Opioid Consumption Research Articles

Comparative Study of Morphine, Fentanyl or Nalbuphine Patient Controlled Analgesia (PCA) for Mucositis Pain in Pediatric Patients Undergoing Cancer Therapy. A Prospective Randomized Clinical Trial

Abstract Background Cancer treatment may cause several side effects, including severe oral mucositis (SOM). Oral mucositis is an inflammation of the oral mucosa that causes severe pain and ulceration. Children and adolescents are more prone to develop chemotherapy-induced SOM. Opiates have been the cornerstone of pain management for moderate to severe oral mucositis. The effective use of opiates requires balancing the desired effects of pain relief with undesired adverse effects Aim of the Work We evaluated the efficacy and safety of Nalbuphine (agonist – antagonist) in comparison with the pure agonist opioids (Morphine and Fentanyl) when used for oral mucositis pain in pediatric patients undergoing cancer therapy. Primary outcomes measures were Pain intensity self- assessment by using VAS, Number of active and total pushes of PCA buttons, Total opioid consumptions for each patient, and Patient satisfaction at the end of the 7 days using Patient Satisfaction Score PSS were assessed using a linear scale where 0 = very satisfied; 10 = very dissatisfied. Secondary outcomes measures were Adverse events including Respiratory depression, Bradycardia, Hypotension, Over sedation, Nausea and vomiting, Pruritus, Urinary retention. Patients and Methods This was a Randomized Clinical Trial conducted on 90 Pediatric patients who were diagnosed with cancer, admitted to Children Cancer Hospital -Egypt (CCHE-57357) and underwent cancer therapy that was complicated with Mucositis grade 3 and 4 (severe oral mucositis) according to the WHO scale for oral mucositis. Patients were randomly allocated into 3 equal groups each included 30 patients using of: PCA Morphine (Group M), PCA Nalbuphine (Group N) and PCA Fentanyl (Group F). Using equipotent doses of the three medications. Results Highly significant decrease in VAS score (7th day) and total opioid consumption (7th day), in Nalbuphine and Morphine groups; compared to Fentanyl group (p < 0.01 respectively). Significant increase in patient satisfaction score PSS in Nalbuphine drug group; compared to other drug groups (p = 0.032). Highly significant decrease in serious side effects (especially respiratory depression and sedation problems), in Nalbuphine and Morphine groups; compared to Fentanyl group (p = 0.0004). Conclusion Nalbuphine proven to be adequately effective, not inferior to Morphine in terms of improving pain relief, decreasing opioid consumptions in pediatric PCA users. However patients reported less satisfaction with Nalbuphine than Fentanyl or Morphine. In terms of safety profile, Nalbuphine had less adverse effects in pediatric patients with oral mucositis related to cancer therapy in comparison to Fentanyl or morphine.

Comparison of Ultrasound Guided Quadratus Lamborum Plane Block versus Intraperitoneal and Port Sites Bupivacaine Infiltration in Post Operative Analgesia after Laparoscopic Cholecystectomy

Abstract Background Poorly controlled acute pain after abdominal surgery is associated with a variety of unwanted postoperative consequences, including patient suffering, distress, respiratory complications, delirium, myocardial ischemia, prolonged hospital stay and an increased likelihood of chronic pain. Aim of the Work The aim of this study is to assess the postoperative analgesic efficacy of quadratus lamborum plain block compared to intraperitoneal and periportal infiltration with bupivacaine after laparoscopic cholecystectomy regarding the pain relief, effect on hemodynamics, requirement of first supplemental doses of analgesia and total number of doses received. Patients and Methods The study was conducted on 70 randomly chosen patients aged 20 to 60 years, American Society of Anesthesiologists (ASA) class I or II scheduled for elective laparoscopic cholecystectomy in Ain Shams University Hospitals after approval of the medical ethical committee. They were allocated in two groups of 35 patients each: QL block Group, intraperitoneal and periportal infiltration Group: Results Patients receiving QL block had significantly lower pain scores at rest for 6 hrs and decrease total need of analgesic in first 24 h post operative compared with patients who received Intraperitoneal and port sites infiltration. Conclusion Quadratus Lumborum block was effective in reducing postoperative pain scores for 6 hours and lower total 24 hrs postoperative opioid and analgesic consumption after laparoscopic cholecystectomy under general anesthesia, compared to intraperitoneal and port sites infiltration. This technique can be a promising mode of postoperative analgesia where epidural catheter insertion is contraindicated.

A Comparative Study Between Ultrasound-Guided Ilioingunial/Iliohypogastric Nerve Block versus Transverse Abdominis Plane Block in Patients Undergoing Oblique Inguinal Hernia Repair

Abstract Background Poorly controlled acute pain after abdominal surgery is related to somatic pain signals derived from the abdominal wall and is associated with a variety of unwanted post-operative consequences, including patient suffering, distress, respiratory complications, delirium, myocardial ischemia and prolonged hospital stay. Objective Regional anesthesia by (Ultrasound guided (US) Transversus abdominis plane block (TAP) or Ultrasound guided ilioinguinal and iliohypogastric nerves (IIN+IHN) block may be used as components of multimodal anesthesia with a comparable effect. In the present study, Bupivacaine is used to compare between them following inguinal hernia repair. Patients and Methods The study was conducted on 60 randomly chosen patients aged above 18 years, American Society of Anesthesiologists (ASA) class I or II scheduled for elective unilateral open inguinal hernia repair under general anesthesia, in Ain Shams University Hospitals after approval of the medical ethical committee. They were allocated in two groups. TAP block Group: received general anesthesia and (0.2 mL/kg of 0.25% bupivacaine per side), by midaxillary approach, under ultrasound guidance, the probe was placed transversely between the iliac crest and costal margin. Ilioinguinal/ iliohypogastric nerves block group: received general anesthesia, with (0.2 mL/kg of 0.25% bupivacaine per side). The inferior portion of linear ultrasound transducer will be placed over the anterior superior iliac spine with the superior margin of the transducer pointed directly in an oblique plane toward the umbilicus. The superior margin of the ultrasound transducer was slowly rotated superiorly and inferiorly until the fascial plane between the internal oblique and transverse abdominis muscle is identified. Results The results of the study revealed that patients received IIN+IHN block had significantly lower pain scores at 8, 12, 16, 20, and 24 hrs after operation, delayed time for rescue analgesia and decreased total need of analgesic in the first 24hrs post-operative compared to patients who received TAP nerves block. Conclusion IIN+IHN block was effective in reducing postoperative pain scores for 4-6 hours, lowering total 24-h postoperative opioid and analgesic consumption and delaying the need for rescue analgesia after inguinal hernia repair under general anesthesia, compared to TAP nerves block. It will be more useful to study in high-risk hypertensive and cardiac patients and to correlate with plasma catecholamine levels, which reflect the stress response and it is necessary to evaluate postoperative pain on movement in farther studies.

Effect of Intra-Operative Erector Spinae Plane Block on Post-Operative Consumption of Opioids after Video-Assisted Thoracoscopic Surgeries (VATS)

Abstract Background Pain is an everyday challenge during all surgeries and it is a chief postoperative complication, so pain management is a corner stone in anesthetic practice. Although VATS is less painful than an open thoracotomy, patients may still feel severe pain and restricted mobility during the first few postoperative hours. Ultrasound guided nerve block is considered a recent technique for pain management. It provides better visualization of the nerves and reduces the risk for complications e.g. unintended injury to adjacent structures. Objective to assess the analgesic efficacy and safety of ultrasound guided ESPB done at lumbar transverse process level in patients undergoing VATS for postoperative analgesia. Patients and Methods The study was conducted in Ain Shams university Hospitals after approval of the ethics committee and written patients’ consent. It included a total of 30 adult patients aged 21-50 years, Scheduled for lumbar spine surgeries. Patients were randomly divided into two equal groups, 15 each, according to the inclusion and exclusion criteria. Group A (n = 15): Received fentanyl 1-2 mcg/kg during induction of anesthesia and maintained by additional boluses of fentanyl.5 mcg/kg, also received ketrolac 30mg and perfelgan 1gm before extubation in addition 40 ml bupivacaine 0.25% (20ml on each side) as a single level bilateral injection for ESPB. Group B (n = 15) (the controlled group): Received only fentanyl 1- 2 mcg/kg during induction of anesthesia and maintained by additional boluses of fentanyl.5 mcg/kg, also received ketrolac 30mg and perfelgan 1gm before extubation. Results The main finding in this study was that ultrasound guided ESPB at level of thoracic process provides a good analgesic effect in patients undergoing VATS also reduced the total amount of postoperative morphine consumption in comparison to controlled group, Prolonged the time to first request of analgesia (duration of analgesia), Provided early mobilization, Increase patient satisfaction in 1st 24 hour and Decrease incidence of nausea and vomiting due to decrease opioids intake. Conclusion Ultrasound-guided bilateral erector spinae plane block reduced postoperative morphine consumption, alleviated postoperative pain scores and improved patients’ satisfaction in the first 24 hours after VATS, without associated any adverse effects or complications like nausea and vomiting, nerve injury, respiratory depression and hematoma formation. The ESPB slightly decreased the rate of PONV. This might be because the use of ESP might have decreased the use of intraoperative opioids.

Bupivacaine 0.25% versus Bupivacaine 0.125% with Dexmedetomidine for Transversus Abdominis Plane Block for Post-operative Analgesia in Cesarean Section

Abstract Background Although beneficial in acute and chronic pain management, the use of local anaesthetics is limited by its duration of action and the dose dependent adverse effects on the cardiac and central nervous system. Adjuvants or additives are often used with local anaesthetics for its synergistic effect by prolonging the duration of sensory-motor block and limiting the cumulative dose requirement of local anaesthetics. The armamentarium of local anesthetic adjuvants have evolved over time from classical opioids to a wide array of drugs spanning several groups and varying mechanisms of action. Objectives The aim of this study is to compare two different concentration of Bupivacaine 0.25% versus 0.125% added to Dexmedetomidine as adjuvant in TAP block on quality of analgesia for postoperative pain for parturients undergoing elective CS as regard: VAS score for pain after TAB block, hemodynamics stability, first dose of rescue analgesia and the side effects. Results We found that Bupivacaine 0.125% with dexmedetomidine is recommended regarding their analgesic properties, and moreover, Bupivacaine 0.25% with dexmedetomidine was proved to prolong the analgesic effect of TAP block in elective CS even with the higher concentrations of local anesthetics is our concern. Conclusion TAP block with bupivacaine 0.125% with dexmetomidine is an effective combination used for postoperative pain relief after elective Cs with lower incidence of LAST, hemodynamic stability and lower opioids consumption.

Intrathecal Dexmedetomidine versus Intrathecal Dexamethasone as Adjuvants to Hyperbaric Bupivacaine to Prolong the Duration of Sensory Block in Patients Undergoing Lower Abdominal Surgeries

Abstract Background Dexmedetomidine can be added to local anesthetics in spinal anesthesia to speed up the block, reduce postoperative pain, increase block duration, and reduce analgesic use. Dexamethasone is used intravenously to lessen shivering because it reduces the body's inflammatory response and tissue temperature gradient. It can also be safely injected into the cerebrospinal fluid as an adjuvant to local anesthetics to improve the quality of regional anesthesia. Intrathecal dexamethasone added to Bupivacaine increased spinal anesthetic sensory block duration without affecting onset time or consequences. Aim Comparing the onset and duration of sensory block and Analgesia and onset and duration of motor block and hemodynamic stability when intrathecal 5 mcg Dexmedetomidine added to 15mg heavy bupivacaine 0.5% to that of 4mg dexamethasone when added to 15 mg heavy bupivacaine 0.5% in patients underwent lower abdominal surgeries under spinal anesthesia. Subject and Methods This study was conducted at Faculty of Medicine; Ain-Shams University Hospitals on 50 patients. Results VAS was significantly lower in group B compared to group A at 8hr and 12hr measurements. there is a significant difference between the groups regarding sensory block duration, motor block duration, onset of sensory block, onset of motor block, time to 2 segment regression, and time to request of 1st analgesia. postoperative opioid consumption was significantly lower in group B always compared to group A. Conclusion adverse events. The current study showed that both Dexmedetomidine and dexamethasone were safe and effective as intrathecal adjuvants in lower abdominal surgeries. Both drugs resulted in comparable hemodynamic stability and incidence of

Ultrasound Guided Bilateral Erector Spinae Plane Block vs Intravenous Patient-Controlled Analgesia for Pain after Total Laparoscopic Hysterectomy

Abstract Background Pain is an everyday challenge during all surgeries and it is a chief postoperative complication, so pain management is a corner stone in anesthetic practice. Total Laparoscopic Hysterectomy (TLH) is a minimally invasive procedure, it has certain advantages over an open abdominal hysterectomy, such as reduced pain, less incidences of wound infection, a rapid recovery, a shorter hospital stay and lower complication Aim of the Work The present study was designed to assess the analgesic efficacy and safety of ultrasound guided ESPB done at lower thoracic transverse process level in patients undergoing TLH for postoperative analgesia versus intravenous patient-controlled analgesia. Patients and Methods This study is as Prospective double blinded cohort study, it was performed on Patients undergoing elective Total laparoscopic hysterectomy (TLH) in the hospital of gynecology of Ain Shams university hospitals over a period of six months. Patients who fulfilled the inclusion criteria and agreed to participate in the study were randomly divided into two groups using computer-generated randomized list such that group A for ESPB and group B for PCA. Results The main finding in this study was that ultrasound guided ESPB at level of thoracic process provided a good analgesic effect in patients undergoing TLH also reduced the need for rescue analgesia and the total amount of postoperative opioid consumption in comparison to PCA group, Prolonged the time to first request of analgesia (duration of analgesia), Provided early mobilization, Increase patient satisfaction in 1st 24 hour and Decrease incidence of nausea and vomiting due to decrease opioids intake. Conclusion Ultrasound-guided erector spinae plane block was found statistically efficient in reducing postoperative opioid consumption, alleviating postoperative pain scores and improving patients’ satisfaction in the first 24 hours after TLH, without associated adverse effects or complications like nausea and vomiting, nerve injury, respiratory depression and hematoma formation.

Effect of Dexamethasone as a Local Anesthetic Adjuvant on Duration of Post Operative Analgesia for Ultrasound Guided Transabdominal Plane Block in Appendectomy – A Randomized, Double-Blind, Placebo-Controlled Trial

Abstract Background Poorly controlled acute pain after abdominal surgery is related to somatic pain signals derived from the abdominal wall and is associated with a variety of unwanted post- operative consequences, including patient suffering, distress, respiratory complications, delirium, myocardial ischemia, prolonged hospital stay, an increased likelihood of chronic pain, increased consumption of analgesics, delayed bowel function and increase the requirement for rescue analgesics. Appropriate pain treatment protocols to reduce postoperative morbidity, improve the results of the surgery and decrease hospital costs. Aim of the Work The aim of this study is to evaluate the effect of adding dexamethasone as a perineural adjuvant on the post operative duration of action of Transversus Abdominus Plane (TAP) block in patients undergoing appendectomy. Patients and Methods The study was conducted on 30 randomly chosen patients aged 17 to 55 years, American Society of Anesthesiologists (ASA) class I or II scheduled for appendectomy under general anesthesia in Ain Shams University Hospitals after approval of the medical ethical committee. They were allocated in two groups of 15 patients each: Results Dexamethasone as an adjuvant to LA has been shown to prolong the duration of pain-free period, less requirement for rescue opioids consumption, more patient satisfaction. A similar finding was observed in our study. Conclusion The addition of dexamethasone to bupivacaine in TAP block in appendectomy provides a prolonged duration of postoperative analgesia, with reduced analgesic requirements, a better quality of analgesia in terms of VAS score compared to bupivacaine alone group.

Erector Spinae Plane Block for Postoperative Analgesia after Video-Assisted Thoracoscopic Surgery (VATS)

Abstract Background Pain is an everyday challenge during all surgeries and it is a chief postoperative complication, so pain management is a corner stone in anesthetic practice. Ultrasound guided nerve block is considered a recent technique for pain management. It provides better visualization of the nerves and reduces the risk for complications. Aim of the Work The present study was designed to assess the analgesic efficacy of ultrasound guided Erector Spinae Plane Block done at the fifth thoracic transverse process level in patients undergoing VATS surgeries for postoperative analgesia. Patients and Methods This prospective randomized clinical study was conducted in Ain Shams University Hospitals. It included a total of 60 adult patients aged 21-60 years, Scheduled for VATS surgeries. Patients were randomly divided into two equal groups 30 patients each. The ESPB group (n = 30): received ESPB after induction of anaethesia, while the Control group (n = 30): received only fentanyl 1- 2 mcg/kg during induction of anesthesia and additional boluses of fentanyl.5 mcg/kg were given according to the patient’s vital data. Results The main finding in this study was that ultrasound guided ESPB provided a good analgesic effect in patients undergoing VATS surgery, it also reduced the need for rescue analgesia and the total amount of postoperative opioid consumption in comparison to controlled group, Prolonged the time to first request of analgesia, allowed early mobilization, Increase patient satisfaction in 1st 24 hour and Decrease incidence of nausea and vomiting. Conclusion Ultrasound-guided erector spinae plane block was found statistically significantly in reducing postoperative opioid consumption, alleviating postoperative pain scores and improving patients’ satisfaction in the first 24 hours after VATS surgeries, without associated adverse effects as postoperative nausea and vomiting, nerve injury, respiratory depression and hematoma formation.

Opioid-Free Anesthesia with a Mixture of Dexmedetomidine, Ketamine and Lidocaine in Severely Obese Patients Undergoing Laparoscopic Cholecystectomy

Abstract Background Opioids have historically been a first-line therapy for surgical pain control. They were considered optimum and the mainstay for balanced anesthesia but recently the concerns about their side effects were raised. The concept of opioid free anesthesia (OFA) was introduced to provide a safer alternative that would provide benefits to selective group of patients as well as enhance recovery after surgery. Methods The current study compares the use of a mixture of dexmedetomidine and ketamine infusion with traditional fentanyl infusion intra-operative on many variables both intra-operative and post- operative in laparoscopic surgeries. Number of patients who will need rescue narcotics after extubation and total nalbuphine consumption, hemodynamic events (bradycardia, hypotension and hypertension), time to extubation, time to reach Alderete score of 9, post-operative hypoxemia, vomiting, pain scores were recorded and compared with the traditional balanced anesthesia (TBA). Results Forty patients were enrolled in the study, 20 patients in each group. The 2 groups, TBA and OFA, were comparable in demographic data (age, sex, body mass index (BMI), lean body weight (LBW)) and duration of surgery. There was significant decrease in pain scores, number of patients who will need rescue narcotics after extubation and nalbuphine consumption in the OFA group that extended to 24 h post-operative. TBA group showed statistically significant less time needed for extubation (P-value 0.018) and reaching Aldrete score of 9 (P-value 0.02). Conclusions OFA has a better profile than TBA as regard to post-operative pain score and opioid consumption post-operative but they have relative increase in time to extubation and time to reach Aldrete score of 9, and they were equally safe regarding post operative hypoxia and hemodynamics.

Effects of ultrasound-guided serratus plane block combined with general anesthesia on postoperative early quality of recovery and analgesia in patients undergoing transapical transcatheter aortic valve implantation surgery: study protocol for a randomized controlled trial

BackgroundCompared to traditional thoracotomy, transapical transcatheter aortic valve implantation (TAVI) surgery offers reduced trauma and faster recovery, fostering the adoption of enhanced recovery after surgery (ERAS) protocols in cardiac surgery. Despite these advancements, postoperative pain management has received insufficient attention. The potential effects of multi-mode analgesia, including ultrasound-guided serratus anterior plane block (SAPB), on postoperative pain and early quality of recovery have not been widely studied, lacking comprehensive prospective evidence. Therefore, this study aims to investigate the impact of SAPB combined with general anesthesia on early recovery quality and analgesic efficacy in transapical TAVI patients.MethodsThis prospective, randomized controlled study will enroll 70 patients undergoing transapical TAVI, randomly allocated to either the SAPB group or the control group. The primary outcome, assessed using Quality of Recovery-40 (QOR-40) scale, focuses on the quality of recovery at 24 h and 48 h postoperatively. Secondary outcomes include the visual analog scale (VAS) pain scores at rest and during coughing at 6 h, 12 h, 24 h, and 48 h after surgery, frequency of patient-controlled analgesia (PCA) utilization at 24 h and 48 h, opioid consumption at 24 h and 48 h, time and frequency of rescue analgesia and severe pain at 24 h and 48 h, incidence of nausea and vomiting at 48 h after surgery, and dosage of antiemetic drugs.DiscussionThe purpose of our study is to evaluate the effects of ultrasound-guided SAPB combined with general anesthesia on postoperative early quality of recovery and analgesia in transapical TAVI patients. The results obtained may provide valuable insight for the implementation of multi-mode analgesia and enhanced ERAS in this specific patient population.Trial registrationChina Clinical Trial Register ChiCTR2300068584. Registered on 24 February 2023.

An Evaluation of the Changing Trends in Substance Use Behavior Among Patients in the Tertiary Care Setting After the Implementation of Liquor Prohibition in Bihar, India: A Cross-Sectional Study.

Background and objective Substance use disorders pose significant global public health challenges, with India being no exception. Bihar, one of India's most populous states, implemented alcohol prohibition in April 2016 to address the adverse effects of alcohol abuse. However, the impact of this policy on overall substance use behavior among patients in healthcare settings remains to be explored. This cross-sectional study aimed to evaluate the changing trends in substance use behavior among patients in the tertiary care setting following the prohibition of alcohol use in Bihar. Methods A total of 372 patients diagnosed with substance use disorders were recruited from tertiary care facilities in Bihar. Data on demographic characteristics, types of substances used, frequency and quantity of use, reasons for use, and awareness of prohibition laws were collected through structured interviews and reviews of medical records. Descriptive and inferential statistics were used for data analysis. Results The majority of the participants were male (n = 346, 93.01%), with a mean age of 38.5 years. While tobacco use remains stable, there are significant increases in opioid and cannabis consumption post-prohibition, highlighting unintended consequences (p-values - opioids: 0.008, cannabis: 0.021). Additionally, heightened daily and weekly substance use after prohibition is evident (p-values: daily: 0.008, weekly: 0.021), emphasizing the necessity for nuanced policy considerations. Reasons for substance use, including coping with stress and peer pressure, showed significant differences before and after the prohibition (p<0.05). Moreover, awareness of alcohol prohibition laws increased significantly after the implementation of the prohibition (p = 0.003). Conclusions Our findings suggest that while alcohol prohibition in Bihar did not significantly lead to any changes in terms of the types of substances used among patients in tertiary care settings, it did influence the frequency and quantity of tobacco and cannabis consumption. Increased awareness of prohibition laws underscores the importance of policy enforcement and public education initiatives in addressing substance use behavior.

Single-shot interscalene block with liposomal bupivacaine vs. non-liposomal bupivacaine in shoulder arthroplasty

Regional anesthesia is a valuable component of multimodal pain control in total shoulder arthroplasty (TSA), and multiple interscalene block anesthetic options exist, including nonliposomal interscalene bupivacaine (NLIB) and liposomal interscalene bupivacaine (LIB). The purpose of this study was to compare pain control and opioid consumption within 48 hours postoperation in those undergoing TSA with either LIB or NLIB. This was a retrospective cohort study at a single academic medical center including consecutive patients undergoing inpatient (>23-hour hospitalization) primary anatomic or reverse TSA from 2016 to 2020 who received either LIB or an NLIB for perioperative pain control. Perioperative patient outcomes were collected including pain levels and opioid usage, as well as 30- and 90-day emergency department (ED) visits or readmissions. The primary outcome was postoperative pain and opioid use. Overall, 489 patients were included in this study (316 LIB and 173 NLIB). Pain scores at 3, 6, 12, and 48 hours postoperatively were not statistically significantly different (P>.05 for all). However, the LIB group had improved pain scores at 24 and 36 hours postoperation (P<.05 all). There was no difference in the incidence of severe postoperative pain, defined as a 9 or 10 numeric rating scale-11 score, between the 2 anesthesia groups after adjusting for preoperative pain and baseline opioid use (odds ratio 1.25, 95% confidence interval 0.57-2.74; P=.57). Overall, 99 of 316 patients receiving LIB (31.3%) did not require any postoperative opioids compared with 38 of 173 receiving NLIB (22.0%); however, this difference was not statistically significant after adjusting for prior opioid use and preoperative pain (P=.33). No statistically significant differences in postoperative total morphine equivalents or mean daily morphine equivalents consumed between the groups were found during their hospital stays (P>.05 for both). Finally, no significant differences were found in 30- and 90-day ED visits or readmission rates (all P>.05). LIB and NLIB demonstrated differences in patient-reported pain scores at 24 and 36 hours postoperation, although these did not reach clinical significance. There were no statistically significant differences in opioid consumption during the hospital stay, including opioid use, total morphine equivalents, and daily mean morphine equivalents consumed during the hospital stay. Additionally, no differences were observed in 30- and 90-day ED visits or readmission rates.

Analgesia efficacy of erector spinae plane block in laparoscopic abdominal surgeries: a systemic review and meta-analysis.

Multimodal analgesia is now widely practised to minimise postoperative opioid consumption while optimising pain control. The aim of this meta-analysis was to assess the analgesic efficacy of erector spinae plane block (ESPB) in patients undergoing laparoscopic abdominal surgeries. This will be determined by perioperative opioid consumption, subjective pain scores, and incidences of postoperative nausea and vomiting. The authors systemically searched electronic databases for randomised controlled trials (RCTs) published up to February 2023 comparing ESPB with other adjuvant analgesic techniques in laparoscopic abdominal surgeries. Nine randomised controlled trials encompassing 666 subjects were included in our study. ESPB was shown to reduce postoperative opioid consumption [mean difference (MD) of -5.95mg (95% CI: -8.86 to -3.04; P <0.0001); I2 =89%], intraoperative opioid consumption MD of -102.4mcg (95% CI: -145.58 to -59.21; P <0.00001); I2 =39%, and incidence of nausea [RR 0.38 (95% CI: 0.25-0.60; P <0.0001); I2 =0%] and vomiting [RR 0.32 (95% CI: 0.17-0.63; P =0.0009); I2 =0%] in laparoscopic abdominal surgeries. Subgroup analysis on laparoscopic colorectal surgeries further showed reduction in postoperative pain scores MD of -0.68 (95% CI: -0.94 to -0.41); P <0.00001; I2 =0%]. This study concludes that ESPB is a valuable technique with proven efficacy to potentially promote faster postoperative recovery through optimising pain control while minimising opioid requirements.

Gabapentin and Rapidity of Recovery Among Patients Undergoing Minimally Invasive Ambulatory Uro-Oncologic Surgeries.

Gabapentin has been used in enhanced recovery after surgery (ERAS) pathways for pain control for patients undergoing ambulatory uro-oncologic surgery; however, it may cause undesirable side effects. We studied the causal association between gabapentin and rapidity of recovery and perioperative pain management after minimally invasive uro-oncologic surgery. We identified 2397 patients ≤ 65 years undergoing prostatectomies or nephrectomies between 2018 and 2022; 131 (5.5%) did not receive gabapentin. We tested the effect of gabapentin use on time of discharge and perioperative opioid consumption, respectively, using multivariable linear regression adjusting for potential confounders including age, gender, BMI, American Society of Anesthesiologists score, and surgery type. On adjusted analysis, we found no evidence of a difference in discharge time among those who did vs did not receive gabapentin (adjusted difference 0.07 hours shorter on gabapentin; 95% CI -0.17, 0.31; P = .6). There was no evidence of a difference in intraoperative opioid consumption by gabapentin receipt (adjusted difference -1.5 morphine milligram equivalents; 95% CI -4.2, 1.1; P = .3) or probability of being in the top quartile of postoperative opioid consumption within 24 hours (adjusted difference 4.2%; 95% CI -4.8%, 13%; P = .4). We saw no important differences in confounders by gabapentin receipt suggesting causal conclusions are justified. Our confidence intervals did not include clinically meaningful benefits from gabapentin, when used with an ERAS protocol, in terms of length of stay or perioperative opioid use. These results support the omission of gabapentin from ERAS protocols for minimally invasive uro-oncologic surgeries.

Intravenous Methadone versus Intrathecal Morphine as Part of an Enhanced Recovery After Cardiac Surgery Protocol on Postoperative Pain and Outcomes: A Retrospective Cohort Study

ObjectiveEvaluate the effect of intravenous (IV) methadone versus intrathecal morphine (ITM) within an Enhanced Recovery After Cardiac Surgery (ERACS) pathway on postoperative pain and outcomes (length of hospital stay, postoperative complications) after cardiac surgery. DesignRetrospective cohort study. SettingTwo tertiary academic medical institutions within the same health system. ParticipantsEligible 289 adult patients undergoing elective cardiac surgery with an enhanced recovery pathway from January 2020 through July 2021. InterventionsPatients were administered ITM (0.25mg) or IV methadone (0.1mg/kg) if ITM was contraindicated. All patients were enrolled in an ERACS pathway utilizing current Enhanced Recovery After Surgery society guidelines. Measurements and Main ResultsPrimary outcome measures included postoperative pain scores and opioid consumption measured as oral morphine equivalents (OMEs). We analyzed patient demographics, procedural factors, intraoperative medications, and outcomes. Adjusted linear mixed models were fit to analyze associations between intervention and pain outcomes. ITM was associated with decrease in pain scores on postoperative day 0 after adjusting for clinical variables (average marginal effect, 95% confidence interval; 0.49 (0.002, 0.977), p=0.049). No difference in opioid consumption could be demonstrated between groups after adjusting for postoperative day and other variables of interest. ConclusionsITM when compared to IV methadone was associated with decrease in pain scores without any difference in opioid consumption after elective cardiac surgery. Methadone can be considered as a safe and effective alternative to ITM for ERACS protocols. Future large prospective studies are needed to validate this finding and further improve analgesia and safety.

Peripheral Nerve Stimulation in Postoperative Analgesia: A Narrative Review.

Recent research has shown the effectiveness of peripheral nerve stimulators (PNS) in managing chronic pain conditions. Ongoing studies aim to explore its potential application in treating acute postoperative pain states. The purpose of this systematic review is to assess the role of PNS in providing relief for postoperative pain. Clinical studies investigating the use of peripheral nerve stimulators (PNS) for analgesia following various surgeries, such as total knee arthroplasty, anterior cruciate ligament repair, ankle arthroplasty, rotator cuff repair, hallux valgus correction, and extremity amputation, have shown promising results. Lead placement locations include the brachial plexus, sciatic, femoral, tibial, genicular, perineal, sural, radial, median, and ulnar nerves. These studies consistently report clinically significant reductions in pain scores, and some even indicate a decrease in opioid consumption following PNS for postoperative pain. PNS involves the subcutaneous placement of electrode leads to target peripheral nerve(s) followed by delivery of an electric current via an external pulse generator. While the precise mechanism is not fully understood, the theory posits that PNS modulates electrical stimulation, hindering the signaling of nociceptive pain. PNS presents itself as an alternative to opioid therapy, holding promise to address the opioid epidemic by offering a nonpharmacologic approach for both acute and chronic pain states.

Perioperative Short-Term Glucocorticoids Do Not Increase Incidence of Complications after Total Joint Arthroplasty in Patients with Rheumatoid Arthritis.

The safety and analgesic efficacy of perioperative glucocorticoids have been established for patients without rheumatoid arthritis. Therefore, our study aims to investigate whether similar benefits can be observed in patients with rheumatoid arthritis undergoing total joint arthroplasty. Specifically, we aim to explore the impact of perioperative glucocorticoid use on postoperative complications, opioid consumption, incidence of hypotension, hyperglycemia, 30-day mortality, and 90-day re-admission in this patient population. Approval for the study protocol was obtained from the Medical Research Ethics Committee at Sichuan University, aligning with the principles outlined in the Declaration of Helsinki. We retrospectively analyzed a consecutive series of patients with rheumatoid arthritis who underwent total joint arthroplasty at our medical center between November 2009 and April 2021 and who were not on chronic glucocorticoid therapy before surgery. Those who received glucocorticoids at any time during hospitalization were compared to those who did not in terms of acute complications within 90 days after surgery as well as postoperative rescue opioid consumption, hypotension, and hyperglycemia during hospitalization. The two groups were also compared in terms of overall duration of hospitalization, all-cause mortality within 30 days, and readmission for any reason within 90 days. Continuous data were assessed for significance using the independent-samples t test. Categorical data were assessed using the Pearson chi-squared test. Of the 849 patients included in the analysis, 598 administered perioperative glucocorticoids and 251 did not. Prior to surgery, the two groups did not differ significantly in any clinicodemographic variable that we examined. The incidence of acute postoperative complications (2.3% vs. 4.0%, p = 0.187) and acute postoperative infection (2.0% vs. 2.8%, p = 0.482) was comparable between those who received perioperative glucocorticoids and those who did not, but the former group exhibited a significantly lower incidence of rescue opioid use (17.9% vs. 44.6%, p < 0.001) as well as significantly lower total rescue opioid consumption (4.7 ± 2.1 mg vs. 8.9 ± 4.6 mg, p < 0.001). However, the two groups showed similar incidences of postoperative hypotension, hyperglycemia, 30-day mortality, and 90-day re-admission. Perioperative glucocorticoids may reduce the need for rescue opioids after total joint arthroplasty of rheumatoid arthritis patients, without increasing the incidence of acute complications, hypotension or hyperglycemia.

Association Between Single-Injection Regional Analgesia and Postoperative Pain in Cardiac Surgery Patients: A Single-Center Retrospective Cohort Study

Effective pain control after cardiac surgery may facilitate recovery. This study aimed to assess the use and association of ultrasound-guided single-injection chest wall blocks with liposomal bupivacaine on postoperative pain scores and short-term opioid requirements after cardiothoracic surgery at a single institution. Retrospective cohort study. Midwestern academic hospital. Adult patients who underwent cardiothoracic surgery between July 1, 2020, and June 30, 2022. Ultrasound-guided single-injection chest wall block with liposomal bupivacaine. Of the 1,038 patients included in this study, 301 (29%) received a perioperative nerve block for postoperative sternotomy pain, and 737 (71%) did not. Most of the single-shot blocks were bilateral parasternal intercostal plane blocks (n = 294 [98%]) performed after induction and before surgical incision (n = 280 [93%]). After adjusting for age, gender, American Society of Anesthesiologists status, select comorbidities, and surgical procedure type, mean postoperative pain scores were not significantly different between groups in the immediate postoperative period at all time points assessed (12 ± 2 hours, 24 ± 4 hours, 48 ± 8 hours, and 72 ± 12 hours). Similarly, there was no difference in mean opioid requirements (milligram morphine equivalents) at 72 hours between groups (68.6 [95% confidence interval, 56.3-83.4] vs 62.9 [95% confidence interval, 52.8-74.9], p = 0.195). In this retrospective study, the implementation of single-shot chest wall nerve blocks with liposomal bupivacaine was not associated with decreased postoperative pain scores or opioid consumption at 72 hours in select cardiac surgical patients at one institution.

Combination of dexamethasone and dexmedetomidine as adjuvants of transversus abdominis plane block for postoperative analgesia in gastric cancer patients: A double-blinded randomized controlled trial

Study objectiveWe conducted this double-blinded randomized controlled trial to examine whether the combination of dexamethasone and dexmedetomidine as adjuvants of transversus abdominis plane (TAP) block could improve analgesia efficacy and duration for gastric cancer patients. DesignRandomized controlled trial. SettingThe preoperative area, operating room, postanesthesia recovery room and bed ward. PatientsA total of 312 adult patients (104 per group) with gastric cancer were included. InterventionsPatients received bilateral subcostal TAP block with three different anesthetics (60 ml 0.25% ropivacaine added with 10 mg dexamethasone and 1 μg·kg-1 dexmedetomidine [A] or 10 mg dexamethasone [B] or 1 μg·kg-1 dexmedetomidine [C]). MeasurementsThe primary outcome was the incidence of moderate-to-severe pain 24 h on movement. Secondary outcomes included incidence of moderate-to-severe pain, pain score, opioids use, recovery quality and adverse events. Main resultsThe incidence of moderate-to-severe pain on movement 24 h postoperatively of group A was significantly lower than group B (45.19% vs 63.46%; RR 0.71; 95% CI, 0.55 to 0.92) and group C (45.19% vs 73.08%, RR 0.62; 95% CI, 0.49 to 0.79). The median moving pain scores decreased significantly at 24 h (3.00 [3.00,5.00] vs 4.00 [3.00,6.00] vs 4.00 [3.00,5.00]; P < 0.001). There were significant differences in the opioids consumption within the first 24 h (27.5 [17.0,37.2] vs 30.0 [20.0,42.0] vs 32.0 [25.0,44.0] mg; P = 0.01) and the duration to first rescue analgesia (65.5 ± 26.7 vs 45.9 ± 34.5 vs 49.2 ± 27.2 h; P = 0.04). ConclusionsThe combination with dexamethasone and dexmedetomidine as adjuvants for TAP block reduced the incidence of moderate-to-severe pain and pain score both on movement and at rest at 24 h with prolonged duration to first rescue analgesia after gastric cancer surgery.Trial registration number: ChiCTR2000037981.