Preoperative Analgesia Research Articles

Comparison of Preoperative and Postoperative Ultrasound-Guided Caudal Block Analgesia for Lower Limb Surgeries in Pediatrics: A Randomized Controlled Trials

Background: Evaluating pain after surgery is particularly important in children due to their limited ability to communicate effectively. The intensity, duration, and threshold of pain make it challenging to assess in this age group. Objectives: The aim of this study was to compare the effects of ultrasound-guided caudal block at different timings on children's pain and drug consumption during unilateral knee osteotomy surgery. Methods: In a randomized clinical trial, fifty patients were randomly included in the study. The patients were children aged 2 - 6 years, candidates for unilateral osteotomy surgery under general anesthesia with total IV anesthesia (TIVA). The patients were divided into two groups based on the timing of the caudal block: The first group received the block after induction, and the second group received it after surgery and before extubation. Results: There was no statistically significant difference between the two groups in terms of the average amount of Propofol and narcotic consumption during recovery at different time points (P > 0.05). However, significant differences in pain levels were observed during the operation at 60 minutes (P-value < 0.001) and 120 minutes (P-value = 0.006) between the two groups. Pain scores at the start of recovery and at 2, 4, 6, 12, and 24 hours postoperatively were significantly lower in the second group than in the first group. Additionally, the mean difference in Bispectral Index (BIS) at 60 minutes between the two groups was significant (P-value = 0.003), but there was no significant difference at 120 minutes (P-value = 0.896). The second group consistently had significantly lower pain levels than the first group at all times. Conclusions: Based on the results of this study, patients who received a caudal block had lower pain scores, and performing the block before extubation had more beneficial effects on postoperative pain management in children undergoing osteotomy surgery than performing it after induction.

Intranasal esketamine versus esketamine-dexmedetomidine combination for premedication in pediatric patients undergoing strabismus surgery: a randomized controlled trial.

Preoperative fear and anxiety are prevalent in children undergoing surgery. The combination of esketamine and dexmedetomidine has been proposed as a promising premedication for enhancing preoperative sedation and analgesia. This study compared the premedication efficacy of intranasal esketamine alone and esketamine-dexmedetomidine combination in pediatric patients undergoing strabismus surgery. One hundred and eighty preschool children aged 2-6 years scheduled for strabismus surgery were enrolled and randomly assigned to one of the three groups: intranasal premedication with esketamine 2 mg/kg (Group K), esketamine 1 mg/kg and dexmedetomidine 1 µg/kg (Group KD1), or esketamine 0.5 mg/kg and dexmedetomidine 2 µg/kg (Group KD2). The primary outcome was the level of sedation following the intervention, as measured by the modified Yale preoperative anxiety scale (mYPAS) and sedation scale (SS). Secondary outcomes included onset time of sedation, the successful rate of peripheral intravenous cannulation, parental separation anxiety scale (PSAS), mask acceptance scale (MAS), wake-up time, duration of stay in the post-anesthesia care unit (PACU), and premedication-related adverse effects. After premedication, the mYPAS score gradually decreased in the three groups, with lower values in Group K than in Group KD1 and Group KD2 patients in 1, 5, and 10 min. SS in Group KD1 and Group KD2 steadily increased until 40 min after premedication, while SS in Group K increased in the first 5 min after premedication and maintained consistent levels during the remaining time. Sedation onset was substantially faster in Group K patients (11.4±7.8 min) than Group KD1 (18.1±7.5 min, P=0.006) and Group KD2 (18.4±6.8 min, P<0.001). PSAS, separation status, the successful rate of peripheral intravenous cannulation, and MAS were comparable among groups. There was no significant difference in terms of emergence time or duration of stay in the PACU among groups. More gastrointestinal events were observed in Group K (P<0.001). Intranasal premedication with 2 mg/kg esketamine produced a more rapid onset of sedation accompanied by more gastrointestinal reactions compared with a combination of esketamine and dexmedetomidine. ClinicalTrials.gov identifier: NCT04757675.

Outpatient Hysteroscopy: (Green-top Guideline no. 59).

All gynaecology departments should provide a dedicated outpatient hysteroscopy service to aid care of women and people with abnormal uterine bleeding, reproductive problems, and insertion/retrieval of intrauterine devices. [Grade A] Written information should be provided to the woman prior to their appointment. This should include details about the procedure, the benefits and risks, advice regarding pre-operative analgesia, as well as alternative options for care and contact details for the hysteroscopy unit. [Good Practice Point] Women should be made aware of other settings and modes of anaesthesia for hysteroscopy (e.g. under general or regional anaesthesia or intravenous sedation). [GPP] The woman should be advised that if they find the procedure too painful or distressing at any point, they must alert the clinical team who will stop the procedure immediately. The clinical team should alert the hysteroscopist if the woman appears to be in too much pain or is experiencing a vasovagal episode and therefore unable to voice the concerns so that the procedure can be stopped. [GPP] Women should be advised to take standard doses of oral non-steroidal anti-inflammatory agents (NSAIDs) one hour before their scheduled appointment. Vaginoscopy should be the standard technique for outpatient hysteroscopy unless the use of a vaginal speculum is required (e.g. for administering local cervical anaesthesia or dilating the cervix). [Grade A] When performing operative hysteroscopy, the smallest diameter hysteroscope should be used, with consideration given to the use of hysteroscopes with expandable outer working channels because they are associated with less pain. [Grade B] Mechanical hysteroscopic tissue removal systems should be preferred over miniature bipolar electrodes to remove endometrial polyps. [Grade A] Local anaesthesia should not be routinely administered prior to outpatient hysteroscopy where a vaginoscopic approach is used. It should be considered where use of a vaginal speculum is planned e.g. for cervical dilatation if anticipated, due to either cervical stenosis and/or the utilisation of larger-diameter hysteroscopes (≥5mm outer diameter). [Grade A] Saline should be instilled at the lowest possible pressure to achieve a satisfactory view. [Grade A] Conscious sedation should not be routinely used in outpatient hysteroscopic procedures. [Grade B].

Comparing the Efficacy of Landmark-Based Fascia Iliaca Compartment Block and Pericapsular Nerve Group Block for Preoperative Positioning and Postoperative Analgesia in Patients Undergoing Surgery for Hip Fractures: A Randomized Controlled Trial.

Subarachnoid block is the most common anesthetic technique for patients having corrective hip surgeries. However, adequate positioning for a successful subarachnoid block is a major challenge in this particular population of patients, owing to the site of fracture. Regional anesthesia, in the form of nerve blocks, is an effective means of alleviating such constraints and gives an added benefit of prolonged postoperative analgesia. The pericapsular nerve group (PENG) block and the fascia iliaca compartment block (FICB), under ultrasonography guidance, are a few examples of the commonly performed peripheral nerve blocks in such settings. However, the landmark-based techniques of nerve blockade still hold good in many resource poor settings, given the lack of ultrasonography facilities. To compare the ease of spinal positioning using the patient sitting satisfaction score between the landmark-guided FICBand PENG block. This study was done on 80 patients of the American Society of Anesthesiology (ASA) grade I or II with intertrochantericfractures of the hip joint scheduled for proximal femoral nailing. Patients were allocated into two groups of 40 each through computer generated random numbers, to receive 30 ml of 0.5% ropivacaine via the landmark-guided technique of FICB in Group F and peripheral nerve stimulator assisted landmark-guided PENG block in Group P, 30 minutes prior to spinal positioning. Time to passive leg raise (PLR) to 15 degrees and time to PLR to 30 degrees with a standard goniometer guidance at visual analogue scale (VAS) score < 4 and ease of spinal positioning through the sitting satisfaction score at the 30th minute were assessed. Any adverse effects and events of failure were noted. The duration of postoperative analgesia was measured through the time to the first dose of paracetamol on arrival at the post-anesthesia care unit. Statistical analysis was done using JASP version (0.18.3.0) using the independent samples t-test and significance was taken when p value was < 0.001. The time to PLR to 15 degrees and 30 degrees were achieved faster in the patients who received the PENG block in comparison to the patients who received the FICB, and the average patient sitting satisfaction score was significantly higher in Group P as compared to Group F (p < 0.001). While the overall amount of analgesics used in both groups was similar, the overall period of postoperative analgesia was prolonged in Group F compared to Group P (p < 0.001). The landmark guided PENG block is feasible and superior to the landmark-guided FICB for preoperative positioning and analgesia. The FICB provides a longer duration of postoperative analgesia for patients with intertrochanteric fractures.

Initial experience of minimally invasive mesh explantation for inguinodynia.

Chronic pain after minimally invasive inguinal hernia repair with mesh can have debilitating effects on quality of life (QOL), limiting daily activities and ability to work. Many medical and surgical options for treatment have been proposed, however there is no consensus on the role of mesh explantation in the management of these patients. We performed a retrospective review of all patients who underwent groin mesh removal by robotic or laparoscopic approach from July 2012 to July 2023 at our institution. Patients were interviewed post-operatively to determine their overall pain scores and QOL was assessed using the Carolinas Comfort Scale (CCS) Questionnaire. Patient characteristics, operative times, pre-operative imaging techniques and analgesia use was also recorded. Twenty-two patients underwent groin mesh removal for chronic pain, including 12 robotic and 10 laparoscopic operations. The mean pre-operative pain score in all patients was 7.6/10 compared to 4.0/10 post-operatively. The mean post-operative CCS score was 24, indicating moderate discomfort. Four patients demonstrated CCS scores <11 indicating no discomfort and no patients demonstrated CCS scores >90, indicating severe debilitating discomfort. The majority of patients had a reduction or total cessation of analgesia intake post-operatively. Both laparoscopic and robotic mesh explantation for treatment of chronic pain post-inguinal hernia repair is safe and effective in achieving a reduction in pain and reducing the need for long-term analgesia.

Effect of pericapsular nerve group block and suprainguinal fascia iliaca block on postoperative analgesia and stress response in elderly patients undergoing hip arthroplasty: a prospective randomized controlled double-blind trial

BackgroundAs a novel regional analgesic technique, ultrasound-guided pericapsular nerve group (PENG) block has some potential advantages, and we designed a randomized clinical trial (RCT) to investigate whether the ultrasound-guided PENG block combined with general anesthesia can better reduce stress response, maintain intraoperative hemodynamic stability, and reduce postoperative analgesia in elderly hip arthroplasty compared with ultrasound-guided suprainguinal fascia iliaca block (SIFIB) combined with general anesthesia.MethodsSeventy-four subjects were enrolled over an 8-month period (20 April 2023 to 31 December 2023). All patients were divided into the test group (group P) and the control group (group S) using the envelope as the randomization method. The test group was treated with preoperative ultrasound-guided PENG block analgesia combined with general anesthesia and the control group was treated with preoperative ultrasound-guided SIFIB analgesia combined with general anesthesia. The primary outcome selected was the patient Visual Analogue Scale (VAS) score at 12 h postoperatively.ResultsAfter generalized estimating equations (GEE) analysis, there was a statistically significant difference in the main effect of postoperative VAS score in group P compared with group S (P = 0.009), the time effect of VAS score in each group was significantly different (P < 0.001), and there was no statistically significant difference in the group-time interaction effect (P = 0.069). There was no statistically significant difference in the main effect of intraoperative mean arterial pressure (MAP) change (P = 0.911), there were statistically significant differences in the time effect of MAP in each group (P < 0.001), and there were statistically significant differences in the interaction effect (P < 0.001).ConclusionsIn summary, we can conclude that in elderly patients undergoing hip fracture surgery, postoperative analgesia is more pronounced, intraoperative hemodynamic parameters are more stable, and intraoperative stress is less induced in patients receiving SIFIB than in patients receiving PENG block.

Effects of a Preoperative Patient-Controlled Analgesia Education Program Using Smart Learning in Laparoscopic Cholecystectomy Patients

BackgroundPatients undergoing laparoscopic cholecystectomy develop severe postoperative pain, and this acute pain often becomes chronic. ObjectivesThis study determines the effects of preoperative education on patient-controlled analgesia (PCA) through smart learning in patients using PCA after undergoing laparoscopic cholecystectomies. DesignWe conducted a quasi-experimental study with a nonequivalent control group pretest–posttest design. ParticipantsA total of 60 adult patients aged 20-65 years, admitted for laparoscopic cholecystectomy at a hospital in Korea, participated in a smart learning training program. MethodsThe concept of smart learning, which integrates learning content and solutions with the fourth industrial revolution using mobile devices such as smartphones and media tablets was applied in this study. This smart learning training program comprised three phases: (1) prebriefing, where patients accessed PCA knowledge via a program created by researchers and accessible using a mobile web device (e.g., smartphone or an iPad), with training covering pain characteristics, PCA effects, precautions, and usage methods; (2) simulation, where patients learned using PCA with a machine; (3) debriefing, where patients reviewed their knowledge and skills. ResultsComparing the pain between the experimental and control groups, the pain decreased significantly in both the experimental (Z = –4.40, p < .001) and control groups (Z = –4.41, p < .001), with no significant difference between groups (Z = –1.00, p = .319). Preoperative knowledge significantly increased in both the experimental (Z = –4.74, p < .001) and control groups (Z = –3.55, p < .001), with a significant difference between groups (Z = –6.05, p < .001). Total satisfaction with pain control was higher in the experimental group than in the control group. ConclusionsA structured educational program on PCA use is an effective nursing intervention. PCA educational programs using smart learning could help patients undergoing laparoscopic cholecystectomy understand postoperative pain, promote efficient PCA use, and enhance their satisfaction with pain control.

Numbing the Heart to Death: A Cautionary Tale About an In-Vogue Preoperative Analgesic.

Numbing the Heart to Death: A Cautionary Tale About an In-Vogue Preoperative Analgesic.

Preoperative Education is Associated with Adherence to Downstream Components and Outcomes in a Colorectal Surgery Enhanced Recovery Program.

This study evaluated the association between preoperative education and adherence to downstream components of enhanced recovery programs (ERPs) and surgical outcomes among patients undergoing elective colorectal surgery. ERPs improve outcomes for surgical patients. While preoperative education is an essential component of ERPs, its relationship with other components is unclear. This was a retrospective cohort study of all ERP patients undergoing elective colorectal surgery from 2019 to 2022. Our institutional ERP database was linked with American College of Surgeons National Surgical Quality Improvement Program data and stratified by adherence to preoperative education. Primary outcomes included adherence to individual ERP components and secondary outcomes included high-level ERP adherence (>70% of components), length of stay (LOS), readmissions, and 30-day complications. A total of 997 patients were included. The mean (SD) age was 56.5 (15.8) years, 686 (57.3%) were female, and 717 (71.9%) were white. On adjusted analysis, patients who received preoperative education (n = 877, 88%) had higher adherence rates for the following ERP components: no prolonged fasting (estimate = +19.6%; P < 0.001), preoperative blocks (+8.0%; P = 0.02), preoperative multimodal analgesia (+18.0%; P < 0.001), early regular diet (+15.9%; P < 0.001), and postoperative multimodal analgesia (+6.4%; P < 0.001). High-level ERP adherence was 13.4% higher (P < 0.01) and LOS was 2.0 days shorter (P < 0.001) for those who received preoperative education. Classification and regression tree analysis identified preoperative education as the first-level predictor for adherence to early regular diet, the second-level predictor for LOS, and the third-level predictor for ERP high-level adherence. Preoperative education is associated with adherence to ERP components and improved surgical outcomes.

Randomized controlled trial on analgesic effect of pre-operative fascia iliaca compartment block in geriatric patients with hip fracture

Objective While most geriatric patients with hip fracture benefit from definitive operative treatment, pre-operative pain management is often overlooked. Conventional oral analgesics may provide suboptimal pain control, resulting in poor morbidity outcomes. Fascia iliaca compartment block (FICB) provides a more consistent analgesic effect. This study aims to provide high level local evidence on the effect of FICB in pre-operative pain control for these patients in Hong Kong. Materials and Methods This study was a double-blinded randomized controlled trial. Mentally competent geriatric patients with acute fracture hip, admitted to United Christian Hospital, were recruited to receive pre-operative FICB. The procedure was carried out by landmark approach with addition of ultrasonography-guidance. They were randomized into intervention group (receiving 0.25% levobupivacaine), and control group (receiving normal saline as placebo). Numeric Rating Scale of pain score (at rest, and on gentle movement) at different time intervals, timing of injection, systemic analgesic use, complications, and demographics were compared. Results Total 80 patients were recruited from July 2019 to September 2021 and randomized into intervention and control groups. Two patients in intervention group and 1 in control group were withdrawn due to development of delirium. Demographics of both groups were comparable. Pain score at rest was significantly lower at 12 h after injection in intervention group (41.4% reduction, p = 0.03). Pain score upon gentle movement was significantly lower in intervention group at 1 h (p = 0.01), 12 h (28.9% reduction, p = 0.003) and 24 h after injection (p = 0.01). There was no complication from the procedure documented. Total systemic analgesic use was similar in both groups. Conclusion FICB is an effective choice of pre-operative analgesia for geriatric hip fracture patients with good safety profile, especially in controlling pain induced by movement. It shall be considered as a routine practice for suitable patients.

THE ROLE AND CORRECTION OF SEXUAL DYSFUNCTION AS A COMPONENT OF THE QUALITY OF LIFE IN PATIENTS OPERATED ON FOR CEREBRAL ANEURYSM RUPTURE

Introduction. Hemorrhagic stroke due to the rupture of the intracranial aneurysm (IA) is a typical clinical manifestation of the disease and one of the main causes of disability, affecting the quality of life in operated patients.&#x0D; The aim. To determine the feasibility and safety of implementing protocols for diabetes mellitus (DM) treatment as part of rehabilitation interventions in patients who have undergone surgery for the rupture of intracranial aneurysm (IA) in the brain.&#x0D; Materials and methods. To determine the effectiveness and safety of implementing diabetes mellitus (DM) treatment protocols in individually developed rehabilitation interventions following surgery for the rupture of intracranial aneurysm (IA) in the brain, a retrospective cohort study was conducted in parallel groups.&#x0D; Results. Sexual dysfunctions (SD) resulting from the rupture of IA are multifactorial. The causes of SD can be categorized as primary, secondary, and tertiary. Primary causes include damage to brain structures by hemorrhagic stroke or vascular ischemic events affecting sexual functioning, pre-existing medical conditions, and side effects related to medication therapy during treatment. Secondary causes encompass persistent sensorimotor disturbances due to a prior stroke. Issues related to cognitive, behavioral, and psychosocial adaptation constitute tertiary causes of SD. The effective and prompt correction of sexual dysfunction in patients following the rupture of cerebral blood vessel aneurysms largely depended on the proper administration of anesthesia during surgical interventions and intensive therapy in the perioperative period. This includes preoperative preparation and patient analgesia, the administration of anesthesia, and adequate postoperative care.&#x0D; Conclusions. The application of SD correction in men as part of rehabilitation measures from the 6th to the 24th month after surgical treatment of intracranial aneurysm (IA) has a positive impact, reducing SD regression from 88.9% (n=56/63) to 34.9% (n=22/63).

Comparison of analgesic efficacy of tramadol, morphine and methadone in cats undergoing ovariohysterectomy.

The aim of this study was to compare the analgesic efficacy and the effect on physiological variables and behavior of the use of tramadol, methadone and morphine as preoperative analgesia in healthy cats undergoing elective ovariohysterectomy. Cats undergoing ovariohysterectomy were randomly assigned to receive one of the following premedication treatments intramuscularly: methadone (0.2 mg/kg; n = 10); morphine (0.2 mg/kg; n = 10); or tramadol (3 mg/kg; n = 10). Induction of anesthesia was done with propofol, and maintenance of anesthesia was done with isoflurane. Intraoperative heart rate, arterial blood pressure, respiratory rate, end-tidal isoflurane concentration and frequency of rescue analgesia (fentanyl 2.5 µg/kg) were compared between groups. Postoperative analgesia was assessed using the UNESP-Botucatu Multidimensional Composite Pain Scale, and perioperative serum glucose, cortisol concentrations and postoperative rescue analgesia were evaluated. Intraoperative rescue analgesia was required in 76.5% of cats at some time during surgery, and 27% of cats required postoperative rescue analgesia up to 6 h after extubation. There were no significant differences between groups with respect to intraoperative and postoperative rescue analgesia, pain scale scores and end-tidal isoflurane concentrations. In the immediate postoperative period, after extubation, most of the patients presented with hypothermia; however, 1-6 h postoperatively, hyperthermia was observed in most of the patients, and was most common in the tramadol group. Under the conditions of this study, methadone, morphine and tramadol produced satisfactory postoperative analgesia in most of the cats undergoing ovariohysterectomy, and the effects lasted up to 6 h postoperatively. Intraoperative analgesia was not sufficient in most cases. Significant cardiovascular or respiratory effects contraindicating the use of these drugs were not found. Postanesthetic hyperthermia occurred with all opioids studied and was more frequent in the tramadol group.

One-year Results of Minimally Invasive Sutured Fixation of the Slipped Ribs in the Pediatric Population

PurposeCostal cartilage resection with or without rib resection is the gold standard surgery for slipping rib syndrome. Minimally invasive restoration of normal anatomy via nonabsorbable sutures has been described in the adult population with encouraging results. We sought to assess the efficacy of minimally invasive sutured fixation of the hypermobile rib in the pediatric population. MethodsA retrospective review was performed at Mayo Clinic involving 31 pediatric patients diagnosed with slipped rib syndrome. Minimally invasive sutured open reduction internal fixation was performed between 2020 and 2022. The standardized Örebro Musculoskeletal Pain Screening Questionnaire was given at dedicated time points pre- and post-operatively to assess efficacy. Significance was determined via the Wilcoxon rank sum test. ResultsSRS was diagnosed clinically in 31 patients (24 females, 7 males, 1220 years-old). Symptoms were present for an average of 18.9 months and patients had seen an average of 4.7 specialists. Traumatic causes were identified in three patients and eight patients had hypermobility. At one month follow up, there were no surgical complications and patients reported significantly less pain (p < 0.001). Preoperative analgesics reduced by 80%. Ultimately, seven patients underwent a second operation; three patients underwent a third operation; one patient underwent five total operations. Recurrent pain was reported in six patients. Only nine patients followed-up at 1-year post-operation. ConclusionPediatric patients with SRS demonstrated an early positive response to suture fixation without costal cartilage excision. Reoperation and recurrent pain, however, remain significant in this population. Level of EvidenceLevel IV. Type of StudyCase series with no comparison group.

Ultrasound-Guided Percutaneous Cryoneurolysis for Perioperative Analgesia Following Major Lower Extremity Amputation: A Randomized, Participant- and Observer-Masked, Sham-Controlled Pilot Study.

Extremity amputations are associated with pain in both the residual limb and the phantom limb. This pain, which is often debilitating, may be prevented by excellent perioperative pain control. Ultrasound-guided percutaneous cryoneurolysis is an analgesic modality offering pain control for weeks or months following surgery. This treatment has not been compared to the sham procedure for large nerves (e.g., femoral and sciatic) to provide preoperative analgesia. We therefore conducted a randomized, controlled pilot study to evaluate the use of this modality for the treatment of pain following amputation to (1) determine the feasibility of and optimize the study protocol for a subsequent definitive clinical trial; and (2) estimate analgesia and opioid reduction within the first postoperative weeks. A convenience sample of seven patients undergoing lower extremity amputation were randomized to receive either active cryoneurolysis or a sham procedure targeting the sciatic and femoral nerves in a participant-masked fashion. This was a pilot study with a relatively small number of participants, and therefore the resulting data were not analyzed statistically. Compared to the participants who received sham treatment (n=3), those who underwent active cryoneurolysis (n=4) reported lower pain scores and decreased opioid consumption at nearly all time points between days one and 21 following amputation. Ultrasound-guided percutaneous cryoneurolysis of the femoral and sciatic nerves prior to lower extremity amputation appears feasible and potentially effective. The data from this pilot study may be used to power a definitive randomized clinical trial.

WITHDRAWN: Efficacy of intra-operative periarticular local infiltration for pain control and ambulation in total knee arthroplasty

Total knee replacement (TKR) is a leading operative procedure for late-stage knee osteoarthritis. Pain, post-replacement hinders an effective rehabilitation protocol. Many preoperative, perioperative, and postoperative analgesia modes have been reported but have some undesirable side effects. To overcome these side effects, an intraoperative local analgesic cocktail can be used. We conducted this study to assess the benefits of intra-operative local infiltration of cocktail in TKR patients in terms of pain, amount of additional analgesia required post-operatively, and ambulation time. 50 patients were chosen and split into two groups of 25 each. The case group received the cocktail injection whereas the control group were injected locally with normal saline. Post-operatively VAS score was assessed at 3, 6,12 and 24 h post-surgery, the amount of analgesics used and ambulation time was assessed. Compared to the control group, the case group had significantly less pain in the first 24 h and a lower amount of additional analgesia and earlier ambulation. Pain reduction with early ambulation was noted in a significant number of individuals with the use of this intraoperative local cocktail injection.

Mid-term results of combined medical and popliteal artery endarterectomy treatment in Buerger's disease

Aim: Our aim in this article is to present the mid-term results of the best preoperative and postoperative medical treatment and analgesia treatment in patients with advanced Buerger's disease who underwent saphenous patchplasty and saphenous distal bypass after endarterectomy to the popliteal artery or trifurcation area. Material and Methods: Between 2015 and 2023, we operated on 83 patients, diagnosed with Buerger's disease, who were in the chronic stage of the disease, and whose advanced imaging was performed. Preoperative, postoperative, and 1st year control evaluations were determined according to Rutherford, Fontaine classification, and Ankle-Brachial Indexes. Medical treatments of the patients were organized by the vascular surgery team and algology department. After determining the surgical approach strategy according to the imaging of the patients, saphenous patchplasty and anatomical bypass were performed. Results: The mean preoperative ankle-brachial index was 0.305, the mean postoperative ankle-brachial index was 0.644, and the mean 1-year ankle-brachial index was 0.629 in 83 patients included in the study. Statistically significant improvements were observed in the Rutherford and Fontaine classifications. (p-value &lt; 0,001) Amputation was performed in 9.6% of patients within 1 year. Conclusion: Good clinical results and limb salvage can be achieved with a combined medical and surgical treatment approach in advancedstage patients who do not respond despite optimal medical treatment. Provided that patients quit smoking, good determination of the target surgical site, Saphenous patchplasty, and Saphenous distal bypass applied after endarterectomy in suitable patients are supported with good medical and analgesia treatment, the results will improve further.

Pain With Differing Insufflation Pressures During Robotic Sacrocolpopexy: A Randomized Controlled Trial

ABSTRACT Pain after surgery may have different origins, such as incisions, affected viscera, surgical positioning, or peritoneal irritation from insufflation. Shoulder pain after gynecological laparoscopic surgery is a common concern thought to be associated with peritoneal irritation. Decreasing this pain is therefore a target for improvement of analgesic requirements and overall postoperative pain. This study aimed to determine changes in postoperative pain, surgical safety, and analgesic use via decreased insufflation pressures. The study was designed as a single-blinded, randomized clinical trial at a singular medical center within the United States where surgical treatment took place for pelvic organ prolapse via robotic-assisted sacrocolpopexy. Included were women 18 years or older who were able to complete the visual analog scale without assistance and who underwent scheduled robotic-assisted sacrocolpopexy. After inclusion, participants were randomized in a 1:1 ratio to undergo robotic-assisted sacrocolpopexy with peritoneal insufflation pressure at either 12 mm Hg (experimental) or 15 mm Hg (standard). Surgeries were performed by a single board-certified urogynecologist and resident assistant using a standard technique, the DaVinci Xi system, and an 8-mm AirSeal assist port. Surgeons and assisting OR professionals were not blinded to insufflation pressure. On the first postoperative day, all participants were asked to rate pain via a visual analog scale, as well as at 2 weeks postoperatively (with the addition of a PGI-I questionnaire). The 2-week surveys were collected by the principal investigator or primary surgeon (unblinded). A Likert scale of 0 to 10 was used to rate the highest preoperative and postoperative pain in the postanesthesia care unit. At the time of surgery, preoperative analgesia and opioid use were verified with active prescription records. After surgery, data were recorded for operative time, analgesic doses, conversion to laparotomy or increased insufflation pressure, additionally performed procedures, estimated blood loss, and length of stay. Enrollment occurred from April 27, 2021, to May 17, 2022, with final follow-up being completed on June 1, 2022. A total of 80 participants were enrolled, with 41 in the experimental insufflation group, and 39 in the standard insufflation group. Baseline differences did not exist between groups for prior abdominal surgeries, medical comorbidities, leading edge of prolapse, age, or body mass index. Although median preoperative pain was recorded as zero for both groups, the standard insufflation group did report a statistically higher pain level in the postoperative period. Furthermore, women in the experimental/lower insufflation group used statistically fewer morphine milliequivalents immediately after surgery as well as after discharge. There were no apparent operative problems significantly associated with lower insufflation pressures, as operative time, estimated blood loss, and length of stay in the hospital were not significantly different between groups. The analysis found that the use of 12 mm Hg insufflation pressure did lower opioid use and pain levels in comparison with 15 mm Hg in the immediate postoperative period. The use of this method proved both feasible and safe in all cases, without blood loss, operating time changes, or changes in completing cases through minimal invasive mess. These encouraging findings provide a zero-cost, surgeon-driven intervention method for the postoperative period of robotic gynecological surgeries with the potential lower patient pain levels and opioid use.

A Novel Multimodal Postoperative Pain Protocol for 1- to 2-Level Open Lumbar Fusions: A Retrospective Cohort Study.

There has been increased interest in exploring methods to reduce postoperative pain without opioid medications. In 2015, a multimodal analgesia protocol was used involving the perioperative use of celecoxib, gabapentin, intravenous acetaminophen, lidocaine, and liposomal bupivacaine. Overall, the goal was to reduce the utilization of scheduled opioids in favor of nonopioid pain management. The results of a consecutive series of 1- to 2-level open primary lumbar fusions were compared to a cohort of patients after the implementation the perioperative multimodal pain management protocol. Primary endpoints included patient-reported pain scores and secondary endpoints included length of stay. There were 87 patients in the preprotocol cohort and 184 in the protocol cohort. Comparing protocol and preprotocol patients, there were no significant differences in patient demographics. There was significantly average lower pain in the protocol group on postoperative day (POD) 1 (4.50 vs 5.00, P < 0.02) and POD2 (4.42 vs 5.50, P < 0.03). There was a lower pain score on POD0 (4.80 vs 5.00), but it was only clinically significant. There was a correlation between pain and duration of surgery in the preprotocol patients (POD0 R = 0.23, POD1 R = 0.02, POD2 R = 0.38), but not in the protocol patients (POD0 R = -0.05, POD1 R = -0.08, POD2 R = -0.04). There was a shorter length of stay in the protocol cohort (2.0 vs 3.0, P < 0.01). Finally, there was an approximately 35% reduction in morphine milligram equivalents of opioids in the protocol vs preprotocol cohorts (36.2 vs 57.0, P < 0.05). Our novel multimodal pain management protocol significantly reduced postoperative pain, length of stay, and opioid consumption in this patient cohort. Opioid usage correlated to pain in the protocol patients, while the preprotocol patients had no correlation between opioid use and pain medication. In this study, we demonstrated that preoperative and intraoperative analgesia can reduce postoperative pain medication requirements. Furthermore, we introduced a novel concept of a correlation of pain with opioid consumption as a marker of effective pain management of breakthrough pain.

Tramadol use before total shoulder arthroplasty: patients have lower risk of complications and resource utilization than those using traditional opioids

Evidence continues to mount for the deleterious effects of preoperative opioid use in the setting of total shoulder arthroplasty (TSA). Tramadol, a synthetic opioid with concomitant neurotransmitter effects, has become a popular alternative to traditional opioids, but it has not been well studied in the preoperative setting of TSA. The purpose of this study is to evaluate postsurgical outcomes in TSA for patients with preoperative tramadol use compared to patients using traditional opioids and those who were opioid naïve. Utilizing the IBM Watson Health Marketscan databases, a retrospective cohort study was performed for patients undergoing TSA from 2009-2018. Filled pain prescriptions were collected and prescribing trends were analyzed. Outcomes were compared between four patient cohorts defined by preoperative analgesia use-opioid naïve, tramadol, traditional opioids, and combination (opioids and tramadol). Multivariate analysis was used to account for small variations in cohort demographics and comorbidities. Analysis focused on resource utilization and complications. Revision rates at 1- and 3-years postoperative were also compared. 29,454 TSA patients were studied, with 8,959 available for 3-year postoperative follow-up. 10,462 (35.5%) were prescribed traditional opioids and 2,214 (7.5%) tramadol only. From 2009-2018, prescribing trends in the United States demonstrated a significant decrease in the number of patients prescribed preoperative narcotics, whereas patients prescribed preoperative tramadol and those who were opioid naïve significantly increased. Compared to opioid naïve patients, the traditional opioid cohort had significantly increased odds of resource utilization and complications, whereas the tramadol cohort did not. Specifically, the traditional opioid cohort had an increased risk of prosthetic joint infection compared to both opioid naïve and tramadol cohorts. The traditional opioid cohort had higher revision rates than opioid naïve patients at 1- and 3-years, whereas the tramadol cohort did not. Despite a decrease in opioid prescriptions over the study period, many patients in the United States remain on opioids. While tramadol is not without its own risks, our results suggest that patients taking preoperative tramadol as an alternative to traditional opioids for glenohumeral arthritic pain had a lesser postoperative risk profile, comparable to opioid naïve patients.

Value of indomethacin suppository for preoperative analgesia and anti-inflammation in laparoscopic appendectomy: a protocol of prospective, double-blinded, single-centre, randomised controlled trial in China

IntroductionPostoperative pain has always been a problem for patients and surgeons. Local inflammation, surgical trauma and pain in the body can cause a systemic stress response and immune imbalance, which...