Need For Rescue Analgesia Research Articles

Analgesic Effects of Magnesium Sulphate as an Adjuvant to Fentanyl for Monitored Anaesthesia Care During Hysteroscopy.

Magnesium sulphate (MgSO4) is conventionally used in the treatment of eclampsia, refractive arrhythmias, asthma, etc. In our study, we aimed to study the analgesic effects of MgSO4 as an adjuvant to fentanyl and reduce the intraoperative opioid requirement to decrease their adverse effects. A total of 122 patients scheduled for hysteroscopy were randomly divided into two groups. Patients in the magnesium group (group A) received intravenous MgSO4 50 mg/kg in 100 ml of isotonic saline over 15 minutes before anaesthesia induction and then 15 mg/kg per hour by continuous intravenous infusion. Patients in the control group (group B) received an equal volume of isotonic saline as a placebo. All the patients were induced with fentanyl and propofol. Perioperative haemodynamic monitoring and postoperative assessment of pain were done. Only 18% of the patients in group A required rescue analgesics as compared to 39.3% of patients in group B. The patients receiving MgSO4 displayed lower verbal numeric rating scale scores in the postoperative period. In addition, the intraoperative requirement of fentanyl (101 (21.33) vs. 144 (28.4) µg, mean (SD)) and propofol (121 (13.3) vs. 140 (16.5) mg, mean (SD)) was significantly lower in group A as compared to that in group B. MgSO4, when administered as an adjuvant to opioids, provided effective postoperative analgesia thereby reducing the need for rescue analgesics. It also decreases intraoperative fentanyl consumption and its dose-related side effects.

Intravenous acetaminophen reduces the length of intubation and rescue analgesics in intensive care unit patients after cardiovascular surgery in Japan: A retrospective analysis.

After cardiovascular surgery, analgesic and sedative management in the intensive care unit (ICU) significantly affects short- and long-term outcomes of patients. This study aimed to clarify the impact of opioid reduction after acetaminophen administration on the length of intubation and rescue analgesic use after cardiovascular surgery. This was a case-control study. This study was conducted in the ICU of a cardiovascular hospital. Datasets of 556 post-cardiac surgery participants were collected; for final analyses, 266 participants were selected by propensity score matching. Equality between the intervention and comparison groups was ensured by calculating the standardized difference and difference test. The intervention group was treated with the multimodal analgesic sedation protocol. The primary outcomes were the length of intubation and use of rescue analgesics. The intervention group demonstrated a decreased total opioid consumption (460.0 vs 580.0 mcg, effect size [ES] = -0.178), opioid administration time (1,130.0 vs 2,070.0 minutes, ES = -0.306), and sedative administration time (955.0 vs 1,577.0 minutes, ES = -0.354). Moreover, the protocol resulted in decreased duration of ventilation (990.0 vs 1,057.5 minutes, ES = -0.140) and reduced need for rescue analgesics, including flurbiprofen axetil (3.5 vs 34.5 percent, ES = -0.392) and loxoprofen sodium (19.5 vs 48.1 percent, ES = -0.284). This study suggested that acetaminophen reduces opioid use and improves patient outcomes after cardiovascular surgery. Moreover, this research provides essential information for developing analgesic management strategies to reduce opioid consumption in patients after cardiovascular surgery.

COMPARATIVE STUDY OF THE EFFICACY OF INTRAVENOUS PARACETAMOL AND DEXMEDETOMIDINE ON POST-OPERATIVE ANALGESIC AND HEMODYNAMICS FOR PATIENTS UNDERGONE UPPER LIMB SURGERY

Background: Comparative study of the efficacy of intravenous paracetamol and dexmedetomidine (DMED) on post-operative analgesic and hemodynamics for patients undergone upper limb surgery. Multimodal analgesia is recommended to reduce the stress response and prevent post-operative pain. Intravenous paracetamol and intravenous DMED are both effective components in respect of multimodal analgesia. Methods: The present prospective randomized, double-blind, controlled study was performed on eighty American Society of Anesthesiologists (ASA) Grade I and Grade II physical status patients aged 18–65 years, of both genders, were selected for elective upper limb orthopedic surgical procedure under general anesthesia. Group P (paracetamol) patients were given 1 g paracetamol intravenously 30 min before surgery. Group D patients, 100 μg DMED/20 mL normal saline, was administered intravenously 30 min before surgery. Post-operative hemodynamic variables, post-operative pain scores (Visual Analogue Scale score), need for rescue analgesics and post-operative complication were recorded and treated accordingly. Results: In both groups, females were in the majority with ASA grade I in the majority of the cases in both groups. Mean heart rate, mean arterial pressure, and Visual Analog Score for pain were comparable between the groups were compared at different time intervals (2, 4, 6, 12, 18, and 24 h) (p>0.05). Regarding complications Nausea, vomiting, itching and stomach irritation was in 17.5%, 15.0%, 7.5% and 20.0% for group D and for group P nausea and vomiting was in 15.0% and 10.0% and no other complication occurs in group D. Conclusion: Pre-emptive administration of paracetamol is a cost-effective and safe method of providing post-operative analgesia for patients undergoing upper limbs surgery.

Perioperative Management of Intradural Extramedullary Tumor Patients Undergoing Hemilaminectomy and Tumor Resection: A Case Report

Introduction: Intradural extramedullary (IDEM) tumor is a benign neoplasm originating in the spinal canal and accounts for approximately two-thirds of cases of primary spinal tumors. This case report aimed to further discuss the anesthetic management of IDEM tumor patients who underwent hemilaminectomy and tumor resection.
 Case presentation: A 25-year-old woman came with complaints of right hemiparesis, hypoesthesia as high as L3-L4, and unable to hold back urination since 4 months ago. Magnetic resonance imaging (MRI) examination showed a heterogeneous intradural extramedullary solid mass in the central spinal cord as high as Th 10-11 posterior, which narrowed the spinal canal. Dextra hemilaminectomy, tumor resection, and unilateral stabilization of dextra Th10-12 fusion were performed under general anesthesia and thoracolumbar interfascial plane blocks (TLIP). General anesthesia with non-kinking endotracheal intubation, controlled ventilation, and prone position is required for spinal thoracic surgery in adult patients. Propofol is a good induction agent, especially in maintaining the depth of anesthesia, because it can prevent side effects that arise from inhalation anesthetics.
 Conclusion: Bilateral modified TLIP block was performed in patients after induction of anesthesia with a median approach and ultrasonography (USG) guidance. TLIP block can reduce cumulative opioid consumption, acute pain intensity, the need for rescue analgesia, and the incidence of nausea and vomiting.

Effects of opioid-free total intravenous anesthesia on postoperative nausea and vomiting after treatments of lower extremity wounds: protocol for a randomized double-blind crossover trial

BackgroundPostoperative nausea and vomiting (PONV) are common after general anesthesia and surgery. This study aims to compare the effects of total intravenous opioid-free anesthesia (OFA) with conventional opioid-based anesthesia (OBA) on PONV in patients following treatments for wounds of lower extremities.MethodsThis randomized, double-blind, crossover trial will include a total of 72 adult patients scheduled for at least two separate surgical treatments of lower extremity wounds under general anesthesia. Patients will be randomized to 1 of 2 anesthesia sequences of OFA and OBA. Patients in sequence 1 will receive OFA in the first treatment procedure and OBA in the second procedure, while patients in sequence 2 will receive the two anesthesia regimens in the reverse order. The washout period is at least 5 days. OFA will be delivered with intravenous esketamine, lidocaine, dexmedetomidine, and propofol. OBA will be delivered with intravenous sufentanil and propofol. The primary endpoint is the incidence of PONV within the first 48 h postoperatively. The secondary endpoints are the severity of PONV, antiemetic rescue therapy, postoperative pain scores, the worst pain, need for rescue analgesia, postoperative sedation, hypotension, bradycardia, hypertension, tachycardia, hypoxemia, psychotomimetic or dissociative effects, time to extubation, and length of postanesthesia care unit stay. Patients who complete two surgical procedures with designated anesthesia regimens will be included in the final analyses.DiscussionThis crossover trial will determine whether total intravenous OFA reduces PONV in patients following treatments for lower extremity wounds. The results of this trial will also represent an important step to understand the benefits and possible risks of OFA in surgical patients.Trial registrationChinese Clinical Trial Registry (ChiCTR2200061511).

Effects of ultrasound-guided erector spinae plane block in radical prostatectomy surgery on pain and surgical stress response

BackgroundErector spina plane block, as a part of a multimodal approach in perioperative pain management, is effective in many surgical procedures on pain management. The aim of this prospective, randomized, controlled study was to investigate the effects of erector spinae plane block on pain, analgesic consumption, and surgical stress in radical prostatectomy operations.ResultsForty-six patients operated for elective open radical prostatectomy surgery were randomly allocated to Group B (n = 23) and Group K (n = 23). Ultrasound-guided erector spinae plane block was performed bilaterally on patients in Group B, while group K was the control group. Remifentanil and tramadol consumption, rescue analgesic need, pain scores, and nausea-vomiting scores were less in Group B. While there was no difference in glucose, cortisol, insulin, and C-reactive protein values at all times between groups, postoperative 24-h prolactin values were higher in Group B. Shapiro–Wilk test, Student t-test, and Mann–Whitney U-test were used for statistical analysis.ConclusionsUltrasound-guided erector spinae plane block is an effective analgesic method in radical retropubic prostatectomy surgeries providing a reduction in intraoperative and postoperative opioid consumption but has limited effect on the surgical stress response.Trial registrationClinicalTrials NCT05170373, Registered 11/03/2021 — retrospectively registered.

Efficacy of bilateral ultrasonography-guided transversus abdominis plane block after laparoscopic sleeve gastrectomy: Prospective, randomized, controlled study

Aim: Transversus Abdominis Plan (TAP) block is an interfascial plane block, commonly used as an analgesic technique in abdominal surgeries. The aim of this study is to investigate the postoperative analgesic efficacy of bilateral ultrasonography (US) guided TAP block in patients scheduled for laparoscopic sleeve gastrectomy.Method: In this randomized prospective study; 48 patients, 18-65 years, ASA I-II, morbidly obese (BMI>35), underwent laparoscopic sleeve gastrectomy were included. The patients randomized into two groups: TAP block Group (group TAP) and Control Group (group C). At the end of the operation, bilateral TAP block were performed to 24 patients in Group TAP with a total 40 ml of local solution. 20 ml of local solution was injected into the trocar incision lines of all patients. Patient-controlled analgesia was administered to all patients at a dose of 5 mg/ml tramadol. Tramadol consumption, visual analogue scores (VAS) and the need of rescue analgesia (paracetamol) of the patients at postoperative first 24th hours were recorded.Results: There is no statistical difference in terms of demographic data. Total tramadol consumption and VAS were significantly higher in the Group C (p<0.01). No complications were found in either group.Conclusions: US-guided TAP block provides effective analgesia in patients underwent laparoscopic sleeve gastrectomy surgery.

Comparison of Analgesic Effect of Intravenous Paracetamol with Intravenous Ketorolac in Patients Presenting With Renal Colic in the Emergency Department

Objective: To compare the effects of intravenous (IV) Paracetamol and intravenous (IV) Ketorolac in pain management of patients with renal colic presenting to the emergency department (ED).
 Study Design: Quasi-experimental study.
 Place and Duration of Study: Emergency Department, Combined Military Hospital, Rawalpindi Pakistan, from Jan to Jul 2021.
 Methodology: Eighty patients were included in the study who were selected and divided into two groups, one receiving Paracetamol 1 g intravenous (PC-Group) and the other receiving Ketorolac 30 mg IV (KET-Group). Their effect was compared using differences in visual analogue scale (VAS) before and after giving analgesia. Record of vital signs pre and post-drug administration, adverse effects and need for rescue analgesia was maintained (Nalbuphine). If further analgesia was required, 100 mg intravenous was used as the rescue drug.
 Results: Ketorolac (KET) Group had a mean age of 37.60±14.56 years, while the Paracetamol (PC) Group had a mean age of 43.2 ± 16.05 years. There was no statistically significant difference in the reduction of pain intensity after giving the drug in the respective study Groups (p=0.09). Adverse effects (p=0.17) and the need for rescue analgesia (p=0.34) were also comparable between the two Groups.
 Conclusion: The use of either intravenous-PC or intravenous-KET in patients with renal colic had similar analgesic effects with no significant difference in side effects and need for rescue analgesia.

Safety and Efficacy of Low-Dose Versus High-Dose Parenteral Ketorolac for Acute Pain Relief in Patients 65 Years and Older in the Emergency Department.

Background There is limited data surrounding acute pain management in elderly ED patients. Ketorolac is a potent non-steroidal anti-inflammatory drug (NSAID) with dose/duration-dependent side effects. There is evidence that an analgesic ceiling effect exists for parenteral ketorolac doses greater than 10 milligrams (mg); however, this has not been studied in patients 65 years and older. Methods This was a retrospective chart review of ED patients 65 years and older who received at least one dose of parenteral ketorolac. Patients were separated into two cohorts based on the ketorolac dose received: 15 mg IV or 30 mg intramuscular (IM) and 30 mg IV or 60 mg IM. The primary objective was to evaluate the analgesic efficacy of parenteral ketorolac doses measured as needing rescue analgesia from 30 minutes to 2 hours after ketorolac administration. Secondary objectives included changes in pain scores and the occurrence of adverse drug events commonly associated with ketorolac. Results Two-hundred and sixty patients received ketorolac doses of 15 mg IV or 30 mg IM, and 52 received 30 mg IV or 60 mg IM. The primary outcome occurred in seven of 52 patients who received ketorolac 30 mg IV or 60 mg IM and 17 of 260 patients who received ketorolac 15 mg IV or 30 mg IM (13.5% vs. 6.5%, p=0094; OR: 2.22, 95% CI: 0.87-5.67). The average change in pain scores were 2.9 (±3.1) and 2.8 (±2.9) for patients who received doses 30 mg IV or 60 mg IM compared to doses 15 mg IV or 30 mg IM, respectively (p=0.154). The occurrence of adverse events was low in both groups. Conclusion Parenteral ketorolac doses of 15 mg IV or 30 mg IM did not demonstrate a greater need for rescue analgesia compared to doses of 30 mg IV or 60 mg IM.

A comparative study of the efficacy of intravenous paracetamol and dexmedetomidine alone and in combination on perioperative hemodynamics and post-operative analgesia for patients undergoing laparoscopic cholecystectomy under general anesthesia

Background: With increase in incidence of gallbladder stone disease, the laparoscopic cholecystectomy is most preferred surgical technique. Laryngoscopy and peritoneal gas insufflation leads to hemodynamic stress response and pain during and after the procedure. Multimodal analgesia is recommended to reduce the stress response and prevent the post laparoscopic pain. Intravenous paracetamol and intravenous dexmedetomidine are both effective components in respect of multimodal analgesia. Aims and Objectives: The aim of this study was to compare and evaluate the effects of intravenous paracetamol and dexmedetomidine alone and in combination as part of multimodal analgesia on perioperative hemodynamics and post-operative analgesia. Materials and Methods: One hundred and five patients between the of age 18–60 years posted for laparoscopic cholecystectomy were randomly assigned to three groups (n=35). Before induction patients in Group D received dexmedetomidine 0.5 μg/kg/h and patients in Group P and Group P+D received 1 g paracetamol infusion over 15 min. Intraoperatively as continuous infusion patients in Group D and Group P+D received dexmedetomidine 0.2 μg/kg/h and Group P received 0.2 mL/kg NS until the removal of gallbladder. Perioperative hemodynamic variables, postoperatively, the need for rescue analgesia and any complications or side effects were recorded, compared, and analyzed. Results: Intraoperative hemodynamic variables were significantly higher in Group P compared to Group D and Group P+D (P<0.05). Prolonged rescue analgesia found in Group P+D (9.06±1.16 h) then Group D (5.52±1.22 h) and Group P (4.35±0.99 h), respectively, which was strongly significant among the groups (P<0.0001). Conclusion: Our study concluded that the combination of paracetamol and dexmedetomidine maintains the better hemodynamic stability and prolonged the duration of analgesia, with the benefit of high patient satisfaction. In addition, there was significantly less post-operative bradycardia and shivering.

The Efficacy of Erector Spinae Plane Block for Patients Undergoing Percutaneous Nephrolithotomy.

Percutaneous nephrolithotomy (PCNL) is accompanied by somatic and visceral pain intraoperatively and postoperatively. However, pain management strategies lack a decisive consensus. Erector spinae plane block (ESPB) is a novel paraspinal fascial block that can be used in PCNL patients, and we aimed to investigate whether ESPB will reduce intraoperative and postoperative opioid consumption and postoperative pain scores in PCNL patients. The study was randomized, controlled, and open-label. Two groups were formed as the control group (GCont) and block group (Gblock), and patients received total intravenous anaesthesia. GBlock received an ESPB catheter in addition in the prone position. Intraoperative parameters and infusion doses, postoperative rescue analgesic doses, and pain scores were recorded. The primary endpoint was intraoperative analgesic consumption, and the secondary endpoints were postoperative pain scores and analgesic consumption. Sixty-four patients were analyzed. Remifentanil consumption of GCont was found to be significantly higher (GBlock: 0.0865 ± 0.030 vs GCont: 0.1398 ± 0.034, μg kg-1 min-1, P < 0.001). The control group reported higher pain scores between the 30th min and 24th hours and needed more analgesics between the 1st and 6th hours postoperatively. GBlock received local anaesthetics via ESPB catheter before nephrostomy tube removal and fewer patients needed analgesics [5 patients (15.6%) vs. 28 patients (87.5%), P < 0.001]. GCont consumed more tramadol postoperatively (262.5 mg vs. 75 mg, P < 0.001). We found that ESPB reduced intraoperative opioid consumption. It also reduced the need for rescue analgesia and postoperative pain scores during nephrostomy tube removal. We concluded that the ESPB catheter may effectively be used in analgesia management during and after PCNL operations.

Comparison of regional anesthetic techniques for postoperative analgesia after adult cardiac surgery: bayesian network meta-analysis.

Patients usually suffer acute pain after cardiac surgery. Numerous regional anesthetic techniques have been used for those patients under general anesthesia. The most effective regional anesthetic technique was still unclear. Five databases were searched, including PubMed, MEDLINE, Embase, ClinicalTrials.gov, and Cochrane Library. The efficiency outcomes were pain scores, cumulative morphine consumption, and the need for rescue analgesia in this Bayesian analysis. Postoperative nausea, vomiting and pruritus were safety outcomes. Functional outcomes included the time to tracheal extubation, ICU stay, hospital stay, and mortality. This meta-analysis included 65 randomized controlled trials involving 5,013 patients. Eight regional anesthetic techniques were involved, including thoracic epidural analgesia (TEA), erector spinae plane block, and transversus thoracic muscle plane block. Compared to controls (who have not received regional anesthetic techniques), TEA reduced the pain scores at 6, 12, 24 and 48 h both at rest and cough, decreased the rate of need for rescue analgesia (OR = 0.10, 95% CI: 0.016-0.55), shortened the time to tracheal extubation (MD = -181.55, 95% CI: -243.05 to -121.33) and the duration of hospital stay (MD = -0.73, 95% CI: -1.22 to -0.24). Erector spinae plane block reduced the pain score 6 h at rest and the risk of pruritus, shortened the duration of ICU stay compared to controls. Transversus thoracic muscle plane block reduced the pain scores 6 and 12 h at rest compared to controls. The cumulative morphine consumption of each technique was similar at 24, 48 h. Other outcomes were also similar among these regional anesthetic techniques. TEA seems the most effective regional postoperative anesthesia for patients after cardiac surgery by reducing the pain scores and decreasing the rate of need for rescue analgesia. https://www.crd.york.ac.uk/prospero/, ID: CRD42021276645.

Efficacy of modified thoracoabdominal nerve block through perichondrial approach following laparoscopic inguinal hernia repair surgery: a randomized controlled trial

BackgroundModified thoracoabdominal nerve block through perichondrial approach is a novel fascial plane block and provides abdominal analgesia by blocking thoracoabdominal nerves. Our primary aim was to evaluate the efficacy of M-TAPA on quality of recovery and pain scores in patients who underwent laparoscopic inguinal hernia repair surgery (Trans Abdominal Pre-Peritoneal approach ‒ TAPP). MethodsPatients with American Society of Anesthesiologists (ASA) physical status I–II aged between 18 and 65 years scheduled for elective TAPP under general anesthesia were enrolled in the study. After intubation, the patients were randomized into two groups: M: M-TAPA group (n = 30) and the control group (n = 30). M-TAPA was performed with total 40 ml 0.25% bupivacaine in the M group. Surgical infiltration was performed in the control group. The primary outcome of the study was the global quality of recovery score, the secondary outcomes were pain scores, rescue analgesic demands, and adverse effects during the 24-h postoperative period. ResultsThe global quality of recovery scores at 24 h were significantly higher in the M group (p < 0.001). There was a reduction in the median static and dynamic NRS for the first postoperative 8 h in the M group compared to the control group (p < 0.001). The need for rescue analgesia was significantly lower in the M group compared to the control group (13 patients vs. 24 respectively, p < 0.001). The incidence of side effects was significantly higher in the control group (p < 0.001). ConclusionIn our study, M-TAPA increased patient recovery scores, and provided pain relief in patients who underwent TAPP. Register NumberNCT05199922.

Comparative Effectiveness of Ketorolac Dosing Strategies for Emergency Department Patients With Acute Pain

Ketorolac is a commonly used nonopioid parenteral analgesic for treating emergency department (ED) patients with acute pain. Our systematic review aims to summarize the available evidence by comparing the efficacy and safety of differing ketorolac dosing strategies for acute pain relief in the ED. The review was registered on PROSPERO (CRD42022310062). We searched MEDLINE, PubMed, EMBASE, and unpublished sources from inception through December 9, 2022. We included randomized control trials of patients presenting with acute pain to the ED, comparing ketorolac doses less than 30 mg (low dose) to ketorolac doses more than or equal to 30 mg (high dose) for the outcomes of pain scores after treatment need for rescue analgesia, and incidence of adverse events. We excluded patients in non-ED settings, including postoperative settings. We extracted data independently and in duplicate and pooled them using a random-effects model. We assessed the risk of bias using the Cochrane Risk of Bias 2 tool and the overall certainty of the evidence for each outcome using the Grading Recommendations Assessment, Development, and Evaluation approach. This review included 5 randomized controlled trials (n=627 patients). Low-dose parenteral ketorolac (15 to 20 mg), as compared to high-dose ketorolac (≥30 mg), probably has no effect on pain scores (mean difference 0.05 mm lower on 100 mm visual analog scale, 95% confidence interval [CI] -4.91 mm to+5.01 mm; moderate certainty). Further, low-dose ketorolac at 10 mg may have no effect on pain scores compared to high-dose ketorolac (mean difference 1.58 mm lower on 100 mm visual analog scale, 95% CI -8.86 mm to+5.71 mm; low certainty). Low-dose ketorolac may increase the need for rescue analgesia (risk ratio 1.27, 95% CI 0.86 to 1.87; low certainty) and may have no difference on rates of adverse events (risk ratio 0.84, 95% CI 0.54 to 1.33; low certainty). In adult ED patients with acute pain, parenteral ketorolac given at doses of 10 mg to 20 mg is probably as effective in relieving pain as doses of 30 mg or higher. Low-dose ketorolac may have no effect on adverse events, but these patients may require more rescue analgesia. This evidence is limited by imprecision and is not generalizable to children or those at higher risk of adverse events.

Comparison of intravenous paracetamol (acetaminophen) to intravenously or intramuscularly administered non-steroidal anti-inflammatory drugs (NSAIDs) or opioids for patients presenting with moderate to severe acute pain conditions to the ED: systematic review and meta-analysis

ObjectiveParacetamol, non-steroidal anti-inflammatory drugs (NSAIDs) and opiates/opioids, administered parenterally via intravenous or intramuscular route, are widely used to provide analgesia for patients with moderate to severe pain. This systematic review...

Interscalene block applied by an experienced anesthesiologist has a good anesthetic effect, a long duration of action, and less postoperative pain after arthroscopic shoulder procedures independent of surgery type and operation duration.

This study aims to evaluate the severity of postoperative pain and the time to the onset of pain after arthroscopic surgical treatment of rotator cuff tear or instability under interscalene block. Between October 2015 and June 2016, a total of 172 patients (82 males, 90 females; mean age: 47.9±16.9 years; range, 15 to 83 years) who underwent shoulder arthroscopy under interscalene block by a single surgeon were retrospectively analyzed. The relationship between the postoperative 24-h Visual Analog Scale (VAS), the time to the onset of pain with the type of surgical procedure (rotator cuff repair, n=101 or instability surgery, n=71), and the duration of surgery (<30 min n=92; ≥30 min n=80) was examined. No significant relationship was found between the type of surgical procedure, VAS scores, and the onset of pain after the block (p=0.577 and p=0.780, respectively). No significant relationship was found between the operation duration, and VAS, and the onset of pain after the block (p=0.570 and p=0.408, respectively). The mean duration until the start of postoperative pain was 734±313 (range, 60 to 1,440) min. There was no statistically significant difference in the need for rescue analgesics at the postoperative 24th h and the duration of surgery between the two groups (p=0.393 and p=0.675, respectively). Our study results show no significant difference in the time for the onset of postoperative pain and the VAS scores according to the characteristics of the surgical procedure, operation duration, or age and sex of the patient. Shoulder arthroscopy performed by experienced surgeons under interscalene block eliminates the need for analgesics within the first 12 h postoperatively.

Efficacy of Low-dose Ketamine for Control of Acute Pain in the Emergency Setting: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Ketamine can be particularly helpful in situations where the clinician is not able to administer opioids and require an alternate analgesic, such as for patients who are already on high-dose opioids, have a history of addiction, or for opioid-naïve children and adults. In this review, our goal was to obtain a comprehensive estimate of the efficacy and safety of low-dose ketamine (dose less than 0.5 milligrams per kilogram or equivalent) compared to opiates for the control of acute pain in the emergency setting. We conducted systematic searches in PubMed Central, EMBASE, MEDLINE, the Cochrane Library, ScienceDirect, and Google Scholar from inception until November 2021. We used the Cochrane risk-of-bias tool to assess the quality of included studies. We carried out a meta-analysis with a random-effects model and reported pooled standardized mean difference (SMD) and risk ratio (RR) with 95% confidence intervals depending on the type of the outcome. We analyzed a total of 15 studies with 1,613 participants. Half of them had high risk of bias and were conducted in the United States of America. The pooled SMD for pain score was -0.12 (95% CI -0.50-0.25; I2=68.8%) within 15 minutes, -0.45 (95% CI -0.84--0.07; I2=83.3%) within 30 minutes, -0.05 (95% CI -0.41-0.31; I2=86.9%) within 45 minutes, -0.07 (95% CI -0.41-0.26; I2=82%) within 60 minutes, and after 60 minutes the pooled SMD was 0.17 (95% CI -0.07-0.42; I2=64.8%). The pooled RR for need of rescue analgesics was 1.35 (95% CI 0.73-2.50; I2=82.2%). The pooled RRs were as follows: 1.18 (95% CI 0.76-1.84; I2=28.3%) for gastrointestinal side effects; 1.41 (95% CI 0.96-2.06; I2=29.7%) for neurological side effects; 2.83 (95% CI 0.98-8.18; I2=47%) for psychological side effects; and 0.58 (95% CI 0.23-1.48; I2=36.1%) for cardiopulmonary side effects. Low-dose ketamine might have higher or equivalent efficacy and safety when compared to opioids for managing acute pain among patients presenting to the emergency setting. However, further studies are required to establish conclusive evidence, owing to the heterogeneity and poor quality of existing studies.

Single-bolus dexmedetomidine in prevention of emergence delirium in pediatric ophthalmic surgeries: A randomized controlled trial.

Emergency delirium (ED), a common postoperative neurologic complication, causes behavioral disturbances leading to self-traumas and also has long-term adverse effects in children. Our aim was to investigate the efficacy of a single-bolus dose of dexmedetomidine in reducing the incidence of ED. Additionally, pain relief, number of patients who needed rescue analgesia, hemodynamic parameters, and adverse events were assessed. One hundred and one patients were randomly allocated into two groups: 50 patients received 15 mL of dexmedetomidine 0.4 μg/kg (group D) and 51 patients received volume-matched normal saline (group C). Hemodynamic parameters such as heart rate (HR), systolic blood pressure (SBP), and diastolic blood pressure (DBP) were monitored regularly throughout the procedure. ED was assessed with Pediatric Anesthesia Emergence Delirium Scale (PAEDS), and pain was measured using the modified Objective Pain Score (MOPS). The incidences of ED and pain were higher in group C than group D (P < 0.0001 and P < 0.0001, respectively). Group D showed significant decrease in MOPS and PAEDS values at 5, 10, 15, and 20 min (P < 0.05), HR at 5 min (P < 0.0243), and SBP at 15 min (P < 0.0127). There was no significant difference in DBP between the two groups at any time point. The mean blood pressure (MBP) at 10 min was significantly less in group D than group C (P < 0.001). Dexmedetomidine 0.4 μg/kg as a single bolus over 10 min immediately after intubation is effective for the prevention of ED and significantly reduces the need of rescue analgesia without compromising the hemodynamic parameters in children undergoing ophthalmic surgery.

A systematic review of sufentanil for the management of adults with acute pain in the emergency department and pre-hospital setting

BackgroundPain is commonly encountered in the Emergency Department (ED) and pre-hospital setting and often requires opioid analgesia. We sought to synthesize the available evidence on the effectiveness of sufentanil for acute pain relief for adult patients in the pre-hospital or ED setting. MethodsThis systematic review was conducted in accordance with PRISMA guidelines. Medline, Embase, Cochrane CENTRAL, and CINAHL were searched from inception to February 1, 2022. The grey literature was also searched. We included randomized controlled trials of adult patients with acute pain who were treated with sufentanil. Two reviewers independently completed screening, full text review, and data extraction. Primary outcome was reduction in pain. Secondary outcomes included adverse events, need for rescue analgesia, and patient and provider satisfaction. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. A meta-analysis was not performed due to heterogeneity. ResultsOf 1120 unique citations, four studies (3 ED and 1 pre-hospital) met full inclusion criteria (n = 467 participants). The overall quality of the included studies was high. Intranasal (IN) sufentanil was superior to placebo for pain relief at 30 min (difference 20.8%, 95% CI 4.0–36.2%, p = 0.01). Both IN (two studies) and IV sufentanil (one study) were comparable to IV morphine. Mild adverse events were common and there was a higher propensity for minor sedation in patients receiving sufentanil. There were no serious adverse events requiring advanced interventions. ConclusionSufentanil was comparable to IV morphine and was superior to placebo for rapid relief of acute pain in the ED setting. The safety profile of sufentanil is similar to IV morphine in this setting, with minimal concern for serious adverse events. The intranasal formulation may provide an alternative, rapid, non-parenteral route that could benefit our unique emergency department and pre-hospital patient population. Due to the overall small sample size of this review, larger studies are required to confirm safety.

Efficacy of erector spinae nerve block for pain control after lumbar spinal surgeries: a systematic review and meta-analysis.

The review aimed to examine the evidence on the efficacy of erector spinae nerve block (ESPB) for pain control after lumbar spinal surgeries. PubMed, CENTRAL, Embase, and Web of Science were examined for published randomized controlled trials (RCTs) assessing ESPB with control for lumbar spinal surgery patients. The primary review outcome was 24-hour total opioid consumption in morphine equivalents. The secondary review outcomes were pain at rest at 4-6 hours, 8-12 hours, 24 hours and 48 hours, first rescue analgesic timing, needing rescue analgesics number, and postoperative nausea and vomiting (PONV). 16 trials were eligible. Total opioid consumption was significantly lower with ESPB as compared to controls (MD: -12.68 95% CI: -18.09, -7.28 I2=99% p<0.00001). Pain scores at 4-6 hours (MD: -1.37 95% CI: -1.98, -0.76 I2=95% p<0.0001), 8-12 hours (MD: -1.18 95% CI:-1.84, -0.52 I2=98% p=0.0004), 24 hours (MD: -0.53 95% CI:-1.03, -0.04 I2=96% p=0.04) and 48 hours (MD: -0.36 95% CI:-0.84, 0.13 I2=88% p=0.15) were significantly lower in the ESPB group. The meta-analysis found that the ESPB group required a significantly longer time for the first analgesic request (MD: 5.26 95% CI: 2.53, 7.99 I2=100% p=0.002), had lower demand for rescue analgesics (OR: 0.12 95% CI: 0.07, 0.21 I2=2% p<0.00001) and fewer incidence of PONV (OR: 0.27 95% CI: 0.15, 0.49 I2=51% p<0.0001). ESPB can be highly efficacious for postoperative analgesia in lumbar surgery patients. The block has the capability of reducing opioid consumption in the first 24 hours and pain scores up to 48 hours along with a significant reduction in the need for rescue analgesics and PONV.