantly among groups. No significant difference was observed in opioid consumption between groups. Cumulative oral morphine equivalents through postoperative day 2 were 89 ± 40 mg (mean ± standard deviation), saline PAI, vs 73 ± 52, active PAI, P = .1. No significant differences were observed for worst pain, fraction of time in severe pain, pain interference, side-effects (nausea, drowsiness, itching, dizziness), quality of recovery, satisfaction, length of stay, chronic pain, and orthopedic outcomes. For TKA patients given a comprehensive analgesic protocol, use of saline PAI did not demonstrate noninferiority compared to active PAI. Neither the primary nor any secondary outcomes demonstrated superiority for active PAI, however. As we cannot claim either technique to be better or worse, there remains flexibility for use of either technique.

Isoflurane sparing effect of a multimodal analgesic protocol for ovariohysterectomy in dogs

Isoflurane sparing effect of a multimodal analgesic protocol for ovariohysterectomy in dogs