Reduction In Opioid Requirements Research Articles

Gabapentin as a novel adjunct for postoperative irritability after superior cavopulmonary connection operation in children.

Describing our institution's off-label use of gabapentin to treat irritability after superior cavopulmonary connection surgery and its impact on subsequent opiate and benzodiazepine requirements. This is a single-center retrospective cohort study including infants who underwent superior cavopulmonary connection operation between 2011 and 2019. Gabapentin was administered in 74 subjects (74/323, 22.9%) during the observation period, with a median (IQR) starting dose of 5.7 (3.3, 15.0) mg/kg/day and a maximum dose of 10.7 (5.5, 23.4) mg/kg/day. Infants who underwent surgery in 2015-19 were more likely to receive gabapentin compared with those who underwent surgery in 2011-14 (p < 0.0001). Infants prescribed gabapentin were younger at surgery (137 versus 146 days, p = 0.007) and had longer chest tube durations (1.8 versus 0.9 days, p < 0.001), as well as longer postoperative intensive care (5.8 versus 3.1 days, p < 0.0001) and hospital (11.5 versus 7.0 days, p < 0.0001) lengths of stays. The year of surgery was the only predisposing factor associated with gabapentin administration in multivariate analysis. In adjusted linear regression, infants prescribed gabapentin on postoperative day 0-4 (n = 64) had reduced benzodiazepine exposure in the following 3 days (-0.29 mg/kg, 95% CI -0.52 - -0.06, p = 0.01) compared with those not prescribed gabapentin, while no difference was seen in opioid exposure (p = 0.59). Gabapentin was used with increasing frequency during the study period. There was a modest reduction in benzodiazepine requirements associated with gabapentin administration and no reduction in opioid requirements. A randomised controlled trial could better assess gabapentin's benefits postoperatively in children with congenital heart disease.

Suprazygomatic Maxillary Nerve Block in Palatoplasty: A Retrospective Cohort Study of Perioperative Outcomes in Syndromic and Non-Syndromic Children.

This study compares the impact of surgical site infiltration of local anesthesia alone to surgical site infiltration plus suprazygomatic maxillary nerve block (SMB) in non-syndromic and syndromic children undergoing primary palatoplasty. Retrospective cohort study of intra- and post-operative outcomes and opioid utilization in children undergoing palatoplasty by a single surgeon. Urban, academic, tertiary care children's hospital. Children 24 months or younger undergoing primary palatoplasty were included (n = 102). Exclusion criteria were concurrent painful procedures, history of neonatal abstinence syndrome, and nurse-controlled analgesia (n = 30). All patients received epinephrine-containing local anesthetic infiltrated at the surgical site. Fifty-seven also underwent placement of ultrasound-guided SMB. Intra-operative opioid requirement, duration of anesthesia, time to wake up, post-operative opioid requirement, hypoxemic episodes, need for respiratory support, FLACC scores, and length of stay. When controlling for syndromic status and cleft phenotype, SMB was associated with a 57% reduction in intraoperative opioid requirements (95% CI = 15-81%, p = 0.024) but also with a 29% (∼5-min) increase in wake-up time post-surgery (95% CI = 3-50%, p = 0.048). Postoperatively, SMB was linked to a 18% reduction in hospital stay length (95% CI = 2-31%, p = 0.027) and a 88% reduction in opioid requirements within 24 h after surgery (p = 0.006). Desaturations and new respiratory support requirements were unaffected by SMB. Compared to surgical site infiltration of local anesthetic alone, adding SMB reduces intra- and postoperative narcotic requirements and decreases length of stay. These benefits apply to both syndromic and non-syndromic children. SMB does not meaningfully affect respiratory outcomes.

447 Modulation of Patient Reported Outcomes and Opioid Consumption Following Open Craniotomy: The Efficacy and Safety of Subcutaneous Sumatriptan

INTRODUCTION: Traditional pain management regimens following open craniotomy commonly employ opioid medications. As a medication class, opioids present a considerable adverse effect profile and the potential for medication abuse. Alternative medication regimens to better address post-craniotomy pain while mitigating opioid-related adverse effects are insufficiently studied. However, as a dural-based 5-HT1D receptor agonist that regulates vasoconstriction and inflammatory peptide signaling, sumatriptan shows promise to improve pain scores and reduce opioid requirements. METHODS: This is a single academic center, retrospective cohort study of 130 consecutive adult patients undergoing open craniotomy between 7/2015 and 8/2021. Patients were divided between a Control and Sumatriptan cohort contingent upon administration of a single 6mg subcutaneous injection of sumatriptan within 1-hour of surgery completion and prior to opioid administration. Opioid consumption at 6, 12 and 24-hours postoperative and admission total, inpatient length of stay (LOS) and 30-day global representation/readmission were evaluated. RESULTS: 130 patients were equally divided between the Sumatriptan and Control cohorts for analysis. No difference in baseline demographics was noted. A significant reduction of mean pain score at 6, 12 and 24-hours following surgery substantially favored the Sumatriptan cohort (p &lt; 0.05). Further, a nonsignificant reduction in opioid requirements was observed at all timepoints favoring the sumatriptan cohort (p &gt; 0.05). 30-day global ED evaluation and readmission rates between cohorts were similar (p &gt; 0.05). Overall LOS in the Sumatriptan and Control cohorts were 5.3 ± 3.6 vs 6.5 ± 5.6 days (p &gt; 0.05). No difference in the rate of incisional or intracerebral hemorrhage was noted between cohorts (p &gt; 0.05). CONCLUSIONS: In the present study, patients in the Sumatriptan cohort demonstrated enhanced pain control and reduced opioid requirements suggesting sumatriptan represents a safe and efficacious agent for the modulation of pain following open craniotomy.

The Effectiveness of Perioperative Parecoxib Intravenous Administration in Foot and Ankle Surgery: A Prospective, Double-Blinded, Randomized, Placebo-Controlled Trial

Category:Trauma; AnkleIntroduction/Purpose:Parecoxib is indicated for the short-term treatment of postoperative pain in adults. A systematic review assessed the analgesic efficacy of single dose intravenous (IV) or intramuscular (IM) parecoxib in acute postoperative pain and concluded that parecoxib is an effective analgesic in the postoperative setting in adults. However, little is known about its effectiveness in the perioperative intravenous administration in foot and ankle surgery. The present study conducts a double- blinded prospective randomized controlled trial via an 'intention-to-treat analysis' principle to compare the effectiveness of perioperative parecoxib versus placebo in patients with unstable ankle fractures who have surgical indications.Methods:A total of 40 patients undergoing open reduction and internal fixation of the unstable ankle fractures were randomly allocated either to Group A (parecoxib 40 mg IV 30 min before surgery and then an additional 40 mg every 12 hours for 48 hours after surgery [n=20]) or Group B (placebo (saline) [n=20]). The baseline data were recorded in each patient. The efficacy of pain control was assessed by total morphine used, pain intensity (at rest/ambulation) and pain relief (at rest/ambulation) using the verbal numerical rating score (VNRS) from 0 (no pain) to 10 (worst imaginable pain) and the verbal numerical rating percentage (VNRP) from 0 (no relief) to 100 (best relief) respectively, as well as each patient's subjective rating of the medication. The patients' subjective rating of the medication used the classifications of 'excellent', 'good', 'fair', or 'poor'. When the patients were moved to the post-anesthesia care unit (PACU) after surgery, the study procedure was to record the time as 0. The data were then recorded at 0, 4, 12, 24, and 48 hours after surgery by trained personnel. The overall adverse effects experienced by patients were reported in both groups. All outcomes were recorded by trained personnel who were blind to the patient group allocation. All surgeons, anesthesiologists, and patients involved in the process were also blind to the group allocations. The outcomes including efficacy, patients' subjective ratings of the medication, and overall adverse effects were statistically compared between the two groups.Results:From a total of 40 patients in the study, four patients were excluded by the study criteria. The remaining 36 patients continued in the study. The mean age of patients was 49.3 +/- 18.0 years. No significant difference was found regarding the mean age of patients between the two groups (p-value > 0.05). Male patients appeared more frequently in the saline group than the parecoxib group (p-value = 0.018). For the main outcomes, there were no significant differences between the two groups in terms of the pain intensity, pain relief, patients' subjective ratings of the medication at both preoperative and postoperative periods, total quantity of morphine used, and side effects and acute complications of surgery (p-values > 0.05).Conclusion:Based on the results of the present study, the perioperative administration of parecoxib could not significantly improve postoperative pain control as defined by the reduction in opioid requirements, lower pain scores, higher pain relief, and higher patients' subjective ratings of the medication when compared to the placebo. Male predominance was significantly found in the placebo group. This may have influenced the level of pain tolerance between the two groups. This may also affect the results as no significant differences of pain parameters between the two groups in the study. Further study with larger numbers of patients is still necessary to clarify the role of preemptive parecoxib on ankle fracture surgery.

Fascia iliaca block for hip fractures in the emergency department: meta-analysis with trial sequential analysis.

Fascia iliaca block (FICB) has been used to reduce pain and its impact on geriatric patients with hip fractures. We conducted this meta-analysis to investigate the analgesic efficacy of this block in comparison to standard of care (SOC) when performed by non-anesthesiologist in the emergency department. Search on PubMed, SCOPUS, EMBASE, Google Scholar and Cochrane database for randomized and quasi-randomized trials were performed. The primary outcome was to compare pain relief at rest at 2-4h. The pain relief at various time intervals, reduction in opioid use, the incidence of nausea/ vomiting, delirium and length of hospital stay were the secondary outcomes studied. Trial Sequential Analysis (TSA) was performed for the primary outcome. Eleven trials comprising 895 patients were included in the meta-analysis. Patients receiving FICB had significant better pain relief at rest at 2-4h with mean difference of 1.59 (95% CI, 0.59-2.59, p=0.002) with I2=96%. However, the certainty of the evidence was low and TSA showed that the sample size could not reach the requisite information size. A significant difference in pain relief at rest and on movement started within 30min and lasted till 4h of the block. Use of FICB was associated with a significant reduction in post-procedure parenteral opioid consumption, nausea and vomiting and length of hospital stay. FICB is associated with significant pain relief both at rest and on movement lasting up to 4h as well as a reduction in opioid requirement and associated nausea and vomiting in geriatric patients with hip fracture. However, the quality of evidence is low and additional trials are necessary.

Erector spinae plane block reduces pain after laparoscopic cholecystectomy.

After laparoscopic cholecystectomy patients have moderate pain in the early postoperative period. According to several studies an erector spinae plane (ESP) block can be avaluable part of multimodal analgesia. Our intention was to evaluate how ESP block influences postoperative pain scores and opioid consumption after laparoscopic cholecystectomy. This single-blinded, prospective, randomized study included 60patients undergoing laparoscopic cholecystectomy to receive either bilateral ESP block at the Th7 level (n = 30) with 20 ml of 0.25% levobupivacaine plus dexamethasone 2 mg per side, or standard multimodal analgesia (n = 30). Patients from the standard multimodal analgesia group received tramadol 100 mg at the end of the procedure. Postoperative analgesia for both groups was acetaminophen 1 g/8 h i.v. and ketorolac 30 mg/8 h. Tramadol 1 mg/kg was arescue treatment for pain breakthrough (numeric rating scale/NRS ≥ 6) in both groups. Pain at rest was recorded at 10 min, 30 min, 2 h, 4 h, 8 h, 12 h and 24 h after surgery using NRS (0-10). An ESP block significantly reduced postoperative pain scores compared to standard multimodal analgesia after 10 min (p = 0.011), 30 min (p = 0.004), 2 h (p = 0.011), 4 h (p = 0.003), 8 h (p = 0.013), 12 h (p = 0.004) and 24 h (p = 0.005). Tramadol consumption was significantly lower in the ESP group 25.02 ± 56.8g than in the standard analgesia group 208.3 ± 88.1g (p < 0.001). An ESP block can provide superior postoperative analgesia and reduction in opioid requirement after laparoscopic cholecystectomy.

Development of a Structured Regional Analgesia Program for Postoperative Pain Management.

We pursued the use of regional analgesia (RA) to minimize the use of postoperative opioids. Our aim was to increase the use of postoperative RA for eligible surgical procedures in the NICU from 0% to 80% by June 30, 2019. A multidisciplinary team determined the eligibility criteria, developed an extensive process map, implemented comprehensive education, and a structured process for communication of postoperative pain management plans. Daily pain team rounds provided an opportunity for collaborative comanagement. An additional 30 minutes for catheter placement was added in operating room (OR) scheduling so that it would not affect the surgeon OR time. There were 21 eligible surgeries in the baseline period and 34 in the intervention period. In total, 30 of 34 infants in eligible surgeries (88%) received RA. The average total opioid exposure in intravenous morphine milligram equivalents decreased from 5.0 to 1.1 mg/kg in the intervention group. The average time to extubation was 45 hours in the baseline period and 19.9 hours in the intervention group. After interventions, 75% of infants were extubated in the OR, as compared with 10.5% in the baseline period. No difference was seen in postoperative pain scores or postoperative hypothermia between the baseline and intervention groups. We used quality improvement methodology to develop a structured RA program. We demonstrated a significant reduction in opioid requirements and need for mechanical ventilation postoperatively for those infants who received RA. Our findings support safe and effective use of RA, and provide a framework for implementation of a similar program.

Assessment of Analgesic Efficacy of Bilateral Superficial Cervical Plexus Block for Thyroid Surgeries under General Anaesthesia: A Routine Data Based Observational Study

Context: Thyroid surgeries done under general anaesthesia use intravenous (iv) drugs as analgesics. A simple superficial cervical plexus block can reduce dose of iv analgesics and provide excellent analgesia. This study evaluated the analgesic efficacy of ultrasound guided Bilateral Superficial Cervical Plexus Block (BSCPB) in thyroidectomies and its opioid sparing effect. Aim: Evaluation of analgesic efficacy of BSCPB and its opioid sparing effect in thyroidectomies. Settings and Design: Routine data based observational study conducted during March 2017 to January 2018 in a tertiary cancer institute in South India. Materials and methods: The study involved fifty adult ASA I and II patients who received BSCPB with 0.5% ropivacaine 10 ml for thyroidectomies along with general anaesthesia and fifty patients without BSCPB from routine database. Postoperative pain scores for 24 hours were compared and reduction in opioid requirement in BSCPB group was analysed. Statistical analysis: Statistical analysis was done using Statistical package for social sciences package 11 software (SPSS Inc, Chicago). Quantitative data was analysed with Student’s t test and categorical data with chi-square test. Friedman two-way ANOVA was used to test significance of pain at different times in BSCPB group. Mann Whitney U test was used to compare pain score between the two groups. Results: There was statistically significant reduction in postoperative pain in the BSCPB group (p=0.0001). The total opioid requirement showed a statistically significant reduction in the BSCPB group (mean ± SD 2.6 ± 2 vs. 6.6 ± 1). Conclusion: BSCPB provides excellent analgesia with a reduction in opioid consumption following thyroidectomies.

Opioid Requirements in Laparoscopic Colectomies: Do Enhanced Recovery After Surgery Protocols Make a Difference?

With the growing opioid epidemic and recent focus on the quantity of opioids prescribed at discharge after surgery, enhanced recovery pathways provide another tool to counteract this epidemic. The aim of this current study is to analyze the differences in opioid requirements and pain scores in the immediate postoperative period for patients who underwent laparoscopic colectomies before and after the implementation of enhanced recovery after surgery (ERAS) protocols. This study is a retrospective review of patients and was conducted at an academically affiliated tertiary care hospital. In patients undergoing elective laparoscopic colectomies before December 1, 2013-July 31, 2015 and after September 1, 2015-May 31, 2018, the implementation of enhanced recovery pathways was included. The primary end point was opioid consumption from the end of surgery until 48hours after surgery. Secondary end points included pain scores, surgery length of time, and hospital length of stay after surgery. A total of 242 patients (122 pre- and 120 postimplementation) were analyzed. Patient characteristics were similar between groups. Pain scores were higher in the preimplementation patients for postoperative day (POD) 0 scores (P = .019). There was a decrease in the morphine milligram equivalents (MME) on POD 0-2 for the postimplementation patients. This decrease resulted in a 61% reduction in opioid requirements after implementation of ERAS protocols (32 vs. 12.5 MME, P < .0001). Enhanced recovery after surgery protocols can reduce opioid requirements after elective laparoscopic colectomies without negatively affecting pain scores.

Efficacy of liposomal bupivacaine vs. traditional anaesthetic infiltration for pain management in total hip arthroplasty: a systematic review and meta-analysis.

In this review, we assess the effectiveness of liposomal bupivacaine against the traditional bupivacaine infiltration in the postoperative management of total hip arthroplasty (THA). Various databases including PubMed Central, Medline, Scopus, Embase, Google Scholar, Cochrane library and ScienceDirect (inception date till August 2020) were searched. The quality of published trials was assessed using Cochrane risk of bias tool, and a random-effects model was used for meta-analysis. We report pooled Risk ratios (RR) or pooled Standardized Mean difference (SMD) with 95% confidence intervals (CIs). We analyzed a total of 13 studies with 62,582 participants. The majority of the studies were retrospective with lower bias risks. Liposomal bupivacaine was significantly associated with the reduction in opioid requirement at 48 hours (SMD = -0.25; 95% CI: -0.40 to -0.09; p=0.002) and length of hospital stay (SMD = -0.25; 95% CI: -0.43 to -0.07, p=0.006) following THA compared with the control group. However, there was no statistically significant difference between the effect of liposomal bupivacaine and other agents for pain score (24 and 48 hours), opioid requirement at 24 hours and incidence of nausea. Liposomal bupivacaine has selective benefits in terms of opioid consumption and length of hospital stay against the traditional bupivacaine among the patients undergoing THA.

Influence of psychiatric disorders and chronic pain on the surgical outcome in the patient with chronic coccydynia: a single institution’s experience

ABSTRACT Objective Performing coccygectomy procedures on patients with psychiatric disorders and/or chronic low back pain have been previously thought of as contributing factors leading to inconsistent and often poor results. To determine if these two variables affect the post-operative pain relief obtained after coccygectomy, an analysis of the opioid requirements and pain descriptions before and after surgery was undertaken in each patient studied. Methods The hospital electronic medical records were searched, and only patients undergoing coccygectomy for chronic coccydynia were selected. A total of 8 patients were found. Each patient underwent a trial of conservative therapy prior to surgical evaluation. Results The average duration of symptoms prior to surgery was 41.3 months. In 7 out of 8 patients, at least one psychiatric disorder was present. In 6 out of 8 patients, chronic low back pain was present. Pain control with opioid-based medicines was required in 5 out of 8 patients prior to surgery. Of those, 4 were able to discontinue or reduce the amount of opioid-based medicines consumed after surgery. The average follow-up was 9 months. Discussion The results of this study indicate that patients with preexisting psychiatric disorders and/or chronic low back pain suffering from debilitating coccyx pain can obtain pain relief after coccygectomy as seen from a reduction in opioid requirements and pain burden. It should be noted that the obtained benefits from coccygectomy usually occur in a delayed fashion.

No Pain, More Gain: Reduced Postoperative Opioid Consumption with a Standardized Opioid-Sparing Multimodal Analgesia Protocol in Opioid-Tolerant Patients Undergoing Colorectal Surgery

The utility of opioid-sparing multimodal analgesia protocols (OSMMAPs) in opioid-tolerant (OT) patients is unknown. We sought to determine the impact of a standardized OSMMAP in OT versus opioid-naïve (ON) patients after major colorectal surgery. Consecutive patients undergoing surgery before (January 2015-March 2017) and after OSMMAP implementation (April 2017-March 2018) were identified from a single-institution prospective colorectal surgery registry. OT was defined by the presence of an opioid on the preadmission medication record. Opioid use (measured in oral morphine equivalents (OMEs)) and surgical outcomes were compared between OT and ON patients pre- and post-OSMMAP. The study cohort of 201 patients included 59 OT patients (25 pre- and 34 post-OSMMAP) and 142 ON controls (34 pre- and 108 post-OSMMAP). The median age was 47.5 years (IQR 32), and 50% were male. 185 patients (92%) had a laparoscopic/robotic resection and 16 (8%) open. There were statistically significant reductions in OME required post-OSMMAP on each postoperative day (days 1 to 4) and cumulative OME for both OT and ON patients. The reduction in opioid requirements was significantly larger in OT than ON patients. We present the first study highlighting a larger opioid usage reduction in OT than in ON patients after OSMMAP implementation.

Efficacy and safety of topical capsaicin for cannabinoid hyperemesis syndrome in the emergency department

Introduction: Cannabinoid hyperemesis syndrome (CHS) is a disorder of cyclic and recurrent nausea, vomiting, and abdominal pain associated with high-frequency and extended-duration marijuana use. Standard antiemetic therapy is often ineffective; however, capsaicin, an agonist of transient receptor potential vanilloid 1 (TRPV1), has shown promise in treating CHS.Methods: This retrospective cohort analysis evaluated the safety and efficacy of topical capsaicin for patients presenting with CHS. The primary outcome was to assess if utilization of capsaicin for ED management of CHS decreased ED length of stay (LOS) as compared to a visit without capsaicin. Secondary outcomes included a cost analysis, use of rescue therapies, and adverse events.Results: Forty-three patients met the inclusion criteria within the study period. ED LOS was reduced with capsaicin by a median of 22 minutes (201 vs. 179 min, p = 0.33). Patients received fewer additional medications if capsaicin was utilized (4 vs. 3 doses, p = 0.015), and 67% of visits where capsaicin was utilized required no further treatment prior to discharge. Additionally, opioid usage was less when utilizing capsaicin (166.5 vs. 69 mg OME). Forty-two percent of patients did not have a repeat CHS presentation to the ED after receiving capsaicin for an additional three months after the study period ended. Total medication cost was minimally more expensive (median difference of $3.26) in the capsaicin group. There were no significant adverse events reported with capsaicin.Conclusion: There was no significant difference in ED LOS when capsaicin was utilized for CHS. However, there was a decrease in total medications administered and a reduction in opioid requirements. While medication costs for capsaicin visits were minimally more expensive, the utility of capsaicin as an over-the-counter (OTC) product may empower at home therapy with OTC products, decreasing potentially unnecessary healthcare encounters and costs.

61. Multi-modal analgesia protocol significantly decreased opioid requirements following lumbar spine surgery: results from a feasibility trial

BACKGROUND CONTEXT Over the past decade, opioid use in the United States has increased rapidly. However, patient satisfaction with pain management has not improved. Instead, with growing number of overdose deaths, over- and misuse of opioids has been declared a public health crisis. Patients presenting for lumbar spine surgery frequently present with pain related to their spine condition, are frequently consuming opioids to treat this pain and, following surgery, this is exacerbated due to disruption of skin, muscle tissue, vertebrae, intervertebral discs, and facet joints. Proper pain management is necessary to reduce pain-related and medication side effects and to promote recovery. While this pain is often treated with opioids, roughly 40% of patient experience suboptimal pain management. Multimodal pain management strategies have been proposed to (1) control preoperative pain; (2) employ nonopioid medication to pre-empt surgical pain; and (3) monitor and control pain intensity before and after surgery. PURPOSE We provide critical evidence that a multi-modal pain management plan for patients undergoing lumbar spine surgery leads to reduction in opioid requirements following surgery and superior pain relief. STUDY DESIGN/SETTING A randomized clinical trial to determine feasibility of comparing two pain management plans. Multimodal Pain Management (MPM): acetaminophen plus gabapentin in the preparation area prior to surgery; preinduction opioid titration with fentanyl until pain is relieved and/or respiratory depression ensues; volatile anesthetic, intravenous ketamine and nitrous oxide during surgery; acetaminophen, valium plus gabapentin during hospitalization; and prescription for acetaminophen, valium plus gabapentin at discharge. Standard postoperative analgesia (SPA) is a protocol directed and clinically appropriate for postoperative analgesia. In this study, standard postoperative analgesia is defined as: oxygen, fentanyl, hydromorphone preceded by an intraoperative general anesthetic of propofol and remifentanil which is often recommended to facilitate intraoperative monitoring (IOM). PATIENT SAMPLE We enrolled 51 participants (2 canceled surgery) and randomized 49 (24 MPM; 25 SPA). Patient sample was 63% white, 55% female, and 60% over the age of 65 years. A majority of patients underwent fusion procedures (70%). There were no demographic or clinical differences between groups. OUTCOME MEASURES The primary outcome measures were postoperative pain scores and analgesic use. METHODS Postoperative pain score (numeric rating scale, 0-10) and narcotic use (total morphine equivalent units [TME] in milligrams) were compared between groups in the post-anesthesia care unit (PACU), postoperative day (POD) 0, POD 1, and following discharge (tablets used). RESULTS Patients in MPM had significantly lower mean pain rating in the PACU, POD 0, and POD 1 compared to SPA (4.1 vs 8.3; 2.7 vs 5.1; and 2.3 vs 4.2; p CONCLUSIONS In our feasibility trial, we were able to demonstrate that patients in MPM experienced significantly less pain following surgery and required less opioid in hospital compared to patients in SPA. These patients may also use less opioid following discharge. It may be important that the intraoperative anesthetic SPA group is typically what is recommended for patients undergoing IOM. A larger, multicenter trial is needed to further examine the impact of MPM on patient outcomes beyond pain and on postoperative opioid use. FDA DEVICE/DRUG STATUS fentanyl (Approved for this indication), acetaminophen (Approved for this indication), valium (Approved for this indication), gabapentin (Approved for this indication), propofol (Approved for this indication), hydromorphone (Approved for this indication), remifentanil (Approved for this indication).

Cognitive Effects of Perioperative Pregabalin: Secondary Exploratory Analysis of a Randomized Placebo-controlled Study.

Pregabalin has shown opioid sparing and analgesic effects in the early postoperative period; however, perioperative effects on cognition have not been studied. A randomized, parallel group, placebo-controlled investigation in 80 donor nephrectomy patients was previously performed that evaluated the analgesic, opioid-sparing, and antihyperalgesic effects of pregabalin. This article describes a secondary exploratory analysis that tested the hypothesis that pregabalin would impair cognitive function compared to placebo. Eighty patients scheduled for donor nephrectomy participated in this randomized, placebo-controlled study. Pregabalin (150 mg twice daily, n = 40) or placebo (n = 40) was administered on the day of surgery and the first postoperative day, in addition to a pain regimen consisting of opioids, steroids, local anesthetics, and acetaminophen. Specific cognitive tests measuring inhibition, sustained attention, psychomotor speed, visual memory, and strategy were performed at baseline, 24 h, and 3 to 5 days after surgery, using tests from the Cambridge Neuropsychological Test Automated Battery. In the spatial working memory within errors test, the number of errors increased with pregabalin compared to placebo 24 h after surgery; median (25th, 75th percentile) values were 1 (0, 6) versus 0 (0, 1; rate ratio [95% CI], 3.20 [1.55 to 6.62]; P = 0.002). Furthermore, pregabalin significantly increased the number of errors in the stop-signal task stop-go test compared with placebo; median (25th, 75th percentile) values were 3 (1, 6) versus 1 (0, 2; rate ratio, 2.14 [1.13 to 4.07]; P = 0.020). There were no significant differences between groups in the paired associated learning, reaction time, rapid visual processing, or spatial working memory strategy tests. Perioperative pregabalin significantly negatively affected subdomains of executive functioning, including inhibition, and working memory compared to placebo, whereas psychomotor speed was not changed.

Can postoperative massage therapy reduce pain and anxiety in cardiac surgery patients?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, 'In patients undergoing cardiac surgery, is postoperative massage therapy effective in reducing pain, anxiety and physiological parameters?' Altogether, 287 papers were found using the reported search, of which 7 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and the results of these papers are tabulated. The specific therapy protocols widely varied between studies, with differences in frequency, specific timing in the postoperative period, techniques used and experience of therapy provider. These variations limit the generalization and transferability of the conclusions. The effect of massage therapy on anxiety levels was reported in 5 studies. All but one demonstrated a significant improvement in anxiety. Pain was also reported in 5 studies, with significant improvement demonstrated in 4 studies. Importantly, a number of these studies failed to report on analgesic requirements nor demonstrate a reduction in opioid requirements, thus limiting the validity of the drawn conclusions. There is significant heterogeneity in randomized trials reporting on the effects of massage therapy. Although there is evidence to suggest that massage therapy reduces pain and anxiety following cardiac surgery, there are often caveats to the conclusions drawn with other studies reporting no significant difference. Therefore, in light of this, it would not be logical to recommend massage therapy as an effective therapy. There is no current evidence to suggest that massage therapy improves physiological parameters, including the onset of atrial fibrillation postoperatively.

Reducing opioid utilization after urologic oncology surgery.

269 Background: Multiple sources have reported on widespread abuse of opioid pain medications among Americans. For many patients, the first encounter with these addictive substances happens when they are prescribed opioids for acute pain management after surgery. Unfortunately, 6% of opioid-naïve patients become newly addicted to opioid medications after surgery. As a high-volume surgical department, we aimed to reduce our reliance on opioid medications to manage post-operative pain by 50% from a baseline morphine equivalent daily dose (MEDD) of 95.1 to a target of 47.5 MEDD. Methods: We retrospectively reviewed daily opioid use, pain scores, and anxiety scores for inpatients recovering from surgery for urologic cancers at our institution over 4 months. We generated process maps, Ishikawa diagrams, and Pareto charts to identify causes contributing to excess opioid use. We designed opioid-sparing pain regimens (using varying combinations of acetaminophen, ketorolac, gabapentin, and local anesthetic) and we identified key drivers required to reliably decrease excess opioid use. Initial interventions were aimed at educating providers and nurses on availability and efficacy of non-opioid medications and later interventions sought to facilitate adoption of the novel pathways. Results: Over the course of this QI project involving 443 patients, the median opioid use per patient decreased 46% from 95.1 to 51.5 MEDD. This reduction in opioid requirements after implementation was successfully achieved across multiple surgery types ranging from robotic prostatectomy (55.1 MEDD) to open radical cystectomy (50.6 MEDD). There was no increase in 24- or 48-hour post-operative pain score associated with use of opioid-minimizing pathways (3.03 vs. 3.04 and 2.92 vs. 2.96, respectively; p &gt; 0.05 for both). Similarly, there was no change in anxiety score at 24- or 48-hours after surgery (0.15 vs. 0.12 and 0.48 vs. 0.30, respectively; p &gt; 0.05 for both). Conclusions: We decreased opioid use after surgery by 46% without compromising pain control. In the nationwide effort to combat the opioid epidemic, health care providers can play a pivotal role as gatekeepers by decreasing reliance on opioids in the post-operative period.

Subcostal transversus abdominis plane block can improve analgesia after laparoscopic cholecystectomy

After laparoscopic cholecystectomy, patients have moderate pain in the early postoperative period. Some studies shown beneficial effects of subcostal transversus abdominis plane block on reducing this pain. Our goal was to investigate influence of subcostal transversus abdominis plane block on postoperative pain scores and opioid consumption. We have randomized 76 patients undergoing laparoscopic cholecystectomy to receive either subcostal transversus abdominis plane block (n=38) or standard postoperative analgesia (n=38). First group received bilateral ultrasound guided subcostal transversus abdominis plane block with 20mL of 0.33% bupivacaine per side before operation and tramadol 1mg.kg-1IV for pain breakthrough (≥6). Second group received after operation tramadol 1mg.kg-1/6h as standard hospital analgesia protocol. Both groups received acetaminophen 1g/8h IV and metamizole 2.5g/12h. Pain at rest was recorded for each patient using NR scale (0-10) in period of 10min, 30min, 2h, 4h, 8h, 12h and 16h after the surgery. We obtained no difference between groups according age, weight, intraoperative fentanyl consumption and duration of surgery. Subcostal transversus abdominis plane block significantly reduced postoperative pain scores compared to standard analgesia in all periods after surgery. Tramadol consumption was significantly lower in the subcostal transversus abdominis plane (24.29±47.54g) than in the standard analgesia group (270.2±81.9g) (p=0.000). Our results show that subcostal transversus abdominis plane block can provide superior postoperative analgesia and reduction in opioid requirements after laparoscopic cholecystectomy.

Local anesthetics for brain tumor resection: current perspectives.

This review summarizes the added value of local anesthetics in patients undergoing craniotomy for brain tumor resection, which is a procedure that is carried out frequently in neurosurgical practice. The procedure can be carried out under general anesthesia, sedation with local anesthesia or under local anesthesia only. Literature shows a large variation in the postoperative pain intensity ranging from no postoperative analgesia requirement in two-thirds of the patients up to a rate of 96% of the patients suffering from severe postoperative pain. The only identified causative factor predicting higher postoperative pain scores is infratentorial surgery. Postoperative analgesia can be achieved with multimodal pain management where local anesthesia is associated with lower postoperative pain intensity, reduction in opioid requirement and prevention of development of chronic pain. In awake craniotomy patients, sufficient local anesthesia is a cornerstone of the procedure. An awake craniotomy and brain tumor resection can be carried out completely under local anesthesia only. However, the use of sedative drugs is common to improve patient comfort during craniotomy and closure. Local anesthesia for craniotomy can be performed by directly blocking the six different nerves that provide the sensory innervation of the scalp, or by local infiltration of the surgical site and the placement of the pins of the Mayfield clamp. Direct nerve block has potential complications and pitfalls and is technically more challenging, but mostly requires lower total doses of the local anesthetics than the doses required in surgical-site infiltration. Due to a lack of comparative studies, there is no evidence showing superiority of one technique versus the other. Besides the use of other local anesthetics for analgesia, intravenous lidocaine administration has proven to be a safe and effective method in the prevention of coughing during emergence from general anesthesia and extubation, which is especially appreciated after brain tumor resection.

Subcostal transversus abdominis plane block can improve analgesia after laparoscopic cholecystectomy

Background and goal of studyAfter laparoscopic cholecystectomy, patients have moderate pain in the early postoperative period. Some studies shown beneficial effects of subcostal transversus abdominis plane block on reducing this pain. Our goal was to investigate influence of subcostal transversus abdominis plane block on postoperative pain scores and opioid consumption. Materials and methodsWe have randomized 76 patients undergoing laparoscopic cholecystectomy to receive either subcostal transversus abdominis plane block (n=38) or standard postoperative analgesia (n=38). First group received bilateral ultrasound guided subcostal transversus abdominis plane block with 20mL of 0.33% bupivacaine per side before operation and tramadol 1mg.kg−1 IV for pain breakthrough (≥6). Second group received after operation tramadol 1mg.kg−1/6h as standard hospital analgesia protocol. Both groups received acetaminophen 1g/8h IV and metamizole 2.5g/12h. Pain at rest was recorded for each patient using NR scale (0–10) in period of 10min, 30min, 2h, 4h, 8h, 12h and 16h after the surgery. Results and discussionWe obtained no difference between groups according age, weight, intraoperative fentanyl consumption and duration of surgery. Subcostal transversus abdominis plane block significantly reduced postoperative pain scores compared to standard analgesia in all periods after surgery. Tramadol consumption was significantly lower in the subcostal transversus abdominis plane (24.29±47.54g) than in the standard analgesia group (270.2±81.9g) (p=0.000). ConclusionOur results show that subcostal transversus abdominis plane block can provide superior postoperative analgesia and reduction in opioid requirements after laparoscopic cholecystectomy.