Multimodal Pain Control Regimens Research Articles

Comparison of Erector Spinae Plane Blocks Versus Multimodal Pain Management for Traumatic Rib Fractures: A Matched Cohort Study

IntroductionErector spinae plane blocks (ESPBs) are frequently utilized when treating patients with multiple rib fractures. While previous work has demonstrated the efficacy of ESPB as an adequate method of pain control, there has been no work comparing a continuous ESPB to “best practice” multimodal pain control. We hypothesize that a continuous ESPB catheter combined with a multimodal pain regimen may be associated with a decrease in opioid requirements when compared to a multimodal pain regimen alone. MethodsThis was a retrospective observational cohort study at a level 1 trauma center from September 2016 through September 2021. Inclusion criteria included patients 18 y or older with at least three unilateral rib fractures who were not mechanically ventilated during admission. The primary outcome was the total morphine equivalents utilized throughout the index admission. ResultsA total of 142 patients were included in this study, 71 in each cohort. Patients included had a mean age of 52.5 y, and 18% were female. Demographic data including injury severity score, total number of rib fractures, and length of stay were similar. While there was a trend toward a decrease in morphine equivalents in the patient cohort undergoing ESPB catheter placement, this was not found to be statistically significant (284.3 ± 244.8 versus 412.6 ± 622.2, P = 0.5). ConclusionsWhile ESPB catheters are frequently utilized for analgesia in the setting of multiple rib fractures, there was no decrease in total opioid usage when compared with patients who were managed with a multimodal pain regimen alone. Further assessment comparing ESPB catheters to best practice multimodal pain control regimens through a prospective, multicenter trial is required to further validate these findings.

Intravenous Dexmedetomidine Use in Total Hip Arthroplasty May Lead to Elevated Rates of Hypotension.

Purpose Enhanced recovery protocols for total hip arthroplasty (THA), using opioid-sparing techniques have become widely used. Reports of novel additions to multimodal pain control regimens have been published, however, a paucity of literature exists on the use of intravenous dexmedetomidine. In this study, we analyzed our experience with intravenous dexmedetomidine and hypothesized that it would reduce postoperative opioid use. Secondary outcomes were also examined, including post-operative hypotension, hemoglobin, length of stay, and discharge disposition. Methods All patients who underwent primary THA at a single tertiary-level center between January 1, 2016, and September 1, 2019, underwent investigation. Diagnosis, surgical approach, anesthetic type, body mass index (BMI), and American Society of Anesthesiologists (ASA) score were recorded. Postoperative clinical measures were analyzed, adjusting for patient and surgical characteristics. Results Of the 599 patients included in the study, 218 patients received intravenous (IV) dexmedetomidine, at a mean dose of 44.9 mg during their operative event. Using a multivariate model, patients in the IV dexmedetomidine group were estimated to have received 24% elevated morphine milligramequivalent at postoperative day zero compared to those in the control group (p = 0.05). In addition, patients in the IV dexmedetomidine group who underwent spinal anesthesia had increased odds of hypotension 3.47 times that of the control [odds ratio (OR) 1.43-8.43, p=0.006]. Conclusions Surprisingly, we found no opioid-sparing effects with the use of IV dexmedetomidine.IV dexmedetomidine may be used cautiously as an anesthesia adjunct with spinal anesthesia in the setting of primary THA, as the experience at our institution illustrated increased odds of postoperative hypotension. Level of evidence This retrospective case-control study has a level of evidence III.

Schedule II Narcotics are often Unnecessary for Pain Control in Patients with Pelvic or Acetabular Fractures

Objectives: Determine if patients with pelvic and acetabular fractures require scheduled II narcotics after discharge. Design: Retrospective case series. Setting: Level I Trauma Center Patients: 124 consecutive patients with operatively managed pelvic (OTA 61B or C) and acetabular fractures (OTA 62A, 62B or C) Intervention: A multimodal oral pain regimen was prescribed at discharge with schedule II narcotic only if needed for pain control. Main Outcome: Primary outcomes were defined as the need for schedule II narcotic at discharge or in follow up. Measurements: Prescription of narcotic on follow up or return to ER for inadequate pain control. Visual Analog Pain Scale score. Results: Ninety-two patients (74%) with adequate follow-up were included for the final analysis, including patients with 25 acetabular fractures, 50 pelvic fractures, and 17 combined injuries. Sixty-four patients (69.6%) were multiply-injured patients. Four (4.3%) patients were discharged with a Schedule II narcotic. Of the remaining patients (n=88), two (2.2%) required delayed prescription of a Schedule II narcotic after discharge and 5 (5.4%) presented to the ED for pain control. There were no readmissions for pain. Overall 81 of 92 (88.0%) patients had pain controlled without schedule II narcotics or ED presentation. The mean VAS pain score for all patients was 4.1±3.6 from 5 to 21 days, 3.2±3.4 at 22 to 60 days, and 2.7±3.3 at greater than 60 to 180 days after discharge, there was no significant difference between groups Conclusion: Multimodal pain control regimens without schedule II narcotics in the immediate postoperative follow-up period can be effective in managing pain in the majority of patients with pelvic or acetabular fractures. Level of Evidence: IV; case series Keywords: narcotics, pain control, acetabular fractures, pelvic fractures

Enhanced recovery after cardiac surgery protocol reduces perioperative opioid use

ObjectiveEnhanced Recovery After Surgery protocols are relatively new in cardiac surgery. Enhanced Recovery After Surgery addresses perioperative analgesia by implementing multimodal pain control regimens that include both opioid and nonopioid components. We investigated the effects of an Enhanced Recovery After Surgery protocol at our institution on postoperative outcomes with particular focus on analgesia. MethodsSingle-center retrospective study comparing perioperative opioid use before and after implementation of an Enhanced Recovery After Surgery protocol at our institution. Subjects were divided into 2 cohorts: Enhanced Recovery After Surgery (study group from year 2020) and pre–Enhanced Recovery After Surgery (control group from year 2018). Baseline and perioperative variables including total opioid use from the day of surgery to postoperative day 5 were collected. Opioid use was calculated as morphine milligram equivalents and compared between the 2 cohorts. ResultsA total of 466 patients were included: 250 in the Enhanced Recovery After Surgery group and 216 in the pre–Enhanced Recovery After Surgery group. Both groups had similar baseline characteristics, but the Enhanced Recovery After Surgery group had significantly more subjects with intravenous drug use history (P < .0001), endocarditis (P < .0001), and liver disease (P = .007) compared with the pre–Enhanced Recovery After Surgery group. Every day from the day of surgery to postoperative day 5, the Enhanced Recovery After Surgery group had significant reduction (57%) in opioid use compared with the pre–Enhanced Recovery After Surgery group. Total opioid use for the entire length of stay was 259 morphine milligram equivalents in the Enhanced Recovery After Surgery group versus 452 morphine milligram equivalents in the pre–Enhanced Recovery After Surgery group (P < .0001). Subgroup analysis of subjects with intravenous drug use history did not demonstrate a significant reduction in opioid use. ConclusionsEnhanced Recovery After Surgery protocols with an emphasis on multimodal pain management throughout perioperative care are associated with a significant reduction in the postoperative use of opioid analgesics.

203. Epidural pain catheter improves postoperative pain control following lumbar fusion compared to patient-controlled analgesia (PCA)

<h3>BACKGROUND CONTEXT</h3> Postoperative pain control for patients in the hospital after lumbar spinal fusion can be quite challenging. Reliance on opioids postoperatively can predispose patients to tolerance and abuse. Multimodal pain control regimens have become the standard of postoperative care, though protocols tend to vary by surgeon and institution. The mainstay of pain control following lumbar spinal fusion surgery involves narcotic pain medication administered by patient controlled intravenous analgesia (PCA), which is typically supplemented by oral pain medications. One potential alternative to PCA is patient-controlled analgesia via epidural catheter. Surgeon-placed epidural catheters under direct visualization have previously been described for their simplicity, efficacy and time efficiency. <h3>PURPOSE</h3> After experiencing clinical success with the use of epidural catheters placed via the loss of resistance technique one- to three- levels above the proximal lumbar fusion level in postoperative care regimens,the senior author (TFA) embarked upon this prospective, randomized trial to assess the relative utility and complication rate of the epidural catheter method of pain management when compared to standard PCA narcotic administration for pain control after one- or two-level circumferential lumbar fusion surgery. <h3>STUDY DESIGN/SETTING</h3> The surgeries in the trial were performed by three surgeons in a university spinal surgery practice. Patients who enrolled agreed to be randomized to either the epidural catheter (EC) or the commonly practiced PCA arm of the study. A power analysis demonstrated that a sample size of 50 patients, using a level of significance of 0.05, would have a power of 0.97 to detect a 2-point difference in pain scores. <h3>PATIENT SAMPLE</h3> Fifty patients from the University spinal surgery practice were recruited to enter the study. Candidates for the study were patients undergoing one- or two-level instrumented lumbar fusion. Patients were randomized over a 10-month period into either the epidural (EA) or IV analgesia (PCA) groups, 27 to EA and 23 to PCA. <h3>OUTCOME MEASURES</h3> Preoperative pain scores, as well as daily postoperative pain scores were recorded. <h3>METHODS</h3> If randomized to the EC arm, an epidural catheter was placed by the surgeon just prior to wound closure, 1-3 levels above the most proximal level of the fusion. A 17-gauge Tuohy epidural needle was used with a loss-of-resistance syringe to locate the epidural space under fluoroscopy if deemed appropriate by the surgeon, and then the catheter was inserted through it. A bolus of 5cc of 0.25% bupivacaine was typically given at the time of catheter placement. Postoperatively, a continuous infusion was begun of 0.125% bupivacaine at 6 cc/hr combined with hydromorphone at 0.2 mg/hr. A patient controlled epidural demand dose of 25mcg of fentanyl with a 10-minute lockout period was also started. If randomized to the PCA group, patients were placed on a patient-controlled analgesia pump administering intravenous hydromorphone with a demand dose of 0.2-0.4 mg with a 10-15-minute lockout <h3>RESULTS</h3> Postoperative pain scores were statistically lower in the EC group on Days 1, 2 and 3: 2.13 vs 4.92 (day 1); 2.71 vs 4.52 (day 2); 3.13 vs 4.52 (day 3). Postoperative complications were similar between the EC and PCA groups. The incidence of nausea/vomiting were 56% and 74% (p=0.43) in EC and PCA groups, respectively, while postoperative symptomatic hypotension was seen in 8% of EC patients and 12% of PCA patients (p=0.67). <h3>CONCLUSIONS</h3> In this prospective, randomized study comparing the use of EC to PCA narcotic for pain control after one- and two-level lumbar fusions, a significant improvement in pain control was noted in the EC group with differences in minor side effects that did not reach statistical significance. Epidural anesthesia for postoperative pain control should be considered for patients undergoing lumbar fusion. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

The erector spinae block: a novel approach to pain management in acute appendicitis

BackgroundAcute abdominal pain is one of the most common complaints that patients present with in the emergency room and has long been a challenge to effectively manage without relying on opioid analgesia. The use of ultrasound-guided peripheral nerve blocks (UGRA) represents a new frontier in multimodal pain control regimens in the acute setting. An erector spinae plane (ESP) block is believed to mediate pain relief in multiple dermatomes through blockage of both visceral and somatic nerves. Analgesia provided by a single injection can help keep a patient comfortable for hours without breakthrough pain and the subsequent need for frequent redosing of opioid pain medication. To this date, there is very limited evidence of an ESP block in the utilization of acute appendicitis in the emergency department.Case reportThis case report presents a 26-year-old female with a past medical history of polycystic ovarian syndrome (PCOS) and a tubal ligation that presented with 7/10 right lower quadrant abdominal pain that began 1 h prior to arrival. She stated that she felt like this was similar to her PCOS exacerbations in the past. During her evaluation, she underwent a computed tomography (CT) scan of her abdomen and pelvis that was remarkable for acute, uncomplicated appendicitis. She was given 4 mg of morphine for her pain with little response, so the offer was made for an erector spinae block that the patient elected to receive. After being consented both for the procedure and for research, she received a right-sided erector spinae block with 20 mL’s of 0.2% ropivacaine (2 mg/mL) at the L1 vertebral level. After approximately 15 min, she stated that she had a reduction in her pain from a 6/10 to a 1/10 that persisted throughout the rest of her stay in the emergency department.

Evaluation of Factors Relevant to Pain Control Among Patients After Surgical Treatment

Opioids are often prescribed after elective surgical treatment despite the potential for misuse. Although various pain control regimens exist, patient preferences for acute postoperative pain management are unknown. To describe patient-reported key attributes of postoperative pain management. This decision analytical model used responses from a survey based on conjoint analysis to investigate the value patients placed on different aspects of postoperative pain management. Participants were patients aged 18 years or older who underwent elective hand surgical procedures between July 1, 2018, and July 23, 2019, at a single academic center. The survey was completed on a web-based platform and took place between November 2019 and January 2020. Data were analyzed from May through July 2021. Participants were presented with a series of discrete-choice tasks and asked to select between 2 postoperative medication options that changed from question to question and had varying characteristics. Attribute importance scores and part-worth utility values for the queried aspects of pain control were calculated. Of 710 individuals invited, 321 (45.2%) completed the survey; there were 212 (66.0%) women and 108 (33.6%) men, and the most common age category was 60 to 69 years (102 participants [31.8%]). Most patients reported previous opioid use (282 individuals [87.9%]). Factors in the decision-making process with the highest attribute importance scores (SDs) were risk of addiction (26.3% [13.0%]) and amount of pain relief (25.6% [14.6%]). Adverse effects 13.9% (7.2%), functional independence 11.8% (7.3%), and level of trust in the prescriber 11.4% (5.8%) had intermediate attribute importance scores (SDs). Cost 7.9% (4.4%) and stigma 3.1% (1.3%) had the lowest attribute importance scores (SDs) in patient decisions. These findings suggest that multimodal pain control regimens that are associated with optimized pain relief and minimized risk of addiction are preferable to treat acute postoperative pain. The results suggest that identifying procedures for which patients prioritize minimizing risk of addiction over pain relief and incorporating patient preferences into decision-making may be associated with decreased postoperative opioid prescribing.

A Proposed Multimodal Pain Control Regimen for Patients Undergoing Mastectomy with Reconstruction and Its Effect on Minimizing Narcotic Use and Hospital Length of Stay

A Proposed Multimodal Pain Control Regimen for Patients Undergoing Mastectomy with Reconstruction and Its Effect on Minimizing Narcotic Use and Hospital Length of Stay

The Efficacy of Ultrasound-Guided Bilateral Transversus Abdominal Plane (TAP) Block in Decreasing the Pain After Laparoscopic Cholecystectomy: A Randomized Clinical Trial

Introduction: Pain after laparoscopic cholecystectomy is complex in nature and several methods are performed to control it. Transversus Abdominis Plane (TAP) block has been used for postoperative pain for some abdominal surgeries. This study was designed to determine the analgesic efficacy of bilateral TAP block for patients undergoing Laparoscopic Cholecystectomy. Methods: Forty-two patients were randomized into 2 groups. Group 1 received TAP block using bupivacaine 0.25% (n=21), and group 2 received TAP block using saline. Before extubation, blocks were performed bilaterally. Tramadol IV was given for breakthrough pain for the first 24 hours. Pain scores using the Visual Analog Scale (VAS) at 0, 1, 2, 4 ,8 ,12, 24 hour-intervals, number of patient demand for Tramadol and patient satisfaction were collected. Results: Patients in the control group have higher VAS scores both during rest and on movement. However, pain was significantly reduced only on the 2nd hour at rest and on the 1st to 4th hours on movement among patients who received Bupivacaine 0.25% on TAP block. Furthermore, there was no significant difference in the requirement for rescue analgesics (p=0.1160) and the satisfaction rate (p=0.2849) between the two groups. Conclusion: TAP block is safe and improved postoperative analgesia in patients receiving laparoscopic cholecystectomy. But its additional analgesic effect in the presence of a dynamic multimodal pain-control regimen is probably rather small and need further investigation in laparoscopic cholecystectomy.

Does Liposomal Bupivicaine Injection Decrease Postoperative Opioid Usage following Bimaxillary Surgery?

PurposeAmong patients undergoing bimaxillary surgery, does the use of liposomal bupivacaine injection reduce the use of opioid analgesics and/or length of hospital admission in the postoperative period? MethodsA retrospective cohort analysis was conducted on subjects who received orthognathic surgery from 2017 to 2019 at Parkland Memorial Hospital. Inclusion criteria were a maxillary Le Fort I procedure and simultaneous bilateral sagittal split osteotomy. Exclusion criteria were a syndromic condition, repeat surgery, concomitant genioplasty or temporomandibular joint surgery, or single-jaw surgery. The predictor variable was the administration of a standard dosage of 266mg (20mL) of liposomal bupivacaine distributed equally among all 4 surgical sites. The primary outcome variable was the total milligram morphine equivalent (MME) of opioids administered to the subject in the immediate postoperative period. Secondary predictor variables were postoperative hospital stay length, defined in days, age, and sex, defined as male or female. Statistical analysis was performed with P < .05 used to determine statistical significance. ResultsNineteen patients met the defined inclusion criteria. The age at the time of surgery ranged from 17 to 51, with the average age being 26 years old. The cohort consisted of 8 males and 11 females. Ten subjects received an injection of 266mg of liposomal bupivacaine, divided equally among all 4 surgical sites (2 maxillary and 2 mandibular) at the completion of surgery, and 9 subjects received no liposomal bupivacaine.Postoperatively, subjects received varying combinations of PRN opioids, including: codeine, hydrocodone, oxycodone, fentanyl, and hydromorphone. MME for each of these medications was then calculated. Patients in the group who received a liposomal bupivacaine injection required a mean of 9.3 MME during their postoperative course, while the group who did not receive liposomal bupivacaine required a mean of 25 MME. Statistical analysis revealed a significant difference in MME usage between the 2 groups (P =.0243). The average postoperative hospital admission duration was 1.32 days, with no significant difference between the 2 study groups (P = .884). There was no significant difference between sex or age and postoperative MME usage (P = .566 and P = .381, respectively). DiscussionManagement of postoperative pain is not only vital to patients’ surgical experiences, but is imperative in preserving hospital resources, decreasing hospital stay, and decreasing readmission rates. In total, 20-80% of patients experience moderate to severe pain during their postoperative course. Opioids remain the leading modality to manage postoperative pain, but the recent opioid epidemic has motivated clinicians to pursue other pathways, including liposomal bupivacaine for pain management to mitigate the use of large doses of opioids. The results of the present study suggest that administration of 266mg of liposomal bupivacaine, given equally in all 4 surgical sites following bilateral Le Fort I and sagittal split osteotomies, leads to a statistically significant decrease in postoperative opioid usage. Future prospective studies utilizing liposomal bupivacaine and standard multimodal pain control regimens following orthognathic procedures will further explore the efficacy of liposomal bupivacaine in opioid reduction and management of postsurgical pain.

Apples to Oranges

Background: Over- prescription of opioids after surgery contributes to the national opioid epidemic. Differences may exist with procedure type, but these are understudied. Objective: This study aims to evaluate opioid consumption patterns following hemorrhoidectomy vs. other anorectal operations, as hemorrhoidectomy recovery is reportedly more painful. Design: Retrospective cohort study with prospective telephone survey. Setting: Single safety net hospital. Patients: Group of 27 and 73 patients undergoing outpatient hemorrhoidectomy and anorectal surgery other than hemorrhoidectomy, respectively, between July 2019 and March 2020. Main Outcome Measures: We measured the prescription and consumption quantities of morphine milligram equivalents (MME) after surgery for hemorrhoids vs. other anorectal procedures. Results: MME prescribed at discharge was higher for the hemorrhoid cohort vs. for other anorectal surgery (86.1 ± 17.5 vs. 76.0 ± 6.3, P &lt; 0.001). The hemorrhoid group utilized higher quantities of MME during recovery: 30 (IQR 75 MME) vs. 6.25 (IQR 30 MME), P = 0.017), and also expressed lower satisfaction with their post-operative pain control regimen (33.3% vs. 88.3%, P &lt; 0.001). No differences were seen in patients continuing on opioids on postoperative day seven (p = 0.348), and patients with complete compliance with their non-opioid multimodal pain control regimen (p = 1.0). Return trips to the emergency department for pain and patients requiring additional opioid medication after discharge were higher in the hemorrhoidectomy group (33.3% vs. 1.3%, P &lt; 0.001 and 14.8% vs. 1.3% P = 0.016, respectively). The 50th, 75th, and 90th percentile for total MME consumed by the hemorrhoidectomy (vs. other anorectal surgery) cohort were 75 (vs. 30), 75 (vs. 54), and 97.5 (vs. 75) MME, respectively. Conclusions: Hemorrhoidectomy surgery requires up to five times the amount of opioids for postoperative pain control compared to other anorectal surgeries. Prescribed opioids still exceed the amount used, although dissatisfaction with pain control remains high after hemorrhoid surgery. Further study is required to better understand this unique entity. Limitations: Retrospective single-center design, patient-reported outcomes, male majority in the non-hemorrhoidectomy group. Conflict of Interest: None.

Perioperative Outcomes of Patients Who Were Not Candidates for Additional Nonsteroidal Anti-inflammatory Drugs in a Multimodal Pain Control Regimen for Total Knee Arthroplasty.

BackgroudPostoperative pain following total knee arthroplasty (TKA) may hamper patients from a rapid recovery and increase perioperative blood loss and stress on the cardiovascular system. Therefore, our objective was to assess perioperative outcomes after TKA in patients who were not candidates for the additional nonsteroidal anti-inflammatory drugs (NSAIDs) in a multimodal pain control regimen.MethodsPropensity score matching for age, sex, body mass index, American Society of Anesthesiologists class, and preoperative hemoglobin level was conducted on patients undergoing unilateral TKA, and thereby 52 patients remained in each group. The control group comprised patients who received parenteral parecoxib every 12 hours during the first 48 hours after TKA. The No-NSAIDs group did not receive NSAIDs because of known contraindications. Identical postoperative pain control including intravenous patient-controlled analgesia was applied for all patients. Visual analog scale (VAS) score for pain, knee flexion, blood loss, serum cardiac troponin-T (cTnT), and length of stay (LOS) were determined.ResultsThe No-NSAIDs group had significantly higher VAS scores in 6–96 hours and consumed more morphine at 24 hours and 48 hours after the surgery than the control group. The No-NSAIDs group had significantly less knee flexion at 48 hours (p = 0.045) and tended to have more emesis and longer LOS than the control group. The blood loss of the No-NSAIDs and control group was 552.52 mL and 397.65 mL (p = 0.02), respectively, and blood transfusion rate was 23.1% and 17.3% (p = 0.63), respectively. The cTnT of the No-NSAIDs group rose over the first 48 hours and was significantly higher than that of the control group at 48 hours.ConclusionsPatients who were not candidates for NSAIDs had significantly higher pain scores and consumed more morphine after TKA. They also tended to have greater blood loss and the rising of cardiac biomarkers during the first 48 hours after TKA. Hence, these patients may benefit from supplementary analgesia and appropriate perioperative monitoring.

Can We Eliminate Opioid Medications for Postoperative Pain Control? A Prospective, Surgeon-Blinded, Randomized Controlled Trial in Knee Arthroscopic Surgery

Background: Orthopaedic surgeons have a responsibility to develop responsible opioid practices. Growing evidence has helped define an optimal number of opioids to prescribe after surgical procedures, but little evidence-based guidance exists to support specific practice patterns to decrease opioid utilization. Hypothesis: After knee arthroscopic surgery with partial meniscectomy, patients who were provided a prescription for opioids and instructed to only fill the prescription if absolutely necessary for pain control would take fewer opioids than patients with opioids automatically included as part of a multimodal approach to pain control prescribed at discharge. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: Patients undergoing arthroscopic partial meniscectomy were provided multimodal pain control with aspirin, acetaminophen, and naproxen and randomized to receive oxycodone as either included with their multimodal pain medications (group 1) or given an optional prescription to fill (group 2). Patients were contacted at time points up to 1 month after surgery to assess opioid utilization and medication side effects. The mean number of tablets utilized was the primary outcome measure, with a 50% reduction defined as a successful outcome. Results: A total of 105 patients were initially enrolled, and 95 (91%; 48 in group 1 and 47 in group 2) successfully completed the study. There was no significant reduction in the number of tablets utilized between groups 1 and 2 (3.5 vs 4.5, respectively; P = .45), days that opioids were required (2.2 vs 3.2, respectively; P = .20), or postoperative pain at any time point. The group with the option to fill their prescription had significantly fewer unused tablets remaining than the group with opioids included as part of the multimodal pain control regimen (75% of potentially prescribed tablets vs 82% of prescribed tablets; P < .001). Overall, 37% of patients did not require any opioids after surgery, and 86% used ≤8 tablets. Conclusion: Patients required a minimal number of opioids after knee arthroscopic surgery with partial meniscectomy. There was no difference in the number of tablets utilized whether the opioid prescription was included in a multimodal pain control regimen or patients were given an option to fill the prescription. Offering optional opioid prescriptions in the setting of a multimodal approach to pain control can significantly reduce the number of unused opioids circulating in the community. Registration: NCT03876743 (ClinicalTrials.gov identifier)

Various modalities for pain control after open cardiac surgeries

We addressed the various analgesic strategies for postoperative cardiac pain relief in this study. While opioid-based is traditionally the cornerstone of postoperative analgesia, there's growing evidence to support a multimodal approach to attenuate opioid side effects and decrease the degree of pain scores and to attenuate the length of hospital stay, and to promote improved rehabilitation approaches that include multimodal regimens as a significant component. For the treatment of postoperative pain following cardiac surgery, several methods are available, including intravenous administration of analgesic drugs such as opioids and non-opioids, local anesthetics infiltration, nerve blocks, and neuraxial methods. Traditionally, after surgery, analgesia is given by analgesic administration. However, the administration of acute opioids is linked to several side defects including respiratory distress, sedation, and lethargy, vomiting and nausea, constipation, retentiveness, purities, and ileus. Therefore, doctors use multimodal pain control regimens including non-opioid analgesic medications for superior pain management. In their understanding of pain, Patients had a specific experience that allows for the difference in pain control. For the treatment of postoperative cardiac pain, several different agents (opioid vs. non-opioid), routes (oral, intravenous, neuraxial, regional), and modes (patient-controlled vs.as required) are accessible.

Delirium Reduced With Intravenous Acetaminophen in Geriatric Hip Fracture Patients.

Postoperative delirium is associated with opioid use in the elderly and is a common complication of geriatric hip fractures, with reported incidences from 16% to 70%. Intravenous (IV) acetaminophen is a safe and efficacious medication in elderly patients and has been shown to reduce use of opioids after hip fracture. At our institution, IV acetaminophen was implemented for the first 24 hours postoperatively as part of a multimodal pain control regimen for geriatric hip fracture patients. A retrospective review of 123 hip fragility fracture patients older than 60 years from January 2016 to December 2016 was performed. Delirium was identified using a validated chart-based review tool. The rate of delirium, as well as length of stay, pain scores, opioid administration, need for one-to-one supervision, and readmissions were analyzed. Sixty-five patients (52.8%) received IV acetaminophen during this period. No notable differences were found in baseline characteristics between groups. Ten of 65 patients receiving IV acetaminophen postoperatively experienced delirium compared with 19 of 58 who did not receive the medication (15.4% versus 32.8%, P = 0.024). The IV acetaminophen group also required fewer doses of IV opioids on postoperative day 1 (0.37 versus 1.19 doses, P = 0.008), were less likely to require one-to-one supervision (9.2% versus 24.1%, P = 0.025), and had shorter lengths of hospital stay (6.37 versus 8.47 days, P = 0.037). Readmission rates and discharge dispositions did not vary with significance between the two groups. The inclusion of IV acetaminophen as part of a multimodal pain regimen led to fewer episodes of delirium in this study. The reduced use of opioids immediately after surgery may have been a large factor in this outcome. Lower delirium rates may reduce the utilization of inpatient resources for direct patient supervision and provide for shorter hospital stays.

Ketorolac for Patients Undergoing Implant-Based Breast Reconstruction: Impact on Hospital Length of Stay and Postoperative Narcotic Use.

Opioid drugs have been a mainstay medication for the management of postoperative pain for several decades; however, in recent years there has been a push towards investigating alternative treatment options. Although ketorolac has been widely used by other medical and surgical specialties for analgesia, its utilization in plastic surgery has been widely debated. The purpose of this study was to investigate the efficacy of ketorolac as an adjunct in postoperative pain management. The authors performed a retrospective review of patients who underwent implant-based breast reconstruction after mastectomy between January 2012 and December 2016. Other risk factors, such as chronic anticoagulation, aspirin, or coagulopathies, were documented as well. There were 198 patients who met the inclusion criteria. The results demonstrated that patients who received ketorolac utilized significantly fewer narcotics than patients who did not: 80 mg vs 108.8 mg (P = 0.002), respectively. The results showed that patients who received ketorolac had a decreased length of hospitalization: 1.9 days vs 2.1 days (P = 0.04), respectively. Generous narcotic prescribing has received greater scrutiny in recent years. Aside from the risk of increased narcotic availability in the community, the side effects of nausea, puritis, and constipation delay patient recovery. These data show that patients who received ketorolac have a decreased length of hospital stay and lower narcotic use, suggesting ketorolac may be a safe and cost-effective adjustment to a multi-modal pain control regimen postoperatively.

Comparative Clinical Study between Preoperative Oral Administration of Paracetamol, Celecoxib and Pregabalin on Postoperative Pain in Gynecological Laparoscope

Background: Since the introduction of laparoscopic surgeries, postoperative pain has been generally reduced. However, it can still peak, especially during the early postoperative period and becomes the main cause of overnight hospital stay and prolonged convalescence after this day-case surgical procedure. Thus, optimizing postoperative pain relief, not only to sub-serve reduction of its intensity but to also enhance the recovery and shorten length of stay became the broader target of multimodal pain control regimens nowadays. That is why; searching for a drug that would be effective in reducing pain, safe from major adverse effects and can meanwhile possess an opioid-sparing potentiality would be a merit so as to improve the success rate of ambulatory day-care surgeries. Objective: To study the analgesic effects of preemptive single oral dose of paracetamol, celecoxib and pregabalin in patients undergoing gynecological laparoscope. Method: Preoperative evaluation, preparation and premedication was assessment, and routine laboratory investigations was done. Postoperative pain, Level of Sedation was measured. Results: There was statistical significant difference between the three groups regarding VAS. There was statistical significant difference between the three groups regarding the total pethidine consumption. Regarding postoperative level of sedation, blood glucose there was no statistical significant difference between the three groups. Conclusion: Oral pregabalin in a dose of 150 mg 2 hour before surgery, is significantly attenuating pain intensity and total meperidine consumption during the first 6 hours postoperatively.

Multimodal Postoperative Pain Control Is Effective and Reduces Opioid Use After Laparoscopic Roux-en-Y Gastric Bypass.

Opioids have been the mainstay for postoperative pain relief for many decades. Recently, opioid-related adverse events and death have been linked to postoperative dependency. Multimodal approaches to postoperative pain control may be part of the solution to this health care crisis. The safety and effectiveness of multimodal pain control regimens after laparoscopic Roux-en-Y gastric bypass (LRYGB) has not been well studied. The primary aim of our study was to determine if an evidence-based, multimodal pain regimen during hospitalization could decrease the total oral morphine equivalent (TME) use after LRYGB. We conducted a retrospective cohort study comparing outcomes prior to the implementation of a multimodal pain protocol (December 2010-December 2012) to those after implementation (April 2013-July 2015). The protocol utilized oral celecoxib and scheduled oral acetaminophen for pain control, with opioids used only as needed for breakthrough pain. Data was extracted from an electronic medical record and an institutionally maintained database of all patients undergoing bariatric surgery at a single center. Compared to controls, the multimodal pain regimen significantly reduced TME used and maximum pain scores with no change in mean pain scores. Multimodal pain protocol patients had a shorter length of stay with no increase in bleeding complications or marginal ulcer rates. An opioid-sparing multimodal pain regimen adequately controls pain while reducing TME use. The regimen appears to be safe and was associated with a reduced length of stay in patients undergoing LRYGB.

Adductor Canal vs. Femoral Nerve Block in Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Trial

Objectives:Peripheral nerve blocks are commonly performed as a part of multimodal pain control regimens, especially for outpatient surgical procedures. Femoral nerve blocks (FNB) have been the traditional gold standard nerve block in the setting of ACL reconstruction; however, adductor canal blocks (ACB) have emerged as a promising alternative. While early findings show less quadriceps strength deficits following adductor canal blocks, results comparing analgesia from adductor canal nerve blockade to femoral nerve blockade are inconsistent. The purpose of this study was to compare adductor canal nerve block to femoral nerve block for pain control following ACL reconstruction.Methods:This study was a prospective, single-blinded, randomized, controlled, parallel single-center trial. 77 adult patients receiving ACL reconstruction were enrolled between December 2015 and April 2016. All patients received either a traditional FNB or an ACB immediately prior to surgery. All patients were given a post-operative smartphone application to record medication usage, pain scores, hours of sleep, and time to straight leg raise for one week following ACL reconstruction.Results:Of the 77 patients recruited, 64 patients were analyzed (83.1%). 13 patients were lost to follow-up. There were no statistically significant differences in post-operative pain, home medication use, recovery room time, or hours of sleep between the two study groups. Patients receiving an ACB had significantly shorter time to straight leg raise and reported greater satisfaction with acute post-operative pain control.Conclusion:Adductor canal nerve blockade had similar analgesic outcomes, improved post-operative mobility, and greater patient satisfaction with pain control than femoral nerve blockade. Our study supports the use of adductor canal block as a viable alternative to femoral nerve block following ACL reconstruction.

Periarticular Injections in Knee and Hip Arthroplasty: Where and What to Inject

BackgroundPeriarticular injections have become a valuable adjunct to multimodal pain control regimens after knee and hip arthroplasties. Injection techniques vary greatly among surgeons with little standardization of practice. MethodsWe performed an extensive literature search to determine where nociceptive pain fibers are located in the hip and the knee and also to explore the pharmacology of periarticular cocktail ingredients. ResultsLarge concentrations of nociceptors are present throughout the various tissues of the knee joint with elevated concentrations in the infrapatellar fat pad, fibrous capsule, ligament insertions, periosteum, subchondral bone, and lateral retinaculum. Less empiric evidence is available on nociceptor locations in the hip joint, but they are known to be located diffusely throughout the hip capsule with elevated concentrations at the labral base and central ligamentum teres. Local anesthetics are the base ingredient in most injection cocktails and function by blocking voltage-gated sodium channels. Liposomal anesthetics may offer longer duration of action over traditional anesthetics. Nonsteroidal anti-inflammatory agents and corticosteroids block peripheral production of inflammatory mediators and may desensitize nociceptors. Opioid receptors are present in lower densities peripherally as compared with the central nervous system, but their inclusion in injections can lead to pain relief. Sympathetic drugs can provide adjunct effects to periarticular cocktails to increase duration of action and effectiveness of medications. ConclusionTargeting specific sites of nociceptors may help to further decrease pain after knee and hip arthroplasties. Altering periarticular cocktail ingredients may aid in multimodal pain control with injections.