Postoperative Morphine Consumption Research Articles

Effect of intravenous lidocaine on pain after head and neck cancer surgery (ELICO trial): A randomised controlled trial.

Treatment of postoperative pain after ear, nose and throat (ENT) cancer surgery is mainly morphine administration. Additional systemic lidocaine has shown promising results in some surgical procedures. The main objective was to evaluate morphine consumption in the first 48 postoperative hours after intra-operative lidocaine infusion during major ENT cancer surgery. A randomised, double-blind, placebo-controlled trial. Bicentric study including a university hospital and a major cancer centre, conducted from December 2016 to December 2019. A total of 144 patients undergoing major ENT cancer surgery were included. The patients were randomly assigned to receive intravenous lidocaine or placebo during surgery and in the recovery room. Endpoints were postoperative morphine consumption in the first 24 and 48 h postoperatively, intra-operative remifentanil consumption, adverse events occurrence and assessment 3 to 6 months after surgery with the McGill pain questionnaire. A total of 118 patients were included (lidocaine n = 57; placebo n = 61, 26 patients were excluded). There was no significant difference in morphine consumption during the first 48 postoperative hours in the lidocaine group compared with the placebo group with a median [IQR] of 0.60 [0.30 to 1.03] mg kg -1 vs. 0.57 [0.37 to 0.96] mg kg -1 , total dose 44 [21 to 73.3] mg vs. 38 [23.3 to 56.5] mg, P = 0.92.There was no significant difference between the two groups in any of the other endpoints, including at follow up 3 to 6 months after surgery. Intravenous lidocaine in ENT cancer surgery did not show any additional analgesic or morphine-sparing effect 48 h after surgery. Three to six months after surgery, there was no significant difference in pain scores or consumption of analgesics. Patients treated pre-operatively with opioids were not evaluated in the study. Clinicaltrials.gov identifier: NCT02894710 and EUDRACT number 2015-005799-90.

Robotic-Assisted Esophagectomy Leads to Significant Reduction in Postoperative Acute Pain: A Retrospective Clinical Trial

BackgroundRobot-assisted minimally invasive esophagectomy (RAMIE) shows promising results regarding postoperative complications in patients with esophageal cancer. To date, no data are available regarding postoperative analgesic consumption. The aim of this work is to evaluate analgesic consumption after esophagectomy.MethodsA total of 274 Ivor Lewis esophageal resections performed sequentially from January 2012 to December 2020 were evaluated. RAMIE cases (n = 51) were compared with the hybrid technique (laparoscopic abdominal phase followed by open thoracotomy, n = 59) and open abdominothoracic esophagectomy (OTE) (n = 164). Data were collected retrospectively. The primary endpoint was the overall postoperative morphine consumption, which represents a reliable indirect measurement of pain. Pain levels recorded on the first, third, and fifth postoperative days were assessed as secondary endpoints.ResultsA total of 274 patients were included. The postoperative opioid consumption rate for patients who underwent RAMIE (quartiles: 0.14, 0.23, 0.36 mg morphine milligram equivalents (MME)/kg body weight (bw)/day) was significantly lower than in the open group (0.19, 0.33, 0.58 mg MME/kg bw/day, p = 0.016). The overall postoperative opioid consumption for patients who underwent RAMIE was significantly lower (2.45, 3.63, 7.20 mg MME/kg bw/day; morphine milligram equivalents per kilogram body weight) compared with the open (4.85, 8.59, 14.63 MME/kg bw/day, p < 0.0001) and hybrid (4.13, 6.84, 11.36 MME/kg bw/day, p = 0.008) groups. Patients who underwent RAMIE reported lower pain scores compared with the open group on the fifth postoperative day, both at rest (p = 0.004) and while performing activities (p < 0.001).ConclusionsThis study shows that patients who underwent RAMIE experienced similar postoperative pain while requiring significantly lower amounts of opioids compared with patients who underwent open and hybrid surgery. Further studies are required to verify the results.

Efficacy of quadratus lumborum block on postoperative pain and side effects in patients who underwent urological surgery: Ameta-analysis.

Ultrasound-guided quadratus lumborum block (QLB) is considered a novel nerve block for postoperative pain control. However, its efficacy after urological surgery remains unclear. The purpose of the current meta-analysis was to evaluate the effects of the QLB block versus control (placebo or no injection) on postoperative pain and other adverse outcomes after urological surgery, providing extensive evidence of whether quadratus lumborum block is suitable for pain management after urological surgery. Systematic review with meta-analysis of randomized clinical trials. We searched PubMed, Cochrane Library, Embase, Web of Science, and ClinicalTrials.gov to collect studies investigating the effects of QLB on analgesia after urological surgery. The primary outcomes included visual analog scale (VAS) at rest and during movement, 24-h postoperative morphine consumption, and the incidence of postoperative nausea and vomiting (PONV). Overall, 13 randomized controlled trials (RCTs) were reviewed, including 751 patients who underwent urological surgery. The QLB group exhibited a lower VAS score postoperatively at rest or on movement at 0, 6, 12, and 24 h, with less 24-h postoperative morphine consumption and lower incidence of PONV. Although the result is stable, heterogeneity exists in the current research. QLB exhibited a favorable effect of postoperative analgesia with reduced postoperative complications at rest or during movement after urological surgery. However, it is still a novel technology at a primary stage, which needs further research to develop.

The effect of lidocaine patch for postoperative pain: A meta-analysis of randomized controlled trials

Study objectiveThe role of lidocaine patch (LP) in reducing postoperative pain by local anesthetic absorption has been evaluated in several studies; however, these trials have shown inconsistent results. This meta-analysis aimed to identify the benefits of LP, focusing on its pain-reducing and morphine-sparing effect in patients after surgery. DesignMeta-analysis. SettingPublished randomized controlled trials (RCTs) comparing the analgesic effects of LP after surgery to those of placebo or no patch. PatientsEleven RCTs including 539 patients. InterventionsWe searched electronic databases to identify relevant RCTs. MeasurementsThe primary outcome was postoperative pain score up to 48 h assessed using a numerical rating or visual analog scale, and the secondary outcomes were postoperative morphine consumption and side effects. The effect size was estimated by calculating the mean difference (MD) or risk ratio (RR), with 95% confidence interval (CI). Main resultsLP significantly decreased postoperative pain score at 6 h (MD, −1.85; 95% CI, −2.98 to −0.72; p = 0.001), 12 h (MD, −1.48; 95% CI, −2.07 to −0.88; p < 0.001), 24 h (MD, −1.18; 95% CI, −1.65 to −0.7; p < 0.001), and 48 h (MD, −1.33; 95% CI, −2.46 to −0.19; p = 0.022). In contrast, no significant effect on postoperative morphine consumption was observed at 24 h (MD, −3.48 mg; 95% CI, −7.94 to 0.98 mg; p = 0.127) or 48 h (MD, −5.29 mg; 95% CI, −13.28 to 2.71; p = 0.195). LP was unrelated to local (RR, 1.00, 95% CI, 0.67 to 1.49; p = 0.987) or systemic side effects (RR, 0.76, 95% CI, 0.52 to 1.11, p = 0.151). ConclusionsLP can lower postoperative pain without side effects, compared to placebo or no patch. However, its morphine-sparing effect remains unclear.

Is continuous Erector Spinae Plane Block (ESPB) better than continuous Serratus Anterior Plane Block (SAPB) for mitral valve surgery via mini-thoracotomy? Results from a prospective observational study.

ABSTRACTAims:Chest wall blocks are effective alternatives for postoperative pain control in mitral valve surgery in right mini-thoracotomy (mini-MVS). We compared the efficacy of Serratus Anterior plane block (SAPB) and Erector Spinae plane block (ESPB) on postoperative pain relief after mini-MVS.Settings and Design:It is a prospective, observational study.Material and Methods:A total of 85 consecutive patients undergoing continuous SAPB and continuous ESPB for mini-MVS from March 2019 to October 2020 were included. The primary outcome was the assessment of postoperative pain evaluated as absolute value of NRS at 12, 24 and 48 h. Secondary outcomes were assessment of salvage analgesia (both opioids and NSAIDs), incidence of mild adverse effects (i.e. nausea, vomiting, and incorrect catheter placement) and timing of postoperative course (ICU and hospital length of stay, duration of mechanical ventilation, ventilator-free days).Results:The median NRS was 0.00 (0.00–3.00) at 12 h and 0.00 (0.00–2.00) at 24 and 48 h. No significant differences were observed between groups. Postoperative morphine consumption in the first 24 h was similar in both groups (P = 0.76), whereas between 24 and 48 h was significantly less in the ESPB group compared with SAPB group, P = 0.013. NSAIDs median consumption and Metoclopramide consumption were significantly lower in the ESPB group compared to SAPB group (P = 0.002 and P = 0.048, respectively).Conclusions:ESPB, even more than SAPB, appears to be a feasible and effective strategy for the management of postoperative pain, allowing good quality analgesia with low consumption of opioids, NSAIDs and antiemetic drugs.

Rescue Paracetamol in Postoperative Pain Management in Extremely Low Birth Weight Neonates Following Abdominal Surgery: A Single Unit Retrospective Study.

BackgroundIntravenous paracetamol added to morphine reduces postoperative morphine consumption in (near)term neonates. However, there are only sparse data on intravenous paracetamol as multimodal strategy in extremely low birth weight (ELBW) neonates.ObjectivesThis study aims to assess the effects of rescue intravenous paracetamol on postoperative pain management (≤48 h postoperatively) in relation to both analgesic efficacy (validated pain assessment, drug consumption, adequate rescue medication) and safety (hypotension and bradycardia). This rescue practice was part of a standardized pain management approach in a single neonatal intensive care unit (NICU).MethodsA single-center retrospective observational study included 20 ELBW neonates, who underwent major abdominal surgery. The primary endpoints of the postoperative study period were pain intensity, over-sedation, time to first rescue analgesic dose, and the effect of paracetamol on opiate consumption. Secondary endpoints were safety parameters (hypotension, bradycardia). And as tertiary endpoints, the determinants of long-term outcome were evaluated (i.e., duration of mechanical ventilation, intraventricular hemorrhage - IVH, periventricular leukomalacia - PVL, postnatal growth restriction, stage of chronic lung disease – CLD or neurodevelopmental outcome according to Bayley-II Scales of Infant Development at 18–24 months).ResultsAll neonates received continuous opioids (sufentanil or morphine) and 13/20 also intravenous paracetamol as rescue pain medication during a 48-h postoperative period. Although opioid consumption was equal in the non-paracetamol and the paracetamol group over 48 h, the non-paracetamol group was characterized by oversedation (COMFORTneo < 9), a higher incidence of severe hypotension, and younger postnatal age (p < 0.05). All long-term outcome findings were similar between both groups.ConclusionsOur study focused on postoperative pain management in ELBW neonates, and showed that intravenous paracetamol seems to be safe. Prospective validation of dosage regimens of analgesic drugs is needed to achieve efficacy goals.

Effects of opioid-free anesthesia on postoperative morphine consumption after bariatric surgery

Study objectivesThe objective of this study was to determine whether postoperative morphine requirement in obese patients undergoing laparoscopic bariatric surgery was reduced by opioid-free anesthesia (OFA), as compared to an anesthetic strategy using opioids (opioid balanced anesthesia (OBA)) and to investigate the differences that may exist between the use of clonidine and dexmedetomidine in the context of OFA. DesignRetrospective cohort study. SettingAcademic medical center in Lyon, France. Patients257 patients who underwent laparoscopic bariatric surgery between March 2017 and March 2019. 77 patients were included in the OBA group and 180 in the OFA group. The OFA group was subdivided in two: 90 patients received OFA with clonidine (OFAC) and 90 received OFA with dexmedetomidine (OFAD). MeasurementsProportion of patients who did not receive morphine during the first 24 postoperative hours. Main resultsDuring the first 24 postoperative hours, the proportion of patients who did not require morphine was significantly higher in the OFA (87%) than in the OBA (52%) group (OR: 6.31; 95% CI [3.38; 11.80], P < 0.001). This difference remained significant after adjustment for age, body mass index, sex, type and duration of surgery (OR: 7.99; 95% CI [4.05; 16.48], P < 0.001). A greater proportion of patients in the OFAD (93%) than in the OFAC group (81%, P = 0.026) did not receive morphine during the same period. ConclusionsOFA is associated with a lower morphine requirement than with OBA during the first 24 h after bariatric surgery. In addition, OFAD seems to be more effective than OFAC in order to reduce morphine consumption.

Erector spinae plane block vs. single shot epidural block for postoperative analgesia in lumbar spine surgery: a randomized controlled trial

Background: Epidural block is an effective route for analgesia in spine surgeries. Erector spinae plane block (ESPB) is a field block that showed promising results in various surgeries. We compared both procedures in spine surgery, regarding postoperative pain, the time to first analgesic request, postoperative total morphine consumption, perioperative hemodynamics, and any adverse events.&#x0D; Methodology: Sixty-seven patients were enrolled in this double-blinded randomized controlled study. Patients were allocated into two groups. The epidural group received an ultrasound-guided single-shot epidural block with 20 mL of 0.25% bupivacaine. The ESPB group received an ultrasound-guided bilateral single-shot ESPB with 20 mL of 0.25% bupivacaine for each side. Postoperative pain, the time to first analgesic request, postoperative total morphine consumption, perioperative hemodynamics, and any adverse events were recorded.&#x0D; Results: The time to the first analgesic requirement was longer in the ESPB group (11.5 [9-14] h, vs. 7 [5-8] h, P &lt; 0.001). The mean morphine consumption was lower in the ESPB group (3.88 ± 0.54 vs. 7.12 ± 1.94 mg; P &lt; 0.001). The numeric rating scale was lower in the epidural group. Less patients experienced intraoperative hypotension and tachycardia in ESPB group.&#x0D; Conclusion: ESPB provides longer postoperative analgesia, less opioid consumption, and more intraoperative hemodynamic stability when compared with a single-shot epidural block in lumbar spine surgery.&#x0D; Trial registration: The ethical approval was obtained from the Research Ethics Committee of Cairo University (M D-82-2019), and the trial was registered on www.clinicaltrials.gov with registration number (NCT04320212). https://clinicaltrials.gov/ct2/show/NCT04320212&#x0D; Abbreviations: ESPB - Erector spinae plane block; LA - Local anesthetics&#x0D; Key words: Erector spinae plane block; Pain, Postoperative; Spine surgery; Analgesia, Epidural; Fascial plane blocks; Neuraxial analgesia&#x0D; Citation: Abdelhamid HS, ElSabbagh HA, Amin SM, Abdelhakim AK. Erector spinae plane block vs. single shot epidural block for postoperative analgesia in lumbar spine surgery: a randomized controlled trial. Anaesth. pain intensive care 2022;26(3):310-317.&#x0D; DOI: 10.35975/apic.v26i3.1897&#x0D; Received: February 01, 2022; Reviewed: March 13, 2022; Accepted: March 23, 2022&#x0D;

Bilateral PECS II Block is Associated with Decreased Opioid Consumption and Reduced Pain Scores for up to 24 hours After Minimally Invasive Repair of Pectus Excavatum (Nuss Procedure): A Retrospective Analysis

Objective(s)Compared to the open surgical technique, the minimally invasive repair of pectus excavatum (MIRPE; Nuss procedure) is a thoracoscopic technique designed to minimize intraoperative tissue damage. It still causes severe postoperative pain due to the insertion and pressure of the retrosternal bar used to raise the sternum and stabilize the chest. This study aimed to identify associations between ultrasound-guided PECS-II block and postoperative analgesia after the Nuss procedure. DesignA retrospective cohort study SettingSingle-center, training and research hospital affiliated with a university ParticipantsFrom Jan 1, 2018 to Nov 15, 2021, 171 consecutive patients were identified who underwent MIRPE surgery under general anesthesia. All patients received intravenous (I) patient-controlled analgesia (PCA) with or without PECS-II blocks for postoperative analgesia. One hundred twenty-five patients who met the inclusion criteria were evaluated. InterventionsDemand-only morphine intravenous PCA was used for postoperative pain management in the PECS and control groups. Bilateral PECS-II block with 0.25% bupivacaine was performed in to the PECS group. Measurements and main resultsThe primary outcome was postoperative opioid consumption, calculated as mg/kg of IV morphine. Secondary outcomes included Numeric Rating Scale (NRS) pain scores at rest (static) and with movement (dynamic) recorded 1, 4, 8, 12, 24 h after surgery. Postoperative morphine consumption was significantly lower in the PECS group than in the control group over the first 24 hours postoperatively: 0.325 mg/kg vs. 0.425 mg/kg (p<0.001). Static and dynamic NRS values were significantly lower in the PECS group for the first 12 postoperative hours (p <0.05). ConclusionsBilateral PECS-II block is associated with decreased pain scores for up to 12 hours, and with decreased opioid consumption for up to 24 hours, following minimally invasive repair of pectus excavatum (Nuss procedure) in adolescents. PECS-II block in this context has not been previously described.

Effects of general anesthesia with and without thoracic epidural block on length of stay after open spine surgery: a single-blinded randomized controlled trial

BACKGROUND CONTEXTLength of hospital stay (LOS) is an important concern in all types of surgery, and the enhanced recovery after surgery (ERAS) protocol has been developed to improve perioperative management and outcomes, which require multidisciplinary management. In terms of pain control, intraoperative regional anesthesia and postoperative opioid-sparing analgesia are recommended. For open spine surgery, we aimed to combine thoracic epidural analgesia to reduce pain and opioid-related side effects, thereby hastening recovery. PURPOSEThis study aimed to compare the length of hospital stay after open complete laminectomy with fusion between general anesthesia and combined general anesthesia involving a single thoracic epidural injection. DESIGNA randomized single-blinded controlled study. PATIENT SAMPLEThirty-eight patients scheduled for elective open laminectomy with fusion between I and III levels were selected. OUTCOME MEASURESLOS, postoperative pain, patient-controlled morphine consumption at 24 hours, patient satisfaction score, and other opioid-related side effects were recorded. METHODSPatients were randomly selected to receive standard general anesthesia (GA) or GA combined with a single-shot thoracic epidural at T11–T12 or T12–L1, a block with 10 mL of 0.25% bupivacaine, and 4 mg of morphine. RESULTSThere were no significant differences in the demographic variables between groups. LOS was significantly lower in the combined epidural and/or GA than in the control group (3.78±0.81 [mean±standard deviation] and 4.79±1.51 days, respectively; p=.017). Numeric rating score (at rest) at the post-anesthesia care unit, 24 hours postoperative morphine consumption (mg), operating time, and blood loss were significantly lower in the epidural group. Patients who received combined epidural and/or GA were more likely to report higher patient satisfaction (p=.008). However, the incidence of intraoperative hypotension was significantly higher in the epidural group (72.2% vs. 21.1%, p=.003). The incidences of adverse events and surgical field rating scores did not differ between the 2 patient groups. CONCLUSIONSCombined lower thoracic epidural and/or GA in patients undergoing elective lumbar spine surgery was associated with decreased LOS.

Comparison of efficacy of erector spinae plane block, thoracic paravertebral block, and erector spinae plane block and thoracic paravertebral block combination for acute pain after video-assisted thoracoscopic surgery: a randomized controlled study.

The aim of this study was to compare the efficacy of ultrasound-guided erector spinae plane block (ESPB), thoracic paravertebral block (TPVB), and ESPB and TPVB combination on acute pain after video-assisted thoracoscopic surgery (VATS). Seventy-five patients were evaluated (three groups: ESPB, TPVB, or combined ESPB-TPVB [comb-group], each 25 patients). All interventions were performed with the same volume of bupivacaine (20 mL). Primary outcome was VAS (Visual Analog Scale) during the first 24 hours. Secondary outcomes were postoperative morphine consumption and rescue analgesic requirements. VAS during rest and coughing of TPVB was significantly higher compared to other groups (in all measurements compared to comb-group; and in all but 24 hours measurement to ESPB) ESPB and comb-group had similar VAS in all measurements (e.g., median VAS in ESPB, TPVB and comb-group at 8th hour: 3-4-2 [P=0.014] during coughing and 2-3-1 in rest [P<0.001], respectively). Morphine consumption was statistically significantly higher in TPVB than comb-group (ESPB: 15.28 mg; TPVB: 19.30 mg; ESPB+TPVB: 10.00 mg) (P=0.003). Rescue analgesic requirement was statistically significantly higher in the TPVB group than comb-group (P=0.009). ESPB alone and the combination of ESPB and TPVB provided superior primary outcomes compared to TPVB alone. Morphine and rescue analgesic consumptions were higher in TPVB than comb-group. ESPB and comb-group were statistically similar in terms of primary and secondary outcomes. This study is one of the first studies using the combination of ESBP and TPVB for pain after VATS, and shows the efficacy of this approach.

Efficacy of ultrasound-guided erector spinae plane block versus paravertebral block for postoperative analgesia in single-port video-assisted thoracoscopic surgery: a retrospective study.

Thoracic paravertebral block (TPVB) is an analgesic method recommended in the enhanced recovery after surgery (ERAS) protocol and proven successful in thoracoscopic surgery. The study aimed to investigate whether the erector spinae plane block (ESPB) administered single-injection in uniportal video-assisted thoracoscopic surgery (VATS) can be an alternative to TPVB as an analgesic method. In this study, American Society of Anesthesiologists (ASA) physical status class I-II-III patients aged between 18-70 years who underwent thoracoscopic wedge resection surgery were analyzed retrospectively; 136 patients in the ESPB group and 114 patients in the TPVB group were included in the study. Postoperative cumulative morphine consumption numerical rating scale (NRS) scores were compared at 1, 6, 12, and 24 hours after surgery at rest and during coughing between the groups. Also, rescue analgesia requirements, postoperative nausea, vomiting and other complications were evaluated. The mean cumulative morphine consumption in the postoperative 24 hours was 20.06 mg in the ESPB group and 11.35 mg in the TPVB group. A statistically significant difference was observed between groups in terms of total morphine consumption in the postoperative 24 hours (P<0.001). NRS score was significantly lower in the TPVB group at postoperative 6th and 24th hours during coughing (P=0.003 and P=0.034, respectively) and at 24th hour at rest (P=0.008) than ESPB group. Median NRS scores at rest were low (<4) in both groups. There was no significant difference between the groups in terms of postoperative pulmonary complications as atelectasis and length of hospital stay (LOS) (P=0.643 and P=0.867 respectively). Ultrasound (US)-guided single-injection TPVB provided superior analgesia in patients undergoing single-port VATS than ESPB. In addition to this, TPVB showed more opioid sparing by reducing morphine consumption.

A Multimodal Analgesic Protocol with Gabapentin-dexmedetomidine for Post-operative Pain Management after Modified Radical Mastectomy Surgery: A Randomized Placebo-Controlled Study

Background and Aim: Modified radical mastectomy (MRM) is accompanied by severe acute postoperative pain. This study evaluated the safety and efficacy of oral gabapentin plus dexmedetomidine infusion as an analgesic multimodal protocol in patients undergoing MRM.&#x0D; Methods: This prospective randomized, double-blind placebo-controlled study included 30 females scheduled for MRM from June 2021 to December 2021. They were randomly divided into two groups. GD Group (n=15) received oral gabapentin 400 mg and IV infusion of Dexmedetomidine 0.4 µg/kg/h over 10 min after a bolus of 0.5 µg/kg before induction of general anesthesia. Placebo Group (n=15) received a placebo capsule and saline infusion identical to the GD Group. The primary outcome measure was total morphine consumption, and secondary outcomes were pain and sedation scores and intraoperative fentanyl consumption.&#x0D; Results: Pain score was significantly lower in the GD Group than the Placebo group, starting immediately postoperative up to 24 hours except after 18 hours. The total intraoperative fentanyl consumption and postoperative morphine consumption were significantly lower in the GD Group. The sedation score was significantly higher in the GD Group compared to the Placebo group immediately postoperative and after 2 hours. The heart rate and mean arterial pressure were within the clinically accepted ranges intra- and postoperatively in the two groups.&#x0D; Conclusion: Preemptive oral gabapentin plus dexmedetomidine IV infusion is a safe and effective analgesic alternative for patients undergoing MRM.

Propofol total intravenous anaesthesia versus inhalational anaesthesia for acute postoperative pain in patients with morphine patient-controlled analgesia: a large-scale retrospective study with covariate adjustment

BackgroundTo compare the postoperative analgesic effect of propofol total intravenous anaesthesia (TIVA) versus inhalational anaesthesia (GAS) in patients using morphine patient-controlled analgesia (PCA).MethodsA retrospective cohort study was performed in a single tertiary university hospital. Adult patients who used PCA morphine after general anaesthesia across 15 types of surgeries were included. Patients who received propofol TIVA were compared to those who had inhalational anaesthesia. Primary outcomes assessed were postoperative numerical rating scale (NRS) pain scores and postoperative opioid consumption.ResultsData from 4202 patients were analysed. The overall adjusted NRS pain scores were significantly lower in patients who received propofol TIVA at rest (GEE: β estimate of the mean on a 0 to 10 scale = -0.56, 95% CI = (-0.74 to -0.38), p < 0.001; GAS as reference group) and with movement (β estimate = -0.89, 95% CI = (-1.1 to -0.69), p < 0.001) from postoperative days (POD) 1–3. Propofol TIVA was associated with lower overall adjusted postoperative morphine consumption (β estimate = -3.45, 95% CI = (-4.46 to -2.44), p < 0.001). Patients with propofol TIVA had lower adjusted NRS pain scores with movement for hepatobiliary/pancreatic (p < 0.001), upper gastrointestinal (p < 0.001) and urological surgeries (p = 0.005); and less adjusted postoperative morphine consumption for hepatobiliary/pancreatic (p < 0.001), upper gastrointestinal (p = 0.006) and urological surgeries (p = 0.002). There were no differences for other types of surgeries.ConclusionPropofol TIVA was associated with statistically significant, but small reduction in pain scores and opioid consumption in patients using PCA morphine. Subgroup analysis suggests clinically meaningful analgesia possibly for hepatobiliary/pancreatic and upper gastrointestinal surgeries.Trial registrationThis study is registered at ClinicalTrials.gov (NCT03875872).

Bilateral erector spinae plane blocks in children undergoing cardiac surgery: A randomized, controlled study

Study objectiveWe aimed to test the hypothesis that erector spinae plane block (ESPB) provides efficient analgesia and reduces postoperative morphine consumption in children undergoing cardiac surgery with median sternotomy. DesignA prospective, blinded, randomized, controlled study. SettingA tertiary university hospital, operating room and intensive care unit. PatientsForty children aged 2–10 years, who underwent cardiac surgery with median sternotomy. The patients were randomly divided into the block group (Group B) and the control group (Group C). InterventionsGroup B (n = 20) were treated with ultrasound-guided bilateral ESPB at the level of the T4-T5 transverse process, whereas no block was administered in Group C (n = 20). In all children, intravenous morphine at 0.05 mg/kg was used whenever the modified objective pain score (MOPS) ≥4 for postoperative analgesia. MeasurementsThe MOPS and Ramsay sedation score (RSS) were assessed at 0, 1, 2, 4, 6, 8, 10, 12, 16, 20 and 24 h postoperatively. Total morphine consumption at 24 h, extubation time and length of intensive care unit (ICU) stay was also evaluated and recorded. Main resultsBilateral ESPB significantly decreased the consumption of morphine in the first 24 h, postoperatively. During the postoperative 24-h follow-up, 11 children in Group C requested morphine and the cumulative dose of morphine was 0.83 ± 0.91 mg, while 4 children in Group B requested morphine and the cumulative dose of morphine was 0.26 ± 0.59 mg (p = 0.043). There was no significant difference between Groups B and C in terms of MOPS and RSS values, extubation time or length of ICU stay. ConclusionUltrasound-guided bilateral ESPB with bupivacaine provides efficient postoperative analgesia and reduces postoperative morphine consumption at 24 h in children undergoing cardiac surgery.

A comparative study between the efficacy of bupivacaine plus nalbuphine versus bupivacaine alone in pectoral nerve block for management of postoperative pain in patients undergoing breast fibroadenoma excision

BackgroundBreast surgeries, even the relatively minor ones, can be associated with significant postoperative pain affecting patients’ physical and psychological well-being. As a result, regional anaesthetic approaches have been used for breast surgery anaesthesia and analgesia. PECS I and II blocks have been proven to be relatively easy and safe in such regards. Moreover, using adjuvants, such as nalbuphine, have been proposed by many studies to intensify the block and decrease postoperative analgesic intake.This current study aims to assess the effects of using nalbuphine (20 mg) as a bupivacaine 0.25% (10 ml) adjuvant in PECS I block compared to injecting bupivacaine 0.25% (10 ml) alone in fibroadenoma excision patients.This trial enrolled 60 patients, 30 of whom received bupivacaine plus nalbuphine (group BN) and 30 in the bupivacaine only (group B). Postoperative VAS, SpO2 and vital signs at 0, 1, 2, 4, 6, 12 and 24 h as well as the amount of morphine consumed, the time it took for the first analgesic to be administered and adverse effects were both recorded and compared.ResultsRegarding postoperative outcomes, a statistically significant difference between the two groups was not detected regarding VAS, SpO2, vital signs and adverse effects. Similarly, there was no statistically significant difference in total morphine intake in the 24 h following surgery between the two groups (p-value = 0.65). Only 9 out of 60 patients needed analgesia, 5 in the BN group and 4 in the B group, and time to the first analgesic was not of statistically significant difference between BN and B groups (211.8 ± 71.29 and 183.5 ± 29.872 min respectively) (p-value = 0.73). In terms of postoperative complications, there was no statistically significant difference between the two groups.ConclusionsAdding nalbuphine (20 mg) to bupivacaine in PECS I block in fibroadenoma patients undergoing excision is not accompanied by a difference with statistical significance in postoperative VAS, morphine consumption and duration to the first analgesia when compared to bupivacaine alone.

Erector Spinae Plane Block for Children Undergoing Cardiac Surgeries via Sternotomy: A Randomized Controlled Trial.

BackgroundIneffective management of postoperative pain following pediatric cardiac surgeries adversely affects a patient’s postoperative course. The erector spinae plane (ESP) block has been described in the literature regarding perioperative pain management. We hypothesized that bilateral ESP blocks in pediatric patients would decrease intraoperative fentanyl consumption, reduce the need for postoperative morphine consumption, and improve pain scores.ObjectivesThe aim of this double-blinded randomized controlled trial was to assess the efficacy and safety of bilateral ESP blocks in pediatric patients undergoing cardiac surgeries through a median sternotomy.MethodsThe study involved 98 children aged 6 months to 7 years who were American Society of Anesthesiologists (ASA) II and III and scheduled for cardiac surgery through a median sternotomy. Patients were divided randomly into 2 groups: the ES group (n = 50) who received bilateral ultrasound-guided ESP blocks, and the N group (n = 48) who received no block. The primary outcome was the total dose of administered fentanyl intraoperatively. Secondary outcomes included morphine consumption in the first 24 hours postoperatively; the length of time before the first need for postoperative analgesia; and FLACC (face, legs, activity, consolability, and cry) scores at the first and second hours postoperatively and every 4 hours, with readings taken for a period of 24 hours.ResultsThere were statistically significantly higher levels of administered fentanyl intraoperatively (6.7 ± 3 vs 4.3 ± 1.9 µg.kg-1) and postoperative morphine consumption (0.5 ± 0.2 vs 0.4 ± 0.2 mg.kg-1) in the N group compared with the ES group (P < 0.001). Moreover, the timing of the first rescue analgesia was significantly delayed in the ES group compared with the N group (231.6 ± 104.5 vs 108.8 ± 47.8 minutes).ConclusionsBilateral ultrasound-guided ESP blocks can be used to reduce perioperative opioid consumption in pediatric patients undergoing cardiac surgery through a sternotomy. It also can be used to decrease postoperative pain scores.

Comparing the Effect of Classical and Modified Thoracolumbar Interfascial Plane Block on Postoperative Pain and IL-6 Level in Posterior Lumbar Decompression and Stabilization Surgery

BackgroundUltrasound (US)-guided classical and modified thoracolumbar interfascial plane (TLIP) blocks are often used to provide adequate analgesia after lumbar spinal surgery. Postoperative pro-inflammatory interleukin 6 (IL-6) blood concentrations after lumbar spine surgery are related to postoperative pain and inflammation.ObjectivesThe purpose of this prospective randomized parallel controlled study was to assess postoperative pain and serum levels of pro-inflammatory IL-6 after posterior lumbar decompression and stabilization surgery with a classical and modified technique of TLIP block.MethodsThis prospective randomized, single-blinded controlled pilot study was conducted on eight patients who will undergo posterior lumbar decompression and stabilization surgery. After obtaining the ethical approval and an informed consent, all subjects were randomly allocated into the classic TLIP group and the modified TLIP group. Following general anesthesia induction, 20 mL bupivacaine 0.25% was injected on each side in interfascialis plane between m. longissimus and m. iliocostalis in modified TLIP group and between m. multifidus and m. longissimus in classical TLIP group. Intraoperative hemodynamic (blood pressure and heart rate) and noxious stimulation response level (qNOX), postoperative IL-6 level, 24-hour morphine consumption, and numerical rating score were recorded and analyzed.ResultsThe median of IL-6 level was found to be lower in the modified TLIP group 12 hours postoperatively compared to classic TLIP (29.91 (8.56 – 87.61) vs. 46.87 (2.87 – 92.35)). The mean Numerical Rating Scale (NRS) in the modified TLIP block was comparable with the classic TLIP group, although it was lower than the classic TLIP group (2.75 ± 1.5 vs. 3.75 ± 1.7 at 6 hours and 3.5 ± 1.3 vs. 4 ± 1.6 12 hours postoperatively). However, there was no difference in intraoperative hemodynamic, Qnox value, and total postoperative morphine consumption between the two groups.ConclusionsOur study showed that modified TLIP block resulted in lower IL-6 level and NRS 12 hours postoperatively compared to classical TLIP block. However, there were no differences in total postoperative morphine consumption between the two groups.

Low-level laser acupuncture reduces postoperative pain and morphine consumption in older patients with total knee arthroplasty: A randomized placebo-controlled trial

BackgroundPatients commonly develop postoperative pain after total knee arthroplasty (TKA). Acupuncture-related techniques and low-level laser therapy could be beneficial for pain management for older individuals. ObjectiveTo examine the effect of low-level laser acupuncture (LA) in reducing postoperative pain, pain-related interference in daily life, morphine consumption, and morphine-related side effects in older patients with knee osteoarthritis who underwent TKA. Design, setting, participants and interventionA single-blind randomized placebo-controlled trial was conducted. Patients (N = 82) were recruited and randomly assigned via a computer-generated list to the LA group or a placebo group. The LA group received low-level laser therapy at Sanyinjiao (SP6), Taixi (KI3), Kunlun (BL60), Fengshi (GB31), Futu (ST32) and Neiguan (PC6) after TKA, while the placebo acupuncture group received the same treatment procedure without laser energy output. Main outcome measuresThe primary outcome was postoperative pain intensity, and it was measured at baseline and hours 2, 6, 10, 24, 48 and 72 after TKA. The secondary outcomes, including relative pain, postoperative pain-related interference in daily life and morphine consumption, were measured at hours 24, 48 and 72 after TKA. ResultsGeneralized estimating equations revealed significant between-group differences in pain intensity (P = 0.01), and trend differences in pain intensity for the LA group starting at hours 10 to 72 (P < 0.05) and morphine consumption at hours 48 and 72 (P < 0.05). The changes in pain-related interference in daily life were significant (P < 0.05) at 72 h, with the exception of the parameters for worst pain, mood, and sleep. Nausea and vomiting side effects from morphine had significant between-group differences at hours 10 and 24 (P < 0.05). ConclusionLow-level LA gradually reduced older patients’ postoperative pain intensity and morphine consumption within the first 72 h after their TKA for osteoarthritis. Low-level LA may have benefits as an adjuvant pain management technique for clinical care. Trial registrationClinicalTrials.gov registration number NCT03995446.

Comparison Between Ultrasound-Guided Suprainguinal Fascia Iliaca Block and Anterior Quadratus Lumborum Block for Total Hip Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Trial.

Nerve block is a key technique in postoperative analgesia for total hip arthroplasty (THA). This study aimed to compare ultrasound-guided suprainguinal fascia iliaca block (SFIB) and anterior quadratus lumborum block (AQLB) in patients undergoing primary THA. In this prospective, double-blind, randomized controlled trial, 100 patients undergoing primary THA under general anesthesia were randomly allocated to receive an ultrasound-guided SFIB+ sham AQLB (SFIB group), or an ultrasound-guided AQLB+ sham SFIB (AQLB group). Before wound suture, all patients received periarticular infiltration analgesia which the local anesthetic was injected into joint capsule, exposed gluteal and abductor muscles, peritrochanteric zone, and subcutaneous tissue under the incision as multiple sites. The primary outcome was postoperative morphine consumption within 24hours after surgery. Secondary outcomes were the time to first rescue analgesia, postoperative pain assessed on the visual analog scale, postoperative quadriceps strength, the time to hospital discharge, and the incidence of postoperative complications. There were no significant differences between the 2 groups concerning morphine consumption within 24hours after surgery (P= .774), the time to first rescue analgesia (P= .890), the time to hospital discharge (P= .532), and the incidence of postoperative complications (P > .05). The visual analog scale pain scores at rest and during motion also were similar at all time points (P > .05). Significantly more patients in the SFIB group experienced quadriceps muscle weakness at 2hours (P= .008) and 6hours (P= .009) after surgery. Under the circumstances of this study, when combined with periarticular infiltration analgesia, the SFIB provided similar pain relief compared with AQLB in patients undergoing THA, but was associated with muscle weakness within 6hours after surgery.