Patient-controlled Analgesia Dose Research Articles

Effectiveness of a Teach-Back Education Program on Perioperative Pain in Patients With Lung Cancer: An Intervention Study Using Behavior Change Wheel

To assess the effect of a teach-back educational intervention using Behavior Change Wheel (BCW) framework on perioperative pain among patients with lung cancer. A prospective quasi-experimental study was conducted in 88 patients with lung cancer from a tertiary hospital in China. According to the order of admission, they were allocated to either control group or intervention group, with 44 patients in each group. Patients in the control group received routine nursing care, while patients in the intervention group were given a teach-back education program based on BCW framework. The visual analog scale (VAS) was adopted to evaluate patients' pain on the day of surgery (T0), 1 (T1), 2 (T2), and 3 (T3) days after surgery. We also recorded the use of patient-controlled analgesia (PCA), the length of hospital stay, and the degree of patients' satisfaction. Rest pain, pain when coughing, and pain during activity that patients in the intervention group experienced were significantly less severe than those in the control group on T0 and T1. The pain when coughing in the intervention group was also significantly milder on T2 and T3. In addition, the number of self-control time, use duration, and total dose of PCA were significantly lower in the intervention group. Moreover, patients' satisfaction of nursing service was significantly higher in the intervention group. A teach-back education program based on BCW framework was effective in pain management among the perioperative patients with lung cancer. This study demonstrates the application of teach-back method and the BCW in the development of patient education intervention to mitigate perioperative pain.

Single-shot liposomal bupivacaine in place of rectus sheath catheters to provide non-opiate analgesia after laparotomy: a quality improvement project to reduce the need for ongoing nursing input

Opioid-sparing pain management is an integral component of enhanced recovery after colonic and rectal surgery. In our hospital, rectus sheath catheters (RSCs) are routinely placed during emergency laparotomy for colorectal...

Genome-Wide Association Study Identifies Genetic Polymorphisms Associated with Estimated Minimum Effective Concentration of Fentanyl in Patients Undergoing Laparoscopic-Assisted Colectomy.

Sensitivity to opioids varies widely among individuals. To identify potential candidate single-nucleotide polymorphisms (SNPs) that may significantly contribute to individual differences in the minimum effective concentration (MEC) of an opioid, fentanyl, we conducted a three-stage genome-wide association study (GWAS) using whole-genome genotyping arrays in 350 patients who underwent laparoscopic-assisted colectomy. To estimate the MEC of fentanyl, plasma and effect-site concentrations of fentanyl over the 24 h postoperative period were estimated with a pharmacokinetic simulation model based on initial bolus doses and subsequent patient-controlled analgesia doses of fentanyl. Plasma and effect-site MECs of fentanyl were indicated by fentanyl concentrations, estimated immediately before each patient-controlled analgesia dose. The GWAS revealed that an intergenic SNP, rs966775, that mapped to 5p13 had significant associations with the plasma MEC averaged over the 6 h postoperative period and the effect-site MEC averaged over the 12 h postoperative period. The minor G allele of rs966775 was associated with increases in these MECs of fentanyl. The nearest protein-coding gene around this SNP was DRD1, encoding the dopamine D1 receptor. In the gene-based analysis, the association was significant for the SERP2 gene in the dominant model. Our findings provide valuable information for personalized pain treatment after laparoscopic-assisted colectomy.

Efficacy of intrathecal morphine administration in pediatric patients undergoing selective dorsal rhizotomy.

The purpose of this study was to evaluate the effectiveness of intrathecal morphine following selective dorsal rhizotomy in pediatric patients previously diagnosed with cerebral palsy. This was a retrospective, cohort analysis over the course of four years. The analysis consisted of a treatment group which received intrathecal morphine (5 mcg/kg) injection and a control group that did not receive the injection prior to dural closure. All patients underwent multilevel laminectomies for selective dorsal rhizotomy at Akron Children's Hospital. The effectiveness of the treatment was measured by total dose of hydromorphone administered on patient-controlled analgesia (PCA), number of days on oral narcotics, and cumulative dose of oral narcotic. Of the analyzed 15 pediatric patients, seven patients received intrathecal morphine injection while the other eight did not receive the treatment prior to dural closure. There was a difference of 1135 mcg in total PCA dose between the study group (3243 mcg) and the control group (4378 mcg). The total PCA dose based on weight was lower in the study group (163 mcg/kg) than in the control group (171 mcg/kg). Based on these findings, the administration of intrathecal morphine clinically reduces the opiate need in the first 96 hours post-operatively.

Clinical study on the effect of remifentanil patient-controlled intravenous labor analgesia compared to patient-controlled epidural labor analgesia.

This study aims to investigate the safety and efficacy of remifentanil for patient-controlled intravenous labor analgesia as an alternative to the patient-controlled epidural labor analgesia. METHODS: Out of 453 parturients who volunteered for labor analgesia and were selected as research objects, 407 completed the trial. They were divided into the research group (n = 148) and the control group (n = 259; patient-controlled epidural analgesia). In the research group, the first dose of remifentanil, the background dose and the patient-controlled analgesia (PCA) dose were 0.4 μg/kg, 0.04 μg/min and 0.4 μg/kg, respectively, with a lockout interval of 3 min. The control group was given epidural analgesia. The first dose and background dose were 6-8 mL, and PCA dose and the locking time of analgesia pump were 5 mL and 20 min, respectively. The following indexes of the two groups were observed and recorded: the analgesic and sedative effects on parturient, labor process, forceps delivery, cesarean section rate and adverse reactions, and maternal and neonatal conditions. 1. The onset time of analgesia in the research group was (0.97 ± 0.08) min, which was noticeably shorter than that in the control group ([15.74 ± 1.91] min), with a statistically significant difference (t = -93.979, p = 0.000). 2. There was no significant difference in the labor process, forceps delivery, cesarean section rate and neonatal condition between the two groups (p > 0.05). Remifentanil patient-controlled intravenous labor analgesia has the advantage of rapid onset of labor analgesia. Although its analgesic effect is not as accurate and stable as epidural patient-controlled labor analgesia, it shows a high level of maternal and family satisfaction.

Regional blocks for pain control at the end of life in pediatric oncology.

Pain management at the end of life is a fundamental aspect of care and can improve patients' quality of life. Interventional approaches may be underutilized for pediatric cancer patients. To describe a single institution's 10 years of experience with regional pain management at the end of life in pediatric oncology. A retrospective cohort study of 27 patients with pediatric cancer who died between April 2011 and December 2021 and received continuous nerve block (CNB) catheters or single-shot nerve blocks (SSBs) during their last three months of life. The type of blocks, analgesic efficacy, and palliative care involvement were evaluated. Twenty-two patients (81.5%) had solid tumor diagnoses, including carcinomas, sarcomas, and neuroblastoma. Most (59%) patients received CNB catheters, and 12 patients (44%) received SSBs for pain control. The mean pain score decreases for CNB catheters and SSBs after interventions were -2.5 and -2.8, respectively, on an 11-point scale. Decreases in opioid patient-controlled analgesia dosing requirements were noted in 56% of patients with CNB catheters; likewise, in 25% of patients with SSBs at 24 h and in 8% at 5 days after interventions. Nearly all patients had PC involvement and received care from pain specialists (96% and 93%, respectively). Twenty-three (85%) had physician orders for scope of treatment orders completed before death. Regional pain control interventions can be effective and safe for relieving regional pain and suffering in dying children and young adults. The collaboration between palliative care and pain management specialists at the end of life can help alleviate suffering and improve quality of life.

Ketamine use for management of vaso-occlusive pain in pediatric sickle cell disease.

Typical sickle cell disease (SCD) vaso-occlusive pain episode (VOE) management includes opioids, which are often inadequate and can be associated with significant side effects. Ketamine, a dissociative anesthetic, is a potentially effective adjunct to VOE management. This study aimed to characterize ketamine use for VOE management in pediatric SCD. This retrospective case series summarizes a single-center experience regarding the use of ketamine for inpatient management of pediatric VOE in 156 admissions from 2014 to 2020. Continuous low-dose ketamine infusion was most commonly prescribed to adolescents and young adults as an adjunct to opioids (median starting dose 2.0μg/kg/min; median maximum dose 3.0μg/kg/min). Ketamine was started a median of 13.7hours after admission. Median ketamine infusion duration was 3days. In most encounters, ketamine infusion was discontinued prior to opioid patient-controlled analgesia (PCA) discontinuation. The majority of encounters (79.3%) had a reduction in either PCA dose, continuous opioid infusion, or both while receiving ketamine. Low-dose ketamine infusion was associated with side effects noted in 21.8% (n=34) of encounters. The most common side effects included dizziness (5.6%), hallucinations (5.1%), dissociation (2.6%), and sedation (1.9%). There were no reports of ketamine withdrawal. Most patients who received ketamine went on to receive it again during a subsequent admission. Further study is needed to determine the optimal timing of ketamine initiation and dosing. The variability of ketamine administration highlights the need for standardized protocols for ketamine use in VOE management.

Effects of catheter orifice configuration (triple-hole versus end-hole) in continuous infraclavicular brachial plexus block on analgesia after upper limb surgery.

The configuration of a nerve block catheter may affect the local anesthetic spread in epidural analgesia and continuous peripheral nerve blocks. This prospective and randomized study aims to compare the multi-orifice nerve block catheter with an end-hole catheter in ultrasound-guided continuous infraclavicular brachial plexus block (BPB) in terms of providing postoperative analgesia for the orthopedic upper limb surgery below the shoulder. The primary outcome measure was mean pain scores. Secondary outcome measures were the consumption of rescue analgesic and the amount of local anesthetics delivered by a Patient-Controlled Analgesia (PCA) device. A total of 58 adult patients who underwent orthopedic upper limb surgery below the shoulder were randomly assigned into two groups: group end-hole catheter (EHC) (n=31) and group multi-orifice catheter (MOC) (n=27). All patients received a single-shot infraclavicular BPB using 100 mg lidocaine 2% and 75 mg bupivacaine 0.5% administrated through a Tuohy needle. Then, a multi-orifice (triple-hole) nerve catheter was placed in the group MOC and an end-hole (one-hole) catheter in the group EHC at the same location. Bupivacaine 0.125% was infused through the catheters via PCA (infusion rate: 2 mlh-1, automated regular bolus: 5 mlh-1, patient-controlled bolus: 3 ml, lock-out time: 1 hour, 4 hours limit: 40 ml). Pain intensity was evaluated using a visual analogue scale (VAS). Mean VAS scores were higher in group EHC than group MOC in the first postoperative day (p=0.001). Mean rescue analgesic consumption, the number of bolus demand on PCA, PCA bolus demand dose, and total PCA dose were higher in group EHC than group MOC during the first postoperative day (p<0.05). It is concluded that the use of MHC is more effective than EHC for continuous infraclavicular brachial plexus blocks in providing postoperative pain relief during the first 24 hours.

Postoperative Pain in Patients Undergoing Cancer Surgery and Intravenous Patient-Controlled Analgesia Use: The First and Second 24h Experiences.

Postoperative cancer pain imposes severe physical and psychological problems. We aimed to investigate the pain experiences of patients with cancer after surgery, analyze the impact of infusion volume by patient-controlled analgesia (PCA), and explore the variations between day1 and day2. Data were retrospectively extracted from a large health data platform. Descriptive statistics were presented for the demographic and clinical profiles of patients. Multiple logistic regression analyses were performed to evaluate associations between intensity of pain and PCA use after adjustment for risk factors. Among 11,383 patients with cancer, the incidence of pain (moderate to severe pain) was 93.3% (18.3%) at the first 24h after operation, while the respect values decreased to 91.1% and 9.5% at the second 24h. Further, female patients consistently experienced higher risk of pain over the whole 48h postoperatively. Surgical sites were related to pain risk, with the highest risk among the respiratory system (OR 2.077, 95%CI 1.392-3.100). High doses of continuous volume (OR 2.453, 95%CI 1.742-3.456) and total volume (OR 2.830, 95%CI 2.037-3.934) of infusions were related to 1-3-fold elevated pain risk. Additionally, the observed associations were mostly repeated and could be up to over 10 times when pain was evaluated with number of PCA pump compressions instead of Numerical Rating Scale (NRS). High risk of postoperative cancer pain, particularly among the high PCA dose group, could possibly indicate inadequate pain control, and presence of modifiable risk factors warrants more aggressive pain management strategies perioperatively.

Analysis on the concept and clinical practice of patient-controlled analgesia in the treatment of cancer pain by Chinese medical providers

Objective: To investigated the concept and clinical practice of patient-controlled analgesia (PCA) in the treatment of cancer pain. Methods: Doctors, nurses, pharmacists from the oncology department, pain department, or hospice department were investigated using an electronic questionnaire from December 1 to December 31, 2021. In addition to the basic information, there were 26 questions were collected, including the current situation of cancer pain treatment, the concept of medical staff on PCA treatment of cancer pain and the clinical practice of PCA. Results: Questionnaires from 2 872 medical staff were collected from 993 hospitals in 30 provincial administrative units. Only 34.8% (955/2 748) of medical staff considered that the satisfaction rate of cancer pain control was over 75%, and 27.9% (548/1 968) of medical staff convinced that the satisfaction rate of breakthrough pain control was less than 50%. 97.1% (2 439/2 513) of medical staff considered that PCA could be effectively used for cancer pain treatment. The proportion of medical staff in secondary and tertiary hospitals who thought that PCA was applicable to cancer pain that could not be effectively alleviated by standardized non-invasive drug administration was 64.6% (319/494) and 69.1% (1 262/1 826) respectively, which was higher than that in primary hospitals [57.0% (110/193)] (P=0.002). In different occupations, the proportion of nurses who convinced PCA treatment of cancer pain increased the risk of addiction and drug overdose was 62.8% (431/686) and 76.1% (522/686), respectively, which was higher than doctors [39.2% (670/1709) and 58.2% (995/1709), respectively] and pharmacists [49.2% (58/118) and 65.3% (77/118), respectively] (all P<0.001). There was no significant difference in type of pump, route of administration, mode of infusion, protocol for PCA administration and selection of common medication in PCA treatment of cancer pain among different hospitals (all P>0.05). The calculation of continuous infusion dose and rescue dose of PCA was not uniform among different hospitals. After initiation of PCA, 71.7% (1 226/1 709) of hospitals had insufficient analgesia and most of them needed to be adjusted for 1-3 times to achieve satisfactory analgesia. Conclusion: Medical staff have insufficient cognition of PCA treatment of cancer pain and there is a lack of unified guidance in clinical practice. Therefore, it is an urgent need to develop an expert consensus on PCA treatment of cancer pain.

Effect of Erector Spinae Plane Block on Postoperative Pain after Laparoscopic Colorectal Surgery: A Randomized Controlled Study.

The erector spinae plane (ESP) block can be used to reduce pain and opioid requirements after abdominal surgery. We evaluated the effect of the ESP block on postoperative pain score, analgesic use, and quality of recovery (QoR) score in patients undergoing laparoscopy. Fifty-nine patients undergoing elective laparoscopic colorectal surgery were randomly assigned to control (n = 30) or ESPB (n = 29) groups after anesthesia induction. In the ESPB group, an ultrasound-guided ESP block was performed immediately after induction using 20 mL of 0.5% ropivacaine bilaterally. The primary outcome was the postoperative pain score, which was evaluated using the 11-point numeric rating scale (NRS) (0 = no pain, 10 = worst imaginable pain), in the recovery room. NRS “at rest” and “on cough” and total dose of fentanyl rescue (in the recovery room) as well as NRS “at rest” and the cumulative administered fentanyl dose of patient-controlled analgesia (24 h post-surgery) were significantly lower in the ESPB group than in the control group. The postoperative QoR score did not differ between the groups. Bilateral ESP block after induction reduced pain scores and opioid requirements for 24 h postoperatively but did not improve the QoR in patients undergoing laparoscopic colorectal surgery.

Demand-only patient-controlled analgesia for treatment of acute vaso-occlusive pain in sickle cell disease.

Sickle cell disease (SCD) is a chronic illness that is associated with frequent admissions for vaso-occlusive episodes (VOE). Opioids are frequently utilized in pain management, but dosing is often provider dependent. Opioids cause both short-term and long-term side effects, so the minimal effective dose is desired. This study examined demand-only patient-controlled analgesia (PCA) in pediatric patients. A new clinical practice guideline (CPG) for a single institution was implemented, which eliminated basal infusion dosing for PCAs on hospital admission. The primary aim of this retrospective study was to evaluate length of stay (LOS) before and after implementation of a CPG of demand-only PCA and, in a selected subpopulation, addition of short-term methadone. Secondary aims included opioid utilization, acute chest syndrome (ACS), and hypoxia. Inclusion criteria included SCD, ≤21 years of age, uncomplicated VOE admission, and ≥ 3 and ≤ 8 hospital admissions for SCD pain control within one calendar year. LOS decreased postintervention (7.2 ± 5.1 vs 4.5 ± 3.8 days, P < 0.001). Mean total opioid utilization in morphine equivalents mg/kg markedly decreased between the cohorts (13.3 ± 33.8 vs 3.6 ± 3.0, P < 0.001). ACS (21.9% vs 2.8%, P = 0.004) and hypoxia (28% vs 6.9%, P< 0.001) decreased significantly as well. Bolus PCA dosing of opioids resulted in decreased LOS and reductions in opioid utilization, hypoxia, and ACS.

Understanding Sleep in Pediatric Patients with Sickle Cell Disease Admitted for Vaso-Occlusive Pain Crisis through Objective Data

▪Introduction: Sickle cell disease (SCD) is an inherited red cell disorder that leads to sickling of red blood cells, anemia and vaso-occlusion. The most common reason for hospitalization and morbidity in children is pain due to vaso-occlusive crisis (VOC). Importantly, poor sleep quality can lead to increased pain the subsequent day and nocturnal pain leads to reduced deep sleep, both which can then modify pain sensitivity. Studies using sleep diaries have shown this cyclical relationship between sleep and pain. Frequent occurrences of restless sleep are therefore believed to contribute to an increased severity and intensity of pain episodes.There is very little data, however, looking at objective data such as vital signs to define sleep in patients with SCD admitted for VOC. We aimed to make comparisons between sleep hours and daytime hours for pain scores, patient controlled analgesia (PCA) usage and vital sign data in effort to better define and understand sleep in SCD.Methods: We performed a retrospective chart review for patients with SCD between January 1, 2014 and January 31, 2017. We included all patients admitted to the pediatric service, admitted for >48 hours for simple VOC, and placed on a PCA during admission. Patients with complications of acute chest syndrome, stroke or surgery were excluded. The primary aim was to describe sleep using objective data during sleep hours for patients with SCD admitted with pain. In this study, sleep was simply defined by time (12am-6am). Objective data included: PCA usage and nursing documentation such as vitals. Secondary aim was to examine potential differences during sleep to other 6-hour intervals of time for objective data. Differences within each patient were analyzed using Wilcoxon signed-rank test, a non-parametric statistical hypothesis test used for repeated measurements on the same sample to compare their population means.Results: We analyzed 50 patients that met criteria (46% female and 78% with HbSS). The median age was 14 (range 2-19) and median days of admission was 6 (range 4-11). Average length of stay was 6.3 days.We found each patient analyzed had extremely different patterns of pain scores, vitals, and PCA usage patterns at day and night during hospitalization for VOC. Mean and median values at night as compared to daytime hours for vitals (HR, systolic blood pressure - SBP, and diastolic blood pressure - DBP), PCA usage, and pain scores did not differ across all patients. In contrast, we did find most individual patient data revealed an increasing HR and blood pressure following admission, which then decreased prior to discharge.Interestingly, within patient analysis found significant differences between night hours and day hours. The number of PCA doses attempted and delivered were both significantly lower in sleep hours (z=-2.7, p=0.007 and z=-3.2, p=0.002). Vital signs indicated that SBP, DBP, and respiratory rate were all also significantly lower during sleep hours (see Table 1). We did not find differences between sleep and daytime hours for pain, HR and temperature.Conclusion: As expected, we found a large amount of variation across all patients for PCA usage and objective measures. Using a simple time definition of sleep, we also found no differences between night hours and daytime hours across all patients. However, while there were no statistically significant differences in vitals across the 50 patients between day and night, we found that the pain levels during their hospitalization to be highly individualized in nature.We found significant differences (at significance level of 0.05) between night hours and daytime hours within each patient. These included PCA usage, SBP, DBP, oxygen saturation, and respiratory rate. Although no differences were found in pain and HR, we did notice interesting trends during hospitalizations, including a gradual increase and eventual decrease in HR and blood pressure for many of the patients. This further highlights the need for clinical decisions and treatments to be tailored to individual patients based on their vitals and medication usage. We are optimistic to find significant differences in objective measures during sleep hours and aim to expand our analysis to determine potential prediction of sleep to subsequent day outcomes (pain and discharge) and definition of ‘good sleep’ by objective measures (such as low HR) using individual patient models. [Display omitted] DisclosuresJonassaint:Sicklesoft: Other: Owner. Shah:Novartis: Other: Speaker; Alexion: Other: Speaker.

Comparison of intraoperative and post-operative effects of serratus anterior plane block performed with ultrasound and infiltration block in patients undergoing video-assisted thoracoscopic surgery.

We aimed to compare the intraoperative and post-operative analgesic activities of the preventive applied serratus anterior plane (SAP) block and infiltration block in patients undergoing video-assisted thoracoscopic surgery (VATS). The study was carried out in 60 patients aged between 18 and 80 who were eligible for elective VATS, with the American Society of Anesthesiologists classification I-II, following ethical committee approval and written informed consent form. Patients were divided into two groups as SAP (group serratus anterior plane block [SAPB]) and group infiltration block after routine monitoring and general anesthesia induction by recording demographic data after randomization. Hemodynamic data of all patients were recorded before, after induction and within intraoperative 30 min period. Patient controlled analgesia (PCA) prepared with morphine was applied to all patients postoperatively. Intraoperative hemodynamic data and opioid consumption of patients, resting time, and coughing visual analog scale, time to first PCA dose, post-operative opioid consumption, rescue analgesic requirement, mobilization times, opioid side effects, and patient and surgical team's satisfaction were evaluated. Intraoperative hemodynamic data and opioid consumption were similar between the two groups. Post-operative pain scores (0 and 30 min, 1, 2, 4, 8, and 12 h) were lower in the SAPB group (p<0.005) and time to use the first PCA (p=0.002) was longer in the SAPB group. Post-operative PCA and rescue analgesic requirement were lower in the SAPB group (p=0.002, p=0.00). It was found that the first mobilization time was shorter in the SAPB group (p=0.003), and opioid-related side effects were similar in both groups (p=0.067). Patient and surgical team satisfaction was high in the SAPB group (p=0.004, p=0.000). As a result, more effective post-operative analgesia was provided with preventively SAPB, compared to infiltration block in patients undergoing VATS.

Ultrasound-Guided Erector Spinae Plane Block for Lumbar Spinal Stenosis Surgery

Background: In this retrospective observational study, we evaluated patients who underwent elective lumbar stenosis surgery between February 1, 2019, and April 1, 2019. Patients who underwent surgery for lumbar spinal stenosis under general anesthesia alone were compared with those who underwent general anesthesia combined with erector spinae plane block. Aims: We aimed to retrospectively evaluate whether erector spinae plane block reduced opioid consumption following surgery for spinal stenosis. Study Design: A retrospective observational study. Methods: We collected data on the pain scores, time for the first requirement for patient-controlled analgesia with tramadol, the cumulative patient-controlled analgesia dose, requirement for rescue analgesia, time to first stand up postoperatively and the incidence of postoperative nausea and vomiting. Results: Sixty patients were included in the study. The numerical rating scale’s pain scores were significantly lower in the erector spinae plane group at 1, 2, 4, 6, 12 and 24 hours than in the general anesthesia group. The cumulative dose of patient-controlled analgesia with tramadol was higher in the general anesthesia group than in the ESP group [212.0 (6.6) mg, vs. 107.3 (36.9 mg), (p Conclusion: ESP block appear to be an effective method to relieve pain after lumbar surgery.

Effect of periarticular multimodal injection versus femoral nerve block on in-hospital rehabilitation after total knee arthroplasty in Chinese population: A prospective randomized control trial study

Introduction: Total knee arthroplasty has been adopted to be the most successful treatment for advanced knee osteoarthritis. The adoption of multimodal periarticular analgesic (MPI) has been shown to have satisfactory pain control after surgery. However, there is relatively lack of data investigating whether this mode of pain control is effective in enhancing rehabilitation. Method: This is a prospective randomized control trial from July 2017 to June 2018, including 82 patients, in which 43 of them had MPI injection and 39 of them had no MPI injection. Primary outcome measures included the number of days required to perform straight leg raise, length of hospital stay, and Insall knee score upon discharge. Secondary outcome measures included total dose of patient-controlled analgesia (PCA) consumption postoperatively and visual analog scale (VAS) at rest and on motion during postoperative days 1–4. Result: The MPI group performed significantly better than the femoral nerve block (FNB) group in terms of early functional outcome, namely the number of days required to perform straight leg raising and length of hospital stay. The total postoperative PCA consumption and VAS score on motion during postoperative day 1 were also significantly better for MPI group. There was no difference in Insall knee score upon discharge between these two groups. Conclusion: Compared to FNB, MPI depicts a faster inpatient rehabilitation, accounted by its quadriceps-sparing, and better pain relief especially in the early postoperative period.

Ultrasound-guided erector spinae block versus mid-transverse process to pleura block for postoperative analgesia in lumbar spinal surgery.

In recent years, promising results were achieved with the use of ultrasound (US)-guided interfascial plane blocks for effective postoperative analgesia in several surgeries. Erector spina plane (ESP) block and mid-transverse to pleura plane (MTP) block are the latest techniques in this area. The aim of this prospective and randomized study was to compare the postoperative analgesic efficacy of bilateral ESP and MTP blocks in patients undergoing lumbar spinal surgery under general anesthesia (GA). Atotal of 120 adult patients were included in the study and randomized into 3groups: group ESP (n = 40), group MTP (n = 40) and group Control (n = 40). The patients in the group ESP received abilateral block by injecting 20 ml of 0.25% bupivacaine at avertebrae level in the mid-point of the incision before GA. The same LA was administrated bilaterally at the T12/L1 level in the group MTP. Postoperatively, amultimodal analgesic regimen including an intravenous tramadol patient-controlled analgesia (PCA), paracetamol and dexketoprofen was used in all groups. Postoperative pain was assessed using avisual analogue scale (VAS) during the first 48 postoperative hours. Pethidine was used as arescue analgesic when VAS score was >3. Primary outcome measure was mean pain scores. Secondary outcome measures were consumption of rescue analgesic and the amount of tramadol delivered by PCA. A p < 0.05 was considered statistically significant. Mean VAS scores were significantly higher in the group Control than in the group MTP and group ESP at all-time points during 48 h (Control > MTP > ESP; p < 0.001). Mean VAS scores were lower in group ESP than group MTP in postoperative 12h (p < 0.001). Rescue analgesic consumption, number of bolus demand on PCA, PCA bolus demand dose, total PCA dose, and complications related to opioid consumption were highest in control group and lowest in ESP group (Control > MTP > ESP; p < 0.001). Both ESP and MTP blocks provided effective pain relief after lumbar spinal surgery but the ESP block was superior to MTP block regarding postoperative analgesia in the first 24 h.

Hydromorphone population pharmacokinetics in pediatric surgical patients.

Hydromorphone is an opioid agonist used for pediatric analgesia. Due to lack of data, pediatric dosing (based on adult pharmacokinetic models) is not optimal. This study characterizes hydromorphone population pharmacokinetics in pediatric surgical patients. In this prospective observational study, 34 children (4-18years, bodyweight 23-89.6kg) received multiple intravenous hydromorphone boluses followed by postoperative hydromorphone patient-controlled analgesia. Arterial blood samples were collected before and at 3, 10, 30, and 90 (and few samples at 1350) minutes after the first dose. Hydromorphone concentrations were measured by validated LC-MS/MS assay. Nonlinear mixed-effects modeling was used for pharmacokinetic model development. The final population pharmacokinetic model was evaluated by visual predictive check and bootstrap analysis. Monte Carlo simulations based on the final pharmacokinetic model determined optimal patient-controlled analgesia parameters to achieve a target of 20ng/mL (as the median effective analgesic concentration), using minimum effective analgesic concentration of 4ng/mL as a proxy for patient-controlled analgesia dose demand, and not exceeding the defined safe upper threshold of 40ng/mL. Hydromorphone pharmacokinetic profiles were adequately described by a two-compartmental model with first-order elimination. Bodyweight was found to be a significant covariate for hydromorphone clearance. Allometrically scaledpharmacokinetic parameter estimates (per 70kg), systemic clearance (0.748L/min), volume of distribution (33L), peripheral clearance (1.57L/min), and peripheral volume of distribution (146L) were similar to reported adult parameter estimates. Sex, race, age, and type of surgery were not identified as significant covariates. To identify optimal patient-controlled analgesia dosing parameters, we simulated several initial loading doses, demand doses, and lockout intervals. Our simulations support an initial patient-controlled analgesia loading dose of 15µg/kg followed by a demand dose of 6µg/kg with lockout intervals of 20minutes. After intravenous hydromorphone, plasma pharmacokinetic profiles in children undergoing different surgeries were well described by a two-compartment population allometric pharmacokinetic model using bodyweight as the size descriptor. Model informed simulations identified patient-controlled analgesia parameters to inform initial settings, with adjustments as needed based on observed individual effects.

Nalbuphine Combined with Ropivacaine for Epidural Labour Analgesia

Background: The addition of a small amount of opioids during epidural labour analgesia can enhance the local analgesic effect, reduce the amount of local anaesthetics required, and prevent motor blockade as much as possible. The use of nalbuphine, a κ-opioid receptor agonist, in epidural labour analgesia has not yet been reported. Methods: This clinical trial applied a prospective, randomized, double-blind, parallel-controlled, multicentre experimental design and was carried out in six tertiary hospitals in different regions of China. We included parturients aged 20 years or older,with a singleton pregnancy cephalic presentation, and who requested labor pain relief. Recruited parturients were randomly divided into two groups: the nalbuphine group (Group N) and the sufentanil group (Group S). Epidural puncture was performed at the L2-3 space. After successful catheterization, the drug was administered in the supine position. Medication regimen:(1) Group N received an epidural injection (5 mL mixture) of 0·1% ropivacaine, 0·3 mg/mL nalbuphine, and 1:400,000 epinephrine. A 10-mL mixture of 0·1% ropivacaine and 0·3 mg/mL nalbuphine was injected; subsequently, the drug was administered by patient-controlled epidural analgesia (PCEA). The background dosage was 6 mL/h, the patient-controlled analgesia (PCA) dose was 6 mL, and the lock-out period was 15 min. (2) Except that nalbuphine was replaced with 0·3 μg/mL sufentanil; all other drug administration and analgesia procedures in Group S were the same as those in Group N. The primary outcome was the time to the first PCA dose. Secondary outcomes included the ropivacaine dose per hour. Findings: Between November 2018 and February 2019,180 parturients were recruited for the study. Compared to the time to the first PCA dose in Group S (131·2 (89·9) min), the time to the first PCA dose in Group N (101·8 (76·7) min) was not significantly extended (P=0·050). The ropivacaine dose per hour in Group N (9·3 (2·4) mg) was significantly greater than that in Group S (8·4 (2·5) mg) (P=0·024). adverse drug reactions or serious adverse events directly associated with analgesics were noted during the study. Interpretation: The combinations of 0·3 mg/mL nalbuphine with ropivacaine and 0·3 μg/mL sufentanil with ropivacaine have comparable effects for labour epidurals. Both combinations are safe, effective, and suitable for labour epidurals, with few adverse reactions. Trial Registration: This study was registered at the Chinese Clinical Trial Registration Center (registration number: ChiCTR1800018810). Funding Statement: The authors stated: No funding received. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: This study was approved by the ethics committee of the Obstetrics & Gynecology Hospital Affiliated of Fudan University (approval number: Obstetrics and Gynecology ethics review 2018-52). Informed consent was obtained from all participating parturients.

Elective Hip And Knee Arthroplasty (HAKA) audit looking at anaesthetic technique, post-op pain scores, nausea, vomiting, first mobilisation times, patient satisfaction and days until discharge prior to the implementation of an enhanced recovery pathway at Pilgrim Hospital

Demand is increasing for elective hip and knee arthroplasties. At Pilgrim Hospital, no consensus existed for the preferred anaesthetic technique. The balance is between anaesthetic technique, good post-op analgesia and early mobilisation. The shared goal is ultimately a good patient journey and early discharge. Enhanced recovery pathways for hip and knee arthroplasties are being used in other hospitals nationwide and their effectiveness studied1,2,3. The aim of this audit is to provide evidence of current management and to roll-out an enhanced recovery pathway. This is a prospective data collection of elective Hip and Knee arthroplasties. Over 11/5/16 to 16/6/16. We included patients receiving Spinals (with or without diamorphine) and general anaesthesia (with or without regional blocks which included femoral, sciatic and/or iliac). We collected: visual analogue pain scores (0–10) in recovery and every six hours for three days; incidence of nausea and vomiting; time until first mobilisation; patient satisfaction and days until discharge. We used a data collection form and ‘WebV’ electronic system. Total 52 patients. 28 Hips (7 Revisions). 24 Knees (1 Revision). Average age 70 yrs and ASA 2. For full results see Table 2. Morphine patient controlled analgesia (PCA) was used for 25 patients with similar usage on day 1 of 19 mg average and satisfaction rating of ‘good/very good’. Without PCA it was ‘good’ despite comparatively less oral morphine. Mobilisation and discharge was delayed for 1) Knees with PCA vs oral morphine (not apply to hips) 2) Hip and knees with blocks. With blocks post-op analgesic requirements were higher with higher pain scores and worse patient satisfaction. Pain, mobilisation and discharge with diamorphine in spinals is comparable to those spinals without diamorphine but incidence of nausea is more with diamorphine. Primary vs revisions: Hip mobilisation and discharge is comparable but for knees is longer for revisions.Table 2Summary of findings.LocationAnaesthetic room: 10Theatre: 6 (pre-bypass: 3)Onset time<30 min: 13; >30 min: 3Cardiac arrest needing CPR1Decision to continue with surgeryPostponed: 10Proceeded: 7Re-operation time4 days-14 months90-day survival100%Allergy clinic review time7 days – 8 months Open table in a new tab There are some limitations such as sample size. Pain scores are subjective and occasionally retrospective which limits their comparison. PCA dose documentation varied. There were three post-op complications reducing weight of discharge data. Experience of operator for regional block not collected. Incidence of Urinary retention not collected. Currently no set standardised management for these cases at Pilgrim. This data supports that 1) Blocks should be considered with caution 2) Spinals without diamorphine should be done 3) Avoid use of PCA in primaries but may benefit in revisions. Action plan from audit was to discuss and implement a standardised anaesthetic practice for elective hip and knee. 1.Paton F, Chambers D, Wilson P, et al . BMJ Open. 2014; Available from http://bmjopen.bmj.com/content/4/7/e005015.2.Christelis N, Wallace S, Sage C, et al. Medical Journal of Australia. 2015; 202 (7): 363–368.3.Available from http://www.qihub.scot.nhs.uk/media/582955/nhs%20improving%20quality%20in%20collaboration%20with%20nhs%20england%20-%20enhanced%20recovery%20care%20pathway%20publication.pdf.