Analgesia For Pain Research Articles

ThP6.12 - Pain relief prescribing in Surgical Emergency Unit triage: are prescribers helping to provide patients with humane care via prompt analgesia prescriptions, and can simple educational interventions improve timeliness?

Abstract Aims The RCEM target for receipt of analgesia for moderate-severe pain is within 15 minutes of arrival in ED. This study aimed to establish if a surgical emergency triage unit was achieving a more generous target of analgesia prescription within 60 minutes of clerking, and whether this could be improved with educational interventions. Methods Records of patients presenting to triage were reviewed. Patients were excluded if they did not report pain of any cause, were under 18 years old, or were prescribed adequate analgesia by the referring department. The integrated EPR system enabled straightforward comparison of timestamps for arrival in the department, clerking by a registered prescriber, and first prescription. Data were considered for a full continuous week each time, in late August, and in mid-December 2023. Educational interventions were made between collection periods: a teaching session about analgesia in emergency surgery; a presentation of first round results at a departmental meeting; and ‘postcards’ attached to all workstations highlighting the EPR pathway. Results Of encounters in which analgesia was prescribed, there was an increase in the proportion of prescriptions made within 60 minutes of clerking, from 67% to 86%. This increase was observed across all prescriber grades, both rotational and non-rotational. Conclusions The precise quantifiable impact of the educational interventions is unclear as the study period spans a changeover for FY1s, but the increase in timely prescription at all grades indicates some effect. This is reassuring from a perspective of considering human patient care.

Management of acute-onset pancreatitis in dogs: a Narrative Review.

Acute-onset pancreatitis (AP) is common in dogs and presents diagnostic as well as management challenges. Until recently, the management of AP in dogs was based mainly on supportive and symptomatic care. Identification and management of a possible cause of the disease is important, but the majority of cases are considered to be idiopathic. Fluid therapy that is tailored to the patient's needs is crucial to provide adequate hydration while preventing overhydration. Antiemetics are required to control vomiting and fluid loss and aid in early nutritional support. Recognition and management of complications is also crucial. Furthermore, analgesics for abdominal pain are very important. More recently, pharmaceutical modification of the inflammatory cascade has gained interest and the first specific therapeutic agent for the treatment of AP, fuzapladib sodium, has been shown to have a reasonable expectation of effectiveness in a pilot study. This drug has been licensed for the treatment of clinical signs of AP in dogs in Japan and also has achieved FDA conditional approval in the US. Antibiotics should not be used indiscriminately but are indicated for patients with aspiration pneumonia, gastrointestinal bacterial translocation, or evidence of another bacterial infection. Proton pump inhibitors and plasma are not routinely prescribed in pancreatitis unless specifically indicated. Nonsteroidal anti-inflammatory drugs should be avoided. Corticosteroid therapy, once thought to be contraindicated, may have some beneficial effects, as shown in a single retrospective study. However, further studies are required before their routine use can be recommended. Finally, a surgical approach is rarely indicated.

Exploring Analgesic Use Patterns Among Cancer Survivors With Chronic Chemotherapy-Induced Peripheral Neuropathy.

To explore cancer survivors' historical and current use of analgesics for chronic chemotherapy-induced peripheral neuropathy (CIPN). 142 post-treatment cancer survivors who received neurotoxic chemotherapy and were experiencing moderate to severe CIPN. Participants completed the Treatment-Induced Neuropathy Assessment Scale at baseline and reported all analgesics used to manage CIPN. Frequency of historical or current prescription analgesic use for chronic CIPN was described and stratified by CIPN pain severity. At baseline, 31% of participants reported historical use of analgesics for CIPN and 46% of participants were currently using analgesics for CIPN. Gabapentin was the most frequently used analgesic, historically (20%) and currently (34%), and duloxetine was used less frequently (6% historical use, 10% current use). Many participants with severe pain (59%) reported using analgesics for CIPN. Duloxetine, the first-line treatment for chronic CIPN pain, was used less frequently than gabapentin, a common prescription analgesic for neuropathic pain. Further research is needed to determine strategies to promote the implementation of evidence-based CIPN treatments in clinical practice.

TO ASSESS THE ROLE OF NASAL TAPENTADOL AS PRE-EMPTIVE ANALGESIA, IN BREAST SURGERY PATIENTS

Patients undergoes moderate to severe postoperative pain after surgery, which is troublesome during the postoperative period. Inadequately treated acute post operative pain causes prolonged morbidity to patients. Pre-emptive analgesic minimises the pain in perioperative period by central neuro sensitization. We assessed the role of Nasal Tapentadol in breast surgery patients, as a pre-emptive analgesic, in the reduction of post-operative analgesic requirement. In a double blinded prospective randomized control study, sixty breast surgery patients, received nasal spray of tapentadol (Group A) or saline Spray (Group B), 30 minutes prior to general anaesthesia. Perioperative analgesic requirement, time taken for first analgesic requirement in post operative period, post operative pain and sedation scores, we compared the following parameters in the first 24h during the postoperative period in all patients: Analgesic requirement during perioperative period, time taken for first post operative analgesic dose, pain score and sedation score in postoperative period.Data Of all sixty patients were analysed. Patients in Tapentadol Group A had significantly lower requirement of analgesics and lower Visual analog scale (VAS) than Saline group in the post operative period. However, Ramsay sedation score was more in Tapentadol group, immediately after shifting the patient to the postanaesthetic care unit. Single Pre-emptive nasal spray of tapentadol (45mg) is an effective intervention to, reduce the surgical pain and lesser requirement of analgesics, in post operative period, without added side effects.

Abdominal Pain and Chronic Opiate Use in Patients with Gastroparesis

Introduction: Although opiate narcotics may worsen gastroparesis(GP), patients can take these for abdominal pain (AP) or other chronic pain syndromes. This study aims to evaluate medications patients with gastroparesis use for AP and compare patients who use opiate analgesics for AP to those using opiate analgesics for non-abdominal pain. Methods: Patients at a tertiary academic center gastroenterology clinic completed the Patient Assessment of Gastrointestinal Disorders–Symptom Severity Index (PAGI-SYM) and Quality of Life Short-Form 8 (QOL SF-8) surveys between 10/2021 and 03/2023. Patients recorded gastroparesis treatments, pain treatments and indication, and any hospitalizations/emergency department (ED) visits within 3 months of a clinic visit. Results: A total of 53 patients were enrolled: 72% reported having AP. Patients were using the following medications for AP: 25% heating pad, ice or hot showers, 20.8% acetaminophen, 14.6% hyoscyamine, 13% opiate use, 13% marijuana use, 10.4% dicyclomine, 8.3% Nonsteroidal anti-inflammatory drugs (NSAIDs), 4% benzodiazepine, and 2.1% gabapentin. The reported reasons for using opiates were 58% AP, 16.6% chronic back pain, 16.6% Reflex Sympathetic Dystrophy (RSD) and fibromyalgia, and 8.3% osteoarthritis. All opiate users reported daily scheduled use. AP severity scores (4.1 vs. 2.8; p = 0.041), morphine equivalent usage (77 ± 44 vs. 32 ± 28; p = 0.037), and the number of ER visits (1.0 vs. 0 over 3 months) were higher in patients using opiates for AP than those using opiates for non-abdominal pain. Conclusions: In this series, 72% of patients with gastroparesis had abdominal pain, and 13% of patients were taking opiates. Patients who used opiate analgesics for abdominal pain had a higher average abdominal pain severity score and used a higher amount of opiate analgesia than patients using opiates for musculoskeletal pain. Abdominal pain in patients with gastroparesis can be harder to control with opiate analgesia compared to non-abdominal pain, supporting the concept of avoiding chronic opiate usage for abdominal pain in gastroparesis.

Efficacy of adductor canal and popliteal plexus block combined with local anesthetic injection in the interspace between the popliteal artery and posterior capsule of the knee and local infiltrative analgesia for postoperative pain and functional outcome after total knee arthroplasty: A randomized controlled study

BackgroundAdductor canal block and periarticular infiltration analgesia (PIA) have been shown to relieve pain in total knee arthroplasty (TKA) effectively. However, their analgesic effectiveness has some limitations. Thus, we considered a novel blocking site that could achieve analgesia without affecting the muscle strength of the lower limbs. MethodsSeventy-two patients undergoing primary unilateral total knee arthroplasty were randomized into two groups. One group was treated with adductor canal and popliteal plexus (APB) combined with interspace between the popliteal artery and posterior capsule of the knee (iPACK) and local infiltration anesthesia (LIA) and the other was treated with PIA. The primary outcomes included postoperative pain, as assessed by the visual analog scale (VAS), and the consumption of oral tramadol. Secondary outcomes included functional recovery and daily ambulation distance. Tertiary outcomes included postoperative adverse effects. ResultsThe APB group had lower VAS scores after surgery at rest and during motion. Compared with the PIA group, the walking distance of the APB group on the second day was greater. The muscle strength of the APB group was lower than that of the PIA group at the early stage. Patients in the APB group also consumed less tramadol than those in the PIA group. There was no difference in the incidence of adverse events between the two groups. ConclusionsAPB combined with iPACK and LIA is a novel block for TKA, and it can reduce postoperative pain sooner after TKA without affecting postoperative functional recovery or increasing complications.

TMEM132C rs7296262 Single-Nucleotide Polymorphism Is Significantly Associated with Nausea Induced by Opioids Administered for Cancer Pain and Postoperative Pain.

Opioids are almost mandatorily used for analgesia for cancer pain and postoperative pain. Opioid analgesics commonly induce nausea as a side effect. However, the genetic factors involved are still mostly unknown. To clarify the genetic background of individual differences in the occurrence of nausea during opioid administration, the incidence of nausea was investigated in 331 patients (Higashi-Sapporo Hospital [HS] group) who received morphine chronically for cancer pain treatment and in 2021 patients (Cancer Institute Hospital [CIH] group) who underwent elective surgery under general anesthesia. We conducted a genome-wide association study of nausea in HS samples. Among the top 20 candidate single-nucleotide polymorphisms (SNPs), we focused on the TMEM132C rs7296262 SNP, which has been reportedly associated with psychiatric disorders. The rs7296262 SNP was significantly associated with nausea in both the HS and CIH groups (TT+TC vs. CC; HS group, p = 0.0001; CIH group, p = 0.0064). The distribution of nausea-prone genotypes for the rs7296262 SNP was reversed between HS and CIH groups. These results suggest that the TMEM132C rs7296262 SNP is significantly associated with nausea during opioid use, and the effect of the SNP genotype on nausea is reversed between chronic and acute phases of opioid use.

Postoperative pain trajectory and opioid requirements after laparoscopic bariatric surgery: a single-centre historical cohort study.

Concerns around delayed emergence and opioid-induced ventilatory impairment in bariatric surgery can lead to intraoperative reliance on short-acting opioids and avoidance of long-acting analgesics with potential sedative effects. Nevertheless, an overly-conservative intraoperative analgesic strategy may result in significant pain at emergence and higher opioid requirements in later phases of care. We sought to establish the pattern of intraoperative analgesic use in bariatric surgical patients as well as their postoperative pain trajectory and opioid requirements. We undertook a single-centre historical cohort study. We explored associations between intraoperative analgesic interventions and pain scores and opioid requirements in postanesthesia care units (PACUs), and associations between the quality of analgesia at emergence and subsequent pain and patient-centred recovery outcomes. We extracted perioperative data for 939 patients who underwent bariatric metabolic surgery between January 2018 and October 2019. Only 39% of patients received long-acting opioids intraoperatively and there was minimal use of nonopioid analgesic adjuncts. Nearly 80% of patients reported moderate-to-severe pain on PACU arrival; 97% of patients received intravenous opioids for rescue analgesia (mean dose, 31mg oral morphine equivalents). Lower pain scores at PACU admission and discharge were associated with subsequent lower inpatient pain scores, lower opioid requirements, shorter time to ambulation, and shorter length of hospital stay. In bariatric surgical patients, effective intraoperative analgesic strategies that improve early pain control may have an impact on recovery and pain experience. Judicious use of intraoperative opioids coupled with opioid-sparing multimodal analgesic techniques should be considered and balanced against concerns regarding opioid-related adverse effects in this patient population.

Advanced statistical approaches for predicting pain after pediatric thoracotomy: a cross-sectional study using zero-inflated and Poisson models

BackgroundThoracotomy is one of the surgical procedures most burdened by chronic post-operative pain. There is poor evidence regarding the possibility that even in pediatric patients, thoracotomy can be followed by post-operative pain. The primary objective of this analysis is to identify associations with home pain therapy, pain intensity, and possible protective factors acting on chronic pain in this population.MethodsA retrospective cross-sectional study was conducted at Ospedale Pediatrico Bambino Gesù IRCCS. The study included pediatric patients undergoing thoracotomy. For statistical analyses, a logistic model and a zero-inflated strategy were implemented to explore associations and predict factors related to home-based analgesic therapy and pain intensity.ResultsGender and age were identified as significant factors in the assignment of home therapy, with males having over seven times the risk compared to females (OR = 7.06, 95% CI = [2.11, 29.7]). At the last measurement, pain intensity was positively associated with age and the number of pain events during the week.ConclusionsThe study highlights significant factors influencing post-thoracotomy pain management in pediatric patients. These findings underscore the importance of tailored pain management strategies that consider gender and age to improve post-operative care and outcomes in pediatric thoracotomy patients.

Randomized placebo controlled trial of phytoterpenes in DMSO for the treatment of plantar fasciitis

Plantar fasciitis is the most common cause of heel pain in adults with an overall prevalence of 0.85% in the adult population of the US, affecting over 2 million adults annually. Most current treatment modalities are not supported by sufficient evidence to recommend one particular strategy over another. Topical application of analgesics for soft tissue pain is well established, however the plantar fascia presents challenges in this regard due to thick skin, fibrotic tissue, and an often thickened fat pad. Sixty-two patients with plantar fasciitis were randomized to a placebo controlled trial testing the efficacy of a topical solution of plant terpenes containing camphor, menthol, eugenol, eucalyptol, and vanillin. Skin permeation of the mixture was enhanced with 15% dimethylsulfoxide (DMSO), 1% limonene, and rosemary oil. One ml of solution was applied topically twice daily, and pain scores evaluated on Day 0, Day 1, Day 3, and Day 10. Using the validated foot function index 78.1% of patients reported an 85% or greater decrease in their total pain score by day 10 while placebo treatment was without effect (One Way ANOVA, P < 0.01). This study adapts the treatment modality of topical analgesia for soft tissue pain to a problematic area of the body and shows therapeutic promise.ClinicalTrials.gov Identifier: NCT05467631

Epidural methadone and morphine pharmacokinetics and clinical effects in healthy volunteers: A randomized, crossover-design trial.

Epidural opioids can provide effective analgesia for acute postoperative pain. Due to its unique physicochemical properties and long systemic elimination half-life, epidural methadone may provide lasting analgesia with minimal adverse effects; however, human studies are lacking. The aim of the study was to test the hypothesis that epidural methadone would exhibit greater segmental analgesia (analgesia at the dermatome of injection vs. distant dermatomes) than epidural morphine. In a prospective, randomized, double-blinded, crossover study, thirteen healthy volunteers received a 4-mg epidural bolus of methadone or morphine at L3-L4 and underwent repeated assessment of dermatomal heat pain tolerance and pressure pain threshold at lumbar (L3) and trigeminal (V2) dermatomes, pupil diameter, respiratory parameters and venous opioid concentration for 24 h. The primary outcome was selective (lumbar vs. trigeminal) segmental analgesia for heat pain, as a marker of a spinal analgesic mechanism. The degree of segmental analgesia to heat pain tolerance was not different between morphine and methadone (P =.09), although morphine (P =.0009) but not methadone (P =.81) produced significant analgesia to heat pain at the lumbar vs. trigeminal dermatome over 0-12 h. Morphine overall provided longer lasting analgesia to heat pain vs. methadone (24 vs. 2 h, respectively). Morphine elicited greater systemic effects, including miosis (P =.009) and opioid-related adverse effects (P =.002). These results suggest that, with equal epidural doses, both methadone and morphine produced analgesia and methadone did not produce greater segmental effects than morphine. Epidural methadone provided a more favourable adverse effect profile.

Mindfulness-Oriented Recovery Enhancement: Implementing an evidence-based intervention for chronic pain, opioid use, and opioid addiction in clinical settings.

The opioid crisis emerged in part due to the overprescribing of opioid analgesics for chronic pain. Although not the only source of the current epidemic of opioid use disorder (OUD), the prescription of opioids for chronic pain remains one vector for the development of opioid misuse and OUD. However, opioid tapering is not appropriate for all patients, and some patients may need to remain on opioid therapy for the long term. To reduce the risk of opioid-related harm among people with chronic pain and to treat incipient or entrenched addictive behaviours, new interventions are needed. This review discusses the clinical outcomes, biobehavioural mechanisms and implementation considerations for a novel, evidence-based intervention for chronic pain, opioid use and OUD called Mindfulness-Oriented Recovery Enhancement (MORE). MORE unites complementary aspects of mindfulness training, cognitive behavioural therapy and principles from positive psychology to simultaneously address addictive behaviour, emotion dysregulation and chronic pain by targeting brain reward and stress systems. MORE has been tested in 13 completed randomized clinical trials, including over 1300 patients, and has demonstrated efficacy against a range of active control conditions for reducing opioid dosing, opioid misuse, illicit drug use, depression, post-traumatic stress symptoms and chronic pain. Opportunities for implementing MORE include facilitating opioid tapering and promoting safe opioid use in primary care and specialty pain clinics, decreasing opioid misuse and enhancing medication-assisted treatment for OUD. Given evidence of MORE's efficacy, it is now time to consider disseminating this evidence-based treatment in the United States, the United Kingdom and worldwide.

Pain Management of Refractory Hidradenitis Suppurativa: Case Report

Background: Hidradenitis suppurativa (HS) is a chronic, relapsing, and painful inflammatory condition of the skin. Pain in HS is one of the most common symptoms and has a devastating effect on quality of life. Here, we present a unique case of a patient with HS and pain management guidelines used to treat her condition. Case Report: This is a 42-year-old woman with a history of HS, hypertension, depression who presented with one month of pain in her groin crease, vulva, and rectum. She was recently discharged from the hospital for HS superinfection. She was treated with intravenous and oral antibiotics. She previously tried treatment with acetaminophen, lidocaine 2% jelly, gabapentin 400 mg TID, oxycodone, dilaudid, adalimumab, infliximab, topical clindamycin, intralesional steroid injections, and doxycycline. The pain management specialist recommended continuing treatment with gabapentin 400 mg TID and titrate to 600 mg TID as tolerated, and to follow up with the dermatology team to restart infliximab. Discussion: This case demonstrates a complicated, refractory HS condition that necessitates first, second, and third line treatment modalities. Pain control in HS starts by having best control of the underlying disease. The United States and Canadian Hidradenitis Suppurativa Foundations clinical guidelines suggest acute pain management should include topical analgesics (ie, lidocaine), oral acetaminophen, and oral nonsteroidal anti-inflammatory drugs. Chronic pain management should focus on a multidisciplinary approach. Clinical guidelines recommend escalating oral analgesics for pain that doesn’t respond to first-line agents. Opiate use should follow the World Health Organization pain ladder of tramadol, codeine, hydrocodone, and morphine. Neuropathic pain can be treated with pregabalin or gabapentin, titrated as tolerated by patients. Chronic HS lesions can be treated with wide local scalpel, CO2, or electrosurgical excision, and recurrent nodules can be deroofed or excised. Superior hypogastric plexus block and/or ganglion impar block can be considered for refractory cases. Conclusion: HS is an extremely painful condition severely affecting quality of life. Adequate pain management is vital, and a stepwise approach is recommended.

Placebo treatment affects brain systems related to affective and cognitive processes, but not nociceptive pain

Drug treatments for pain often do not outperform placebo, and a better understanding of placebo mechanisms is needed to improve treatment development and clinical practice. In a large-scale fMRI study (N = 392) with pre-registered analyses, we tested whether placebo analgesic treatment modulates nociceptive processes, and whether its effects generalize from conditioned to unconditioned pain modalities. Placebo treatment caused robust analgesia in conditioned thermal pain that generalized to unconditioned mechanical pain. However, placebo did not decrease pain-related fMRI activity in brain measures linked to nociceptive pain, including the Neurologic Pain Signature (NPS) and spinothalamic pathway regions, with strong support for null effects in Bayes Factor analyses. In addition, surprisingly, placebo increased activity in some spinothalamic regions for unconditioned mechanical pain. In contrast, placebo reduced activity in a neuromarker associated with higher-level contributions to pain, the Stimulus Intensity Independent Pain Signature (SIIPS), and affected activity in brain regions related to motivation and value, in both pain modalities. Individual differences in behavioral analgesia were correlated with neural changes in both modalities. Our results indicate that cognitive and affective processes primarily drive placebo analgesia, and show the potential of neuromarkers for separating treatment influences on nociception from influences on evaluative processes.

Monoclonal antibodies as analgesia of chronic low back pain: a systematic review and meta-analysis of efficacy and safety

Introduction. Monoclonal antibodies (mAb) emerged as a possible option in addressing the partial response to current treatment modalities in chronic low back pain (CLBP). Objective: to evaluate the efficacy and safety of mAb for CLBP. Materials and Methods. Randomized controlled trials on adult patients with CLBP who received mAb-therapy compared to those who did not as a control group. The result was the changes in Low Back Pain Intensity (LBPI) Numeric Rating Score and Roland–Morris Disability Questionnaire (RMDQ) indicating improved pain, disability, and the risk of adverse events. Meta-analysis, risk of bias, and confidence in the evidence for each analysis were assessed. We aimed at reviewing current treatment methods for degenerative lumbosacral spinal stenosis with an emphasis on surgical treatment methods. Results. Six studies were included, with a total of 3851 participants. mAb significantly reduce LBPI and RMDQ score (weighted mean difference –1.48; 95% CI –2.63 to –0.33; p = 0.01). Tanezumab and fasinumab were significantly reduced both LBPI (weighted mean difference of –4.11; 95% CI –6.27 to –1.95; p = 0.0002 and weighted mean difference –0.24; 95% CI –0.47 to –0.02; p = 0.04 respectively) and RMDQ scores (weighted mean difference –3.72; 95% –5.48 to –1.97 and weighted mean difference –0.50; 95% –0.73 to –0.26 respectively, both p 0.0001). The mAb have significantly greater odds of any adverse events (OR 1.23; 95% 1.06 to 1.43; p = 0.007) but no greater odds regarding serious adverse events (OR 1.00; 95% 0.69 to 1.46; p = 0.98). Conclusion. Depending on the types of drugs used, mAb had a favorable outcome and were relatively safe in reducing LBPI and RMDQ scores.

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.

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 &amp;lt; 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.

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.

Agony of Choice: Caudal Block versus Ilioinguinal/Iliohypogastric Nerve Block in Unilateral Orchidopexy.

Objective: This prospective study aimed to compare the efficacy of caudal block (CB) and ilioinguinal/iliohypogastric nerve block (IINB) for providing additional analgesia during unilateral orchidopexy. Methods: Seventy-one boys aged <48 months, classified as ASA I/II, were assigned into CB (n = 37) and IINB (n = 34) groups. Outcome measures included intra- and postoperative analgesic requirements, pain scores, and administration duration. Additional intraoperative analgesia was administered for a 10% increase in heart rate, while postoperative pain was assessed using the Children's and Infants Postoperative Pain Scale (CHIPPS), with scores >4 prompting supplementary analgesia. Monitoring was extended for 24 h post-surgery. Results: CB significantly reduced the need for intraoperative (p < 0.001) and early postoperative (p = 0.008) analgesia compared to IINB. However, the CB group exhibited a slightly higher but non-significant analgesic requirement on the ward. No clinically relevant side effects were observed in either group. Conclusions: Both CB and IINB are effective and safe methods for providing regional analgesia during orchidopexy. CB demonstrates superior efficacy intraoperatively and in the early postoperative period, while IINB may offer advantages in the later recovery phase. However, additional analgesia is often required for orchidopexy, especially in outpatient settings.

Paravertebral vs. Epidural Analgesia for Liver Surgery (PEALS): Protocol for a randomized controlled pilot study

Background Perioperative thoracic epidural analgesia (TEA) is commonly used in hepatectomy patients since it is opioid-sparing. However, TEA has a high failure rate and is associated with potentially devastating complications (spinal haematoma) and the risk is increased with hepatectomy. Thus, some centres favour systemic opioid-based modalities which, in turn, are associated with inferior analgesia and well-known risks/side-effects. Hence, alternative analgesic methods are desirable. Paravertebral block (PVB) has been used in liver resection with advantages including haemodynamic stability, low failure rates, and low risk of spinal haematoma. The purpose of this pilot RCT is to compare continuous TEA (traditional standard of care is local anesthetic (LA) + opioids) with PVB (traditional standard of care is with LA without opioid) for patients undergoing hepatectomy. We hypothesise that pain outcomes will be comparable between groups, but PVB patients will require fewer perioperative vasopressors/blood products, have fewer opioid-related side effects and a shorter hospital length of stay. Methods With ethics approval, this non-inferiority, pilot RCT with a convenience sample of 50 hepatectomy patients will examine whether PVB imparts analgesia comparable to TEA but with fewer adverse effects. Primary outcomes are surrogates of analgesia for 72 h postoperatively (i.e., opioid consumption, time to first analgesic request and pain scores at rest and with coughing); Secondary outcomes are blood products/fluids administered; side effects/complications until 72 h postoperatively; length of hospital stay. The results will be used to plan a large multicentre trial comparing TEA vs. PVB in hepatectomy patients. This study has a high potential to positively impact the quality/safety of patient care. ClinicalTrials.gov registration NCT02909322 (09-21-2016); Available at URL: https://clinicaltrials.gov/ct2/show/NCT0290932