Opioid Requirements Research Articles

Continuous peripheral nerve blocks for pain control after orthopaedic surgery

BACKGROUND Continuous peripheral nerve blocks (CPNB) provide an opioid-free alternative for pain control after orthopaedic surgery. However, postdischarge ambulatory patient care and follow-up concerns have prevented CPNB use at home. OBJECTIVE To address physicians’ concerns about the outpatient use of CPNB. DESIGN Prospective, cohort, observational study. SETTING Single centre, teaching private hospital in Santiago, Chile, between July 2016 and March 2020. PATIENTS We included patients aged at least 18 who underwent orthopaedic surgery using CPNB for postoperative pain management. Patients scheduled simultaneously for non-orthopedic surgery on the same event were excluded. MAIN OUTCOME MEASURES Pain scores, opioid use, and complication rates at both in-hospital and at-home sites. RESULTS CPNB were provided as an analgesia plan in 497 patients who met inclusion criteria, and 387 (77.87%) were discharged home with this continuous analgesia. At 48 h, 70% of the patients reported no-worse-than-mild pain. Less than 3.1% of patients reported an episode of severe pain, and less than 13% of the patients required opioid rescue medication. Transient neurological symptoms were observed in 13% (95% confidence interval (CI), 10.4 to 16.1) of the patients. No long-term or severe complications were observed. High rates of satisfaction were reached among patients. CONCLUSION In-hospital and at-home use of CPNB supervised by a pain service team provides a feasible and safe alternative after orthopaedic surgery, pain control with a low requirement of opioids.

Wearable, noninvasive, pulsed shortwave (radiofrequency) therapy for postoperative analgesia: A randomized, double-masked, sham-controlled pilot study.

Nonthermal, pulsed shortwave (radiofrequency) therapy (PSWT) is a nonpharmacologic, noninvasive modality that limited evidence suggests provides analgesia. Its potential favorable risk-benefit ratio stems from its lack of side effects and significant medical risks, applicability to any anatomic location, long treatment duration, and ease of application by simply affixing it with tape. Even with a relatively small treatment effect, PSWT might contribute to a multimodal analgesic regimen, similar to acetaminophen. However, widespread clinical use is hindered by a lack of systematic evidence. The current randomized, controlled pilot study was undertaken to determine the feasibility and optimize the protocol for a subsequent definitive investigation and estimate the treatment effect of PSWT on postoperative pain and opioid consumption. Within the recovery room following primary knee and hip arthroplasty, cholecystectomy, hernia repair, and non-mastectomy breast surgery, we applied 1-3 PSWT devices (Model 088, BioElectronics Corporation, Frederick, Maryland) over the surgical bandages. Participants were randomized to 28 days of either active or sham treatment in a double-masked fashion. The outcomes of primary interest were the cumulative opioid consumption and the mean of the "average" and "worst" daily pain measured with the Numeric Rating Scale over the first 7 postoperative days. During the first 7 postoperative days, oxycodone consumption in participants given active treatment (n = 55) was a mean (SD) of 21 mg (24) versus 17 mg (26) in patients given sham (n = 57): difference 4 (95% CI, -5 to 13), p = 0.376. During this same period, the "average" daily pain intensity in patients given active treatment was 2.4 (1.6) versus 2.6 (1.7) in sham: difference -0.2 (95% CI -0.8 to 0.5), p = 0.597. Concurrently, the worst/maximum pain for the active group was 4.6 (2.0) versus 4.7 (2.1) in sham: difference -0.1 (95% CI -0.8 to 0.7), p = 0.888. No device-related systemic side effects or serious adverse events were identified. Pulsed shortwave (radiofrequency) therapy did not reduce pain scores and opioid requirements to a statistically significant or clinically relevant degree during the initial postoperative week in this pilot study. These results must be replicated with a subsequent study before being considered definitive. Data from this preliminary study may be used to help plan future trials.

Pain control and analgesic requirements following laparoscopy-assisted transversus abdominus plane (TAP) block compared to port site infiltration post-paediatric laparoscopic appendicectomy. A Randomised controlled trial.

Appendicectomy is a common procedure in children. Regional anaesthesia helps reduce requirements for opioids and hospital stay and enhances recovery. Laparoscopic-assisted Transversus Abdominus Plane block (L-TAP) was shown to be efficient and potentially superior to port site infiltration (PSI); however, this was not previously studied in paediatric appendicitis. This study aimed to evaluate the effectiveness of L-TAP compared to PSI in children undergoing laparoscopic appendicectomy (LA). A single-blinded RCT was performed to compare L-TAP to PSI with 0.25% plain bupivacaine at the end of an LA. Patients aged 6-16 years diagnosed with uncomplicated acute appendicitis (AAST grade 1) were randomised to either group in a 1:1 fashion. Complicated appendicitis, open or Lap-converted to open appendicectomies, were excluded. Outcome measures included the total amount and number of doses of opiates and clonidine required, length of stay (LOS), and visual analogue score (VAS) of pain. 49 patients in the PSI group and 41 in the L-TAP group were included; the mean age was 11.3 ± 2.4 years. There was no significant difference in age and weight between the groups. One patient in each group required opioid-based patient-controlled analgesia (PCA) in the theatre recovery room; however, on retrospective review, this was not clinically warranted. Seven patients in each group required morphine while in recovery (p = 0.4). There was no significant difference in total morphine (PSI 0.12 vs L-TAP 0.04 mg/kg body weight, p = 0.1) and clonidine (PSI 0.57 vs L-TAP 0.59 micro gm/kg body weight, p = 0.5) requirement during the hospital stay. Patients in the L-TAP group had two hours shorter LOS than the PSI group (38.0 ± 3.9 vs 39.7 ± 4.1, p = 0.38). There was no significant difference in VAS scores. There was no difference between L-TAP and PSI. L-TAP was feasible, easy to earn, and safe. We recommend that it be considered in clinical protocols and local guidelines as part of the peri-operative analgesia regimen, especially when ultra-sound guided blocks are unavailable. Overall, patients with uncomplicated appendicitis who undergo LA have low VAS scores and require mostly simple analgesia.

Lumpectomy Patients are at Highest Risk for Opioid Overprescription: A Comparison Between Practice Patterns and OPEN National Guidelines.

Nearly 25% of opioid-related deaths are from prescribed opioids, and the exacerbation of the opioid epidemic by the coronavirus disease 2019 (COVID-19) pandemic underscores the urgent need to address superfluous prescribing. Therefore, we sought to align local opioid prescribing practices with national guidelines in postoperative non-metastatic breast cancer patients. A single-institution analysis included non-metastatic breast surgery patients treated between April 2020 and July 2021. 'Overprescription' was defined as a discharge prescription quantity of oral morphine equivalents (OMEs) greater than the upper limit of the procedure-specific Michigan Opioid Prescribing Engagement Network (OPEN) recommendations. Univariable and multivariate analyses identified risk factors associated with opioid prescribing. Overall, 464 patients met the inclusion criteria: 280 patients underwent lumpectomy, and 184 patients underwent mastectomy. 52% of patients were overprescribed opioids, including 74% of lumpectomy patients (p<0.001) and 90% of patients undergoing lumpectomy with axillary surgery (p<0.001). Mastectomy patients were overprescribed less frequently (< 25%). The quantity of opioids prescribed at discharge did not correlate to inpatient opioid requirements (r=0.024, p=0.604). Increased age, tobacco use, and long surgery duration were associated with higher quantities of opioids prescribed at discharge. Patients undergoing less aggressive breast surgery are at very high risk of overprescription, and real-life prescribing patterns do not correlate to national guidelines or inpatient need. Future work will optimize adherence to procedure-specific guidelines and implement tailored discharge protocols.

Do transversus abdominis plane (TAP) blocks improve pain after laparoscopic bilateral inguinal hernia repairs beyond the recovery unit? A randomized control trial.

While surgeons agree that perioperative field blocks should be performed for open inguinal hernia surgery, there lacks consensus in the minimally invasive context. Prior small-scale randomized trials study pain scores only up to 24h postoperatively. Thus, we sought to investigate the analgesic benefits of a bupivacaine transversus abdominis plane (TAP) block in the first 4 postoperative days. This is a prospective single-institution randomized control trial involving patients undergoing elective totally extraperitoneal inguinal hernia repairs, who received either a TAP block with bupivacaine 0.25% or saline placebo. Postoperatively, patients completed a pain survey (based on a 0-10 visual analog score) and an opioid/non-opioid pain medication log. Differences were detected using a Wilcoxon rank sum test for continuous variables, and a Fisher's exact test or chi-squared for categorical variables. A total n = 90 patients were included in the per-protocol analysis, of which n = 46 received TAP blocks with bupivacaine versus n = 44 placebo. Patient characteristics were similar between the groups, including recurrent hernias and number of tacks placed (p > 0.05). All cases were bilateral. Postoperatively, pain scores (at rest and with movement) and pain medication use were similar for all postoperative days 1-4. Our study shows no significant difference in pain or opioid requirement within the first 4days postoperatively, suggesting that the analgesic benefits of plain bupivacaine TAP blocks in totally extraperitoneal inguinal hernia repairs do not exist beyond the recovery unit. This will help inform anesthesiologists and patients in discussing risks and benefits of a TAP block in their surgical context.

Influence of intravenous lidocaine infusion on haemodynamic response to tracheal intubation and metabolic-hormonal responses during laparoscopic procedures in children: a randomised controlled trial

BackgroundLidocaine, a widely used local anaesthetic, also serves as an adjuvant in pain management. However, its use in children is off-label. This study aimed to determine if intravenous lidocaine alleviates the haemodynamic, metabolic, and hormonal responses to intubation and laparoscopic surgery in children.MethodsA single-centre, parallel, double-masked, randomised, placebo-controlled trial. 132 patients, aged 18 months to 18 years, with no contraindications to lidocaine administration and qualified for laparoscopic appendectomy were enrolled. The intervention studied was a lidocaine bolus of 1.5 mg⋅kg− 1 over 5 min given before induction of anaesthesia, followed by intraoperative lidocaine infusion at 1.5 mg⋅kg− 1⋅h− 1 intraoperatively. Patients in the control group were administered a placebo. Mean arterial pressure, glucose, cortisol, lidocaine blood levels, lidocaine-related side effects, and intraoperative opioid requirements were analysed.Results132 participants completed the trial. The number of patients who experienced an excessive cardiovascular response to induction of anaesthesia or intubation was 23 (37%) in the control group and 21 (34%) in the lidocaine group (p = 0.707). No statistically significant difference was found between the control and lidocaine groups in the hormonal and metabolic responses, as well as intraoperative fentanyl requirements. Serum lidocaine levels remained below the toxic threshold in all patients.ConclusionsAlthough the studied intervention appears to be safe, with no clinical side effects observed and serum lidocaine levels remaining below the toxic threshold, its intraoperative administration is not recommended, as it does not demonstrate any significant benefit during the anaesthesia period when compared to placebo.Trial registration numberNCT05238506. The date of first registration: 14/02/2022.

Reducing Postoperative Opioid Use: A Comparison of Open Versus Ultrasound-Guided Regional Anesthesia for Patients Undergoing Open Pancreatoduodenectomy.

Opioid crisis is a national issue with significant economic burden and marked increase in opioid-related deaths, particularly following surgical procedures. Reducing opioid requirements while maintaining effective analgesia is critically challenging, perioperatively. Multimodal drug regimens and guided regional anesthesia (RA) have been adopted to address this issue. We aimed to assess postoperative opioid consumption in patients undergoing open pancreatoduodenectomy based on the routes of RA administration: open versus ultra-sound guided. This retrospective cohort study was conducted at Emory University Saint Joseph's Hospital, encompassing patients who underwent open pancreatoduodenectomy (PD) from 2020 to 2022 who received ultrasound-guided RA (U-RA) or open RA (O-RA). Patient demographics, surgical details, and postoperative outcomes, including opioid consumption measured in morphine milligram equivalents (MME) at 24, 48, and 72 h, were analyzed. Multivariable linear regression identified predictors of postoperative opioid use. Of 95 patients, 47 met inclusion criteria: 27 received U-RA and 20 O-RA. Preoperative and intraoperative characteristics were similar between patients receiving O-RA and U-RA. A lower opioid requirement was noted in the O-RA group compared to the U-RA group at all time points. (24 h: 6.5 vs. 18, p = 0.004; 48 h: 18 vs. 37, p = 0.001; 72 h: 30.5 vs. 57, p = 0.002). On multivariable analysis, only route of regional anesthesia was independently associated with reduced opioid use across all time points (24 h: mean difference = -5.75, 95% CI: -11.3, -0.18; 48 h: mean difference = -16.95, 95% CI: -27.5, -6.4; 72 h: mean difference = -20.39, 95% CI: -35.4, -5.3) Patient age, gender, race, obesity, neoadjuvant chemotherapy, small pancreatic duct, and pancreatic fistula were not independently associated with opioid use. O-RA may offer a better approach than U-RA in minimizing opioid consumption after open PD. These findings suggest the incorporation of O-RA for upper abdominal surgeries to decrease the necessity of postoperative opioids.

Pharmacogenetics of opioid medications for relief of labor pain and post-cesarean pain: a systematic review and meta-analysis.

Several studies have attempted to identify genetic determinants of clinical response to opioids administered during labor or after cesarean section. However, their results were often contrasting. A systematic review and meta-analysis was conducted to quantitatively assess the association between gene polymorphisms and clinical outcomes of opioid administration in the treatment of labor pain and post-cesarean pain. A comprehensive search was performed up to December 2023 using PubMed, Web of Knowledge, Cochrane Library, and OpenGrey databases. The clinical endpoints of interest were pain score after opioid treatment, total opioid consumption, patient's analgesic satisfaction, and incidence of opioid side effects. Random-effects meta-analyses were conducted when data were available in at least three studies. Twenty-six studies enrolling 7765 patients were included in the systematic review. Overall, a total of 12 candidate polymorphic genes (OPRM1, COMT, CYP2D6, CYP3A4, ABCB1, ABCC3, UGT2B7, CGRP, OPRK1, OPRD1, KCNJ6, KCNJ9) were considered by the included studies, among which the most investigated variant was OPRM1 rs1799971. Overall pooled results indicated that individuals carrying the G allele of OPRM1 rs1799971 required higher opioid doses for pain management in comparison to rs1799971 AA subjects (standardized mean difference: 0.26; 95% CI: 0.09-0.44; P = 0.003). Such an association was confirmed in the subgroups of patients with labor pain and post-cesarean pain. The present meta-analysis provides strong evidence of an association between OPRM1 rs1799971 and opioid dose requirement for relief of labor pain or post-cesarean pain. However, given the insufficient evidence for other polymorphic gene variants, large studies are still needed to investigate the impact of genetic variability on the efficacy and safety of opioid medications for relief of labor pain and post-cesarean pain (INPLASY Registration No. 202410040).

COMPARE THE ANALGESIC EFFICACY OF 0.25% BUPIVACAINE AND 0.25% BUPIVACAINE WITH 0.9 μG/KG DEXMEDETOMIDINE IN TAP BLOCK

Objectives: The transversus abdominis plane (TAP) block is a relatively new regional anesthesia technique that provides analgesia to the parietal peritoneum as well as the skin and muscles of the anterior abdominal wall. Despite a relatively low risk of complications and a high success rate using modern techniques, TAP blocks remain overwhelmingly underutilized. The objective is to compare the analgesic efficacy of 0.25% bupivacaine and 0.25% bupivacaine with 0.9 μg/kg dexmedetomidine in TAP block as a part of a multimodal analgesia regimen for post-cesarean delivery pain management. Methods: Patients more than 18 years old posted for elective/emergency caesarean section in ABVGMC, Vidisha, Madhya Pradesh. After approval from the institutional ethical committee and written informed patients consent, 20 each pregnant women were included in the both study group. Group A: TAP block with 0.25% bupivacaine 20 mL each side Group B: TAP block with 0.25% bupivacaine with 0.9 μg/kg dexmedetomidine 20 mL each side. We studied TAP block in patients posted for elective caesarean section. Results: The women received 0.25% bupivacaine or 0.25% bupivacaine with 0.9 μg/kg dexmedetomidine. The median visual analogue scale (VAS) for pain was significantly higher in the bupivacaine Group A at 12 h with compare to Group B. Overall, there was no difference in VAS score at 0.5, 2, 4, 6, and 24 h demands between the two groups. The mean time to first rescue analgesia in Group A was 14.6±5.5 h and in Group B was 16.8±4.2 h. Conclusion: We conclude that the using dexmedetomidine as an additive to bupivacaine in ultrasound-guided TAP block for elective/emergency caesarean section provides prolonged duration of post-operative analgesia, and lowered VAS pain scores. The addition of dexmedetomidine to bupivacaine also reduced the total dose of opioid requirement in the first 24 h after caesarean section.

Methadone for Surgical Patients

What Is the Issue? Opioids such as morphine and hydromorphone are commonly used to treat postoperative pain; however, they are associated with serious risks such as respiratory depression. Methadone (a synthetic opioid) has been proposed as a potential option for preoperative or postoperative analgesia that may improve pain relief and reduce overall opioid requirements. What Did We Do? We sought to identify and summarize studies of the clinical effectiveness and safety of oral methadone for preoperative or postoperative analgesia in adults as well as recommendations from evidence-based guidelines. We searched key resources, including journal citation databases, and conducted a focused internet search for relevant evidence published since 2019. One reviewer screened articles for inclusion based on predefined criteria, critically appraised the included publications, and narratively summarized the findings. What Did We Find? We identified 1 randomized controlled trial (RCT) that evaluated the use of preoperative oral methadone versus placebo in adults undergoing sternotomy for isolated coronary artery bypass graft surgery. We did not identify any studies that compared oral methadone to other analgesics that met our criteria. We did not identify any evidence-based guidelines that included recommendations on the use of oral methadone for preoperative and postoperative analgesia. There were no differences in pain scores 24, 48, and 72 hours postoperatively in patients who received oral methadone versus placebo. Postoperative morphine requirements were lower in the methadone group than the placebo group at 24 hours; however, there were no differences between groups at 48 or 72 hours. There were no differences in common side effects related to opioid use (nausea, vomiting, pruritus, constipation, urinary retention, hypoventilation, or hypoxia) between patients undergoing surgery treated with oral methadone versus placebo at 24, 48, or 72 hours. What Does It Mean? We identified very limited evidence on the use of oral methadone for preoperative or postoperative analgesia in patients undergoing surgery. There were no differences between patients undergoing surgery treated preoperatively with oral methadone versus placebo in most of the pain outcomes measured in the included RCT. Additional evidence may be necessary to aid decision-making around the use of oral methadone as preoperative or postoperative analgesia for adult patients undergoing surgery.

Effect of intraoperative methadone in robot-assisted cystectomy on postoperative opioid requirements: A randomized clinical trial.

Postoperative pain management is a challenge after robot-assisted cystectomy (RAC). Methadone has a long duration of action, and we therefore hypothesized that a single dose of intraoperative methadone would reduce postoperative opioid requirements and pain intensity in bladder cancer patients undergoing RAC. We conducted a blinded randomized controlled clinical trial from July 2020 to August 2023. Patients scheduled to undergo RAC because of bladder cancer were randomized to receive intraoperative methadone (0.15 mg/kg-1) or morphine (0.15 mg kg-1) 1 h before endotracheal extubation. The primary outcome was opioid requirements after 24 h. Secondary outcomes were opioid requirements after 3 h, pain intensity at rest and during coughing, postoperative nausea and vomiting (PONV), sedation, hypoxemia, hypoventilation, time spent in the post-anesthetic care unit, and patient satisfaction. A total of 114 patients were randomized. Data from 99 patients (14 females, 85 males; mean age 69.8 ± 8.9 years) were available for analysis; 52 received methadone and 47 received morphine. Opioid consumption was similar between the methadone group and morphine group at 3 h (median, mg, 45 (IQR 30 to 75) vs. 45 (IQR 15 to 82.5) p = .97) and at 24 h (median, mg, 125 (IQR 75 to 198.5) versus 105 (IQR 72 to 157.5), p = .29). Pain intensity was significantly lower in the morphine group at 48 h compared with the methadone group. Patient satisfaction at 24 h was increased in the methadone group compared with the morphine group (median, (IQR), NRS; 9 (IQR 7 to 10) versus 7 (IQR 4 to 9), p = .020). There were no differences between treatment groups in terms of time spent in the post-anesthetic care unit and the occurrence of opioid-related side effects. A single dose of intraoperative methadone does not reduce postoperative opioid requirements compared with a single dose of morphine in bladder cancer patients undergoing RAC.

TECHNICAL AND QUANTITATIVE ANALYSIS OF PAIN MANAGEMENT IN MAJOR SURGERIES USING REGIONAL ANESTHESIA WITH OPIOID-SPARING DRUGS

The management of acute postoperative pain (APP) in major abdominal surgeries remains a critical challenge due to the adverse effects associated with opioid use, such as respiratory depression, nausea, vomiting, and decreased gastrointestinal motility. These complications underscore the need for alternative pain management strategies that minimize opioid dependence while ensuring effective analgesia. This study systematically reviews the opioid-sparing effects of regional anesthesia techniques, with a specific focus on the transversus abdominis plane (TAP) block and quadratus lumborum block (QLB). Both techniques are increasingly recognized as essential components of multimodal analgesia strategies, which aim to optimize postoperative recovery and reduce opioid-related complications. The findings reveal that TAP and QLB are highly effective in controlling postoperative pain, significantly decreasing opioid requirements and enhancing recovery outcomes. TAP block has demonstrated particular efficacy in reducing pain and opioid consumption in colorectal and bariatric surgeries, while QLB has shown promise in managing pain for more extensive abdominal procedures, offering prolonged analgesic effects. Despite their shared benefits, each technique presents unique efficacy profiles, which are influenced by factors such as surgical type, patient characteristics, and the choice of local anesthetic. These distinctions highlight the importance of tailoring regional anesthesia techniques to individual patient needs. This study also emphasizes the role of multimodal analgesic approaches that combine regional anesthesia with other non-opioid analgesics, such as ketamine and lidocaine, to further enhance pain control and minimize opioid use. Such approaches not only improve pain management but also contribute to faster recovery and fewer complications, such as postoperative nausea and delayed gastrointestinal transit. In conclusion, integrating regional anesthesia techniques like TAP and QLB into multimodal pain management protocols offers substantial benefits in reducing opioid consumption and enhancing postoperative recovery. Future research should focus on direct comparisons between regional techniques, their long-term effects, and their potential to reduce chronic pain recurrence, ensuring continued advancements in perioperative care.

Effect of Nicotine Replacement Therapy on Perioperative Pain Management and Opioid Requirement in Abstinent Tobacco Smokers Undergoing Spinal Fusion: A Double-blind Randomized Controlled Trial

Background: Smoking negatively impacts postoperative outcomes but acute abstinence from smoking during hospitalization can increase postoperative pain, lower pain thresholds, disrupt pain management, and trigger hyperalgesia due to abrupt nicotine withdrawal in tobacco users. Nicotine replacement therapy has been recommended to minimize these complications. We hypothesized that a high dose (21 mg/24 h) transdermal nicotine (TDN) patch would reduce postoperative pain and opioid requirements. Methods: One hundred abstinent tobacco smokers undergoing single-level spinal fusion were randomized into placebo (n=50) and nicotine treatment (n=50) groups. Placebo and TDN patches were applied 24 hours before surgery until 48 hours after surgery. Primary outcomes were postoperative pain scores and opioid (morphine) consumption, and serum nicotine levels. The relationship between daily tobacco use and pain and opioid requirements, and between serum nicotine levels and morphine consumption, were assessed. Results: Postoperative pain scores at rest and on movement were lower in the nicotine group than in the placebo group at 6 hours, 12 hours, and 24 hours after surgery (P&lt;0.05). Postoperative morphine consumption was lower in the nicotine group than in the placebo group (9.92 ± 4.0 vs. 15.9 ± 5.0 mg, respectively; P=0.0002). There was a positive correlation between the number of cigarettes smoked per day and postoperative pain scores at rest (r = 0.4553; P = 0.0001) and during movement and a negative correlation between serum nicotine concentration and postoperative morphine consumption (r =−0.3664; P = 0.0089) Conclusions: TDN patches (21 mg/24 h) reduced postoperative pain and opioid requirements in abstinent tobacco smokes undergoing spinal fusion.

Intraoperative virtual reality for older patients undergoing total knee arthroplasty: study protocol for a randomized clinical trial

BackgroundIn an aging surgical patient population, preventing complications such as oversedation has taken increasing priority in perioperative care. Intraoperative use of virtual reality (VR) may decrease sedative requirements. We hypothesize that the use of immersive VR during total knee arthroplasty (TKA) will lead to decreased propofol requirements, improved patient-reported satisfaction, and reduced postoperative opioid requirements compared to active and usual care controls.MethodsThis is a single-center, randomized clinical trial of older (age > 60) patients undergoing TKA. Participants will be randomized into three groups (2:2:1): VR immersion, music, and sham VR plus usual care. All patients will receive a regional block and spinal anesthesia. Patients in the immersive VR and music groups will use patient-controlled sedation (PCS) with propofol, while those in the sham VR group will act as the standard of care control group and will receive monitored anesthesia care (MAC) with propofol infusion.Statistical analysisAnalyses will be conducted using IBM SPSS Statistics Version 25, considering a two-sided p-value < 0.05 to be statistically significant. The primary outcome is the intraoperative dose of propofol (mg kg−1 min−1). Secondary outcomes include patient satisfaction, post-anesthesia care unit (PACU) length of stay, postoperative pain scores and analgesic requirements, functional outcomes, postoperative delirium, and postoperative neurocognition.DiscussionVR used as a non-pharmacological adjunct to regional and spinal anesthesia during TKA may reduce sedative requirements while maintaining patient satisfaction. If true, this approach to minimizing sedation may impact clinical outcomes including perioperative complications and length of stay for older patients, while maintaining a high degree of patient satisfaction.Trial registrationThis trial was registered on ClinicalTrials.gov on January 29, 2021. The registration number is NCT04748549.

Effect of Low-dose Ketamine on Inflammatory Markers, Perioperative Analgesia, and Chronic Pain in Patients Undergoing Laparoscopic Inguinal Hernia Surgery: A Prospective, Randomized, Double-blind, Comparative Study.

The neutrophil lymphocyte ratio (NLR) and platelet lymphocyte ratio (PLR) are indicators of postoperative inflammatory response. Low-dose ketamine has analgesic and anti-inflammatory properties. Inguinal hernia surgery is associated with a higher incidence of chronic pain. Sixty patients aged 18-60 years; American Society of Anesthesiologists status I and II who were scheduled for laparoscopic inguinal hernia surgery were included. After the induction of general anaesthesia, a ketamine 0.5 mg kg-1 bolus, followed by a 0.2 mg kg-1 h-1 infusion (group K) or saline bolus and infusion (group S) was administered until the end of the surgery. Blood samples were collected at various time intervals. Fentanyl requirement, hemodynamics, verbal analog scale (VAS), emergence delirium, recovery, postoperative nausea and vomiting, and chronic pain were recorded. Median (interquartile range) NLR was 4.63 times increased at 2 hours postoperatively from the baseline in group S [2.07 (1.72-2.79) to 7.91 (5.74-14.7)] as compared to 2.53 times increase in group K [1.85 (1.4-2.61) to 5.45 (2.89-7.61)] (P=0.02). The increase in median PLR from baseline to 2 hours postoperatively was greater in group S (2.98 times) than in group K (1.94 times) (P=0.02). The NLR and PLR were comparable on POD1 between the groups. Fentanyl requirement was significantly higher in group S compared to Group K both intraoperatively, (P=0.01) and two hours postoperatively (P=0.047). More patients had chronic pain and VAS scores in group S than in group K (13 vs 5, P=0.05). Low-dose ketamine reduces postoperative inflammatory response, decreases perioperative opioid requirement, and reduces incidence of chronic pain after laparoscopic inguinal hernia surgery with no significant side effects.

Cryoanalgesia for Pectus Excavatum Repair: A Systematic Review

Cryoanalgesia, or cryoablation, has emerged as a promising approach for postoperative pain control in pediatric patients undergoing minimally invasive pectus excavatum repair. Traditional pain management strategies, including thoracic epidural and patient-controlled analgesia, can effectively reduce pain but often lead to increased hospital stays and opioid dependency, which may delay recovery and heighten risks. Cryoablation addresses these challenges by targeting intercostal nerves, temporarily blocking pain transmission and minimizing opioid requirements. This systematic review analyzes studies sourced from PubMed that evaluate cryoanalgesia’s effectiveness, comparing short- and long-term outcomes of pain control, functional recovery, and patient quality of life following the Nuss procedure. Findings show that cryoanalgesia significantly reduces acute pain, hospital stay length, and opioid use. However, residual symptoms, including mild discomfort and chest sensations, persist in some patients, suggesting a need for improved long-term management and anticipatory guidance. This review provides evidence supporting cryoanalgesia as a beneficial alternative for pain control in pediatric pectus excavatum repair while addressing gaps in research on long-term symptomatology and quality of life.

Combination of ultrasound-guided pectoral nerve block I and serratus anterior plane block for attenuation of surgical stress response during modified radical mastectomy: A prospective interventional randomized controlled trial

Background: General anesthesia with multimodal analgesia is the standard anesthetic management during modified radical mastectomy. In this study, a combined ultrasound-guided pectoral nerve block (PECS I) and serratus anterior plane (SAP) block were used for surgical stress response attenuation and post-operative analgesia. Aims and Objectives: This study aimed to compare the efficacy of combined PECS I and SAP block to intravenous (IV) multimodal analgesia in attenuating surgical stress response and post-operative analgesia in patients who underwent modified radical mastectomy with axillary clearance. The primary objective was to estimate the intraoperative fentanyl requirement to reduce autonomic response due to surgical stimulus. The intraoperative vitals, post-operative numeric rating scale pain score, post-operative analgesic use in the recovery room, and incidence of post-operative nausea vomiting were the secondary objectives. Materials and Methods: Thirty-six consenting patients were randomized into two groups. After induction of general anesthesia, Group B patients received ultrasound-guided PECS I and SAP block whereas Group C patients received IV analgesics only. Intraoperative fentanyl dosage to keep the systolic blood pressure (SBP) and heart rate (HR) within 20% of baseline were noted in the both groups. Intraoperative vitals, post-operative pain score, analgesic requirement, and incidence of post-operative nausea, and vomiting were also recorded in the both groups. Results: Surgical stress response attenuation was achieved with a lower dosage of fentanyl in Group B compared to Group C (intraoperative fentanyl [mean±SD], 116.11±25.70 μg vs. 134.44±20.07 μg, P=0.023). Compared to Group C, intraoperative reduction in SBP and HR was higher in Group B (SBP reduction [mean±SD], 24.03±12.5 mm of Hg vs. 15.2±13.05 mm of Hg, P=0.045 and HR reduction [mean±SD], 18.61±6.6 beats/min vs. 10.73±10.03 beats/min, P=0.009, respectively). The apparently higher pain scores in the control group were statistically insignificant. Conclusion: A combined PECS I and SAP block attenuates intraoperative autonomic stress response due to the surgical stimulus with significantly less opioid requirement.

Procedure time-of-day effects on postoperative opioid requirements in children.

Postoperative analgesic requirements in adults follow circadian rhythm patterns with requirements for opioids and local anesthetics highest in the morning. Procedure time of day may also potentially affect circadian rhythm patterns with surgery at night promoting wakefulness during nighttime hours. This disruption may produce a shift in the circadian rhythm and potentially affect when postoperative opioid requirements are highest. We hypothesized that children undergoing surgery at night would have higher postoperative opioid requirements during nighttime hours secondary to a shift in the circadian rhythm with those requirements remaining higher than daytime requirements for the duration of the hospital stay. A retrospective cohort was completed on all children aged 1-18 years undergoing a laparoscopic appendectomy for complicated appendicitis between January 2018 and December 2019. Outcomes were total postoperative morphine equivalents (mg/kg), including total daytime and nighttime postoperative morphine equivalents (mg/kg) in children undergoing surgery during the day and at night. There were 999 children who underwent a laparoscopic appendectomy for complicated appendicitis at Texas Children's Hospital from January 1, 2018 to December 31, 2019. Of these, 758 children underwent the procedure during the day and 241 children at night. The total, daytime, and nighttime median morphine equivalents (mg/kg) for children undergoing an appendectomy during the day were 0.1 (0.0-0.4), 0.0 (0.0-0.2), 0.1 (0.0-0.2), respectively. The total, daytime, and nighttime morphine equivalents (mg/kg) for children undergoing an appendectomy at night were 0.2 (0.0-0.5) (p = -0.01), 0.1 (0.0-0.3) (p = 0.01), and 0.1 (0.0-0.2) (p = 0.03), respectively. All children, irrespective of the procedure time of day, required more morphine equivalents during daytime hours than during nighttime hours. We found that procedure time of day did not impact postoperative opioid requirements in children undergoing a laparoscopic appendectomy for complicated appendicitis. Both children undergoing an appendectomy during the day or at night required more morphine equivalents during daytime hours than during nighttime hours. Surgery at night did not produce a shift in opioid requirements postoperatively from daytime hours to nighttime hours in children undergoing an appendectomy at night.

The Effect of Epidural Analgesia on In-Hospital Outcomes in Patients with Acute Pancreatitis: A Systematic Review and Meta-Analysis of Randomized Clinical Trials.

Acute pancreatitis (AP) can lead to severe complications and high mortality. Previous studies suggest that epidural analgesia (EA) may reduce AP severity and improve outcomes. This systematic review and meta-analysis aimed to evaluate the efficacy of EA on in-hospital outcomes in AP patients. Electronic databases (PubMed, Medline-Ovid, Scopus, CINAHL, Web of Science) were systematically searched until mid-May 2024 for RCTs comparing EA with other pain management strategies in AP patients. Variables were pooled using weighted mean difference (WMD) or risk ratio (RR) with 95% confidence intervals (CIs). Data analysis employed a random-effects model and the Mantel-Haenszel method. Study heterogeneity was assessed using the I2 statistic. Five RCTs with 260 participants were included. Meta-analysis showed no significant differences in in-hospital mortality (RR = 0.69, 95% CI [0.29, 1.65], p = 0.40), mechanical ventilation (RR = 0.82, 95% CI [0.61, 1.10], p = 0.19), sepsis events (RR = 0.88, 95% CI [0.42, 1.86], p = 0.74), hospital/ICU stay (WMD = 0.49 days, 95% CI [-1.13, 2.10], p = 0.55), and pain score (WMD = 1.49, 95% CI [-0.42, 3.40], p = 0.13). However, opioid requirements were significantly lower, as reported by one study with morphine milligram equivalent of 15 mg/day compared to 52 mg/day in the control group (p = 0.001). Heterogeneity was low to moderate for most outcomes but high for pain score (I2 = 92%). The overall certainty of evidence was very low due to the small number of studies, risk of bias, and limited sample size. EA did not significantly improve in-hospital outcomes in AP patients. However, findings indicated reduced opioid consumption in the EA group, suggesting potential benefits in pain management. Further high-quality, large-scale randomized trials are needed to understand the potential benefits of EA in this population.

Outcomes After Thoracoscopic and Open Repair of Esophageal Atresia With Tracheoesophageal Fistula at US Children's Hospitals.

Thoracoscopic repair of esophageal atresia with tracheoesophageal fistula (EA/TEF) has been reported to have superior outcomes to the open approach. We sought to evaluate adoption of thoracoscopic repair at US children's hospitals and compare outcomes to open repair. The Pediatric Health Information System database was used to identify patients with EA/TEF who underwent repair between 2016 and 2023. Patients with birthweight less than 1800g and/or repair after the first 3 days of life were excluded. Postoperative complications, length of stay, and opioid requirements were assessed. Inclusion criteria were met in 618 patients. Eighty thoracoscopic repairs were reported (13%). The proportion of thoracoscopic operations did not change over the study period. Infants managed with a thoracoscopic or open approach were demographically similar. Thoracoscopic repair was associated with a higher incidence of anastomotic stricture (39% vs. 26%, p=0.02), recurrent laryngeal nerve (RLN) injury (11% vs 3%, p=0.001), and fewer days of postoperative opioid (5.2 vs. 6.5, p=0.04). Other operative complications, LOS, and duration of TPN did not differ based on operative approach. A small proportion of EA/TEF repairs in US children's hospitals were completed thoracoscopically and adoption of this approach did not increase between 2016 and 2023. Anastomotic stricture and RLN injury were significantly more likely after thoracoscopic repair. Although opioids were administered for one day fewer after thoracoscopic operations, no other metrics favored this approach. These data contrast with recent literature and suggest that the experience of high-volume hospitals may underestimate the morbidity of thoracoscopic EA/TEF repair and overestimate its benefits.