Postsurgical Analgesia Research Articles

Implementation of a Post-Surgical, Multimodal Analgesia Pain Management Order Set in Opioid-Naive Patients

Perioperative pain management guidelines recommend using multimodal analgesia to improve pain control while reducing opioids administered. The primary objective of this study was to assess whether implementing multimodal analgesia on general surgery postoperative pain management order sets would reduce opioid quantities postoperatively. Opioid-naive patients undergoing nonemergent general surgery procedures were evaluated before and after order set revision. The primary outcome was the total quantity of inpatient opioids administered. The secondary outcomes were inpatient naloxone administration, patient-reported pain scores, and opioid quantities prescribed at discharge. The average daily opioid consumption was less each postoperative day (POD) after implementing the revised postsurgical multimodal analgesia pain management order set. On POD 1 and POD 2, average opioid consumption was 53.6 and 47.9 oral morphine equivalents (OME) before the multimodal analgesia order set, respectively, compared with 21.2 and 21.4 OME after, respectively (p < 0.01 and p < 0.01, respectively). Average daily opioid consumption through POD 3 was 60.6 OME before and 21.14 OME after the revision. Average daily pain scores were similar on POD 0, 1, and 2 before and after (3.2, 2.8, and 2.4 compared with 2.8, 3.1, and 2.7, respectively; p = 0.09, 0.33, and 0.12, respectively). On POD 3, pain scores were higher in the postorder set group (2.8 compared with 1.9; p < 0.01), but this was considered clinically insignificant. Average daily pain score through POD 3 was 2.6 before implementation compared with 2.8 after implementation. Neither group required naloxone administration. Using perioperative multimodal analgesia reduces opioid consumption without increasing pain scores.

Ultrasound Guided Erector Spinae Block with Costotransverse Ligament Puncture Is More Effective than Erector Spinae Block Alone; Eight Cases for Oncologic Breast Surgery; A Brief Technical Report

Objectives: Due to the complex breast innervation, postoperative analgesia after breast surgery is a challenge for the anesthesiologists. The erector spinae plane block (ESP) is a newly defined promising technique for this purpose. Since the description by Forero, ultrasound-guided erector spinae block (ESP) has performed for several surgeries for postoperative analgesia. Many regional methods pectoral nerve block (PECs), serratus plane block (SPB), were described in the literature for maintaining postoperative analgesia. Among all these regional anesthesia techniques, paravertebral block (PVB) is the most studied and found to be a valid regional technique for this purpose. Due to its anatomic proximity to the pleura and central neuraxial system, it’s also one of the most challenging techniques. Materials and Methods: Patients aged between 37 and 47 years, American Society of Anesthesiologists physical status I-II and scheduled for elective unilateral modified radical mastectomy (MRM) surgery without axillary lymph node dissection were enrolled to this case series. In this report, we describe a novel combination of ESP and simplified PVB block and its successful application in 8 cases of oncologic breast surgery. In our clinic, ESP block is performed for all oncological breast cases. Eight cases of MRM without axillary dissection were randomly selected by the same anesthesiologist (AS). 15 mL 0.25% bupivacaine was administered between the erector spinae muscles and the transverse process at the level of the 4th thoracal vertebra with the caudo-cranial approach. Additionally, the needle tip was directed to T4 superior costotransverse ligament, and the ligament was perforated at the top point where it attaches to the T4 transverse process. Results: The ESP block is used for a local anesthetic depot, as a safe and straightforward technique and costotransverse ligament puncture facilitates diffusion and ensures local anesthetic passage to the paravertebral area for thoracic postsurgical analgesia. Using lower doses, comparing this combination with all studies with ESP, it appears that there are a better Numeric Pain Rating Scale (NPRS) scores in the first postoperative hours. NPRS scores at the 12th and 24th hours appear to be similar to those performed in ESP without costotransverse ligament puncture. Conclusion: We submit the first description of a novel combination of ESP block and simplified paravertebral block (PVB) and its successful application in 8 cases of oncologic breast surgery.

Multivesicular Liposome (Depofoam) in Human Diseases.

Drug development is a key point in the research of new therapeutic treatments for increasing maximum drug loading and prolonged drug effect. Encapsulation of drugs into multivesicular liposomes (DepoFoam) is a nanotechnology that allow delivery of the active constituent at a sufficient concentration during the entire treatment period. This guarantees the reduction of drug administration frequency, a very important factor in a prolonged treatment. Currently, diverse DepoFoam drugs are approved for clinical use against neurological diseases and for post-surgical pain management while other are under development for reducing surgical bleeding and for post-surgical analgesia. Also, on pre-clinical trials on cancer DepoFoam can improve bioavailability and stability of the drug molecules minimizing side effects by site-specific targeted delivery. In the current work, available literature on structure, preparation and pharmacokinetics of DepoFoam are reviewed. Moreover, we investigated approved DepoFoam formulations and preclinical studies with this nanotechnology.

Evolving Role of Liposomal Bupivacaine in Managing Post-Surgical Analgesia in Oral Surgery

Evolving Role of Liposomal Bupivacaine in Managing Post-Surgical Analgesia in Oral Surgery

A prospective analysis describing the innovative use of liposomal bupivacaine in burn patients

Burn patients frequently require autograft harvesting to facilitate wound healing, often resulting in significant pain. Liposomal bupivacaine is indicated for administration into a surgical site to produce postsurgical analgesia. The objective of this study was to evaluate efficacy, safety, and duration of postoperative analgesia with liposomal bupivacaine for donor site pain in burn patients. This was an observational, case–control study including adult patients with <20% total body surface area (TBSA) burned who received liposomal bupivacaine for postoperative pain management after autograft harvesting from lower extremity donor site(s). Patients from the case group were matched to historical control patients treated with traditional pain management. The primary outcome was the cumulative pain scores on postoperative day one measured by the area under the curve (AUC0–24). Secondary outcomes included AUC0–72, total milligram morphine equivalents (MME), length of stay, and adverse events. Data were collected in 36 patients who received liposomal bupivacaine, with 21 patients eligible for matching to historical controls. Patients included in the intervention and control groups were well-matched at baseline. Patients in the intervention group had a significantly lower median (IQR) AUC0–24 [578 (408,740) vs. 680 (544,803); p = 0.05] and shorter length of stay [4 days (1,9.5) vs. 6 days (318); p = 0.01]. No differences in adverse events related to the administration of liposomal bupivacaine or opioid-related adverse events were observed. Results indicate liposomal bupivacaine is safe and effective in burn patients. The results of this study add to the limited body of literature examining efficacy in this population.

Local Anesthetics on Postsurgical Analgesia Following Posterior Colporrhaphy

Local Anesthetics on Postsurgical Analgesia Following Posterior Colporrhaphy

Study to Evaluate the Pharmacokinetics, Pharmacodynamics and Safety, of EXPAREL Administered as Sciatic Nerve Block (In Popliteal Fossa), for Postsurgical Analgesia in Subjects Undergoing Bunionectomy

Study to Evaluate the Pharmacokinetics, Pharmacodynamics and Safety, of EXPAREL Administered as Sciatic Nerve Block (In Popliteal Fossa), for Postsurgical Analgesia in Subjects Undergoing Bunionectomy

Impact of liposomal bupivacaine on opioid use, hospital length of stay, discharge status, and hospitalization costs in patients undergoing total hip arthroplasty

Aims: Effective postsurgical analgesia hastens recovery, reduces hospital length of stay (LOS), and decreases hospitalization costs for total hip arthroplasty (THA). Improving these outcomes is critical for value-based surgical bundled payment programs such as the Medicare Comprehensive Care for Joint Replacement and similar programs for commercial insurance providers. This study compared clinical outcomes and hospitalization costs for patients undergoing THA with and without liposomal bupivacaine (LB).Materials and methods: This retrospective, comparative cohort study used data from the Premier Healthcare Database from the 10 hospitals with highest use of LB for THA from January 2011 through April 2017. A cohort undergoing THA with LB at those hospitals was compared with a propensity-score matched cohort at those hospitals who had THA without LB. Descriptive, univariate, and multivariable analyses compared post-surgical inpatient opioid consumption, hospital LOS, discharge status, same-hospital readmissions, and total hospitalization costs. Analyses were performed using the Pearson Chi-square test (categorical variables) and Wilcoxon or Student t-test (continuous variables).Results: For patients with Medicare (with LB, n = 3622; without LB, n = 3610) and commercial insurance (with LB, n = 2648; without LB, n = 2709), use of LB was associated with lower post-surgical inpatient opioid consumption (105 and 81 mg, respectively; p < 0.0001), a 0.7-day shorter LOS (p < 0.0001), a 1.6–1.7-fold increased likelihood of home discharge (p < 0.0001), and no increase in readmissions (p ≥ 0.103). Total hospitalization costs were $561 lower with LB in the Medicare population (p < 0.0001) and $41 higher with LB in the commercial population (p = 0.7697).Limitations: Hospitalization costs were estimated from the hospital chargemaster. Findings from these 10 hospitals may not represent other US hospitals.Conclusions: At select hospitals, THA with LB was associated with reduced post-surgical inpatient opioid consumption, shorter hospital LOS, increased likelihood of home discharge, and lower hospitalization costs. Post-surgical pain management with LB may help hospitals in value-based bundled payment programs.

A Phase 3, Randomized, Double Blinded, Active Controlled, Multicenter Study to Evaluate the Efficacy, Safety &amp; Pharmacokinetics of EXPAREL vs Bupivacaine Administered as Combined Sciatic and Femoral Triangle Nerve Block, For Postsurgical Analgesia in Subjects Undergoing Lower Extremity Surgeries

A Phase 3, Randomized, Double Blinded, Active Controlled, Multicenter Study to Evaluate the Efficacy, Safety &amp; Pharmacokinetics of EXPAREL vs Bupivacaine Administered as Combined Sciatic and Femoral Triangle Nerve Block, For Postsurgical Analgesia in Subjects Undergoing Lower Extremity Surgeries

The Efficacy of Liposomal Bupivacaine Over Traditional Local Anesthetics in Periarticular Infiltration and Regional Anesthesia During Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

BackgroundSince its Food and Drug Administration approval in 2011 as a local anesthetic for postsurgical analgesia, liposomal bupivacaine (LB) has been incorporated into the periarticular injection (PAI) of many knee surgeons. The slow release of this medication from vesicles should significantly extend the duration of its analgesic effect, but current evidence has not clearly demonstrated this benefit. MethodsWe systematically searched electronic databases including PubMed, MEDLINE, Cochrane Library, EMBASE, ScienceDirect, and Scopus, as well as the Journal of Arthroplasty web page for relevant articles. All calculations were made using Review Manager 5.3. ResultsWe identified 42 studies that compared LB to an alternate analgesic modality. Seventeen of these studies were controlled trials that were included in meta-analysis. Significant differences were seen in pain scores with LB over a peripheral nerve block (mean difference = 0.45, P = .02) and LB over a traditional PAI (standard mean difference = −0.08, P = .004). ConclusionWhile LB may offer a statistically significant benefit over a traditional PAI, the increase in pain control may not be clinically significant and it does not appear to offer a benefit in reducing opioid consumption. However, there is no standardization among current studies, as they vary greatly in design, infiltration technique, and outcome measurement, which precludes any reliable summarization of their results. Future independent studies using a standardized protocol are needed to provide clear unbiased evidence.

Post-surgical Evaluation of the Analgesic Impact of Epidural Tramadol, when Associated with Levobupivacaine, in Bitches Undergoing Mastectomy and Ovariohysterectomy

Background:Mammary tumors are the most common neoplasms in female dogs. Surgical removal of the mammary gland chain is considered the standard treatment and is usually performed along with ovariohysterectomy (OH) to suppress ovarian hormonal influence. Mastectomies cause moderate to severe pain and require preferential multimodal analgesic protocols. The aim of this study was to compare the postoperative analgesic efficacy and the recovery times on female dogs undergoing mastectomies and OH between those treated with epidural levobupivacaine alone and those treated with associated doses of tramadol and anesthetized with propofol.Materials, Methods &amp; Results:Eighteen female dogs were pretreated with acepromazine (0.03 mg/kg), using propofol (4 mg/kg)for induction andanesthesia maintenance. The dogs were randomly divided into three groups (n = 6) treated with epidural anesthesia with levobupivacaine alone at 1.5 mg/kg (GL) or associated with tramadol at doses of 2 mg/kg (GLT2) or 4 mg/kg (GLT4). After anesthesia,the mean propofol infusion rate for each groupwere calculed. During the postoperative period,the degree of analgesia according to the University of Melbourne Pain Scale for 6 hours were determined, considering seven time points for evaluation (M30, M60, M90, M120, M180, M240, and M360). Supplemental analgesia with morphine (0.5 mg/kg) to those dogs with scores ≥13 were provided. During the recovery period,the time intervals between the end of anesthesia, and the following events: extubation (EX), the first head movement (MC), and the establishment of sternal (PE) and quadrupedal (PQ) positions were measured. The data were subjected to the Friedman test for analysis of non-parametric variables within the same group and to the Mann–Whitney test for independent variables, comparing the mean scores between groups (statistical significance was set at P&lt;0.05). In the GL group, a higher mean propofol infusion rate than in either the GLT2 or GLT4 groups were found. The EX, PE, and PQ times were similar between the groups with a lower MC interval (P=0.041) for dogs in the GLT2 group. The pain assessment revealed higher scores for dogs in the GL group than for those in the GLT4 group (M30 to M120 and M360). Over time, the initial scores increased after M90 (GL group) and afterM120 (in all groups) andadditional analgesia were required only in GL dogs.Discussion:Mammary tumors were more frequent in middle-aged and elderly female dogs, corroborating current literary data. Regarding anesthesia recovery, no differences in the time for extubation and sternal and quadrupedal positions were found, probably due to similar propofol infusion times and to similar metabolism among the dogs, independent of the higher mean infusion rates used in the group treated only with the local anesthetic. The post-surgical analgesic evaluation revealed lower pain scores in the groups in which tramadol was associated with levobupivacaine, in agreement with studies reporting its analgesic potential to approach surgical pain at doses ranging from 1 to 4 mg/kg. However, even lower scores with the highest dose of the proposed opioid were detected, suggesting improved effectiveness for occupying opioid and monoaminergic pathway receptors. Considering the results, epidural anesthesia with levobupivacaine and tramadol seems to provide adequate post-surgical analgesia for a minimum period of 6 hours, and the best comfort is obtained with a dose of 4 mg/kg of opioid.

Evaluating analgesic efficacy and administration route following craniotomy in mice using the grimace scale

Most research laboratories abide by guidelines and mandates set by their research institution regarding the administration of analgesics to control pain during the postoperative period. Unfortunately, measuring pain originating from the head is difficult, making adequate decisions regarding pain control following stereotaxic surgery problematic. In addition, most postsurgical analgesia protocols require multiple injections over several days, which may cause stress and distress during a critical recovery period. Here we sought to (1) assess the degree of postoperative pain following craniotomy in mice, (2) compare the efficacy of three common rodent analgesics (carprofen, meloxicam and buprenorphine) for reducing this pain and (3) determine whether the route of administration (injected or self-administered through the drinking supply) influenced pain relief post-craniotomy. Using the mouse grimace scale (MGS), we found that injectable analgesics were significantly more effective at relieving post-craniotomy pain, however, both routes of administration decreased pain scores in the first 24 h postsurgery. Specifically, buprenorphine administered independently of administration route was the most effective at reducing MGS scores, however, female mice showed greater sensitivity to carprofen when administered through the water supply. Although it is necessary to provide laboratory animals with analgesics after an invasive procedure, there remains a gap in the literature regarding the degree of craniotomy-related pain in rodents and the efficacy of alternative routes of administration. Our study highlights the limitations of administering drugs through the drinking supply, even at doses that are considered to be higher than those currently recommended by most research institutions for treating pain of mild to moderate severity.

The effect of methadone on postoperative quality of recovery in patients undergoing laparoscopic cholecystectomy: A prospective, randomized, double blinded, controlled clinical trial

Study objectivesThe aim of the present study was to assess the quality of recovery from anesthesia in patients undergoing laparoscopic cholecystectomy (LC) under total intravenous anesthesia, who received either methadone or morphine for post-surgical analgesia by means of questionnaire Quality of Recovery-40 (QoR-40). DesignProspective Randomized Clinical Trial. SettingThe setting was at an operating room, postoperative recovery area and hospital ward. PatientsSeventy patients who underwent LC under remifentanil-based anesthesia were randomly assigned to receive methadone 0.1 mg kg−1 or morphine 0.1 mg kg−1. MeasurementsThe primary outcome was the quality of recovery, using the Quality of Recovery Questionnaire (QoR-40). Secondary outcomes included time to eye opening, the occurrence of nausea and vomiting, pain score, use of supplemental analgesics, and PACU length of stay. Main resultsNo differences were observed in the total or individual QoR-40 dimension scores. During the PACU stay, the occurrence of PONV and pain scores were similar between groups. Opioid consumption (p < 0.02) and the level of sedation (p < 0.01) were higher in the morphine group. There were no differences in the amount of time required to achieve PACU discharge criteria. The frequency of nausea or emesis, the severity of pain, and tramadol consumption were comparable between both groups while on the ward. ConclusionsPain scores and the Quality of Recovery did not differ between patients who underwent LC under total intravenous anesthesia, who received either methadone or morphine for post-surgical analgesia.

Dexamethasone as an Adjuvant to Femoral Nerve Block in Children and Adolescents Undergoing Knee Arthroscopy: A Prospective, Randomized, Double-Blind, Placebo-Controlled Trial.

Perineural dexamethasone has been demonstrated to extend postsurgical analgesia after peripheral nerve blockade in adults. The mechanism of action of dexamethasone as a regional anesthetic adjuvant is unclear as intravenous dexamethasone has been shown to have similar analgesic efficacy as perineural dexamethasone. The efficacy of perineural dexamethasone has not been previously explored in the pediatric population. After obtaining informed consent, children (aged 10-18 years) presenting for arthroscopic knee surgery with a femoral nerve block were randomized to 1 of 3 groups: ropivacaine 0.5% and intramuscular saline (group R), ropivacaine 0.5% plus perineural dexamethasone 0.1 mg/kg (maximum 4 mg) and intramuscular saline (group D), and ropivacaine 0.5% and intramuscular dexamethasone 0.1 mg/kg (maximum 4 mg) (group M). The primary outcome was the number of doses of analgesic agents in the first 48 hours after hospital discharge. The number of doses was compared across study groups using Wilcoxon rank sum tests. Seventy-seven patients were enrolled in the study, of whom 4 were withdrawn because of additional surgical repair being performed, emergence delirium requiring unblinding, or loss to follow-up. The remaining 36 boys and 37 girls (aged 15 ± 2 years) included 23 patients randomized to group D, 23 patients randomized to group M, and 27 patients randomized to group R. The median number of pain medication doses within 48 hours of discharge was 2, 3, and 2 in groups D, M, and R, respectively. There were no significant differences in this outcome between groups D and M (difference in medians, 1; 95% confidence interval [CI] of difference in medians, -1 to 2; P = 0.475), groups D and R (difference in medians, 0; 95% CI of difference, -2 to 1; P = 0.821), or groups M and R (difference in medians, -1; 95% CI of difference, -2 to 1; P = 0.594). Other secondary outcomes, including time to first analgesic consumption after discharge, visual analog scale pain score, and subjective intensity of motor block, did not evince statistically significant differences among the study groups. In the pediatric population, perineural or intramuscular dexamethasone did not improve analgesia after femoral nerve blockade for knee arthroscopy. Whether the observed lack of benefit reflects a true adult-pediatric difference or a limitation of the study could not be determined. Future pediatric studies are needed to evaluate dexamethasone for other block types and other types of surgery. This study was registered at ClinicalTrials.gov, identifier NCT01971645.

The effects of morphine on gas exchange, ventilation pattern and ventilatory responses to hypercapnia and hypoxia in dwarf caiman (Paleosuchus palpebrosus)

Morphine and other opioids cause respiratory depression in high doses and lower the ventilatory responses to hypoxia and hypercapnia in mammals. Recent studies indicate that turtles respond similarly, but although they are used routinely for post-surgical analgesia, little is known about the physiological effects of opioids in reptiles. We therefore investigated the effects of morphine (10 and 20 mg kg−1) on gas exchange and ventilation in six dwarf caiman (Paleosuchus palpebrosus) using pneumotachography in a crossover design. Intraperitoneal injections of morphine changed the ventilation pattern from a typical intermittent/periodic pattern with a few or several breaths in ventilatory bouts to single breaths and prolonged the apnoea, such that respiratory frequency was depressed, while tidal volume was elevated. Furthermore, the duration of inspiration and especially expiration was prolonged. The resulting decrease in minute ventilation was attended by a lowering of the respiratory exchange ratio (RER) (especially for 20 mg kg−1 dose) indicating CO2 retention with a long time constant for approaching the new steady state. The changes in ventilation pattern and gas exchange reached a new stable level approximately 3 h after the morphine injection and did not significantly affect steady state O2 uptake, i.e. O2 consumption. As expected, the ventilatory response to 5% O2 was lower in morphine-treated caimans, but minute ventilation upon exposure to 2% CO2 did not differ significantly different from control animals.

The Opioid Crisis: a Comprehensive Overview

The opioid crisis most likely is the most profound public health crisis our nation has faced. In 2015 alone, 52,000 people died of drug overdoses, with over 30,000 of those people dying from opioid drugs. A recent community forum led by the Cleveland Clinic contrasted this yearly death rate with the loss of 58,000 American lives in 4years of the Vietnam War. The present review describes the origins of this opioid epidemic and provides context for our present circumstances. Alarmingly, the overwhelming majority of opioid abusers begin their addiction with prescription medications, primarily for chronic pain. Chronic postoperative pain, which occurs in 10-50% of surgical patients, is a major concern in many types of surgery. Nationwide, the medical community has made it a priority to ensure that postsurgical analgesia is sufficient to control pain without increasing non-medically appropriate opioid use. The opioid epidemic remains a significant pressing issue and will not resolve easily. Numerous factors, including the inappropriate prescription of opioids, lack of understanding of the potential adverse effects of long-term therapy, opioid misuse, abuse, and dependence, have contributed to the current crisis.

Medication, equipment, and supply costs for common interventions providing extended post-surgical analgesia following total knee arthroplasty in US hospitals

Aims: To estimate the cost to hospitals of materials (i.e. medications, equipment, and supplies) required to administer common interventions for post-surgical analgesia after total knee arthroplasty (TKA), including single-injection peripheral nerve block (sPNB), continuous peripheral nerve block (cPNB), periarticular infiltration of multi-drug cocktails, continuous epidural analgesia, intravenous patient-controlled analgesia (IV PCA), and local infiltration of bupivacaine liposome injectable suspension (BLIS).Materials and methods: This analysis was conducted using a mixed methods approach combining published literature, publicly available data sources, and administrative data, to first identify the materials required to administer these interventions, and then estimate the cost to the hospital of those materials. Medication costs were estimated primarily using the Wholesale Acquisition Costs (WAC), the cost of reusable equipment was obtained from published sources, and costs for disposable supplies were obtained from the US Government Services Administration (GSA) database. Where uncertainty existed about the technique used when administering these interventions, costs were calculated for multiple scenarios reflecting different assumptions.Results: The total cost of materials (i.e. medications, equipment, and supplies) required to provide post-surgical analgesia was $41.88 for sPNB with bupivacaine; $756.57 for cFNB with ropivacaine; $16.38 for periarticular infiltration with bupivacaine, morphine, methylprednisolone, and cefuroxime; $453.84 for continuous epidural analgesia with fentanyl and ropivacaine; $178.94 for IV PCA with morphine; and $319.00 for BLIS.Limitations: This analysis did not consider the cost of healthcare providers required to administer these interventions. In addition, this analysis focused on the cost of materials and, therefore, did not consider aspects of relative efficacy or safety, or how the choice of intervention for post-surgical analgesia might impact outcomes such as length of stay, re-admissions, discharge status, adverse events, or total hospitalization costs.Conclusions: This study provided an estimate of the costs to hospitals for materials required to administer commonly used interventions for post-surgical analgesia after TKA.

Pain management in total knee arthroplasty by intraoperative local anesthetic application and one-shot femoral block.

Background:Pain after total knee arthroplasty (TKA) is a big problem in orthopaedic surgery. Although opioids and continuous epidural analgesia remain the major options for the postoperative pain management of TKA, they have some undesirable side effects. Epidural analgesia is technically demanding, and the patient requires close monitoring. Different types of local anesthetic applications can successfully treat TKA pain. Local anesthetics have the advantage of minimizing pain at the source. This study investigates the efficacy of different local anesthetic application methods on early, (1st day) pain control after total knee arthroplasty.Materials and Methods:200 patients who underwent unilateral TKA surgery under spinal anesthesia were randomly assigned into four different groups (fifty in each group) and were administered pain control by different peri- and postoperative regimens. Group A was the control group wherein no postsurgical analgesia was administered to assess spinal anesthesia efficacy; in Group B, only postsurgical one-shot femoral block was applied; in Group C, intraoperative periarticular local anesthetic was applied; in Group D, a combination of the one-shot femoral block and intraoperative periarticular local anesthetics were applied. Demographic data consisting of age, weight, gender and type of deformity of patients were collected. The data did not differ significantly between the four groups.Results:Group D patients experienced significantly better postoperative pain relief (P < 0.05) and were therefore more relaxed in pain (painless time, VAS score) and knee flexion (degrees) than the other patient groups in the 1st postoperative day followup. Painless time of Group D was 10.5 hours and was better than Group C (6.8 hours), Group B (6.2 hours) and Group A (3.0 hours) (P < 0.05). Group A got the best pain Vas score degrees in the 1st postoperative day which showed the success of combined periarticülar local anesthetic injection and femoral nerve block.Conclusion:The intraoperative periarticular application of local anesthetics in addition to one-shot femoral block is an efficient way of controlling postsurgical pain after TKA.

Local infiltration for postsurgical analgesia following total hip arthroplasty: a comparison of liposomal bupivacaine to traditional bupivacaine

Objective: To assess postsurgical clinical and economic outcomes of patients who received local infiltration containing liposomal bupivacaine versus traditional bupivacaine for pain management following total hip arthroplasty (THA).Methods: This retrospective study included two groups of consecutive patients undergoing THA. The experimental group received local infiltration with a combination of liposomal bupivacaine, bupivacaine HCl 0.25% with epinephrine 1:200,000, and ketorolac for postsurgical analgesia. The historical control group received the previous standard of care: local infiltration with a combination of bupivacaine HCl 0.25% with epinephrine 1:200,000 and ketorolac. Key outcomes included distance walked, length of stay (LOS), opioid medication use, numeric pain scores, hospital charges, hospital costs, all-cause 30 day readmission rate, and adverse events (AEs). Both unadjusted and adjusted (i.e. age, sex, insurance type, living situation, body mass index, procedure side, and comorbidity) outcomes were compared between the two groups.Results: The experimental group (n = 64) demonstrated statistically significant improvement versus the historical control group (n = 66) in mean distance walked on discharge day (249.2 vs. 180.0 feet; unadjusted p = .025, adjusted p = .070), mean LOS (2.0 vs. 2.7 days; p < .001, p = .002), proportion of patients who used opioid rescue medication on postoperative day (POD) 1 (29.7% vs. 56.1%; p = .002, p = .003) and POD 2 (7.8% vs. 30.3%; p = .001, p = .003), mean cumulative area under the curve for pain score on POD 0 (127.6 vs. 292.5; p < .001, both), POD 1 (92.9 vs. 185.0; p < .001, both), and POD 2 (93.8 vs. 213.8; p = .006, both). Among a subgroup of patients with available financial information, mean hospital charges were lower in the experimental group ($43,794 [n = 24] vs. $48,010 [n = 66]; p < .001, both). Rates of all-cause 30 day readmission and AEs were not significantly different between groups. No falls occurred.Conclusions: Infiltration at the surgical site with liposomal bupivacaine was associated with improved postsurgical outcomes when compared with traditional bupivacaine in patients undergoing THA.

(350) Interactive tool to estimate the total cost of postsurgical analgesia in patients undergoing total knee arthroplasty

(350) Interactive tool to estimate the total cost of postsurgical analgesia in patients undergoing total knee arthroplasty