Postoperative Pain Management Research Articles

The role of methadone in cardiac surgery for management of postoperative pain

BackgroundThis retrospective study evaluated the efficacy and safety of intraoperative methadone compared with short-acting opioids. MethodsPatients undergoing cardiac surgery with cardiopulmonary bypass (n=11 967) from 2018 to 2023 from a single health system were categorised into groups based on intraoperative opioid administration: no methadone (Group O), methadone plus other opioids (Group M+O), and methadone only (Group M). ResultsPatients in Groups M and M+O had lower mean pain scores until postoperative day (POD) 7 compared with Group O after adjusting for covariates (P<0.01). Both Groups M and M+O had lower total opioid administered compared with Group O for all days POD0–POD6 (all P<0.001). The median number of hours until initial postoperative opioid after surgery was 2.55 (inter-quartile range [IQR]=1.07–5.12), 6.82 (IQR=3.52–12.98), and 7.0 (IQR=3.82–12.95) for Group O, Group M+O, and Group M, respectively. The incidence of postoperative complications did not differ between groups. ConclusionsIntraoperative administration of methadone was associated with better pain control without significant side-effects after cardiac surgery.

Beyond measurement: a deep dive into the commonly used pain scales for postoperative pain assessment.

This review explores the essential methodologies for effective postoperative pain management, focusing on the need for thorough pain assessment tools, as underscored in various existing guidelines. Herein, the strengths and weaknesses of commonly used pain scales for postoperative pain-the Visual Analog Scale, Numeric Rating Scale, Verbal Rating Scale, and Faces Pain Scale-are evaluated, highlighting the importance of selecting appropriate assessment tools based on factors influencing their effectiveness in surgical contexts. By emphasizing the need to comprehend the minimal clinically important difference (MCID) for these scales in evaluating new analgesic interventions and monitoring pain trajectories over time, this review advocates recognizing the limitations of common pain scales to improve pain assessment strategies, ultimately enhancing postoperative pain management. Finally, five recommendations for pain assessment in research on postoperative pain are provided: first, selecting an appropriate pain scale tailored to the patient group, considering the strengths and weaknesses of each scale; second, simultaneously assessing the intensity of postoperative pain at rest and during movement; third, conducting evaluations at specific time points and monitoring trends over time; fourth, extending the focus beyond the intensity of postoperative pain to include its impact on postoperative functional recovery; and lastly, interpreting the findings while considering the MCID, ensuring that it is clinically significant for the chosen pain scale. These recommendations broaden our understanding of postoperative pain and provide insights that contribute to more effective pain management strategies, thereby enhancing patient care outcomes.

Experiences and perspectives of adults on using opioids for pain management in the postoperative period: A scoping review.

Opioids play an important role in peri-operative pain management. However, opioid use is challenging for healthcare practitioners and patients because of concerns related to opioid crises, addiction and side effects. This review aimed to identify and synthesise the existing evidence related to adults' experiences of opioid use in postoperative pain management. Systematic scoping review of qualitative studies. Inductive content analysis and the Theoretical Domains Framework (TDF) were applied to analyse and report the findings and to identify unexplored gaps in the literature. Ovid MEDLINE, PsycInfo, Embase, CINAHL (EBSCO), Cochrane Library and Google Scholar. All qualitative and mixed-method studies, in English, that not only used a qualitative approach that explored adults' opinions or concerns about opioids and/or opioid reduction, and adults' experience related to opioid use for postoperative pain control, including satisfaction, but also aspects of overall quality of a person's life (physical, mental and social well being). Ten studies were included; nine were qualitative (n = 9) and one used mixed methods. The studies were primarily conducted in Europe and North America. Concerns about opioid dependence, adverse effects, stigmatisation, gender roles, trust and shared decision-making between clinicians and patients appeared repeatedly throughout the studies. The TDF analysis showed that many peri-operative factors formed people's perceptions and experiences of opioids, driven by the following eight domains: Knowledge, Emotion, Beliefs about consequences, Beliefs about capabilities, Self-confidence, Environmental Context and Resources, Social influences and Decision Processes/Goals. Adults have diverse pain management goals, which can be categorised as proactive and positive goals, such as individualised pain management care, as well as avoidance goals, aimed at sidestepping issues such as addiction and opioid-related side effects. It is desirable to understand the complexity of adults' experiences of pain management especially with opioid use and to support adults in achieving their pain management goals by implementing an individualised approach, effective communication and patient-clinician relationships. However, there is a dearth of studies that examine patients' experiences of postoperative opioid use and their involvement in opioid usage decision-making. A summary is provided regarding adults' experiences of peri-operative opioid use, which may inform future researchers, healthcare providers and guideline development by considering these factors when improving patient care and experiences.

Incidence of Surgically Managed Post-Tonsillectomy Hemorrhage Associated With NSAID Prescribing for Postoperative Pain Management.

Tonsillectomy ranks high among the most common pediatric surgical procedures in the United States. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), such as ibuprofen, are routinely prescribed to manage post-tonsillectomy pain, but may carry the risk of hemorrhage. This retrospective, longitudinal, secondary-data analysis study compared the incidence of surgically managed post-tonsillectomy hemorrhage (sPTH) in pediatric patients prescribed ibuprofen at Brooke Army Medical Center (BAMC) after tonsillectomy compared to a similar cohort of pediatric patients at the Children's Hospital of Philadelphia (CHOP) not prescribed ibuprofen. Additional regression analysis examined predictors of sPTH at BAMC. The odds of sPTH was lower in patients who were prescribed ibuprofen at BAMC, relative to patients who were not at CHOP (OR 0.57, 95% CI, 0.37, 0.87; P < 0.01). In a generalized linear model evaluating BAMC patient data, there was a lack of a relationship between reason for tonsillectomy (tonsillitis versus tonsillar obstruction), primary procedure (tonsillectomy-only versus tonsillectomy with adenoidectomy), and presence of a co-occurring procedure. Post-tonsillectomy ibuprofen prescribing practices were not associated with an elevated risk of sPTH, relative to patients at CHOP not exposed to ibuprofen.

Feasibility and Analgesic Efficacy of Thoracolumbar Dorsal Ramus Nerve Block Using Multiorifice Pain Catheters for Scoliosis Surgery: A Prospective Cohort Study.

Approximately 38,000 scoliosis surgery correction operations are performed annually in the United States; these operations are associated with considerable postoperative pain which can be difficult to manage. This is largely attributed to an incision spanning multiple vertebral segments with paraspinal muscle dissection and retraction to facilitate the implantation of segmental hardware and rods. Frequently utilized analgesic modalities include intravenous patient-controlled analgesia and epidural analgesia, often in combination. We sought to ascertain the feasibility and analgesic efficacy of continuous thoracolumbar dorsal ramus nerve (TDRN) block using surgically placed multiorifice catheters. Forty-two patients diagnosed with idiopathic scoliosis who underwent a posterior spinal fusion (PSF) were enrolled after consent was obtained. Patients were managed utilizing a standardized Enhanced Recovery After Surgery) protocol including a perioperative opioid-sparing regimen. Data were collected at specified time intervals during the recovery period. These data points included pain scores using the Numeric Rating Scale. Parenteral or both oral and parenteral opioid consumption doses were also collected every 4 hours. Any significant postoperative adverse events were recorded as well. A total of 42 patients had surgically placed TDRN catheters, and 40 patients were included in this study. The patients all reported low to moderate pain scores with low opioid consumption postoperatively, while the TDRN catheter delivery of local anesthetic analgesics did not result in significant complications. A regional technique utilizing TDRN catheters could be a valuable component of the postoperative pain management protocols for PSF surgery, and additional studies are warranted. This study evaluated the feasibility and analgesic efficacy of TDRN catheters for postoperative pain control following multilevel PSF for idiopathic scoliosis. Continuous local anesthetic delivery through TDRN catheters is a feasible and safe technique for postoperative pain control in these patients. Selective blockade of the dorsal rami might have benefits over epidural analgesia or other regional techniques.

Postoperative pain score does not correlate with injury severity in isolated tibial plateau fractures.

Appropriate management of acute postoperative pain is critical for patient care and practice management. The purpose of this study was to determine whether postoperative pain score correlates with injury severity in tibial plateau fractures. A retrospective review of prospectively collected data was completed at a single academic level one trauma center. All adult patients treated operatively for tibial plateau fractures who did not have concomitant injuries, previous injury to the ipsilateral tibia or knee joint, compartment syndrome, inadequate follow-up, or perioperative regional anesthesia were included (n = 88). The patients were split into groups based on the AO/OTA fracture classification (B-type vs C-type), energy mechanism, number of surgical approaches, need for temporizing external fixation, and operative time as a proxy for injury severity. The primary outcome measure was the visual analog scale (VAS) pain score (average in the first 24h, highest in the first 24h, two- and six-week postoperative appointments). Psychosocial and comorbid factors that may affect pain were studied and controlled for (history of diabetes, neuropathy, anxiety, depression, PTSD, and previous opioid prescription). Additionally, opioid use in the postoperative period was studied and controlled for (morphine milligram equivalents (MME) administered in the first 24h, discharge MME/day, total discharge MME, and opioid refills). VAS scores were similar between groups at each time point except the two-week postoperative time point. At the two-week postoperative time point, the absolute difference between the groups was 1.3. The groups were significantly different in several injury and surgical variables as expected, but were similar in all demographic, comorbid, and postoperative opioid factors. There was no clinical difference in postoperative pain between AO/OTA 41B and 41C tibial plateau fractures. This supports the idea of providers uncoupling nociception and pain in postoperative patients. Providers should consider minimizing extended opioid use, even in more severe injuries.

Functional and Clinical outcomes of total hip replacement surgery via Lateral approach

Background: Total hip arthroplasty (THA) is a critical surgical intervention for patients with severe hip dysfunction primarily due to conditions such as osteoarthritis, trauma, and other degenerative diseases. The choice of surgical approach can significantly influence the outcomes of the procedure, including postoperative recovery, pain management, and functional mobility. Objective: This study aims to evaluate the clinical and functional outcomes of the lateral approach in total hip replacement, comparing its efficacy and safety with other surgical techniques. Methods: A retrospective cohort study was conducted at a single medical teaching institution, involving 74 patients who underwent total hip replacement using the lateral approach between January 2022 and December 2023. Data were collected on patient demographics, surgical details, and postoperative outcomes. Key measures included the Harris Hip Score (HHS), rates of postoperative pain, limb length discrepancy (LLD), and complications such as dislocation and infection. Statistical analysis was performed using IBM SPSS Statistics for Windows, version 25, with a significance threshold set at P &lt; 0.05. Results: The study population had an equal distribution of male and female patients, with an average age of 57.20 years (SD ± 14.68). Trauma was the most common indication for surgery (67.6%), followed by osteoarthritis (18.9%) and avascular necrosis (9.5%). Postoperative evaluation showed that 62.26% of patients achieved an 'excellent' HHS at two weeks, while 28.38% were rated as 'good'. The overall complication rate was low, with dislocation occurring in 4.1% of cases. Pain was reported in 12.2% of patients post-surgery. Conclusion: The lateral approach for total hip arthroplasty provides effective pain relief and functional recovery with a low complication rate. This study supports the continued use of the lateral approach as a viable option for hip replacement surgery, showing comparable or superior outcomes to other surgical approaches.

Enhancing pediatric postoperative pain management: strategies, challenges, and Innovations-A comprehensive review and observational study.

Enhancing pediatric postoperative pain management: strategies, challenges, and Innovations-A comprehensive review and observational study.

Multimodal anesthesia: integrated strategies to improve pain management and recovery: a literature review

With the overprescription of opioids fueling the opioid epidemic, postoperative pain management has emerged as a crucial component of surgical treatment. The shift to multimodal anesthesia as a substitute for postoperative pain management is examined in this review of the literature, with a focus on the contribution of ERAS protocols to lower opioid use and enhance patient outcomes. A methodical exploration of PubMed, Google Scholar, and Scopus was carried out to ascertain pertinent publications released during the last five years. Included were articles on non-opioid analgesics, local anesthetic, regional anesthesia, and multimodal analgesia approaches. Targeting different pain pathways and lowering opioid use, multimodal anesthesia incorporates a number of drugs and strategies, such as NSAIDs, acetaminophen, gabapentin, dexamethasone, and NMDA receptor antagonists. Research indicates that multimodal anesthesia is beneficial in lowering postoperative pain, improving healing, and minimizing opioid-related side effects in a variety of surgical specialties. By placing an emphasis on customized preoperative and postoperative therapies, the use of ERAS protocols further optimizes perioperative care. Multimodal anesthesia reduces postoperative pain, shortens hospital stays, and enhances patient satisfaction, according to studies. Nevertheless, obstacles including insufficient funding and poor training prevent regional anesthesia methods from being widely used. To address the effects of the opioid crisis on patient health and healthcare systems, as well as to advance surgical treatment, it is imperative that multimodal anesthesia procedures be clinically implemented and researched further.

Challenges in provision of anesthesia to transgender patients in India: A scoping review

Abstract The care of transgender individuals has gained increasing attention in health-care settings, encompassing a wide range of medical specialties. Anesthesia is vital in perioperative care for them despite challenges like health-care access disparities, stigma, and discrimination. As they undergo routine surgeries or specific gender-affirming surgeries, anesthesia providers must be cognizant of anatomical, physiological, and psychosocial considerations that may impact the perioperative experience. Anesthesia for transgender individuals requires gender identity assessment, understanding of surgical needs, hormone therapy impact, preoperative assessments evaluating comorbidities, medication history, and psychosocial factors. Anesthesiologists should modify airway care and pain management techniques to accommodate patients’ preferences and gender-affirming surgical goals. They should also take into account any potential differences in the airways of transgender patients and optimize postoperative pain management in accordance with each patient’s particular surgical recovery. This article aims to focus on the perioperative care of transgender individuals, highlighting the distinct challenges encountered and potential solutions to address these unique issues.

To compare the efficacy of ropivacaine alone versus ropivacaine with magnesium sulphate for postoperative analgesia in peripheral nerve stimulator-guided supraclavicular plexus block in upper limb surgeries

Background Postoperative pain management is a crucial part of patient care for surgeries involving the upper limbs. A popular technique for providing both postoperative analgesia and regional anaesthesia is a supraclavicular plexus block guided by a peripheral nerve stimulator. Recent research has demonstrated that the analgesic effect of ropivacaine, a common local anaesthetic, can be enhanced by the addition of magnesium sulphate. The study aims to assess the safety and effectiveness of utilising magnesium sulphate in addition to ropivacaine alone for postoperative analgesia in patients having upper limb surgeries under peripheral nerve stimulator-guided supraclavicular plexus block. Methods This protocol outlines a prospective, double-blind, randomised, controlled trial that assesses the efficacy of ropivacaine versus ropivacaine plus magnesium sulphate for analgesia post surgery in patients undergoing upper limb surgeries under the guidance of a peripheral nerve stimulator (PNS). 50 Patients will be included in the study in total, and they will be split into two groups at random. PNS-guided supraclavicular plexus block with ropivacaine alone will be administered to one group, while ropivacaine combined with magnesium sulphate will be administered to the other. Regular monitoring will be done during the postoperative phase to determine pain levels, use of analgesics, motor and sensory blockade, and adverse events. Results The study aims to determine if ropivacaine with magnesium sulphate postoperative analgesia is superior to ropivacaine alone in supraclavicular plexus blocks. The motor and sensory blockade duration, opioid use, and any negative results will be evaluated as secondary outcomes. Statistical analysis will be performed to determine the significance of the differences between the two groups. Conclusion This study protocol compares the effectiveness of ropivacaine alone against ropivacaine with magnesium sulphate in peripheral nerve stimulator-guided supraclavicular plexus block, with the goal of adding to the repository of information on postoperative analgesia in upper limb procedures. The study’s findings could be very helpful in enhancing pain management strategies and enhancing patient outcomes in this context.

Risk factors for prolonged opioid consumption following hip arthroscopy: A secondary analysis of the Femoroacetabular Impingement RandomiSed controlled Trialand embedded cohort study.

The purpose of the study was to identify prognostic risk factors for prolonged opioid use at 2 and 6 weeks after hip arthroscopy using data from the Femoroacetabular Impingement RandomiSed controlled Trial and its external validation cohort study. Opioids were prescribed for postoperative pain management at the surgeon's discretion, with a majority being prescribed a combination of oxycodone and paracetamol (5/325 mg). Prolonged opioid use was defined as the ongoing use of any dosage of opioids reported at either 2 or 6 weeks after surgery to treat femoroacetabular impingement, as recorded in the patient's study medication log. Multivariable logistic regressions were performed to evaluate patient and surgical characteristics, such as preoperative opioid use, type of surgical procedure and intraoperative cartilage statethat may be associated with prolonged opioid use at either 2 and 6 weeks postoperatively. A total of 265 and 231 patients were included for analysis at 2 and 6 weeks postoperatively, respectively. The median age of participants was 35 years (interquartile range [IQR]: 27-42) and 33% were female. At 2 weeks postoperatively, female sex (odds ratio [OR]: 2.56; 95% confidence interval: [CI] 1.34-4.98, p = 0.005), higher body mass index (BMI) (OR: 1.10; 95% CI: 1.02-1.18, p = 0.009), active tobacco use (OR: 4.06; 95% CI: 1.90-8.97, p < 0.001), preoperative opioid use (OR: 10.1; 95% CI: 3.25-39.1, p < 0.001) and an Outerbridge classification of ≥3 (OR: 2.33; 95% CI: 1.25-4.43, p = 0.009) were significantly associated with prolonged opioid use. At 6 weeks postoperatively, only preoperative opioid use was significantly associated with prolonged opioid consumption (OR: 10.6; 95% CI: 3.60-32.6, p < 0.001). Preoperative opioid use was significantly associated with continued opioid use at 2 and 6 weeks postoperatively. Specific patient factors including female sex, higher BMI, active tobacco useand more severe cartilage damage should be considered in developing targeted strategies to limit opioid use after surgery. Level III.

Evaluating the Efficacy of Methocarbamol and Nefopam in Orthopedic Surgical Pain.

Introduction Pain after orthopedic surgeries represents a special concern in patients with fractures. The use of multimodal analgesia significantly reduced the opioid need and reduced the risk of their side effects. Objectives This study compared the effectivenessand safety of methocarbamol and nefopam in the reduction of post-operative pain for patients undergoing orthopedic surgeries. Method This prospective, double-blind, randomized controlled trial took place at Al-Sader Teaching Hospital in Basrah, Iraq, from the first of February 2022 to the end of October 2023. The study aimed to assess the post-operative pain relief efficacy and safety of intramuscular nefopam (20 mg) and intravenous methocarbamol (1 g) in 110 adults (aged 18-65) undergoing elective orthopedic surgeries. Exclusions were made for allergies to the drugs, substance abuse history, and severe hepatic or renal impairment. Participants were randomized into two groups, with pain intensity measured at one hour, six hours, and 12 hours post-operation using the visual analog scale (VAS). Side effects were also evaluated. Statistical analysis was done using SPSS 27, with a significance level set at p<0.05 and a 95% confidence interval (CI). Results In this study, we conducted a rigorous comparison between two groups, methocarbamol and nefopam, to evaluate their efficacy and safety in post-operative pain management. We started by ensuring that the groups were well-matched in terms of age, gender distribution, and body mass index (BMI). The results showed remarkable similarities in mean age, gender distribution, and BMI, supported by robust p-values, affirming the effective matching of the two groups. Moving to pain management, we observed a significant advantage in favor of methocarbamol. At all-time intervals (one hour, six hours, and 12 hours post-operation), methocarbamol consistently demonstrated lower mean VASscores compared to nefopam. These differences were highly statistically significant, underscoring the superior pain relief efficacy of methocarbamol. Exploring side effects, we found no statistically significant disparities in the occurrence of nausea and vomiting between the two groups. However, there was a noticeable trend towardhigher tachycardia incidence in the nefopam group, though it did not reach statistical significance. Conclusion The present study showed a higher efficacy of methocarbamol in post-operative pain reduction in comparison to nefopam. No serious side effects were observed with both drugs.

STANDARD OPIATE PRESCRIBING IN PEDIATRIC AND ADOLESCENT GYNECOLOGIC SURGERY TO REDUCE OPIATE USE: BRIEF REPORT

Study objective: The aim of this quality improvement (QI) project was to assess postoperative narcotic use after pediatric gynecologic surgeries and establish standard postoperative opioid dosing. Through standard dosing we hoped to decrease variability in postoperative opioid prescriptions and decrease excess opioid doses in the community. Methods: This QI project was approved by the Children's Minnesota IRB. Counseling on postoperative pain management was provided pre- and post-operatively. At the two-week postoperative visit, patients were asked the number of opioid doses used and pain control satisfaction. Baseline data was collected for 6 months with surgeons prescribing the number of opioid doses based on their personal preference. After reviewing the prescribing practices and number of doses used, standard opioid doses were established, and data collection repeated. Results: Complete data was recorded for 30 cases prior to implementation of standard doses and for 29 cases following implementation. Standardized opioid dosing resulted in 30% decrease in total opioid doses in circulation (252→176 doses; P=0.014) and 15% reduction in excess doses in circulation (162→137 doses). Forty-three percent of patients did not use any opioid doses. There was no significant difference P=0.8818) in patient pain control satisfaction rating. Conclusions: Standard opioid dose prescribing is feasible for common pediatric gynecologic surgeries without affecting patient pain control satisfaction. Opioid dose standardization may decrease opioid circulation within the community. Approximately 2 out of every 5 patients used zero opioid doses which suggests further reduction in the standard dose prescriptions is possible.

Acute Pain and Analgesia in children

Acute pain is a complex process involving activation of nociceptors, chemical mediators and inflammation. All the major children’s hospitals now have dedicated pain services to provide evaluation and immediate treatment of pain in any child. Children experience pain in a similar way to adults. Pain intensity in children depends on the surgical procedure itself but also on numerous other factors such as age, emotional state or the level of anxiety associated with the hospital stay. The perception and communication of the child’s pain depends on his or her intellectual and social development. Expression of pain therefore relies on the child’s ability to understand, quantitate and communicate it. Previous pain experiences or chronic diseases that required many medical procedures may significantly change the pain threshold in paediatric patients. Moreover, genetic predispositions and environmental effects are significant. The American Academy of Pediatrics and the American Pain Society have reiterated the importance of a multidisciplinary approach in order to eliminate pain in children. In all pediatric settings, an adequate assessment is the initial stage in a proper clinical approach to pain, especially in the emergency departments; therefore, an increasing number of age-related tools have been validated. Systemic opioids, nonsteroidal anti-inflammatory agents and regional analgesics alone or combined with additives are currently used to provide effective postoperative analgesia. These modalities are best utilized when combined as a multimodal approach to treat acute pain in the perioperative setting. The total number of behaviors that are present in the child are used to estimate his/her pain at the time of assessment. Pain assessment is important to facilitate effective postoperative pain management in these vulnerable children. The purpose of this study is to investigate acute pain as well as analgesia and availability of the used analgesic drugs in children. A multimodal approach to preventing and treating pain is usually used.

Comparison of effectiveness of intraoperative subperiosteal versus periarticular analgesic cocktail injection for post operative analgesia in patients undergoing total knee arthroplasty

Background: Early postoperative pain management is pivotal in patients undergoing Total knee arthroplasty. The advantage of Local infiltration analgesia is its ability to provide control of pain without interfering with motor strength of the lower extremity, thereby allowing early mobilization of patients. This study compares the effectiveness of local analgesic cocktail injection given through subperiosteal vs. periarticular routes. Methods: The study included 30 patients admitted for primary total knee arthroplasty. They were grouped into two groups based on different injection sites. Group A included patients who received subperiosteal injection and Group B included patients who received periarticular injection, under spinal anaesthesia. The difference in pain among the two groups, using VAS at 12, 24, 48, and 72 hrs postoperatively, postoperative range of movements, and Functional outcome using IKDC score at the end of 6 months were assessed and compared between the two groups. Results: The mean VAS scores at 12, 24, 48, and 72 hrs were 0.87±0.35, 1.47±0.52, 1.80±0.41, 1.07±0.46 in subperiosteal group and 2.00±0.53, 2.47±0.52, 2.80±0.56, 1.93±0.59 in periarticular group. The 6 months postoperative IKDC scores were 51.34±0.41 and 51.04±0.61 respectively. Conclusions: Subperiosteal cocktail injection can significantly reduce the postoperative pain and result in early recovery of range of movements, compared with periarticular cocktail injection in patients undergoing Total knee arthroplasty. But the long-term functional outcomes were comparable among both the groups.

The effect of ultrasound-guided rectus sheath block on postoperative analgesia in robot assisted prostatectomy: A randomized controlled trial.

Postoperative pain continues to represent an important problem even after minimally invasive robotic-assisted laparoscopic radical prostatectomy, which results in discomfort in the postoperative period and sometimes prolongs hospital stays. Regional anesthesia and analgesia techniques are used in addition to systemic analgesics with the multimodal approach in postoperative pain management. Ultrasound-guided fascial plane blocks are becoming increasingly important, especially in minimally invasive surgeries. Another important cause of discomfort is urinary catheter pain. The present randomized controlled study investigated the effect of rectus sheath block on postoperative pain and catheter-related bladder discomfort in robotic prostatectomy operations. This randomized controlled trial was conducted from March to August 2022. Written informed consent was obtained from all participants. Approval for the study was granted by the Clinical Research Ethics Committee. All individuals provided written informed consent, and adults with American Society of Anesthesiologists Physical Condition classification I to III planned for robotic prostatectomy operations under general anesthesia were enrolled. Following computer-assisted randomization, patients were divided into 2 groups, and general anesthesia was induced in all cases. Rectus sheath block was performed under general anesthesia and at the end of the surgery. No fascial plane block was applied to the patients in the non-rectus sheath block (RSB) group.Postoperative pain and urinary catheter pain were assessed using a numerical rating scale. Fentanyl was planned as rescue analgesia in the recovery room. In case of numerical rating scale scores of 4 or more, patients were given 50 µg fentanyl IV, repeated if necessary. The total fentanyl dose administered was recorded in the recovery room. IV morphine patient-controlled analgesia was planned for all patients. All patients' pain (postoperative pain at surgical site and urethral catheter discomfort) scores and total morphine consumption in the recovery unit and during follow-ups on the ward (3, 6, 12, and 24 hours) in the postoperative period were recorded. Sixty-one patients were evaluated. Total tramadol consumption during follow-up on the ward was significantly higher in the non-RSB group. Fentanyl consumption in the postanesthesia care unit was significantly higher in the non-RSB group. Total morphine consumption was significantly lower in the RSB group at 0 to 12 hours and 12 to 24 hours. Total opioid consumption was 8.81 mg in the RSB group and 19.87 mg in the non-RSB group. A statistically significant decrease in urethral catheter pain was noted in the RSB group at all time points. RSB exhibits effective analgesia by significantly reducing postoperative opioid consumption in robotic prostatectomy operations.

A direct saphenous nerve block in TKA: A surgeon friendly technique! Cadaveric study

IntroductionEffective management of postoperative pain in total knee arthroplasty (TKA) poses a significant challenge for surgeons. Achieving rapid recovery without pain and promoting early ambulation in immediate and early postoperative periods are essential for patient satisfaction. There are many pain management protocols including nerve blocks. Nerve blocks procedures were done using USG and anaesthetist dependent. This cadaveric study aimed to define the VMO (Vastus medialis obliquus) triangle to target the ‘safe zone’ of the saphenous nerve during TKA: A surgeon's friendly technique. Methods12 formalin-fixed embalmed cadaveric lower limbs were dissected to explore anatomy, trajectory, the relation of saphenous nerve and measured the distances from the nearby palpable bony landmarks. ResultsThe average distance to target the saphenous nerve i.e target point from midpoint of superior pole of the patella was 10.6cm, the average angle to target the saphenous nerve is the angle between the line joining the medial epicondyle to the midpoint of the superior pole of the patella is found to be 64.2°. The average distance from midpoint of superior pole patella to medial epicondyle is found to be 8.1cm. Therefore, triangle so formed using these three points (1. Medial epicondyle, 2. The midpoint of superior pole of the patella, 3. Target point of the saphenous nerve) is called a VMO triangle. ConclusionsThe saphenous nerve course, relations, and the distances from intraoperative bony landmarks for the VMO triangle during TKA which is a reproducible triangle so may be useful for arthroplasty surgeons to achieve successful saphenous nerve block and to avoid related complications during total knee arthroplasty (TKA).

Randomised control trial comparing postoperative analgesia between nalbuphine and fentanyl as an adjuvant with intrathecal levobupivacaine for lower abdominal gynaecological surgeries

Background Effective post-operative pain management is crucial for patient comfort and recovery following lower abdominal gynaecological surgeries. This study protocol outlines a randomised control trial designed to compare the efficacy and safety of two intrathecal adjuvants, nalbuphine and fentanyl, in conjunction with hyperbaric levobupivacaine for postoperative analgesia. Methods The study will be conducted at the Department of Anaesthesiology, Jawaharlal Nehru Medical College, DMIMS (DU), and affiliated institutions. Sixty eligible patients aged 35-75 years undergoing lower abdominal gynaecological surgeries under subarachnoid block will be randomly assigned to one of two groups. Group A will receive nalbuphine with levobupivacaine, while Group B will receive fentanyl with levobupivacaine. Patients will be monitored for the duration of post-operative analgesia, onset of sensory and motor block, hemodynamic effects, and side effects. Outcomes The primary outcome is the comparison of post-operative analgesia duration between nalbuphine and fentanyl. Secondary outcomes include assessing sensory and motor block onset, hemodynamic changes, ephedrine usage, and side effects. Aim To evaluate the efficacy and safety of intrathecal nalbuphine and fentanyl as adjuvants with hyperbaric levobupivacaine for postoperative analgesia in lower abdominal gynaecological surgeries.

Advancing Postoperative Pain Management in Oral Cancer Patients: A Systematic Review.

The goal of this review is to shed light on the management of orofacial discomfort after a cancer diagnosis in the head and neck region. A search was conducted on PubMed, Scopus, and Web of Science to identify studies on postoperative pain control in oral cancer. The review included open-access research, investigations into pain management, randomized clinical trials, retrospective studies, case-control studies, prospective studies, English-written studies, and full-text publications. Exclusion criteria included animal studies; in vitro studies; off-topic studies; reviews, case reports, letters, or comments; and non-English language. Three reviewers independently accessed databases and assigned a quality rating to the chosen articles. The review explores postoperative pain management in oral cancer patients; highlighting persistent opioid use; the efficacy of adjuvant drugs, such as gabapentin; and a multimodal approach. It emphasizes the need for personalized pain management, recognizing individual pain perception and tailoring interventions. Integrating pharmacological and non-pharmacological strategies is crucial for comprehensive pain management. The review also serves as a guide for future research, emphasizing the need for standardized methodologies and diverse participant populations.