Administration Of Postoperative Analgesia Research Articles

Evaluating the Efficacy of a Peripheral Nerve Simulator-Guided Brachial Plexus Block in Rabbits Undergoing Orthopaedic Surgery Compared to Systemic Analgesia.

Locoregional anaesthetic techniques are invaluable for providing multimodal analgesia for painful surgical procedures. This prospective, randomised study describes a nerve stimulator-guided brachial plexus blockade (BPB) in rabbits undergoing orthopaedic surgery in comparison to systemic lidocaine. Premedication was provided with intramuscular (IM) medetomidine, fentanyl, and midazolam. Anaesthesia was induced (propofol IV) and maintained with isoflurane. Nine rabbits received a lidocaine BPB (2%; 0.3 mL kg-1), and eight received a lidocaine constant rate infusion (CRI) (2 mg kg-1 IV, followed by 100 µg kg-1 min-1). Rescue analgesia was provided with fentanyl IV. Carprofen was administered at the end of the surgery. Postoperative pain was determined using the Rabbit Grimace Scale (RGS) and a composite pain scale. Buprenorphine was administered according to the pain score for two hours after extubation. Rabbits were filmed during the first two hours to measure distance travelled and behaviours. Food intake and faeces output were compared. Every rabbit in CRI required intraoperative rescue analgesia compared to none in BPB. However, rabbits in both groups had similar pain scores, and there was no difference in the administration of postoperative analgesia. There were no significant differences in food intake or faeces production over 18 h, and no significant differences in distance travelled or behaviours examined during the first two hours. BPB seems superior for intraoperative analgesia. Postoperatively, both groups were comparable.

Postoperative Analgesia Management Evaluation in the Postanesthesia Unit: An Exploratory Analysis Based on Patient and Surgery Characteristics

Purpose:Several methods have been proposed for postoperative pain management, including administration of opioid analgesics, epidural analgesia, and perineural and infiltrative techniques; however, data are lacking on the relationship between pain intensity, patients’ age and gender, and surgery duration. Design: Prospective, observational, single-center study. Methods: The study included patients greater than or equal to 18 years old who underwent surgery with different anesthesia types, grouped according to the American Society of Anesthesiologists’ physical status classification score. The McGill Pain Questionnaire was used to assess postoperative pain intensity. The postoperative pain evaluation was performed in the first 5 minutes on entering the postanesthesia care unit (PACU), and at 30 minutes and 24 hours after the operation. Results: Our results showed a significant negative relationship between pain intensity as assessed at 5 and 30 minutes postoperatively and age. Postoperative pain intensity at 24 hours was significantly lower after low-risk surgeries lasting up to 1 hour; pain intensity was also significantly lower at 30 minutes following epidural anesthesia. When nonsteroidal anti-inflammatory drugs were not administered in the PACU, pain intensity was significantly lower at 5 minutes, 30 minutes, and 3 hours. Conclusions: Postoperative analgesic administration should be conducted in accordance with age and surgery type. Additionally, epidural anesthesia can reduce the immediate postoperative pain intensity.

Efficacy of Various Laser Wavelengths in the Surgical Treatment of Ankyloglossia: A Systematic Review.

Ankyloglossia, commonly known as tongue-tie, is the most common disorder of tongue morphology characterized by aberrant attachment of the lingual frenum. This study aimed to provide a comprehensive literature review and evaluate the effectiveness of various laser wavelengths in the surgical treatment of patients with ankyloglossia. An electronic screening of PubMed and the Cochrane Central Register of Controlled Trials (CENTRAL) databases was conducted on 8 November 2021. The following search terms were used to review the available data on the subject of interest: (ankyloglossia OR tongue tie OR short lingual frenulum OR lingual frenectomy OR lingual frenulectomy OR lingual frenotomy OR lingual frenulotomy) AND laser. The use of lasers in ankyloglossia treatment resulted in shorter procedure time, reduced indications for general anesthesia, reduced administration of postoperative analgesics, fewer sutures or none needed, reduced postoperative bleeding, and improved healing. Despite many advantages, this method has its clinical limitations: it requires the use of expensive equipment; well-trained personnel familiar with lasers; and personal protective equipment for the patient, caregiver, operator, and assistant. The laser procedure does not eliminate the need for myofunctional exercises and work with a speech therapist.

Perioperative subcutaneous methylnaltrexone does not enhance gastrointestinal recovery after posterior short-segment spinal arthrodesis surgery: a randomized controlled trial

BACKGROUND CONTEXTPostoperative ileus is a major barrier to gastrointestinal recovery following surgery. Opioid analgesics likely play an important causative role, particularly in spinal or orthopedic surgeries not involving bowel manipulation. Methylnaltrexone, a peripherally-acting µ-opioid receptor antagonist, is a potential prophylactic treatment. PURPOSETo assess the influence of perioperative subcutaneous methylnaltrexone administration on gastrointestinal recovery following short-segment lumbar arthrodesis surgeries. DESIGNThis is a randomized, double-blind, controlled trial. PATIENT SAMPLEEligible patients undergoing posterior short-segment lumbar arthrodesis surgeries at a single institution between February 2019 and April 2021 were enrolled in this study. OUTCOME MEASURESThe primary outcome measure was time-to-first bowel movement. Secondary outcome measures included time-to-discharge/discharge eligibility. Exploratory outcome measures included daily postoperative opioid consumption and pain scores. METHODSIn this study, eligible patients were enrolled to receive either methylnaltrexone or placebo perioperatively. Time-to-bowel movement, time-to-discharge/discharge eligibility, intra and postoperative analgesic administration, and pain scores were recorded and compared. RESULTSEighty two patients in total were enrolled; 41 to the methylnaltrexone and 41 to the placebo group. Both groups were similar in their baseline characteristics. There was no difference in median (range) time-to-bowel movement between the 2 groups [61.8 hours (35.7–93.6) versus 50.7 hours (17.8–110.8), p = .391]. There was also no difference in time-to-discharge/discharge eligibility [105.0 hours (81.0 – 201.3) versus 90.7 (77.5 – 184.5), p=.784]. Finally, there were no differences in either postoperative opioid consumption or numeric rating scores for back, leg, or abdominal pain on postoperative days 0 to 4 (p>.05). CONCLUSIONSMethylnaltrexone did not accelerate gastrointestinal recovery and did not affect opioid consumption or pain scores following short-segment spinal surgery as compared to placebo. Additional studies will be needed to identify effective opioid receptor antagonist dosing regimens for patients undergoing either short- or long-segment spinal arthrodesis procedures.

The Utilization of an Opioid-Free Anesthetic for Pediatric Circumcision in an Ambulatory Surgery Center.

Circumcision is one of the most common urologic procedures performed at pediatric ambulatory centers. Emerging data on the short- and long-term effects of perioperative opioid administration has highlighted the importance of an opioid-free anesthetic regimen. We sought to evaluate the effectiveness of an opioid-free anesthetic in pediatric circumcision and its correlation with ambulatory surgery center efficiency. Patients, 3 years of age and younger, who underwent circumcision or circumcision revision by two surgeons pre and post introduction of an opioid-free anesthetic fast-track regimen at an outpatient surgical center were included. There were 100 patients included in this analysis, with 50 patients in each cohort. On univariate analysis, fast-tracking was associated with a decrease in median combined in-room and post-anesthesia care unit times (102.5 vs. 129.0 min, p-value < 0.001). This difference continued after multivariable analysis with an adjusted median combined in-room and post-anesthesia care unit time difference of −15.6 min (95% CI −34.2 to −12.7 min, p-value 0.018). In addition, the fast-track cohort received less intraoperative morphine equivalents without an increase in post-operative analgesic administration or change in postoperative questionnaire score. This demonstrates that opioid-free anesthesia may be used effectively in pediatric circumcision while also allowing for significant time savings for surgical centers.

Ultrasound-guided Interfascial Plane Blocks for Non-anesthesiologists in Breast Cancer Surgery: Functional Outcomes and Benefits.

Acute post-operative pain following modified radical mastectomy (MRM) in patients with breast cancer is challenging for anesthesiologists. This study aimed to prospectively compare the quality outcome of interfascial plane blocks performed with ultrasound guidance, and evaluate the consequences of sharing tasks with the breast surgeon. The study involved 255 patients scheduled for unilateral MRM, who were divided into two groups: Pecs group: General anesthesia plus ultrasound-guided modified pectoral nerves blocks type I and II, including serratus and parasternal infiltration according to surgical requirements; and Control group: general anesthesia only. Quality was evaluated based on perioperative opioid consumption, reported pain intensity, rescue analgesic requirement, side-effects and length of hospital stay. Moreover, a breast surgeon with expertise in ultrasound-guided breast biopsy was trained to perform the blocks. The patient benefits from regional anesthesia delivered by a non-anesthesiologist were assessed. Significant reductions were noted in all of the following: Intraoperative opioid consumption (p<0.001), Numerating Rating Scale pain scores taken 0 and 24 h after surgery (p<0.001), post-operative analgesic administration (p<0.001), nausea and vomiting at 0, 6, and 12-h intervals (p<0.05), and hospital stay (p<0.001) were observed in the Pecs group compared with the control group. Furthermore, data obtained from patients receiving the block from the surgeon showed comparable benefits with no complications. Interfascial plane blocks may be an important alternative protocol in MRM, enhancing patient safety and cost benefits. Improvements in cross-disciplinary expertise through flexibility in the training of professionals with other backgrounds may provide effective analgesia and favorable outcomes.

Anaesthetic and Perioperative Management of 14 Male New Zealand White Rabbits for Calvarial Bone Surgery.

Simple SummaryBone substitutes are commonly used when bone grafts are necessary in human craniofacial surgery. To study the properties and biologic behaviour of those substitutes, they can be implanted in experimental animals. A frequently used model involves the creation of critical-sized defects (defects that are too large to heal by themselves) in the rabbits calvaria (the top part of the skull). The procedure was initially described in 1989 and the authors considered and reported that post-operative analgesia was not necessary. In our experience, this procedure is invasive and can result in severe postoperative pain. The anaesthetic management of rabbits undergoing this procedure is challenging. Most of the recent publications using this model fail to provide sufficient information on perioperative animal management. With this report we have aimed to document a possible practical and simple anaesthetic and postoperative management of rabbits undergoing this procedure. Particular emphasis has been placed on postoperative pain assessment, duration and treatment.Calvarial bone surgery on rabbits is frequently performed. This report aims to document a simple and practical anaesthetic and perioperative management for this procedure. Fourteen male New Zealand white rabbits were included in the study. Subcutaneous (SC) dexmedetomidine, ketamine and buprenorphine ± isoflurane vaporized in oxygen administered through a supraglottic airway device (V-gel®) provided clinically suitable anaesthesia. Supplemental oxygen was administered throughout recovery. Monitoring was clinical and instrumental (pulse-oximetry, capnography, invasive blood pressure, temperature, arterial blood gas analysis). Lidocaine was infiltrated at the surgical site and meloxicam was injected subcutaneously as perioperative analgesia. After surgery, pain was assessed five times daily (composite behavioural pain scale and grimace scale). Postoperative analgesia included SC meloxicam once daily for four days and buprenorphine every 8 h for three days (unless both pain scores were at the lowest possible levels). Rescue analgesia (buprenorphine) was administered in case of the score > 3/8 in the composite pain scale, >4/10 on the grimace scale or if determined necessary by the caregivers. Airway management with a V-gel® was possible but resulted in respiratory obstruction during the surgery in two cases. Hypoventilation was observed in all rabbits. All rabbits experienced pain after the procedure. Monitoring, pain assessments and administration of postoperative analgesia were recommended for 48 h.

Postoperative Nausea and Vomiting and Phase I Post-anesthesia Recovery After Strabismus Operations.

To ascertain postoperative nausea and vomiting (PONV) rates in adult patients after strabismus operations and assess causes for prolonged post-anesthesia recovery. This was a retrospective observational study of consecutive adult patients who underwent strabismus operations at one institution from January 1, 2010, to May 31, 2017. The anesthetic records were abstracted and PONV rates were ascertained. On the basis of the cohort's 75th percentile of anesthesia recovery duration, patients were categorized into goal recovery (lower three quartiles) and prolonged recovery (upper quartile). Multivariable logistic regression analyses were performed to assess associations between clinical characteristics and prolonged recovery. A total of 794 adult patients who underwent strabismus surgery were identified. PONV was present in 31 (3.9%) patients. The median (interquartile range) post-anesthesia recovery was 45 minutes (range: 33 to 63 minutes). Prolonged recovery was associated with long-term benzodiazepine use (odds ratio [OR]: 3.07; 95% CI [confidence interval]: 1.23 to 7.80; P = .02). Patients with prolonged recovery had higher rates of PONV (15 [7.2%] vs 16 [2.7%], P = .007), oversedation (107 [51.4%] vs 226 [38.6%], P = .001), and postoperative analgesic administration (138 [66.4%] vs 222 [37.9%], P < .001). Inverse associations were found between desflurane and oversedation (OR: 0.63; 95% CI: 0.45 to 0.86; P = .004) and between acetaminophen administration and postoperative analgesic administration (OR: 0.57; 95% CI: 0.38 to 0.86; P = .007). Adult patients undergoing general anesthesia for strabismus surgery had a low PONV rate. However, the presence of PONV was associated with delayed recovery room discharge. Other factors associated with prolonged Phase I recovery were long-term benzodiazepine use and longer operations, which likely resulted in an increased need for anesthetic agents and therefore more intense postoperative sedation. [J Pediatr Ophthalmol Strabismus. 2019;56(3):151-156.].

A comparative study of caudal epidural bupivacaine with bupivacaine plus fentanyl and bupivacaine plus neostigmine for anaesthesia and postoperative analgesia in children undergoing sub-umbilical surgeries

Background: Single-shot caudal anaesthesia with local anaesthetic has a limited duration of action.Therefore, many children undergoing sub-umbilical surgery with caudal analgesia require furtheranalgesia during the postoperative period. This study compared the effect of single-dose caudal epiduralbupivacaine, bupivacaine plus fentanyl and bupivacaine plus neostigmine for anaesthesia andpostoperative analgesia in children. Objective: To evaluate effectiveness of bupivacaine with the addition of fentanyl or neostigmine forcaudal anaesthesia and analgesia in children undergoing sub-umbilical surgeries. Methods: Total ninety (90) paediatric patients, aged 2-8 years with ASA(American society ofanesthesiologist) grades I &amp; II who were scheduled for surgery in Sher-E-Bangla Medical college Hospital,Barisal were included in this study. Data were collected by using a pre-designed questionnaire. Thepatients were randomly allocated to one of the three groups. Group A was received caudal 1 ml/kg ofbupivacaine 0.25%, Group B 1 ml/kg of bupivacaine 0.25% with fentanyl 1 μg/kg and Group C 1 ml/kgof bupivacaine 0.25% with neostigmine 2 μg/kg. Heart rate (HR), Blood pressure (BP), oxygen saturation(SpO2), Respiratory rate (RR) were recorded during operation and every five minutes thereafter. Theduration of analgesia was defined as the time from caudal injection to first dose of rescue analgesia.Rescue analgesia was given for an objective pain scale (greater than or equal to) 4 in the form of oralparacetamol (15mg/kg). Results: Assessment of anaesthesia was significantly longer in the two groups of children who receivedadditives compared with local anaesthetics group alone (p&lt;0.01). Mean time to first postoperativeanalgesic administration was 167.37±17.30 min, 280.57±14.40min, and 357.77±19.08 min in groupA, Group B, and group C respectively. The difference was statistically significant (p&lt;0.01) between thethree groups. In these cases duration of analgesia was considered from the placement of caudal to firstanalgesia. Conclusion: Addition of fentanyl or neostigmine to bupivacaine prolonged the duration of surgicalanaesthesia and postoperative analgesia after a single shot caudal injection with minimal incidence ofside effects in children undergoing sub-umbilical surgeries. This could be a safe and cheap alternative toextradural catheter placement for surgical procedures of intermediate duration. JBSA 2019; 32(1): 3-9

Perioperative Ketorolac for Supracondylar Humerus Fracture in Children Decreases Postoperative Pain, Opioid Usage, and Length of Stay

Royalty: Zimmer Biomet, Wolters Kluwer (Flynn) Perioperative administration of ketorolac in children undergoing closed reduction and percutaneous pinning for displaced supracondylar humerus fracture will lower pain scores, decrease opioid requirements, and permit earlier discharge from the hospital. This is a retrospective case-control investigation of children (aged 0–18 years) treated with closed reduction percutaneous pinning (CRPP) for closed, Gartland type III extension-type supracondylar humerus fractures at a single children's hospital between 2011 and 2017. Patients who received ketorolac perioperatively were randomly matched 1:2 by sex and age (±1 year) with patients who did not receive ketorolac. Elbow radiographs were reviewed to determine eligibility. Data abstraction included demographic and surgical details, length of stay, inpatient postoperative analgesic administration, pain ratings using the Wong-Baker FACES scale, and complications within 90 days. Differences between groups were compared with 2-tailed Mann-Whitney U and chi-square tests. 342 patients were included in the investigation including 114 patients who received ketorolac and 228 controls. Age (mean 6.2 ± 2.4 years) and sex ratio (M:F, 1.28:1) were equivalent between groups. There was also no difference in the operative time or total number of pins between groups. Mean pain rating at 0 to 29 minutes postoperatively was lower in the ketorolac group (0.7 ± 1.9) than in the control group (1.4 ± 2.6, P = .017). Mean pain rating at 30 to 120 minutes postoperatively was also lower in ketorolac group (1.1 ± 2.3) than the control group (1.7 ± 2.8, P = .036). Other pain ratings were not statistically different between groups (Figure 21-1). Patients in the ketorolac group received a lower number of inpatient oxycodone doses (1.0 ± 0.6) than did patients in the control group (1.2 ± 0.5, P = 0.003). Average postoperative morphine doses were not significantly different (0.5 ± 0.6 vs 0.6 ± 0.7, P = .137). Mean postoperative length of stay (LOS) was significantly longer for the control group (20.2 ± 11.2 hours) than the ketorolac group (13.5 ± 8.8 hours, P < .001). There was no difference in the 90-day complication rate between patients in the ketorolac group and the control group (P = .905). •There is a need for improved narcotic stewardship in orthopedic surgery.•The complementary administration of ketorolac reduces postoperative pain and opioid use in children with displaced supracondylar humerus fractures.•Ketorolac use reduces length of stay following CRPP for supracondylar humerus fractures and offers an opportunity for cost savings.

Analgesic Effect of Double-Level Retrolaminar Paravertebral Block for Breast Cancer Surgery in the Early Postoperative Period: A Placebo-Controlled, Randomized Clinical Trial

Thoracic epidural anesthesia (TEA) and paravertebral block (PVB) have been performed for perioperative regional anesthesia in the trunk. However, TEA and PVB are associated with a risk of serious complications, such as pneumothorax, hypotension, or nerve damage. Retrolaminar paravertebral block (RLB) was introduced as a new alternative to PVB. This new approach might lower the risk of serious complications, but its use has not been well established yet. Therefore, we conducted a double-masked, placebo-controlled, randomized clinical trial to evaluate the efficacy of a double-level RLB for postoperative analgesia after breast cancer surgery. A total of 122 women who underwent breast cancer surgery with axillary lymph node dissection under general anesthesia were allocated into RLB group (60 patients) and Control group (62 patients). RLB was performed upon surgery completion with 15 ml ropivacaine (0.5%) for each lamina of the T2 and T4 vertebrae. In Control group, the same volume of normal saline was injected at each level. The time to first postoperative analgesic administration was significantly longer in RLB group than that in Control group (161.5 min vs. 64.0 min). The pain score in RLB group was significantly lower immediately after surgery. However, the number of patients requiring analgesics during the 12-hour post-surgical period was similar between RLB group (20 patients) and Control group (22 patients). In conclusion, the double-level RLB could delay the time to initial administration of analgesics, but this technique may be insufficient to reduce the analgesic requirement within the 12-hour postoperative period following breast cancer surgery.

Effects of dexmedetomidine as an adjuvant to ropivacaine in ultrasound-guided supraclavicular brachial plexus Block: A prospective, randomized, double-blind study.

Background and Aims:Various adjuvants have been added to local anesthetics in single shot blocks so as to prolong the duration of postoperative analgesia. The present study was conceived to evaluate the effect of dexmedetomidine as an adjuvant to ropivacaine for institution of supraclavicular brachial plexus block.Material and Methods:Ninety adult patients (ASA physical status I, II) scheduled for elective upper limb surgeries under ultrasound-guided subclavian perivascular brachial plexus block were allocated randomly into two groups; the study was designed in double-blind fashion. All patients received 20 ml 0.75% ropivacaine, in addition, patients in group A (n = 43) received 2 ml 0.9% normal saline and those in group B (n = 44) received dexmedetomidine (1 μg/kg body weight); total volume was made up to 22 ml with sterile 0.9% saline in both groups. The onset and duration of sensory and motor blocks, time to first request of analgesia, total dose of postoperative analgesic administration, and level of sedation were also studied in both the groups. All the data were analyzed by using unpaired t-test. P < 0.05 was considered significant.Results:Sensory and motor block durations (613.34 ± 165.404 min and 572.7 ± 145.709 min) were longer in group B than those in group A (543.7 ± 112.089 min and 503.26 ± 123.628 min; P < 0.01). Duration of analgesia was shorter in group A (593.19 ± 114.44 min) compared to group B (704.8 ± 178.414 min; P < 0.001).Conclusion:Addition of dexmedetomidine to 0.75% ropivacaine in supraclavicular brachial plexus block significantly prolongs the duration of analgesia.

Analgesic efficacy and safety of four different anesthesia/postoperative analgesia protocols in patients following total hip arthroplasty

Background/Aim. Hip replacement surgery can initiate significant postoperative pain caused by bone alterations, implant, and soft tissue or nerve injuries. Postoperative analgesia using regional techniques has been shown to have numerous advantages over the intravenous use of morphine. However, numerous side effects and complications of postoperative continuous epidural analgesia have been reported recently. The aim of this prospective, randomized study was to investigate whether continuous lumbar plexus block can be a safe and efficacious alternative for postoperative analgesia in comparison with epidural analgesia and patient-controlled analgesia with morphine (PCA morphine) for hip arthroplasty. Methods. This prospective study included 60 patients, scheduled for total hip arthroplasty. Patients were randomized into 4 groups: the group central nerve block ? epidural (CNB), the group peripheral nerve block ? lumbar plexus block (PNB), the group spinal anesthesia-PCA morphine (SAM) and the group general anesthesia-PCA morphine (GAM). The quality of analgesia and side effects (hypotension, nausea, vomiting, urinary retention) were recorded in all groups at 4 h, 12 h, and 24 h after surgery. Pain scores were assessed using Visual Analogue Scale (VAS), both at rest and on moving. Results. Our findings demonstrated that the use of a continuous lumbar plexus block provides effective analgesia at rest and on moving, during 24 h after hip arthroplasty. Pain scores varied significantly among the groups 4 h postoperatively (F = 21.827; p &lt; 0.01), 12 h postoperatively (F = 41.925; p &lt; 0.01) and 24 h postoperatively (F = 33.768; p &lt; 0.01) with the highest scores ? 3 in the GAM group. Patients from the PNB group had satisfactory analgesia, comparable with patients from the CNB group. The incidence of nausea was significantly lower in the PNB group 12 h after the operation (?2 = 9.712; p &lt; 0.01). The incidence of urine retention was significantly different 12 h after the operation, with a presence only in the CNB group, with the incidence of 33.3% (?2 = 16.365; p &lt; 0.01). In all studied groups, the incidence of hypotension was not significantly different postoperatively. Conclusion. Administration of postoperative analgesia using continuous lumbar plexus block produces satisfactory analgesia with a low incidence of side effects when compared to epidural analgesia or parenteral opioids following hip arthroplasty.

Surgical stress response following hip arthroplasty regarding choice of anesthesia and postoperative analgesia

Background/Aim. Significant surgical stress response consisting of hormonal, metabolic and inflammatory changes can be initiated by the hip replacement surgery. Appropriate choice of anesthesia and postoperative analgesia should provide diminution of surgical stress response and may reduce number of perioperative complications. Surgical stress response after peripheral nerve blocks has not been studied extensively in patients who underwent hip replacement. The aim of the study was to investigate whether continuous lumbar plexus block can significantly reduce surgical stress response in comparison to other types of postoperative analgesia – continuous epidural analgesia and intravenous patient controlled analgesia (PCA) with morphine. Methods. Prospective study included 60 patients, scheduled for total hip arthroplasty. The patients were randomized into 4 groups: group CNB (central nerve block - epidural), group PNB (Peripheral nerve block - lumbar plexus block), SAM (Spinal anesthesia- PCA (anesthesia) morphine) and GAM (General anesthesia + PCA with Morphine). Serum levels of cortisol, thyroid hormones (T3, T4) and thyroid stimulating hormone (TSH), insulin, glucose and C-reactive protein (CRP) were measured in all groups – preoperatively, as well as 4 h, 12 h and 24 h after surgery. Results. The study showed that average serum cortisol levels were significantly lower 4 h after the operation in the groups where methods of regional anesthesia were performed intraoperatively (SAM, CNB, PNB); (F = 19.867; p < 0.01). Groups with postoperative continuous catheter analgesia (CNB, PNB) had significantly lower serum cortisol levels 12 h after the operation (F = 8.050; p < 0.01). The highest serum insulin levels were detected 4 h postoperatively in the CNB and PNB group, while the lowest were in the GAM group (F = 5.811; p < 0.05). Twelve hours after the operation, the lowest values of insulin were measured in the SAM group (F = 5.052; p < 0.05), while 24 h postoperatively, the lowest values were found in the SAM and GAM group (F = 6.394; p < 0.05). T3, T4 and TSH levels showed slight reduction in comparison to preoperative values without statistical significance. Blood glucose levels were significantly different among the groups 4 h after surgery with the highest values recorded in the GAM group and the lowest ones in the SAM group (F = 10.084; p < 0.01). On the other hand, 12 h after the operation significant rise in blood glucose levels was detected in the SAM group (F = 7.186; p < 0.01) Levels of CRP increased remarkably 12 h and 24 h after the surgery, but without significant difference among the groups. Conclusion. Administration of postoperative analgesia using continuous lumbar plexus block following hip arthroplasty reduces significantly stress response in comparison to postoperative PCA with morphine and has comparable effects on hormone release to epidural analgesia. Spinal anesthesia provides the best diminution of surgical stress response in the early postoperative period in comparison with other types of intraoperative analgesia.

Clinical Evaluation of a Novel Technology for Oral Patient-Controlled Analgesia, the PCoA® Acute Device, for Hospitalized Patients with Postoperative Pain, in Pilot Feasibility Study.

Background Acute postoperative pain delays recovery and increases morbidity and mortality. Traditional administration of postoperative analgesics by nurses is often inefficient. The present study evaluated the safety, efficacy, and usability of a novel, patient-controlled analgesic dispenser, the PCoA Acute. Methods A controlled pilot study was conducted at three medical centers. Patients scheduled for elective surgery were enrolled into two groups, both taking oral analgesics: a control group (n = 43), opioids dispensed by nurses, and a test group (n = 27), opioids dispensed via the PCoA Acute. Pill intake data were recorded. Pain ratings at rest and during movement were surveyed. Results No severe adverse events were recorded. Average pill intake time was reduced from 8 : 58 minutes in the control group to 1 : 17 minutes in the test group (P value < 0.05). The test group took 67% more pills than the control group, indicating enhanced compliance. Pain scores were significantly lower for patients in the test group (P value < 0.05). Over 90% of PCoA Acute users were satisfied with its use. Conclusions The study confirmed that PCoA Acute is safe and effective. It is well accepted by patients and medical staff. Its use can optimize pain medication administration.

Ureteral Endometriosis and Silent Renal Loss: A Retrospective Study

Objective To present six cases of ureteral endometriosis with renal loss managed by a multidisciplinary minimally invasive approach. Introduction Severe ureteral endometriosis can potentially lead to urinary tract obstruction and silent loss of renal function. Nephrectomy should be considered and may be performed by a multidisciplinary minimally invasive approach. Material and methods Retrospective observational study of patients with deep endometriosis with ureteral involvement and consequently loss of renal function who underwent laparoscopic nephrectomy between April 2009 and April 2016 in a tertiary care university hospital. The clinical presentation, imaging characteristics, surgical findings, surgical procedures, operative time, blood loss, postoperative analgesic administration, mean hospital stay and recurrence rates were analyzed. Results The mean age of patients was 28 years (range 26 to 40). Mean overall operative time for the laparoscopic procedures was 382 minutes (range 310 to 705). Mean blood loss was 200 cc and there were no intraoperative complications in our series with no need to laparotomy conversion. Mean overall hospital stay was 157 hours (range 48 to 364). Regarding complications, a case of pyelonephritis and one of urinary retention were registered, the latter requiring bladder neurostimulation 2 years after surgery. All women remain asymptomatic in follow-up. Conclusions In ureteral deep endometriosis, nephrectomy should be considered for significant renal functional impairment associated with persistent ureterohydronephrosis and renal parenchymal atrophy. It may be performed by laparoscopy with minimal morbidity, minimal postoperative discomfort, and a short hospital stay.

Distal Peripheral Nerve Blocks in the Forearm as an Alternative to Proximal Brachial Plexus Blockade in Patients Undergoing Hand Surgery: A Prospective and Randomized Pilot Study

Limited data exist regarding the role of perineural blockade of the distal median, ulnar, and radial nerves as a primary anesthetic in patients undergoing hand surgery. We conducted a prospective and randomized pilot study to compare these techniques to brachial plexus blocks as a primary anesthetic in this patient population. Sixty patients scheduled for hand surgery were randomized to receive either an ultrasound-guided supraclavicular, infraclavicular, or axillary nerve block (brachial plexus blocks) or ultrasound-guided median, ulnar, and radial nerve blocks performed at the level of the mid to proximal forearm (forearm blocks). The ability to undergo surgery without analgesic or local anesthetic supplementation was the primary outcome. Block procedure times, postanesthesia care unit length of stay, instances of nausea/vomiting, and need for narcotic administration were also assessed. The 2 groups were similar in terms of the need for conversion to general anesthesia or analgesic or local anesthetic supplementation, with only 1 patient in the forearm block group and 2 in the brachial plexus block group requiring local anesthetic supplementation or conversion to general anesthesia. Similar durations in surgical and tourniquet times were also observed. Both groups reported similarly low numerical rating scale pain scores as well as the need for postoperative analgesic administration (2 patients in the forearm block group and 1 in the brachial plexus block group reported numerical rating scale pain scores > 0 and required opioid administration in the postanesthesia care unit). Block procedure characteristics were similar between the 2 groups. Forearm blocks may be used as a primary anesthetic in patients undergoing hand surgery. Further research is warranted to determine the appropriateness of these techniques in patients undergoing surgery in the thumb or proximal to the hand. Therapeutic II.

Postoperative pain management in Latino families: parent beliefs about analgesics predict analgesic doses provided to children.

The present study examined whether parental perceptions of children's pain impacted home-based pain management following outpatient surgery in a sample of Latino families from low socioeconomic backgrounds. Latino parents of children (n = 161) who underwent outpatient surgery were recruited for this study and completed measures assessing attitudes on pain and analgesic use (Parental Pain Expression Perceptions and Medication Attitudes Questionnaire) before their child's surgery. Parents also rated their child's pain after their child's surgery using the Parent Postoperative Pain Measure and collected data on the amount of analgesics they gave to their child on the first postoperative day. Hierarchical regression analyses examined whether parental attitudes predicted pain assessment and management at home. A majority of parents reported multiple misconceptions regarding children's pain and fears of side effects as well as avoidance of analgesic use. For example, over 80% reported believing that a child always tells their parents when they are in pain. Hierarchical regression analyses found that more fear and avoidance regarding analgesic use for children's pain predicted parents providing fewer doses of analgesic to their children on the first postoperative day (β = -0.21, P = 0.028). Preoperative parents' beliefs regarding analgesics for treatment of children's pain may adversely impact parent postoperative analgesic administration at home in Latino families.

Treatment with analgesics after mouse sciatic nerve injury does not alter expression of wound healing-associated genes.

Animal models of sciatic nerve injury are commonly used to study neuropathic pain as well as axon regeneration. Administration of post-surgical analgesics is an important consideration for animal welfare, but the actions of the analgesic must not interfere with the scientific goals of the experiment. In this study, we show that treatment with either buprenorphine or acetaminophen following a bilateral sciatic nerve crush surgery does not alter the expression in dorsal root ganglion (DRG) sensory neurons of a panel of genes associated with wound healing. These findings indicate that the post-operative use of buprenorphine or acetaminophen at doses commonly suggested by Institutional Animal Care and Use Committees does not change the intrinsic gene expression response of DRG neurons to a sciatic nerve crush injury, for many wound healing-associated genes. Therefore, administration of post-operative analgesics may not confound the results of transcriptomic studies employing this injury model.

Evaluation of complications and feasibility of indwelling epidural catheter use for post-operative pain control in dogs in the home environment

AIMS: The objective of this study was to describe the use of indwelling epidural catheters post-operatively in dogs in a home environment, and to report associated complications.METHODS: Dogs undergoing surgical procedures of the hind limb (n=83) were included in the study and were administered 0.05 or 0.10 mg/kg epidural morphine via an indwelling epidural catheter every 6 hours. Data compiled relating to catheter placement included time of placement, ease of placement and problems encountered, number of attempts of placement, and individual placing the catheter. A client questionnaire was provided to evaluate side effects, complications, pain, and ease of use of the epidural catheter system after discharge from the hospital and catheter removal at home. Side effects were compared between the dogs receiving 0.05 or 0.1 mg/kg epidural morphine.RESULTS: The most common patient complication was abnormal urination patterns (32/82, 39%); specifically dribbling urine where laying, emptying the entire bladder where laying, not urinating for extended periods of time, and taking a longer time to pass urine were reported. There were no significant differences in the number or types of side effects reported in either dosing group. The most common technical issues reported by owners were difficulty getting the needle into the injection port (10/81, 12%) and removing the adhesive covering keeping the epidural catheter system in place (19/78, 24%). There were no reports of inflammation or discharge at the catheter site in any of the dogs. Of the respondents surveyed, 76/79 (97%) found the epidural catheter system easy to use at home in the post-operative period.CONCLUSIONS: Indwelling epidural catheters are a feasible method of administration of post-operative analgesia in the immediate post-operative period in the home environment and were associated with only a few minor complications in this population.