Perioperative Multimodal Analgesia Research Articles

Environmental impact of intravenous versus oral administration materials for acetaminophen and ketoprofen in a French university hospital: an eco-audit study using a life cycle analysis.

The combination of acetaminophen with a nonsteroidal anti-inflammatory drug is the cornerstone of perioperative multimodal analgesia. These drugs can be administered intravenously or orally as premedication, consistent with the concept of pre-emptive and preventive analgesia. We aimed to assess the environmental impact of their intravenous and oral administration in a French university hospital. We carried out a life cycle assessment to determine the amount of greenhouse gas emissions and depletion of water resources resulting from the oral vs intravenous administration of 1g acetaminophen and 50mg ketoprofen. We assessed two schemes of intravenous administration, depending on the use of the same or a different infusion set for each drug. At our centre, the intravenous administration of both drugs was associated with the emission of 444-556g CO2 equivalent (CO2e), and with 9.8-12.2 L of water waste. The oral administration of both drugs generated 8.36g of CO2e emissions and consumed 1.16 L of water. At a national level, the switch from intravenous to oral premedication of the drugs could avoid the emission of 2,900-3,700 tons of CO2e and the waste of 58,000-74,000 m3 of water each year. This eco-audit indicates that oral administration of acetaminophen and ketoprofen results in significantly lower carbon emissions and water consumption than intravenous administration. These findings highlight the importance of using the oral route for most patients, limiting intravenous administration for those with specific needs because of higher environmental impact and cost.

Updating Clinical Practice: Improving Perioperative Pain Management for Adeno-Tonsillectomy in Children.

Perioperative acute pain management in pediatric patients is essential to reduce complications. Adenoidectomy-Tonsillectomy are surgical procedures requiring pain control, and risk minimization for postoperative bleeding, nausea, and vomiting. Despite their known secondary effects, the use of opioid analgesics is still preponderant in pediatric perioperative management. We performed a comprehensive review on adeno-tonsillectomy perioperative pain management in children. We developed and implemented a multimodal analgesia protocol aimed to improve patients' pain management while consistently reducing opioids use. relevant Information was summarized, then compared to our clinical needs. Learnings were used to create and implement a multimodal analgesia protocol that we use in patients 3-9 years-old undergoing adenoidectomy/tonsillectomy. The full protocol is presented. Analgesic strategies have emerged to reduce or avoid the use of opioids. Among these strategies, combining different non-opioid analgesics (Ibuprofen, Paracetamol, Metamizole) has been shown to be an effective and safe pharmacological strategy when implemented as part of perioperative multimodal analgesia protocols. Considerable evidence associating the use of NSAIDs with a bigger risk of postoperative bleeding does not exist. Perioperative management of adenotonsillectomy pain should include preventive and multimodal analgesia, which have shown to provide significantly more effective analgesia than some opioid regimens. Ibuprofen offers highly effective analgesia for postoperative pain, particularly when combined with acetaminophen.

Effect of pericapsular nerve group block on perioperative analgesia characteristics for hip fracture operations

Aims: Pericapsular nerve group (PENG) block is a new regional analgesia technique that has recently been used for perioperative analgesia for hip fracture operations. The purpose of this research was to examine the perioperative analgesic characteristics of PENG block in patients who were going to undergo spinal anesthesia for a hip fracture procedure. Methods: The study was conducted as a prospective randomized controlled study between February 2021 and May 2021 after ethics committee approval. Patients with consent were included in the study. The patients were randomly divided into two groups (Group-I and Group-II). Patients in Group I underwent a PENG block with a 0.25% concentration of 20 cc bupivacaine in the preoperative waiting room 30 minutes before the operation. Afterward, spinal anesthesia was applied in the operating room. The patients in Group II received only spinal anesthesia. Preoperative visual analog scale (VAS) scores were recorded for both groups in the preoperative period. ECG, arterial blood pressure, pulse, and oxygen saturation measurements were performed in all patients preoperatively, intraoperatively, and postoperatively. Pulse, arterial blood pressure, oxygen saturation measurements, and VAS scores were recorded in the lateral decubitus position before and at the 5th minute after spinal anesthesia. In addition, the comfort of the anesthetist who will administer the spinal anesthesia during the application was questioned (0: poor, 1: moderate, 2: good, 3: very good). All patients 5 min after spinal anesthesia It remained in the lateral position for the duration. VAS scores were recorded during the postoperative phase at the 0th, 2nd, 8th, 16th, and 24th hours, along with the time of the first analgesic administration. The total amount of tramadol and paracetamol taken during the first 24 hours following surgery was noted. Results: Patients; gender, age, body weight, height, BMI, and ASA values were statistically similar (p > 0.05). In comparisons between the groups; During position, postoperative 2nd, 8th, 16th, 24th hours, and their sum, VAS values were found to be statistically lower in Group-I (p < 0.05). While it was found that the first analgesic administration time was statistically longer in Group-I patients (p < 0.001), the amounts of paracetamol and tramadol consumed in the first 24 hours were found to be statistically lower (p < 0.001). In addition, the comfort of the anesthetist during spinal anesthesia was found to be better in Group-I (p: 0.014). Conclusion: PENG block can be used effectively as a part of perioperative multimodal analgesia in hip fracture surgery. PENG can reduce the pain levels of patients with hip fractures as well as reduce the need for additional analgesia. It also increases the comfort of the anesthetist who will administer regional anesthesia.

Greater ischiatic notch plane versus parasacral block in dogs undergoing pelvic limb surgery: a retrospective noninferiority cohort study on perioperative opioid consumption

ObjectiveTo compare perioperative opioid consumption in dogs undergoing pelvic limb surgeries and receiving a lumbosacral plexus block by combining a lumbar [lateral pre-iliac (LPI)] block with a lumbosacral trunk [i.e. parasacral (PS group) or greater ischiatic notch plane (GIN group)] block.Study design Retrospective, descriptive, exploratory, noninferiority cohort study. MethodsMedical records of 37 client-owned dogs were analyzed. Intraoperative (primary outcome) and postoperative (24 hours) opioid use, 24 hour cumulative pain scores and prevalence of complications were compared between the two groups. Opioid use was quantified in morphine equivalents (ME, mg kg–1 ). The noninferiority limit for intraoperative opioid consumption was set at 0.05 ME kg–1 hour–1. Demographic data, procedure duration, surgery type and perioperative dexmedetomidine and ketamine use were also collected. A t-test or Wilcoxon rank-sum test, a Fisher's exact test and multivariable linear regression were used. Significance was set at p < 0.05. ResultsThe GIN and PS groups comprised 17 and 20 dogs, respectively. Total intraoperative ME consumption was 0.17 (0.11–0.21) and 0.22 (0.16–0.30) mg kg–1 hour–1 for the GIN and PS groups, respectively (p = 0.077). The noninferiority analysis adjusted by surgery type and body mass revealed that the mean difference between the groups (GIN – PS) was –0.039 (95% CI –0.11–0.03, p = 0.247) ME mg kg–1 hour–1, indicating that the GIN group was not inferior to the PS group regarding intraoperative ME consumption. Dexmedetomidine and ketamine use, postoperative ME consumption and pain scores were similar between groups. Conclusions and clinical relevanceThis retrospective study and preliminary observations support the clinical use of the GIN plane block, demonstrating its noninferiority to the PS block when combined with the LPI block for multimodal perioperative analgesia in dogs undergoing pelvic limb surgeries.

Current challenges for therapy of comorbid patients: a new look at celecoxib. A review

The use of non-steroidal anti-inflammatory drugs (NSAIDs) for a wide range of diseases is increasing, in part due to an increasing elderly population. Elderly patients are more vulnerable to adverse drug reactions, including side effects and adverse effects of drug-drug interactions, often occurring in this category of patients due to multimorbidity and polypharmacy. One of the most popular NSAIDs in the world is celecoxib. It is a selective cyclooxygenase (COX)-2 inhibitor with 375 times more COX-2 inhibitory activity than COX-1. As a result, celecoxib has a better gastrointestinal tract safety profile than non-selective NSAIDs. Gastrointestinal tolerance is an essential factor that physicians should consider when selecting NSAIDs for elderly patients. Celecoxib can be used in a wide range of diseases of the musculoskeletal system and rheumatological diseases, for the treatment of acute pain in women with primary dysmenorrhea, etc. It is also increasingly used as part of a multimodal perioperative analgesia regimen. There is strong evidence that COX-2 is actively involved in the pathogenesis of ischemic brain damage, as well as in the development and progression of neurodegenerative diseases, such as Alzheimer's disease. NSAIDs are first-line therapy in the treatment of acute migraine attacks. Celecoxib is well tolerated in patients with risk factors for NSAID-associated nephropathy. It does not decrease the glomerular filtration rate in elderly patients and patients with chronic renal failure. Many meta-analyses and epidemiological studies have not confirmed the increased risk of cardiovascular events reported in previous clinical studies and have not shown an increased risk of cardiovascular events with celecoxib, irrespective of dose. COX-2 activation is one of the key factors contributing to obesity-related inflammation. Specific inhibition of COX-2 by celecoxib increases insulin sensitivity in overweight or obese patients. Combination therapies may be a promising new area of treatment for obesity and diabetes.

Transversus abdominis plane block as a component of anesthesia in kidney transplantation

Aim. To evaluate the safety and efficacy of the transversus abdominis plane block in kidney transplantation from deceased donor.Material and methods. The first stage included a retrospective comparative analysis of the results using the transversus abdominis plane block in renal transplantation. Group I (n=30) included patients who underwent transversus abdominis plane block after kidney transplantation; in comparative group II (n=58) the TAP-block wasn’t performed. We assessed the daily requirement for trimeperidine on the first day after kidney transplantation. The second stage was a prospective randomized placebo-controlled study. The patients were randomly divided into 2 groups with respect to whether the transversus abdominis plane block was provided with an active drug, or placebo was used; so the sodium chloride 0.9% was injected into the transversus abdominis plane in the intermuscular fascial plane between the internal oblique and transversus abdominis muscle in patients of Group III (n=31), and a local anesthetic was injected in patients of Group IV (n=34).) The daily requirements for trimeperidine, tramadol were assessed as well as the pain severity according to visual analogue scale at 1, 6, 12, 24 hours after surgery, the incidence of adverse events in the gastrointestinal tract; and several laboratory parameters (cortisol, interleukin-1, interleukin-6) related to pain syndrome were analyzed.Results. As a result of pseudorandomization, 17 cases were included in each of two retrospective stage, which were comparable in terms of patients' main characteristics (p&gt;0.05). The daily requirement for trimeperidine in the transversus abdominis plane block group (Group I) was lower than in the comparison group with a trend toward statistical significance (p=0.07). The median daily dose of trimeperidine in Group III (placebo control) was 59.5 mg (interquartile range: 51.5–72.0), which was higher than in Group IV (45.5 mg; interquartile range: 38.5–62.0) (p=0.039). The postoperative pain severety assessed by visual analogue scale was also statistically significantly higher in group III at the timepoint of 12 hours after surgery, making 4.0 points (interquartile range: 2.5–5.0) versus 1.5 points (interquartile range: 0.5–2.5) in group VI (p=0.015). There were no differences between the groups in pain severity at 1, 6, and 24 hours after surgery. The daily requirement for tramadol was also statistically significantly higher in Group III, amounting to 50 mg (interquartile range: 0–100) versus 0 (interquartile range: 0–55 mg) in the active drug Group IV (p=0.045).Conclusion. Our study showed that the use of the transversus abdominis plain block was safe and effective, yielding encouraging results, which demonstrated a clinically significant reduction in the need for opioid analgesics and in the incidence of adverse events in the postoperative period after transversus abdominis plane block which contributes to the early activation of patients. Therefore, further studies are needed to improve the package of multimodal perioperative analgesia after kidney transplantation.

Optimizing the use of ketamine to reduce chronic postsurgical pain in women undergoing mastectomy for oncologic indication: study protocol for the KALPAS multicenter randomized controlled trial

BackgroundMastectomies are commonly performed and strongly associated with chronic postsurgical pain (CPSP), more specifically termed postmastectomy pain syndrome (PMPS), with 25–60% of patients reporting pain 3 months after surgery. PMPS interferes with function, recovery, and compliance with adjuvant therapy. Importantly, it is associated with chronic opioid use, as a recent study showed that 1 in 10 patients continue to use opioids at least 3 months after curative surgery. The majority of PMPS patients are women, and, over the past 10 years, women have outpaced men in the rate of growth in opioid dependence. Standard perioperative multimodal analgesia is only modestly effective in prevention of CPSP. Thus, interventions to reduce CPSP and PMPS are urgently needed. Ketamine is well known to improve pain and reduce opioid use in the acute postoperative period. Additionally, ketamine has been shown to control mood in studies of anxiety and depression. By targeting acute pain and improving mood in the perioperative period, ketamine may be able to prevent the development of CPSP.MethodsKetamine analgesia for long-lasting pain relief after surgery (KALPAS) is a phase 3, multicenter, randomized, placebo-controlled, double-blind trial to study the effectiveness of ketamine in reducing PMPS. The study compares continuous perioperative ketamine infusion vs single-dose ketamine in the postanesthesia care unit vs placebo for reducing PMPS. Participants are followed for 1 year after surgery. The primary outcome is pain at the surgical site at 3 months after the index surgery as assessed with the Brief Pain Inventory-short form pain severity subscale.DiscussionThis project is part of the NIH Helping to End Addiction Long-term (HEAL) Initiative, a nationwide effort to address the opioid public health crisis. This study can substantially impact perioperative pain management and can contribute significantly to combatting the opioid epidemic.Trial registrationClinicalTrials.gov NCT05037123. Registered on September 8, 2021.

The Influence of Pre-operative Pain and Anxiety on Acute Postoperative Pain in Cardiac Surgery Patients Undergoing Enhanced Recovery after Surgery.

Perioperative multimodal analgesia is an important step in enhanced recovery after surgery (ERAS) care. Many factors, such as preoperative chronic pain and anxiety, may provide information about the expected postoperative pain. In this study, we evaluated preoperative pain and anxiety and investigate their effects on acute postoperative pain in patients undergoing elective cardiac surgery. After ethics committee approval, 67 consenting patients undergoing on-pump cardiac surgery under the ERAS program were included in our prospective observational study. Pre- and postoperative pain scores were obtained using a numeric rating scale (NRS) at rest and during movement. Preoperative anxiety was assessed on a 0-10 scale, and data were recorded. The relationships between pre-operative pain/anxiety and postoperative pain were evaluated using correlation analysis. In preoperative pain assessment, the percentage of patients with a pain score above 4 with NRS was 1.5%, regardless of whether they were at rest or mobilize. In postoperative pain assessment, there were 20.9% and 34.3% patients with NRS >4 at rest and mobilization, respectively. 7.5% of patients had preoperative anxiety of grade 5 or higher. While preoperative pain was not correlated with postoperative pain, preoperative anxiety had a moderate positive correlation with postoperative pain (r=0.382, P=0.003). The prevalence of preoperative pain in patients who underwent cardiac surgery is quite low and is not associated with postoperative pain. There is also a significant relationship between the severity of preoperative anxiety and postoperative pain.

Molecular mechanisms of electropuncture in cerebrovascular protection during enhanced recovery after surgery period

The core intent of enhanced recovery after surgery (ERAS) is to alleviate the perioperative stress response and postoperative complications through perioperative multimodal analgesia and intensive surgery. Previous studies have demonstrated that multiple molecular mechanisms function in improving ischemic stroke, reversing the process of ischemia reperfusion, relieving intracerebral hemorrhage and traumatic brain injury. Meanwhile, electroacupuncture (EA) has been validated with regard to its efficacy and safety in perioperative treatment, which has an important impact on rehabilitation research and ERAS development. Currently, studies have showed that EA provides a new approach for cerebrovascular protection by activating various molecular mechanisms. In this review, we display the recent progress of main molecular mechanisms of EA in ERAS from the perspectives of protecting cerebrovascular functions, in order to provide guidance for the clinical treatment.

Comparative effect of preoperative oral pregabalin 50 mg vs. 75 mg on nerve growth factor (NGF) levels in parturients undergoing cesarean section

Background &amp; objectives: Postoperative pain after cesarean section (CS) is a crucial problem faced by the parturients. Pregabalin is a choice of preventive analgesia to reduce neuropathic pain, inflammation, tissue irritation, and post-cesarean section pain. The purpose of this study was to compare the effect of giving pregabalin 50 mg or 75 mg in combination with paracetamol 1 g on nerve growth factor (NGF) levels after cesarean section. &#x0D; Methodology: A prospective, comparative model was used in this study. The study took place at Mother and Children Hospital of Sitti Khadijah I, Makassar, Indonesia. A total of 30 patients who underwent CS were randomly divided into two groups; group P1 who received pregabalin 50 mg orally and 1 g paracetamol intravenously, 1 h before surgery (n = 15), and group P2 who received pregabalin 75 mg orally and 1 g paracetamol intravenously, 1 h before surgery (n = 15). Nerve Growth Factor (NGF) levels were measured 2 h before surgery, and at 4 and 6 h post-surgery. Data were analyzed by the Mann-Whitney test using SPSS 26.0.&#x0D; Results: There was a decrease in NGF levels in the pregabalin 75 mg group at 6 h post-surgery, while in the pregabalin 50 mg group it tended to increase at 4 and 6 h post-surgery. In the pregabalin 50 mg group, there was a significant increase in NGF levels from measurements of NGF1 to NGF2 and NGF0 to NGF2 (P &lt; 0.05), whereas, in the pregabalin 75 mg group, there was a significant decrease in NGF levels from measurements of NGF1 to NGF2 and NGF0 to NGF2 (P &lt; 0.05). &#x0D; Conclusion: The combination of pregabalin 75 mg orally with paracetamol 1 g intravenously is effective as perioperative multimodal analgesia by reducing nerve growth factor levels after cesarean section surgery.&#x0D; Abbreviations: BDNF- brain-derived neurotrophic factor; CS- Cesarean section; GABA- Gamma Amino Butyric Acid; NGF- Nerve Growth Factor&#x0D; Keywords: Cesarean section; Nerve Growth Factor (NGF); Postoperative; Pregabalin&#x0D; Citation: Ahmad MR, Harahap MW, Wirawan NS. Comparison between pregabalin 50 mg and 75 mg on nerve growth factor (NGF) levels after cesarean section. Anaesth. pain intensive care 2022;27(6):721−725; DOI: 10.35975/apic.v27i6.2159&#x0D; Received: February 20, 2923; Revised: July 11,2023; Accepted: October 29, 2023

The use of a combination of Diclofenac and Orphenadrine for analgesia in knee replacement

The objective was to assess the effectiveness and safety of the use of a fixed combination of Diclofenac and Orphenadrine (Neodolpasse) for analgesia in patients who underwent knee replacement.Materials and methods. 40 patients who underwent knee replacement in conditions of combined spinal-conduction analgesia (femoral nerve block) were included into the study. In the main group(n = 20), Neodolpasse (a combination of Diclofenac 75mg and of Orphenadrine 30 mg in 250 ml of solution) was administered intravenously 30 minutes before surgery, and then in the postoperative period 2 times a day for 2 days. In the comparison group (n = 20), Ketoprofen (intravenously,100 mg) was used instead of Neodolpasse 30 minutes before surgery, in the postoperative period, it was continued 2 times a day for 2 days (intravenously, 100 mg). The severity of the pain was assessed with a visual analog scale (VAS) 6, 12, 24 and 48 hours after surgery. The assessment of the restoration of the supporting function of the operated leg and the ability of the patient to perform active movements in the knee joint was carried out after 24 and 48 hours. The possible side effects was assessed throughout the entire period.Results. The median value of VAS after 24 hours in the main group was 2.5 (2;3) points, which was significantly lower in compassion to VAS of the control group 4(3;5) p = 0.006. A more pronounced analgesic effect while using Diclofenac and Orphenadrine persisted for 48 hours, the median value of VAS in the main group after surgery was 2 (2;3), in the control group – 3 (2.8;4) p = 0.021. There were no significant differences in the recovery time of restoration of the supporting ability of the operated leg and knee joint function, in the frequency of Tramadol use in the compared groups. Side effects and complications were not identified. Conclusion. The use of the fixed dose of Neodolpasse as part of multimodal perioperative analgesia in patients, who underwent knee replacement, contributed to a decrease in the severity of pain syndrome in the postoperative period.

A Survey Study of Surgeons and Anesthesiologists Regarding Perioperative Multimodal Analgesia for Opioid-Tolerant Patients

PurposePerioperative pain management of opioid-tolerant patients can be challenging. Although regional anesthesia and multimodal analgesics may be beneficial, these modalities are often underused. It is unclear whether practice patterns for perioperative pain management are determined by the knowledge, attitudes, and beliefs of surgeons and anesthesiologists. DesignDescriptive survey. MethodsUsing a Qualtrics survey, we polled a randomly selected group of 25 surgeons and 25 anesthesiologists regarding their knowledge, attitudes, beliefs, and practices for pain management in an opioid-tolerant patient. FindingsOf 25, 23 anesthesiologists and 18/25 surgeons responded to the survey. Demographics were similar between the 2 groups. Most of the participant surgeons and anesthesiologists believed that pain management may be challenging in an opioid-tolerant patient. However, only 56% of surgeons would recommend a preoperative pain consultation. Most surgeons and anesthesiologists believed in the efficacy of regional anesthetics. However, 43% of surgeons would not advocate for a regional block, perhaps due to their perception of the added perioperative time. Multimodal analgesics were widely accepted by both surgeons and anesthesiologists. ConclusionsThere is an urgent need to reinforce the importance of patient-centered care, with a specific focus on addressing knowledge gaps and improving perceptions for all the members of the team, including surgeons, anesthesiologists, and perioperative nursing teams, if optimal outcomes are to be achieved for our patients.

The Tailored Opioid Reduction Strategy (TORS): A Quality Improvement Initiative to Reduce Opioid Prescription Following Hysterectomy

ObjectiveTo evaluate a tailored opioid reduction strategy (TORS) in minimizing opioid prescriptions for patients undergoing hysterectomy. MethodsThis quality improvement initiative was developed by multiple stakeholders at an academic hospital in a Canadian urban centre. The intervention consisted of a three-pronged approach: (1) patient and provider education, (2) perioperative multimodal analgesia, and (3) a targeted opioid reduction strategy. All eligible patients were asked to fill pre- and postoperative questionnaires. Analysis of outcomes pre- and post-TORS implementation as well as intervention compliance was performed. ResultsFrom September 2020 to April 2021, 133 patients who underwent hysterectomy were included in the study, 69 in the pre-intervention group and 64 in the post-intervention group. Of 133 hysterectomies, 78 (58.6%) were performed laparoscopically, 16 (12%) open, 14 (10.5%) vaginally, and 25 (18.8%) robotically. The rate of discharge opioid prescriptions was significantly reduced in the post-intervention group compared with the pre-intervention group (37/64, 58% versus 62/69, 90%, respectively, P < 0.001), as well as the amount of opioid prescribed in oral morphine equivalents (OME) (mean 47 mg pre-intervention, 28 mg post-intervention, P < 0.001). There was no significant difference in patient satisfaction or postoperative pain scores between groups. Overall, compliance with 2 or more components of TORS intervention was seen in 64/64 (100%) cases. ConclusionTORS implementation was successful in reducing the rate of discharge opioid prescriptions and the total amount of opiates prescribed in patients undergoing hysterectomy with no decrease in patient satisfaction or change in postoperative pain scores. We believe it can be applied more broadly across different surgical patient populations to prevent opioid abuse.

Ultrasound-Guided Occipital Nerve Blocks as Part of Multi-Modal Perioperative Analgesia in Pediatric Posterior Craniotomies: A Case Series.

Various regional anesthetics have been used for postoperative analgesia for pediatric craniotomy. In this case series, we report retrospectively collected data on postoperative pain and analgesic use in 44 patients who received ultrasound-guided occipital nerve blocks in addition to intravenous analgesic agents for posterior craniotomy procedures. In the immediate post-anesthesia care unit, pain was rated as zero or well controlled in 77% of patients, with only 43% requiring intravenous or demand patient-controlled analgesia opioids. There were no block-related complications. Occipital nerve blocks may constitute a safe and effective component of multimodal analgesia in this population.

Postoperative analgesic effectiveness of ultrasound guided combined femoral - sciatic nerve block versus combined adductor canal block – I PACK block in patients undergoing total knee arthroplasty: A double- blind randomized study

ABSTRACT Background For successful rehabilitation and optimal functional outcomes after total knee arthroplasty surgery, patients must have effective pain control. Peripheral nerve blocks offer an excellent solution for perioperative multimodal analgesia and are advocated to reduce postoperative opioid consumption. Objectives The objective of this study is to compare the efficacy of combined Femoral-Sciatic nerve block and Adductor- interspace between the popliteal artery and the capsule of the posterior knee (IPACK) block in terms of total rescue analgesia dosage and ambulation on the first postoperative day. Method This is a prospective, randomized, double-blinded trial was conducted at Ain Shams University Hospital. Sixty patients scheduled for total knee arthroplasty (TKA) were randomly divided into two equal groups: one group received a Femoral-Sciatic nerve block, and the other received an Adductor-IPACK block. Both ultrasound-guided blocks were performed by injecting 20 mL of 0.25% bupivacaine immediately after anaesthesia induction. The postoperative opioid requirement in the first 24 hours was assessed using the visual analogue scale (VAS). Motor power, intraoperative fentanyl consumption, intraoperative hemodynamic changes, procedure time, surgery duration, tourniquet time, and technique complications were also recorded. Results Femoral-Sciatic group had lower opioid consumption. The Adductor-IPACK group showed a statistically significant higher Modified Bromage score. However, there was no statistically significant difference between the groups in the postoperative pain score assessed using the VAS. Conclusion Based on our study, we conclude that Femoral-Sciatic blocks required a lower dose of rescue analgesia compared to the Adductor-IPACK group. The Adductor-IPACK group also experienced lesser postoperative muscle power impairment.

A Comparative Study to Evaluate the Effectiveness of Perioperative Multi Modal Analgesia with Ultrasound Guided Bilateral Subcostal TAP Block for Post-Operative Analgesia in Patients undergoing Elective Laparoscopic Cholecystectomy under General Anaesthes

Background: Laparoscopic cholecystectomy is usually performed as a day care procedure for diseases involving the gall bladder. Pain in the immediate post-operative period is due to multiple factors and hence different modalities of pain relief are used. The present study was conducted to study the effectiveness of Peri-operative Multi-Modal Analgesia with ultrasound guided bilateral subcostal TAP block for Post-operative analgesia in 60 patients undergoing elective laparoscopic cholecystectomy.&#x0D; Methods: In this hospital based, randomized prospective interventional study patients were randomly allocated into 4 groups of 15 in each group, Group B received Bilateral Ultrasound guided Subcostal TAP Block with 20 ml of 0.25% Bupivacaine, Group P received Tab Pregabalin tablet 150 mg, Group D received Inj Dexamethasone 8 mg IV and Group C was the control group. The hemodynamic changes like heart rate, blood pressure, saturation was monitored both intra and post operatively. The post-operative VAS scoring, duration of analgesia, time for first rescue analgesic and the total dose of analgesics in 24 hours were noted.&#x0D; Results: The VAS Scores indicated that Group B&gt; P&gt; D&gt; C provided better analgesia to the patients with a P Value of &lt; 0.01. Group B took the longest mean duration (6.8± 1.15 hours) to take the 1st rescue analgesic and least mean total dose of rescue analgesic in 24 hours followed by Group P, Group D and Group C which was statistically significant.&#x0D; Conclusion: USG guided B/L TAP Block was superior to other modalities in providing postoperative analgesia for patients undergoing laparoscopic cholecystectomy.

Pain Prevalence and Management in a General Hospital Through Repeated Cross-Sectional Surveys in 2011 and 2021.

There is great scope for improving the quality of pain management. Although pain prevalence has been investigated in several countries, few studies have comparatively assessed changes in pain prevalence and management over a span of multiple years. This work was aimed at determining the pain prevalence and evaluating the condition of pain management in a Chinese general hospital in 2021 and comparing them with corresponding data from 10 years ago. Repeated single-center cross-sectional studies were initiated on June 14th, 2011, and September 2nd, 2021, in the same tertiary grade A Chinese general hospital. The same structured questionnaire was used to collect inpatient data on pain intensity and classification and pain management outcomes. We performed statistical analyses to compare categorical variables to assess changes over time. The sample sizes for the investigations in 2011 and 2021 were 2323 and 4454, respectively. In 2021, 24.34% of patients experienced pain; this percentage was significantly lower than that in 2011. Meanwhile, the prevalence of moderate and severe pain decreased from 14.73% in 2011 to 4.98% in 2021. The other six indicators of pain management outcomes also improved significantly. The percentages of patients using painkillers, opioid analgesics, and multiple analgesics increased from 44.61 to 51.38%, 24.01% to 44.61%, and 6.82% to 14.11%, respectively. Furthermore, the percentages of patients who received pain information and who actively reported pain increased from 27.56% to 96.5% and from 85.54% to 98.71%, respectively. The percentage of patients qualified to accurately use the Numerical Rating Scale increased from 10.5% to 79.98%. The quality and outcomes of pain management improved greatly after the establishment and implementation of the pain management system. Nonetheless, pain of different intensities is common after major surgeries, and it is recommended that hospitals popularize and implement perioperative multimodal analgesia strategies to reduce the incidence of postoperative pain.

Clinical application of electroacupuncture in enhanced recovery after surgery.

Enhanced recovery after surgery (ERAS) is currently the recommended surgical strategy, the main content of which is to reduce perioperative stress response and postoperative complications through perioperative multimodal analgesia and intensive surgery. Since ERAS was introduced, many rehabilitation medicine teams have been deeply involved, including physical therapy, occupational therapy, nutrition therapy and psychological counseling. However, ERAS lacks several powerful means to address perioperative prognostic issues. Therefore, how to further improve the effects of ERAS, reduce perioperative complications and protect vital organ functions has become an urgent problem. With the continuous development of traditional Chinese medicine, electroacupuncture (EA) has been widely used in various clinical applications, and its efficacy and safety have been fully proved. Recent studies have shown that the application of EA in ERAS has had an important impact on rehabilitation researches. In terms of reducing complications, the therapeutic effects of EA treatment mainly include: reducing pain and the use of analgesics; Improvement of postoperative nausea and vomiting; Postoperative immune function treatment; Relieve anxiety and depression. In addition, EA also protects the recovery of physiological functions, including cardiovascular function, cerebrovascular function and gastrointestinal function, etc. To sum up, the complementary strengths of EA and ERAS will allow them to develop and combine. This review discusses the potential value and feasibility of EA in ERAS from the aspects of improving perioperative efficacy and protecting organ functions.

Analgesic Efficacy of Intraoperative Superior Hypogastric Plexus (SHP) Block during Abdominal Hysterectomy: A Systematic Review and Meta-Analysis of Controlled Trials.

Background and Objectives: Abdominal hysterectomy is a major surgery that is often associated with pronounced postsurgical pain. The objective of this research is to conduct a systematic review and meta-analysis of all randomized controlled trials (RCTs) and nonrandomized comparative trials (NCTs) that have surveyed the analgesic benefits and morbidity of intraoperative superior hypogastric plexus (SHP) block (intervention) compared with no SHP block (control) during abdominal hysterectomy. Materials and Methods: The Cochrane Central Register of Controlled Trials (CENTRAL), Google Scholar, Web of Science, PubMed, Scopus, and Embase were searched from inception until 8 May 2022. The Cochrane Collaboration tool and Newcastle-Ottawa Scale were used to evaluate the risk of bias of RCTs and NCTs, respectively. In a random effects mode, the data were pooled as risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI). Results: Five studies (four RCTs and one NCT) comprising 210 patients (SHP block = 107 and control = 103) were analyzed. The overall postsurgical pain score (n = 5 studies, MD = -1.08, 95% CI [-1.41, -0.75], p < 0.001), postsurgical opioid consumption (n = 4 studies, MD = -18.90 morphine milligram equivalent, 95% CI, [-22.19, -15.61], p < 0.001), and mean time to mobilization (n = 2 studies, MD = -1.33 h, 95% CI [-1.98, -0.68], p < 0.001) were significantly decreased in the SHP block group contrasted with the control arm. Nevertheless, there was no significant variance between both arms regarding operation time, intraoperative blood loss, postsurgical NSAID consumption, and hospital stay. There were no major side effects or sympathetic block-related aftermaths in both groups. Conclusions: During abdominal hysterectomy and receiving perioperative multimodal analgesia, the administration of intraoperative SHP block is largely safe and exhibits better analgesic effects compared to cases without administration of SHP block.

Abstract OT3-20-01: Ketamine Analgesia for Long Lasting Pain Relief after Surgery (KALPAS) Study

Abstract Background: Post-mastectomy pain syndrome (PMPS) affects up to 60% of women undergoing mastectomy. Standard perioperative multimodal analgesia remains only moderately effective in preventing PMPS, and many patients continue to rely on opioids for their chronic pain. In the context of the opioid overdose crisis, alternative interventions are urgently needed. Ketamine targets risks factors for PMPS including acute pain and negative mood, making it an ideal candidate for the prevention of PMPS. Trial Design: This is a multisite, three-arm, double-blind, RCT to test the effectiveness of ketamine in reducing PMPS in women undergoing mastectomy for oncologic indication. Arm 1 consists of continuous perioperative ketamine infusion that begins during surgery and continues for 2 hours in the post-anesthesia care unit (PACU). Arm 2 consists of a single-dose of ketamine in the PACU given over 50-60 minutes. Arm 3 consists of placebo. Standard surgical and postsurgical care remain unchanged across all arms. Eligibility Criteria: Inclusion criteria are: women ≥18 years of age undergoing total mastectomy for oncologic indication +/- lymph node dissection and +/- immediate or delayed reconstruction with no distant metastases. Exclusion criteria include: (1) history of cognitive impairment (2) past ketamine or phencyclidine misuse or abuse, (3) schizophrenia or history of psychosis, (4) history of post-traumatic stress disorder, (5) known sensitivity or allergy to ketamine, (6) liver or renal sufficiency, (7) uncontrolled hypertension, chest pain, cardiac arrhythmia, stroke, head trauma, intracranial mass or hemorrhage, glaucoma, porphyria, uncontrolled thyroid disease, or other contraindication to ketamine, (8) lamotrigine alfentanil, physostigmine, or 4-aminopyridine use, (9) currently pregnant, (10) body mass index greater than 35, (11) non-English or non-Spanish speaker, (12) currently participating in another pain interventional trial, (13) patient has started or undergone hormone therapy for gender transition into male, or (14) patient is scheduled for bilateral (or greater) flap reconstruction. Specific Aims: The primary outcome is pain intensity on the Brief Pain Inventory short form scale at the surgical site three months after mastectomy. Secondary outcomes include pain severity and interference at the surgical site, incidence of PMPS, anxiety, and depression over 12 months after surgery. Tertiary outcomes include neuropathic symptoms, fatigue, sleep, physical function, and opioid use. Statistical Methods: We will test the differences in the primary outcome between 1) the continuous ketamine infusion and the control; and 2) the single-dose ketamine and the control, each at 0.025 significance level (adjusted for multiple comparisons using the Bonferroni correction), based on the two-sample t-tests (allowing unequal variances) if outcome variables are approximately normal, or Wilcoxon’s rank-sum tests otherwise. Accrual: The target accrual for this study is ~750. Recruitment began January 2022. Recruitment is expected to be complete by October 2025. As of July 14, 2022, 43 participants have been enrolled across all sites. If interested in the KALPAS Study, please contact kalpas@nyulangone.org, jing.wang@nyulangone.org, or lisa.doan@nyulangone.org This research is supported by the National Institutes of Health through the NIH HEAL Initiative under UH3CA261067. It is also supported by the NCATS Trial Innovation Network under award numbers U24TR001608 (CCC), U24TR001597 (DCC), U24TR001609 (SSC), U24TR001579 (RIC) Citation Format: Lisa Doan, Raven Perez, Jeana Chun, Randy Cuevas, Pabel Miah, Amber Guth, Karen Hiotis, Freya Schnabel, Michele Curatolo, Robert Edwards, Hyung Park, John Rotrosen, Deborah Axelrod, Jing Wang. Ketamine Analgesia for Long Lasting Pain Relief after Surgery (KALPAS) Study [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr OT3-20-01.