Perioperative Opioid Requirements Research Articles

Enhanced Recovery After Craniotomy: Global Practices, Challenges, and Perspectives.

The global demand for hospital care, driven by population growth and medical advances, emphasizes the importance of optimized resource management. Enhanced Recovery After Surgery (ERAS) protocols aim to expedite patient recovery and reduce health care costs without compromising patient safety or satisfaction. Its principles have been adopted in various surgical specialties but have not fully encompassed all areas of neurosurgery, including craniotomy. ERAS for craniotomy has been shown to reduce the length of hospital stay and costs without increasing complications. ERAS protocols may also reduce postoperative nausea and vomiting and perioperative opioid requirements, highlighting their potential to enhance patient outcomes and health care efficiency. Despite these benefits, guidelines, and strategies for ERAS in craniotomy remain limited. This narrative review explores the current global landscape of ERAS for craniotomy, assessing existing literature and highlighting knowledge gaps. Experts from 26 countries with diverse cultural and socioeconomic backgrounds contributed to this review, offering insights about current ERAS protocol applications, implementation challenges, and future perspectives, and providing a comprehensive global overview of ERAS for craniotomy. Representatives from all 6 World Health Organization geographical world areas reported that barriers to the implementation of ERAS for craniotomy include the absence of standardized protocols, provider resistance to change, resource constraints, insufficient education, and research scarcity. This review emphasizes the necessity of tailored ERAS protocols for low and middle-income countries, addressing differences in available resources. Acknowledging limitations in subjectivity and article selection, this review provides a comprehensive overview of ERAS for craniotomy from a global perspective and underscores the need for adaptable ERAS protocols tailored to specific health care systems and countries.

Understanding the role of intraoperative hypothermia in perioperative opioid requirements in immediate implant-based breast reconstruction

BackgroundThe relationship between perioperative temperatures and postoperative pain is unknown. The present study investigated the relationship of intraoperative hypothermia and perioperative opioid requirements after immediate implant-based breast reconstruction. MethodsA retrospective chart review was conducted on patients undergoing immediate implant-based breast reconstruction from 2019-2023. Patients were classified into the hypothermic group (majority of procedure < 36.0 °C) or normothermic group (majority of procedure ≥ 36.0 °C). Cumulative inpatient opioid requirements (morphine milli-equivalents [MMEs]) and frequency of patients requiring “high-dose opioids” (≥ 100 MMEs) were collected and compared between groups. ResultsIn total, 536 patients (835 breasts) were included, of which 135 (25.1%) were hypothermic. The hypothermic group had lower mean intraoperative (88.4 vs 99.1 MMEs, P = 0.007) and postoperative (44.2 vs 56.8 MMEs, P = 0.006) than the normothermic group. Mean (B = 14.6, P = 0.004) and nadir (B = 10.4, P = 0.038) intraoperative temperatures directly predicted higher opioid requirements while higher percentages of the procedure time spent under 36 °C (B = -27.6, P = 0.004) predicted lower opioid requirements. The hypothermic group was associated with 66% decreased odds of requiring high-dose opioids after adjusting for differences in patient and operative characteristics (P = 0.007). ConclusionHypothermia is associated with decreased perioperative opioid requirements. Future studies should further investigate ideal temperature thresholds for warming protocols to minimize postoperative pain.

Use of Dexmedetomidine versus Nitroglycerine to Provide Hypotensive Anesthesia in ENT Surgeries (Functional Endoscopic Sinus Surgery)

Abstract Background controlled (deliberate/induced) hypotension is a technique by which the arterial blood pressure is lowered in a controllable manner to reduce surgical blood loss and improve the operative field visibility. There are pharmacological and nonpharmacological techniques for inducing hypotension. The nonpharmacological methods for deliberate hypotension include positioning and positive pressure ventilation to control venous return. Aim of the Work to evaluate the efficacy of dexmedetomidine (DEX) as a hypotensive agent in comparison to nitroglycerin (NTG) in FESS regarding the bloodless field, reduction of mean arterial blood pressure, decrease inhalational anesthetic requirements (MAC), decrease perioperative opioid requirements, increase the time to first postoperative analgesic request and recovery profile and increase hemodynamics stability. Patients and Methods we conducted this study on 20 patients who were planned to perform functional endoscopic sinus surgery and were randomly distributed into 2 equal groups: 10 patients received dexamedotomidine and equal number of patients received nitroglycerine. Serial measurements of mean arterial blood pressure and heart rate were obtained and records between both groups were compared. Results There were statistically significant differences between both groups regarding heart rate as mean values of heart rate were lower among dexamedotomidine group. There were no statistically significant differences between both groups regarding mean arterial blood pressure values at different time points during the operation. Regarding the period after stopping infusion, mean values of heart rate and blood pressure were lower among dexamedotomidine group than nitroglycerine group after 5 minutes and after 10 minutes and the differences had statistically significant differences. Regarding postoperative period, both groups were comparable regarding heart rate and blood pressure immediately postoperative. Conclusion From the results of this study, we could conclude that both Dexmedetomidine and Nitroglycerin can be effectively used in induced hypotensive anesthesia for ENT surgery as FESS. Both groups were comparable with intra operative MAP with no statistically significant differences. This study also show that Dexmedetomidine has added advantages as better haemodynamic stability than Nitroglycerin (No rebound HTN, no tachycardia). Has sedative and analgesic effect, reduce requirement of anesthetic agents and perioperative analgesia. Postoperative recovery score (Time to reach modified Aldert score more than nine significantly higher. Postoperative complication as nausea and vomiting is less.

A retrospective analysis of perioperative medications for opioid-use disorder and tapering additional postsurgical opioids via a transitional pain service.

To investigate perioperative opioid requirements in patients on methadone or buprenorphine as medication for opioid-use disorder (MOUD) who attended a transitional pain clinic (Personalized Pain Program, PPP). This retrospective cohort study assessed adults on MOUD with surgery and attendance at the Johns Hopkins PPP between 2017 and 2022. Daily non-MOUD opioid use over 6 time-points was evaluated with regression models controlling for days since surgery. The time to complete non-MOUD opioid taper was analysed by accelerated failure time and Kaplan-Meier models. Fifty patients (28 on methadone, 22 on buprenorphine) were included with a median age of 44.3 years, 54% male, 62% Caucasian and 54% unemployed. MOUD inpatient administration occurred in 92.8% of patients on preoperative methadone but only in 36.3% of patients on preoperative buprenorphine. Non-MOUD opioid use decreased over time postoperatively (β = -0.54, P < .001) with a median decrease of 90 mg morphine equivalents (MME) between the first and last PPP visit, resulting in 46% tapered off by PPP completion. Older age and duration in PPP were associated with lower MME, while mental health conditions, longer hospital stays and higher discharge opioid prescriptions were associated with higher MME. The average time to non-MOUD opioid taper was 1.79× longer in patients on buprenorphine (P = .026), 2.75× in males (P = .023), 4.66× with mental health conditions (P < .001), 2.37× with chronic pain (P = .031) and 3.51× if on preoperative non-MOUD opioids; however, higher initial MOUD level decreased time to taper (P = .001). Postoperative opioid tapering utilizing a transitional pain service is possible in patients on MOUD.

Efficacy of Bilateral Erector Spinae Block in Patients Undergoing Posterior Spine Fusion Surgeries: A Comparative Randomised Controlled Trial.

Introduction During spine surgeries, various levels of tissue injury can result in varying hemodynamic responses and significant postoperative pain. Perioperative pain management is essential to controlling hemodynamic responses and postoperative pain management. Erector spinae plane (ESP) blocks can help alleviate this pain by blocking the dorsal rami of the spinal nerve. This study aims to evaluate the efficacy of ESP by assessing the perioperative opioid requirement, hemodynamic parameters, and visual analogue score (VAS) during the postoperative period. Methods In this study, 56 patients underwent elective posterior spine fusion surgeries under conventional anaesthesia and were allocated into two groups: 28 patients were included in the conventional group (Group C) and 28 patients in the ESP group (Group E). Group C patients received 20 ml of 0.9% sodium chloride (NaCl) on each side, and Group E patients received 20 ml of 0.25% bupivacaine + 4 mg dexamethasone on each side under ultrasound sonography guidance. Postoperative pain was assessed using the VAS score. The hemodynamic parameters during the intraoperative period, the time for the first opioid analgesia requirement until 24 hours in the postoperative period, and the amount of cumulative opioid consumption during the perioperative period were observed. Results Postoperative VAS was lower in Group E (P < 0.001). There were significant differences in hemodynamic parameters: heart rate (P < 0.045), systolic blood pressure (P < 0.002), diastolic blood pressure (P < 0.003), and mean arterial pressure (P < 0.002) at the time of incision in Group E. Intraoperative opioid requirements at the time of incision (P < 0.036), 60th minutes (P < 0.023), 120th minutes (P < 0.023), and postoperative opioid requirements at the first hour (P < 0.001), sixth hour (P < 0.004), 14th hour (P < 0.025), 20th hour (P < 0.009), and 24th hour (P < 0.025) had lower opioid requirements in Group E than Group C. Conclusion ESP block is a more site-specific dorsal rami block with a better perioperative hemodynamic profile, a part of multimodal analgesia intraoperatively, and excellent postoperative analgesia with fewer postoperative opioid requirements in multilevel spine fusion surgeries.

Influence of a chronic beta-blocker therapy on perioperative opioid consumption – a post hoc secondary analysis

BackgroundBeta-blocker (BB) therapy plays a central role in the treatment of cardiovascular diseases. An increasing number of patients with cardiovascular diseases undergoe noncardiac surgery, where opioids are an integral part of the anesthesiological management. There is evidence to suggest that short-term intravenous BB therapy may influence perioperative opioid requirements due to an assumed cross-talk between G-protein coupled beta-adrenergic and opioid receptors. Whether chronic BB therapy could also have an influence on perioperative opioid requirements is unclear.MethodsA post hoc analysis of prospectively collected data from a multicenter observational (BioCog) study was performed. Inclusion criteria consisted of elderly patients (≥ 65 years) undergoing elective noncardiac surgery as well as total intravenous general anesthesia without the use of regional anesthesia and duration of anesthesia ≥ 60 min. Two groups were defined: patients with and without BB in their regular preopreative medication. The administered opioids were converted to their respective morphine equivalent doses. Multiple regression analysis was performed using the morphine-index to identify independent predictors.ResultsA total of 747 patients were included in the BioCog study in the study center Berlin. 106 patients fulfilled the inclusion criteria. Of these, 37 were on chronic BB. The latter were preoperatively significantly more likely to have arterial hypertension (94.6%), chronic renal failure (27%) and hyperlipoproteinemia (51.4%) compared to patients without BB. Both groups did not differ in terms of cumulative perioperative morphine equivalent dose (230.9 (BB group) vs. 214.8 mg (Non-BB group)). Predictive factors for increased morphine-index were older age, male sex, longer duration of anesthesia and surgery of the trunk. In a model with logarithmised morphine index, only gender (female) and duration of anesthesia remained predictive factors.ConclusionsChronic BB therapy was not associated with a reduced perioperative opioid consumption.Trial registrationThis study was registered at ClinicalTrials.gov (NCT02265263) on the 15.10.2014 with the principal investigator being Univ.-Prof. Dr. med. Claudia Spies.

Risks associated with chronic cannabis use on opioid use, length of stay, and revision rate for patients undergoing posterior lumbar interbody fusion

BACKGROUND CONTEXTOpioids are commonly prescribed to treat spinal pain, especially those undergoing surgery. Cannabis has been suggested as an agent that can modulate opioid needs in these patients. PURPOSETo investigate the effect of cannabis use on perioperative opioid requirement and revision surgery rate in patients undergoing lumbar fusion. STUDY DESIGNRetrospective cross-sectional study. PATIENT SAMPLEA total of 48,499 patients from PearlDiver national database who underwent posterior lumbar interbody fusion. OUTCOME MEASURESOpioid-use rates, MME, length of stay, and revision rates. METHODSUsing PearlDiver, we identified patients for posterior lumbar interbody fusion (PLIF), cannabis use disorder, revision lumbar fusion, demographics, and comorbidities. Cannabis users and non-users were propensity matched for age, sex, and tobacco use. Pre and postoperative cumulative morphine milli equivalence (MME) were calculated. Opioid-use rates, MME, length of stay (LOS), and revision rates were compared using univariate analysis. Revision rates were compared using Kaplan-Meyer log-rank analysis, and logistic and cox regression. RESULTSOf 48,499 patients undergoing PLIF, 3.4% were identified as chronic cannabis users. They were younger, and more likely to be male and use tobacco. They had a higher rate and amount of opioid use within 90-days preoperatively, and 90- and 365-days postoperatively, after controlling for age, sex, and tobacco use. Cannabis users had longer LOS (4.4 vs 4.0 days), and a higher rate of revision surgery (6.9% vs 3.2%). Log-rank analysis, as well as logistic and cox regression confirmed an increased revision rate. Concurrent tobacco and cannabis use also had an additive effect on revision rate to 8.1%, compared with those who used only cannabis (5.4%) or tobacco (4.5%). CONCLUSIONSChronic cannabis use is associated with an increased preoperative and long-term postoperative opioid use, a longer length of stay, and an increased revision rate.

Comparative evaluation of the perioperative anesthesia methods for cancer patients undergoing pancreaticoduodenectomy

BACKGROUND: Pancreatoduodenal resections are one of the most traumatic and technically complex interventions in abdominal surgery. The correct anesthetic management and pain relief allow to substantially reduce the risk of perioperative complications, which remains high even in high-volume oncology centers with extensive experience. Finding new components and methods of anesthesia combined with evaluation of their effectiveness and safety remains a pressing issue.&#x0D; AIM: To evaluate the efficacy and safety of using intravenous lidocaine infusion as a component of anesthesia and postoperative analgesia in cancer patients during pancreatoduodenal resection.&#x0D; MATERIALS AND METHODS: We analyzed the course of anesthesia, operation and postoperative period of 43 patients (mean age 63.2±7.1 years) undergoing pancreaticoduodenectomy. For the purposes of the study, patients were randomly divided into 2 groups, based on anesthesia method: for the first group (n=19) we used epidural analgesia as a component of perioperative anesthesia, for the second group (n=24) we used prolonged intravenous infusion of lidocaine at an average dose of 1 mg/(kg×h). We analyzed the severity of pain syndrome according to Numeric rating scale for pain in postoperative period, as well as opioid requirement, the time of gastrointestinal function recovery, and post-operative complications frequency. In order to prevent systemic toxicity, drug monitoring was carried out — the determination of the plasma concentration of lidocaine.&#x0D; RESULTS: Perioperative opioid requirement was comparable between groups, with no statistically significant differences observed. The degree of pain syndrome according to the Numeric rating scale for pain did not differ statistically, except for the number of points during activation on day 3: 4.00 (95% confidence interval 3.49–4.51) for epidural analgesia group, compared to 3.12 (95% confidence interval 2.64–3.61) for lidocaine infusion group, p=0.014. There was also a statistically significant increase in infusion volume for epidural analgesia group compared to lidocaine infusion group [8.83 ml/(kg×h) (Q1=7.90; Q3=10.06) and 7.33 ml/(kg×h) (Q1=6.28–Q3=8.49) respectively, p=0.034], as well as a greater need for intraoperative vasopressor support among the patients [15 (78.9%) and 10 (43.5%) respectively, p=0.029]. In the lidocaine group, the time to onset of peristalsis was significantly shorter than in the epidural analgesia group [median 48.0 h (Q1=48.00; Q3=72.00) compared to median 60.0 h (Q1=36.00; Q3=64.50) respectively, p=0.042]. The frequency of postoperative complications did not differ between the groups.&#x0D; CONCLUSION: Based on a comparative analysis of the study results, it can be concluded that prolonged intravenous infusion of lidocaine, as a component of perioperative anesthetic protection during pancreatoduodenal resections, is safe and comparable in terms of analgesic efficacy to epidural blockade.

Moving the needle: a narrative review of enhanced recovery protocols in breast reconstruction.

After a relatively late introduction to the literature in 2015, enhanced recovery protocols for breast reconstruction have flourished into a wealth of reports. Many have since described unique methodologies making improved offerings with superior outcomes attainable. This is a particularly interesting procedure for the study of enhanced recovery as it encompasses two dissident approaches. Compared to implant-based reconstruction, autologous free-flap reconstruction has demonstrated superiority in a range of long-term metrics at the expense of historically increased peri-operative morbidity. This narrative review collates reports of recovery protocols for both approaches and examines methodologies surrounding the key pieces of a comprehensive pathway. All primary clinical reports specifically describing enhanced recovery protocols for implant-based and autologous breast reconstruction through 2022 were identified by systematic review of PubMed and Embase libraries. Twenty-five reports meeting criteria were identified, with ten additional reports included for narrative purpose. Included studies were examined for facets of innovation from the pre-hospital setting through outpatient follow-up. Notable findings were described in the context of a comprehensive framework with attention paid to clinical and basic scientific background. Considerations for implementation were additionally discussed. Of 35 included studies, 29 regarded autologous reconstruction with majority focus on reduction of peri-operative opioid requirements and length of stay. Six regarded implant-based reconstruction with most discussing pathways towards ambulatory procedures. Eighty percent of included studies were published after the 2017 consensus guidelines with many described innovations to this baseline. Pathways included considerations for pre-hospital, pre-operative, intra-operative, inpatient, and outpatient settings. Implant-based studies demonstrated that safe ambulatory care is accessible. Autologous studies demonstrated a trend towards discharge before post-operative day three and peri-operative opioid requirements equivalent to those of implant-based reconstructions. Study of enhanced recovery after breast reconstruction has inspired paradigm shift and pushed limits previously not thought to be attainable. These protocols should encompass a longitudinal care pathway with optimization through patient-centered approaches and multidisciplinary collaboration. This framework should represent standard of care and will serve to expand availability of all methods of breast reconstruction.

Analgesic Effect of Addition of Pectointercostal Block to Serratus Anterior Plane Block in Breast Surgeries: A Randomized, Controlled Trial

BACKGROUND: Ultrasound-guided serratus anterior plane block (SAPB) is an efficient perioperative analgesic modality for breast surgeries. SAPB does not block the anterior cutaneous branches of the intercostal nerves; thus, it does not provide adequate analgesia for the parasternal region and the medial side of the breast. A new parasternal block, the pectointercostal fascial plane block (PIFB) has been developed to overcome this issue. OBJECTIVES: The study aimed to evaluate the perioperative analgesic effect of using PIFB in addition to SAPB. The primary outcome was to evaluate the postoperative pain score. The secondary outcomes were to assess perioperative opioid requirements, hemodynamic stability, and the satisfaction of the patient and surgeon. STUDY DESIGN: The current study was a prospective, double-blinded, randomized controlled study. The current study was registered at the Pan-African Clinical Trials Registry (PACTR202001789968542) and was designed after obtaining ethical institutional approval (Institutional Review Board No 00012098, Federalwide Assurance No 00018699). SETTING: The study involved 60 women between 21 and 69 years old with breast cancer who were scheduled for modified radical mastectomy or conservative breast surgeries in a university hospital. METHODS: After verbal and informed written consent, the patients were allocated to Group 1, which received SAPB, and Group 2, which received SAPB with PIFB. We assessed the Visual Analog Scale (VAS), perioperative opioid requirements, intraoperative hemodynamic stability, rescue analgesia, and complications. Patient and surgeon satisfaction were surveyed using a questionnaire where one is very dissatisfied and 5 is very satisfied. RESULTS: Intraoperative mean arterial blood pressure (MABP) and heart rate were significantly lower in Group 2 (SAPB+PIFB). The number of patients who needed intraoperative fentanyl was also significantly lower in Group 2 (SAPB+PIFB) (P value = 0.010). Postoperative VAS showed no significant difference in both groups. The number of patients who needed postoperative rescue morphine, time for the first rescue analgesia, first morphine dose (mg), and total opioid consumption were also comparable for both groups. Patient satisfaction and surgeon satisfaction were comparable for both groups (P values = 1.000 and 0.496, respectively). LIMITATIONS: VAS was not recorded during movements and no follow-up was done to detect the potential effect on chronic postmastectomy pain. Moreover, after reviewing the literature, there was no efficient data about adding PIFB with different regional blocks for breast surgery. CONCLUSIONS: The number of patients who needed intraoperative fentanyl, as well as the MABP and heart rate were significantly lower in Group 2 (SAPB+PIFB). Postoperative vital signs, VAS, postoperative analgesic requirements, and opioid consumption were comparable for both groups. Patient satisfaction was comparable for both groups, while surgeon satisfaction was higher in Group 2 (SAPB+PIFB) but statistically not significant. KEY WORDS: Pectointercostal, fascial plane block, serratus anterior plane block, breast surgery, regional analgesia for mastectomy

Effective Local Anesthetic Use in Nasal Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Studies.

The primary outcome of this systematic review and meta-analysis was postoperative pain scores; secondary outcomes included perioperative opioid requirements, patient satisfaction scores, and time to first analgesic requirement. PubMed, Embase, and MEDLINE databases were searched, and two independent reviewers conducted article screening. Methodological quality assessment of studies utilized the Jadad instrument, and interrater reliability was assessed using Cohen kappa. An inverse-variance, fixed-effects model was used for meta-analysis with Cohen d used to normalize effect size between studies. I2 and Q statistics were used to assess interstudy variability. Four studies were included for meta-analysis, totaling 265 randomized patients. The nerve blocks assessed included infraorbital nerve, sphenopalatine ganglion, external nasal nerve, central facial nerve blocks, and total nerve blocks. All demonstrated significantly reduced postoperative pain compared with controls, with a large effect size (P < 0.001). Opioid requirements were lower in the nerve block groups (P < 0.001), and patient satisfaction scores were higher (P < 0.001). Supplemental meta-analyses showed a longer time to first analgesic requirement for patients who received a nerve block (P < 0.001). These findings support the efficacy of nerve blocks in providing postoperative pain relief and enhancing patient satisfaction with pain management. Perioperative nerve blocks, in combination with general anesthesia, should be considered for postoperative pain control.

MP32-07 SURGEON-ADMINISTERED ULTRASOUND-GUIDED TRANSVERSUS ABDOMINIS PLANE BLOCKS DURING RADICAL CYSTECTOMY: DESCRIPTION OF TECHNIQUE AND PERIOPERATIVE OPIOID REQUIREMENT

You have accessJournal of UrologyCME1 Apr 2023MP32-07 SURGEON-ADMINISTERED ULTRASOUND-GUIDED TRANSVERSUS ABDOMINIS PLANE BLOCKS DURING RADICAL CYSTECTOMY: DESCRIPTION OF TECHNIQUE AND PERIOPERATIVE OPIOID REQUIREMENT Justin Refugia, Hilary Brownstead, Parth Thakker, Randy Casals, Corey Able, Emily Roebuck, and Matvey Tsivian Justin RefugiaJustin Refugia More articles by this author , Hilary BrownsteadHilary Brownstead More articles by this author , Parth ThakkerParth Thakker More articles by this author , Randy CasalsRandy Casals More articles by this author , Corey AbleCorey Able More articles by this author , Emily RoebuckEmily Roebuck More articles by this author , and Matvey TsivianMatvey Tsivian More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003265.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Implementation of standardized analgesic regimens is paramount to developing enhanced recovery after surgery (ERAS) protocols for radical cystectomy (RC). Transversus abdominis plane (TAP) blocks have demonstrated decreased length of stay (LOS) and perioperative opioid requirement. To date, no studies have reported on ultrasound (US) guided blocks performed by the surgeon in this setting. In this study, we present our technique for surgeon-administered, US-guided TAP (sUTAP) blocks and review postoperative opioid requirements. METHODS: We retrospectively reviewed patients that received sUTAP blocks just prior to incision for RC. The blocks were performed with US-guidance to advance the needle into the transversus abdominis plane at the anterior axillary line between the subcostal margin and iliac crest. Next, 25-cc of an anesthetic solution was instilled into this plane and the procedure was repeated on contralateral side (total of two injection sites). The primary objective was overall perioperative opioid requirement. Due to protocol changes, we also compared two groups of patients that received a 50-cc mixture of: 0.25% bupivacaine mixed with liposomal-bupivacaine (LB) or 0.25% bupivacaine only. Analyses were performed on demographics, surgical and anesthetic details, and perioperative medications. RESULTS: Between 2020 and 2022, we identified 47 patients that received sUTAP blocks during RC. The men (79%) had a median age of 70 years (IQR 61-75), and women (21%) had a median age 77 years (IQR 67-80). RC approach was open (81%) or robotic (19%). Urinary diversion was with ileal conduit (53%) or cutaneous ureterostomy (47%). Overall median perioperative MMEs: intraoperative – 85 (53-107), POD0 – 25 (15-45), POD1 – 15 (0-40), POD2 – 7.5 (0-25), POD3 – 2.5 (0-16), and POD4 – 0 (0-11). The overall median length of stay was 4 days (IQR 3-6). LB was included for 14 patients (30%) and intraoperative/POD1 MMEs were higher than the 33 patients (70%) that received bupivacaine only (p<0.05). CONCLUSIONS: Our results suggest that addition of sUTAP blocks may reduce postoperative opioid requirements. Learning our technique should be considered by surgeons that are developing ERAS protocols for RC. Further comparative studies between anesthesia-administered TAP blocks and other peri-operative regional pain management modalities may clarify efficacy of sUTAP. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e442 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Justin Refugia More articles by this author Hilary Brownstead More articles by this author Parth Thakker More articles by this author Randy Casals More articles by this author Corey Able More articles by this author Emily Roebuck More articles by this author Matvey Tsivian More articles by this author Expand All Advertisement PDF downloadLoading ...

Nociception level response to calibrated stimulations in children: First assessment of the nociception level index in pediatric anesthesia

IntroductionIntraoperative monitoring of nociception has made great progress in adult anesthesia. However, pediatric data are scarce. The Nociception Level (NOL) is one of the most recent indexes of nociception. Its originality is that it provides a multiparametric assessment of nociception. In adults, NOL monitoring allowed lower perioperative opioid requirements, hemodynamic stability, and qualitative postoperative analgesia. So far, the NOL has never been used in children. Our objective was to validate the ability of NOL to provide a quantitative assessment of nociception in anesthetized children. MethodsIn 5–12 years old children anesthetized with sevoflurane and alfentanil (10 µg kg−1), before surgical incision, we performed three standardized tetanic stimulations (5 s, 100 Hz) of different intensities (10−30–60 mA) in a randomized order. NOL, heart rate, blood pressure and Analgesia-Nociception Index variations were assessed after each stimulation. ResultsThirty children were included. Data were analyzed with a covariance pattern linear mixed regression model. NOL increased after the stimulations (p < 0.05 at each intensity). NOL response was influenced by stimulation intensity (p < 0.001). Heart rate and blood pressure were barely modified by the stimulations. Analgesia-Nociception Index decreased after the stimulations (p < 0.001 at each intensity). Analgesia-Nociception index response was not influenced by stimulation intensity (p = 0.064). NOL and Analgesia-Nociception Index responses were significantly correlated (Pearson r = 0.47; p < 0.001). ConclusionsNOL allows a quantitative assessment of nociception under anesthesia in 5–12 years-old children. This study provides a solid basis for all future investigations on NOL monitoring in pediatric anesthesia. RegistrationNCT05233449.

Perioperative Sleep Disturbance Following Mastectomy: A Longitudinal Investigation of the Relationship to Pain, Opioid Use, Treatment, and Psychosocial Symptoms.

Sleep disturbance negatively impacts the quality of life and recovery. Our objective was to evaluate the relationship between the individual patient and surgical factors with greater sleep disturbance following breast surgery. In this prospective longitudinal study, patients completed validated measures regarding sleep disturbance, pain, opioid use, and psychological symptoms preoperatively and then 2 weeks, 6 and 12 months postoperatively. Univariable and multivariable generalized estimating equations evaluated demographic, surgical, pain, and psychological predictors of sleep disturbance during the first year after breast surgery. Female patients (n=259) reported varying degrees of sleep disturbance, which were longitudinally associated with pain and psychosocial factors (eg, anxiety, depression, and affect). Independent preoperative predictors of worse sleep disturbance included younger age (B=-0.09, P =0.006), opioid use (B=3.09, P =0.02), and higher pain (B=0.19, P =<0.001) and anxiety (B=0.45, P =<0.001) at baseline. In addition, higher baseline positive affect (B=-0.14, P =<0.012) and the surgical category total mastectomy without reconstruction (B=-2.81, P =<0.006) were independently associated with lower sleep disturbance. Those with worse baseline sleep required more opioid analgesics during surgical recovery, and continued use of opioids at 2 weeks postsurgery was associated with disturbed sleep. Certain patient characteristics, including younger age and baseline anxiety, positive affect, pain, and opioid use, were associated with greater sleep disturbance in the first year after breast surgery. Sleep disturbance was also associated with the greater perioperative and postoperative opioid requirements. Preoperative interventions (eg, anxiety management, cultivating positive affect, and multimodal pain management) in high-risk individuals may enhance sleep and recovery postoperatively, and allow more moderate and less prolonged opioid use.

Paravertebral Blocks in Tissue Expander Breast Reconstruction: Propensity-Matched Analysis of Opioid Consumption and Patient Outcomes.

The paravertebral block (PVB) is an adjunctive perioperative pain control method for patients undergoing breast reconstruction that may improve perioperative pain control and reduce narcotic use. This study determined the efficacy of preoperative PVBs for perioperative pain management in patients undergoing tissue expander breast reconstruction. A retrospective review was performed of patients who underwent tissue expander breast reconstruction from December of 2017 to September of 2019. Two patients with PVBs were matched using propensity scoring to one no-block patient. Perioperative analgesic use, pain severity scores on days 2 to 10 after discharge, and BREAST-Q Physical Well-Being scores before surgery and at 2 weeks, 6 weeks, and 3 months after surgery were compared between the two groups. The propensity-matched cohort consisted of 471 patients (314 PVB and 157 no block). The PVB group used significantly fewer morphine milligram equivalents than the no-block group (53.7 versus 69.8; P < 0.001). Average daily postoperative pain severity scores were comparable, with a maximum difference of 0.3 points on a 0-point to 4-point scale. BREAST-Q Physical Well-Being scores were significantly higher for the PVB group than the no-block group at 6 weeks after surgery (60.6 versus 51.0; P = 0.015) but did not differ significantly at 2 weeks or 3 months after surgery. PVBs may help reduce perioperative opioid requirements but did not reduce pain scores after discharge when used as part of an expander-based reconstruction perioperative pain management protocol. Continued research should examine additional or alternative regional block procedures as well as financial cost and potential long-term impact of PVBs. Therapeutic, III.

Opioid‐sparing anaesthesia techniques in dog and cat undergoing bilateral thoracotomy

AbstractMultimodal analgesia is the foundation of opioid‐sparing analgesia protocols in major surgery, being locoregional anaesthesia their keystone. Its aim is to provide adequate analgesia while minimising opioid requirements, and thus opioid‐related adverse effects. The blossoming of ultrasound‐guided fascial plane blocks offers a new spectrum of safer and simpler alternatives to traditional locoregional anaesthesia techniques. This report describes the anaesthetic management of a dog and a cat that underwent bilateral thoracotomy for treatment of chylothorax. The multimodal analgesia protocol consisted of preoperative methadone, ultrasound‐guided serratus plane and erector spinae plane blocks, and epidural catheter for postoperative analgesia management. The combination of these techniques allowed for a reduction of perioperative opioid requirements, good‐quality recovery and opioid‐free analgesia in the postoperative period.

Ultrasound-Guided Quadratus Lumborum Block Combined with General Anaesthesia or General Anaesthesia Alone for Laparoscopic Radical Gastrectomy for Gastric Adenocarcinoma: A Monocentric Retrospective Study.

PurposeTo investigate, in patients with gastric carcinoma undergoing laparoscopic radical gastrectomy, the effects of ultrasound-guided quadratus lumborum block (UG-QLB) combined with general anaesthesia (GA) on the postoperative recovery compared with GA alone.Patients and MethodsThe retrospective study enrolled 231 patients with gastric carcinoma undergoing laparoscopic radical gastrectomy, including 119 patients who received UG-QLB combined with GA (Group QG), and 112 patients undergoing GA alone (Group GA). The primary endpoint was the postoperative 3-year recurrence-free survival (RFS). The secondary endpoints were the average visual analogue scale (VAS) scores within 48 h after surgery, the first time of postoperative ambulation, the first time of flatus, postoperative hospitalization, perioperative opioid requirement and adverse effects after surgery.ResultsUG-QLB combined with GA did not affect the 3-year RFS in patients undergoing laparoscopic radical gastrectomy (HR 0.659, 95% CI 0.342–1.269, P=0.212). However, the VAS ranking analysis implicated that it could significantly alleviate the postoperative pain in laparoscopic radical gastrectomy patients (P<0.01). In addition, it dramatically facilitated the early recovery of postoperative ambulation and flatus, while shortening the duration of postoperative hospitalization (P<0.01). The most important was it could remarkably reduce the opioid consumption (P<0.01), which in the meanwhile, reduced the incidence of postoperative nausea and vomiting (PONV) (P=0.01).ConclusionAlthough UG-QLB combined with GA did not improve the 3-year RFS for patients with gastric carcinoma undergoing laparoscopic radical gastrectomy, it could provide satisfactory postoperative pain relief, reduce opioid consumption and adverse effects, which subsequently facilitates postoperative early rehabilitation.

PO005 / #279 EFFECTIVENESS OF LIDOCAINE INFUSION IN CHRONIC PAIN STATES: E-POSTER VIEWING

Background Lidocaine is a local anaesthetic, analgesic and antiarrhythmic agent. Recently, there has been interest in the use of intravenous lidocaine to treat chronic pain. A recent study has shown its effectiveness in decreasing perioperative pain and opioid requirements. In gastrointestinal surgery, both open and laparoscopic procedures, intravenous lidocaine increases early oral intake, improves mobilization, reduces time to bowel recovery, and facilitates early discharge. Intravenous lidocaine has been used in individuals who have undergone elective or emergency surgery, including neurosurgery, spine, orthopaedics, trauma, vascular, and other procedures.

Does surgical plethysmographic index-guided analgesia affect opioid requirement and extubation time? A systematic review and meta-analysis

PurposeThis meta-analysis of all relevant clinical trials investigated surgical plethysmographic index (SPI)-guided analgesia’s efficacy under general anesthesia for perioperative opioid requirement and emergence time after anesthesia.MethodsPubMed, Embase, Web of Science, and Cochrane Library were searched up to January 2022 to identify clinical trials comparing SPI-guided and conventional clinical practice for patients who underwent general anesthesia. With the random-effects model, we compared intraoperative opioid consumption, emergence time, postoperative pain, analgesia requirement, and incidence of postoperative nausea and vomiting (PONV).ResultsThirteen randomized controlled trials (RCTs) (n = 1314) met our selection criteria. The overall pooled effect sizes of all RCTs indicated that SPI-guided analgesia could not significantly reduce opioid consumption during general anesthesia. SPI-guided analgesia accompanied with hypnosis monitoring could decrease intraoperative opioid consumption (standardized mean difference [SMD] − 0.31, 95% confidence interval [CI] − 0.63 to 0.00) more effectively than SPI without hypnosis monitoring (SMD 1.03, 95% CI 0.53–1.53), showing a significant difference (p < 0.001). SPI-guided analgesia could significantly shorten the emergence time, whether assessed by extubation time (SMD − 0.36, 95% CI − 0.70 to − 0.03, p < 0.05, I2 = 67%) or eye-opening time (SMD − 0.40, 95% CI − 0.63 to − 0.18, p < 0.001, I2 = 54%). SPI-guided analgesia did not affect the incidence of PONV, postoperative pain, and analgesia management.ConclusionSPI-guided analgesia under general anesthesia could enhance recovery after surgery without increasing the postoperative complication risk. However, it did not affect intraoperative opioid requirement. Notably, SPI-guided analgesia with hypnosis monitoring could effectively reduce intraoperative opioid requirement.

Impact of Gabapentin on PACU Length of Stay and Perioperative Intravenous Opioid Use for ERAS Hysterectomy Patients.

We investigated the impact of preoperative gabapentin on perioperative intravenous opioid requirements and post anesthesia care unit length of stay (PACU LOS) for patients undergoing laparoscopic and vaginal hysterectomies within an Enhanced Recovery After Surgery (ERAS) pathway. A multidisciplinary team retrospectively examined 2,015 patients who underwent laparoscopic or vaginal hysterectomies between October 2016 and January 2020 at a single academic institution. The average PACU LOS was 168min among patients who did not receive gabapentin vs. 180min both among patients who received ≤ 300mg of gabapentin and patients who received > 300mg of gabapentin. After adjusting for demographics and medical comorbidities, PACU LOS for patients given ≤ 300mg gabapentin was 6% longer (rate ratio (RR) = 1.06, 95% CI = 1.01-1.11) than for patients who were not given gabapentin, and for patients who received > 300mg of gabapentin was 7% longer (RR = 1.07, 95%CI = 1.01-1.13) than for those who did not receive gabapentin. Patients who received ≤ 300mg gabapentin received 9% less perioperative intravenous hydromorphone than patients who did not receive gabapentin (RR = 0.91, 95% CI = 0.86 - 0.97); patients who received > 300mg of gabapentin received 12% less perioperative intravenous hydromorphone than patients who did not receive gabapentin (RR = 0.88, 95% CI = 0.82 - 0.95). These findings represent an absolute difference of 0.09mg intravenous hydromorphone. There were no statistically significant differences in total intravenous fentanyl received. Preoperative gabapentin given as part of an ERAS pathway is associated with statistically but not clinically significant increases in PACU LOS and decreases in total perioperative intravenous opioid use.