Satisfactory Pain Control Research Articles

Intraoperative Psoas Compartment Block vs Preoperative Fascia Iliaca Block for Pain Control After Direct Anterior Total Hip Arthroplasty: A Randomized Controlled Trial

BackgroundModern joint arthroplasty protocols place an emphasis on minimizing patient-reported postoperative pain while minimizing opioid consumption. The use of multimodal pain management protocols has been reported to improve patient outcomes and satisfaction after total hip arthroplasty. MethodsIn a prospective, single-surgeon trial, 50 patients undergoing primary direct anterior approach total hip arthroplasty were randomized to receive a preoperative fascia iliaca compartment block (FICB) or an intraoperative surgeon-delivered psoas compartment block (PCB). Patient-reported pain was recorded in the postanesthesia care unit, recovery floor and 3 weeks postoperatively. Opioid use was recorded during the hospital stay. ResultsAverage visual analog scale pain scores in the postanesthesia care unit were 38.7 ± 8.7 vs 35.6 ± 8.3 (P = .502) for the preoperative FICB and intraoperative PCB groups, respectively. No significant difference was found between groups at the 3-week visit for postoperative pain (FICB: 2.9 ± 1.4; PCB: 3.2 ± 2.0; P = .970) and patient-reported pain satisfaction (FICB: 8.8 ± 2.2; PCB: 9.7 ± 0.6; P = .110). ConclusionDuring the direct anterior approach for total hip arthroplasty, PCB is an effective and efficient regional anesthesia technique. It may be used to obtain satisfactory postoperative pain control and patient satisfaction while decreasing hospital resources.

Postoperative pain and analgesia administration in children after urological outpatient procedures

There are limited data about pain patterns, analgesic requirements and factors predicting opioid requirements of children undergoing outpatient urologic surgery. This prospective study aimed to assess recovery profiles and pain medication requirements. Patients between 6 months and 12 years of age were recruited prospectively between December 2013 and June 2014. Demographic and operative characteristics were collected. Following discharge home, the parents were asked to administer both acetaminophen and ibuprofen Q6H at a weight-adjusted dose, based on a schedule, until the end of postoperative day 2, and to administer the medication as required on postoperative day 3. Pain severity was recorded using validated pain scores (Face, Legs, Activity, Cry, Consolability/Parents' Postoperative Pain Measurement). A morphine prescription was provided for breakthrough pain. A Likert scale was used to assess parent's satisfaction with the pain management. A total of 249 patients were recruited, 111 patients (45%) returned appropriately completed surveys and were included in the final analysis. Mean age was 44.1 months (SD=37.3). The performed procedures were orchidopexy (31), hypospadias repair (26), hernia/hydrocele repair (15), Fowler-Stephens procedure (13), meatoplasty (7), phalloplasty (4), scrotoplasty (1), circumcision (7), and diagnostic laparoscopy (5). After discharge home 17 patients (15.3%) received morphine. Mean utilization of non-opioid analgesia was 79% on postoperative day 1, 67% on day 2, 36% on day 3, and 2% on day 4. Parental satisfaction was high (92.0% satisfied/very satisfied). No patient, anaesthetic or surgical factors were associated with opioid use or prolonged need for postoperative analgesia. The combination of scheduled non-opioid medications for maintenance and opioids for breakthrough pain provided satisfactory pain control after outpatient urologic surgery in children. There wereno specific patient, anesthetic or surgical factors that predicted postoperative opioid requirements.

UNderstanding pain in aged care: the UNPAC study – exploring the nature and treatment of chronic pain in the Australian aged care setting

AbstractObjectiveTo analyse management of chronic pain in the Australian aged care setting.MethodsIn the course of performing medication reviews, details of medications prescribed (including dosage) were collated and stored in a secure database along with information about medical morbidities, demographic data and the results of clinical investigations. Details of analgesic and adjuvant medication used in pain management was subjected to de‐identified analysis.ResultsThere were 22 319 reviews analysed. Prescribing of opiate analgesics was widespread, with products containing oxycodone used in 24% of cases. Many residents were concurrently prescribed two or more analgesics. Adjuvant agents were prescribed in 3073 cases, with the most commonly used individual agent being pregabalin (n = 1411). Use of medications for management of adverse effects associated with opioids was common.ConclusionUse of analgesics and related medications is widespread in the aged care sector. These agents are associated with significant adverse effects, and older people may not tolerate doses that deliver satisfactory pain control.

Effectiveness of postoperative analgesia in the management of acute pain in day-case surgeries.

Background:Surgery is the most common source of acute pain.Aim:To determine the intensity of acute pain following day case surgery and evaluate the effectiveness of the prescribed analgesics.Methods:A descriptive observational study carried out at the main operating and the Urology Outpatient theatre suites of the University College Hospital, Ibadan. Seventy consecutive adult patients presenting for day case surgeries between July and September 2013 were recruited. The procedures were stratified as follows: peripheral, groin/perineal, urologic/endoscopy or orthopedic/plastic surgeries. The prescribed postoperative oral analgesics were paracetamol alone or in combination with diclofenac, tramadol or both. Postoperative pain intensity was assessed on arrival in the recovery room and at 6, 12, 24, 48, & 72 hours using the Verbal Intensity Pain Scale (VIPS). The pain scores were presented as mean±SD at different time intervals for each stratified surgical procedures and analgesics using tables and frequency bar charts. A mean pain score of less than 2 for each category of surgical procedures or analgesics group was considered as satisfactory pain control and thus effective analgesia.Result:The overall prevalence of moderate to worst possible pain after surgery in this study was 54.3% on arrival in the recovery room. The mean pain score was greater than 2 at 6 hours postoperative in all surgical categories except in patients who had peripheral surgeries irrespective of single or combination analgesic therapy.Conclusion:A high proportion of patients arrived in the recovery room with a high pain score; measures to improve intraoperative analgesia should be employed.

Surgical Management of Breast Cancer under Local Anaesthesia: A Surgeon's Perspective

Background: Treatment of breast cancer without surgery may not be effective. But in elderly patients with lots of co-morbidities, surgical management often cannot be done due to the significant risks of general anesthesia. The need for a safe, easy and effective alternative anaesthetic technique that can provide adequate peroperative analgesia as well as reduced anxiety in such group of patients was the main indication for this study.Materials and method: This prospective study was done on eleven patients, with coexisting medical conditions and who were not at all fit for general anaesthesia, and underwent breast cancer surgery under local anaesthesia. The patients were studied with regard to intraoperative analgesia, haemodynamic stability and complications related to technique. The study was done in Delta Medical College Hospital, Dhaka, Bangladesh.Results: Mean±SD of study patients were 64.7±7 years old and all were suffering from coexisting medical conditions. Following local anaesthesia, mean intraoperative heart rate was 81.5±11.8 beats/min and the mean blood pressure was 127.3/79±9.6/7.0 mmHg. Patients felt no pain after infiltration of local anaesthetics, but experienced it if any place was missed before dissection. No complication occurred due to this procedure. All the candidates were fully satisfied with the procedure.Conclusion: Local anaesthesia provides satisfactory pain control along with keeping haemodynamics stable for surgical treatment of breast cancer among elderly patients having co-morbid conditions.Delta Med Col J. Jul 2017 5(2): 63-67

Truebeam Radiosurgery for the Treatment of Trigeminal Neuralgia: Preliminary Results at a Single Institution.

IntroductionRadiosurgery is now an established method of satisfactory pain control in patients with trigeminal neuralgia (TN). The Varian Truebeam STx (Varian Medical Systems, Palo Alto, CA) linear accelerator (LINAC) system is an arc-based, frameless stereotactic radiosurgery system used for the treatment of TN. To our knowledge, there has been only one published series of patient histories that documents the use of a frameless LINAC system for the treatment of TN. We describe the treatment parameters, patient outcomes, and complications associated with the treatment of TN.MethodsAll patients treated with the Truebeam system for TN between 2012 and 2015, with at least a six-month follow-up, were identified. A dose of 90 Gy was delivered to the isocenter using a 0.5 cm diameter cone. The cisternal segment of the trigeminal nerve was placed at the location of the LINAC isocenter using an ExacTrac™ (Brainlab, Munich, Germany) image guidance system. The radiosurgical dose, Barrow Neurologic Institute pain score (BNI PS), symptom recurrence, magnetic resonance imaging (MRI) radiographic changes, and other complications, including Barrow Neurologic Institute facial numbness score (BNI FN), were analyzed.ResultsA total of 18 patients—15 women and 3 men—with a mean age of 58 years (median: 59 years; range: 22-84 years) were treated at our institution. Fourteen patients (78%) had a BNI PS of IIIb or better, which was considered successful treatment. Twelve patients had excellent (BNI PS I) pain relief and two patients had good (BNI PS II-IIIB; recurrence after one year) pain relief. The pain of four patients recurred after a mean of 10 months.ConclusionTruebeam radiosurgery can provide effective and safe treatment for patients suffering from TN. The efficacy appears similar to other frame- and frameless-based systems

The clinical significance of persistent trigeminal nerve contrast enhancement in patients who undergo repeat radiosurgery.

OBJECTIVE Contrast enhancement of the retrogasserian trigeminal nerve on MRI scans frequently develops after radiosurgical ablation for the management of medically refractory trigeminal neuralgia (TN). The authors sought to evaluate the clinical significance of this imaging finding in patients who underwent a second radiosurgical procedure for recurrent TN. METHODS During a 22-year period, 360 patients underwent Gamma Knife stereotactic radiosurgery (SRS) as their first surgical procedure for TN at the authors' center. The authors retrospectively analyzed the data from 59 patients (mean age 72 years, range 33-89 years) who underwent repeat SRS for recurrent pain at a median of 30 months (range 6-146 months) after the first SRS. The isocenter was 4 mm, and the median maximum doses for the first and second procedures were 80 Gy and 70 Gy, respectively. A neuroradiologist and a neurosurgeon blinded to the treated side evaluated the presence of nerve contrast enhancement on MRI series at the time of the repeat procedure. The authors correlated the presence of this imaging change with clinical outcomes. Pain outcomes and development of trigeminal sensory dysfunction were evaluated with the Barrow Neurological Institute (BNI) Pain Scale and BNI Numbness Scale, respectively. The mean length of follow-up after the second SRS was 58 months (95% CI 49-68 months). RESULTS At the time of the repeat SRS, contrast enhancement of the trigeminal nerve on MRI scans was observed in 31 patients (53%). Five years after the SRS, patients with this enhancement had lower actuarial rates of complete pain relief after the repeat SRS (27% [95% CI 7%-47%]) than patients without the enhancement (76% [95% CI 58%-94%]) (p < 0.001). At the 5-year follow-up, patients with the contrast enhancement also had a higher risk for trigeminal sensory loss after repeat SRS (75% [95% CI 59%-91%]) than patients without contrast enhancement (26% [95% CI 10%-42%]) (p = 0.001). Dysesthetic pain after repeat SRS was observed for 8 patients with and for 2 patients without contrast enhancement. CONCLUSIONS Trigeminal nerve contrast enhancement on MRI scans observed at the time of a repeat SRS for TN was associated with less satisfactory pain control and more frequently detected facial sensory loss. Residual contrast enhancement at the time of a repeat SRS may warrant consideration of dose reduction or further separation of the radiosurgical targets.

Iliocostalis Thoracis-Lumborum Myofascial Pain: Reviewing a Subgroup of a Prospective, Randomized, Blinded Trial. A Challenging Diagnosis with Clinical Implications

Background: Pain of myofascial origin is a well-recognized pathology characterized by the presence of two components: referred pain; which is often distant from its source and specific to each muscle, and the trigger point, a localized hyperirritable band present in the affected muscle and able to reproduce the referred pain when stimulated. Myofascial pain (MP) commonly coexists in patients with acute or chronic pain of other etiologies. The uniqueness of the clinical presentation of some MPs and the lack of training of most specialties represent a clinical challenge. Thus, many patients with MPS receive less than optimal management of this condition. Objective: Pain at the anterior torso, originating at the posterior torso, can mimic common pathologies that correlate with the same anatomical area such as cardiac and intra-abdominal conditions. These clinical characteristics could be caused by MP of the iliocostalis thoracis-lumborum (ITL) muscle. However, this entity has not been well addressed in the medical literature. In this report we characterize the manifestations, diagnosis, and clinical implications of ITL MP. Study Design: Observational assessment. Setting: Two university-based academic emergency medicine departments (ED) in an urban setting in the United States. Methods: A convenience sample of 43 patients who presented to the ED with pain at the anterior aspect of the torso (chest, abdomen, or pelvis) and clinical evidence of MP originated in the ITL muscle. Of a clinical trial of patients with MP, we describe a subgroup of patients with MP of the ITL which was clinically evident by the presence of a trigger point (TP) in its ability to reproduce the referred pain present at the anterior aspect of the torso. Patients received a TP injection. In this trial we intend to demonstrate that TP injections using particulate steroids mixed with a local are no more effective than saline alone to treat MP. The primary outcome was pain control (decrease in intensity of 50% or more below baseline numeric pain rating). A follow-up telephone interview was performed by third-party abstractors. Results: Forty-three patients presented with pain of the anterior torso and ipsilateral back, both correlating with the level of the TP of the ITL muscle. The pain had been present from 2 days to 7 years. The most common locations of pain were the right-lower quadrant and the left side of the chest. In many of them a pattern of missed diagnosis was evident despite extensive workups and consultations. Only 17 patients were able to identify the precipitating event; the most common was coughing. Two weeks after TP injection, all patients still had satisfactory pain control. After treatment, no missed pathology or returns to the ED were reported. Limitations: This descriptive portion of the ongoing study does not affect the integrity of the trial itself but could be subject to the introduction of subject selection and selective reporting bias. Similarly, this convenience sample does not establish the incidence of this pathology and challenges the external validity to other clinical settings. Conclusions: Anterior torso pain often resulted in extensive workups before ITL myofascial pain was diagnosed. TP injections were diagnostic and therapeutic of ITL myofascial pain. Key words: Iliocostalis thoracis-lumborum muscle, myofascial pain, referred pain, trigger point injection

Ultrasound-guided block of selective branches of the brachial plexus for vascular access surgery in the forearm: a preliminary report.

The operative field for vascular access (VA) surgery in the forearm is on the volar surface, and motor nerve block is not necessary for regional anesthesia. Therefore, selective block of branches of the brachial plexus may be a more efficient anesthesia technique. Individual nerve blocks in the axillary brachial plexus and selective blocks of the musculocutaneous and medial antebrachial cutaneous nerves in the upper arm were performed using low doses and concentrations of a local anesthetic mixture of lidocaine and ropivacaine under ultrasound (US) guidance in patients undergoing VA surgery in the forearm. The targeted nerves were identified by continuous US tracing along the upper arm to the axilla in a short-axis view. We performed three VA surgeries in the forearm using an axillary brachial plexus block and four using a selective two-nerve bock in the upper arm. We recorded any additional anesthetic requirement and evaluated intraoperative pain using the Wong-Baker Faces Pain Rating Scale (WBFRS; 0 = no pain; 10 = worst pain). All of the target nerve branches were clearly identified by US tracing. All patients had satisfactory intraoperative pain control (0 or 2 score on WBFRS). Four patients required small additional doses of local anesthetic. US-guided block of individual branches of the brachial plexus at the axilla achieved effective anesthesia using small amounts of local anesthetic. An advanced selective nerve block in the upper arm allows minimum necessary anesthesia and provides safe and efficient analgesia for VA surgery in the forearm.

Transitional Study of Patient-Controlled Analgesia Morphine With Ketorolac to Patient-Controlled Analgesia Morphine With Parecoxib Among Donors in Adult Living Donor Liver Transplantation: A Single-Center Experience

BackgroundIn this study, as our center transitions from using patient-controlled analgesia (PCA) morphine with intravenous (IV) ketorolac to PCA morphine with IV parecoxib, the two regimens are compared in terms of quality of pain control. MethodsPost-operative pain management sheets were collected retrospectively among the living donors of liver transplantation during this transitional period. Group parecoxib was given plain PCA morphine. A single dose of IV parecoxib 40 mg was given 30 minutes before the end of surgery. Group ketorolac was given PCA morphine pre-mixed ketorolac with a concentration of 1.87 mg/mL. Daily and total morphine consumption, Visual Analog Score (VAS), and number of rescue attempts made up to 3 post-operative days, together with satisfaction score and incidence of side effects of PCA usage, were analyzed and compared by means of the Mann-Whitney U test; a value of P < .05 was regarded as significant, and data are given as mean ± SD. ResultsFifty patients were analyzed; group 1 comprised 21 patients and group 2 comprised 29 patients. There was no difference between group 1 and group 2 in terms of daily VAS. PCA morphine requirements were significantly lower at day 2 and day 3 in group 1. However, the total overall morphine usage and satisfactory score was not statistically different (P = .863, P = .052). ConclusionsA single dose of IV parecoxib 40 mg can provide satisfactory pain control when paired with PCA morphine for donors undergoing living donor liver transplantation. The use of parecoxib in the multimodal analgesia regimen has similar efficacy, with possibly less morphine consumption, when compared with ketorolac.

Pain Management for Gynecologic Procedures in the Office.

Satisfactory pain control for women undergoing office gynecologic procedures is critical for both patient comfort and procedure success. Therefore, it is important for clinicians to be aware of the safety and efficacy of different pain control regimens. This article aimed to review the literature regarding pain control regimens for procedures such as endometrial biopsy, intrauterine device insertion, colposcopy and loop electrosurgical excisional procedure, uterine aspiration, and hysteroscopy. A search of published literature using PubMed was conducted using the following keywords: "pain" or "anesthesia." These terms were paired with the following keywords: "intrauterine device" or "IUD," "endometrial biopsy," "uterine aspiration" or "abortion," "colposcopy" or "loop electrosurgical excisional procedure" or "LEEP," "hysteroscopy" or "hysteroscopic sterilization." The search was conducted through July 2015. Articles were hand reviewed and selected by the authors for study quality. Meta-analyses and randomized controlled trials were prioritized. Although local anesthesia is commonly used for gynecologic procedures, a multimodal approach may be more effective including oral medication, a dedicated emotional support person, and visual or auditory distraction. Women who are nulliparous, are postmenopausal, have a history of dysmenorrhea, or suffer from anxiety are more likely to experience greater pain with gynecologic procedures. Evidence for some interventions exists; however, the interpretation of intervention comparisons is limited by the use of different regimens, pain measurement scales, patient populations, and procedure techniques. There are many options for pain management for office gynecologic procedures, and depending on the procedure, different modalities may work best. The importance of patient counseling and selection cannot be overstated.

A randomised, double-blinded study comparing giving etoricoxib vs. placebo to female patients with fibromyalgia.

Current therapeutic approaches to fibromyalgia syndrome (FMS) do not provide satisfactory pain control to a high percentage of patients. This unmet need constantly fuels the pursuit for new modalities for pain relief. This randomised, double-blind, controlled study assessed the efficacy and safety of adding etoricoxib vs. placebo to the current therapeutic regimen of female patients with FMS. In this double-blind, placebo-controlled study, female patients were randomised to receive either 90 mg etoricoxib once daily or placebo for 6 weeks. Several physical and mental parameters were assessed throughout the study. The primary end-point was the response to treatment, defined as ≥ 30% reduction in the average Brief Pain Inventory score. Secondary outcomes were changes in the Fibromyalgia Impact Questionnaire, SF-36 Quality of Life assessment questionnaire and Hamilton rating scales for anxiety and depression. Overall, 73 patients were recruited. Although many outcome measures improved throughout the study, no difference was recorded between the etoricoxib- and placebo-treated groups. The Brief Pain Inventory, Fibromyalgia Impact Questionnaire, The Hamilton Anxiety and Depression scores did not differ between the two groups. This is the first randomised, double-blind study assessing the effect of adding etoricoxib to pre-existing medications for female patients with FMS. Although being mildly underpowered this study clearly has shown that etoricoxib did not improve pain scores and did not lead to any beneficial mental or physical effects.

Association between UGT2B7 gene polymorphisms and fentanyl sensitivity in patients undergoing painful orthognathic surgery.

BackgroundFentanyl is often used instead of morphine for the treatment of pain because it has fewer side effects. The metabolism of morphine by glucuronidation is known to be influenced by polymorphisms of the UGT2B7 gene. Some metabolic products of fentanyl are reportedly metabolized by glucuronate conjugation. The genes that are involved in the metabolic pathway of fentanyl may also influence fentanyl sensitivity. We analyzed associations between fentanyl sensitivity and polymorphisms of the UGT2B7 gene to clarify the hereditary determinants of individual differences in fentanyl sensitivity.ResultsThis study examined whether single-nucleotide polymorphisms (SNPs) of the UGT2B7 gene affect cold pain sensitivity and the analgesic effects of fentanyl, evaluated by a standardized pain test and fentanyl requirements in healthy Japanese subjects who underwent uniform surgical procedures. The rs7439366 SNP of UGT2B7 is reportedly associated with the metabolism and analgesic effects of morphine. We found that this SNP is also associated with the analgesic effects of fentanyl in the cold pressor-induced pain test. It suggested that the C allele of the rs7439366 SNP may enhance analgesic efficacy. Two SNPs of UGT2B7, rs4587017 and rs1002849, were also found to be novel SNPs that may influence the analgesic effects of fentanyl in the cold pressor-induced pain test.ConclusionsFentanyl sensitivity for cold pressor-induced pain was associated with the rs7439366, rs4587017, and rs1002849 SNPs of the UGT2B7 gene. Our findings may provide valuable information for achieving satisfactory pain control and open to new avenues for personalized pain treatment.

N19 - Efficacy and tolerability of oxycodone-naloxone prolonged release tablets (o/n –prt) for moderate to severe bone pain in cancer patients (pts) bone metastases (bm): data from a single-centre experience

Background: Bone pain still represents a major issue in cancer pts with bone metastases. Mild to moderate bone pain can be efficiently controlled using NSAIDs +/- weak opioids +/- adjuvant drugs whereas strong opioids are needed to control moderate to severe pain. Due to its unique mechanism of action, O/N-PRT can achieve a satisfactory control of pain with less side effects in terms of constipation. In our center we have evaluated efficacy and safety of O/N-PRT in cancer pts with symptomatic BM. Patients And methods: From March 2013 to November 2014, we evaluated efficacy and tolerability of O/N-PRT in 203 consecutive cancer pts with painful BM. Median age was 62.4 years ( range: 37-86 yrs); all pts had moderate to severe bone pain despite analgesic treatment with NSAIDs +/- weak opioids +/- adjuvant drugs. Median pain intensity (assessed on a 10-point NRS) at baseline was 6.9 (range: 6-9). After discontinuation of weak opioids, O/N-PRT was administered at dose 20/10 mg bid; after baseline, pain intensity was evaluated at day 1, 3, 5 and 7 whereas adverse events and QoL scores were daily assessed for 7 consecutive days. Results: Efficacy and safety of O/N-PRT were assessed in all recruited pts. Median pain intensity progressively decreased as follows: at day 1 a median NRS of 4.8 (range 3-6)was detected; at day 3, 5 and 7 median NRS values were 3.6 (range 3-5), 3.1 (range 2-5) and 2,2 (range 1-4), respectively. During the entire period of evaluation no modifications of QoL scores were reported; adverse events were modest: only 43 pts experienced mild constipation easily treated with common laxatives. Conclusions: In our experience, O/N-PRT confirmed its satisfactory efficacy and tolerability in cancer pts with moderate to severe pain due to BM: it represents an effective therapeutic option in cancer pts with symptomatic BM.

Treatment of Central Deafferentation and Trigeminal Neuropathic Pain by Motor Cortex Stimulation: Report of a Series of 20 Patients.

Motor cortex stimulation (MCS) is an alternative treatment modality for central neuropathic pain, if conservative treatment failed. Study aim was outcome assessment after MCS. This study is a retrospective case series review of patients who had undergone MCS for central pain (n = 8), deafferentation pain (n = 3) and neuropathic trigeminal pain (n = 9) between April 2001 and May 2011. In all patients, four contact-paddle electrodes were placed in the epidural space overlying the motor cortex via burr hole trepanation under local anesthesia. The follow-up period was 6 months to 6 years. Pain control was assessed by the visual analog scale (VAS). A total of 22 patients (11 men, 11 women) were treated; after trial stimulation two male patients were excluded for incompliance reasons. The mean patient age was 59.8 years (range: 31-79 years). In the central pain group, three patients reported complete, and four patients satisfactory pain control. In the trigeminal neuropathic pain group, seven patients reported complete, and two patients satisfactory pain control. In the deafferentation pain group, one patient reported complete, and two patients satisfactory pain control. None of the patients showed new neurologic deficits after the MCS. MCS is an effective treatment modality for central neuropathic pain and trigeminal pain with low morbidity and mortality. Future studies are necessary to evaluate and optimize this treatment option in more detail.

Efficacy of an Acute Pain Titration Protocol Driven by Patient Response to a Simple Query: Do You Want More Pain Medication?

We assess the efficacy of a simple pain titration protocol of 1-mg increments of intravenous hydromorphone, given at fixed intervals, driven solely by patient response to a yes/no question. This was a prospective interventional cohort study of nonelderly adults with acute severe pain defined asrequiring intravenous opioids in the judgment of the attending emergency physician. All patients received 1 mg intravenous hydromorphone and 30 minutes later were asked, "Do you want more pain medication?" Patients responding yes received an additional 1 mg of intravenous hydromorphone and were asked the same question 30minutes after receiving it. Those responding no did not receive additional opioid and were asked the question again 30minutes later. Each patient was queried 4 times. The primary endpoint was the proportion of patients achieving satisfactory pain control, defined as declining additional pain medication on 1 or more occasions. Of 215 patients enrolled, there were 8 protocol violations, leaving 207 patients with analyzable data; 205 of207 patients (99%; 95% confidence interval 97% to 100%) achieved satisfactory analgesia at 1 or more points during the study. Nine patients desaturated below 95% on room air, 2 had respiratory rates less than 10 breaths/min, and 2had pulse rates less than 50 beats/min. No adverse events were associated with amount of hydromorphone received. A pain protocol, based on titration of 1 mg intravenous hydromorphone, driven solely by patient response to a simple standardized question repeated at intervals, resulted in achievement of satisfactory analgesia on at least 1occasion in 99% of patients.

Effect of Cyclooxygenase-2-Specific Inhibitors on Postoperative Analgesia after Major Open Abdominal Surgery

The aim of this study was to examine the effect of cyclooxygenase-2 (COX-2)-specific medications on postoperative analgesia after major open abdominal surgery. This is was a prospective, randomized controlled, double-blind study conducted on 90 patients who underwent major open abdominal surgery between September 2011 and June 2012, in the General Surgery Department, Jinling Hospital. After written informed consent, patients were prospectively and randomly assigned to one of three treatment groups before surgery, and were scheduled to receive different analgesic drugs according to randomization. We assessed the patients' pain levels using pain intensity score and adverse events during our study period. The group that received intravenous parecoxib for 3 days, and continued oral celecoxib for 4 days had better postoperative analgesia than other groups. COX-2-specific inhibitors are safe and effective in reducing postoperative pain in patients who have undergone major open abdominal surgery. Additionally, sufficient postoperative analgesia, lasting for 1 week, was necessary for patients to obtain satisfactory pain control after major open abdominal surgery.

Putting it all together: recommendations for pain management in nonsurgical facial rejuvenation.

Nonsurgical procedures for facial rejuvenation vastly outnumber surgical procedures among board-certified plastic surgeons; interest in nonsurgical cosmetic procedures is rapidly growing for patients and physicians, with less down time, less scars, and potentially less cost. Nonsurgical procedures are often a gateway for patients into more invasive surgical procedures. Providing patients with a comfortable, pleasant experience increases the chance of referrals and return for future procedures, surgical and nonsurgical. In this review article, we describe basic principles for providing patients with a pleasant, minimal pain experience during nonsurgical facial rejuvenation procedures. The procedures are grouped into injectables, noninvasive devices, and minimally invasive devices, and basic guidelines for pain management are provided. A review of each nonsurgical facial rejuvenation procedure is provided with typical patient perception of discomfort and methods to reduce or eliminate pain. This article covers the most popular procedures performed in many plastic surgery offices but is not inclusive of all devices and technologies available on the market. A wide range of nonsurgical options exist for rejuvenation, and there is nearly as much variety in pain associated with these procedures. As with any procedure that potentially may lead to pain or anxiety for a patient, it is important to assess patient's pain tolerance preprocedurally to determine the level of intervention needed. Providing a relaxed, calm environment and satisfactory pain control helps to reduce anxiety and improve the overall perception of the procedure and provider.

OPRM1 A118G gene variant and postoperative opioid requirement: a systematic review and meta-analysis.

Although a number of studies have investigated the association of the OPRM1 A118G polymorphism with pain response, a consensus has not yet been reached. The authors searched PubMed, EMBASE, and the Cochrane Library to identify gene-association studies that explored the impact of the OPRM1 A118G polymorphism on postoperative opioid requirements through July 2013. Two evaluators independently reviewed and selected articles on the basis of prespecified selection criteria. The authors primarily investigated the standardized mean difference (SMD) of required amounts of opioids between AA homozygotes and G-allele carriers. The authors also performed subgroup analyses for race, opioid use, and type of surgery. Potential bias was assessed using the Egger's test with a trim and fill procedure. Three hundred forty-six articles were retrieved from databases, and 18 studies involving 4,607 participants were included in the final analyses. In a random-effect meta-analysis, G-allele carriers required a higher mean opioid dose than AA homozygotes (SMD, -0.18; P = 0.003). Although there was no evidence of publication bias, heterogeneity was present among studies (I(2) = 66.8%). In the subgroup meta-analyses, significance remained robust in Asian patients (SMD, -0.21; P = 0.001), morphine users (SMD, -0.29; P <0.001), and patients who received surgery for a viscus (SMD, -0.20; P = 0.008). The OPRM1 A118G polymorphism was associated with interindividual variability in postoperative response to opioids. In a subpopulation, identifying OPRM1 A118G polymorphism may provide valuable information regarding the individual analgesic doses that are required to achieve satisfactory pain control.

P-0123 - Post Operative Pain Management in Whipples' Procedure -Epidural Analgesia Versus Intravenous Analgesia

Introduction: This study evaluated best palliation of pain management by two procedures –Epidural analgesia versus intravenous analgesia of 62 patients of pancreatic carcinoma who underwent uncomplicated surgeries of more than 3 hours duration between 2009 and 2012. The management of severe post-operative pain in patients of cancer surgery may be problematic. Parenterally administered opioids remain the cornerstone of treatment for mild to moderate pain, while epidural routes should be considered for post-operative patients who require rapid onset of analgesia and whose dose requirements cannot be properly titrated. The use of intravenous fentanyl analgesia is attractive for the management of post-operative pain but patients of general anaesthesia receiving supplemental epidural anesthesia and analgesia experienced faster recovery in the post-operative period.Methods: For post-operative pain management patients received either epidural analgesia (EA group) with 0.125% bupivacaine and 0.5% fentanyl sulfate or parenteral fentanyl therapy via intravenous analgesia as per patients demand after balanced general anesthesia. Patients in both the EA (n = 34) and IV (n = 28) groups were compared for demographics, length of surgical intensive care unit (SICU) and hospital stays. Intensity of pain was compared with visual analogue scale (VAS).Results: Demographically both groups were comparable. All patients reported adequate dynamic pain control as evaluated with visual analog pain scores (VAS < 4/10), during the treatment periods (5 +/- 3 versus 5 +/- 2 days, EA versus IV analgesia). All patients were admitted to the SICU after the operation. Patients in the EA group required less ventilator support than did those in the IV-PCA group (0.5 +/- 0.8 versus 1.2 +/- 0.9 days, P < .05). Patients in the EA group also spent less time in both the SICU (1.3 +/- 0.8 versus 2.8 +/- 0.6 days, P < .05) and in the hospital (11 +/- 3 versus 17 +/- 5 days, P < .05) than did their counterparts in the IV-PCA group.Conclusion: The use of both analgesic techniques was associated with satisfactory postoperative pain control. However, patients receiving epidural anesthesia and analgesia experienced faster recovery as judged by shorter mechanical ventilation time, and decreased SICU and hospital stays, resulting in significantly lower hospitalization costs. The use of perioperative epidural techniques should be considered to expedite recovery of surgical patients, and has the added benefit of being cost effective by reducing hospital stays. Introduction: This study evaluated best palliation of pain management by two procedures –Epidural analgesia versus intravenous analgesia of 62 patients of pancreatic carcinoma who underwent uncomplicated surgeries of more than 3 hours duration between 2009 and 2012. The management of severe post-operative pain in patients of cancer surgery may be problematic. Parenterally administered opioids remain the cornerstone of treatment for mild to moderate pain, while epidural routes should be considered for post-operative patients who require rapid onset of analgesia and whose dose requirements cannot be properly titrated. The use of intravenous fentanyl analgesia is attractive for the management of post-operative pain but patients of general anaesthesia receiving supplemental epidural anesthesia and analgesia experienced faster recovery in the post-operative period. Methods: For post-operative pain management patients received either epidural analgesia (EA group) with 0.125% bupivacaine and 0.5% fentanyl sulfate or parenteral fentanyl therapy via intravenous analgesia as per patients demand after balanced general anesthesia. Patients in both the EA (n = 34) and IV (n = 28) groups were compared for demographics, length of surgical intensive care unit (SICU) and hospital stays. Intensity of pain was compared with visual analogue scale (VAS). Results: Demographically both groups were comparable. All patients reported adequate dynamic pain control as evaluated with visual analog pain scores (VAS < 4/10), during the treatment periods (5 +/- 3 versus 5 +/- 2 days, EA versus IV analgesia). All patients were admitted to the SICU after the operation. Patients in the EA group required less ventilator support than did those in the IV-PCA group (0.5 +/- 0.8 versus 1.2 +/- 0.9 days, P < .05). Patients in the EA group also spent less time in both the SICU (1.3 +/- 0.8 versus 2.8 +/- 0.6 days, P < .05) and in the hospital (11 +/- 3 versus 17 +/- 5 days, P < .05) than did their counterparts in the IV-PCA group. Conclusion: The use of both analgesic techniques was associated with satisfactory postoperative pain control. However, patients receiving epidural anesthesia and analgesia experienced faster recovery as judged by shorter mechanical ventilation time, and decreased SICU and hospital stays, resulting in significantly lower hospitalization costs. The use of perioperative epidural techniques should be considered to expedite recovery of surgical patients, and has the added benefit of being cost effective by reducing hospital stays.