Opioid Rescue Research Articles

Ultrasound-guided bilateral superficial cervical plexus block is more effective than landmark technique for reducing pain from thyroidectomy.

PurposeThyroidectomy causes postoperative pain and patient discomfort. Bilateral superficial cervical plexus block is a regional anesthesia technique that can provide analgesia during and after surgery. This study aims to compare the effectiveness of ultrasound (US)-guided versus landmark (LM) technique for bilateral superficial cervical plexus block in thyroidectomy.Patients and methodsThirty-six patients undergoing thyroidectomy were divided into two groups randomly (n=18); either US-guided (US group) or LM technique (LM group) for bilateral superficial cervical plexus block. Patient-controlled analgesia was used to control postoperative pain. Intraoperative opioid rescue, postoperative visual analog scale (VAS) score and opioid consumption were measured.ResultsThe number of patients who required intraoperative opioid rescue was significantly lower in the US group (p≤0.05). There was no significant difference in postoperative VAS score at 3 hours (p>0.05), but postoperative VAS score at 6 and 24 hours was significantly lower in the US group (p≤0.05). Twenty-four hour postoperative opioid consumption was significantly lower in the US group (p≤0.05).ConclusionUltrasound-guided bilateral superficial cervical plexus block is more effective in reducing pain both intra- and postoperatively compared with landmark technique in patients undergoing thyroidectomy.

Randomized, Crossover Study of Immersive Virtual Reality to Decrease Opioid Use During Painful Wound Care Procedures in Adults.

The objective of this study was to evaluate the effect of immersive virtual reality (IVR) distraction therapy during painful wound care procedures in adults on the amount of opioid medications required to manage pain. A convenience sample of consenting, adult inpatients requiring recurrent painful wound care procedures was studied. Using a within-subject, randomized controlled trial study design, 2 sequential wound procedures were compared, 1 with IVR distraction therapy and 1 without IVR. Total opioid medications administered before and during the wound procedures were recorded and pain and anxiety were rated before and after the 2 wound procedures. The IVR intervention included the wearing of virtual reality goggles and participation in an immersive, computer generated, interactive, 3-dimensional virtual world program. Data were analyzed with Student's t test and chi-square analysis, with P < 0.05 considered significant. A total of 18 patients were studied, with 12 completing both study wound procedures and 6 completing a single wound procedure. The amount of opioid administered before each of the 2 wound procedures was similar with and without IVR. Total opioid administration during the dressing procedures with IVR was significantly less than when no IVR was used, 17.9 ± 6.0 and 29.2 ± 4.5 mcg/kg fentanyl, respectively (t = -2.7; df = 14; P = 0.02). Two of 15 patients (11%) requested more than 1 opioid rescue dose with IVR and 9 of 15 patients (60%) requested more than 1 rescue dose without IVR. Seventy-five percentage of participants stated that they would want to use IVR with future dressing changes. Pain and anxiety scores were similar for the wound procedures with and without IVR (P > 0.05). IVR significantly reduced the amount of opioid medication administered during painful wound care procedures when IVR was used compared with no IVR. Since pain scores were similar before and after the wound procedures with IVR and without IVR, the 39% reduction in opioid medication during IVR supports its use as a pain distraction therapy during painful procedures.

LOCAL PERIARTICULAR ANALGESIA IN TOTAL KNEE ARTHROPLASTY.

ABSTRACTObjective: To evaluate the use of infiltration of periarticular analgesic agents intraoperatively in total knee arthroplasty (TKA), with regard to benefits, reduction of pain, opioid consumption, improvement of range of motion and early ambulation. Methods: To analyze the benefits of periarticular drug infiltration, the patients submitted to TKA were evaluated, being separated into two groups. One group received the local periarticular infiltration protocol containing 0.5% bupivacaine (400mg/20ml), 1/1000 epinephrine (0.3ml), triamcinolone hexacetonide (20mg/1ml), clonidine (150mcg/1ml) and 20 ml of saline (0.9% SS) and, the other group underwent conventional intravenous analgesia. The results were compared and the variables analyzed were age, sex, BMI, comorbidities, postoperative complications, pain, functional capacity, range of motion, transfusion and rescue opioids for analgesia. Results: The mean age of the patients was 68 years and most were female and presented involvement of the left knee. Postoperatively, patients who had received periarticular infiltration showed improvement of pain as well as functional capacity. Conclusion: The analysis of data obtained demonstrated that the periarticular infiltration of analgesic agents is significantly effective for pain control and functional recovery.Level of Evidence II, Prospective Comparative Study.

Effectiveness and safety of continuous ultrasound-guided femoral nerve block versus epidural analgesia after total knee arthroplasty

Abstract Objectives Total knee arthroplasty is associated with severe postoperative pain. The aim of this study was to compare continuous ultrasound-guided femoral nerve block with continuous epidural analgesia, both with low concentrations of local anaesthetic after total knee arthroplasty. Material and methods A prospective, randomised, unblinded study of 60 patients undergoing total knee replacement, randomised into two groups. A total of 30 patients received continuous epidural block, while the other 30 received continuous ultrasound-guided femoral nerve block, as well as using 0.125% levobupivacaine infusion in both groups. Differences in pain control, undesirable effects, and complications between the two techniques were assessed, as well as the need for opioid rescue and the level of satisfaction with the treatment received during the first 48 h after surgery. Results No differences were found in demographic and surgical variables. The quality of analgesia was similar in both groups, although in the first six hours after surgery, patients in the epidural group had less pain both at rest and with movement (p = 0.007 and p = 0.011). This difference was not observed at 24 h (p = 0.084 and p = 0.942). Pain control at rest in the femoral block group was better at 48 h after surgery than in the epidural group (p = 0.009). The mean consumption of morphine and level of satisfaction were similar. Epidural analgesia showed the highest rate of side effects (p = 0.003). Conclusions Continuous ultrasound-guided femoral nerve block provides analgesia and morphine consumption similar to epidural analgesia, with the same level of satisfaction, but with a lower rate of side effects after total knee arthroplasty.

Conversion from prolonged intravenous fentanyl infusion to enteral methadone in critically ill children.

AIMTo describe our institutional experience with conversion from intravenous (IV) fentanyl infusion directly to enteral methadone and occurrence of withdrawal in critically ill mechanically ventilated children exposed to prolonged sedation and analgesia.METHODSWith Institutional Review Board approval, we retrospectively studied consecutively admitted invasively mechanically ventilated children (0-18 years) sedated with IV fentanyl infusion > 5 d and subsequently converted directly to enteral methadone. Data were obtained on subject demographics, illness severity, daily IV fentanyl and enteral methadone dosing, time to complete conversion, withdrawal scores (WAT-1), pain scores, and need for rescue opioids. Patients were classified as rapid conversion group (RCG) if completely converted ≤ 48 h and slow conversion group (SCG) if completely converted in > 48 h. Primary outcome was difference in WAT-1 scores at 7 d. Secondary outcomes included differences in overall pain scores, and differences in daily rescue opioids.RESULTSCompared to SCG (n = 21), RCG (n = 21) had lower median WAT-1 scores at 7 d (2.5 vs 5, P = 0.027). Additionally, RCG had lower overall median pain scores (3 vs 6, P = 0.007), and required less median daily rescue opioids (3 vs 12, P = 0.003) than SCG. The starting daily median methadone dose was 2.3 times the daily median fentanyl dose in the RCG, compared to 1.1 times in the SCG (P = 0.049).CONCLUSIONWe observed wide variation in conversion from IV fentanyl infusion directly to enteral methadone and variability in withdrawal in critically ill mechanically ventilated children exposed to prolonged sedation. In those children who converted successfully from IV fentanyl infusion to enteral methadone within a period of 48 h, a methadone:fentanyl dose conversion ratio of approximately 2.5:1 was associated with less withdrawal and reduced need for rescue opioids.

The effect of perioperative esmolol on early postoperative pain: A systematic review and meta-analysis.

Esmolol has been shown to improve postoperative pain and reduce opioid requirements. The aim of this systematic review was to evaluate the effect of perioperative esmolol as an adjunct on early postoperative pain intensity, recovery profile, and anesthetic requirement. Databases were searched for randomized placebo-controlled trials evaluating the effects of esmolol during general anesthesia. Primary outcomes were related to early postoperative pain whereas secondary outcomes were related to emergence time, postoperative nausea and vomiting, and intraoperative anesthetic requirement. Nineteen trials were identified involving 936 patients (esmolol = 470, placebo = 466). In esmolol group, numeric pain scores at rest in the immediate postoperative period were reduced by 1.16 (95% confidence interval [CI]: 1.97–0.35, I2 = 96.7%) out of 10. Opioid consumption was also decreased in the postanesthesia care unit compared with placebo, mean difference of 5.1 mg (95% CI: 7.0–3.2, I2 = 96.9%) morphine IV equivalents; a 69% reduction in opioid rescue dosing was noted (odds ratio [OR]: 0.31, 95% CI: 0.16–0.80, I2 = 0.0%). A 61% reduction in postoperative nausea and vomiting was also evident (OR: 0.39, 95% CI: 0.20–0.75, I2 = 60.7%). A reduction in propofol induction dose was noted in the esmolol group (mean difference: −0.53 mg/kg, 95% CI: −0.63–−0.44, I2 = 0.0%). A decrease in end-tidal desflurane equivalent (mean difference: 1.70%, 95% CI: −2.39–−1.02, I2 = 92.0%) and intraoperative opioid usage (fentanyl equivalent, mean difference: 440 μg, 95% CI: −637–−244, I2 = 99.6%) was observed in esmolol group. Esmolol had no effect on the emergence time. Perioperative esmolol as an adjunct may reduce postoperative pain intensity, opioid consumption, and postoperative nausea vomiting. Given the heterogeneity, larger clinical trials are warranted to confirm these findings.

A targeted remifentanil administration protocol based on the analgesia nociception index during vascular surgery

BackgroundThe intraoperative modulation of opioids continues to be based on clinical signs. This may result in adverse events such as sympathetic reactivity or opioid-induced hyperalgesia. Recently, the Analgesia/Nociception Index (ANI), a non-invasive 0–100 index derived from heart rate variability analysis, has been proposed for nociception assessment. However, the ability of the ANI to adequately guide intraoperative opioid administration has never been demonstrated. We designed a prospective study to evaluate the ability of the ANI to guide remifentanil administration in vascular surgery. MethodsOne hundred and eighty adults presenting for elective surgery were included. All received total intravenous anaesthesia with propofol adjusted to entropy and remifentanil adjusted to the ANI. The primary endpoint was the number of patients without any episode of reactivity defined as a 20% increase in heart rate or arterial pressure or the occurrence of movement. Secondary endpoints included opioid use and maximal pain rate in the first postoperative day. ResultsAnaesthesia was achieved without any episode of reactivity in 160 (89%) patients. Twenty-five episodes of reactivity occurred in 20 (11%) patients. The median remifentanil dose was 0.042 [0.040–0.044]μg.kg−1.min−1. At 24hours, the maximal NRS pain score was 2 [2,3]. One hundred and fifty-five patients (86%) did not receive any postoperative opioids, whereas 25 (14%) received a median dose of 5[5–10] mg of oxycodone. ConclusionThis prospective study demonstrated that the ANI can be used to adequately guide intraoperative remifentanil administration during vascular surgery. Such guidance resulted in low remifentanil consumption, low postoperative pain rates and low opioid rescue analgesia.

Retrolaminar block: analgesic efficacy and safety evaluation.

Retrolaminar block (RLB) is a thoracic truncal block that can produce analgesia for the thoracic and abdominal wall. However, the characteristics of RLB are not well known. The aim of this study was to determine analgesic efficacy by measuring postoperative consume of patient-controlled analgesia (PCA), additional nonsteroidal antiinflammatory drug (NSAID) rescue, and opioid rescue. Our secondary analysis included assessment of the chronological change in arterial levobupivacaine concentrations after the block. This prospective, randomized, double-blinded study included 30 patients scheduled for modified radical mastectomy under general anesthesia. The patients were randomized to receive either a landmark-guided RLB or paravertebral block (PVB) catheter placement on T4. Continuous infusion with 4ml/h of 0.25% levobupivacaine was started for 72h, after initial injection of 20ml 0.375% levobupivacaine before surgery. Postoperative pain was compared using the amount of block PCA (3ml 0.25% levobupivacaine with 30-min lockout), NSAID, and opioid rescue. Arterial blood was sampled for 120min after the initial injection. The frequency of postoperative block PCA use was significantly high after RLB in 24h [p=0.01; 6 (3-12) vs. 2.5 (0.3-3) times, respectively]. There was no PCA use after 24h in either group. There was no postoperative opioid rescue use throughout the study. After RLB and PVB, there was no significant difference in T max (p=0.14; 15±8 vs. 15±8min, respectively) and C max (p=0.2; 0.9±0.2 vs. 0.9±0.3µg/ml, respectively), and all the concentrations were below the threshold of local anesthetic systemic toxicity. Continuous RLB was not inferior to PVB except for the first 24h, and was satisfactory after mastectomy. RLB showed safe, low peak arterial levobupivacaine concentrations.

Multimodal analgesia model to achieve low postoperative opioid requirement following bariatric surgery.

To investigate whether a new anaesthesia protocol can reduce opioid use in obese patients following laparoscopic sleeve gastrectomy. This prospective observational case series was conducted in a private hospital in Hong Kong that has been accredited as a Centre of Excellence for Bariatric Surgery. Thirty consecutive patients scheduled for laparoscopic sleeve gastrectomy from 1 January 2015 to 31 March 2015 were reviewed. Of the 30 patients, 14 (46.7%) did not require any opioids for rescue analgesia during the entire postoperative period; six (20.0%) required rescue opioids only in the post-anaesthetic care unit, but not in the surgical ward. The mean postoperative total opioid requirement per patient was 32 mg of pethidine. With combination of multimodal analgesia with local anaesthetic infiltration, it is possible to avoid giving potent long-acting opioids in anaesthesia for bariatric surgery.

Eficacia y seguridad del bloqueo femoral continuo guiado con ecografía frente a la analgesia epidural en el postoperatorio de artroplastia total de rodilla

ObjectivesTotal knee arthroplasty is associated with severe postoperative pain. The aim of this study was to compare continuous ultrasound-guided femoral nerve block with continuous epidural analgesia, both with low concentrations of local anaesthetic after total knee arthroplasty. Material and methodsA prospective, randomised, unblinded study of 60 patients undergoing total knee replacement, randomised into two groups. A total of 30 patients received continuous epidural block, while the other 30 received continuous ultrasound-guided femoral nerve block, as well as using 0.125% levobupivacaine infusion in both groups. Differences in pain control, undesirable effects, and complications between the two techniques were assessed, as well as the need for opioid rescue and the level of satisfaction with the treatment received during the first 48hours after surgery. ResultsNo differences were found in demographic and surgical variables. The quality of analgesia was similar in both groups, although in the first six hours after surgery, patients in the epidural group had less pain both at rest and with movement (P=.007 and P=.011). This difference was not observed at 24hours (P=.084 and P=.942). Pain control at rest in the femoral block group was better at 48hours after surgery than in the epidural group (P=.009). The mean consumption of morphine and level of satisfaction were similar. Epidural analgesia showed the highest rate of side effects (P=.003). ConclusionsContinuous ultrasound-guided femoral nerve block provides analgesia and morphine consumption similar to epidural analgesia, with the same level of satisfaction, but with a lower rate of side effects after total knee arthroplasty.

Disminución de los requerimientos anestésicos y analgésicos postoperatorios, en pacientes sometidos a colecistectomía laparoscópica: premedicación con paracetamol versus ketorolaco intravenoso, un estudio aleatorizado y doble ciego

ObjectiveTo compare the effects of premedication with intravenous paracetamol versus ketorolac, in decreasing intraoperative anaesthetic and postoperative opioid analgesics requirements in patients undergoing laparoscopic cholecystectomy. MethodAn experimental, prospective, comparative, double blind, and randomised clinical trial was conducted to determine intraoperative opioid requirements, and pain and analgesic requirements in the postoperative period in 100 healthy patients undergoing laparoscopic cholecystectomy. They were randomised into 2 groups: Group 1: pre-medicated with paracetamol 1g, and Group 2: with ketorolac 30mg (both administered intravenously 30minutes prior to surgery). ResultsThere were no statistically significant differences between groups as regards intraoperative remifentanil use (Group 1: 0.0739±0.016μg/kg/min, Group 2: 0.0741±0.018μg/kg/min). The number of patients in Group 2 that had values of VAS>4 points (22.4%) was lower than in Group 1 (28.6%), but with no statistically significant difference. Of the patients who needed postoperative opioid rescue, most required a single rescue and application of analgesics during hospitalisation, that prevailed between 3 and 12hours, without any significant differences between groups. No adverse effects were observed in the study sample. ConclusionParacetamol 1g IV given preoperatively decreased anaesthetic requirements and the need for postoperative analgesics similar to the preoperative administration of ketorolac 30mg IV.

Continuous Popliteal Sciatic Blocks: Does Varying Perineural Catheter Location Relative to the Sciatic Bifurcation Influence Block Effects? A Dual-Center, Randomized, Subject-Masked, Controlled Clinical Trial

Multiple studies have demonstrated that, for single-injection popliteal sciatic nerve blocks, block characteristics are dependent upon local anesthetic injection relative to the sciatic nerve bifurcation. In contrast, this relation remains unexamined for continuous popliteal sciatic nerve blocks. We, therefore, tested the hypothesis that postoperative analgesia is improved with the perineural catheter tip at the level of the bifurcation compared with 5 cm proximal to the bifurcation. Preoperatively, subjects having moderately painful foot or ankle surgery were randomly assigned to receive an ultrasound-guided subepimyseal perineural catheter inserted either at or 5 cm proximal to the sciatic nerve bifurcation. Subjects received a single injection of mepivacaine 1.5% either via the insertion needle preoperatively or the perineural catheter postoperatively, followed by an infusion of ropivacaine 0.2% (6 mL/h basal, 4 mL bolus, and 30-min lockout) for the study duration. The primary end point was the average pain measured on a numeric rating scale (0-10) in the 3 hours before a data collection telephone call the morning after surgery. The average numeric rating scale of subjects with a catheter inserted at the sciatic nerve bifurcation (n = 64) was a median (10th, 25th to 75th, and 90th quartiles) of 3.0 (0.0, 2.4-5.0, and 7.0) vs 2.0 (0.0, 1.0-4.0, and 5.0) for subjects with a catheter inserted proximal to the bifurcation (n = 64; P = 0.008). Similarly, maximum pain scores were greater in the group at the bifurcation: 6.0 (3.0, 4.4-8.0, and 9.0) vs 5.0 (0.0, 3.0-8.0, and 10.0) (P = 0.019). Differences between the groups for catheter insertion time, opioid rescue dose, degree of numbness in the foot/toes, catheter dislodgement, and fluid leakage did not reach statistical significance. For continuous popliteal sciatic nerve blocks, a catheter inserted 5 cm proximal to the sciatic nerve bifurcation provides superior postoperative analgesia in subjects having moderately painful foot or ankle surgery compared with catheters located at the bifurcation. This is in marked contrast with single-injection popliteal sciatic nerve blocks for which benefits are afforded to local anesthetic injection distal, rather than proximal, to the bifurcation.

Liposomal Bupivacaine Injection Technique in Total Knee Arthroplasty.

Liposomal bupivacaine has gained popularity for pain control after total knee arthroplasty (TKA), yet its true efficacy remains unproven. We compared the efficacy of two different periarticular injection (PAI) techniques for liposomal bupivacaine with a conventional PAI control group. This retrospective cohort study compared consecutive patients undergoing TKA with a manufacturer-recommended, optimized injection technique for liposomal bupivacaine, a traditional injection technique for liposomal bupivacaine, and a conventional PAI of ropivacaine, morphine, and epinephrine. The optimized technique utilized a smaller gauge needle and more injection sites. Self-reported pain scores, rescue opioids, and side effects were compared. There were 41 patients in the liposomal bupivacaine optimized injection group, 60 in the liposomal bupivacaine traditional injection group, and 184 in the conventional PAI control group. PAI liposomal bupivacaine delivered via manufacturer-recommended technique offered no benefit over PAI ropivacaine, morphine, and epinephrine. Mean pain scores and the proportions reporting no or mild pain, time to first opioid, and amount of opioids consumed were not better with PAI liposomal bupivacaine compared with PAI ropivacaine, morphine, and epinephrine. The use of the manufacturer-recommended technique for PAI of liposomal bupivacaine does not offer benefit over a conventional, less expensive PAI during TKA.

Repeated Time-to-event Analysis of Consecutive Analgesic Events in Postoperative Pain.

Reduction in consumption of opioid rescue medication is often used as an endpoint when investigating analgesic efficacy of drugs by adjunct treatment, but appropriate methods are needed to analyze analgesic consumption in time. Repeated time-to-event (RTTE) modeling is proposed as a way to describe analgesic consumption by analyzing the timing of consecutive analgesic events. Retrospective data were obtained from 63 patients receiving standard analgesic treatment including morphine on request after surgery following hip fracture. Times of analgesic events up to 96 h after surgery were extracted from hospital medical records. Parametric RTTE analysis was performed with exponential, Weibull, or Gompertz distribution of analgesic events using NONMEM, version 7.2 (ICON Development Solutions, USA). The potential influences of night versus day, sex, and age were investigated on the probability. A Gompertz distribution RTTE model described the data well. The probability of having one or more analgesic events within 24 h was 80% for the first event, 55% for the second event, 31% for the third event, and 18% for fourth or more events for a typical woman of age 80 yr. The probability of analgesic events decreased in time, was reduced to 50% after 3.3 days after surgery, and was significantly lower (32%) during night compared with day. RTTE modeling described analgesic consumption data well and could account for time-dependent changes in probability of analgesic events. Thus, RTTE modeling of analgesic events is proposed as a valuable tool when investigating new approaches to pain management such as opioid-sparing analgesia.

An Overdose Antidote Goes Mainstream.

Expanded access to the opioid overdose rescue drug naloxone has raised complex questions for policy makers.

Age as a predictor of rescue opioid administration immediately after the emergence of general anesthesia

Background and objectivesWhile previous studies have shown that elderly patients require lower dosages of opioids, the literature suggests that pain is undertreated in the geriatric population, which may lead to postoperative pain and high rescue analgesia requirements. The purpose of this study is to determine whether elderly patients undergoing hip and knee arthroplasty require higher levels of postoperative rescue opioids than their younger counterparts early after emergence from anesthesia. MethodsUsing a nonconcurrent retrospective cohort study design, patients who underwent hip or knee arthroplasty under general anesthesia at a tertiary academic hospital from 2007 to 2012 were identified. Demographic information and data regarding patients' anesthetic care were obtained from the institution's anesthesia information management system. To assess the presence of pain after the emergence of anesthesia, we used, as a proxy, opioid administration by the anesthesia provider after leaving the operating room and before the end of anesthesia care. ResultsA total of 2731 patients met inclusion criteria, of which 487 (17.8%) received rescue opioids. Patients older than 80 years were less likely to receive opioids after leaving the operating room (odds ratio, 0.57; 95% confidence interval, 0.37-0.88; P = .01) and received 1.37 mg less of hydromorphone equivalent opioid compared to patients younger than the age of 50 years (95% confidence interval, 1.18-1.55; P < .001). The proportion of patients who received rescue opioids varied significantly between anesthesia providers from 0% to 38% (P < .001). ConclusionsWhile elderly patients received lower doses of opioids intraoperatively, they were less likely to require rescue analgesia. The variability among providers in rescue opioid administration after emergence presents an opportunity for further research.

Transversus Abdominis Plane Block to Alleviate Postoperative Pain in Children: A Meta-Analysis of Randomized Controlled Trials

Background: Transversus abdominis plane (TAP) block has been applied as one of multimodal approaches to alleviate postoperative pain in children. The aim of this meta-analysis was to determine the effect of TAP block on postoperative pain management for children who underwent surgery. Methods: The randomized controlled trials (RCTs) which evaluated the analgesia effect of TAP block in children who underwent surgery were searched on the databases of Medline, Embase, the Cochrane Controlled Trials Register and Google Scholar. The RCTs which compared the analgesic effect of TAP block group with control group (placebo or no treatment) in children were included. Postoperative opioid consumption (48 hours) was considered as the primary outcomes. The secondary outcomes included the number of children needed postoperative opioid analgesia rescue, the time to first analgesic administration (hours) and pain score. The risk ratios (RR), weighted mean differences (WMDs), and their corresponding 95% confidence intervals (95% CIs) were calculated for both dichotomous and continuous outcomes.Results: Five RCT trials with 257 children met our criteria and were included in the analysis. Compared with the control group, TAP block reduced the 48 hours morphine consumption by 0.03 mg/kg (95% CI -0.05 to -0.00, P=0.03, 159 children in 3 RCTs). Besides, the non-significant reductions were shown in the number of children needed postoperative opioid analgesia rescue (217 children in 4 RCTs) and time to first analgesic administration (hours, 184 children in 3 RCTs). Conclusions: TAP block is one of the safe and effective multimodal-approaches to alleviate postoperative pain in children. Specially, when the TAP block was used, it can significantly reduce the opioid consumption, which may avoid the occurrence of dose-dependent side effects of opioid drugs. Citation: Xiang Li, Xiao-Yun Li, Ji-Bin Xing, Ping Xiang, Zi-Qing Hei. Transversus abdominis plane block to alleviate postoperative pain in children: a meta-analysis of randomized controlled trials. J Anesth Perioper Med 2015; 2: 197-204. doi: 10.24015/JAPM.2015.0027This is an open-access article, published by Evidence Based Communications (EBC). This work is licensed under the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium or format for any lawful purpose. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/.

Transcutaneous electrical acupoint stimulation for the treatment of withdrawal syndrome in heroin addicts.

To assess the therapeutic effect of transcutaneous electric acupoint stimulation (TEAS) for the treatment of withdrawal syndrome in heroin addicts. A total of 63 male heroin addicts with withdrawal score higher than 20 were recruited in the Detoxification Center of Zhongshan city, Guangdong province, China. They were randomly distributed into two groups: TEAS group (n = 31) received TEAS by using a Han's acupoint nerve stimulator (HANS) model 200A with two output channels, 2-3 sessions per day, 30 minutes per session for 10 consecutive days. Electrical stimulation of alternating frequencies of 2- and 100-Hz with 3 second each, and with intensity of 10-15 mA was applied on Hegu (LI-4) and Laogong (PC-8) points on one hand, and Neiguan (PC-6) and Waiguan (SJ-5) points on the other forearm via electroconductive skin pads of 4 cm × 4 cm in size. The control group (n = 32) was treated with similar procedure except that the leads of the output of the stimulator was disconnected. Assessments of the severity of the withdrawal syndrome were conducted one day before and on each day during the whole treatment period of 10 days. Buprenorphin of 1 mg per day sublingually was provided to all subjects in the first two days, and then to those with withdrawal score over 20 in the following days. The TEAS treatment dramatically alleviated the withdrawal syndrome during heroin detoxification. No significant difference was found in withdrawal scores between the two groups at the beginning of the observation. Withdrawal scores showed a more marked drop in TEAS group than the control starting from the second day, and maintained at a lower level for the whole course of treatment. The area under the curve of withdrawal score in TEAS group was only 40% of that in the control (P < 0.001, two way repeated measures analysis of variance), and the requirement of buprenorphine was only 10% of that in the control. No adverse effects were observed in either group. TEAS of 2/100 Hz for 10 days in abrupt abstinence of the heroin addicts resulted in a marked reduction of the withdrawal syndrome as well as a reduced requirement for rescue opioids.

(401) Analgesic effectiveness of a new, extended-release ibuprofen in postoperative dental pain

Analgesic effects of an immediate-release/extended-release (IR/ER) 600 mg formulation of ibuprofen (IBU) with q12h dosing were evaluated in 2 single-center, randomized, double-blind, placebo-controlled dental pain studies (Study 1: single dose, 24-hour study; Study 2: multiple doses, 48-hour study). Subjects aged 16–40 years with at least moderate pain following third molar extraction received single doses of 2 IBU 600 mg IR/ER formulations (A or B), naproxen sodium (NAP) 220 mg, or placebo (2:2:2:1 ratio) in Study 1; 4 doses IBU 600 mg IR/ER or placebo (1:1 ratio) in Study 2. Primary efficacy: Study 1, time-weighted sum of pain intensity difference (SPID) scores from 0–12 and 8–12 hours; Study 2, time-weighted sum of pain relief and pain intensity differences (SPRID) from 0–12 and 8–12 hours. In Study 1 (N=196), mean (standard deviation [SD]) SPID 0–12 scores were 0.05 (9.2), 16.87 (9.4), 17.34 (10.5), and 12.66 (10.0) and mean (SD) SPID 8–12 scores were -0.03 (4.1), 6.57 (4.4), 7.14 (5.2), and 5.14 (5.0) for placebo, IBU IR/ER A, IBU IR/ER B, and NAP, respectively (P<0.001, all comparisons vs placebo). In Study 2 (N=106), mean (SD) SPRID 0–12 scores were 18.2 (20.0) vs 41.5 (21.0) and mean (SD) SPRID 8–12 scores were 10.3 (12.0) vs 18.4 (12.1) for placebo and IBU IR/ER, respectively (P<0.001, both favoring IBU IR/ER). SPID score separation from placebo at predefined intervals was maintained throughout the 48-hour study, except for the 20- to 24-hour interval. Significantly more AEs occurred with placebo in Study 1 (P=0.045) and Study 2 (P=0.001); gastrointestinal AEs predominated in subjects receiving placebo, likely due to opioid rescue medication use. No serious AEs occurred. IBU 600 mg IR/ER administered every 12 hours provided safe and effective analgesia following both single and multiple doses. Supported by Pfizer Consumer Healthcare. Analgesic effects of an immediate-release/extended-release (IR/ER) 600 mg formulation of ibuprofen (IBU) with q12h dosing were evaluated in 2 single-center, randomized, double-blind, placebo-controlled dental pain studies (Study 1: single dose, 24-hour study; Study 2: multiple doses, 48-hour study). Subjects aged 16–40 years with at least moderate pain following third molar extraction received single doses of 2 IBU 600 mg IR/ER formulations (A or B), naproxen sodium (NAP) 220 mg, or placebo (2:2:2:1 ratio) in Study 1; 4 doses IBU 600 mg IR/ER or placebo (1:1 ratio) in Study 2. Primary efficacy: Study 1, time-weighted sum of pain intensity difference (SPID) scores from 0–12 and 8–12 hours; Study 2, time-weighted sum of pain relief and pain intensity differences (SPRID) from 0–12 and 8–12 hours. In Study 1 (N=196), mean (standard deviation [SD]) SPID 0–12 scores were 0.05 (9.2), 16.87 (9.4), 17.34 (10.5), and 12.66 (10.0) and mean (SD) SPID 8–12 scores were -0.03 (4.1), 6.57 (4.4), 7.14 (5.2), and 5.14 (5.0) for placebo, IBU IR/ER A, IBU IR/ER B, and NAP, respectively (P<0.001, all comparisons vs placebo). In Study 2 (N=106), mean (SD) SPRID 0–12 scores were 18.2 (20.0) vs 41.5 (21.0) and mean (SD) SPRID 8–12 scores were 10.3 (12.0) vs 18.4 (12.1) for placebo and IBU IR/ER, respectively (P<0.001, both favoring IBU IR/ER). SPID score separation from placebo at predefined intervals was maintained throughout the 48-hour study, except for the 20- to 24-hour interval. Significantly more AEs occurred with placebo in Study 1 (P=0.045) and Study 2 (P=0.001); gastrointestinal AEs predominated in subjects receiving placebo, likely due to opioid rescue medication use. No serious AEs occurred. IBU 600 mg IR/ER administered every 12 hours provided safe and effective analgesia following both single and multiple doses. Supported by Pfizer Consumer Healthcare.

Assessment of rescue opioid use in patients with post-bunionectomy pain treated with diclofenac potassium liquid-filled capsules

When used in multimodal analgesia for acute pain, nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce the requirement for opioids during the perioperative period. To provide more insight into pain treatment during the outpatient period, we examined the use of opioid rescue medication (RM) and described the relationship between pain intensity and RM use in patients with acute pain after bunionectomy. Patients received placebo or 25 mg of a liquid-filled capsule version of the NSAID diclofenac potassium (DPLFC; n=188 patients/group) every 6 hours during the 48-hour inpatient period through the end of outpatient dosing on day 4. Opioid RM (hydrocodone/acetaminophen tablets, 5 mg/500 mg) was available as needed, but taken at least 1 hour post-study medication. Fewer patients taking DPLFC versus placebo requested opioid RM during the inpatient period (4.8%–44.7% versus 25.0%–90.4%) and also during the outpatient period (3.7%–16.0% versus 13.1%–46.4%). Moderate or severe pain after surgery (P=0.0307 and P=0.0002, respectively) or at second dose (P=0.0006 and P=0.0002, respectively) was predictive of RM use. Patients taking RM (placebo/DPLFC) reported more adverse events (RM 55.7%/40.6%; no RM 29.4%/26.0%). Most adverse events in the RM group were opioid-related. In summary, this study shows that DPLFC lowers the requirement for opioids, which is associated with a reduction in the occurrence of treatment side effects, while maintaining adequate analgesia for patients with moderate acute pain in both the outpatient and outpatient periods. Patients with more severe pain are more likely to use RM, but they still use fewer opioids when treated with DPLFC. This suggests that multimodal treatment using DPLFC and an opioid may offer an important clinical benefit in the treatment of acute pain, including in the home environment.