Need For Additional Analgesia Research Articles

Systematic review and meta-analysis of oral paracetamol versus combination oral analgesics for acute musculoskeletal injuries.

The aim of this systematic review and meta-analysis was to determine if a combination of analgesics conveys any significant clinical benefit over paracetamol alone in managing acute musculoskeletal injuries. Two reviewers independently searched MEDLINE (via PubMed), EMBASE and Cochrane electronic databases. Randomised controlled trials comparing paracetamol with paracetamol plus other oral analgesics in managing acute musculoskeletal injuries (e.g. sprains, contusions) were identified. Outcomes were reduction in pain score, adverse events and need for additional analgesia. Studies were critiqued using the Cochrane Risk of Bias Assessment Tool and data analysed using RevMAN meta-analysis software. Six studies were included (n = 1254). No paediatric studies were identified. Five studies compared paracetamol to paracetamol plus NSAID. One study also included an opioid in the combination group. There was no clinically important difference between groups for reduction in pain score in the first 2 h, 24 h or 72 h. At 2 h the mean difference in reduction in pain score at rest on 100 mm VAS was 0.72 mm (-1.36, 2.79), P = 0.5. On activity it was -1.79 mm (-4.08, 0.49), P = 0.12. The risk of adverse events in ED was -0.00 (-0.04, 0.03). More patients receiving combination therapy required additional analgesia in the first 2 h: -0.03 (-0.06, -0.01), P = 0.01. Paracetamol monotherapy is a reasonable first-line analgesic for acute musculoskeletal injuries as combining additional oral agents does not result in any significant additional analgesic effect.

Opioid free post-operative pain management in day case surgery of tonsillectomy

Background: Post-surgical pain is a challenging problem. Different modifications of surgical procedures and use of different analgesics had been reported. However, no consensus had been reached for post-surgical pain control. Tonsillectomy is one of the most commonly performed surgical procedure and pain control still controversial. Aim of the work:To investigation safety and efficacy of intravenous paracetamol, ibuprofen, or both for post-tonsillectomy pain control. Patients and Methods:The study had been carried at Otorhinolaryngology and Eye, Al-Jabr hospital,Anesthesia and Intensive Care Department in collaboration with Otorhinolaryngology department and the day care surgery unit], Al-Ahasa directorate, Kingdom of Saudi Arabia [KSA]. It included children aged 2 to 10 years. Patients had been randomly allocated into 3 equal groups [each 30 patients]. Group A [intravenous paracetamol 15mg/kg], Group B [intravenous ibuprofen 10mg/kg], and Group C [intravenous paracetamol 7.5 mg/kg and ibuprofen 5mg/kg]. The examined drug had been administrated 20 minutes after induction of general anesthesia. The analgesic effects and hemodynamics had been assessed on regular postoperative intervals till patient discharge, and patient satisfaction had been addressed. Any side effects and need for postoperative analgesia had been documented. Results: Studied groups were comparable regarding patient demographics, recovery time, hospital stay duration and need for additional analgesia. However, pain was significantly variable between studied groups till 3 hours postoperatively. Pain was significantly reduced at groups B [IV ibuprofen] and C [IV paracetamol and Ibuprofen with reduced dose] when compared to group A [IV paracetamol] at all times. In addition, hemodynamic variability was observed for mean arterial pressure and heart rate. At five minutes, blood pressure was significantly higher in group B when compared to group C, and at 5 minutes to 2.5 hours, it was significantly increased among group A when compared to group C. Conclusion: Drug combination with reduced [half the dose] of both intravenous paracetamol and ibuprofen is more effective and safer than single drug with higher dose. The studied drugs avoid the well-known side effects of opioids.

The efficacy of transversus abdominis plane block for postoperative analgesia in laparoscopic cholecystectomy cases: a retrospective evaluation of 515 patients.

ObjectiveTo compare patients that received intravenous (i.v.) analgesics with those that received transversus abdominis plane (TAP) block for pain relief after laparoscopic cholecystectomy.MethodsThis retrospective study enrolled patients that had undergone laparoscopic cholecystectomy and divided them into two groups: the i.v. analgesic group (controls; group A) and the TAP block group (group T). Data retrieved from the medical records included postoperative visual analogue scale (VAS) pain scores, duration of intensive care unit (ICU) stay, total hospital stay, additional analgesic requirements and the occurrence of nausea and vomiting.ResultsA total of 515 patients were included (group A, n = 247; group T, n = 268). Postoperative VAS pain scores at 0, 2, 4 and 6 h and the need for additional analgesics were significantly lower in group T than in group A. Postoperative VAS pain scores at 12 and 24 h were significantly higher in group T than in group A. Postoperative nausea and vomiting were significantly lower in group T than in group A. The rate of ICU admission in group T was significantly lower than in group A.ConclusionsEffective postoperative analgesia can be achieved with TAP block and undesirable effects can be reduced.

Effect of self-administered vaginal dinoprostone on pain perception during copper intrauterine device insertion in parous women: a randomized controlled trial

To assess efficacy and safety of self-administered 3 mg dinoprostone vaginally in reducing pain during copper intrauterine device (IUD) insertion in parous women. Randomized, double-blinded, placebo-controlled trial. Family planning clinic in a tertiary referral hospital. Multiparous women who were attending a family planning clinic and requesting copper IUD insertion. We randomly assigned 160 participants into two groups: The dinoprostone group (n = 80) received 3 mg dinoprostone vaginally, and the placebo group (n = 80) received placebo vaginally. Our primary outcome was mean pain scores during IUD insertion. Our secondary outcomes were mean pain scores during tenaculum application, during uterine sounding, and 15 minutes after insertion, ease of insertion, satisfaction score, need for additional analgesics, and side-effects. Both groups showed no significant difference in anticipated pain score (P=.41), pain during tenaculum placement (P=.22), and pain during sound insertion (P=.07). The dinoprostone group had significantly lower pain scores during IUD insertion (34.8 ± 10.1 vs. 57.8 ± 11.8) and 15 minutes after insertion (20.6 ± 6.4 vs. 29.6 ± 6.2), easier IUD insertion (43.6 ± 21.9 vs. 64.7 ± 18.1), and higher satisfaction (83.9 ± 11.6 vs. 63.0 ± 9.1) compared with the placebo group. Fewer patients required additional analgesics in the dinoprostone group compared with the placebo group (P=.01). Side-effects were similar between the groups. Self-administered 3 mg dinoprostone vaginally before copper IUD insertion in parous women reduces pain scores during IUD insertion, making insertion easier and increasing women's satisfaction, with tolerable side-effects. NCT04046302.

Aspirin (single dose) for perineal pain in the early postpartum period.

Aspirin (single dose) for perineal pain in the early postpartum period.

Comparison of Retrograde Intrarenal Surgery and Percutaneous Nephrolithotomy Used in the Treatment of 2-4 cm Kidney Stones in Terms of Pain and Need for Additional Analgesics: A Prospective Randomized Study.

Purpose: To compare the effects of retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PNL) on postoperative pain and their differences in terms of the postoperative need for analgesics in the treatment of 2-4 cm kidney stones. Methods: A total of 132 patients who suffered from renal stones 2-4 cm in size and had surgery at our urology clinic between April 2015 and April 2017 were enrolled in this prospective study (NCT02430168). Patients were randomized into either the RIRS group (Group 1) or PNL group (Group 2) in a ratio of 1:1. Postoperative visual analog scale (VAS) values at 8 and 24 hours postoperatively and analgesic treatments of patients were recorded. Results: Patients from both groups had similar demographic characteristics. Stone-free states were achieved in 37 (74%) patients in the RIRS group and 45 (90%) patients in the PNL group. Postoperative complication rates were similar in two groups. Moreover, there was no statistically significant difference between the groups in terms of the postoperative need for analgesics (P = .309). However, the PNL group had higher VAS values (P < .001). Conclusion: Although the early postoperative pain scales were high in the PNL group, there was no significant difference between the groups in terms of the standard analgesic treatments for achieving patient's comfort. PNL, which has similar complications, but with higher success rates, compared with RIRS, did not require additional analgesic treatment during postoperative pain management. Thus, in our opinion, PNL should still remain as a first choice in treatment of 2-4 cm renal stones.

Evaluation of the Effects of Preoperative Dexamethasone Administration on Postoperative Patient Comfort in Laparoscopic Cholecystectomy.

ObjectivePostoperative recovery process following laparoscopic cholecystectomy depends on many factors such as pain, fatigue and exhaustion. The objective of this study was to investigate whether the administration of dexamethasone, a glucocorticoid, has positive effects of postoperative patient comfort in patients who underwent laparoscopic cholecystectomy in our clinic.MethodsPatients who presented to the general surgery clinic of our hospital and scheduled for laparoscopic cholecystectomy due to cholelithiasis were included in this study. Patients in Group 1 received dexamethasone 90 minutes before the skin incision, while patients in Group 2 were given placebo (normal saline). Pain scores, presence of nausea and vomiting in the postoperative period were compared between the study and control groups.ResultsNo statistically significant difference was observed between the groups in terms of incisional pain at rest and in motion and visceral pain at rest at postoperative 6th, 12th and 24th hours. Although there was a difference between the groups in terms of visceral pain in motion at the postoperative 12th and 24th hours, this was not statistically significant (p > 0.05). Although the need for additional analgesics and antiemetic drugs was lower in the study group compared to the control group, the difference between the groups was not statistically significant (p > 0.05).ConclusionWe can expect better results with the use of multimodal analgesic and anti-emetic combination instead of a single agent in studies to be performed about the prevention of postoperative pain, nausea and vomiting.

Benefits of Self-administered Vaginal Dinoprostone 12 Hours before Levonorgestrel-releasing Intrauterine Device Insertion in Nulliparous Adolescents and Young Women: A Randomized Controlled Trial.

To assess safety and efficacy of self-administered vaginal dinoprostone 12hours before a 52-mg levonorgestrel intrauterine device (LNG-IUD) insertion in adolescents and young nulliparous women. Randomized controlled trial. Tertiary referral hospital. Nulliparous adolescents and young women aged 18-22years. Participants were randomly assigned into 2 groups; the dinoprostone group (n=65) received dinoprostone 3mg vaginally, and the placebo group (n=65) received placebo tablets vaginally. Primary outcome was pain scores during LNG-IUD insertion measured using a visual analogue scale. Secondary outcomes were pain scores during speculum insertion, tenaculum placement, uterine sounding, and 20minutes postprocedure, ease of insertion, Women's satisfaction score, need for additional analgesics, and side effects. The dinoprostone group had significantly lower pain scores during LNG-IUD insertion (2.83±1.08 vs 3.95±1.63), tenaculum placement (2.97±1.41 vs 4.55±1.53) and sounding of uterus (3.55±1.71 vs 5.12±1.37) compared with the placebo group (P<.001). No significant differences were found between both groups regarding anticipated pain scores (P=.85), pain during speculum insertion and 20minutes postinsertion and insertion duration (P=.53). Women's satisfaction, provider reported ease of insertion, and need for additional analgesia were significantly better among dinoprostone users (P<.001, < .001, and .02, respectively). Side effects and procedure complications were similar for the 2 groups. Self-administered dinoprostone 3mg vaginally 12hours before a 52-mg LNG-IUD insertion in nulliparous adolescent and young women effectively reduced pain during insertion and increased women's satisfaction and ease of insertion reported by clinicians.

Topical lidocaine-prilocaine cream versus rectal meloxicam suppository for relief of post-episiotomy pain in primigravidae: A randomized clinical trial

ObjectivesTo compare the analgesic effect of topical lidocaine-prilocaine (LP) cream and rectal meloxicam suppository on the post-episiotomy pain in primigravidae. Patients and methodsA randomized open-label clinical trial included primigravidae delivered vaginally with episiotomy. Eligible women were recruited and randomized to topical LP cream on the episiotomy line or rectal meloxicam suppository 15 mg. The intensity of the perineal pain was assessed using a visual analog scale (VAS) immediately, at 6, 12 h and after 5 days post-episiotomy. ResultsOne hundred ninety women were enrolled (n = 95 in each arm). No difference between both groups in the VAS scores immediately (mean ± SD: 8.54 ± 1.35 vs. 8.33 ± 1.50, p = 0.419) and 6 h after episiotomy (p = 0.859). However, women in the LP arm were more likely to report lower VAS scores at 12 h and 5 days post-episiotomy (mean ± SD: 1.20 ± 0.50 vs. 5.65 ± 1.65, p = 0.0001; 1.19 ± 0.49 vs. 2.64 ± 1.73, p < 0.001; respectively). ConclusionApplication of topical LP cream after repair of episiotomy in primigravidae seems to substantially alleviate the induced pain with subsequent less need for additional analgesia and more patients’ satisfaction.

Comparison of Sufentanil- and Fentanyl-based Intravenous Patient-controlled Analgesia on Postoperative Nausea and Vomiting after Laparoscopic Nephrectomy: A Prospective, Double-blind, Randomized-controlled Trial.

Background: The incidence of postoperative nausea and vomiting (PONV) remains high. The effects of sufentanil for PONV is not firmly confirmed. The aim of this study was to compare the effect of sufentanil- and fentanyl-based intravenous patient-controlled analgesia (IV-PCA) on the incidence of PONV after laparoscopic nephrectomy.Methods: Eighty-six patients were randomly allocated to receive either the sufentanil (n =43) or fentanyl (n =43). IV-PCA was prepared using either sufentanil 3 µg/kg or fentanyl 20 µg/kg, ramosetron 0.3 mg, and ketorolac 120 mg. The primary outcome of was the incidence of PONV during 24 h after post anesthesia care unit (PACU) discharge. The secondary outcomes were the modified Rhodes index and patient satisfaction scores at 24 h after PACU discharge, need for rescue antiemetics, pain score, need for additional analgesics, and cumulative consumption of IV-PCAResults: The incidence of PONV was comparable between the sufentanil and fentanyl groups (64.3% vs. 65%, p = 0.946; respectively). The number of patients who required antiemetics (p = 0.946) and the modified Rhodes index at 24 h after post-anesthesia care unit discharge (p = 0.668) were also comparable in both groups. No significant differences were found in the secondary outcomes, including the analgesic profiles and adverse events between the groups.Conclusions: In conclusion, sufentanil- and fentanyl-based IV-PCA showed similar incidence of PONV with comparable analgesic effects after laparoscopic nephrectomy. Based on these results, we suggest that sufentanil and fentanyl may provide comparable effects for IV-PCA after laparoscopic nephrectomy.

Rectal misoprostol after cesarean delivery: does it affect recovery of bowel functions? A prospective randomized trial

Aim: To assess the efficacy of rectally administered misoprostol in the improvement of bowel function recovery after cesarean delivery (CD). Methods: This prospective randomized trial was conducted among 171 pregnant women subjected to term elective CD. Patients were divided equally into 3 groups by simple randomization. Participants in group A were given misoprostol 200 μg rectally; those in group B were given misoprostol 400 μg rectally just after CD but before leaving the operating theater, while the participants in group C did not receive any rectal drug. The study outcome measures were: duration before first bowel movement and start of the regular oral diet. Adverse effects, need for additional analgesics, and post-CD hospital stay period were also recorded. Results: The mean times to first audible intestinal sounds and to the first passage of flatus were significantly lower in group B (14.1 ± 1.4 h and 16.7 ± 2.3 h, respectively) when compared to both groups A and C [ 21.9 ± 5.3 h and 24.9 ± 5.7 h (A) vs. 23.6 ± 6.9 h and 27.1 ± 7.9 h (C)] (p = 0.001). It was found that notably, patients in group B resumed diet more quickly, with a mean period of 20.5 h, which was significantly faster than the remaining groups (29.8 h and 33.1 h in groups A and C, respectively Of great interest, patients in group B had a lower post-CD hospital stay (38.5 h vs. 59.2 h in group A and 64. 8 h in group C). Conclusion: For the recovery of bowel functions after CD, rectal administration of 400 μg misoprostol appears to be more effective than 200 μg of rectally administrated misoprostol or traditional feeding regimens.

Medications Used for Prevention and Treatment of Postoperative Endodontic Pain: A Systematic Review.

Objective:Prevention and management of postoperative endodontic pain is a common challenge for the endodontists. This systematic review was conducted to evaluate the efficacy and safety of medicament therapeutic protocols in the prevention and management of endodontic pain.Methods:A literature search was undertaken in MEDLINE, Cochrane Library, LILACs, and SciELO, for articles published until December 2017, without year restriction and written only in English. An additional search was performed in the references of the retrieved studies.Study eligibility criteria, participants, and interventions: The inclusion criteria were randomised clinical trials that evaluated the use of medications to prevent or control moderate to severe pain in adult patients, using a visual analog scale as a tool for pain measurement. The primary outcome evaluated was the reduction of pain scores. The second outcome evaluated was the need for additional analgesia and the occurrence of adverse events.Study appraisal and synthesis methods: The quality assessment of the included studies was performed following the Jadad scale to measure the likelihood of bias in pain research reports.Results:After removing duplicates and excluding the studies that did not meet the selection criteria, ten studies were included tin the systematic review. Among these studies, five studies administered the medications before the endodontic procedures and five studies after. These studies evaluated non-opioid analgesics (acetaminophen), opioid analgesics (tramadol and codeine), nonsteroidal anti-inflammatories (ibuprofen, flurbiprofen, ketorolac tromethamine, etodolac, tenoxicam, and naproxen), steroidal anti-inflammatory (prednisolone) or the association of medications to prevent or control postoperative pain. It was possible to establish a significant relationship between the use of additional analgesics and periapical diagnosis. Adverse events were not observed when the administration occurred before the endodontic procedure. When it was administered after the procedure, adverse reactions were reported in 2 of 3 trials included in the analysis.Limitations: A restricted number of randomised clinical trials were found, and the difference in the methodology of the studies did not meet the definition of a systemic treatment protocol for prevention or control of postoperative pain.Conclusion:Nonsteroidal anti-inflammatory drugs are the most common medicament to prevent and control postoperative pain, with ibuprofen being the most investigated. There is a significant association between the use of additional analgesics and periapical diagnoses.

Effectiveness of ketamine and propofol (ketofol) in 1:2 versus 1:3 combinations for procedural sedation and analgesia in pediatric patients undergoing bone marrow aspiration and / or biopsy: A prospective cohort study

BackgroundBone marrow aspiration (BMA) and Biopsy is a painful procedure done in children with hematologic disorders. Ketamine and Propofol mixture is widely used for its combined effect of amnesia and analgesia as well as hemodynamic stability and decreased post procedural adverse events. Smooth analgesia and anesthesia is mandatory in such like pediatrics procedures. ObjectiveTo compare the effectiveness of ketofol in 1:2 versus 1:3 combinations for Procedural sedation and analgesia in children undergoing Bone marrow aspiration and Biopsy at Tikur Anbessa Specialized Hospital from December 2019–March 2020. MethodsThis prospective cohort study recruits 128 American Society of Anesthesiologist class I and II, pediatric patients age between 1–12 years undergoing for BMA and Biopsy with ketofol 1:2 or 1:3 combination were included. Hemodynamic, respiratory and RSS (Ramsay sedation score) variables were noted and recorded every 10 min during the procedure. Normality of the data was checked using Kolmogorov-smirnov test and analyzed using student t-test for normally distributed data and chi-square test for categorical data. Non-parametric data was analyzed using Mann –Whitney U test with 95% CI and p-value less than 0.05 is considered as statistically significant. Resultsketofol 1:2 group (n = 64) compared with ketofol 1:3 group (n = 64) had similar sedation level assessed by RSS, hemodynamic and respiratory outcome, as well as general postoperative adverse events profile, but the total intraoperative analgesia consumption was significantly higher in ketofol 1:3 group (29.7%) when compared to ketofol 1:2 group (7.8%) with p = 0.002. ConclusionKetofol 1:3 group shows the need for additional analgesia in this combination. Whereas ketofol 1:2 combination for pediatrics undergoing BMA and Biopsy has decreased intraoperative analgesia requirement.

COMT val158met Polymorphism and Spinal Analgesia Efficacy of Laparoscopic Surgery for Colorectal Cancer (a Pilot Study)

The aim: To assess the effect of COMT G1947A genetic polymorphism (val158met) on the efficacy of spinal analgesia on day 1 after laparoscopic surgery for colorectal cancer.Material and methods. In a pilot study involving 100 patients with colorectal cancer, operated through laparoscopic access, using spinal analgesia (10.0–12.5 mg of bupivacaine + 200 mcg of morphine), the frequency of COMT gene G1947A (val158met) polymorphism, the intensity of pain on day 1 after surgery, the frequency and severity of nausea, vomiting, skin itching, the need for additional analgesia have been assessed.Results. The frequency distribution of alleles val/val (25%), val/met (45%) and met/met (30%) was consisted with Hardy-Weinberg equilibrium (χ2=0.96; P&gt;0.05) and was not significantly different from the healthy donor group. In the groups of patients with various COMT alleles of val158met polymorphism, the studied parameters also did not differ significantly.Conclusion. Study did not find significant link between spinal analgesia efficacy on day 1 after laparoscopic surgery for colorectal cancer and COMT rs4680 G1947A (val158met) polymorphism. Further research to enhance the power of the study is warranted to reach the final conclusions.

Comparison the Effect of Paracetamol and Ketorolac on Pain Relief after Cesarean Section

Introduction: Cesarean section is one of the most common surgical procedures in women. Effective pain control is an important component of post-operative care, as calming the mother increases her ability to take care of herself, reduce nosocomial infections, and hospitalization costs. The aim of this study was to compare the effect of paracetamol and ketorolac on the relief of post-cesarean pain in order to find a drug with minimal complications.&#x0D; Methods: This study was performed on 140 women admitted to Ali Ibn Abi Talib Hospital due to cesarean section. Patients were divided into two groups of 500 mg paracetamol after cord clamp and 30 mg intravenous ketorolac group. Pain score, need for additional analgesia and visual analogue scale (VAS) were measured and compared in two groups. Data were analyzed using SPSS software.&#x0D; Results: In this study, mean pain scores at 0, 6, 12 and 24 hours were significantly lower in the ketorolac group than in the paracetamol group. There was no complication in any of the experimental groups in this study. There was no significant difference between the mean time of first request for the additional analgesic of two groups. Frequency of additional analgesic request in the ketorolac group was significantly lower than in the paracetamol group.&#x0D; Conclusion: Overall, the results of this study showed that the rate of pain reduction after cesarean section with ketorolac was significantly higher than paracetamol.

Efficiency and safety of intrathecal morphine for analgesia after hysterectomy

Introduction/Objective. This prospective, randomized study was done to determine the efficiency and safety of the administration of intrathecal morphine chloride combined with the local anesthetic levobupivacaine given to female patients subjected to hysterectomy to ensure postoperative analgesia. Methods. The study sample consisted of 50 patients who were to undergo hysterectomy with adnexectomy and they were divided into two groups of 25 each. The patients in group A were given the combination of 0.3 mg of morphine chloride with 1.7 ml of 0.5% levobupivacaine immediately before the surgery, whereas the patients in group B were intravenously administered 5 mg of morphine chloride before the end of surgery, and after the surgery at certain time intervals. The postoperative pain was assessed at the first, sixth, 12th, and 24th hour by Numeric Rating Scale (NRS). Side effects, such as nausea, vomiting, itching and respiratory depressions were followed as well. Results. The postoperative pain was less expressed at any time interval both at rest and on exertion in group A (p &lt; 0.001) and therefore the need for additional analgesia was less in group A (p &lt; 0.001). The subjective feeling of satisfaction with postoperative analgesia was statistically significant in group A (p &lt; 0.001). Conclusion. Intrathecal administration of morphine chloride combined with levobupivacaine ensures better postoperative analgesia after hysterectomy than intravenous morphine chloride, their side effects being equally frequent..

Pain control with ultrasound-guided ilioinguinal-iliohypogastric nerve block compared with local infiltration anesthesia in patients undergoing transfemoral transcatheter aortic valve implantation: a prospective randomized trial

Introduction Ilioinguinal-ilioinguinal nerve block is frequently performed for analgesia in inguinal surgery. The authors hypothesized that preoperative ultrasound-guided ilioinguinal-iliohypogastric (II-IH) nerve block produce better intraoperative analgesia and less analgesic requirement in comparison to commonly used local infiltration anesthesia in patients undergoing transfemoral transcatheter aortic valve implantation (TF-TAVI). Methods 87 elderly patients scheduled for TF-TAVI were randomized to receive either II-IH nerve block (Group A) or local infiltration anesthesia (Group B) between July 2018 and April 2019 (ClinicalTrials.gov; ID: NCT03863899). In patients in group A ultrasound-guided II-IH nerve block was performed preoperatively by anesthesiologist. Patients in group B received local anesthetic infiltration of the operative area performed by surgeon. Pain intensity was assessed using numeric rating scale (NRS 0-10; 0 = no pain; 10 = the worth pain imaginable) in five time-points intraoperatively (femoral artery cannulation (1), aortic valve system introduction (2), aortic valve system removal (3), vessel closure devices insertion (4), the end of the operation (5)). When NRS was 4, fentanyl was given. The need for additional analgesics was also evaluated during the procedure. Results After exclusion of 10 patients the analysis was performed in 77 patients: 40 in group A and 37 patients in group B. In time points (1-4) pain intensity was lower in group A than in group B (p The need for supplementary fentanyl administration was lower in group A in comparison to group B (p = 0.02). Time from arrival in operation room to start surgery was longer in group A than in group B (median: 60 min. vs. 50 min., respectively; p = 0.01). Discussion Ultrasound-guided II-IH nerve block produce better intraoperative analgesia and less analgesic consumption than local infiltration anesthesia in patients undergoing TF-TAVI, at the cost of slightly longer patient's preparation to surgery.

Hyperalgesia and fentanyl dosing in on-pump coronary artery bypass grafting

Introduction Opioids have many known side-effects. However opioid-induced hyperalgesia (OIH), as a result of central sensitization, remains more obscure. The increase in hyperalgesia is dose-related and postoperatively an increased secondary wound hyperalgesia may be a factor in the development of chronic or persistent pain. This prospective, randomized and double-blind clinical trial aims to investigate the effects of fentanyl on secondary wound hyperalgesia in patients undergoing on-pump coronary artery bypass grafting. Methods Secondary wound hyperalgesia was investigated between two study-groups, respectively a low dose bolus group (n = 14, 3mcg/ kg) and a continuous infusion group (n = 17, Shibutani). The primary endpoint of this study was the area of secondary wound hyperalgesia after 24 hours. The area was measured using a Von Frey filament (256mN). Additionally we looked at hyperalgesia after 48 hours and we investigated following secondary endpoints: time to extubation, ICU/hospital length of stay, PONV, pain scores, the need for additional analgesia and the total dose of opioids administered 24 and 48 hours after surgery. This study is a subgroup analysis of a larger study, in which the possible association between the area of secondary wound hyperalgesia and persistent pain at 3, 6 and 12 months after surgery will be investigated. Results The examination of preliminary results showed no statistically significant difference for the area of secondary wound hyperalgesia after 24 hours (p = 0.3268). However the results became significant after 48 hours, where the area of secondary wound hyperalgesia was smaller in the low dose bolus group (p = 0.0389). No significant differences were found for the other secondary endpoints. Discussion There was less secondary wound hyperalgesia in the low dose bolus group after 48 hours, although at 24 hours this was not statistically significant. These findings are the result of preliminary data. We need to wait for the definitive results of hyperalgesia and for the results regarding chronic pain to draw any conclusions about the clinical significance of OIH.

Combined Interscalene and Superficial Cervical Plexus Block for Clavicle Surgery: Case Series

General Anesthesia is preferred over regional anesthesia in clavicle surgery. We report 3 cases of clavicle fracture which was performed under USG guided combined Interscalene and Superficial cervical plexus block. All the patients were comfortable and there was no need for additional analgesia. Thus regional anesthesia can be used as a sole anesthetic technique in patients with clavicle fracture and can be an alternative where general anaesthesia and its adverse effects needs to be avoided.&#x0D; Keywords: clavicle fracture; interscalene brachial plexus block; superficial cervical plexus block. Correspondance: Dr.

LO62: Intranasal dexmedetomidine for procedural distress in children: a systematic review and meta-analysis

Introduction: Intranasal dexmedetomidine (IND) is an emerging agent for procedural distress in children. However, studies to date have been limited by small samples and imprecise estimates of effect size. We sought to summarize the evidence on the effectiveness of IND for procedures associated with distress in children. Methods: We performed electronic searches of MEDLINE (1946-2018), EMBASE (1980-2018), Google Scholar (2018), CINAHL (1981-2018), Cochrane Central Register of Controlled Trials (2018), 6 clinical trials registries and conference proceedings (2010-2018). Title searches, data abstraction, and risk of bias assessments were performed in duplicate. We included all published and unpublished, randomized and quasi-randomized trials of IND for procedures in children younger than 19 years of age without language restriction. The methodological quality of studies was evaluated using the Cochrane Collaboration's Risk of Bias tool. The primary outcome was the proportion of participants that were deemed to be adequately sedated for the procedure. Results: Of 661 studies, 18 met inclusion criteria. Trials involved 2128 participants, age 1 month - 14 years (836, 39.3% females), who received IND 1 - 4 mcg/kg either by drops (n = 12), atomizer (n = 4), or both (n = 2). 12 trials were eligible for meta-analysis. 13 trials used validated instruments to assess sedation. All studies except one were associated with low or moderate risk of bias. For painful procedures (IV insertion; laceration repair; dental extraction), the pooled OR (95% CI) for adequate sedation and need for additional analgesia was non-significant [1.19 (0.53, 2.65)] and [2.16 (0.62, 7.49)], respectively (n = 5). For non-painful procedures (diagnostic imaging), the corresponding pooled OR (95% CI) favored IND [3.04 (1.58, 5.82)] and [4.44 (2.11, 9.35)], respectively (n = 7). Time to onset and duration of sedation ranged from 13-31 minutes and 41-91.5 minutes, respectively. For adverse effects, the pooled OR (95% CI) was not significantly different between IND and comparators [0.58 (0.22, 1.55] and there were no serious adverse events. Conclusion: IND at doses 1 to 4 mcg/kg are safe and adequately sedate children undergoing non-painful procedures, although the ease of administration must be weighed against the risk of prolonged sedation. Additional trials with larger sample sizes and greater methodologic rigor are needed for painful emergency department procedures such as laceration repair and IV insertion.