Pharmacological Analgesia Research Articles

Virtual reality for reduction of intraprocedural pharmacological sedation and analgesia in adult patients: A systematic review and meta-analysis.

Pharmacological sedation and analgesia are used to alleviate discomfort during awake medical procedures but can cause adverse effects like apnea and hypoxemia, increasing the need for airway management and prolonging recovery. Virtual reality (VR) has emerged as a non-pharmacological intervention to reduce the need for procedural sedatives and analgesics. A systematic review and meta-analysis were conducted, assessing the impact of VR immersion on intraprocedural sedation and analgesia usage in adults (≥ 18 years). We searched MEDLINE (PubMed), Embase, Cochrane CENTRAL, and Web of Science from inception to August 1 st, 2024. We included analytical studies utilizing VR immersion in the intervention arm, and reporting tailored dosages of intraprocedural sedatives (propofol, midazolam) and/or opioids. Statistical analyses used standardized mean differences (SMD), and heterogeneity was assessed with I². Of 2714 identified papers, 11 (560 patients) were included. VR significantly reduced propofol usage (SMD = -1.70; 95% CI -3.10 to -0.31; P = 0.02; I² = 92%) and midazolam usage (SMD = -0.29; 95% CI -0.57 to 0.00; P = 0.05; I² = 0%). However, our analysis showed no reduction in opioid usage (SMD = -0.21; 95% CI -0.60 to 0.19; P = 0.31; I² = 74%) in the VR group. VR immersion effectively reduces the required dose of intraprocedural sedatives, but its impact on opioid consumption remains unclear, especially in the absence of regional or neuraxial anesthesia. Further research is needed to clarify these effects and optimize VR use in clinical practice. This review's protocol was prospectively registered on PROSPERO (CRD42024569462).

Characteristics of Helicopter Emergency Medical Services (HEMS) Interventions for Burn Patients-A Four-Year Retrospective Analysis.

Background: The World Health Organization (WHO) estimates that 180,000 patients die from burns every year, which is considered a serious public health issue. Patients with burns require immediate pre-hospital care and transport to specialized treatment facilities. The aim of this study was to outline the profile of the burn patient from the perspective of the Polish Medical Air Rescue (PMAR), as well as to analyze the medical procedures being implemented. Methods: The study includes 2154 interventions by air emergency medical teams (AEMS) which provided aid for burn patients. The analysis covered the period from 2018 to 2022, including nationwide data made available from the IT systems of the PMAR. Statistical design was used, allowing for correlations of variables, at a significance level of p < 0.05. Results: Patients' ages ranged from 1 month to 96 years (mean 35.05; SD ± 26.88). Adult patients (n = 1409; 65.41%) constituted the vast majority. The number of interventions to children below 1-year-old was noticeable (n = 394; 18.29%). Men were the most likely to suffer burns, up to three times more often than women (n = 1574, 73.07% vs. n = 570, 26.46%. T29-burns to multiple body areas (n = 890)-and T21-burns to the trunk (n = 255)-were most frequently reported as diagnoses according to the ICD-10 classification. A statistically significant association was found between age group and ICD-10 diagnosis (p < 0.001). The vast majority of patients were transported from the scene directly to Burn Treatment Centers (n = 1373; 63.74%). Treatment of pain by helicopter emergency medical services (HEMS) crews appeared to be effective (p < 0.001), and other interventions consisted of administering medications-ketamine (23.72%), rocuronium bromide (15.78%), propofol (14.02%)-and procedures such as sedation (30.87%), as well as intubation (13.42%) and mechanical ventilation (13.23%). Conclusions: The burn patient profile indicates men with a mean age of 35 years. Nevertheless, HEMS crews often carry out missions to infants and newborns. The most common diagnosis was extensive body burns. In 63.74% of the missions, patients were transported to the Burn Treatment Center. The HEMS crews implement effective pharmacological analgesia, and handle rescue medications and procedures to stabilize the patient's condition.

The impact of different music genres on pain tolerance: emphasizing the significance of individual music genre preferences

Music is a promising (adjunctive) treatment for both acute and chronic pain, reducing the need for pharmacological analgesics and their side effects. Yet, little is known about the effect of different types of music. Hence, we investigated the efficacy of five music genres (Urban, Electronic, Classical, Rock and Pop) on pain tolerance. In this parallel randomized experimental study, we conducted a cold pressor test in healthy volunteers (n = 548). The primary outcome was pain tolerance, measured in seconds. No objective (tolerance time) or subjective (pain intensity and unpleasantness) differences were found among the five genres. Multinomial logistic regression showed that overall genre preference positively influenced pain tolerance. In contrast, the music genres that participants thought would help for pain relief did not. Our study was the first to investigate pain tolerance at genre level and in the context of genre preference without self-selecting music. In conclusion, this study provides evidence that listening to a favored music genre has a significant positive influence on pain tolerance, irrespective of the kind of genre. Our results emphasize the importance of individual music (genre) preference when looking at the analgesic benefits of music. This should be considered when implementing music in the clinical setting.

The effect of antenatal hypnosis training on pharmacological analgesia use during labour and birth: A systematic review and meta-analysis

BackgroundThe use of hypnosis as a means of pain management during labour is becoming increasingly popular. While recent reviews have reported on pain perception, relaxation and other psychological benefits the impact of hypnosis on the use of pharmacological analgesia use has not been specifically examined. QuestionFor women in labour at term, does antenatal hypnosis instruction compared to no instruction result in decreased use of pharmacological analgesia and influence maternal and infant birth outcomes. MethodsDatabases such as PubMed, CINAHL, Cochrane Central Register of Controlled Trials and Embase were searched with dates ranging from 1947-2024. We included randomised controlled trials (RCTs) that compared antenatal hypnosis training to no hypnosis control groups, published in English and reported on pharmacological analgesia use. The Cochrane's Risk of Bias 2 for RCTs was used to assess design quality. Study selection, quality assessment, data extraction and analysis were undertaken by two independent researchers. FindingsSix RCTs met the inclusion criteria (n=2937). The use of hypnosis did not result in a significant reduction in the risk of epidural use (RR. 0.79 95% CI 0.39-1.61) or other forms of pharmacological analgesia. Factors such as blinding of care providers to the participants allocated group may have reduced the chances of successful use of hypnosis. Variations in the presentation of hypnosis between studies may also impact on outcomes. Discussion and ConclusionThis review reports no effect on the use of pharmacological analgesia in women trained in hypnosis antenatally compared with those who were not. Our review does highlight several RCT design characteristics that could impact on the measurement and analysis of the use and efficacy of hypnosis.

Frontiers in Acute Pain Management: Emerging Concepts in Pain Pathways and the Role of VX-548 as a Novel NaV1.8 Inhibitor: A Narrative Review.

Despite ongoing research into alternative postsurgical pain treatments, opioids remain widely used analgesics regardless of associated adverse effects, including dependence and overdose, as demonstrated throughout the current opioid crisis. This is likely related to a failure in proving the efficacy of alternative analgesics in clinical trials, despite strong evidence supporting the potential for effective analgesia through in vitro studies. While NaV1.7 and NaV1.8 channels have shown to be key components of pain perception, studies regarding pharmacological agents utilizing these channels as targets have largely failed to demonstrate the efficacy of these proposed analgesics when compared to current multimodal pain treatment regimens. However, the novel NaV1.8 channel inhibitor, VX-548 has surpassed previously studied NaV1.8 inhibitors in clinical trials and continues to hold promise of a novel efficacious analgesic to potentially be utilized in multimodal pain treatment on postsurgical patients. Additionally, NaV1.8 is encoded by the SCN10A, which has been shown to be minimally expressed in the brain, suggesting a lower likelihood of adverse effects in the CNS, including dependence and abuse. Novel pharmacologic analgesics that are efficacious without the significant side effects associated with opioids have lacked meaningful development. However, recent clinical trials have shown promising results in the safety and efficacy of the pharmacological agent VX-548. Still, more clinical trials directly comparing the efficacy of VX-548 to standard of care post-surgical drugs, including opioids like morphine and hydromorphone are needed to demonstrate the long-term viability of the agent replacing current opioids with an unfavorable side effect profile.

Pharmacologic Analgesia for Cesarean Section: An Update in 2024.

With the increasing prevalence of cesarean section globally, the importance of perioperative analgesia for cesarean section is becoming increasingly evident. This article provides an overview and update on the current status of cesarean section worldwide and associated analgesic regimens. Some recent studies unveiled potential association of neuraxial analgesia might be associated with children's autism, pharmacologic analgesia in obstetric will potentially gain some more attention. Various commonly used techniques and medications for analgesia in cesarean section are highlighted. While neuraxial administration of opioid remains the most classic method, the use of multimodal analgesia, particularly integration of nonsteroidal anti-inflammatory drugs, acetaminophen, peripheral nerve blocks has provided additional and better options for patients who are not suitable for intrathecal and neuraxial techniques and those experiencing severe pain postoperatively. Optimal pain management is crucial for achieving better clinical outcomes and optimal recovery, and with the continuous development of medications, more and better pharmacologic regimen will be available in the future.

Risk Factors and Contemporary Management Options for Pain and Discomfort Experienced During a Prostate Biopsy.

Prostate fusion biopsy, an innovative imaging modality for diagnosing prostate cancer, presents certain challenges for patients including discomfort and emotional distress, leading to nonadherence to treatment and follow-ups. To inform clinicians and offer pain relief alternatives to patients, this review delves into the risk factors for increased pain and modern management options to alleviate pain during prostate biopsy. Individual responses to pain vary, and the overall experience of pain during a prostate biopsy has been contributed to numerous factors such as patient age, prostate volume, previous biopsy experience, and more. As a result, several strategies aim to mitigate pain during in-office procedures. Notably, techniques including pharmacological analgesics, hand holding, heating pads, entertainment/virtual reality, and distraction have shown significant efficacy. Existing studies explore risk factors influencing pain intensity during prostate biopsy and effective pain management strategies. This review consolidates available information to guide clinicians in enhancing patient comfort and thus, encourage surveillance adherence.

Clinical Limitations of Non-pharmacological Comfort Tools for Needle Sticks in Neonatal Intensive Care Units (NICU)

During a neonate’s stay in the neonatal intensive care unit (NICU), they will undergo many painful, but necessary, procedures to deliver treatment and to monitor physiological status. Many of these methods will involve skin breaks by a needle. While pharmacological analgesics are available for larger procedures like surgeries and intubation, the volume of painful procedures neonates must endure makes the use of pharmacological analgesics impractical for every painful procedure. Due to their immature nervous system, preterm neonates have limited ability to modulate pain. Recent studies have demonstrated that repeated pain endured during the neonatal period is associated with long-term neurological deficits. Over the past decades, studies have begun to quantify the effectiveness of non-pharmacological comfort tools (nonnutritive sucking, swaddling, oral sucrose, ShotBlocker, etc.) in reducing neonatal pain during needles sticks

Hypnosis-Assisted Awake Craniotomy for Eloquent Brain Tumors: Advantages and Pitfalls.

Awake craniotomy (AC) is recommended for the resection of tumors in eloquent areas. It is traditionally performed under monitored anesthesia care (MAC), which relies on hypnotics and opioids. Hypnosis-assisted AC (HAAC) is an emerging technique that aims to provide psychological support while reducing the need for pharmacological sedation and analgesia. We aimed to compare the characteristics and outcomes of patients who underwent AC under HAAC or MAC. We retrospectively analyzed the clinical, anesthetic, surgical, and neuropsychological data of patients who underwent awake surgical resection of eloquent brain tumors under HAAC or MAC. We used Mann-Whitney U tests, Wilcoxon signed-rank tests, and repeated-measures analyses of variance to identify statistically significant differences at the 0.05 level. A total of 22 patients were analyzed, 14 in the HAAC group and 8 in the MAC group. Demographic, radiological, and surgical characteristics as well as postoperative outcomes were similar. Patients in the HAAC group received less remifentanil (p = 0.047) and propofol (p = 0.002), but more dexmedetomidine (p = 0.025). None of them received ketamine as a rescue analgesic. Although patients in the HAAC group experienced higher levels of perioperative pain (p < 0.05), they reported decreasing stress levels (p = 0.04) and greater levels of satisfaction (p = 0.02). HAAC is a safe alternative to MAC as it reduces perioperative stress and increases overall satisfaction. Further research is necessary to assess whether hypnosis is clinically beneficial.

Mechanisms and Preventative Strategies for Persistent Pain following Knee and Hip Joint Replacement Surgery: A Narrative Review.

Chronic postsurgical pain (CPSP) following total knee arthroplasty (TKA) and total hip arthroplasty (THA) is a prevalent complication of joint replacement surgery which has the potential to decrease patient satisfaction, increase financial burden, and lead to long-term disability. The identification of risk factors for CPSP following TKA and THA is challenging but essential for targeted preventative therapy. Recent meta-analyses and individual studies highlight associations between elevated state anxiety, depression scores, preoperative pain, diabetes, sleep disturbances, and various other factors with an increased risk of CPSP, with differences observed in prevalence between TKA and THA. While the etiology of CPSP is not fully understood, several factors such as chronic inflammation and preoperative central sensitization have been identified. Other potential mechanisms include genetic factors (e.g., catechol-O-methyltransferase (COMT) and potassium inwardly rectifying channel subfamily J member 6 (KCNJ6) genes), lipid markers, and psychological risk factors (anxiety and depression). With regards to therapeutics and prevention, multimodal pharmacological analgesia, emphasizing nonopioid analgesics like acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs), has gained prominence over epidural analgesia. Nerve blocks and local infiltrative anesthesia have shown mixed results in preventing CPSP. Ketamine, an N-methyl-D-aspartate (NMDA)-receptor antagonist, exhibits antihyperalgesic properties, but its efficacy in reducing CPSP is inconclusive. Lidocaine, an amide-type local anesthetic, shows tentative positive effects on CPSP. Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) have mixed results, while gabapentinoids, like gabapentin and pregabalin, present hopeful data but require further research, especially in the context of TKA and THA, to justify their use for CPSP prevention.

The comparison of the effect of non-pharmacological pain relief and pharmacological analgesia with remifentanil on fear of childbirth and postpartum depression: a randomized controlled clinical trial

IntroductionChildbirth may be associated with psychological, social, and emotional effects and provide the background for women’s health or illness throughout their life. This research aimed at comparing the impact of non-pharmacological pain relief and pharmacological analgesia with remifentanil on childbirth fear and postpartum depression.Materials and methodThis randomized clinical trial with two parallel arms was conducted on 66 women with term pregnancy referred to Taleghani Hospital in Tabriz for vaginal delivery during September 2022 to September 2023. First, all of the eligible participants were selected through Convenience Sampling. Then, they were randomly assigned into two groups of pharmacological analgesia with remifentanil and non-pharmacological analgesia with a ratio of 1:1 using stratified block randomization based on the number of births. Before the intervention, fear of childbirth (FOC) was measured using Delivery Fear Scale (DFS) between 4 and 6 cm cervical dilatation. Pain and fear during labor in dilatation of 8 cm were measured in both groups using VAS and DFS. After delivery, FOC was assessed using Delivery Fear Scale (W DEQ Version B) and postpartum depression using the Edinburgh’s postpartum depression scale (EPDS). Significance level was considered 0.05. Mean difference (MD) was compared with Independent T-test and ANCOVA pre and post intervention.ResultsThe mean score of FOC in the non-pharmacological analgesia group was significantly lower than that in the pharmacological analgesia group after the intervention by controlling the effect of the baseline score (MD: -6.33, 95%, Confidence Interval (CI): -12.79 to -0.12, p = 0.04). In the postpartum period, the mean score of FOC in the non-pharmacological analgesia group was significantly lower than that in the pharmacological analgesia group after controlling the effect of the baseline score (MD: -21.89; 95% CI: -35.12 to -8.66; p = 0.002). The mean score of postpartum depression in the non-pharmacological analgesia group was significantly lower than that in the pharmacological analgesia group (MD: -1.93, 95% CI: -3.48 to -0.37, p = 0.01). Trial registration: Iranian Registry of Clinical Trials (IRCT): IRCT20170506033834N10. Date of registration: 05/07/2022 Date of first registration: 05/07/2022. URL: https://www.irct.ir/trial/61030; Date of recruitment start date05/07/2022.ConclusionThe study results indicated a reduction in FOC and postpartum depression among parturient women receiving non-pharmacological strategies with active participation in childbirth compared to women receiving pharmacological analgesia. Owing to the possible side effects of pharmacological methods for mother and fetus, non-pharmacological strategies with active participation of the mother in childbirth are recommended to reduce the FOC and postpartum depression.

Incorporation, adaptation and rejection of obstetric practices during the implementation of the “Adequate Childbirth Program” in Brazilian private hospitals: a qualitative study

BackgroundThe “Adequate Childbirth Program” (PPA) is a quality improvement project that aims to reduce the high rates of unnecessary cesarean section in Brazilian private hospitals. This study aimed to analyze labor and childbirth care practices after the first phase of PPA implementation.MethodThis study uses a qualitative approach. Eight hospitals were selected. At each hospital, during the period of 5 (five) days, from July to October 2017, the research team conducted face to face interviews with doctors (n = 21) and nurses (n = 28), using semi-structured scripts. For the selection of professionals, the Snowball technique was used. The interviews were transcribed, and the data submitted to Thematic Content Analysis, using the MaxQda software.ResultsThe three analytical dimensions of the process of change in the care model: (1) Incorporation of care practices: understood as the practices that have been included since PPA implementation; (2) Adaptation of care practices: understood as practices carried out prior to PPA implementation, but which underwent modifications with the implementation of the project; (3) Rejection of care practices: understood as those practices that were abandoned or questioned whether or not they should be carried out by hospital professionals.ConclusionsAfter the PPA, changes were made in hospitals and in the way, women were treated. Birth planning, prenatal hospital visits led by experts (for expecting mothers and their families), diet during labor, pharmacological analgesia for vaginal delivery, skin-to-skin contact, and breastfeeding in the first hour of life are all included. To better monitor labor and vaginal birth and to reduce CS without a clinical justification, hospitals adjusted their present practices. Finally, the professionals rejected the Kristeller maneuver since research has demonstrated that using it’s harmful.

Transcutaneous electrical nerve stimulation for the treatment of acute postoperative pain following spine surgery: a scoping review.

Given the ubiquity and severity of postoperative pain following spine surgery, developing adequate pain management modalities is critical. Transcutaneous electrical nerve stimulation (TENS) is a promising noninvasive modality that is well studied for managing postoperative pain following a variety of surgeries, but data on using TENS for pain management in the acute postoperative period of spine surgery are limited. Therefore, this review aimed to recapitulate the existing evidence for the use of TENS in postoperative pain management for spine surgery and explore the potential of this modality moving forward. A scoping review was conducted according to 2020 PRISMA guidelines. Two independently operating reviewers then conducted a systematic search of PubMed, Embase, and Scopus databases to identify studies that reported the use of TENS for the treatment of acute postoperative pain following spine surgery. The following data were abstracted from included studies: study type, sample size, demographics, surgery details, comparison group, assessment parameters, timing of postoperative assessment, TENS technical characteristics, relevant findings, length of hospital stay, complications with TENS, and notable limitations. Nine hundred thirty-two publications were screened, resulting in 6 studies included in this review, all of which were prospective clinical trials. The publication dates ranged from 1980 to 2011. Spine surgery types varied; the most common was posterior lumbar interbody fusion. No studies evaluated pain control in cervical- or thoracic-only surgeries. All 6 studies evaluated the level of postoperative pain directly. Five of the 6 studies that directly examined postoperative pain reported lower levels of pharmacological analgesia usage in the TENS groups compared with controls, with 4 of these studies reporting this difference as statistically significant. Length of hospital stay was evaluated in 2 studies, both of which reported decreases in mean length of stay, but these differences were not significant. Notably, every study reported distinct TENS administration parameters while also reporting similar results. This review concludes that TENS is effective at reducing postoperative pain in spine surgery. Further investigation is needed regarding the optimal settings for TENS administration, as well as efficacy in the thoracic and cervical spine.

Impact of Hypnotherapy on Fear, Pain, and the Birth Experience: A Systematic Review.

In recent times, research has been conducted on the use of hypnosis during childbirth preparation and its effects on pain, fear, and overall childbirth experience. The main objective of this study was to analyze the published scientific literature on the use of hypnotherapy during childbirth preparation and the outcomes achieved during labor. A systematic literature review was conducted following the PRISMA 2020 protocol, with a search performed on the PubMed, Cinahl, Scopus, and WOS databases. Studies meeting inclusion criteria, including randomized controlled trials (RCTs), were evaluated for methodological quality using the PEDro scale. The searches yielded a total of 84 results, from which 7 RCTs of high scientific quality were selected. Each article examined the impact of a hypnosis intervention during pregnancy and the results obtained during labor. The analysis covered the use of epidural anesthesia, pharmacological analgesia during labor, self-reported pain, labor duration, type of delivery, fear of childbirth, and childbirth experience. The results demonstrated benefits in reducing fear and pain during labor, along with an enhancement in the overall childbirth experience. Hypnotherapy can be a valuable resource for reducing fear and pain during labor and improving the lived childbirth experience.

Analgesia for rib fractures: a narrative review.

Rib fracture(s) is a common and painful injury often associated with significant morbidity (e.g., respiratory complications) and high mortality rates, especially in the elderly. Risk stratification and prompt implementation of analgesic pathways using a multimodal analgesia approach comprise a primary endpoint of care to reduce morbidity and mortality associated with rib fractures. This narrative review aims to describe the most recent evidence and care pathways currently available, including risk stratification tools and pharmacologic and regional analgesic blocks frequently used as part of the broadly recommended multimodal analgesic approach. Available literature was searched using PubMed and Embase databases for each topic addressed herein and reviewed by content experts. Four risk stratification tools were identified, with the Study of the Management of Blunt Chest Wall Trauma score as most predictive. Current evidence on pharmacologic (i.e., acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamine, lidocaine, and dexmedetomidine) and regional analgesia (i.e., thoracic epidural analgesia, thoracic paravertebral block, erector spinae plane block, and serratus anterior plane block) techniques was reviewed, as was the pathophysiology of rib fracture(s) and its associated complications, including the development of chronic pain and disabilities. Rib fracture(s) continues to be a serious diagnosis, with high rates of mortality, development of chronic pain, and disability. A multidisciplinary approach to management, combined with appropriate analgesia and adherence to care bundles/protocols, has been shown to decrease morbidity and mortality. Most of the risk-stratifying care pathways identified perform poorly in predicting mortality and complications after rib fracture(s).

Global cross-sectional survey on neonatal pharmacologic sedation and analgesia practices and pain assessment tools: impact of the sociodemographic index (SDI).

There is variability in the use of sedatives and analgesics in neonatal intensive care units (NICUs). We aimed to investigate the use of analgesics and sedatives and the management of neonatal pain and distress. This was a global, prospective, cross-sectional study. A survey was distributed May-November 2022. The primary outcome of this research was to compare results between countries depending on their socio-sanitary level using the sociodemographic index (SDI). We organized results based on geographical location. The survey collected 1304 responses, but we analyzed 924 responses after database cleaning. Responses from 98 different countries were analyzed. More than 60% of NICUs reported having an analgosedation guideline, and one-third of respondents used neonatal pain scales in more than 80% of neonates. We found differences in the management of sedation and analgesia between NICUs on different continents, but especially between countries with different SDIs. Countries with a higher SDI had greater availability of and adherence to analgosedation guidelines, as well as higher rates of analgosedation for painful or distressing procedures. Countries with different SDIs reported differences in analgosedation for neonatal intubation, invasive ventilation, and therapeutic hypothermia, among others. Socio-economic status of countries impacts on neonatal analgosedation management. There is significant variability in the pain management practices in neonates. There is a lack of knowledge related to how neonatal pain management practices differ between regions. Sociodemographic index is a key factor associated with differences in neonatal pain management practices across global regions.

Increasing the use of anxiolysis and analgesia for paediatric procedures in a community emergency department network: a quality improvement initiative

Prior reports describe the care children receive in community EDs (CEDs) compared with paediatric EDs (PEDs) as uneven. The Emergency Medical Services for Children (EMSC) initiative works to close these...

Let Kids Play: Using Virtual Reality as a Substitute for General Anesthesia for Minor Procedures in Pediatric Population

BackgroundIn the pediatric population, virtual reality (VR) has been used as an adjunct to augment analgesia and reduce the need for opioids. In this study, we review our experience using VR in lieu of anesthesia or sedation to enable minor procedures in children. MethodsA retrospective chart review study was performed on patients who presented to our institution from 2019 to 2022 for hormone implant placement, exchange, or removal with VR distraction. Demographic and procedure information was recorded. The primary outcome was successful procedure completion without requiring pharmacologic sedation or analgesia. ResultsA total of 111 patients underwent the following minor procedures with VR and without anesthesia or sedation. Fourteen patients had multiple encounters resulting in a total of 126 encounters. The median age was 11 [6] years. 43 patients were female, 23 were female to male, 6 were non-binary, 7 were male, and 32 were male to female. 58 % had private insurance. Most common diagnosis was precocious puberty (54 %) followed by gender dysphoria (46 %). Most common procedure was implant placement (72 %). 69 % of procedures were performed in the clinic and 31 % in the OR. All procedures were completed without requiring the administration of additional sedation or anesthesia. None of the patients required intravenous catheter placement for the procedure. No intra-procedural complications were recorded. ConclusionVR is a feasible option that can spare children from sedation or general anesthesia for minor procedures. VR may enable minor procedures in children to be successfully performed in clinic setting. Level of Evidence4

Chronic pelvic pain: An underrecognised perioperative consideration

Chronic pelvic pain (CPP) is a prevalent disorder amongst women. The physiology of CPP is attributed to various neurophysiological mechanisms and endometriosis, adenomyosis, chronic infection and functional disorders such as irritable bowel syndrome or interstitial cystitis are all diseases which fall under the umbrella term of CPP. CPP and its associated multitude of causes can affect perioperative care through several mechanisms. Patients with CPP may be more likely to experience significant pain in the perioperative setting and preoperative pain can be a predictor of post-operative pain. Thus, optimisation of CPP prior to the perioperative period is an important consideration. Currently limited and conflicting evidence exists regarding the peri-operative pharmacological analgesia. The various aetiologies of CPP and patient medical history result in the inability to generalise one analgesic regime. Areas of further research includes neuromodulation techniques, genomic and proteomic biomarker studies and the applicability of artificial intelligence.

Transcutaneous electrical nerve stimulation (TENS) versus sham TENS in adult ED patients with abdominal pain: A clinical trial

ObjectiveThere is a growing consensus that the risks of current pharmacologic analgesics warrant consideration of alternative modalities for acute and chronic pain control. The objective of this study was to evaluate the effectiveness of transcutaneous electrical nerve stimulation (TENS) in adult emergency department (ED) patients presenting with abdominal pain. MethodsWe conducted a patient and observer blinded randomized controlled trial comparing TENS to sham TENS. The study was conducted at a large suburban academic ED. Patients with abdominal pain and a verbal numeric pain scale (VNS) of 5 or greater were randomized to TENS or sham TENS applied via 4 skin pads, one in each abdominal quadrant for 30 min. The primary outcome was change in pain scores 30 min after the intervention. Our study had 80% power to detect a between group difference of 1.5 points on the VNS. Results81 patients were randomized to TENS (n = 41) or sham TENS (n = 40). Groups were similar in baseline characteristics. The mean (SD) reductions in pain scores were 1.9 (2.1) and 1.7 (2.6) in patients treated with TENS and sham TENS respectively (P = 0.81). Use of rescue medications in patients with treated with TENS and sham TENS was similar (49 vs 55% respectively, P = 0.66). ConclusionsApplication of TENS to the abdominal wall did not result in more effective pain relief than sham TENS in adult ED patients with abdominal pain.