Multimodal Analgesia Protocol Research Articles

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 < 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 < 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 < 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.

Comparison of ultrasound-guided erector spinae plane block versus transmuscular quadratus lumborum block for postoperative analgesia after caesarean delivery: a prospective randomized non-inferiority clinical trial

Abstract Background and Aims: Regional techniques are a part of multimodal analgesia following cesarean delivery. Cesarean delivery warrants a regional technique, which can provide somatic and visceral analgesia-like quadratus lumborum block (QLB) and erector spinae plane block (ESPB). In this study, we investigated the non-inferiority of ESPB at T12 and transmuscular-QLB (TQLB) at L2-L3 for postoperative analgesia in cesarean delivery. Material and Methods: In this prospective, randomized, non-inferiority trial, 124 patients undergoing cesarean delivery were enrolled to receive bilateral TQLB or ESPB with 20 mL of 0.25% ropivacaine on each side. All patients received prophylactic acetaminophen and ketorolac for 2 days. Our primary objective was to compare the total tramadol consumption in the first 48 h between the two groups. Secondary objectives were to compare cumulative tramadol consumption, postoperative Numeric Rating Scale (NRS) score at rest, and with movement at various time points, the time for first rescue analgesic requirement, development of complications related to the block, and patient satisfaction with analgesia between the two groups. Results: The total tramadol consumption in 48 h (47.3 ± 34.9 mg in ESPB and 50.9 ± 38.7 mg in TQLB), duration of first rescue analgesic (22.8 ± 15.8 h in ESPB and 22.7 ± 15.6 h in TQLB), and patient satisfaction were similar between the two groups. Both groups had similar pain scores except at rest at 6 h and on movement at 4 h, 6 h, and 36 h, whereas the ESPB group had lower NRS scores (P < 0.05). Conclusion: The analgesic effect of bilateral ESPB at T12 was non-inferior to that of bilateral TQLB post-caesarean delivery. Key Message: What is already known about the topic: Cesarean delivery warrants a regional analgesia technique which can provide somatic and visceral analgesia postoperatively. While quadratus lumborum block (QLB) is a well-established technique for cesarean delivery there are very few comparative studies on erector spinae plane block (ESPB) in cesarean delivery. In the studies comparing ESPB for other lower abdominal procedures, it has been given at T9 only. What new information this study adds: The analgesic effect of bilateral ESPB at T12 was non-inferior to that of bilateral TQLB performed at L2-L3 with the same volume post-cesarean delivery and can be an important addition to multimodal analgesia protocols after cesarean delivery.

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.

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.

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.

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

Effectiveness of a multimodal analgesia protocol in the perioperative period of knee replacement surgery in men

Effectiveness of a multimodal analgesia protocol in the perioperative period of knee replacement surgery in men

Implementation of a nonopioid multimodal analgesia protocol significantly reduces opioids prescribed after total shoulder arthroplasty: a retrospective study

BackgroundThe purpose of this study was to evaluate the impact of a nonopioid multimodal pain protocol on the amount of opioids prescribed, pain level, and complications in patients undergoing total shoulder arthroplasty (TSA) compared to a standard opioid regimen. MethodsWe retrospectively reviewed 2 consecutive cohorts who underwent either primary anatomic or reverse TSA by a single surgeon. The opioid cohort included patients from 2016 to 2020 who received an intraoperative periarticular injection (Ropivacaine, Epinephrine, and Ketorolac cocktail) and were prescribed Oxycodone/Acetaminophen 5/325 mg on discharge. The nonopioid cohort included patients from 2020 to 2022, consisting of preoperative oral analgesics (Celecoxib, Pregabalin, and Tramadol); intraoperative intravenous Dexamethasone and Acetaminophen and periarticular injection; and postoperative oral Dexamethasone and oral analgesics (Pregabalin, Tizanidine, Magnesium, Ibuprofen, and Acetaminophen). The nonopioid cohort had the option to ask for an opioid prescription postoperatively if needed. Patient-reported outcomes collected included visual analog scale scores for pain and Patient-Reported Outcome Measurement Information System up to 1 year after surgery. Opioid consumption using Morphine Milligram Equivalents were compared up to 3 months postoperatively. ResultsThere were 232 patients in the opioid and 112 in the nonopioid cohorts, respectively. The nonopioid protocol had lower mean visual analog scale scores at preoperative (6.4 vs. 7.4, P < .05), 10-day (3.5 vs. 4.2, P < .05), and 6-week postoperative time points (2.1 vs. 2.8, P < .05), but no differences between the groups were noted 3 months postoperatively. No differences in Patient-Reported Outcome Measurement Information System–upper extremity, pain interference, or depression were found preoperatively and up to 1 year after surgery. Opioid consumption was lower in the nonopioid cohort at all time periods (P < .01). Patients in the nonopioid cohort had significantly lower Morphine Milligram Equivalents at discharge, 10-day, 6-week, and 90-day time periods (P < .01) when compared to the opioid cohort. When analyzing risk factors for continued opioid prescriptions for the whole cohort, preoperative opioid use within 90 days before surgery (relative risk 4.69 [95% confidence interval 3.18-6.91; P < .01) and current tobacco use (relative risk 2.61 [95% confidence interval 1.50-4.54]; P = .01) were associated with continued refills >30 days. Complications in the perioperative period and 90-day hospital readmissions were not significantly different between the groups. ConclusionA nonopioid postoperative regimen for patients undergoing TSA significantly reduces opioid prescriptions with similar patient-reported outcomes, subjective pain scores, and without increased complication rates compared to an opioid-only regimen.

A Retrospective Comparison of Clinical Efficacy between Multimodal Analgesia and Patient-Controlled Epidural Analgesia in Patients Undergoing Total Knee Arthroplasty.

Background and Objectives: Adequate pain management during early rehabilitation is mandatory for improving the outcomes of patients undergoing total knee arthroplasty (TKA). Conventional pain management, mainly comprising opioids and epidural analgesia, may result in certain adverse effects such as dizziness, nausea, and motor blockade. We proposed a multimodal analgesic (MA) strategy involving the use of peripheral nerve block (NB), periarticular injection (PAI), and intravenous patient-controlled analgesia (IVPCA). This study compared the clinical efficacy and adverse effects of the proposed MA strategy and patient-controlled epidural analgesia (PCEA). Materials and Methods: We enrolled 118 patients who underwent TKA under spinal anesthesia. The patients followed either the MA protocol or received PCEA after surgery. The analgesic effect was examined using a numerical rating scale (NRS). The adverse effects experienced by the patients were recorded. Results: A lower proportion of patients in the MA group experienced motor blockade (6.45% vs. 22.98%) compared to those in the PCEA group on the first postoperative day. Furthermore, a lower proportion of patients in the MA group experienced numbness (18.52% vs. 43.33%) than those in the PCEA group on the first postoperative day. Conclusions: The MA strategy can be recommended for reducing the occurrence of motor blockade and numbness in patients following TKA. Therefore, the MA strategy ensures early rehabilitation while maintaining adequate pain relief.

Pain Management, Functional Recovery, and Stress Response Expressed by NLR and PLR after the iPACK Block Combined with Adductor Canal Block for Total Knee Arthroplasty-A Prospective, Randomised, Double-Blinded Clinical Trial.

This study aimed to investigate pain management, functional recovery, and stress response expressed by the neutrophile-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) after the popliteal artery and posterior knee capsule infiltration (iPACK) block combined with adductor canal block (ACB) in total knee arthroplasty (TKA). This was a prospective, double-blinded, randomised, controlled trial in a tertiary referral hospital. Three hundred and sixty-six patients were randomly allocated into the sham block group and iPACK combined with the ACB group. The primary outcome was postoperative pain scores. The secondary outcomes were opioid consumption, functional recovery expressed by a range of motion, and quadriceps strength. Also, the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were calculated. There were significant differences between the sham block and iPACK + ACB group in pain scores p < 0.0001 at all time points. Therefore, there was a significant difference in opioid consumption (p < 0.0001) and functional recovery (p < 0.0001). Also, NLR and PLR levels 12 h (p < 0.0001) and 24 h (24 h) after surgery (p < 0.0001) were much lower in the iPACK + ACB group. After total knee arthroplasty, the iPACK combined with ACB block group improved pain management, functional recovery, and stress response. Therefore, we strongly recommend this technique as a part of a multimodal analgesia protocol in knee surgery.

Rebound pain after interscalene brachial plexus block for shoulder surgery: a randomized clinical trial of the effect of different multimodal analgesia regimens

BACKGROUND: Rebound pain is characterized by sudden, significant acute postoperative pain occurring after the resolution of inter-scalene block (ISB); it affects the quality of recovery postoperatively. Dexamethasone increases ISB resolution time and decreases opioid consumption and the incidence of rebound pain. OBJECTIVE: Evaluate whether multimodal analgesia including intravenous dexamethasone administration with preoperative ISB reduces the incidence of rebound pain. DESIGN: Prospective, randomized, controlled trial SETTING: Tertiary university hospital SAMPLE SIZE: 60 patients PATIENTS AND METHODS: Patients who underwent shoulder surgery under general anesthesia were assigned randomly to two different multimodal analgesia protocols. Thirty patients received 5 mg IV dexamethasone with non-steroid, paracetamol, and ISB with 15 mL 0.5% bupivacaine, while the control patients received the same regimen and ISB with 15 mL 0.5% bupivacaine without dexamethasone. Postoperative opioids were given to any patient on demand. MAIN OUTCOMES MEASURES: Effect of IV dexamethasone on pain score and incidence of rebound pain after ISB resolution and postoperative opioid consumption at 0–48 hours, numerical pain rating scale (NPRS) scores, sleep scale scores, and quality of recovery-15 scores (QoR-15). RESULTS: The incidence of rebound pain was lower in the dexamethasone group than in the control group (73.3% and 30%, respectively, P =.001). NPRS scores after ISB resolution were lower in the dexamethasone group (5 ([4–7]), 8 ([5.75–8]), P &lt;.001, respectively). Those who received IV dexamethasone had less sleep disturbances ( P &lt;.001) and higher QoR-15 on day 1 ( P &lt;.001) and day 7 ( P =.020) postoperatively. CONCLUSIONS: IV dexamethasone added to the ISB block resulted in a lower incidence of rebound pain. In addition, better results were obtained in postoperative sleep quality and QoR-15. LIMITATIONS: Single-center study

Efficacy and safety of thoracoscopic-guided multiple paravertebral block for video-assisted thoracoscopic lobectomy surgery: a randomized blinded controlled study

BackgroundParavertebral block (PVB) has been increasingly popular for postoperative analgesia. However, few studies estimated the efficacy and safety of multiple PVB using thoracoscope-assisted technique for intraoperative analgesia and postoperative pain management for video-assisted thoracoscopic lobectomy (VATS LOBECTOMY).MethodsA total of 120 patients scheduled to undergo VATS LOBECTOMY were randomly assigned into two groups: a placebo group and a PVB group in a ratio of 1:2. Thoracoscopic-guided multi-point PVB was carried out with 0.5% ropivacaine (PVB group) or 0.9% NaCl (placebo group) at the beginning and the end of surgery. The primary endpoint was consumption of intraoperative opioid.ResultsConsumption rate of intraoperative opioids was significantly lower in the PVB group (878.14 ± 98.37 vs. 1,432.20 ± 383.53 for remifentanil; 123.83 ± 17.98 vs. 266.42 ± 41.97 for fentanyl). Postoperatively, significantly longer duration of using patient-controlled intravenous analgesia for the first time, reduced times of analgesic pump pressing, and less rescue analgetic consumption were observed in the PVB group. Visual analog scale scores at rest and during exercising were significantly lower in the PVB group at all time points within the first 48 h after surgery. The PVB group was also associated with significantly higher total QoR-40 scores and lower incidence of analgesia-related adverse events.ConclusionsThoracoscopic-guided multiple PVB was a simple and effective technique in controlling pain both intra- and postoperatively for VATS LOBECTOMY. It was also associated with the absence of detrimental effects attributed to opioid overuse and benefits of the early resumption of activity and physical function recovery. Therefore, this regional anesthesia technique should be advocated as part of a multimodal analgesia protocol for VATS LOBECTOMY.

Noninvasive Bioelectronic Treatment of Postcesarean Pain

Improved strategies are needed to decrease opioid use after cesarean delivery but still adequately control postoperative pain. Although transcutaneous electrical stimulation devices have proven effective for pain control after other surgical procedures, they have not been tested as part of a multimodal analgesic protocol after cesarean delivery, the most common surgical procedure in the United States. To determine whether treatment with a noninvasive high-frequency electrical stimulation device decreases opioid use and pain after cesarean delivery. This triple-blind, sham-controlled randomized clinical trial was conducted from April 18, 2022, to January 31, 2023, in the labor and delivery unit at a single tertiary academic medical center in Ohio. Individuals were eligible for the study if they had a singleton or twin gestation and underwent a cesarean delivery. Of 267 people eligible for the study, 134 (50%) were included. Participants were randomly assigned in a 1:1 ratio to a high-frequency (20 000 Hz) electrical stimulation device group or to an identical-appearing sham device group and received 3 applications at the incision site in the first 20 to 30 hours postoperatively. The primary outcome was inpatient postoperative opioid use, measured in morphine milligram equivalents (MME). Secondary outcomes included pain scores, measured with the Brief Pain Inventory questionnaire (scale, 0-10, with 0 representing no pain), MME prescribed at discharge, and receipt of additional opioid prescriptions in the postpartum period. Normally distributed data were assessed using t tests; otherwise via Mann-Whitney or χ2 tests as appropriate. Analyses were completed following intention-to-treat principles. Of 134 postpartum individuals who underwent a cesarean delivery (mean [SD] age, 30.5 [4.6] years; mean [SD] gestational age at delivery, 38 weeks 6 days [8 days]), 67 were randomly assigned to the functional device group and 67 to the sham device group. Most were multiparous, had prepregnancy body mass index (calculated as weight in kilograms divided by height in meters squared) higher than 30, were privately insured, and received spinal anesthesia. One participant in the sham device group withdrew consent prior to treatment. Individuals assigned to the functional device used significantly less opioid medication prior to discharge (median [IQR], 19.75 [0-52.50] MME) than patients in the sham device group (median [IQR], 37.50 [7.50-67.50] MME; P = .046) and reported similar rates of moderate to severe pain (85% vs 91%; relative risk [RR], 0.77 [95% CI, 0.55-1.29]; P = .43) and mean pain scores (3.59 [95% CI, 3.21-3.98] vs 4.46 [95% CI, 4.01-4.92]; P = .004). Participants in the functional device group were prescribed fewer MME at discharge (median [IQR], 82.50 [0-90.00] MME vs 90.00 [75.00-90.00] MME; P < .001). They were also more likely to be discharged without an opioid prescription (25% vs 10%; RR, 1.58 [95% CI, 1.08-2.13]; P = .03) compared with the sham device group. No treatment-related adverse events occurred in either group. In this randomized clinical trial of postoperative patients following cesarean delivery, use of a high-frequency electrical stimulation device as part of a multimodal analgesia protocol decreased opioid use in the immediate postoperative period and opioids prescribed at discharge. These findings suggest that the use of this device may be a helpful adjunct to decrease opioid use without compromising pain control after cesarean delivery.

The effect of dexamethasone on functional pain following Transoral Robotic Surgery: a randomized double blinded clinical trial

Background Pain is prevalent after most TransOral Robotic Surgery (TORS) procedures and may limit function i.e. swallowing. Currently, there is limited knowledge regarding optimal pain treatment in TORS. Aims/objectives This clinical trial randomized patients to either a high-dose dexamethasone or low-dose dexamethasone treatment in addition to a multimodal basic analgesic protocol. The aim of the trial was to investigate the pain intensity during rest and swallowing using the Visual Analogue Scale (VAS) after TORS lingual tonsillectomy. Secondary outcomes were acceptable food consistency, nausea, vomiting, opioid rescue usage, length of hospitalization, feeding tube placements, readmissions, blood glucose levels and postoperative complications. Methods The trial was conducted between August 2020 and October 2022. Eligible patients were patients scheduled for TORS-L treatment of obstructive sleep apnea syndrome or as part of the diagnostic work-up of head and neck carcinoma of unknown primary. Results Eighteen patients were and randomized 1:1. There were overall no significant differences between groups in the reported VAS scores during rest or swallowing (p ≥ .05). Overall, there were no differences in the secondary outcomes. Conclusion There were no differences in the pain intensity in the two treatment groups allocated to a basic multimodal analgesic package and either high-dose dexamethasone or low-dose dexamethasone treatment. The trial is the first RCT to include pain measurement during a procedure-relevant activity, thus creating a platform for future recovery studies.

Intraperitoneal and incisional ropivacaine did not improve postoperative analgesia after multimodal anaesthesia compared with saline in dogs undergoing ovariohysterectomy.

Intraperitoneal administration of local anaesthetics may reduce postoperative pain after ovariohysterectomy in dogs. The aim of this prospective, randomised, blinded, placebo-controlled clinical trial was to compare postoperative analgesia and opioid requirements after intraperitoneal and incisional administration of ropivacaine versus 0,9 % NaCl (saline). Forty-three client-owned dogs were enrolled in the study and anaesthetised using a standardized protocol that included premedication with acepromazine (0,03-0,05 mg/kg) and dexmedetomidine (0,01 mg/kg) intramuscularly. Anaesthesia was induced with propofol titrated to effect and ketamine (1 mg/kg) intravenously and maintained with isoflurane in oxygen. The analgesic regimen included carprofen (4 mg/kg) subcutaneously and morphine (0,2 mg/kg) intravenously. Depending on group assignment, each dog received either an intraperitoneal and incisional splash with ropivacaine (2 mg/kg and 1 mg/kg, respectively) (group R), or an equal volume of saline (group S). Buprenorphine (0,02 mg/kg) was administered intramuscularly once the uterus was removed. Sedation and pain were assessed 0,5, 1, 2, 4, 6 and 8 hours after extubation using a sedation scale, the short form of the Glasgow Composite Pain Scale (CMPS-SF) and a dynamic interactive visual analogue scale (DIVAS). Postoperatively, buprenorphine (0,01 mg/kg) was administered intravenously if dogs scored 6/24 on CMPS-SF. The ordinal mixed model showed no difference in pain scores between groups. Fisher's exact test showed no significant difference in postoperative buprenorphine requirements between group S (3/22 dogs) and group R (1/21 dogs) at the doses used. In addition, lower sedation scores were associated with higher DIVAS scores. In this multimodal analgesic protocol, ropivacaine could not improve analgesia compared to saline.

A Novel Multimodal Postoperative Pain Protocol for 1- to 2-Level Open Lumbar Fusions: A Retrospective Cohort Study.

There has been increased interest in exploring methods to reduce postoperative pain without opioid medications. In 2015, a multimodal analgesia protocol was used involving the perioperative use of celecoxib, gabapentin, intravenous acetaminophen, lidocaine, and liposomal bupivacaine. Overall, the goal was to reduce the utilization of scheduled opioids in favor of nonopioid pain management. The results of a consecutive series of 1- to 2-level open primary lumbar fusions were compared to a cohort of patients after the implementation the perioperative multimodal pain management protocol. Primary endpoints included patient-reported pain scores and secondary endpoints included length of stay. There were 87 patients in the preprotocol cohort and 184 in the protocol cohort. Comparing protocol and preprotocol patients, there were no significant differences in patient demographics. There was significantly average lower pain in the protocol group on postoperative day (POD) 1 (4.50 vs 5.00, P < 0.02) and POD2 (4.42 vs 5.50, P < 0.03). There was a lower pain score on POD0 (4.80 vs 5.00), but it was only clinically significant. There was a correlation between pain and duration of surgery in the preprotocol patients (POD0 R = 0.23, POD1 R = 0.02, POD2 R = 0.38), but not in the protocol patients (POD0 R = -0.05, POD1 R = -0.08, POD2 R = -0.04). There was a shorter length of stay in the protocol cohort (2.0 vs 3.0, P < 0.01). Finally, there was an approximately 35% reduction in morphine milligram equivalents of opioids in the protocol vs preprotocol cohorts (36.2 vs 57.0, P < 0.05). Our novel multimodal pain management protocol significantly reduced postoperative pain, length of stay, and opioid consumption in this patient cohort. Opioid usage correlated to pain in the protocol patients, while the preprotocol patients had no correlation between opioid use and pain medication. In this study, we demonstrated that preoperative and intraoperative analgesia can reduce postoperative pain medication requirements. Furthermore, we introduced a novel concept of a correlation of pain with opioid consumption as a marker of effective pain management of breakthrough pain.