Acute Pain Relief Research Articles

Effects of a novel acetaminophen (APAP) analog on survival time after extremity trauma and moderate or severe conscious hemorrhage in rats

Background: Multiple analgesics are used for acute pain relief following trauma in both the military and civilian settings. However, in addition to their ability to relieve pain, medical providers must also be concerned about secondary effects of the analgesics, especially effects on the cardiovascular and respiratory systems when the pain of trauma is associated with hemorrhage. Kalyra Pharmaceuticals has developed novel analogs of APAP to circumvent liver toxicity and improve analgesic efficacy. These analogs have the potential to replace opioids for severe pain while minimizing adverse effects. The objective of this study is to test a pain-reducing dose of D-112, an APAP analog, for its effects on survival to hemorrhage after extremity trauma (ET). We hypothesize that D-112 will not affect survival after either moderate or severe hemorrhage. Methods: Male Rats (~360 grams) were randomly assigned to receive either 0.9% saline (V) or 50 mg/kg D-112 (D) after either ~37% or ~50% of blood volume hemorrhage. All rats were surgically implanted with a carotid catheter under anesthesia. Carotid catheters were used for blood withdrawal and for injection of V or D. 24 hrs later, rats were briefly (~10 min) anesthetized again and ET consisting of soft tissue injury (crushing of the right gastrocnemius and semimembranosus muscles for 30 sec with forceps) and fibula fracture was performed. After completion of ET, rats were allowed to recover. 90 min after ET, rats underwent a conscious hemorrhage via the indwelling catheter. At the end of hemorrhage, rats received either V or D via the carotid catheter. Rats were observed for a maximum of 4 hrs after the start of the 25 min hemorrhage. Results: Survival after hemorrhage was recorded in the 4 groups: V-37% (n=13), D-37% (n=11), V-50% (n=10), D-50% (n=11). The survival proportions at 240 min were 92.3% for V-37%, 81.8% for D-37%, 60.0% for V-50%, and 18.1% for D-50%. While there was no significant difference in the survival curves of V-37% and D-37%, the survival curves of V-50% and D-50% were significantly different ( p = 0.036). Conclusions: The analgesic dose of D-112 tested decreased survival after ET and severe hemorrhage (~50% of blood volume), but not after ET and moderate hemorrhage (~37%). These results suggest that D-112 may not be an appropriate analgesic following traumatic hemorrhage. Applied Pain Research Program, US Army Clinical and Rehabilitative Medicine/Joint Program Committee 8, and US Army Combat Casualty Care Research Program, US Army Medical Research and Development Command. This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

A systematic review of sufentanil for the management of adults with acute pain in the emergency department and pre-hospital setting

BackgroundPain is commonly encountered in the Emergency Department (ED) and pre-hospital setting and often requires opioid analgesia. We sought to synthesize the available evidence on the effectiveness of sufentanil for acute pain relief for adult patients in the pre-hospital or ED setting. MethodsThis systematic review was conducted in accordance with PRISMA guidelines. Medline, Embase, Cochrane CENTRAL, and CINAHL were searched from inception to February 1, 2022. The grey literature was also searched. We included randomized controlled trials of adult patients with acute pain who were treated with sufentanil. Two reviewers independently completed screening, full text review, and data extraction. Primary outcome was reduction in pain. Secondary outcomes included adverse events, need for rescue analgesia, and patient and provider satisfaction. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. A meta-analysis was not performed due to heterogeneity. ResultsOf 1120 unique citations, four studies (3 ED and 1 pre-hospital) met full inclusion criteria (n = 467 participants). The overall quality of the included studies was high. Intranasal (IN) sufentanil was superior to placebo for pain relief at 30 min (difference 20.8%, 95% CI 4.0–36.2%, p = 0.01). Both IN (two studies) and IV sufentanil (one study) were comparable to IV morphine. Mild adverse events were common and there was a higher propensity for minor sedation in patients receiving sufentanil. There were no serious adverse events requiring advanced interventions. ConclusionSufentanil was comparable to IV morphine and was superior to placebo for rapid relief of acute pain in the ED setting. The safety profile of sufentanil is similar to IV morphine in this setting, with minimal concern for serious adverse events. The intranasal formulation may provide an alternative, rapid, non-parenteral route that could benefit our unique emergency department and pre-hospital patient population. Due to the overall small sample size of this review, larger studies are required to confirm safety.

Effect of massage made with aromatherapy oil after mastectomy on acute arm pain and anxiety: a randomized controlled study protocol

Background: This article summarizes the study protocol currently used to evaluate the efficacy of aromatherapy massage for the relief of post-mastectomy anxiety and acute arm pain. Methods: It is a prospective interventional type three-group, randomized controlled, drug-free clinical trial. Eligible patients will be randomly assigned to one of three groups. The population of the study will consist of 90 patients who have undergone simple mastectomy (SM) and modified radical mastectomy (MRM) in the general surgery ward of a training and research hospital in Turkey. After the operation, the arm on the operated side will be massaged with sesame oil in the first group (n=30), sesame-lavender oil in the second group (n=30), and paraffin oil in the third group (n=30). Conclusions: The primary outcome is the level of acute arm pain and the level of state anxiety. The secondary outcome is vital signs and analgesic use status. Trial registration: International standard randomized controlled trial number NCT05658367.

The Effectiveness of Ketamine Versus Opioids in Patients With Acute Pain in the Emergency Department: A Systematic Review and Meta-Analysis.

Opioids arethe mainstay of treatment for acute pain in the emergency department. However, its misuse led to the investigation of alternative effective analgesic options for acute pain complaints such as ketamine. Therefore, this systematic review and meta-analysis aimed to determine the effectiveness of ketamine in comparison to opioids in the management of acute pain. This was a systematic review and meta-analysis of randomized controlled trials comparing ketamine to opioids for the relief of acute pain in the ED. Eligible studies were identified by searching the following electronic databases: Medline, Embase, and Central. Studies utilizing either the visual analog scale (VAS) or the numeric rating scale (NRS) for pain scoring in ketamine vs opioids were included. The revised Cochrane risk-of-bias tool for randomized trials was utilized. A random-effects model was performed, and all outcomes were pooled by the inverse variance weighting method.The total number of studies that met the criteria of systematic reviews was nine of which seven of them were included in the meta-analysis with 789 participants. The overall effect of NRS trials was the standardized mean difference (SMD) = -0.07, 95% confidence interval (CI)-0.31 to 0.17, P-value = 0.56,I2=85%.While VAS trials showed an overall effect of SMD =-0.02, 95% CI -0.22 to 0.18, P = 0.84,I2= 59%). Moreover, higher adverse events were reported in opioids; however, this was not statistically significant (SMD = 1.23, 95% CI 0.93-1.64, P = 0.15, I2 =38%). Ketamine for immediate pain relief at 15 minutes could be an effective alternative to opioids, but its overall effect in comparison to opioids for improving the pain has not shown a statistically significant difference. There was high heterogeneity in the included studies; thus, a sub-group analysis was performed.

DENTAL USE OF KETOROLAC TROMETHAMINE: STATUS AND FUTURE PERSPECTIVES

The history of evidence-based use of non-steroidal anti-inflammatory drugs (NSAIDs) goes back at least two hundred and fifty years. Over the past period, the path has been passed from the use of willow bark decoctions to the synthesis and introduction of selective cyclooxygenase inhibitors into clinical practice. To date, the research direction has shifted from the search for new substances to the search for new routes of administration. The wide range of existing drug substances, however, has only in a few dosage forms. Thus, ketorolac tromethamine is known only as a solution for parenteral and intranasal administration, as well as oral tablets. This drug belongs to NSAIDs, particularly non-selective cyclooxygenase inhibitors, and shows a pronounced analgesic activity. Due to this property, ketorolac can serve as an alternative to opioid analgesics or can reduce the dosage of the latter when used in combination. However, a number of systemic side effects (ulcerogenic properties, negative effect on the blood), unfortunately, impose their limitations. A possible solution to this situation may be the creation of local delivery systems, in particular, in situ implants. This review highlights the problem of developing local systems for the delivery of ketorolac tromethamine for the relief of acute pain. Special attention is paid to in situ implants based on bioadhesive polymers.

Transversus Abdominis Plane (TAP) Steroid Block for Chronic Abdominal Pain Caused by Chronic Postoperative Pain

Introduction: Various factors including surgical, psychological, amount of acute pain relief have been proposed as risk factors for developing CPSP. Different treatment modalities like nerve and plane blocks, psychiatric counselling have been described to counter this pain.
 Case: The patient was a 30-year-old female with complaints of severe pain in the right lower quadrant of the abdomen and found a surgical scar with hyperalgesia and a history of open appendicectomy surgery, two times section caesarean section surgery. The patient experienced pain after section caesarean section surgery 6 months ago. Because the pain was also felt in the right hypochondrium, the patient was unable to move his body, unable to sit and stand. The patient was diagnosed as a case of chronic post surgical pain syndrome (CPSP). We performed transversus abdominis plane block (TAP) with ultrasound guidance and lidocaine 15 ml combined with 40mg methylprednisolone. VAS scores showed significant improvement from 8/10 and 2/10 during the 10-day follow-up. We conclude that ultrasound-guided TAP block can be a treatment option for CPSP cases.
 Conclusion: Chronic post surgical pain (CPSP) is a definite clinical entity after laparatomy. We report a successful management of such a case with ultrasound guided transversus abdominis plane block. The patient had very significant pain relief after procedure follow up continue until today without any side effects.

Characteristics, completion and publication of PROSPERO records in regional anesthesia for acute perioperative pain.

Aim: We analyzed characteristics and completion status of Systematic Reviews (SRs) about regional anesthesia for acute perioperative pain relief registered in PROSPERO. Materials & methods: PROSPERO was searched on 5January2022. Characteristics of PROSPERO records, completion status and publication information were extracted. PubMed and Google Scholar were searched by 31May2022, for additional published SRs. The inconsistency of PROSPERO records' status was analyzed by comparing the most recent PROSPERO status with subsequent publication of completed SR. Time-to-publication was calculated. Results: Almost half of 174 included PROSPERO records (49%) were registered in 2021. A median of 3 (IQR: 2-4.75) authors, and a search of 4 information sources (IQR: 3-5) was planned. At first registration, 51 (29%) records had already started or completed formal screening. PROSPERO records included mostly adults (48%) undergoing trunk blocks (56%), with pain intensity (74%) as a main outcome. 147(84%) PROSPERO records had a status "ongoing". Yet, 71 (41%) PROSPERO records were completed SRs, published after a median of 291days. Inconsistency in status was found in 34% of PROSPERO records. Conclusion: Despite an increase in PROSPERO registrations about regional anesthesia, most were not published, and a third had inaccurate status.

Online education for safer opioid prescribing in hospitals-lessons learnt from the Opioid Use Change (OUCh) project.

Opioids are often required for acute inpatient pain relief but lack of knowledge about common and less common long-term side effects can lead to inappropriate discharge prescribing. There are few validated educational tools available for junior prescribers on hospital wards. Education around opioid prescribing and deprescribing remains limited in the undergraduate curriculum and yet almost all controlled drug prescribing in hospitals is done by junior doctors. A 5-minute video was developed with iterative feedback from medical students, junior prescribers, pain specialists, primary care educational leads, and a patient who had developed opioid addiction after hospital prescribing. It explained the need for clear stop dates on discharge summaries and the range of opioid side effects. It also highlighted the hospital admission as an opportunity to reduce inappropriate high-dose opioids. A short knowledge-based quiz before and after viewing the video was used to evaluate the impact on and change in knowledge and confidence around opioid prescribing. This tool was designed to be used entirely online to allow delivery within existing mandatory training. Feedback was positive and showed that knowledge of side effects significantly increased but also contacts with ward pharmacists and the acute pain team increased. Junior doctors highlighted that the undergraduate curriculum did little to prepare them for prescription addiction and that pharmacy and senior support was needed to support any changes in longer-term, high-dose opioids. This short educational video improved knowledge of safe opioid prescribing and could be incorporated within wider opioid education in UK healthcare.

Management of stenosing flexor tenosynovitis in primary care.

Management of stenosing flexor tenosynovitis in primary care.

Dry needling for the treatment of acute myofascial pain syndrome in general practitioners’ clinics: a cohort study

BackgroundMusculoskeletal pain is one of the leading complaints in the ambulatory setting. There are many ways to treat it, including pharmacologic and non-pharmacologic approaches. Dry needling (DN) is an option that is easy to learn, cheap and has a good safety profile. The aim of this study was to assess the association between DN performed by GPs for acute myofascial pain syndrome (MPS) and pain relief and to evaluate factors associated with treatment success.MethodsIn this prospective cohort study, two GPs performed DN in their clinics. Patients were asked to rank their pain using the Short-Form McGill Pain Questionnaire (SF-MPQ) before, 10-min and 1-week after the procedure. The SF-MPQ index consists of 3 parts; visual analog scale (VAS), pain rating index (PRI) and present pain intensity (PPI).Logistic regressions were performed to assess the variables associated with short- and medium- term success.ResultsFifty two patients were recruited from September 2019 until August 2020. VAS was 6.0 ± 2.3 (before), 4.1 ± 2.5 (10-min after) and 2.6 ± 2.71 (1-week after), P < 0.05. PRI was 17 ± 9.1 (before), 10.8 ± 8.5 (10-min after) and 5.1 ± 6.5 (1-week after), P < 0.05. PPI was 2.6 ± 1.0 (before), 1.7 ± 1.0 (10-min after) and 1.1 ± 1.2 (1-week after), P < 0.05.Short-term success was associated with the physician who performed the procedure (OR 10.08, 95% CI 1.15,88.4) and with the use of a single needle (vs. multiple needles inserted) (OR 4.55, 95% CI 1.03,20.11). Medium-term success was associated with being a native born (non-immigrant), OR 8.59, 95% CI 1.11,66.28 and with high level of initial pain, OR 11.22, 95% CI 1.82,69.27.ConclusionOur study demonstrated improvement in acute pain 10-min and 1-week after DN performed by a GP, in all parts of the SF-MPQ. Therefore, we believe DN is a good therapeutic option for GPs to aid patients suffering from MPS.

CSF neuron-specific enolase as a biomarker of neurovascular conflict severity in drug-resistant trigeminal neuralgia: a prospective study in patients submitted to microvascular decompression.

Although neurovascular conflict (NVC) is the most widely accepted cause of trigeminal neuralgia (TN), few articles have analyzed molecular and biochemical mechanisms underlying TN. In the present study, we dosed neuron-specific enolase (NSE) on serum and CSF samples of 20 patients submitted to microvascular decompression (MVD) and correlated these findings with the type of NVC. Blood samples were obtained preoperatively and 48 h after MVD. CSF from trigeminal cistern was intraoperatively obtained. NSE levels were measured using the Diasorin kit (LIAISON®NSE). NVC was classified as "contact" or "trigeminal nerve distortion/indentation" or "trigeminal root atrophy" based on MRI and intraoperative findings. Clinical outcome was measured by acute pain relief (APR) and Barrow Neurological Institute (BNI) scale at last available follow-up (FU; 6.40 ± 5.38 months). APR was obtained in all patients. A statistically significant BNI reduction was obtained at latest FU (p < 0.0001). Serum NSE levels significantly decreased following MVD (from 12.15 ± 3.02 ng/mL to 8.95 ± 2.83 ng/mL, p = 0.001). The mean CSF NSE value was 48.94 ng/mL, and the mean CSF/serum NSE rate was 4.18 with a strong correlation between these two variables (p = 0.0008). CSF NSE level in "trigeminal root atrophy" group was significantly higher compared to "contact" (p = 0.0045) and "distortion/indentation" (p = 0.010) groups. NSE levels seem to be related to the etiopathology and severity of NVC. A significant reduction of serum NSE levels could be related to the resolution of the NVC and clinical TN improvement.

PREVALENCE AND INTENSITY OF ACUTE POST-OPERATIVE PAIN AND MANAGEMENT ASPECTS IN ADULT PATIENTS: A CROSS-SECTIONAL TERTIARY HOSPITAL-BASED STUDY

The prevalence of acute postoperative pain varies widely, but quite often inadequate relief of acute postoperative pain is found, which, in turn, is associated with the development of chronic postoperative pain and other health consequences. The aim of the study was to determine the prevalence of acute postoperative pain and the degree of satisfaction of patients with anesthesia after surgery in four specialized hospitals in the capital of the country. The results showed that the post-operative pain prevalence is high 88.5% (95.0% CI = 81.2-95.8). Mean pain relief - 76.3, SD -14.8, median - 80%. Patients’ satisfaction with pain relief measured by NRS at the scores 9 and 10 composed 36.5% and 25.0% accordingly. Adequate perioperative pain management should be integral to patient care with active engagement of patients in pain management and taking decision in pain therapy.

Electroacupuncture relieves hyperalgesia by regulating neuronal-glial interaction and glutamate transporters of spinal dorsal horns in rats with acute incisional neck pain.

Glial cells are involved in the analgesic effect of electroacupuncture (EA) in rats with chronic neurological pain. The objective of this study was to observe the role of neuronal-glial interaction and glutamate (Glu) transporters in EA-induced acute neck pain relief in rats. Male rats were placed into the following five groups: control, model, EA Futu (LI18), EA Hegu (LI4)-Neiguan (PC6), and EA Zusanli (ST36)-Yanglingquan (GB34). The incisional neck pain model was established by making a longitudinal incision along the midline of the neck. The thermal pain threshold (TPT) was measured using a radiation heat detector. The immunoactivities of glial fibrillary acidic protein (GFAP), ionized calcium-binding adapter molecule 1 (Iba-1), neurokinin-1 receptor (NK-1R), Glu aspartate transporter (GLAST), and Glu transporter-1 (GLT-1) in the dorsal horns (DHs) of the cervico-spinal cord (C2-C5) were detected using immunofluorescence histochemistry. The expression levels of GFAP, Iba-1, GLAST, and GLT-1 mRNAs were determined using quantitative real-time polymerase chain reaction (PCR). The TPT and levels of mRNAs expression and immunoactivity of GLT-1 and GLAST were significantly decreased, and those of Iba-1 and GFAP were significantly increased in the model group than those of the control group (P < 0.05). The activated microgliacytes were gathered around the NK-1R positive neurons, and co-expression of NK-1R and astrocytes was observed in the model group. EA LI18 significantly increased the TPT and expression of GLAST and GLT-1 mRNAs (P < 0.05) and notably decreased the number of Iba-1 positive cells and Iba-l mRNA expression (P < 0.05), whereas GLAST and GLT-1 antagonists inhibited the analgesic effect of EA LI18. However, these effects, except for the downregulation of Iba-1 mRNA, were not observed in the EA ST36-GB34 group. Fewer NK-1R-positive neurons were visible in the spinal DHs in the EA LI18 group, and the co-expression of NK-1R and astrocytes was also lower than that in the three EA groups. Electroacupuncture of LI18 had an analgesic effect in rats with neck incisions, which may be related to its functions in suppressing the neuronal-glial cell interaction through NK-1R and upregulating the expression of GLAST and GLT-1 in the spinal DHs.

Contemporary opioid-sparing approaches after hysterectomy

Hysterectomy is one of the most common interventions in the field of operative gynecology that can be done in various surgical ways. Regardless of the operative technique, the uterine ablation causes moderate to severe postoperative pain. The pain has both visceral and somatic origins. High-quality analgesia after hysterectomy is an important precondition for obtaining rapid convalescence and dehospitalization in the conditions of a psychoemotional comfort. Good analgesia decreases the risk of developing chronic neuropathic pain syndromes. Morphine mimetics are the most commonly used analgesics for obtaining a pain relief after hysterectomy. Their powerful analgesic effect, unfortunately, is related to a number of side effects such as nausea, vomiting, alteration of consciousness, and others. This evokes the research of new analgesic strategies in postoperative pain relief that are able to reduce the use of opioids for acute pain relief. The simultaneous use of different analgesic medicaments and techniques, with various modes of action and site of application, constitutes the modern approach in the aim of reducing opioid consumption. This article provides a brief overview of the modern possibilities for the implementation of multimodal analgesia in the postoperative period after hysterectomy. The main groups of different analgesics, their potential, side effects and recommended dosages are discussed. We have made a brief presentation of the regional anesthesia techniques and local anesthetic agents that have a potential to provide pain relief after hysterectomy.

Erector Spinae Block Reduces Opioid Use After Transaxillary First Rib Resection

Recent federal initiatives mandate reductions in opioid analgesic prescribing to control postoperative pain. The severe pain associated with first rib resection for thoracic outlet syndrome is an ideal area of focus. The erector spinae block (ESB) is a new regional anesthesia technique used to provide analgesia for relief of acute postoperative pain. The objective of this study is to evaluate the potential benefit of ESB to reduce opioid requirements after transaxillary first rib resection.

Ketamine Pharmacodynamics Entangled: Reply.

We thank Bowdle et al.1 for their interest in our article,2 and for the important issue they raise, paraphrased as follows: what is the best anthropocentric description of the “mind-altering” effects of a heterogeneous group of compounds and drugs that act at the brain and cause significant changes in mental state. The group of drugs that we are referring to includes N-methyl-d-aspartate (NMDA) receptor antagonists (ketamine, nitrous oxide, xenon), serotonergic psychedelics (5-HT2a receptor agonists psilocybin and lysergic acid diethylamide and serotonin-releasing 3,4-methylenedioxymethamphetamine), ayahuasca, cannabinoids (CB-1 receptor agonists), and κ-opioid receptor agonists Salvinorin A and B; this list is certainly not complete (see List of Psychedelic Drugs3). During the past two decades we studied ketamine, cannabis, and recently also psilocybin in patients and healthy volunteers and observed several similarities in the subjective expression of feelings and emotions during and after treatment. One important commonality is that these drug consumers display a certain disconnection or dissociation from reality. In this sense, the word “dissociation” and “dissociative drug” have a different meaning than described by Bowdle et al.1 It may indeed not be the correct wording because dissociation does not encompass all of the symptoms experienced and expressed by the users of these drugs (not all symptoms relate to a disconnect with reality). Moreover, there are clear distinctions in symptomatology between these different drugs. For example, the hallucinogenic effects of cannabinoids are very different from those of ketamine or ayahuasca. Hence, it may just not be possible to have one denominator that describes the mind-altering effects of these drugs. The conclusion of Bowdle et al.1 is that it is best to describe the anesthetic drugs that have psychedelic effects by their mechanism of action, for example, the NMDA-receptor antagonist ketamine. However, there is ample evidence that many of the ketamine effects are non-NMDA related. For example, acute pain relief may be related to the μ-opioid receptor and/or specific background potassium channels.4,5 Therefore, we argue that we need another approach. One term that describes both the NMDA-receptor antagonists and serotonergic psychedelics is psychoplastogen. Psychoplastogens are molecules that have a neurotrophic effect and promote rapid neural plasticity in the cortex (rewiring of pathologic neurocircuitry).6 Although this term does not describe the subjective experiences caused by these drugs, it does describe the mechanisms associated with their healing effects, whether it be antidepression or pain relief. Hence, in future studies we will refer to ketamine as a psychoplastogen. We thank Dr. Bowdle et al. for this mental exercise that we hope will result in an improved description of the behavioral effects of psychedelic drugs.The Anesthesia &amp; Pain Research Unit of the Department of Anesthesiology, Leiden University Medical Center (Leiden, The Netherlands), received/receives funding from AMO Pharma Ltd. (Leeds, United Kingdom), Bedrocan BV (Veendam, the Netherlands), Grünenthal GmbH (Aachen, Germany), Medtronic (Minneapolis, Minnesota), MSD Nederland BV (Haarlem, the Netherlands), LTS Lohmann Therapie Systeme AG (Andernach, Germany), and Trevena Inc. (Chesterbrook, Pennsylvania). Dr. Dahan received consultancy and/or speaker fees from Enalare Therapeutics Inc. (Princeton, New Jersey), Grünenthal BV (Woerden, the Netherlands), Medasense Biometrics Ltd. (Ramat Gan, Israel). Dr. Dahan received grants/awards from ZonMW (The Hague, the Netherlands) and US Food and Drug Administration (Silver Spring, Maryland).

Surgical and Clinical Outcomes of Microvascular Decompression: A Comparative Study between Young and Elderly Patients.

Microvascular decompression (MVD) is the only etiological technique for the treatment of trigeminal neuralgia (TN). Whilst there is a consensus MVD is likely effective regardless of age, the elderly population is thought to be more prone to have a higher rate of surgical complication, morbidity, and mortality. The main objective of our single-center, retrospective study was to analyze the surgical and clinical outcomes of MVD in TN elderly patients. From a surgical series of patients with TN who had undergone MVD from April 2018 to April 2022, 76 patients who matched the inclusion criteria were divided into two groups: twenty-five (32.9%) patients were older than 65 years and included in the elderly group, while the remaining fifty-one (61.1%) patients were below 65 years included in the non-elderly one. There were no differences between the groups in terms of acute pain relief (APR), Barrow Neurological Index (BNI) at follow-up, complications, and recurrence rate. In multivariate analysis (Cox proportional hazards regression analysis) the presence of an offending artery with nerve root distortion/indentation emerged as the only independent prognostic factor for pain-free survival (p = 0.0001). Our data endorse MVD as a safe and effective surgical procedure also for elderly patients with TN.

Analgesic Efficacy of Intravenous Dexamethasone as an Adjunct to Ultrasound-Guided Paravertebral Block with Bupivacaine in Video-Assisted Thoracoscopic Surgery.

PurposeThoracic paravertebral block (TPVB) is a recommended regional analgesia during video-assisted thoracoscopic surgery (VATS). However, single-injection TPVB does not last long enough to provide sufficient acute postoperative pain relief. Continuous TPVB through a catheter is technically challenging and often unreliable. Intravenous dexamethasone extends the analgesic duration with some peripheral nerve blocks. However, data on the effect of intravenous dexamethasone on pain relief with TPVB are limited. This study aimed to assess the analgesic efficacy of intravenous dexamethasone in patients who received TPVB for VATS.Patients and MethodsIn this multicenter prospective randomized controlled trial, we recruited patients aged between 18 and 80 years with the American Society of Anesthesiologists of physical status class 1–3 and underwent elective VATS. Patients under general anesthesia randomly received 8 mg of intravenous dexamethasone (group D) or normal saline (group C). Ultrasound-guided TPVB (USG-TPVB) was performed at the T4–T5 and T6-T7 spaces. Multimodal analgesia was achieved via paracetamol, tramadol and intravenous morphine for both study groups. The primary outcome was time for the first analgesic requirement. Postoperative pain in terms of numeric rating score (NRS), total morphine consumption and postoperative nausea and vomiting (PONV) were assessed.ResultsAfter excluding one patient, 59 patients were analyzed. There were no intergroup differences in baseline characteristics. The time to first analgesic requirement was longer in group D (305 [240, 510] minutes) than in group C (270 [180, 300] minutes) (P value = 0.02). The NRS at rest and on movement was lower in group D than in group C at 12 hours but did not differ at other time points. Postoperative morphine consumption was significantly lower in group D than in group C at 6,12,24 and 48 hours. Incidences of PONV were comparable between the groups.ConclusionIntravenous dexamethasone, used as an adjunct to a single-injection USG-TPVB prolonged analgesic duration, had an opioid-sparing effect and provided better postoperative pain relief after VATS.

COMPARISION OF LANDMARK GUIDED FEMORAL NERVE BLOCK AND SYSTEMIC INTRAVENOUS ANALGESIA FOR PAIN RELIEF IN TRAUMATIC SHAFT FEMUR FRACTURE.

Background: Femoral nerve block is useful technique for acute pain relief in case of fracture shaft femur in comparison to systemic analgesia. a) To study and compare whether femoral nerve block is more efficaciousAims and Objective: in pain management of femoral shaft fractures than systemic intravenous analgesia. b) To study the duration of action of femoral nerve block for pain relief in femoral shaft fractures. c) To notify any complication. 60Materials and Methods: patients of ASA I and II, aged 20-60 years, having fracture traumatic shaft femur at either level (mid, upper, lower) were studied after admission of patient in emergency ward. They were randomly allocated to group A (n-30, femoral nerve block using 15 ml 2% Lignocaine) and group B (n-30, systemic analgesia using Inj. Paracetamol 1 gm). Each case was subsequently followed up for onset and total duration of analgesia till 6 hrs. Efficacy in both groups was assessed by visual analogue scale. There is no significant difference in onset of action between both theResults and Summary: groups. The duration of action in group A was more (4.08±1.06 hours) than group B (2.18±1.24hours). Visual analogue score showed significant pain reduction in group A after 15 minutes and also at 180 minutes (p=0.000) in comparison with group B. femoral nerve block is safe, simple and more efficacious procedure in comparison toConclusion: systemic IV analgesia for acute pain management in patients with fracture shaft femur.

Pre-pperative low intensity vestibular shockwave therapy (LiSWT) decreases opioid use post-vestibulectomy: A pilot study

ABSTRACT Introduction Surgeons performing complete vestibulectomy with vaginal advancement flap reconstruction for suspected neuroproliferative vestibulodynia (NPV) take into consideration the need for acute pain relief in the early postoperative period as well as risks for persistent post-operative opioid use. Post-operative acute pain has traditionally been managed with narcotics which are effective but are highly addictive and can cause unwanted side effects including nausea/vomiting, impaired mental function, and severe constipation/obstipation. We serendipitously observed that one patient who tried to avoid surgery by undergoing numerous vestibular low intensity shockwave therapy (LiWST) treatments used very few narcotics post vestibulectomy. LiWST is FDA-cleared for pain amelioration. It has been hypothesized that LiSWT downregulates inflammatory cytokines, promotes enhancement of blood flow and angiogenesis through expression of vascular endothelial growth factor and nitric oxide synthesis. Objective We performed a pilot study using pre-operative LiSWT to determine whether or not it might decrease post-operative opioid use (oxycodone/acetaminophen tablets; 5mg/325mg) for acute pain management in patients undergoing complete vestibulectomy with vaginal advancement flap for suspected NPV. Method We studied the post-op opioid use of women who underwent complete vestibulectomy at our facility during the period January 1, 2019 through June 30, 2021. We assessed opioid use based on the patient's recall of the total oxycodone/acetaminophen tablets required in the first 30 days post-vestibulectomy. When possible, patients confirmed the use by counting tablets left in the pill container. Women scheduled to undergo vestibulectomy for suspected NPV were placed in the LiSWT study group if they agreed to undergo vestibular LiSWT treatment daily for the three business days immediately pre-operatively. Using the Urogold 100™MTS, LiSWT involved delivery of 1800 shocks to the vestibule per session, energy flux density 0.05-0.1 mJ/mm2, 3 Hz, membrane pressure 3. We compared the post-op opioid use by women in the LiSWT study group to the use by women who did not undergo pre-op LiSWT. Results Forty-five women (mean age 28 years; range 17 - 57) underwent complete vestibulectomy for suspected NPV during the 30 month period. Twenty women (mean age 27 +/- 9 years) agreed to undergo pre-op LiSWT and post-op opioid use was obtained in all. Twenty-five women (mean age 29 +/- 11 years) did not undergo pre-op LiSWT and opioid use was obtained in 19/25 (76%). Mean post-operative opioid use was 47 +/- 13 (range 25 - 90) tablets in those vestibulectomy patients who did not undergo pre-op vestibular LiSWT; opioid side effects included constipation, nausea, fainting, drowsiness, fatigue, and blurred vision. Mean post-op opioid use was 22 +/- 10 (range 1 - 26) tablets in the 20 vestibulectomy patients who did undergo pre-op vestibular LISWT sessions; opioid side effects were restricted to constipation, sleepiness, and nausea. Conclusion In this pilot study, pre-operative low intensity shockwave therapy decreased post-operative opioid use after complete vestibulectomy with vaginal advancement flap. While encouraging, more research is needed. Disclosure Work supported by industry: no.