Multimodal Postoperative Analgesia Research Articles

Optimization of acute postoperative pain management in trauma and orthopedic patients

Background. The modern approach to multimodal postoperative analgesia involves the administration of two or more analgesic agents that exert a polymodal effect on the pathogenetic mechanisms of pain. Nefopam hydrochloride can prevent opioid-induced hyperalgesia, relieve pain without respiratory depression and without affecting platelet aggregation, the state of the gastrointestinal mucosa and intestinal motility, which differentiates it from traditional non-opioid analgesics. Objective: to assess the impact of nefopam hydrochloride as a component of multimodal analgesia on pain intensity and stress response markers in trauma and orthopedic patients during postoperative pain management. Materials and methods. A prospective randomized open-label controlled clinical study was conducted in 120 patients (47 men, 73 women) aged 19 to 94 years (mean (M ± σ) of 55.97 ± 19.78 years) who underwent lower limb surgeries under spinal anesthesia. Patients were divided into two groups: the controls (n = 60) received standard multimodal analgesia (ketorolac, acetaminophen), while people in the main group (n = 60) additionally received 20 mg of nefopam hydrochloride intramuscularly 4 times per day. Pain intensity was evaluated using the Numeric Rating Scale, narcotic analgesic consumption, and cortisol levels in blood serum were assessed as well. Data analysis was performed using SPSS 20 (SPSS Inc.), version 21.0.0 for Windows. Results. It was found that the use of nefopam hydrochloride as a component of multimodal postoperative analgesia in patients undergoing trauma and orthopedic surgeries significantly reduces score on the Numeric Rating Scale: by 23.6 % during the first 6 hours after surgery (p < 0.001), and by 1.5, 2.3, and 3.6 times at 12, 18, and 24 hours postoperatively, respectively (p < 0.001). It was also associated with lower mean serum cortisol concentrations — 5.20 ± 4.43 vs. 8.51 ± 3.48 µg/dL in the control group 6 hours after surgery, and 2.08 ± 1.63 vs. 4.11 ± 1.70 µg/dL in 12 hours (p < 0.001). Additio-nally, it reduced the average cumulative morphine dose by 1.5 times during the first 24 hours postoperatively (p < 0.001). The opioid-reducing effect of multimodal analgesia with nefopam hydrochloride reached 61.7 %. Conclusions. Nefopam hydrochloride is an effective component of multimodal postoperative analgesia in trauma and orthopedic patients, improving the quality of postoperative pain management and reducing stress response intensity.

Effect of nalbuphine on analgesia and pain factors after gastric cancer resection.

Gastric cancer (GC) is a prevalent tumor in the digestive system, with around one million new cases reported annually, ranking it as the third most common malignancy. Reducing pain is a key research focus. This study evaluates the effect of nalbuphine on the analgesic effect and the expression of pain factors in patients after radical resection. To provide a reference for postoperative analgesia methods. One hundred eight patients with GC, admitted between January 2022 and June 2024, underwent radical gastrectomy. They received a controlled analgesia pump and a transverse abdominis muscle plane block, divided into two groups of 54 patients in each group. The control group received sufentanil, while the observation group received nalbuphine as an analgesic. Postoperative analgesic effects, pain factor expression, and adverse effects were compared. The resting pain and activity pain scores in the observation group at 6, 12, 24 and 48 hours were significantly lower than those in the control group. Additionally, the number of presses and consumption of the observation group at 48 hours were lower than those of the control group; and the response rate of the observation group was higher than that of the control group (P < 0.05). The prostaglandin E2, substance P, and serotonin levels 24 hours after the observation group were lower than those in the control group, and the incidence of adverse reactions was 5.56% lower than 22.22% in the control group (P < 0.05). The findings suggest that nalbuphine enhances postoperative multimodal analgesia in patients with radical GC, effectively improving postoperative analgesic effect, relieving postoperative resting and active pain, and reducing postoperative pain factor expression, demonstrating its potential for clinical application.

Transversus abdominis plane block in oncourology: a narrative review

Transversus abdominis plane block (TAP block) is a regional anesthesia technique used as part of multimodal postoperative analgesia for a wide range of abdominal surgical procedures. However, the use and effectiveness of this technique in urological surgeries are not well documented in Russian literature. We conducted a literature search in PubMed, EMBASE, Web of Knowledge, and Cochrane Library databases to evaluate the effectiveness of using transversus abdominis plane blocks compared to other anesthesia techniques in oncourological surgery. It has been determined that transversus abdominis plane block, serving as an integral component of multimodal anesthesia in patients undergoing oncourological procedures, significantly curtails the reliance on opiates both during and following surgery. Moreover, it mitigates the intensity of pain syndrome in the postoperative phase and fosters a swifter and more comprehensive recovery process for patients.

Suprainguinal fascia iliaca compartment block in pediatric-aged patients: An educational focused review

Regional anesthesia has become an integral component of postoperative analgesia and multimodal analgesia during surgery, providing opioid sparing effects and maintaining a beneficial adverse effect profile. Although neuraxial techniques were initially the primary techniques used for intraoperative and postoperative anesthesia and analgesia, many of these techniques have been replaced by selective nerve blockade. This has been facilitated by the widespread use of ultrasound-guided over conventional landmark techniques. Fascia iliaca compartment blockade (FICB) is performed by depositing a local anesthetic agent underneath the FI fascial sheath which lies on top of the iliopsoas muscle. With the landmark technique, the FICB is more commonly applied using an approach below the inguinal ligament. Advancements in the use of ultrasound have led to development of a potentially superior suprainguinal fascia iliaca (SIFI) block for hip and thigh surgery. An improved cephalad distribution of the local anesthetic solution within the fascia iliaca compartment and comparable analgesic efficacy compared to the more invasive lumbar plexus block has resulted in increased use of the SIFI block in both adults and pediatric-aged patients. The SIFI block aims to target the femoral nerve (FN), lateral femoral cutaneous nerve (LFCN), and obturator nerve (ON), thus providing analgesic coverage for hip, femur, and thigh surgery. Although the FN and LFCN are reported to be consistently blocked by the suprainguinal approach, blockade of the ON may be less reliable and requires a higher volume of the local anesthetic agent, proving this technique to be a volume-dependent block. A lower volume of local anesthetic solution may be associated with block failure, especially in the area supplied by the ON and less frequently in the distribution of the LFCN. Thus, local anesthetic concentration must be adjusted in smaller children and infants to maintain effective volume while not exceeding local anesthetic dosing limitations. The current manuscript reviews the innervation of the lower extremity including the anatomy of the fascia iliaca compartment, outlines different approaches for the fascia iliaca block, and reviews the current practice of SIFI blockade in adults and children.

Effects of continuous pecto-intercostal fascial block for management of post-sternotomy pain in patients undergoing cardiac surgery: a randomized controlled trial.

Managing postoperative pain following median sternotomy has long been a notable challenge for anesthesiologists. The administration of postoperative analgesia traditionally relies on intravenous pumps for the delivery of opioids. With the development of regional block techniques and postoperative multimodal analgesia, pecto-intercostal fascial block (PIFB) has gained widespread utilization due to its distinctive advantages. However, its application is limited to a single block. This study aimed to indicate whether continuous PIFB analgesia in cardiac surgery via sternotomy could possess clinical advantages compared with intravenous analgesia in terms of postoperative pain management. If continuous PIFB analgesia was the priority, the secondary objective would involve determining the most effective administration method, making it a critical area of exploration. Totally, 114 patients were randomly allocated to three groups: the PCIA group, receiving intravenous opioid infusion exclusively via pump, and the C-PIFB and I-PIFB groups, where ultrasound-guided PIFB with a nerve blocking pump was administered. The C-PIFB group received a constant basal infusion, while programmed intermittent boluses were administered in the I-PIFB group. The primary endpoint was postoperative visual analogue scale (VAS) scores, and secondary outcomes included intraoperative sufentanil consumption, time to extubation, mobilization, length of stay in intensive care unit (ICU) and hospital, and the incidence of postoperative complications. The VAS scores at rest and during coughing were noticeably diminished in the two block groups relative to the intravenous pump group at 12, 24, 48, and 72h postoperatively. Notably, intraoperative sufentanil consumption was significantly reduced in the C-PIFB group (3.12 [0.93] ug.kg-1) and the I-PIFB group (3.42 [0.77] ug.kg-1) compared with the PCIA group (4.66 [1.02] ug.kg-1, P<0.001). Time to extubation, mobilization, length of stay in ICU and hospital, and use of rescue analgesics did not exhibit statistically significant differences among the three groups. However, the postoperative complication rates were markedly lower in the C-PIFB group (42.11%) and I-PIFB group (36.84%) relative to the PCIA group (81.58%, P<0.001). There were no significant differences between C-PIFB and I-PIFB groups regarding VAS score, secondary outcomes, and postoperative complications. Continuous PIFB can provide satisfactory postoperative analgesia while reducing perioperative opioid consumption, diminishing the risk of postoperative complications, and accelerating postoperative recovery for patients undergoing median sternotomy in cardiac surgery. The constant basal infusion method may be the optimal approach for administering continuous PIFB.

Comparison of the Analgesic Effect of Erector Spinae Plane Block Versus Caudal Epidural Block Following Unilateral Pediatric Inguinal Hernia Surgery: A Prospective, Randomized Study

Background: Caudal epidural block (CEB) has long been used as a standard method for pain control in pediatric surgery. Erector spinae plane block (ESPB) is a newer technique that has attracted attention for its potential to provide analgesia in children. Aim: The aim of this study was to compare and evaluate the effectiveness of ESPB and caudal block on postoperative pain in pediatric patients who underwent unilateral inguinal hernia surgery. Methods: This prospective, randomized trial was conducted with a total of 60 pediatric patients, aged 1–8 years, in the ASA I–II group. The patients were randomly divided into two groups as Group CEB (n = 30), and Group ESPB (n = 30). In the caudal block group, 0.25% bupivacaine 0.5 ml/kg (max 20 ml) was administered in the caudal space, while in the ESPB block group, the block was performed with 0.5 ml/kg 0.25% (max 20 ml) bupivacaine at the L1 vertebral level. Face, legs, activity, cry, and consolability (FLACC) scores were recorded postoperatively at 1, 2, 4, 6, 12, and 24th hours. The first analgesic requirements and time for rescue analgesia were also recorded. Results: While no significant difference was noticed between the two groups’ FLACC scores at the zeroth hour, first hour, second hour, fourth hour, and sixth hour (i.e. postoperatively [P &gt; 0.05]), the FLACC scores of 12th hour in the ESPB group were significantly lower than the caudal block group (P &lt; 0.05). There was also no significant difference in intraoperative additional analgesia requirements between the groups (P &gt; 0.05). The time to first postoperative analgesia in the ESPB group was higher than that in the caudal block group (P &lt; 0.05). Conclusion: The ESPB provided superior postoperative analgesia to the CEB in pediatric patients undergoing inguinal hernia surgery, and ESPB can be used as a relatively safer postoperative multimodal analgesia approach as an alternative to CEB.

Which individual components of a colorectal surgery enhanced recovery program are associated with improved surgical outcomes?

Enhanced recovery programs improve surgical outcomes. However, the association of adherence to individual components and outcomes in a comprehensive enhanced recovery program remains unclear. We performed a retrospective study of all elective colorectal surgery patients at our institution from 2019 to 2022 (n= 1,175). Data were acquired from our institution's enhanced recovery program dashboard and American College of Surgeons National Surgical Quality Improvement Program database. Traditional analyses and machine-learning classification trees were used to identify enhanced recovery program components associated with length of stay, readmissions, and complication rates. The average length of stay was 5.0days, readmission rate was 12.3%, and complication rate was 32.6%. On linear regression analysis, adherence to preoperative education, regional analgesia, pre- and postoperative multimodal analgesia, no nasogastric tube, early mobilization, early regular diet, early discontinuation of maintenance intravenous fluids, postoperative venous thromboembolism prophylaxis, and early Foley catheter removal were associated with an decrease in length of stay by 0.7-7.1days (P < .05). Patients who adhered to no prolonged fasting had a 4.1% decrease in readmission rate (P= .04). Patients who adhered to no nasogastric tube, early mobilization, early regular diet, postoperative multimodal analgesia, and discontinuation of maintenance intravenous fluids had decreases in complication rates ranging from 7.0 to 28.2% (P < .001). Machine learning demonstrated that no nasogastric tube and discontinuation of maintenance intravenous fluids were significant predictors of shorter length of stay and no nasogastric tube and early mobilization were significant predictors of reduced complication rates. Although multiple components were associated outcomes, no nasogastric tube, early mobilization, early regular diet, postoperative multimodal analgesia, and early discontinuation of maintenance intravenous fluids were associated with more than 1 outcome. Focusing on these components may make enhanced recovery program implementation more feasible for resource-limited hospitals.

Postoperative Multimodal Analgesia Strategy for Enhanced Recovery After Surgery in Elderly Colorectal Cancer Patients.

Enhanced Recovery After Surgery (ERAS) protocols have substantially proven their merit in diminishing recuperation durations and mitigating postoperative adverse events in geriatric populations undergoing colorectal cancer procedures. Despite this, the pivotal aspect of postoperative pain control has not garnered the commensurate attention it deserves. Typically, employing a multimodal analgesia regimen that weaves together nonsteroidal anti-inflammatory drugs, opioids, local anesthetics, and nerve blocks stands paramount in curtailing surgical complications and facilitating reduced convalescence within hospital confines. Nevertheless, this integrative pain strategy is not devoid of pitfalls; the specter of organ dysfunction looms over the geriatric cohort, rooted in the abuse of analgesics or the complex interplay of polypharmacy. Revolutionary research is delving into alternative delivery and release modalities, seeking to allay the inadvertent consequences of analgesia and thereby potentially elevating postoperative outcomes for the elderly post-colorectal cancer surgery populace. This review examines the dual aspects of multimodal analgesia regimens by comparing their established benefits with potential limitations and offers insight into the evolving strategies of drug administration and release.

Efficacy of Unilateral External Oblique Intercostal Fascial Plane Block Versus Subcostal TAP Block in Laparoscopic Cholecystectomy: Randomized, Prospective Study.

This study aimed to evaluate the effectiveness of unilateral external oblique intercostal nerve block (EOIB) in laparoscopic cholecystectomy surgery. After ethics committee approval, ASA I-II patients aged 18-70 who would undergo laparoscopic cholecystectomy surgery were included in the study. The patients were divided into two groups, external oblique intercostal nerve block (Group EOIB) and oblique subcostal transversus abdominis plane block (Group OSTAP). After surgery, EOIB or OSTAP block was administered with 20mL of .25% bupivacaine then routine analgesia protocol was applied with iv paracetamol, and tramadol. Visual analog scale (VAS) scores and patient-controlled analgesia (PCA) consumption were monitored 24 hours after the operation. It was administered 25mg pethidine as a rescue analgesic to patients with VAS ≥4. Thirty six patients for Group EOIB and thirty four patients for Group OSTAP were included in the study. Lower VAS scores were observed in all groups. When PCA consumption, side effects, rescue analgesia consumption, and patient satisfaction were evaluated, there was no statistically significant difference between the groups (P > .05). It was observed that EOIB showed similar analgesic activity to the OSTAP block. EOIB may also be a part of postoperative multimodal analgesia by reducing postoperative opioid consumption in LC.

Preoperative Education is Associated with Adherence to Downstream Components and Outcomes in a Colorectal Surgery Enhanced Recovery Program.

This study evaluated the association between preoperative education and adherence to downstream components of enhanced recovery programs (ERPs) and surgical outcomes among patients undergoing elective colorectal surgery. ERPs improve outcomes for surgical patients. While preoperative education is an essential component of ERPs, its relationship with other components is unclear. This was a retrospective cohort study of all ERP patients undergoing elective colorectal surgery from 2019 to 2022. Our institutional ERP database was linked with American College of Surgeons National Surgical Quality Improvement Program data and stratified by adherence to preoperative education. Primary outcomes included adherence to individual ERP components and secondary outcomes included high-level ERP adherence (>70% of components), length of stay (LOS), readmissions, and 30-day complications. A total of 997 patients were included. The mean (SD) age was 56.5 (15.8) years, 686 (57.3%) were female, and 717 (71.9%) were white. On adjusted analysis, patients who received preoperative education (n = 877, 88%) had higher adherence rates for the following ERP components: no prolonged fasting (estimate = +19.6%; P < 0.001), preoperative blocks (+8.0%; P = 0.02), preoperative multimodal analgesia (+18.0%; P < 0.001), early regular diet (+15.9%; P < 0.001), and postoperative multimodal analgesia (+6.4%; P < 0.001). High-level ERP adherence was 13.4% higher (P < 0.01) and LOS was 2.0 days shorter (P < 0.001) for those who received preoperative education. Classification and regression tree analysis identified preoperative education as the first-level predictor for adherence to early regular diet, the second-level predictor for LOS, and the third-level predictor for ERP high-level adherence. Preoperative education is associated with adherence to ERP components and improved surgical outcomes.

Comparison of the Analgesic Effect of Pericapsular Nerve Group Block and Lumbar Erector Spinae Plane Block in Elective Hip Surgery.

Background and Objectives: The aim of this study was to compare the effectiveness of pericapsular nerve group (PENG) and lumbar erector spinae plane (L-ESP) blocks, both administered with a high volume (40 mL) of local anesthetic (LA), for multimodal postoperative analgesia in patients undergoing hip surgery. Materials and Methods: This was a prospective, double-blind, randomized study that included 75 adult patients who were divided into three equal groups: control, PENG, and L-ESP. The study compared pain intensity, morphine consumption, time to first morphine request, and postoperative satisfaction between the control group, which received standard multimodal analgesia, and the block groups, which received PENG or L-ESP block in addition to multimodal analgesia. The numerical rating scale (NRS) was used to measure pain intensity. Results: The results showed that the block groups had lower pain intensity scores and morphine consumption, a longer time to the first morphine request, and higher postoperative satisfaction compared to the control group. The median maximum NRS score during the first 12 h was four in the control group, two in the PENG group, and three in the L-ESP group. The control group (21.52 ± 9.63 mg) consumed more morphine than the two block groups (PENG, 11.20 ± 7.55 mg; L-ESP, 12.88 ± 8.87 mg) and requested morphine 6.8 h earlier and 5 h earlier than the PENG and L-ESP groups, respectively. The control group (median 3) had the lowest Likert satisfaction scores, while the PENG group (median 4) had the lowest NRS scores (L-ESP, median 4). Conclusions: The application of PENG or L-ESP blocks with high-volume LA in patients undergoing hip surgery reduces the need for postoperative analgesia and improves the quality of multimodal analgesia.

Efficacy of Trans Abdominis Plane (TAP) Block for Post-caesarean Delivery Analgesia: A Prospective Randomized Controlled Study

Background: Caesarean delivery is a major surgical procedure after which substantial post-operative pain and discomfort can be anticipated. A substantial component of pain experienced by patients is derived from abdominal wall incision. Currently multimodal analgesia technique involving abdominal field block with parenteral analgesia are becoming popular for these patients. Transversus abdominal plane (TAP) blockcan relieve pain associated with abdominal incision. We carried out this study to evaluate the efficacy of TAP block in providing post operativepain relief and the cumulative requirement of analgesic over first 48 hour in patients who underwent LSCS under spinal anaesthesia.Methods: This prospective randomized controlled study was carried out with 60 patients posted for electivecaesarean section, two groups with 30 patients each. Both groups were compared to see the effectiveness of Trans Abdominis Plane (TAP) Block as a method for post-operative multimodal analgesia technique using VAS score. Total number of rescue analgesia required upto 48hrs and total dose of rescue analgesia given in both the groups was also compared.Results: The mean VAS score at rest andon movement was decreased significantly after Trans Abdominis Plane (TAP) Block. The total dose and number of rescue analgesia was also decreased significantly.Conclusions: TAP block as a component of multimodal analgesia after caesarean section was effective in providing analgesia with delayed time for 1st rescue analgesia and reduction in total analgesic requirement in 1st 48 hr.

Clinical Effectiveness of Transversus Abdominis Plane (TAP) Block versus Local Anesthesia Wound Infiltration for Postoperative Pain Relief After Laparoscopic Appendicectomy in Children: A Study Protocol for a Multicenter Double-Blind Randomized Controlled Phase III Trial.

Postoperative pain relief after laparoscopic appendicectomy is a key determinant of early rehabilitation in children. Recent guidelines recommend performing either a transversus abdominis plane (TAP) block or local anesthesia (LA) wound infiltration as part of multimodal postoperative analgesia after appendectomy. To date, the clinical effectiveness of TAP block versus LA wound infiltration has never been compared. The hypothesis of this study is that the TAP block may provide a greater opioid-sparing effect after laparoscopic appendicectomy in children than LA wound infiltration. We designed a multicenter double-blind randomized controlled phase III trial and aim to include 110 children who undergo laparoscopic appendicectomy. Children are randomized to receive either TAP block (TAP group) or LA wound infiltration (infiltration group). Multimodal analgesia is standardized in the two groups using the same protocol, which includes the stepwise prescription of paracetamol, phloroglucinol, ketoprofene, and nalbuphine according to the hetero-evaluation of pain performed by the nurses who were blinded to the treatment allocated using the validated FLACC scale. The primary outcome is the total dose of nalbuphine administered within 24 hours after surgery. No study has specifically compared the clinical effectiveness of TAP block versus LA wound infiltration for postoperative pain relief after laparoscopic appendectomy in children. This paper describes the protocol for a randomized trial that addresses this issue. The results of this trial will be useful for editing guidelines with a higher level of evidence on this topic.

Enhanced recovery after endoscopic sinus surgery: Establishing comprehensive protocols for improvement of perioperative patient care

AbstractObjectivesEnhanced recovery after surgery (ERAS) protocols for endoscopic sinus surgery (ESS) have not been widely implemented, and a critical review of ERAS recommendations and a comprehensive analysis of the supporting literature has not been undertaken. We describe an ESS ERAS protocol including key perioperative interventions for patients undergoing ESS and assess the available evidence.Data SourcesA search was conducted of all relevant ERAS literature in otorhinolaryngology, anesthesia, and surgery using Medline (via PubMed), and Scopus. Keywords included “endoscopic sinus surgery,” “sinus surgery,” “FESS,” and “ESS” for each area of intervention. Where applicable, the authors considered high‐level evidence for recommendations devised for patient cohorts in otorhinolaryngology not undergoing ESS, as well as cohorts undergoing surgical procedures for which ERAS protocols have been extensively evaluated.MethodsStudies received grades of “low,” “moderate,” or “high” quality evidence based on the Oxford Centre for Evidence‐Based Medicine criteria. Each intervention was subsequently assigned a grade of “strong,” “weak,” or “conditional” based on the available evidence.ResultsStrong recommendations include comprehensive patient education and counseling, minimization of preoperative fasting, application of topical/local anesthetics and vasoconstrictors, use of total intravenous anesthesia, avoidance of pharyngeal packing, and use of postoperative nasal irrigation and multimodal analgesia. Conditional recommendations include antibiotic prophylaxis. Weak recommendations include perioperative venous thromboembolism prophylaxis, controlled hypotension, and use of postoperative nasal packing/dressing.ConclusionA comprehensive ERAS protocol for ESS can include a variety of high yield, evidence‐based interventions that would likely improve surgical outcomes and patient satisfaction.

Perioperative regional anaesthesia in kidney transplantation

Background. Postoperative analgesia in kidney transplant recipients is challenging due to potential nephrotoxicity of nonsteroidal anti-inflammatory drugs and the reduced clearance of opioid metabolites during transient renal impairment. Opioid-sparing multimodal postoperative analgesia using regional analgesia methods could provide better pain control and early activation after kidney transplantation.Aim. To evaluate the clinical results of treatment using regional pain management methods in kidney transplant recipients.Material and methods. A single-center study was conducted at Republican Research Center of Emergency Medicine from 2020 to 2022. The study included 97 patients who underwent heterotopic kidney transplantation from a living related donor. Patients were divided into 3 groups. In group 1 (31 patients), general anesthesia was used. For postoperative analgesia opioid analgesics in combination with metamizole 1000 mg were used. In group 2 (33 recipient patients), a combination of general anesthesia and open transversus abdominis plane block was used. In group 3 (33 recipient patients), a combination of general anesthesia and erector spine plane block was performed. Opioid analgesics were used as a "rescue analgesia" when necessary. The primary study end points were the pain intensity assessed by a visual analogue scale and opioid consumption on the first day after surgery. Secondary endpoints were the time of intestinal motility recovery, the presence of nausea and vomiting, the Intensive Care Unit length of stay and the hospital length of stay.Results. Pain intensity 6 hours after surgery in patients of group 1 was 13.5% and 24.6% higher than in patients of group 2 and 3, respectively. In group 2, pain intensity was 12.8% higher compared to group 3 (p=0.0017). At 12 hours after surgery, the pain intensity was 42% higher in group 1 compared to group 2 and group 3 (p&lt;0.0001). After 18 hours, the pain score in group 3 was 48.5% and 35.7% lower compared to groups 1 and 2, respectively (p&lt;0.0001 and p=0.0016). 24 hours after surgery, the sensation of pain was 18.6% and 65.3% higher in group 1 compared to groups 2 and 3 (p&lt;0.0001). The mean dose of narcotic analgesic equivalent to morphine in group 1 was 22.6±8.6 mg, which was 18.5% higher than in group 2 patients. In group 3, it was 12.0±4.3 mg and was 47% lower compared to group 1 (p&lt;0.0001) and 34.7% lower compared to group 2 (p&lt;0.0001) (all comparisons are statistically significant). The adequacy of analgesia and less opioid consumption contributed to the absence of postoperative nausea and vomiting in 75% of cases, early restoration of intestinal motility in 63% compared with the group of patients where opioid analgesics were used for postoperative pain relief.Conclusion. The combined use of general anesthesia and erector spine plane block may be recommended as a method of effective perioperative analgesia in kidney transplantation.

Non-opioid analgesic combinations following total hip arthroplasty (RECIPE): a randomised, placebo-controlled, blinded, multicentre trial

Multimodal postoperative analgesia following total hip arthroplasty is recommended, but the optimal combination of drugs remains uncertain. The aim of the RECIPE trial was to investigate the relative benefit and harm of the different combinations of paracetamol, ibuprofen, and the analgesic adjuvant dexamethasone for treatment of postoperative pain following total hip arthroplasty. The RECIPE trial was a randomised, blinded, placebo-controlled trial conducted at nine Danish hospitals. Adults scheduled for total hip arthroplasty were randomly assigned (1:1:1:1) using a computer-generated list with stratification by site to receive combinations of oral paracetamol 1000 mg every 6 h, oral ibuprofen 400 mg every 6 h, or a single-dose of intravenous dexamethasone 24 mg in the following groups: paracetamol plus ibuprofen, ibuprofen plus dexamethasone, paracetamol plus dexamethasone, and paracetamol plus ibuprofen plus dexamethasone. The primary outcome was 24 h intravenous morphine consumption, analysed in a modified intention-to-treat population, defined as all randomly assigned participants who underwent total hip arthroplasty. The predefined minimal important difference was 8 mg. Safety outcomes included serious and non-serious adverse events within 90 days and 24 h. The trial was registered with ClinicalTrials.gov, NCT04123873. Between March 5, 2020, and Nov 15, 2022, we randomly assigned 1060 participants, of whom 1043 (589 [56%] women and 454 [44%] men) were included in the modified intention-to-treat population. 261 were assigned to paracetamol plus ibuprofen, 262 to ibuprofen plus dexamethasone, 262 to paracetamol plus dexamethasone, and 258 to paracetamol plus ibuprofen plus dexamethasone. Median 24 h morphine consumption was 24 mg (IQR 12-38) in the paracetamol plus ibuprofen group, 20 mg (12-32) in the paracetamol plus dexamethasone group, 16 mg (10-30) in the ibuprofen plus dexamethasone group, and 15 mg (8-26) in the paracetamol plus ibuprofen plus dexamethasone group. The paracetamol plus ibuprofen plus dexamethasone group had a significantly reduced 24 h morphine consumption compared with paracetamol plus ibuprofen (Hodges-Lehmann median difference -6 mg [99% CI -10 to -3]; p<0·0001) and paracetamol plus dexamethasone (-4 mg [-8 to -1]; p=0·0013), however, none of the comparisons showed differences reaching the minimal important threshold of 8 mg. 91 (35%) of 258 participants in the paracetamol plus ibuprofen plus dexamethasone group had one or more adverse events, compared with 99 (38%) of 262 in the ibuprofen plus dexamethasone group, 103 (39%) of 262 in the paracetamol plus dexamethasone group, and 165 (63%) of 261 in the paracetamol plus ibuprofen group. In adults undergoing total hip arthroplasty, a combination of paracetamol, ibuprofen, and dexamethasone had the lowest morphine consumption within 24 h following surgery and the most favourable adverse event profile, with a lower incidence of serious and non-serious adverse events (primarily driven by differences in nausea, vomiting, and dizziness) compared with paracetamol plus ibuprofen. The Novo Nordisk Foundation and Næstved-Slagelse-Ringsted Hospitals' Research Fund.

Efficacy of Serratus Posterior Superior Intercostal Plane Block on Postoperative Pain and Total Analgesic Consumption in Patients Undergoing Reduction Mammoplasty Surgery: An Evidence Based Report.

Serratus posterior superior intercostal plane block (SPSIPB) is a novel technique that provides analgesia in shoulder, hemithorax and in the back of the neck. In this study, the efficacy of this block on postoperative pain and quality of recovery is reported in ten consecutive patients who had undergone reduction mammoplasty. Blocks were performed bilaterally with 30 ml 0.25 % bupivacaine for each side, at the end of surgery. Cumulative tramadol consumption and numerical rating scale (NRS) scores during rest (static) and coughing (dynamic) were assessed within the first postoperative 24 hours. Mean total tramadol consumption was 39 ±9.94 mg. NRS scores above 4 were observed in 5 patients in the dynamic NRS assessment at the postoperative 1st hour, while static and dynamic NRS scores were ≤4 at other durations. SPSIPB may play a part in postoperative multimodal analgesia following mammoplasty in the future and may reduce total analgesic consumption. Key Words: Serratus posterior superior intercostal plane block, Reduction mammoplasty, Breast surgery, Postoperative analgesia.

Regional anaesthesia for postoperative pain management following laparoscopic, visceral, non-oncological surgery a systematic review and meta-analysis.

Postoperative pain management following laparoscopic, non-oncological visceral surgery in adults is challenging. Regional anaesthesia could be a promising component in multimodal pain management. We performed a systematic review and meta-analysis with GRADE assessment.Primary outcomes were postoperative acute pain intensity at rest/during movement after 24h, the number of patients with block-related adverse events and the number of patients with postoperative paralytic ileus. 82 trials were included. Peripheral regional anaesthesia combined with general anaesthesia versus general anaesthesia may result in a slight reduction of pain intensity at rest at 24h (mean difference (MD) -0.72 points; 95% confidence interval (CI) -0.91 to -0.54; I2=97%; low-certainty evidence), which was not clinically relevant. The evidence is very uncertain regarding the effect on pain intensity during activity at 24h (MD -0.8 points; 95%CI -1.17 to -0.42; I2= 99%;very low-certainty evidence) and on the incidence of block-related adverse events. In contrast, neuraxial regional analgesia combined with general anaesthesia (versus general anaesthesia) may reduce postoperative pain intensity at rest in a clinical relevant matter (MD -1.19 points; 95%CI -1.99 to -0.39; I2 = 97%; low-certainty evidence), but the effect is uncertain during activity(MD -1.13 points; 95%CI -2.31 to 0.06; I2= 95%; very low-certainty evidence). There is uncertain evidence, that neuraxial regional analgesia combined with general anaesthesia (versus general anaesthesia) increases the risk for block-related adverse events (relative risk (RR) 5.11; 95%CI 1.13 to 23.03; I2= 0%; very low-certainty evidence). This meta-analysis confirms that regional anaesthesia might be an important part of multimodal postoperative analgesia in laparoscopic visceral surgery, e.g. in patients at risk for severe postoperative pain, and with large differences between surgical procedures and settings. Further research is required to evaluate the use of adjuvants and the additional benefit of regional anaesthesia in ERAS programmes. PROSPERO CRD42021258281.

Spinal Anestezi Altında Sezaryen Doğumda Postoperatif Analjezi için Transversalis Fasya Plan Bloğunun Transversus Abdominis Plan Bloğuyla Karşılaştırılması: Retrospektif Bir Çalışma

Objective: Transversalis fascia plane (TFP) and transversus abdominis plane (TAP) blocks are used for postoperative analgesia in many lower abdominal procedures such as cesarean section. This study aimed to retrospectively compare the postoperative effects of TFP and TAP blocks for postoperative multimodal analgesia in patients who underwent cesarean section under spinal anesthesia. Methods: We retrospectively searched electronic medical records to identify patients who underwent cesarean section under spinal anesthesia between November 2021 and June 2022. A total of 497 patients were identified, and 120 patients were included that meet our criteria in our analysis. The patients were divided into three groups: TFP, TAP, and control. Data were obtained from the files of the patients. Results: The block groups had significantly lower numeric rating scale (NRS) scores, less non-steroidal anti-inflammatory drug consumption, and lower complications than the control group. No opioid consumption was observed in the block groups. Although no non-steroidal anti-inflammatory drug consumption until the 4th hour and no opioid consumption until the 8th hour were observed in the control group, the need for additional analgesics increased as time passed. While the TFP group needed analgesics later than the TAP group, the NRS scores and total analgesic consumption were lower (p&lt;0.001). Patient satisfaction was higher in the block groups than in the control group (p&lt;0.001). Conclusion: Transversalis fascia plane and TAP blocks are effective as part of multimodal analgesia in cesarean section. The TFP block is superior to the TAP block in terms of pain scores, additional analgesic requirements, and patient satisfaction. Keywords: Cesarean section, postoperative pain, ultrasound-guided regional anesthesia, transversus abdominis plane block, transversalis fascia plane block

Postoperative pain relief quality after cesarean section using a stress monitor (Neon FSC system): prospective single-center randomized clinical comparative study

BACKGROUND: The objective assessment of pain levels during labor, postpartum period, and effectiveness of analgesic response remains difficult. We suppose that the dynamics of the activity of the sympathetic nervous system by measuring the galvanic skin response may become a promising method for solving this problem.&#x0D; OBJECTIVE: To evaluate the effectiveness of various multimodal analgesia regimens after cesarean section using the NeonFSC stress monitoring system.&#x0D; MATERIALS AND METHODS: A prospective single-center clinical comparative study was conducted to evaluate the effectiveness of various postoperative multimodal analgesia regimens in 48 postpartum women who underwent elective cesarean section under spinal anesthesia. For postoperative analgesia, group 1 (n=24) underwent a TAP block, and ketorolac and tramadol were prescribed, and group 2 (n=24) received only ketorolac and tramadol. Randomization was made using the envelope method. The visual analog scale (VAS) and NeonFSC system were used to assess the effectiveness of postoperative pain relief. The observation time was 19–22 h.&#x0D; RESULTS: The patients were comparable in age, gestational age, physical status, method of pain management and delivery. At baseline and during the 2-h postoperative period, the median and distribution of visual analogue scale pain scores did not show a statistically significant difference between groups. During the study period, the highest level of spectral power of skin conductance (SC) was recorded in group 2. Baseline skin conductance variability (SCV) values were comparable between groups (p 0.001). Lower SCV values were noted in patients of group 1, compared to group 2, at night (p=0.003 vs p 0.001). The median values of the level of total spectral power of skin conductivity (DASS) in patients of group 1 were 1.5–2 times lower, starting from the second hour until the end of observation.&#x0D; CONCLUSION: The NeonFSC system can be a component of an objective assessment of the effectiveness of analgesia after cesarean section.