Postoperative Morphine Consumption Research Articles

Loco-Regional Ropivacaine Analgesia Via a Surgically Placed Intercostal Catheter after Anatomic Lung Resection: Prospective, Placebo-Controlled, Double-Blind; Randomized Superiority Trial

Abstract Background Even after minimally invasive anatomic lung resection, pain remains a burden for patients. Current guidelines recommend the surgical placement of intercostal catheters at the end of the surgery to promote faster recovery after lung surgery. Aims The aim of this trial was to investigate the analgesic efficacy of continuous loco-regional application of ropivacaine via an intercostal catheter and to establish this method as a possible standard of care in postoperative analgesia management. Methods Between December 2021 and October 2023, we evaluated the efficacy of surgically inserted intercostal catheters. Patients were eligible when undergoing anatomic VATS lung resection under general anesthesia for confirmed or suspected stage I lung cancer (UICC, 8th edition). Patients received ropivacaine at a concentration of 2 mg/ml or a placebo through an elastomer pump, flow rate of 6-8 ml/h for 72 hours after surgery. The sample size was calculated to find an NRS (numerical rating scale) difference associated with a pain reduction of 1.5 points. Results 14 patients were randomly included in the ropivacaine group and 18 in the placebo group. The patients’ characteristics and preoperative pain scores were similar in both groups. Between the observed groups there was no statistically significant difference in postoperative pain scores and morphine consumption. The NRS score for cough 24 hours postoperatively was 4.9 (±2.2) in the ropivacaine group and 4.3 (±2.4); p=0.474 in the placebo group. In addition, we were unable to determine any influence of the pain management on the relative postoperative pulmonary function. Conclusion Our results suggest that the analgesic efficacy of continuous loco-regionally applied ropivacaine administered through a surgically placed intercostal catheter after surgery does not have a positive effect on postoperative pain scores or morphine requirements. Instead, local analgesia started at the beginning of the procedure and covering several intercostal spaces should be considered.

Role of tramadol as an adjuvant in ultrasound-guided serratus anterior muscle block for modified radical mastectomy - A randomized control trial

Abstract Background and Aims: Modified radical mastectomy (MRM) is associated with significant acute post-operative pain that may progress to chronic pain syndromes in 25–60% of patients. Serratus anterior muscle (SAM) block has proved to be an excellent analgesic option in patients undergoing MRM. Although many adjuvants have been utilized for the prolongation of analgesia, the role of tramadol in SAM has not been studied as yet. We hypothesize that the addition of tramadol to ropivacaine for SAM block may reduce morphine consumption in the post-operative period in patients undergoing elective MRM surgeries. The primary aim of the study was to compare cumulative post-operative morphine consumption over 24 h in patients receiving SAM block with or without tramadol. The secondary aims were to observe adverse events related to the procedure or medications. The other parameters recorded were non-invasive blood pressure (NIBP), pulse rate, respiratory rate, and nausea or vomiting. Material and Methods: Patients scheduled to undergo MRM were randomly allocated by block randomization into two groups. The study group (Group T) received a SAM block with 0.25% ropivacaine (18 ml) with tramadol 100 mg while the control group (Group P) received a SAM block with 18 ml of 0.25% ropivacaine and 2 ml of saline. Patients were assessed for pain scores, analgesic requirement, time to first analgesic request, hemodynamic variables, and any side-effects at 30 min, 1 h, 4 h, 8 h, 12 h, and 24 h post-operatively. Results: Cumulative morphine consumption over 24 h in the post-operative period was less in the group T (3.06 ± 1.53 mg vs 4.34 ± 1.53 mg; P 0.001). Time to the first analgesic requirement was more in group T (10.44 ± 5.04 h vs 6.11 ± 2.73 h; P < 0.001). Pain scores were significantly lower in the group T at all time points. Conclusion: Tramadol, when used as an adjuvant to ropivacaine for SAM block reduces post-operative pain scores in the first 24 h and prolongs the time of first morphine requirement.

Comparison Between Erector Spinae Plane Block versus Serratus Anterior Plane Block Regarding Analgesia and Stress Response After Modified Radical Mastectomy: Randomized Controlled Trial.

Modified radical mastectomy (MRM) is the primary surgical treatment for breast cancer, yet it leads to significant postoperative pain. This randomized controlled trial evaluates the effects of an erector spinae plane block (ESPB) versus a serratus anterior plane block (SAPB) on post-MRM pain management and stress response reduction. Sixty individuals scheduled for unilateral MRM under general anesthesia from October 2021 to October 2022 were divided into three groups. Group A comprised 20 patients who received ultrasound-guided ESPB (20 mL of 0.25% bupivacaine). Group B included 20 patients who received ultrasound-guided SAPB (20 mL of 0.25% bupivacaine). Group C was treated with intravenous morphine based on pain scores. Anesthesia was induced using 2 μg/kg of fentanyl and 2 - 3 mg/kg of propofol. The study compared the three groups regarding pain scores using a numerical rating scale, serum cortisol levels, total fentanyl, and morphine consumption, changes in mean arterial blood pressure (MAP) and heart rate (HR) during surgery, and the occurrence of postoperative complications. Statistically significant reductions in pain scores were observed in group A compared to groups B and C. Moreover, group A exhibited a significant decrease in postoperative morphine consumption, serum cortisol levels 1 hour post-surgery (P = 0.021), MAP, and postoperative vomiting and nausea compared to group B. Furthermore, groups A and B showed statistically significant improvements in all parameters compared to group C. The study demonstrates that ESPB provides superior analgesic effects compared to SAPB in patients undergoing MRM, with reduced morphine use and lower postoperative cortisol levels. Both blocks offer more effective pain control than intravenous morphine alone.

Effects of Adding Dexamethasone Plus Ketamine to Bupivacaine for Ultrasound-guided Serratus Plane Block as Analgesia in Major Breast Surgery: A Randomized, Double-blind Trial

BACKGROUND: Post-operative pain after mastectomy is associated with poor recovery, prolonged hospital stays, and increased liability for chronic persistent pain. AIM: This work aimed to test the analgesic efficacy of adding ketamine to a dexamethasone bupivacaine combination in ultrasound-guided serratus anterior plane block (SAPB) in patients undergoing modified radical mastectomy (MRM). METHODS: This randomized, double-blind trial included 60 females aged 20–60 undergoing MRM. They were randomized into two groups: Group DB (n = 30) received SAPB using 30 ml of bupivacaine 0.25% and dexamethasone 4 mg. Group KD (n = 30) received the same block with the addition of ketamine 50 mg. RESULTS: The time to the first analgesic request was significantly delayed in Group KD than in Group DB (p < 0.001). The number of patients requiring morphine and its total consumption during the first 24 post-operative hours in Group KD were significantly less than in Group DB (p = 0.001 and p < 0.001, respectively). Visual Analog Scale scores at rest and movement at 4, 6, 8, 10, 12, and 18 h were significantly lower in Group KD than in Group DB. CONCLUSIONS: Adding ketamine to bupivacaine plus dexamethasone in ultrasound-guided SAPB is associated with better analgesic outcomes in patients undergoing MRM, including prolonged duration of analgesia and decreased post-operative morphine consumption and pain scores at rest and movement.

Single Dose Intravenous Paracetamol versus Placebo in Postorthognathic Surgery Pain: A Randomized Clinical Trial.

The postorthognathic surgery patients experienced moderate to severe pain and could be at risk for opioid-related side effects. The aim of this study was to evaluate the efficacy of a single dose of intravenous paracetamol to control postorthognathic surgery pain and reduce opioid consumption. The patients were randomized into two groups. The study group received intravenous paracetamol and the control group received a placebo immediately postoperation. The visual analogue pain scale (VAS) at 1-, 4-, 8-, 12-, 16-, 20-, and 24 -h postoperatively, morphine consumption, side effects from morphine, and patient satisfaction were analyzed. Sixty-two patients (thirty-one patients in each group) were included. The postoperative VAS in the study group was significantly lower than those in the control group (p value <0.001) at all time points. The total postoperative morphine consumption in the study group (45.1 ± 21.2 mcg/kg) was significantly lower compared with the control group (136.5 ± 49.9 mcg/kg) (p value <0.001). Patient satisfaction was significantly higher in the study group (4.7 ± 0.5 out of 5 points) than in the control group (4.1 ± 0.7 out of 5 points) (p value <0.001). The incidence of nausea and vomiting was significantly lower in the study group compared with the control group (p value <0.001 and 0.002, respectively). A single dose of intravenous paracetamol as part of multimodal analgesia was effective for postorthognathic surgery pain. It provided significant benefits to patients, including reduced pain scores, decreased opioid consumption, reduced nausea and vomiting, and improved satisfaction. This trial is registered with TCTR20210908002.

Perioperative intravenous lidocaine in thoracoscopic surgery for improved postoperative pain control: a randomized, placebo-controlled, double-blind, superiority trial.

Pain, including associated pain management, remains a burden on patients after thoracic surgery. Our objective was to investigate whether perioperative intravenous administration of lidocaine reduces postoperative morphine consumption and pain intensity after video-assisted thoracoscopic surgery (VATS). In this double-blind, placebo-controlled superiority trial, patients undergoing VATS with a planned duration of ≤90 minutes were randomized within an intention-to-treat setting. Patients received either intravenous lidocaine or placebo as a bolus of 1.5 mg/kg 30 minutes before incision, followed by a continuous infusion of 3.0 mg/kg/hour until 2 hours after skin closure. Pain and morphine consumption were evaluated when resting and when coughing 1, 2, 4, 8, 16, 24, and 48 hours after skin closure and in a follow-up 14, 90, and 180 days postoperatively. Twenty-eight patients were included in the lidocaine group, 24 in the placebo group. Patients' characteristics and preoperative pain scores were similar in both groups. When coughing, patients of the lidocaine group had less pain within 24 hours after skin closure than the placebo group (4.60±1.64 vs. 5.52±1.65; P=0.02). Morphine consumption was not statistically significantly lower in lidocaine group (18.22±12.87 vs. 21.26±9.39 mg; P=0.26). There were no significant differences between groups in secondary outcomes. Our results suggest that perioperative intravenous lidocaine administration reduces pain scores after VATS. The beneficial clinical effects are limited. Nevertheless, intravenous lidocaine may be helpful as part of a multimodal analgesia protocol or with patients in whom the use of other analgesics is contraindicated. ClinicalTrials.gov NCT03677817.

Is there a role for ischaemic pre-conditioning in orthopaedic and trauma surgery? A systematic review and meta-analysis of randomised controlled trials

Surgical procedures using a tourniquet submit tissues to ischaemia and reperfusion on restoring blood flow. Ischaemia-reperfusion may lead to local or remote tissue damage resulting in pain and complications. We aimed to evaluate the effectiveness of ischaemic preconditioning with a tourniquet in preventing pain, disability, adverse events, inflammation and facilitating recovery and discharge in patients receiving orthopaedic and trauma surgery. We conducted a systematic review of randomised controlled trials investigating ischaemic preconditioning in patients undergoing trauma and orthopaedic surgery. We searched The Cochrane Library, Medline and Embase until January 2021. Where possible continuous data were pooled and meta-analysis performed. Ten RCTs met inclusion criteria, eight of which underwent meta-analysis. Three studies reported lower acute post-operative pain or morphine consumption in patients randomised to IPC. We found weak evidence for shorter length of stay in the intervention group (MD-0.54 days; 95%CI-1.11, 0.03; p=0.0615). Malondialdehyde levels were lower in patients randomised to IPC at two hours following tourniquet deflation (MD -1.39 nmol/ml; 95%CI-2.23, -0.55; p=0.0012). We found no between group differences in Tumour Necrosis Factor-α, Lactate or Interleukin-6. The mechanism behind IPC may be related to reduced lipid peroxidation rather than reduced inflammation. There is evidence IPC reduces post-operative pain following knee surgery that merits further study.

Triple injection peri-sartorius (TIPS) block for postoperative analgesia after total knee arthroplasty: Randomised controlled study.

Motor-sparing analgesia after total knee arthroplasty (TKA) is crucial. The primary endpoint was the postoperative visual analogue scale (VAS) score after triple injection peri-sartorius (TIPS) block after TKA. Secondary endpoints were postoperative morphine consumption, 24-h postoperative ambulation distances and the degrees of active knee extension. After general anaesthesia or spinal anaesthesia administration and before surgical incision, 80 patients undergoing TKA were randomised into group TIPS (received ultrasound-guided TIPS block where 40 ml 0.25% bupivacaine and 4 mg dexamethasone were injected: 10 ml at the distal femoral triangle, 10 ml above the sartorius and 20 ml at the distal adductor canal) and group FNB (femoral nerve block; received ultrasound-guided FNB with 20 ml 0.25% bupivacaine mixed with 4 mg dexamethasone). Postoperative pain score was noted and compared. Dynamic VAS scores were lower in the TIPS group than in FNB, while the resting VAS scores were not significantly different. Mean (standard deviation [SD]) postoperative morphine consumption was 5.82 (2.47) mg in the TIPS group (95% confidence interval [CI] 5.03,6.61) versus 9.87 (2.99) mg in the FNB group (95% CI 8.91,10.83). Ambulation distances and active postoperative knee extension in the TIPS group showed greater significance than in the FNB group (TIPS: 18.0 [7.37] m, 95% CI 15.64,20.35] vs. FNB: 8.95 [5.93] m, 95% CI 7.05,10.84) and (TIPS: 52.12 [16.39], 95% CI 46.88,57.33 vs. FNB: 26.05 [11.10], 95% CI 22.501,29.59). Nausea was more evident in FNB patients. TIPS block provides superior analgesia than FNB with motor sparing of the quadriceps after TKA.

Minimal important difference in postoperative morphine consumption after hip and knee arthroplasty using nausea, vomiting, sedation and dizziness as anchors.

Morphine-sparing effects are often used to evaluate non-opioid analgesic interventions. The exact effect that would warrant the implementation of these interventions in clinical practice (a minimally important difference) remains unclear. We aimed to determine this with anchor-based methods. This was a post hoc analysis of three studies investigating pain management after hip or knee arthroplasty (PANSAID [NCT02571361], DEX-2-TKA [NCT03506789] and Pain Map [NCT02340052]). The overall population was median aged 70, median ASA 2, 54% female. We examined the correlation between 0 and 24 h postoperative iv morphine equivalent consumption and the severity of nausea, vomiting, sedation and dizziness. The anchor was different severity degrees of these opioid-related adverse events. The primary outcome was the difference in morphine consumption between patients experiencing no versus only mild events. Secondary outcomes included the difference in morphine consumption between patients with mild versus moderate and moderate versus severe events. We used Hodges-Lehmann median differences, exact Wilcoxon-Mann-Whitney tests and quantile regression. The difference in iv morphine consumption was 6 mg (95% confidence interval: 4-8) between patients with no versus only mild events, 5 mg (2-8) between patients with mild versus moderate events and 0 mg (-4 to 4) between patients with moderate versus severe events. In populations comparable to this post-hoc analysis (orthopaedic surgery, median age 70 and ASA 2), we suggest a minimally important difference of 5 mg for 0-24 h postoperative iv morphine consumption.

Efficacy of intraoperative systemic lidocaine on quality of recovery after laparoscopic colorectal surgery: a randomized controlled trial

Introduction Many clinical trials have demonstrated the benefits of intraoperative systemic lidocaine administration in major abdominal surgeries. We tested the hypothesis that systemic lidocaine is associated with an enhanced early quality of recovery in patients following laparoscopic colorectal resection. Patients and Methods We randomly allocated 126 patients scheduled for laparoscopic colorectal surgery in a 1:1 ratio to receive either lidocaine (1.5 mg kg−1 bolus over 10 min, followed by continuous infusion at 2 mg kg−1 h−1 until the end of surgery) or identical volumes and rates of saline. The primary outcome was the Quality of Recovery-15 score assessed 24 h after surgery. Secondary outcomes were areas under the pain numeric rating scale curve over time, 48-h morphine consumption, and adverse events. Results Compared with saline, systemic lidocaine improved the Quality of Recovery-15 score 24 h postoperatively, with a median difference of 4 (95% confidence interval: 1–6; p = 0.015). Similarly, the area under the pain numeric rating scale curve over 48 h at rest and on movement was reduced in the lidocaine group (p = 0.004 and p < 0.001, respectively). However, these differences were not clinically meaningful. Lidocaine infusion reduced the intraoperative remifentanil requirements but not postoperative 48-h morphine consumption (p < 0.001 and p = 0.34, respectively). Additionally, patients receiving lidocaine had a quicker and earlier return of bowel function, as indicated by a shorter time to first flatus (log-rank p < 0.001), yet ambulation time was similar between groups (log-rank test, p = 0.11). Conclusions In patients undergoing laparoscopic colorectal surgery, intraoperative systemic lidocaine resulted in statistically but not clinically significant improvements in quality of recovery (see Graphical ). Trial registration: Chinese Clinical Trial Registry; ChiCTR1900027635.

Efficacy of Oral Nefopam on Multimodal Analgesia in Total Knee Arthroplasty: A Prospective, Double-Blind, Placebo-Controlled, Randomized Trial

BackgroundMultimodal analgesia is central to pain management after total knee arthroplasty (TKA). This study aimed to evaluate the efficacy of adding oral nefopam to multimodal analgesia for post-TKA pain management. MethodsIn this prospective, double-blind, placebo-controlled, randomized trial, 100 patients who underwent TKA at our hospital were randomized to either the nefopam or the control group. After surgery, patients in the nefopam group received 200 mg of celecoxib, 150 mg of pregabalin, and 40 mg of nefopam twice daily to control postoperative pain. Patients in the control group received 200 mg of celecoxib, 150 mg of pregabalin, and a placebo. Oxycodone hydrochloride (10 mg) was used as the rescue analgesic. If the pain remained poorly controlled, 10 mg of morphine hydrochloride was injected subcutaneously as a secondary rescue analgesic. The primary outcome was the postoperative consumption of oxycodone and morphine as rescue analgesics. Secondary outcomes were postoperative pain assessed using the visual analogue scale (VAS), functional recovery assessed by the range of knee motion and ambulation distance, time until hospital discharge, indicators of liver function, and complication rates. ResultsPatients in the nefopam group had significantly lower postoperative oxycodone and morphine consumption within 24 hours after surgery and during hospitalization, lower VAS pain scores at rest and during motion within 24 h after surgery, better functional recovery on postoperative days 1 and 2, and a shorter hospital stay. However, the absolute reduction in 0 to 24 h opioid consumption, VAS pain scores, and knee range of motion did not exceed the reported minimal clinically important difference. Both groups had similar indicators of liver function and complication rates. ConclusionsAdding oral nefopam to multimodal analgesia resulted in statistically significant improvements in opioid consumption, VAS pain scores, and functional recovery. However, the amount of improvement may not be clinically important.

Optimal analgesic regimen for total shoulder arthroplasty: a randomized controlled trial and network meta-analysis

ObjectiveClinical approaches to analgesia following total shoulder arthroplasty include liposomal bupivacaine, local infiltration analgesia, single-shot interscalene block, and continuous interscalene block. However, the best method remains contentious. This study conducts a network meta-analysis comparing these four methods, aiming to identify the most effective analgesic approach.MethodsRandomized controlled trials on analgesic regimens for total shoulder arthroplasty were identified through searches of PUBMED, Cochrane Central Register of Controlled Trials, EMBASE, Web of Science, and Scopus databases, covering their inception through November 2023. Network meta-analysis was performed using STATA 15.1, and the Cochrane Handbook version 5.1.0 risk of bias tool was employed for quality assessment of the literature.ResultsTwelve randomized controlled trials were included, comprising 1537 patients undergoing total shoulder arthroplasty. The interventions compared were ssISB, cISB, LIA, and LB. Regarding the quality of the literature, four studies were deemed low risk, one high risk, and seven moderate risk. The network meta-analysis revealed that in terms of VAS scores in the PACU, the ssISB group was the most effective, followed by cISB and LB, with LIA being the least effective. This pattern continued in VAS scores on the first and second postoperative days. Regarding morphine consumption, the cISB group showed the most significant reduction in the PACU and on the first postoperative day, while the LIA group performed best in total postoperative morphine consumption. The shortest average hospital stay was noted in the cISB group.ConclusionThe ssISB method excels in controlling early postoperative pain, particularly during the PACU stage and early postoperative period. Additionally, the cISB method is notable for reducing postoperative morphine consumption and shortening average hospital stays. While the LIA method ranks first in reducing total morphine consumption, it is weaker in pain control. The LB method is underwhelming across most assessment parameters. These findings underscore the importance of selecting appropriate analgesic strategies for different postoperative recovery phases and provide valuable insights for clinicians to optimize postoperative pain management. Furthermore, they suggest a need for future research to explore the specific application and effectiveness of these methods in varying clinical contexts.

The effect of adding dexmedetomidine or dexamethasone to bupivacaine-fentanyl mixture in spinal anesthesia for cesarean section.

Many strategies are available to prevent spinal-induced hypotension in cesarean section, especially the use of a low dose of spinal anesthesia combined with adjuvants. This study investigated the effect of adding either dexmedetomidine or dexamethasone to the intrathecal bupivacaine-fentanyl mixture on the postoperative analgesia duration, after elective cesarean section. This prospective, randomized, double-blind study was conducted on 90 full-term parturients undergoing elective cesarean section, who were randomly distributed into three groups. They all received spinal anesthesia with the bupivacaine-fentanyl mixture (2.5 ml), in addition to 0.5 ml normal saline (control group), 5 μg dexmedetomidine dissolved in 0.5 ml normal saline (dexmedetomidine group), or 2 mg dexamethasone (dexamethasone group). The time to the first request of morphine rescue analgesia was recorded, in addition to the total dose of morphine consumed in the first 24 h after surgery, the postoperative numerical rating score (NRS), and maternal and fetal outcomes. As compared to the control group and the dexamethasone group, the use of dexmedetomidine as an additive to the bupivacaine-fentanyl mixture significantly prolonged the time to the first request of rescue analgesia, decreased postoperative morphine consumption, and decreased the pain score 4 and 6 h after surgery. There was an insignificant difference between the control and dexamethasone groups. The use of dexmedetomidine as an additive to bupivacaine-fentanyl mixture in spinal anesthesia for cesarean section prolonged the postoperative analgesia and decreased the postoperative opioid consumption in comparison to the addition of dexamethasone or normal saline.

Analgesic benefits of pre-operative versus postoperative transversus abdominis plane block for laparoscopic cholecystectomy: a frequentist network meta-analysis of randomized controlled trials

BackgroundTransversus abdominis plane (TAP) block has been utilized to alleviate pain following laparoscopic cholecystectomy (LC). However, the optimal timing of administration remains uncertain. This study aimed to compare the efficacy of pre-operative and postoperative TAP blocks as analgesic options after LC.MethodsA frequentist network meta-analysis of randomized controlled trials (RCTs) was conducted. We systematically searched PubMed (via the National Library of Medicine), EMBASE, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science up to March 2023. The study included RCTs that enrolled adult patients (≥ 18 years) who underwent LC and received either pre-operative or postoperative TAP blocks. The primary outcome assessed was 24-hour postoperative morphine consumption (mg). Additionally, pain rest scores within 3 hours, 12 hours, and 24 hours, as well as postoperative nausea and vomiting (PONV), were considered as pre-specified secondary outcomes.ResultsA total of 34 trials with 2317 patients were included in the analysis. Postoperative TAP block demonstrated superiority over the pre-operative TAP block in reducing opioid consumption (MD 2.02, 95% CI 0.87 to 3.18, I2 98.6%, p < 0.001). However, with regards to postoperative pain, neither pre-operative nor postoperative TAP blocks exhibited superiority over each other at any of the assessed time points. The postoperative TAP block consistently ranked as the best intervention using SUCRA analysis. Moreover, the postoperative TAP block led to the most significant reduction in PONV.ConclusionsThe findings suggest that the postoperative TAP block may be slightly more effective in reducing 24-hour postoperative opioid consumption and PONV when compared to the pre-operative TAP block.Trial registrationPROSPERO, CRD42023396880.

Ultrasound-guided quadratus lumborum block: Posterior versus anterior approach in paediatrics undergoing laparoscopic inguinal hernia repair

Abstract Background and Aims: Regional anaesthesia has gained popularity in managing post-operative pain in paediatric patients. Quadratus lumborum block (QLB) is recognised as one of the peri-operative pain management techniques used during abdominal surgeries. However, no consensus about the best approach has been reached. Material and Methods: Sixty paediatric patients with ages ranging from 1 to 6 as well as classification I and II of the American Society of Anesthesiologists, scheduled for laparoscopic inguinal hernia, were allocated to receive either a posterior approach (Group I) or an anterior approach (Group II) QLB. Twenty four-hour morphine consumption, the face, legs, activity, cry, and consolability (FLACC) score, duration of analgesia, performance time, and block-related complications were recorded. Results: Group II showed significantly lower morphine consumption as well as a longer duration of analgesia (P = 0.039*, 0.020*, respectively), with an equivalent period for block performance being reported in the two groups (P = 0.080). At 2, 4, 6, and 12 hours post-operatively, the FLACC scores were substantially diminished in Group II compared to Group I (P = 0.001*, 0.012*, 0.002*, 0.028*, respectively). However, at twenty-four hours, comparable pain scores were observed between both groups (P = 0.626). In addition, there were no block-related complications. Conclusions: In paediatric patients scheduled for laparoscopic inguinal hernia repair, the ultra-sound-guided anterior approach of the QLB was associated with significantly reduced post-operative morphine consumption, a lower FLACC score, and a longer analgesia duration when compared to the posterior approach.

Role of vitamin C in multimodal analgesia for sleeve gastrectomy: a prospective randomized controlled trail

Background &amp; Objective: The laparoscopic sleeve gastrectomy is a popular intervention in morbidly obese patient. Postoperative pain relief is a major challenging issue in this procedure with known adverse effects on the respiratory excursion and the ability to cough by the patient. Various analgesic protocols have been tries to conquer this pain. Vitamin C is a micronutrient, water soluble vitamin with antioxidant and antinociceptive actions. We assessed the effect of vitamin C when used as a component of the multimodal analgesic technique in this cohort of the patients.&#x0D; Methodology: After obtaining the ethical committee approval and trial registration, 50 patients scheduled for laparoscopic sleeve gastrectomy were enrolled in this study. The patients were randomly divided into two equal groups according to the study protocol. Group C received vitamin C 500 mg every 8 h for 5 days perioperatively, while Group N received placebo in the same fashion. The surgery was performed under routine general anesthesia. We monitored hemodynamic, VAS, rescue analgesia profile, and gastrointestinal side effects in the immediately after operation, and then at 1, 2, 4, 8, 12, and at 24 h postoperatively. The postoperative morphine consumption was noted as a primary objective of the study. Independent sample T test, Mann-Whitney test, chi square test or Kruskal Wallis test were utilized to detect statistical differences between the studied groups. P &lt; 0.05 was considered significant.&#x0D; Results: Postoperative morphine consumption was lower in Group C than in Group N (16.36 ± 2.37 vs. 20 ± 4.13 mg, P = 0.001). The frequency of morphine was significantly lower in Group C than in Group N (P = 0.009). VAS was lower in Group C than Group N at 4, 8, and 12 h postoperatively (P = 0.02, 0.001, 0.001), while other parameters where comparable.&#x0D; Abbreviation: CBC: complete blood count; IRB: Institutional Research Board; LFTs: liver function tests; LSG: laparoscopic sleeve gastrectomy; MABP: mean arterial blood pressure; NMDA: N-methyl D-aspartate; OSAS: obstructive sleep apnea syndrome; PACTR: Pan African Clinical Trial Registry; PEEP: positive end expiratory pressure.; PFT: pulmonary function tests; RFTs: renal function tests; TFTs: thyroid function test; TOF: train of four; VAS: visual analogue score.&#x0D; Preregistration: Institutional Research Board, Mansoura Faculty of Medicine (IRB # R.20.02.738, Feb 15-2020). Pan African clinical trial registry (PACTR- 202003565796463, date of registration: March 02-2020).&#x0D; Conclusion: Vitamin C via its antioxidant, antinociceptive properties and NMDA-receptor antagonist action can be used as a part of multimodal analgesic techniques. Vitamin C acts as co-analgesic, improves postoperative pain profile, and reduces the needs for other analgesic modalities.&#x0D; Key words: Vitamin C; Analgesia; VAS; Pain; Sleeve Gastrectomy&#x0D; Citation: Aboelelea M, Abedelkhalek M, Mamoun M. Role of vitamin C in multimodal analgesia for sleeve gastrectomy: a prospective randomized controlled trial. Anaesth. pain intensive care 2023;27(1):82−88.&#x0D; DOI: 10.35975/apic.v27i1.2110&#x0D; Received: October 02, 2022; Reviewed: October 25, 2022; Accepted: December 09, 2022

Deep Parasternal Intercostal Plane Block for Intraoperative Pain Control in Cardiac Surgical Patients for Sternotomy: A Prospective Randomized Controlled Trial

Sternotomy pain is common after cardiac surgery. The deep parasternal intercostal plane (DPIP) block is a novel technique that provides analgesia to the anterior chest wall. The aim of this study was to investigate the analgesic effect of bilateral DPIP blocks on intraoperative pain control in cardiac surgery. This is a double-blinded, prospective randomized controlled trial (Oct 2020-Dec 2022). This study was conducted in a single institution, which is an academic university hospital. Eighty-six elective cardiac surgical patients with median sternotomy were recruited. Patients were randomly divided into DPIP or control group. Either 20ml 0.25% levobupivacaine or 0.9% normal saline was injected for the DPIP under ultrasound guidance after induction of general anaesthesia. The primary outcome was intraoperative opioids consumption and hemodynamic changes at sternotomy. Secondary outcomes included postoperative morphine consumption, postoperative pain and time to tracheal extubation. Intraoperative opioids requirement was reduced from a median (IQR) intravenous morphine equivalence of 21.4mg (13.8-24.3mg) in control group to 9.5mg (7.3-11.2mg) in the DPIP group (P<0.001). Hemodynamic parameters were more stable in DPIP group at sternotomy, as evidenced by lower percentage increase in systolic, diastolic and mean arterial blood pressure from baseline. No difference was observed in time to tracheal extubation, postoperative morphine consumption, postoperative pain score and spirometry. Bilateral DPIP block provides effective intraoperative analgesia and opioid-sparing. It may be included as part of the multimodal analgesia for enhanced recovery in cardiac surgery.

Combined pectoralis II block and transversus thoracic plane block compared to erector spinae plane block for post-operative analgesia in patients undergoing modified radical mastectomy: A randomized clinical trial

ABSTRACT Background About 30% of Egyptian females had breast cancer. Surgery is a cornerstone of the treatment plan. New fascial plane block techniques enhance recovery and improve intra-operative and post-operative pain control. Aim of the study Effect of combined pectoralis II plus transversus thoracic plane blocks (PECS II- TTP) versus erector spinae plane block (ESPB) on post-operative morphine consumption, and interleukin-6 (IL-6) levels 24 hours after surgery. Methods Sixty-four female patients 18–60 years of age, ASA I or II were divided into two equal groups (32 patients each). Group (P) received a combination of PECS II and TTP blocks (injection of 10 ml 0.25% bupivacaine between pectoralis major (PM) and minor (Pm) muscles and 10 ml between the Pm and serratus anterior (Sa) muscles) at the third or the fourth rib, then 10 ml and the internal inter-costal muscles and the transversus thoracic muscle. Group (E) received ESPB (30 ml of 0.25% bupivacaine injected deep to the erector spinae muscle at the transverse process of the fifth thoracic vertebrae). Results Morphine consumption was significantly lower in group (E) throughout the 24 hours period of post-operative follow-up (0.93 ± 0.63 vs. 2.13 ± 0.42 (mg); p = 0.03). Both groups had comparable time till the first analgesic request (p = 0.23). There was statistically non-significant difference between the two groups regarding the numeric rating scale (NRS) (P > 0.05), and post-operative IL6 either at baseline (10.03 ± 4.09 vs. 10.73 ± 3.54; p = 0.48) or at 24 hours after surgery (239.01 ± 122.11 vs. 278.08 ± 151.29; p = 0.30). Both groups had non-significant difference regarding post-operative nausea and vomiting. Conclusion ESPB is as effective as PECS II-TTP with lower morphine consumption in the first 24 hours and comparable NRS, time to first analgesic request, and interleukin-6 levels. Both blocks were safe without any major complications.

Postoperative Analgesic Efficacy of Nefopam after Anorectal Surgery: A Retrospective Observational Study

Abstract Objective To examine the effectiveness of nefopam on postoperative pain control after anorectal surgeries. Methods We retrospectively reviewed the electronic medical records of patients who underwent anorectal surgeries from January 2019 to March 2022 at two medical centers. The data were divided into nefopam and conventional groups. The primary outcome was the number of patients who requested additional opioids in the 24-h postoperative period. The secondary outcomes were numeric rating pain scores (NRPS) within a 24-h postoperative period and analgesic drugs-related side effects. Results Eighty-seven patients in the conventional group and 60 in the nefopam group were recruited. The nefopam group reported less additional opioid consumption than the conventional group in all dimensions of analysis, including overall, adjusted to anesthetic techniques and types of surgery. However, these did not reach statistical significance (P = 0.093). Only patients in the nefopam group who underwent hemorrhoidectomy under TIVA or spinal anesthesia significantly required fewer additional opioids (P = 0.016, 60% mean difference). Similarly, the 24-h postoperative morphine consumption was lower in the nefopam group (mean difference = −3.4, 95%CI: 0.72,6.08). Furthermore, significantly lower NRPS were reported in the nefopam group during the 12-18 h postoperative period (P = 0.009). On the other hand, analgesic drugs related side effects were similar in both groups. Conclusions The administration of nefopam after major anorectal surgery is beneficially evident in reducing postoperative opioid requirements.

Which ultrasound-guided parasternal intercostal nerve block for post-sternotomy pain? Results from a prospective observational study

BackgroundParasternal intercostal blocks (PSB) have been proposed for postoperative analgesia in patients undergoing median sternotomy. PSB can be achieved using two different approaches, the superficial parasternal intercostal plane block (SPIP) and deep parasternal intercostal plane block (DPIP) respectively.MethodsWe designed the present prospective, observational cohort study to compare the analgesic efficacy of the two approaches. Cardiac surgical patients who underwent full sternotomy from January to September 2022 were enrolled and divided into three groups, according to pain control strategy: morphine, SPIP, and DPIP group. Primary outcomes were was postoperative pain evaluated as absolute value of NRS at 12 h. Secondary outcomes were the NRS at 24 and 48 h, the need for salvage analgesia (both opioids and NSAIDs), incidence of postoperative nausea and vomiting, time to extubation, mechanical ventilation duration, and bowel disfunction.ResultsNinety-six were enrolled. There was no significant difference in terms of median Numeric Pain Rating Scale at 24 h and at 48 h between the study groups. Total postoperative morphine consumption was 1.00 (0.00–3.00), 2.00 (0.00–5.50), and 15.60 mg (9.60–30.00) in the SPIP, DPIP, and morphine group, respectively (SPIP and DPIP vs morphine: p < 0.001). Metoclopramide consumption was lower in SPIP and DPIP group compared with morphine group (p = 0.01). There was no difference in terms of duration of mechanical ventilation and of bowel activity between the study groups. Two pneumothorax occurred in the DPIP group.ConclusionsBoth SPIP and DPIP seem able to guarantee an effective pain management in the postoperative phase of cardiac surgeries via full median sternotomy while ensuring a reduced consumption of opioids and antiemetic drugs.