Postanesthesia Care Unit Pain Scores Research Articles

Music Listening as a Postanesthesia Care Unit (PACU) Nursing Intervention for Laparoscopic Radical Prostatectomy Patients: A Mixed Method Randomized Comparative Clinical Trial

<h3>Introduction/Background</h3> Laparoscopic radical prostatectomy surgery patients have reported severe pain post operatively and experienced psychological distress for potential urinary incontinence and sexual dysfunction. Over this past year, PACU nurses identified anxiety and pain management as the primary cause of these patients' increased length of stay in PACU. <h3>Identification of the problem</h3> Patients undergoing major cancer surgery frequently express increased anxiety about how severe their pain will be as well as their oncology surgical outcomes. Mid-Atlantic academic teaching hospital's postanesthesia care unit (PACU) Standards of Care Committee met to discuss investigating complementary music listening methods to enhance pharmacologic pain management to address concerns in this surgical population. <h3>Purpose of the Study</h3> To compare two methods of music listening interventions on anxiety, pain, heart rate, blood pressure, and oxygen saturation among post anesthesia care unit (PACU) patients who are recovering from laparoscopic radical prostatectomy surgeries: a) patient-preferred music listening via Spotify selections; and b) relaxation breathing narrative over minimalistic hypnotic music. <h3>Methodology</h3> Randomization of participants by computer-generated table of random numbers for effective balance between the two groups. A power analysis was calculated to have 77 male participants: Group I (n=37) and Group II (n=40). Inclusion criteria/exclusion criteria established. Nurses blinded to study interventions. The study started in December 2019 and concluded in December 2020. Data collection began in PreOP and continued through discharge. <h3>Results</h3> Both Groups I and II had reduced pain scores at discharge as compared to PACU admission; both groups had significant reduction (p=0.046 Group I, and Group II (p=0.002), but changes for comparative groups (I and II) were not significant between the two groups (p=0.53). <h3>Discussion</h3> Both interventions reduced State Trait Anxiety Inventory scores and pain scores to a similar degree; this reduction was clinically and statistically significant. Pain medication use did not differ between the two groups. Notably, three study participants did not require any pain medication throughout their entire PACU stay. Qualitative inquiry question on discharge revealed significant relaxation, distraction, pain relief, and comfort when listening to music. <h3>Conclusion</h3> Study revealed both relaxation/breathing track and personally selected music can meaningfully improve patients' anxiety and PACU pain scores. <h3>Implications for perianesthesia nurses and future research</h3> Future multicenter studies of music listening methods should be studied in other surgical/procedural patients recovering in PACU.

Preoperative Cryoneurolysis for Total Knee Arthroplasty: A Case Series

PurposeThe purpose of this pilot project case series is to describe the use of preoperative cryoneurolysis for 10 patients presenting for total knee arthroplasty (TKA). DesignDescriptive research design. MethodsBilling codes were used to identify 10 patients who had previously undergone TKA, preoperative cryoneurolysis and physical therapy (PT) at a Midwestern community hospital. Data collected included anesthetic management strategies, multimodal analgesic therapies, postanesthesia care unit pain scores (PACU), pain scores during physical therapy, and achievement of a range of motion during physical therapy. FindingsNine of 10 patients who received preoperative cryoneurolysis had PACU pain scores of 0 (0-10 scale) up to 90 minutes postoperatively. Pain scores immediately following cryoneurolysis therapy were reduced in all patients reporting pain greater than 0 (1-10 pain scale) before their treatment. Increased active range of motion trends were noted with reports of decreased pain scores during postoperative physical therapy sessions. ConclusionsThis pilot project case series demonstrates potential benefits of using preoperative cryoneurolysis to provide postoperative pain control and aid with physical therapy recovery following TKA.

Dexmedetomidine reduces postoperative pain and speeds recovery after bariatric surgery: a meta-analysis of randomized controlled trials.

Dexmedetomidine in opioid-sparing analgesia promotes enhanced recovery and improves postoperative outcomes. This study aimed to explore the safety and efficacy of dexmedetomidine in bariatric surgery. Meta-analysis. We selected studies from Pubmed, Embase, Web of Science, and the Cochrane Central Registry of Controlled Trials before 20 April, 2021. The primary outcomes were pain scores and intravenous morphine equivalents (IVME) in the post anesthesia care unit (PACU) and postoperative day 1 (POD1). The secondary outcomes included postoperative nausea and vomiting (PONV), the length of hospital stay (LOS), intraoperative mean arterial pressure (MAP) and heart rate (HR). We extracted 697 participants from 10 randomized controlled trials. Dexmedetomidine reduced PACU pain scores (MD = -1.51, 95% confidence interval [CI]: -2.60 to -.42) after bariatric surgery, especially laparoscopic Roux-en-Y gastric bypass (MD = -3.05, 95%CI: -3.77 to -2.33), but it did not affect POD1 pain scores (MD = .20, 95%CI: -.85 to 1.26). Dexmedetomidine can reduce PACU IVME (MD = -4.29, 95%CI: -6.59 to -1.99), but does not reduce POD1 IVME (MD = -.36, 95%CI: -2.41 to 1.68). In addition, dexmedetomidine significantly reduced PONV both in PACU (OR = .28, 95%CI: .14-.54) and POD1 (OR = .24, 95%CI: .14-.4), shortened LOS (MD = -.29, 95%CI: -.49 to -.10), and had little effect on intraoperative MAP (MD = -6.64, 95%CI: -9.52 to -3.76) and HR (MD = -4.8, 95%CI: -11.55 to 1.94). In conclusion, the use of dexmedetomidine in opioid-sparing analgesia contributes to postoperative analgesia after bariatric surgery, but the heterogeneity was high. In addition, dexmedetomidine is beneficial for enhanced recovery.

Music Listening as a Postanesthesia Care Unit (PACU) Nursing Intervention for Laparoscopic Radical Prostatectomy Patients: A Randomized Comparative Clinical Trial

PurposeRandomized comparative mixed method approach with qualitative inquiry study's aim sought to determine if there was a difference in pre/post-intervention State-Trait Anxiety Inventory (STAI) scores and postanesthesia pain scores between two music listening groups of laparoscopic radical prostatectomy patients. DesignProspective randomized comparative mixed method approach with a qualitative inquiry. MethodsSample size of 77 male participants assigned by a table of random numbers to Spotify patient-preferred music selection Group I (n = 37) or minimalist hypnotic music with guided relaxation breathing (MHMGRB) instructional narrative Group II (n = 40). Outcome measures used patients’ STAI questionnaire and reported PACU admission and discharge pain scores. ResultsBoth Groups I and II had reduced pain scores at discharge as compared to admission; both groups had a significant reduction (P = .046 Group I, and Group II (P = .002), but changes for comparative groups (I and II) were not significant between the two groups (P = .53). ConclusionsStudy revealed that both patient-preferred selected music and MHMGRB can meaningfully reduce patients’ anxiety and PACU pain scores.

Effects of an opioid stewardship program on opioid consumption and related outcomes after multilevel lumbar spine fusion: a pre- and postimplementation analysis of 268 patients.

Opioid stewardship programs combine clinical, regulatory, and educational interventions to minimize inappropriate opioid use and prescribing for orthopedic and spine surgery. Most evaluations of stewardship programs quantify effects on prescriber behavior, whereas patient-relevant outcomes have been relatively neglected. The authors evaluated the impact of an opioid stewardship program on perioperative opioid consumption, prescribing, and related clinical outcomes after multilevel lumbar fusion. The study was based on a retrospective, quasi-experimental, pretest-posttest design in 268 adult patients who underwent multilevel lumbar fusion in 2016 (preimplementation, n = 141) or 2019 (postimplementation, n = 127). The primary outcome was in-hospital opioid consumption (morphine equivalent dose [MED], mg). Secondary outcomes included numeric rating scale pain scores (0-10), length of stay (LOS), incidence of opioid-induced side effects (gastrointestinal, nausea/vomiting, respiratory, sedation, cognitive), and preoperative and discharge prescribing. Outcomes were measured continuously during the hospital admission. Differences in outcomes between the epochs were assessed in bivariable (Wilcoxon signed-rank or Fisher's exact tests) and multivariable (Wald's chi-square test) analyses. In bivariable analyses, there were significant decreases in preoperative opioid use (46% vs 28% of patients, p = 0.002), preoperative opioid prescribing (MED 30 mg [IQR 20-60 mg] vs 20 mg [IQR 11-39 mg], p = 0.003), in-hospital opioid consumption (MED 329 mg [IQR 188-575 mg] vs 199 mg [100-372 mg], p < 0.001), the incidence of any opioid-related side effect (62% vs 50%, p = 0.03), and discharge opioid prescribing (MED 90 mg [IQR 60-135 mg] vs 60 mg [IQR 45-80 mg], p < 0.0001) between 2016 and 2019. There were no significant differences in postanesthesia care unit pain scores (4 [IQR 3-6] vs 5 [IQR 3-6], p = 0.33), nursing floor pain scores (4 [IQR 3-5] vs 4 [IQR 3-5], p = 0.93), or total LOS (118 hours [IQR 81-173 hours] vs 103 hours [IQR 81-132 hours], p = 0.21). On multivariable analysis, the opioid stewardship program was significantly associated with decreased discharge prescribing (Wald's chi square = 9.45, effect size -52.4, 95% confidence interval [CI] -86 to -19.0, p = 0.002). The number of lumbar levels fused had the strongest effect on total opioid consumption during the hospital stay (Wald's chi square = 16.53, effect size = 539, 95% CI 279.1 to 799, p < 0.001), followed by preoperative opioid use (Wald's chi square = 44.04, effect size = 5, 95% CI 4 to 7, p < 0.001). A significant decrease in perioperative opioid prescribing, consumption, and opioid-related side effects was found after implementation of an opioid stewardship program. These gains were achieved without adverse effects on pain scores or LOS. These results suggest the major impact of opioid stewardship programs for spine surgery may be on changing prescriber behavior.

Liposomal compared to 0.25% bupivacaine in patients undergoing hemorrhoidectomy: A pre- and post-implementation quality improvement evaluation

Study objectiveThe efficacy of infiltration of liposomal bupivacaine against an active comparator, such as bupivacaine, remains debated on acute postoperative pain control. We evaluated the analgesic efficacy, patient satisfaction, and side effects of liposomal bupivacaine compared to bupivacaine during hemorrhoidectomy procedures. DesignA pre- and post-implementation quality improvement evaluation. SettingOperating room and post-anesthesia care unit. PatientsNinety-four consecutive adult patients with hemorrhoid surgery between October 2019 and November 2020. InterventionsA preintervention control group of 0.25% bupivacaine (50 ml, 125 mg, n = 47) and a postintervention group of liposomal bupivacaine (30 ml, 266 mg, n = 47) for perianal local anesthetic administration. MeasurementsThe primary endpoint was analgesic efficacy of liposomal bupivacaine compared to bupivacaine based on a reduction in the number of patients administered opioids and patient-reported pain scores in the postanesthesia care unit (PACU). Secondary endpoints included constipation, post-discharge patient-reported pain management satisfaction, and opioid prescription refill requests in telephonic interviews three days after surgery. Main resultsPACU peak pain scores were significantly higher in the bupivacaine compared to the liposomal bupivacaine group (median 3 [IQR 0–6] vs. 0 [IQR 0–4], p = 0.03), respectively with no differences in PACU discharge pain scores. There was no difference in the frequency of rescue opioid use (38.2% vs. 25.5%, p = 0.18) or the morphine milligram equivalents administered to each of those patients (median 15 [IQR 10–23] vs. 15 [IQR 15–25], p = 0.39) in the PACU comparing the bupivacaine and liposomal bupivacaine groups respectively. Secondary endpoints were similar in each group with respect to requests for opioid refills (10.6 vs. 12.8%, p = 0.75), >75% satisfied with their pain management (p = 0.94), and constipation reported on day 3 after surgery (p = 0.07). ConclusionsLiposomal bupivacaine compared to a bupivacaine perianal block reduces early PACU pain scores without affecting opioid refill requests, has a similarly low incidence of complications, and high satisfaction in both groups.

Sacroiliac Joint Fusion Using Robotic Navigation: Technical Note and Case Series.

Patients undergoing sacroiliac (SI) fusion can oftentimes experience significant improvements in pain and quality of life. To describe a novel application of robotic navigation to assist with minimally invasive SI joint fusion. Patients undergoing stand-alone SI joint fusion with ExcelsiusGPS robotic navigation from July 2020 through June 2021 were retrospectively enrolled. Baseline demographic and perioperative variables including radiation exposure, postoperative pain scores, and narcotic requirements in the postanesthesia care unit (PACU) were recorded. Length of stay and any postoperative complications were also noted. A total of 10 patients (64.4 ± 8.2 years, body mass index 28.7 ± 4.8 kg/m2) met inclusion criteria. Seven patients (70.0%) were female, and there was a 6:4 split between left-sided and right-sided SI joint fusion. The total operative time was 54 ± 9 minutes, and the estimated blood loss was 21.0 ± 16.7 mL. The intraoperative radiation exposure was 13.7 ± 6.2 mGy, and there were no complications. The average pain score in PACU was 5.2 ± 1.0, and the average opioid administration in PACU was 27.6 ± 10.3 morphine equivalents. Length of stay was 0.4 ± 0.7 days, with 7 of 10 patients discharged on the same day as surgery. There were no readmissions. The average length of follow-up was 4.3 ± 2.5 months. At the last follow-up, patients reported an average of 73.1% ± 30.1% improvement in their preoperative pain. Robot-navigated SI joint fusion is a feasible and reproducible method for addressing refractory SI joint disease. Further investigation on clinical outcomes and long-term fusion rates is needed, as are studies comparing robot-navigated SI joint fusion with more traditional techniques.

313 Sacroiliac Joint Fusion Using Robotic Navigation: Technical Note and Case Series

INTRODUCTION: Degenerative sacroiliac (SI) joint disease can cause significant pain and disability. Patients undergoing SI fusion can oftentimes experience significant improvements in pain and quality of life. METHODS: Patients undergoing standalone SI joint fusion from July 2020 through June 2021 were retrospectively enrolled. Demographic and comorbid variables collected included age, sex, body mass index, and laterality. Recorded operative variables included operative time, estimated blood loss, and any intraoperative complications. Pain scores in the post-anesthesia care unit (PACU) were recorded using the visual analogue scale (VAS) every 30 minutes, as were total morphine equivalents for PACU administered intravenous and oral narcotic pain medications according to pain scales. Length of stay and any postoperative complications including 30-day inpatient admissions or emergency department (ED) presentations were also recorded. Intraoperative radiation exposure was also recorded. RESULTS: A total of 8 patients were analyzed. Average patient age was 65.6 ± 7.6 years with BMI of 28.2 ± 3.6 kg/m2. Four (50.0%) patients were female and equal numbers of left and right-sided SI joint fusions were performed. Average operative time was 56 ± 9 minutes, and average estimated blood loss was 22.5 ± 18.7cc. Average intraoperative radiation exposure was 12.7 ± 6.7 mGy and there were no intraoperative complications. Average pain scores in PACU were 5.1 ± 1.0 with average maximum pain score of 7.6 ± 1.7 and average minimum pain score of 2.0 ± 2.2. Average narcotic administration in PACU was 22.8 ± 11.1 morphine equivalents. Average length of stay was 0.4 ± 0.8 days, with 75% of patients discharged on the same day of surgery. Two patients required inpatient stay: one patient required intravenous pain medications overnight and one patient had shortness of breath without clear etiology, resolved without sequela. No patients presented back to the ED or were admitted within 30-days of surgery. CONCLUSION: Robot-navigated SI joint fusion is a feasible and reproducible method for addressing refractory sacroiliac joint disease. Further investigation on clinical outcomes and long-term fusion rates is needed, as are studies comparing robot-navigated SI joint fusion to more traditional techniques.

An Opioid Sparing Anesthesia Protocol for Pediatric Open Inguinal Hernia Repair: A Quality Improvement Project.

Introduction:Using plan-do-study-act (PDSA) cycles, this quality improvement (QI) project aimed to standardize an anesthetic protocol to optimize multimodal pain management for pediatric open inguinal hernia repair (OIHR).Methods:PDSA cycle 1: in December 2017, we standardized the intraoperative OIHR anesthesia protocol by replacing transversus abdominis plane (TAP) or ilioinguinal-iliohypogastric (II) blocks and fentanyl with exclusively II blocks and fentanyl. PDSA cycle 2: in January 2019, we used an opioid sparing strategy, replacing II blocks and fentanyl with II blocks and dexmedetomidine. We used statistical process control (SPC) charts to analyze data from the medical record. Outcome measures included the percent of patients requiring rescue morphine in the postanesthesia care unit (PACU), maximum PACU pain score, PACU length of stay (LOS), and anesthesia preparation duration.Results:The team performed a total of 641 pediatric OIHRs between July 2015 and June 2021. The three groups included 203 patients in our baseline group, 127 patients in the PDSA cycle 1 group, and 311 patients in the PDSA cycle 2 group. Special cause variation (SCV) occurred for the percent of patients requiring rescue morphine, anesthesia preparation duration, and PACU LOS. The percent of patients requiring rescue morphine showed improvement. Anesthesia preparation duration improved compared to baseline. There was no SCV detected in the SPC chart for maximum PACU pain score.Conclusion:We implemented an opioid sparing anesthetic protocol for pediatric OIHR utilizing II blocks and dexmedetomidine without adversely affecting postoperative pain score or morphine rescue rate over 6 years.

The impact of fascia iliaca nerve blockade on early postoperative pain and recovery after hip arthroscopy for femoroacetabular impingement syndrome.

ABSTRACTFascia iliaca nerve blockade (FIB) has been previously described as an effective technique for reducing postoperative pain and opioid consumption after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). We hypothesize that an FIB will significantly reduce opioid consumption, pain scores and recovery time in our population. A retrospective observational study of 326 consecutive patients undergoing hip arthroscopy for FAIS at a single institution was performed. Patients were classified based on whether or not they received an FIB. Patient demographics, surgical details, medication details and 6-month postoperative outcomes were collected. The primary endpoint was the amount of narcotics required intraoperatively and in the postanesthesia care unit (PACU). Of the 326 patients included in the study, 37 received an FIB. No differences in sex, age or other surgical details were observed between groups. Patients receiving an FIB were more likely to receive celecoxib (P < 0.001), pregabalin (P = 0.001) and methocarbamol (P = 0.002). The FIB group received lower doses of narcotics intraoperatively (P = 0.001), postoperatively (P < 0.001) and in total (P < 0.001). The FIB group also self-reported lower first pain scores upon arrival to PACU (P = 0.001) and experienced shorter PACU recovery times (P < 0.001). After controlling for differences between groups, patients who received an FIB required significantly lower amounts of narcotics, had shorter PACU times and lower first PACU pain score than those who did not (P < 0.001). No differences in complication rates were noted between groups. The use of FIB resulted in lower pain scores, reduced recovery time and decreased early postoperative narcotic requirements for patients undergoing hip arthroscopy for femoroacetabular impingement. Further study is required to validate these findings and determine the optimal approach to regional analgesia in this patient population.

Recent Preoperative Concussion and Postoperative Complications: A Retrospective Matched-cohort Study.

Physiological alterations during the perianesthetic period may contribute to secondary neurocognitive injury after a concussion. Patients exposed to concussion and who received an anesthetic within 90 days were matched to unexposed patients without concussion. Intraoperative and postoperative events were compared. Subgroup analyses assessed relationships among patients with a concussion in the prior 30, 31 to 60, and 61 to 90 days and their respective unexposed matches. To facilitate identification of potential targets for further investigation, statistical comparisons are reported before, as well as after, correction for multiple comparisons. Sixty concussion patients were matched to 176 unexposed patients. Before correction, 28.3% postconcussion versus 14.8% unexposed patients reported postanesthesia care unit pain score≥7 (P=0.02); 16.7% concussion versus 6.5% unexposed patients reported headache within 90 days of anesthesia (P=0.02) and 23.5% of patients who received surgery and anesthesia within 30 days of concussion experienced headache within 90 days of anesthesia compared with 7.1% in the unexposed group (P=0.01). Patients who experienced concussion and had anesthesia between 31 and 60 days after injury had a postanesthesia care unit Richmond Agitation and Sedation Scale score of -1.61±1.29 versus a score of -0.2±0.45 in unexposed patients (P=0.002). After adjusting the P-value threshold for multiple comparisons, the P-value for significance was instead 0.0016 for the overall cohort. Our study revealed no significant associations with application of adjusted significance thresholds. There were no differences in intraoperative and postoperative outcomes in patients with recent concussion compared with unexposed patients. Before correction for multiple comparisons, several potential targets for further investigation are identified. Well-powered studies are warranted.

Clinical effect of normal saline injectate into interscalene nerve block catheters given within one hour of local anesthetic bolus on analgesia and hemidiaphragmatic paralysis

BackgroundPrevious case reports describe the reversal of phrenic nerve blockade from the interscalene nerve block using normal saline injectate washout. This randomized clinical trial aimed to evaluate whether using normal...

Opioid-Sparing Anesthetic Technique for Pediatric Patients Undergoing Adenoidectomy: A Pilot Study.

IntroductionAn opioid-sparing anesthetic involves a multi-modal technique with non-opioid medications targeting different analgesic pathways. Such techniques may decrease adverse effects related to opioids. These techniques may be considered in patients at higher risk for opioid-related adverse effects including obstructive sleep apnea or sleep disordered breathing.MethodsA prospective, pilot study was performed in 10 patients (3–8 years of age), presenting for adenoidectomy. The perioperative regimen included oral dextromethorphan (1 mg/kg) and acetaminophen (15 mg/kg) plus single boluses of intraoperative dexmedetomidine (0.5 μg/kg) and ketamine (0.5 mg/kg). Pain scores were assessed in the post anesthesia care unit (PACU) using the FLACC (Face, Legs, Activity, Cry, Consolability) scale. Patients with a pain score >4 received fentanyl as needed. PACU time, pain scores, and parent satisfaction were recorded. Postoperatively, patients were instructed to use oral acetaminophen or ibuprofen every 6 hours as needed for pain.ResultsThe study cohort included 10 patients, 3–8 years of age. All patients had opioid-free anesthetic care. PACU time ranged from 24 to 102 minutes (median: 56 minutes). FLACC pain scores were 0 for all PACU assessments. Nine patients were discharged home and 1 patient had a planned overnight admission. Following hospital discharge, the pain scores were satisfactory during the 72-hour study period and 90% of the patients’ guardians were satisfied or highly satisfied with their child’s pain control.ConclusionThis opioid-sparing approach provided safe and effective pain control as well as parental satisfaction following adenoidectomy in children. Additional prospective studies are needed to determine whether this regimen is effective in a larger cohort of patients with and for other otolaryngology procedures.

Prospective Single-Blinded Randomized Controlled Trial Comparing Pericapsular Injection Versus Lumbar Plexus Peripheral Nerve Block for Hip Arthroscopy

Background: Hip arthroscopy has become the standard for the operative treatment of symptomatic femoroacetabular impingement. Given the high levels of postoperative pain associated with hip arthroscopy, optimal analgesia is critical to ensure patient comfort and safety after discharge. Purpose/Hypothesis: Our purpose was to perform a single-blinded randomized controlled trial comparing the use of pericapsular injection versus lumbar plexus blockade for postoperative pain control after arthroscopic surgery on the hip. We hypothesized that pericapsular injection would provide equivalent pain relief to that of lumbar plexus blockade while minimizing adverse effects and alleviating the dependence on a qualified individual to administer. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 64 consecutive patients undergoing hip arthroscopy were prospectively assessed over a 6-month period between 2017 and 2018. Patients were randomly allocated to 1 of 2 groups: 32 patients received a lumbar plexus blockade by a single anesthesiologist, while 32 patients received a pericapsular injection of 30 mL of ropivacaine and 12 mg of morphine. Postoperative pain in the postanesthesia care unit (PACU) as measured using the numeric rating scale, time to discharge, PACU morphine equivalents, and adverse effects were collected by PACU staff. Postoperative day 1 and 2 narcotic use was obtained through a telephone call with the patient on postoperative day 3. Results: We found no statistically significant difference in PACU pain scores at all time points, although there was a trend toward lower pain for patients receiving a pericapsular injection. PACU and short-term narcotic demand did not vary across the 2 arms. Time to discharge from the PACU did not differ. There were no major adverse events reported for either intervention. Conclusion: Pericapsular injection provides equivalent analgesia when compared with lumbar plexus blockade. It is a safe intervention that allows for efficient postoperative analgesia for patients undergoing hip arthroscopy. Registration: ClinicalTrials.gov ID: NCT03244631.

Lumbar Plexus Block versus Peri-capsular Injection for Hip Arthroscopy: A Single-Blinded Randomized Controlled Trial

Objectives:To perform a single-blinded, randomized controlled trial comparing pericapsular injection versus lumbar plexus blockade for post-operative pain control following arthroscopic surgery on the hip.Methods:70 consecutive patients undergoing hip arthroscopy were prospectively assessed over a six-month period from 2017 to 2018. Patients were randomly allocated to 1 of 2 groups. 35 patients received a lumbar plexus blockade by a single anesthesiologist, while 35 patients received a pericapsular injection of 30cc of ropivacaine and 12mg of morphine. Post-operative pain in the post-anesthesia care unit (PACU) as measured by the numeric rating scale (NRS), time to discharge, PACU morphine equivalents and adverse effects were collected by PACU staff. Post-operative day (POD) 1 and POD 2 narcotic use was obtained through a phone call with the patient on post-operative day 2.Results:We found no statistically significant difference in PACU pain scores at all time-points, although there was a trend towards lower pain for patients receiving a pericapsular injection. PACU and short-term narcotic demand did not differ significantly between the two arms. Time to discharge from the PACU did not differ. There were no major adverse events reported for either intervention.Conclusion:Pericapsular injection provides equivalent analgesia when compared to lumbar plexus injection. It is a safe, time-saving intervention that allows for efficient post-operative analgesia for patients undergoing hip arthroscopy.

Impact of a perioperative oral opioid substitution protocol during the nationwide intravenous opioid shortage: A single center, interrupted time series with segmented regression analysis.

To mitigate the recent nationwide shortage of intravenous opioids, we developed a standardized perioperative oral opioid guideline anchored with appropriate use of nonopioid analgesia, neuraxial and loco-regional techniques. We hypothesize that adoption of this new guideline was associated with: 1) equivalent patient reported pain scores in the post-anesthesia care unit (PACU); and 2) equivalent total opioid use (oral and parenteral) during the perioperative period. Cases performed from July 1, 2017 to May 31, 2019 were screened. All opioids administered were converted to intravenous morphine milligram equivalents. Segmented regression analyses of interrupted time series were performed examining the change in opioid use, PACU pain scores and number of non-opioid analgesic medications used before and after the protocol implementation in April 2018. After exclusions, 29, 621 cases were included in the analysis. No significant differences in demographic, ASA status, case length and surgical procedure type were present in the pre and post-intervention period. A significant decrease in total (Estimate: -39.9 mg, SE: 6.9 mg, p < 0.001) and parenteral (Estimate: -51.6 mg, SE: 7.1 mg, p < 0.001) opioid use with a significant increase in oral opioid use (Estimate: 9.4 mg, SE: 1.1 mg, p < 0.001) was noted after the intervention. Pain scores were not significantly different between the pre- and post-intervention period (Estimate: 0.05, SE: 0.13, p = 0.69). We report our experience with a primary perioperative oral based opioid regimen that is associated with decreased total opioid consumption and equivalent patient reported pain scores.

Analgesic efficacy of cannabinoids for acute pain management after surgery: a systematic review and meta-analysis

BackgroundEvidence regarding the role of cannabinoids in managing acute postoperative pain is conflicting. The purpose of this systematic review and meta-analysis was to determine the analgesic efficacy of perioperative cannabinoid...

DIFFERENCES IN ACUTE POSTOPERATIVE PAIN AFTER ACL RECONSTRUCTION IN ADOLESCENT PATIENTS: ALL SOFT-TISSUE QUADRICEPS VERSUS HAMSTRING AUTOGRAFT

Background:Postoperative pain after anterior cruciate ligament (ACL) reconstruction is a subjective experience that contributes significantly to patient satisfaction and subjective outcomes. As such, it is important for surgeons to counsel their patients and set appropriate expectations following surgery. ACL reconstruction with hamstring (HS) tendon autograft remains the most popular graft choice in adolescent patients with open physes, yet recently, reconstruction using all soft-tissue quadriceps tendon autograft has gained in popularity. However, studies are lacking that evaluate acute postoperative pain after quadriceps autograft.Hypothesis/Purpose:To investigate differences in acute postoperative pain between adolescent patients undergoing ACL reconstruction with all soft-tissue quadriceps versus HS autograft.Methods:A retrospective review was performed of 65 patients that underwent primary ACL reconstruction using either quadriceps (n = 33) or HS (n = 32) autografts between October 2017 and April 2019. All patients received ultrasound-guided adductor canal catheters and single-shot sciatic nerve blocks preoperatively and followed a standard postoperative multi-modal pain management plan. Intraoperative and postoperative intravenous (IV) morphine equivalents (MEQ), post-anesthesia care unit (PACU) length of stay (LOS), and PACU pain scores (numeric rating scale, 0-10) were recorded. Pain scores and supplemental oxycodone use were recorded on postoperative days (POD) 1-3. Differences were compared between the two groups.Results:The mean age at the time of surgery was 15.2 ± 1.5 years. There were no statistically significant differences in age (p = 0.62), sex (p = 0.72), BMI (p = 0.18), concomitant meniscus repairs (p = 0.71), or surgical time (p = 0.52) between the two groups. There were no statistically significant differences in intraoperative IV MEQs (p = 0.44), PACU IV MEQ (p = 0.43), or PACU LOS (p = 0.47) between the two groups. Patients treated with quadriceps autograft has lower max PACU pain scores (3.2 ± 3.2 vs 4.1 ± 3.1; p = 0.27) and required less supplemental oxycodone doses on POD 1 (1.1 ± 1.2 vs 1.8 ± 1.6; p = 0.07) but the differences were not statistically significant. Max pain scores (at rest and with movement) on POD 1-3 and oxycodone use on both POD 2 and POD 3 were similar between groups.Conclusion:In the setting of a multi-modal pain management plan including regional anesthesia, adolescent patients undergoing ACL reconstruction with quadriceps tendon autograft and hamstring autograft have similar pain levels and opioid use in the acute postoperative period.

MP66-18 THE PUDENDAL NERVE BLOCK FOR AMBULATORY UROLOGY: THE OLD IS NEW AGAIN

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Quality Improvement & Patient Safety III (MP66)1 Apr 2020MP66-18 THE PUDENDAL NERVE BLOCK FOR AMBULATORY UROLOGY: THE OLD IS NEW AGAIN Chinonyerem Okoro*, Shannon Cannon, Daniel Low, and Thomas Lendvay Chinonyerem Okoro*Chinonyerem Okoro* More articles by this author , Shannon CannonShannon Cannon More articles by this author , Daniel LowDaniel Low More articles by this author , and Thomas LendvayThomas Lendvay More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000941.018AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Caudal epidural analgesia (CEA) is a common analgesic technique performed for pediatric penile surgeries. Recent evidence has implicated an association between hypospadias fistulas and CEA. Risks of CEA include epidural related complications, motor blockade, urinary retention, and is contraindicated in children with lower back abnormalities or coagulopathy. The pudendal nerve block (PNB) is an effective analgesic alternative to CEA and lasts up to 12 hours post-injection. We demonstrate our initial experience employing PNB for ambulatory pediatric urology procedures. METHODS: Using retrospective, non-randomized, time-series, observational real world data, a comparative effectiveness study of CEA and PNB was performed. Patients less than three years old, who underwent circumcision, hypospadias repair, congenital chordee repair, correction of penile angulation, buried penis repair with or without scrotoplasty, meatotomy, or lysis of penile adhesions between January 1, 2015 and September 1, 2019 in an Ambulatory Surgery Center at a single institution were included. Post Anesthesia Care Unit (PACU) pain scores, morphine rescue rates and length of stay (PACU minutes) were determined. RESULTS: A total of 999 patients were identified; 746, 172 and 81 received CEA, ultrasound guided PNB (US PNB) and surgeon administered PNB respectively. Demographic data was comparable between the two cohorts. Anesthetic protocols are in Table 1. There was no special cause variation or difference between the CEA, US PNB and surgeon administered PNB cohorts for PACU pain score (2.49, 2.98, 2.16); morphine rescue rates (2.8%, 6.98%, 2.47%); and PACU length of stay in minutes (57.8, 59.1, 57.3) respectively (Figure 1). CONCLUSIONS: For pediatric penile surgeries, PNB is as effective as CEA. The simplicity and safety of the PNB as well as the equivalent results of our observational study warrants further prospective investigation and may reduce potential morbidity from caudal anesthesia. PNB may have broader application for effective post-operative analgesia in adult penile and urethral surgery. Source of Funding: n/a © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e990-e991 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Chinonyerem Okoro* More articles by this author Shannon Cannon More articles by this author Daniel Low More articles by this author Thomas Lendvay More articles by this author Expand All Advertisement PDF downloadLoading ...

Perioperative Continuation of Buprenorphine at Low-Moderate Doses Was Associated with Lower Postoperative Pain Scores and Decreased Outpatient Opioid Dispensing Compared with Buprenorphine Discontinuation.

An increasing number of individuals are prescribed buprenorphine as medication-assisted treatment for opioid use disorder. Our institution developed guidelines for perioperative buprenorphine continuation with an algorithm for dose reduction based upon the surgical procedure and patient's maintenance dose. The objective of this study was to compare the effects of buprenorphine continuation with those of discontinuation on postoperative pain scores and outpatient opioid dispensing. Retrospective observational study. Surgical patients on buprenorphine from March 2018 to October 2018. Patients on buprenorphine for chronic pain and those with minor procedures were excluded from analysis. We compared postoperative outpatient opioid dispensing and postanesthesia care unit (PACU) pain scores in patients where buprenorphine was continued compared with held perioperatively, collecting single surgical subspecialty prescriber data on outpatient full mu-opioid agonist prescriptions dispensed, converted into mean morphine equivalents. Buprenorphine formulations were not included in our morphine milligram equivalents (MME) total. There were 55 patients total (38 cont. vs 17 held). There was no difference in postoperative buprenorphine treatment adherence (91% cont. vs 88% held, P = 0.324). The number of opioid prescriptions dispensed was significantly higher with buprenorphine discontinuation (53% cont. vs 82% held, P = 0.011), as was MME dispensed (mean of 229 cont. vs mean of 521 held, P = 0.033). PACU pain scores were higher with buprenorphine discontinuation (mean 2.9 cont. vs mean 7.6 held, P < 0.001). There was a significant reduction in opioid prescriptions filled, MME dispensed, and PACU pain scores in patients where buprenorphine was continued vs held perioperatively. We provide evidence to support that buprenorphine can be continued perioperatively and that continuation is associated with decreased postoperative pain and decreased outpatient opioid dispensing. These results contribute to the existing literature supporting the perioperative continuation of buprenorphine.