Patient-controlled Analgesia Morphine Research Articles

Comparison of the postoperative effects of the erector spinae plane block and local infiltration analgesia in patients operated with lumbotomy surgery incision: Randomized clinical study.

Our aim was to observe the effects of local infiltration analgesia (LIA) or erector spinae plane block (ESPB) methods, which we applied preemptively in patients who were scheduled for surgery with a lumbotomy surgical incision and on intraoperative remifentanil consumption, and to compare the postoperative numerical rating scale (NRS), morphine demand, consumption, and pain degrees. Sixty American Society of Anesthesiologists I to III patients aged 18 to 75 years who were due to be operated on with a lumbotomy surgical incision were included in the study. The present study was conducted via prospective, randomized controlled, double-blind trials. After the induction of standard anesthesia, LIA was applied to 30 patients and ESPB was applied to 30 patients preemptively. The dose of remifentanil consumed in the intraoperative period was measured, and the hemodynamic parameters were measured every 5 minutes. Morphine bolus treatment with the postoperative patient-controlled analgesia and rescue analgesia with paracetamol were planned for the patients. Postoperative morphine and additional analgesia consumption, NRS, hemodynamic parameters, and complications were recorded for 48 hours. There was no difference between the groups in terms of demographic and hemodynamic data. The mean consumption of remifentanil was measured as 455 ± 165.23 µg in the intraoperative ESPB group and 296.67 ± 110.59 µg in the LIA group, and a statistical difference was observed (P = .001). In the postoperative follow-ups, the ESPB group drug consumption and NRS score averages were significantly lower at all times (P = .01; patient-controlled analgesia-morphine, 41.93 ± 14.47 mg vs 57.23 ± 15.5 mg and additional analgesic-paracetamol: 2.1 ± 1.06 vs 4.27 ± 1.14 g). The mean duration of additional analgesic intake of the groups was 10.6 ± 8.1 in the LIA group, while it was 19.33 ± 8.87 in the ESPB group, a significant difference. The patient satisfaction questionnaire was also significantly in favor of ESPB (P = .05). In conclusion, it has been shown that the intraoperative LIA method is more effective in terms of remifentanil consumption and in controlling pain in operations performed with a flank incision, but the ESPB method provides longer and more effective pain control in postoperative follow-ups.

Efficacy of Multimodal Analgesia with Transversus Abdominis Plane Block in Comparison with Intrathecal Morphine and Intravenous Patient-Controlled Analgesia after Robot-Assisted Laparoscopic Partial Nephrectomy.

Background: Robot-assisted laparoscopic partial nephrectomy (RAPN) for renal tumor treatment provides ergonomic advantages to surgeons and improves surgical outcomes. However, moderate-to-severe pain is unavoidable even after minimally invasive surgery. Despite the growing interest in multimodal analgesia, few studies have directly compared its efficacy with intrathecal morphine, a traditional opioid-based analgesic. Methods: We retrospectively investigated the efficacy of multimodal analgesia compared with that of intrathecal analgesia and intravenous patient-controlled analgesia (IV-PCA) in patients who underwent transperitoneal RAPN at our institute between 2020 and 2022. Among the 334 patients who met the inclusion criteria, intrathecal analgesia using morphine 200 µg was performed in 131 patients, and multimodal analgesia, including transversus abdominis plane block and intraoperative infusion of paracetamol 1 g and nefopam 20 mg, was administered to 105 patients. The remaining 98 patients received postoperative IV-PCA alone. Results: As the primary outcome, the area under the curve of pain scores over 24 h was significantly lower in the intrathecal analgesia and multimodal analgesia groups than in the IV-PCA group (89 [62-108] vs. 86 [65-115] vs. 108 [87-126] h, p < 0.001). Cumulative opioid requirements were also significantly lower in the intrathecal analgesia and multimodal analgesia groups at 24 h after surgery (p < 0.001). However, postoperative nausea and vomiting were significantly increased in the intrathecal analgesia group (27.5% vs. 13.3% vs. 13.3%, p = 0.005). Conclusions: Multimodal analgesia with a transversus abdominis plane block is an efficient analgesic method with fewer adverse effects compared to other analgesic methods. Our findings suggest the efficacy and safety of a multimodal approach for opioid-sparing analgesia after RAPN in the current opioid epidemic.

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.

Bilateral ultrasound-guided erector spinae plane block for postoperative pain relief in major traumatic spine surgery: A randomized controlled trial.

Spine fixation surgery for traumatic vertebral fractures is associated with severe pain and is often difficult to control. Traditionally systemic opioids have been the mainstay of analgesia for these procedures, which can lead to hyperalgesia, nausea, ileus, sedation, cognitive impairment, dependence, etc., limiting usage of opioids. The Erector spinae plane block (ESPB) is a novel ultrasound-guided procedure with easily identifiable sonoanatomy. We hypothesized that a multimodal approach involving ESPB to a conventional analgesic regimen with local infiltration for patients undergoing major traumatic spine surgeries might provide better perioperative analgesia and reduce the need for postoperative opioid requirements. A randomized control prospective trial was conducted on 34 ASA grade I -II patients aged 18 to 65 years who were scheduled to undergo elective posterior spine fixation surgery with ASIA B to E after traumatic spine fracture under general anesthesia. Patients were randomized to Group A which included patients who received general anesthesia with ESPB, and Group B, or the control group, included patients who received general anesthesia with systemic analgesics and postoperative local infiltration without ESPB. Intraoperative total fentanyl consumption, VAS score at 0, 3, 6, 12, 18, and 24 hours, time to activate patient-controlled analgesia (PCA) pump, total morphine consumption, and opioid-related side effects were monitored and compared in both groups. Postoperative PCA morphine consumption was significantly lower in group A patients who received ESPB than those in the control group (17.06 ± 9.59 vs 37.82 ± 9.88 P value = <0.0001). VAS scores at rest and movement at 0, 3, 6, 9, 12, 18, and 24 hours were significantly lower (P value = 0.05) in the ESPB group compared with the control group at all time points. Bilateral ultrasound-guided Erector spinae plane block, when administered in traumatic spine patients undergoing spine fixation surgery, provides better analgesia with statistically decreased VAS scores and less postoperative opioid requirement.

Single-bolus injection of local anesthetic, with or without continuous infusion, for interscalene brachial plexus block in the setting of multimodal analgesia: a randomized controlled unblinded trial

IntroductionPrevious trials favored a continuous interscalene brachial plexus block over a single injection for major shoulder surgery. However, these trials did not administer a multimodal analgesic regimen. This randomized, controlled...

The effect of ultrasound-guided rectus sheath block on postoperative analgesia in robot assisted prostatectomy: A randomized controlled trial.

Postoperative pain continues to represent an important problem even after minimally invasive robotic-assisted laparoscopic radical prostatectomy, which results in discomfort in the postoperative period and sometimes prolongs hospital stays. Regional anesthesia and analgesia techniques are used in addition to systemic analgesics with the multimodal approach in postoperative pain management. Ultrasound-guided fascial plane blocks are becoming increasingly important, especially in minimally invasive surgeries. Another important cause of discomfort is urinary catheter pain. The present randomized controlled study investigated the effect of rectus sheath block on postoperative pain and catheter-related bladder discomfort in robotic prostatectomy operations. This randomized controlled trial was conducted from March to August 2022. Written informed consent was obtained from all participants. Approval for the study was granted by the Clinical Research Ethics Committee. All individuals provided written informed consent, and adults with American Society of Anesthesiologists Physical Condition classification I to III planned for robotic prostatectomy operations under general anesthesia were enrolled. Following computer-assisted randomization, patients were divided into 2 groups, and general anesthesia was induced in all cases. Rectus sheath block was performed under general anesthesia and at the end of the surgery. No fascial plane block was applied to the patients in the non-rectus sheath block (RSB) group.Postoperative pain and urinary catheter pain were assessed using a numerical rating scale. Fentanyl was planned as rescue analgesia in the recovery room. In case of numerical rating scale scores of 4 or more, patients were given 50 µg fentanyl IV, repeated if necessary. The total fentanyl dose administered was recorded in the recovery room. IV morphine patient-controlled analgesia was planned for all patients. All patients' pain (postoperative pain at surgical site and urethral catheter discomfort) scores and total morphine consumption in the recovery unit and during follow-ups on the ward (3, 6, 12, and 24 hours) in the postoperative period were recorded. Sixty-one patients were evaluated. Total tramadol consumption during follow-up on the ward was significantly higher in the non-RSB group. Fentanyl consumption in the postanesthesia care unit was significantly higher in the non-RSB group. Total morphine consumption was significantly lower in the RSB group at 0 to 12 hours and 12 to 24 hours. Total opioid consumption was 8.81 mg in the RSB group and 19.87 mg in the non-RSB group. A statistically significant decrease in urethral catheter pain was noted in the RSB group at all time points. RSB exhibits effective analgesia by significantly reducing postoperative opioid consumption in robotic prostatectomy operations.

Preemptive multimodal analgesia for gynecologic oncology patients undergoing laparotomy: a randomized controlled trial.

Gynecologic oncology laparotomy leads to severe postoperative pain. We aimed to evaluate the effects of preemptive multimodal analgesic regimen on postoperative opioid consumption for patients undergoing gynecologic oncology laparotomy. In this prospective, randomized clinical trial, 80 female patients scheduled for gynecologic oncology laparotomy were randomized to receive preemptive multimodal analgesia consisted of transversus abdominis plane (TAP) block, cyclooxygenase-2 inhibitors, acetaminophen and intravenous morphine patient-controlled analgesia (PCA) (Study group) or conventional analgesia with cyclooxygenase-2 inhibitors and morphine PCA (Control group). The primary outcome was morphine consumption in the first 24 h after surgery. Secondary outcomes were pain scores, nausea, vomiting, time to ambulation and flatus, length of hospital stay, satisfaction score, the 40-item Quality of Recovery score (QoR-40) and the Short-Form Health Survey (SF-36) scale. Morphine consumption in the first 24 h was 6 (3-9.8) mg in the Study group and 7 (3.5-12.5) mg in the Control group (p = 0.222). The Study group showed lower morphine consumption up to 6 h, lower pain scores up to 48 h, and earlier time to ambulation and flatus. The global QoR-40 score at 48 h [182 (173-195) vs. 173.5 (154-185.5), p = 0.024], subdimension scores of physical dependence at 24 h, physical comfort and pain at 48 h were significantly improved in the Study group. Preemptive multimodal analgesia was not superior to conventional analgesia in reducing 24 h morphine consumption; however, it showed a significantly improved pain control and early quality of recovery thus can be recommended for gynecologic oncology patients undergoing laparotomy.

Erector spinae plane block for post-operative analgesia in thoracolumbar spine surgery: A randomised controlled trial

Background and Aims: Thoracolumbar spine surgery is one of the most painful surgical procedures. This study's primary objective was to evaluate the effect of erector spinae plane (ESP) block on post-operative cumulative morphine consumption at 24 h in patients undergoing thoracolumbar spine surgery. Methods: Seventy adults posted for thoracolumbar spine surgery were randomised into the control group [Number of patients (n)=35], who received general anaesthesia without any nerve block, and the intervention group (n = 35), who received bilateral ultrasound (US)-guided ESP block at the level of spine surgery with 0.25% bupivacaine 20 mL after standard general anaesthesia. Along with intravenous patient-controlled analgesia morphine, post-operative analgesia was standardised for both groups. Total morphine consumption, visual analogue scale (VAS) score to evaluate pain, overall patient satisfaction, and any side effects were compared at 24 h. The statistical analysis was done using Statistical Package for Social Sciences (SPSS Inc., Chicago, IL). Results: Post-operative total morphine consumption at 24 h was significantly decreased in the intervention group compared to the control group [5.69 (1.549) versus 9.51 (1.634) mg; P &lt; 0.001]. Post-operative VAS scores were also significantly decreased in the intervention group at rest (P &lt; 0.001) and on movement (P &lt; 0.001). Patient satisfaction scores were more favourable in the intervention group [3.8 (0.4) versus 3.2 (0.6); P &lt; 0.001]. Post-operative nausea and vomiting were found more in the control group but were not significant (n = 14 versus 8; P = 0.127). Conclusion: US-guided ESP block significantly reduces post-operative morphine consumption and improves analgesia and patient satisfaction without adverse effects in patients undergoing thoracolumbar spine surgery.

Stigma and patient-controlled analgesia: Trust is the essential ingredient of successful patient education in the patient-doctor relationship

A clinical decision report using: Van Beers EJ, Van Tuijn CFJ, Nieuwkerk PT, et al. Patient-controlled analgesia versus continuous infusion of morphine during vaso-occlusive crisis in sickle cell disease, a randomized controlled trial. Am J Hematol. 2007;82(11):955-960. https://doi.org/10.1002/ajh.20944 for a patient with recurrent vaso-occlusive crisis secondary to Sickle Cell Disease.

Sufentanil Sublingual Tablet System vs. Intravenous Patient-Controlled Analgesia with Morphine: Postoperative Pain Control and Its Impact in Quality of Recovery.

Patient-controlled analgesia (PCA) is commonly used for postoperative pain control. Although widely used, intravenous (IV) morphine PCA may not be suitable for all patients. Sufentanil sublingual tablet system (SSTS) PCA is a recent technique that has had success as a safe and effective alternative for acute pain management. This study aims to compare both the efficacy and safety of SSTS PCA versus IV morphine PCA in postoperative pain control and the quality of recovery in adult patients following scheduled gynecological or orthopedic surgery. Open-label, parallel-group, randomized controlled trial with 54 patients. The primary outcome was postoperative pain control, while the secondary outcomes included adverse effects associated with two analgesic modalities, total opioid dose required, patient satisfaction, and impact on the quality of postoperative recovery. Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 26.0 (Released 2019; IBM Corp., Armonk, New York, United States). The chi-squared test was used in categorical variables. When distribution was normal, T-student (mean ± standard deviation) was used in continuous variables. In contrast, when distribution was not normal, the Mann-Whitney test (median (minimal-maximal)) was used. The results showed that there was a statistically significant difference in the total dose of opioid used by patients at 24 hours postoperatively, with patients receiving SSTS PCA requiring a higher total dose when compared to those receiving IV morphine PCA. However, there were no statistically significant differences in pain scores, adverse events, or patient satisfaction. The study suggests that both IV morphine and sublingual sufentanil are safe and effective for postoperative pain management.

Effects of intraoperative liposomal bupivacaine on postoperative opioid usage in kidney transplant recipients.

This study retrospectively evaluated the use of intraoperative locally infiltrated peri-incisional liposomal bupivacaine in kidney transplant recipients with the primary outcome of oral morphine equivalent reduction during the transplant admission. Secondary outcomes included pain scores, time to first bowel movement and length of stay. Postoperative morphine equivalents were significantly lower in the liposomal bupivacaine group <24 hours (50% reduction, p < 0.05) and 24-48 hours (56.5% reduction, p < 0.05). When accounting for analgesic medication choices, liposomal bupivacaine did not result in a significant reduction in opioid use within 48 hours postoperatively with the exception of a 51% (p = 0.02) median reduction in fentanyl patient-controlled analgesia morphine equivalents <24 hours postoperatively. Morphine equivalence reductions >48 hours, differences in pain scores, time to first bowel movement or length of stay did not reach significance. Intraoperative liposomal bupivacaine reduced kidney transplant recipient's postoperative opioid requirements, but this benefit did not reliably extend past 24 hours postoperatively.

Comparative Study Between Intravenous Patient-Controlled Analgesia Morphine and Computerized Ambulatory Delivery Device Epidural Morphine for Post Operative Analgesia for Nuss Procedure in Pectus Excavatum: A Retrospective Analysis.

Pectus deformities are commonly seen in chest wall deformities among the pediatric age group. Pectus deformities occur due to defective growth of the sternum and its surrounding cartilage. The Nuss procedure is the technique of choice for correcting the deformity surgically which includes placing a convex bar under the sternum without resection or injury to costal cartilages. Adequate pain control is utmost to improve wound healing, patient satisfaction, short hospital stays, and decrease the financial burden on attendants. Therefore, it is necessary to investigate which analgesic method is more advantageous for the Nuss procedure. To compare the analgesic effects of intravenous patient-controlled analgesia (IVPCA) morphine versus computerized ambulatory delivery device (CADD) epidural morphine on acute post-operative pain management in Nuss procedures. A retrospective study was done at Rajiv Gandhi Cancer and Research Hospital, New Delhi from 2015 to 2020 to assess the efficacy and safety between IVPCA morphine and CADD epidural for post-operative analgesia following pectus excavatum repair. A total of 34 cases of Nuss procedures were taken with 17 cases in each group. Group 1 (intravenous PCA morphine) was given 39 ml normal saline + 6 ml morphine (total 45 ml, 2 mg/ml morphine), set at demand dose 0.5 ml, i.e. 1 mg, lockout interval 7 minutes, doses per hour was six and Group 2 (CADD epidural morphine) was given 42 ml normal saline + 3 ml morphine (1 mg/ml morphine) with continuous infusion at the rate of 0.5 ml/hr. Demand dose 0, lockout interval nil. Visual analog pain scores using a scale of 0-10 and Ramsay Sedation Score (RSS) scores were obtained on arrival at the post-anesthesia care unit, at 12, 24, 48, and 72 hours throughout the subsequent hospital stay. This study yielded positive information about our experience with the pectus post-operative pain management. The mean visual analogscale (VAS) score was lower in Group 1 compared to Group 2 but significantly different at 12 and 72 hours only. The mean RSS score was comparable between groups. The mean hospital stay (days) and requirement of rescue analgesia doses were 3.47±0.51 and 0.12±0.33 in Group 1 and 4.76±0.44, 0.59±1.12 in Group 2. Both IVPCA morphine and CADD morphine were effective in controlling post-surgical pain in the Nuss procedure, but IVPCA morphine was better as compared to CADD morphine in this regard because it was noninvasive, safe, and cost-effectivewith non-significant complications.

The Efficacy of Patient Controlled Analgesia for Acute Non Traumatic Abdominal Pain in Emergency Department

INTRODUCTION: Patient-Controlled Analgesia (PCA) is an intravenous selfadministration of small doses of opioids (such as morphine) using a programmable pump, The goal of PCA is to efficiently reduce patients’ pain at patient's preferred dose and schedule. Thus, we conducted a study to compare patient PCA morphine with intravenous bolus morphine for acute abdominal pain of non-traumatic origin in the emergency department (ED). MATERIALS AND METHODS: A randomised, non-blinded clinical trial was conducted in patients presented with severe acute non traumatic abdominal pain of less than 24 hours requiring opioid analgesic based on numerical pain score of more than seven at triage. The primary outcome was visual analogue pain score (VAS) recorded at 0, 30th, 60th and 120th minutes during the management in the ED and after admission to wards, and the secondary outcomes were total dosage of morphine used and degree of patient satisfaction. RESULTS: A total of 62 participants who fulfilled study criteria were randomized into PCA morphine group or bolus morphine group. The average amount of analgesic used for bolus morphine group was lower compared to PCA morphine (4.23 mg)(s.d 1.89 vs 5.29 mg)(s.d 2.16) (p=0.027). Despite of significant VAS score changes within group analysis, between group repeated measure ANOVA (RMA) VAS score analysis was not statistically significant. [Bolus group (6.7+2.03) compared to PCA group (5.83 + 2.38)](p=0.089). Patient satisfaction was statistically significant for the PCA group [PCA (1.65+0.709) compared to bolus group (2.23+0.920)](p=0.007). CONCLUSIONS: There was no significant difference in pain score reduction between PCA and intravenous bolus of morphine for the management of severe acute non traumatic abdominal pain in ED. However, PCA provided more patient satisfaction and should be considered as an alternative modality of acute pain management in ED.

Association between intraoperative remifentanil use and postoperative hyperalgesia in adolescent idiopathic scoliosis surgery: a retrospective study

BackgroundThe liberal use of remifentanil in spine surgery has been associated with an increased incidence of postoperative hyperalgesia. Nevertheless, controversies remain as the existing evidence is inconclusive to determine the relationship between remifentanil use and the development of opioid-induced hyperalgesia. We hypothesized that intraoperative infusion of higher dose remifentanil during scoliosis surgery is associated with postoperative hyperalgesia, manifesting clinically as greater postoperative morphine consumption and pain scores.MethodsNinety-seven patients with adolescent idiopathic scoliosis (AIS) who underwent posterior spinal fusion surgery at a single tertiary institution from March 2019 until June 2020 were enrolled in this retrospective study. Anesthesia was maintained using a target-controlled infusion of remifentanil combined with volatile anesthetic desflurane in 92 patients, while five patients received it as part of total intravenous anesthesia. Intravenous ketamine, paracetamol, and fentanyl were administered as multimodal analgesia. All patients received patient-controlled analgesia (PCA) morphine postoperatively. Pain scores at rest and on movement, assessed using the numerical rating scale, and the cumulative PCA morphine consumption were collected at a six-hourly interval for up to 48 h. According to the median intraoperative remifentanil dose usage of 0.215 µg/kg/min, patients were divided into two groups: low dose and high dose group.ResultsThere were no significant differences in the pain score and cumulative PCA morphine consumption between the low and high dose remifentanil group. The mean duration of remifentanil infusion was 134.9 ± 22.0 and 123.4 ± 23.7 min, respectively.ConclusionIntraoperative use of remifentanil as an adjuvant in AIS patients undergoing posterior spinal fusion surgery was not associated with postoperative hyperalgesia.

Ultrasound -guided erector spinae plane block (ESPB) versus intravenous opioids based analgesia in patients with rib fractures

ABSTRACT Background There has been a great interest in the erector spinae plane block (ESPB) to control pain in patients who are presented with rib fractures. ESPB has been shown to achieve adequate analgesia with little adverse effects, although its effectiveness in comparison to other analgesic alternatives has not been sufficiently studied. Aim of the study Our target was to compare the effectiveness of ESPB and opioid based analgesia in relieving pain in rib fractures patients. Methodology Fifty-two patients between 21 and 60 years old, divided into 2 equal groups, received either Ultrasound-guided (US) ESPB with 20 ml of bupivacaine 0.25% or intravenous (IV) morphine 0.1 mg/kg then IV Patient-controlled analgesia (PCA) containing morphine. Assessment of visual analogue scale (VAS) score before and after spirometer exercise at baseline, then at 30 minutes, 6 hours, and 12 hours after the intervention was done. Also Peak Inspiratory Flow Rate (PIFR) was measured by an incentive spirometer, first 12-hour morphine consumption as rescue analgesia was calculated, the incidence of complications was noted, and patients satisfaction was assessed. Results The VAS score was higher in morphine group compared to ESPB group before and after spirometry. PIFR was higher in ESPB group. Less opioid consumption and side effects, along with better patient satisfaction, were recorded in the ESPB group. Conclusion Erector spinae plane block provided superior analgesia and improved respiratory function for IV PCA morphine. Furthermore, ESPB was linked to fewer side effects, less opioid use, and better patient satisfaction.

Comparison between pericapsular nerve group block and morphine infusion in reducing pain of proximal femur fracture in the emergency department: A randomized controlled study

ABSTRACT Background This study aimed to assess the safety and efficacy of analgesia with pericapsular nerve group (PENG) block as an adjuvant to morphine infusion for the management of preoperative pain in patients with proximal femur fractures. Methods This single-blinded, parallel-group, randomized trial enrolled 36 adult patients with proximal femur fractures who were prepared for surgery. The patients were randomly allocated to two groups. In the PENG group, 18 patients received a US-guided PENG block as an adjuvant to patient-controlled morphine analgesia (PCA), while in the PCA group, 18 patients received PCA only. The primary outcome was the total morphine consumption in 24 hours before the surgery. The secondary outcomes included the visual analogue scale (VAS), need for rescue analgesia, total sleep hours, incidence of respiratory depression, hemodynamic stability, and incidence of nausea and vomiting during the first 24 hours post-procedure. Results The PENG block significantly decreased the total dose of morphine, VAS score at one-hour post-procedure, need for rescue analgesia, incidence of respiratory depression and nausea but increased the sleeping hours. Vomiting was comparable in the two groups (p = 0.121). Significantly higher mean arterial pressures from 8 to 20 hours after the block as well as heart rates immediately after the block were observed in the PENG group compared to the PCA group. Conclusion In patients with proximal femur fractures, preoperative PENG block can be used as an adjuvant to morphine infusion for controlling the pain and the total dose of morphine usage.

Salivary cortisol as a biomarker of stress in surgical patients.

Surgical stress and pain result in activation of hypothalamus-pituitary-adrenal axis. The aim of this study was to establish the effects of postoperative pain and various modalities of analgesic administration on salivary and serum cortisol levels, as well as to establish the validity of salivary cortisol as a stress indicator in surgical patients. A randomized controlled trial involved 60 patients scheduled for elective abdominal aortic aneurysm surgery. Patients were randomly divided into two groups depending on the model of postoperative analgesia. The first group (MI - morphine intermittently) included patients given morphine doses 0.1 mg/kg/6h s.c. intermittently. The second group (MPCA - morphine patient-controlled analgesia) included patients who received morphine via the PCA system - intravenous administration of morphine adjusted to a dose of 1 mg per shot and a lockout interval of 6 minutes.

ROBOTIC ASSISTED MINIMALLY INVASIVE CARDIAC SURGERY DA VINCI ROBOTIC SYSTEM. ANALYSIS OF PERIOPERATIVE CONSIDERATIONS

<h3>Introduction</h3> Robotic assisted minimally invasive cardiac surgery is a complex procedure where the anesthesiologist works in situations that require management skills. <h3>Method</h3> The study design is a retrospective observational model, which was performed with chart review. Data were collected from 104 patients who underwent minimally invasive cardiac surgery and were repaired using the Da Vinci robot-assisted minimally invasive approach from November 2019 to March 2022. The variables collected were assigned into three groups: preoperative variables, intraoperative variables and postoperative variables. The preparatory variables were age, sex, personal history of interest, Anesthetic Risk Scale (ASA), European System for Cardiac Operation Risk Evaluation II (EUROESCORE II), preoperative echocardiography, preoperative laboratory tests and diagnosis. Intraoperative variables were type of anesthesia, airway device used, invasive monitor, intraoperative transesophageal echocardiography data, complications, vasoactive drug use, blood product transfusion, extracorporeal circulation times and aortic clamping times, analgesic technique, extubation and surgical outcome. Finally, the postoperative variables were length of stay in the intensive care unit, length of hospital stay and postoperative complications. <h3>Results</h3> On the ASA 101 patients (97.1%) were in the ASA IV group and only 3 patients were in the ASA V group (2.9%). In the Euroescore II 103 patients scored less than 3 (99.03 %) and only one patient scored above 3 (0.9 %). Regarding anesthesia, 71 patients received total intravenous general anesthesia (68,3%) and 32 patients received balanced general anesthesia (30,7%) and in 1 patient this information could not be collected (0,9%)).. For airway management, a left double-lumen tube was used in 21 patients (20.8%), a Vivasight-type camera tube in 47 patients (46.6%) and a bronchial blocker through a conventional tube under fibrobronchoscopic vision in 33 patients (32.6%). In 3 patients this information could not be collected. Only 1 patient suffered serious complications during surgery (0.96 %). Vasoactive drugs were used in 81 patients (78%). Blood products were transfused in 7 patients (6.7%). The analgesic technique used consisted of locoregional blocks in 59 patients (56%), Locoregional block + patient-controlled morphine analgesia (PCA) in 14 patients (13,4%), PCA only in 29 patients (27,8%) and in 4 patients we do not know this information (3,8%). With regard to postoperative complications, 26 patients (25 %) were recorded. One patient died (0.96%). <h3>Conclusions</h3> In minimally invasive robotic-assisted cardiac surgery there are fundamental details to consider before, during and post-intervention such as the selection of the right patient, preoperative assessment, anesthetic technique, airway management, performing a good transesophageal echocardiographic study, hemodynamic behavior of the patient during the intervention, measures to take in case of complications and postoperative management, among others. Little literature exists so far and more studies are needed. ANALYSIS OF ANAESTHETIC CONSIDERATIONS

Sufentanil sublingual tablet system for enhanced recovery after total knee arthroplasty: a prospective observational case study

BackgroundPostoperative pain is one of the main factors that delays recovery after prosthetic knee surgery. The use of sufentanil sublingual tablet systems (SSTS) can effectively relieve postoperative pain, but their value in facilitating early mobilization has been little studied so far. Our aim here was to assess whether their use could facilitate recovery after knee arthroplasty in an enhanced recovery program.Case presentationIn a prospective observational single-center study, thirty patients operated on for primary knee arthroplasty in the enhanced recovery pathway were included. Patients who received the SSTS (n=15) were compared with those who received an intravenous morphine patient-controlled analgesia (PCA) (n=15). Our recovery program included in particular the use of an adductor canal block, periarticular infiltration of local anesthetic by the surgeon, removal of the venous cannula from the recovery room if possible, the use of an SSTS when available or an IV morphine PCA otherwise, and early physiotherapy. Recovery parameters including the Timed-Up and Go test, pain scores at rest and on exertion, knee flexions, complications, and lengths of hospital stay were not significantly different between the two groups. However, the postoperative opioid consumption in morphine equivalents was significantly greater in the SL-sufentanil group and these patients had their venous cannula removed earlier than in IV-morphine group.ConclusionIn our center, the use of a SSTS was suitable for treating postoperative pain after knee arthroplasty, but it did not improve early recovery in comparison with a morphine PCA.

Comparative efficacy of ketamine, lidocaine, acetaminophen, and dexmedetomidine combined with morphine patient-controlled analgesia in treating opium-addicted patients undergoing tibia fracture surgery

Objective: To compare the effect of ketamine, lidocaine, acetaminophen, and dexmedetomidine combined with morphine patient-controlled analgesia for opium addicts after tibial fracture surgery. Methods: This double-blind clinical trial included opium-addicted patients undergoing tibia fracture surgery. Patients were recruited and randomized to four different groups including the ketamine group, the lidocaine group, the acetaminophen group, and the dexmedetomidine group. The hemodynamic parameters such as heart rate (HR), mean arterial pressure, and arterial SaO2, alongside visual analog scale pain scores, sedation assessed by Ramsay score, nausea and vomiting, and opioid use were recorded and compared among the four groups. Results: This study included 140 patients, aged 37 (32, 41) years, with 92 males and 48 females, and each group had 35 patients. Dexmedetomidine-sedated subjects had the lowest blood pressure from 1 to 24 h after surgery, decreased HR at 12 and 24 h after surgery, and more satisfactory sedation (P&lt;0.05). Notwithstanding no significant difference was noted in the pain scores, or nausea and vomiting among the groups (P&gt;0.05). Conclusions: Dexmedetomidine has a better sedation effect compared to ketamine, lidocaine, and acetaminophen for pain control, but the final choice hinges on the patients’ physical condition and the anesthesiologist's preference. Clinical registarion: It is registered in Iranian Registry Clinical Trial by code IRCT20141209020258N146.