Severe Acute Postoperative Pain Research Articles

Catastrophic Cognition Is a Stronger Predictor Than Emotional Factors of Acute Postoperative Pain in Patients With Traumatic Orthopedic Injuries

BackgroundBoth cognitive factor (Pain Catastrophizing, PC) and emotional factors (anxiety, depression, and optimism) play vital roles in Acute Postoperative Pain (APOP) management among patients with Traumatic Orthopedic Injuries (TOI). It remains uncertain if these psychological factors independently or collectively impact APOP in patients with TOI, and the underlying mechanisms which various psychological factors impact APOP in TOI patients are also ambiguous. PurposeTo analyze the effects of PC and emotional factors (anxiety, depression, and optimism) on APOP in patients with TOI and to explore the potential mechanisms through which PC and emotional factors influence APOP, based on a hypothetical moderated mediation pathway mediated by pain-related fear. MethodsIt was an observational cross-sectional study. Results(i) PC was a significantly positive predictor of APOP regardless of co-existence with emotional factors, the TOI patients who had higher PC, had more severe APOP (β = 0.57, SE = 0.005, P < 0.01, adjusted R2 = 0.78; β = 0.84, SE = 0.003, P < 0.01, adjusted R2 = 0.77, respectively). Furthermore, when positive and negative emotions coexist (adjusted R2 = 0.74), anxiety levels were a significant positive predictor of APOP (β = 0.71, SE = 0.009, P < 0.01), optimism was a significant negative predictor of APOP (β = -0.24, SE = 0.008, P < 0.01).(ii) Pain-related fear played a mediating role in the association between the level of PC (effect = 0.044, 95% CI = 0.027 to 0.062) / anxiety (effect = 0.102, 95% CI = 0.075 to 0.137) and APOP in patients with TOI. Optimism moderated the strength of the relationship between PC (95% CI = -0.020 to -0.010) / anxiety (95% CI = -0.045 to -0.003) and APOP mediated by pain-related fear. ConclusionsClinical staff should assess the level of PC and emotional factors to identify TOI patients at high risk for APOP, subsequently, facilitating the optimization of pain management and the efficient utilization of nursing resource through early discussion.

Association of peri-operative prescription of non-steroidal anti-inflammatory drugs with continued prescription of opioids after total knee arthroplasty: a retrospective claims-based cohort study.

Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the mainstays of multimodal pain management. While effective for acute pain control, recent pre-clinical evidence has raised concerns regarding an association between NSAIDs and chronic pain and potential opioid use. Our objective was to explore the association between peri-operative use of prescription NSAIDs and the need for continued opioid prescriptions lasting 90-180 days in previously opioid-naïve patients undergoing total knee arthroplasty. A database of health claims in the USA was used to identify all opioid-naïve adult patients who underwent primary knee arthroplasty between January 2010 and October 2021. We evaluated the magnitude of association between peri-operative prescription NSAID claims and claims for opioids at 90 days postoperatively using multivariable logistic regression models. Secondary outcomes included: the magnitude of association between peri-operative NSAID prescription and claims for opioids at 180 days postoperatively; and identifying other potential factors associated with opioid claims at 90 days postoperatively. After risk adjustment using multivariable logistic regression models in the 789,736-patient cohort, the adjusted odds ratio (95%CI) for a continuous claim of opioids at 90 and 180 days postoperatively among patients with a peri-operative NSAID prescription within 30 days was 1.32 (1.30-1.35), p < 0.001; and 1.12 (1.10-1.15), p < 0.001, respectively. This estimate of effect remained robust at 90 days after accounting for known potential confounders, including pre-existing knee pain and acute postoperative pain severity. Similar analysis of other pain medications (e.g. paracetamol) did not detect such an association. This population-based cohort study suggests that peri-operative prescription NSAID use may be associated with continued opioid prescription claims at 90 and 180 days after knee arthroplasty, even after adjusting for other observed covariates for continuous opioid claims. These novel findings can inform clinical decision-making for post-surgical pain management, risk-benefit discussions with patients and future research.

Acute postoperative pain management techniques, their efficacy and complications after major gastrointestinal and hepato-pancreato-biliary cancer surgeries: An observational study.

Patients undergoing major gastrointestinal (GI) surgery including hepato-pancreato-biliary (HPB) surgeries have large incisions, which cause severe acute postoperative pain that, if untreated, is associated with a higher incidence of postoperative morbidity and delayed recovery. Our study included all patients who underwent elective major upper GI and HPB surgeries from 1 January 2018 to 31 December 2018. The patients were divided into two groups: the epidural and the non-epidural group. The average and worst pain scores at rest and movement were compared between both groups. We also studied the effect of pain relief in the two groups and associated postoperative outcomes, resumption of feeding, ambulation, hospital stay and intensive care unit stay. A total of 566 patients were included in the study, out of which 490 received epidurals, and the rest, 76, belonged to the non-epidural group (transversus abdominis plane, rectus sheath block or no regional analgesia technique). The median average pain score at rest and movement was 2.0 and 3.0, respectively, in the epidural and non-epidural groups. The postoperative outcomes showed no statistical difference. The epidural group and the non-epidural group had similar pain scores, and the postoperative outcomes were also comparable.

A random forest algorithm-based prediction model for moderate to severe acute postoperative pain after orthopedic surgery under general anesthesia

BackgroundPostoperative pain is one of the most common complications after surgery. In order to detect early and intervene in time for moderate to severe postoperative pain, it is necessary to identify risk factors and construct clinical prediction models. This study aimed to identify significant risk factors and establish a better-performing model to predict moderate to severe acute postoperative pain after orthopedic surgery under general anesthesia.MethodsPatients who underwent orthopedic surgery under general anesthesia were divided into patients with moderate to severe pain group (group P) and patients without moderate to severe pain group (group N) based on VAS scores. The features selected by Lasso regression were processed by the random forest and multivariate logistic regression models to predict pain outcomes. The classification performance of the two models was evaluated through the testing set. The area under the curves (AUC), the accuracy of the classifiers, and the classification error rate for both classifiers were calculated, the better-performing model was used to predict moderate to severe acute postoperative pain after orthopedic surgery under general anesthesia.ResultsA total of 327 patients were enrolled in this study (228 in the training set and 99 in the testing set). The incidence of moderate to severe postoperative pain was 41.3%. The random forest model revealed a classification error rate of 25.2% and an AUC of 0.810 in the testing set. The multivariate logistic regression model revealed a classification error rate of 31.3% and an AUC of 0.764 in the testing set. The random forest model was chosen for predicting clinical outcomes in this study. The risk factors with the greatest and second contribution were immobilization and duration of surgery, respectively.ConclusionsThe random forest model can be used to predict moderate to severe acute postoperative pain after orthopedic surgery under general anesthesia, which is of potential clinical application value.

Incidence and predictors of postoperative severe acute pain within 24 hours after cesarean section performed under spinal anesthesia at public hospitals in West Shoa, Ethiopia, 2022 prospective cohort study.

Acute postoperative pain is common after a caesarean section; the mother suffers severe pain in the first 24 h after the caesarean section compared to spontaneous birth. Failure to discover predictors of pain leads to maternal dissatisfaction, increased expenses, and restricted movement; it increases the risk of deep vein thrombosis, lengthens hospital stays, and decreases social intimacy. An institution-based prospective cohort study was conducted among 422 women who went to undergo caesarean sections under spinal anaesthesia at public hospitals in West Shoa from 30 July to 30 October. Participants were selected by systematic random sampling. Data were collected by a structured questionnaire, and the collected data were entered into SPSS version 20 and exported into STATA 64 for analysis. The results were presented in tables and figures. Risk factors were assessed by Poisson regression with a robust standard error. The overall incidence of severe postoperative pain after a caesarean section performed under spinal anaesthesia within 24 h of follow-up was 50.4% [95% confidence interval (CI): 40.7, 60.1]. Preoperative anxiety risk ratio 1.7 (95% CI: 1.4-2.0), preoperative pain risk ratio 1.3 (95% CI: 1.0-1.48), type of incision risk ratio 11.3 (95% CI: 1.1-1.6), spinal anaesthesia without adjuvants risk ratio 4.1 (95% CI: 1.5-10.9), and duration of surgery risk ratio 1.5 (95% CI: 1.3-1.8) were found to be predictors for postoperative severe acute pain after caesarean section performed under spinal anaesthesia. In this study, the overall incidence of severe acute pain after a caesarean section under spinal anaesthesia was high. Preoperative fear, duration of the operation, preparatory pain, spinal anaesthesia without the use of adjuvants, and the type of incision were risk factors for severe acute postoperative pain after a caesarean section under spinal anaesthesia.

The mechanisms and management of persistent postsurgical pain.

An estimated 10%-50% of patients undergoing a surgical intervention will develop persistent postsurgical pain (PPP) lasting more than 3 months despite adequate acute pain management and the availability of minimally invasive procedures. The link between early and late pain outcomes for surgical procedures remains unclear-some patients improve while others develop persistent pain. The elective nature of a surgical procedure offers a unique opportunity for prophylactic or early intervention to prevent the development of PPP and improve our understanding of its associated risk factors, such as pre-operative anxiety and the duration of severe acute postoperative pain. Current perioperative pain management strategies often include opioids, but long-term consumption can lead to tolerance, addiction, opioid-induced hyperalgesia, and death. Pre-clinical models provide the opportunity to dissect mechanisms underpinning the transition from acute to chronic, or persistent, postsurgical pain. This review highlights putative mechanisms of PPP, including sensitisation of peripheral sensory neurons, neuroplasticity in the central nervous system and nociceptive signalling along the neuro-immune axis.

A service evaluation of the newly introduced sciatic nerve local anaesthetic infusion catheters for acute pain management of major lower limb amputations

Background: Patients who undergo lower limb amputations experience severe acute postoperative pain. Despite having no strong evidence for the efficacy of peripheral nerve blocks in reducing phantom limb pain, the reduction in acute postoperative pain and opioid-sparing effect1 make these techniques important to consider. Acute pain management has been identified as a key priority in the management of patients undergoing amputation.2 An initial audit, in October 2021, found that postoperative pain scores and opiate use were high. In April 2022, postoperative local anaesthetic nerve catheters for major lower limb amputations were introduced at our institution. The aim of this service evaluation was to ascertain the postoperative pain scores and analgesic consumption for patients having undergone a lower limb amputation and who subsequently received a continuous postoperative local anaesthetic infusion (levobupivacaine 0.125%, at 6–10 ml h−1 for up to 5 days) via a sciatic nerve catheter. Methods: A retrospective audit was undertaken between July and September 2022 at Birmingham Heartlands Hospital. We included patients having undergone a lower limb amputation with a sciatic nerve catheter placed intraoperatively by surgeons under direct vision and left along the nerve in the cut nerve sheath. Data collected included patient characteristics, postoperative pain scores days 1–5, postoperative opioid use including opioid side-effects, postoperative neuropathic pain, and block related complications. Results: We collected data for 24 patients. Compared with the period before the introduction of sciatic nerve catheters, we observed that the mean pain scores on the numeric rating scale (NRS) decreased. This was particularly evident on day 1 postoperatively when the mean pain scores decreased from the moderate to mild range. On days 1–5 of the postoperative period, the mean immediate-release opioid consumption was 16.1 mg day−1 and mean prolonged-release opioid consumption was 11.6 mg day−1. This was in comparison to the audit in October 2021 that found mean opioid use of 24.1 mg day−1 and 21 mg day−1, respectively. Opioid side-effects reported were sedation (18%), constipation (13%), and nausea or vomiting (8%). Fifty percent of patients reported neuropathic pain. Conclusion: The postoperative pain scores improved and the postoperative opioid consumption reduced slightly with the addition of a sciatic nerve catheter. Opioid side-effects and acute neuropathic pain remain an issue for this group of patients postoperatively. Overall, the introduction of a continuous local anaesthetic infusion via a sciatic nerve catheter after major lower limb amputations in our hospital has been a success and the technique is likely to play a significant future role as part of our multi-modal analgesia regimen for these patients. The Acute Pain Team at University Hospitals Birmingham NHS Foundation Trust. 1.Ilfeld BM. Anesth Analg 2011; 113: 904–252.Gough MJ, Juniper M, Freeth H, Butt A, Mason M. Lower limb amputation: Working together. A report by the National Confidential Enquiry into Patient Outcome and Death, 2014. https://www.hqip.org.uk/wp-content/uploads/2018/02/lower-limb-amputation-report.pdf (accessed 20/03/23)

Enhancing the Use of Opioid Sparing Protocol in the PACU

IntroductionOpioids serve as the cornerstone for severe acute post-operative pain management in the PACU. Opioids have been used for their quick onset and efficacy without analgesic ceiling yet have significant side effects. Identification of the problemAcute post-operative pain remains a major problem, resulting in the multiple undesirable outcomes if inadequately controlled. In the PACU setting, opioid use is common as the primary treatment for post-operative pain. Purpose of the studyThe purpose of the study is to assess the impact of the Opioid Sparing Protocol on opioid-naive patients in the PACU post knee and hip arthroplasty. MethodsRetrospective analysis by chart review of 200 comparable cases, from each period, for implementation of the Opioid Sparing Protocol pre-intervention (Q2, 2018) and post-intervention (Q2, 2019). Outcomes/ResultsSignificant increase in the use of Tramadol (+242.86%), along with reduction in the use of Percocet (-44.44%) and Oxycodone (-56.52%) have shown to be effective in providing analgesia and improved patient outcomes. DiscussionThere is an ongoing effort to develop strategies for safe and effective alleviation of post-operative pain. This analysis of comparable cases shows that changes in pain management methodologies can lead to positive results for the patient's surgical experience and post-operative clinical outcome. ConclusionUtilizing the multimodal approach outlined in the Opioid Sparing Protocol provides pain relief while reducing opioid requirements and opioid related events. Effective management of acute pain in the PACU results in reduced PACU length of stay and improved patient outcomes. Implications for peri-anesthesia nurses and future researchAs health care professionals, it is our responsibility to provide safe and effective pain management. Considering the heavy societal cost of the opioid crisis, enhanced pain management addresses opioid misuse. The challenge for the healthcare workforce is to develop new, effective and non-addictive approaches to pain management.

The use of centrally acting analgesics in the postoperative analgesia in patients with the consequences of a severe mine-explosive injury of the lower extremities

In this article, the authors discuss the place of modern analgesics of central action (nefopam hydrochloride) in the analgesia of patients with explosive injuries of the lower extremities. Currently, there is no information in global practice regarding the use of centrally acting analgesics for analgesia in patients with combat trauma. An example was the analgesia of patients in the p/o period with a severe explosive injury of the lower extremities. Attention is drawn to the need for effective analgesia for patients with a combo injury not only in the acute period. A feature of the treatment of such patients is the need for major restorative and reconstructive surgical interventions, which in turn are accompanied by a pronounced pain syndrome. In our experience, the addition of non-narcotic analgesics of central action (nefopam hydrochloride) to the scheme of multimodal analgesia is appropriate to improve analgesia in this category of patients. The addition of nefopam hydrochloride to a multimodal analgesia regimen at 20 mg IV every 6 hours was effective in the treatment of severe acute postoperative pain.

Pro: Regional Anesthesia for Cardiac Surgery With Sternotomy

With the growing prevalence of cardiovascular disease worldwide, over 2 million patients undergo median sternotomy for cardiac surgery annually.1 The incidence of severe acute postoperative pain after sternotomy is as high as 49%, and appropriate management of this pain has important implications for short- and long-term recovery.2 Inadequate post-surgical pain control following sternotomy in cardiac surgery has profound negative consequences on pulmonary function, hemodynamics, myocardial oxygen demand, postoperative delirium, and ICU and hospital length of stay.3 Severe pain has also been shown to harm long-term outcomes such as quality of life4,5 and is associated with the development of persistent post-sternotomy pain with an incidence as high as 35% at 1-year follow-up.1,6

Does Preoperative Hookwire Localization Influence Postoperative Acute and Chronic Pain After Video-Assisted Thoracoscopic Surgery: A Prospective Cohort Study

This study aimed to investigate whether preoperative computerized tomography-guided hookwire localization-associated pain could affect acute and chronic postsurgical pain (CPSP) in patients undergoing video-assisted thoracoscopic surgery (VATS). We enrolled 161 adult patients who underwent elective VATS; sixty-nine patients experienced hookwire localization (Group A) and 69 did not (Group B). Group A was further subdivided into the multiple localization group (n=35, Group Amultiple) and the single localization group (n=34, Group Asingle) according to the number of hookwires. The numerical rating scale (NRS) was used preoperatively, during recovery at the post-anesthesia care unit (PACU), and the first two days, 3 and 6 months postoperatively. Furthermore, multivariate regression analysis was used to identify the risk factors associated with CPSP. The postoperative adverse events, length of hospital stay, and satisfaction in pain management were also recorded. The incidence and severity of acute postoperative pain were similar between Group A and Group B (p > 0.05). The incidence (56.5% vs 30.4%, p = 0.002) and the NRS scores (2.0 [2.0-3.0] vs 1.0 [1.0-2.0], p = 0.011) for CPSP were significantly higher in Group A than in Group B at 3 months postoperatively. On subgroup analysis, compared with Group Asingle, the intensity of CPSP (2.0 [2.0-3.0] vs 2.0 [1.0-2.0], p = 0.005) in Group Amultiple was slightly higher at 3 months postoperatively. Conversely, the CPSP incidence (60.0% vs 29.4%, p = 0.011) was significantly higher at 6 months postoperatively in Group Amultiple. The multivariate regression analysis further validated hookwire localization as a risk factor for CPSP (odds ratio: 6.199, 95% confidence interval 2.049-18.749, p = 0.001). Patient satisfaction relating to pain management at 3 months postoperatively was lower in Group A (p = 0.034). The preoperative pain stress of hookwire localization increased the incidence and intensity of CPSP rather than acute pain at 3 months postoperatively, especially in patients with multiple hookwires.

Efficacy of Fentanyl Transdermal Patch in Impacted Mandibular Third Molar Surgery-A Comparative Study.

Removal of mandibular third molars surgically is one of the most frequently performed oral surgical procedures which are often accompanied with post-operative pain, swelling and trismus. Despite general progress in pain management, moderate to severe acute post-operative pain after removal of lower third molars remains a problem. Fentanyl is an extremely effective drug in the treatment of severe chronic pain such as cancer pain and post-operative pains which acts by increasing patient's tolerance to pain. Fentanyl Transdermal System (FTS) is a rectangular transdermal patch which contains high concentration of fentanyl, a potent short-acting Schedule II opiate. In this study the efficacy of transdermal fentanyl for management of post-operative pain after impacted mandibular 3rd molar surgery is evaluated. 20 patients within the age group of 18-40 years with asymptomatic impacted mandibular third molars were equally divided into 2 groups as group A & group B which underwent surgery in Local Anaesthesia. In every patient one side belonged to group A and other side belonged to group B. 50 μg FTS was applied in group A while placebo patch was applied in group B. Patients in group A performed significantly better than group B in terms of mean pain intensity scores assessed by VAS and VRS along with minimum need of post-operative rescue analgesics. It was found that FTS resulted in significantly better pain relief, longer pain-free intervals, and lesser post-operative analgesic consumption.

DYSAESTHESIA ASSOCIATED WITH THORACIC SURGERY

<h3>Introduction</h3> Chronic pain is experienced by 50% of patients following thoracic surgery. Neuropathic pain is commonly associated with dysaesthesia. Acute pain has been associated with dysaesthesia after sternotomy.(1) The aims of this study were to compare the total area of dysaesthesia after thoracic surgery on the operated with that on the contra-lateral non-operated side of the thorax and to determine whether the severity of acute postoperative pain is associated with the total area of dysaesthesia. <h3>Methods</h3> Fourteen patients admitted for elective thoracic surgery, either thoracotomy or video-assisted thoracic surgery (VATS), were recruited. Areas of dysaesthesia were identified by applying a monofilament and a needle in 1cm intervals down the anterior and posterior thorax from the level of the clavicle down to the level of the umbilicus, comparing the operated with the non-operated side as control. Areas of dysaesthesia were marked using different coloured pens then the areas were copied onto tracing paper of a known weight per area. Areas of dysaesthesia was estimated by weighing the tracing paper. Acute pain was scored using a verbal rating scale. <h3>Results</h3> There was no significant difference (p=0.101) in total area of dysaesthesia between the operated and the non-operated side [91 cm2 (Q1= 3, Q3=332); 0 cm2 (Q1=0, Q3=16)]. When comparing the total area of dysaesthesia between the operated side of the thorax, with the non-operated side of the thorax, 9 out of 14 patients (p= 0.101) had larger areas of dysaesthesia on the operated side and 4 out of 14 patients had a larger area of dysaesthesia on the non-operated side (p= 0.101). No significant correlations were found between the total area of dysaesthesia on the operated side with acute pain after inspiration (r = 0.341, p = 0.232) or at rest (r = 0.269, p = 0.352) <h3>Conclusion</h3> The difference in total area of dysaesthesia was not significantly different between the operated and non-operated sides of the thorax. The unexpected finding of areas of dysaesthesia on the non-operated side that was acting as control inflated the risk of Type II error. Unlike after sternotomy, no significant correlation was found between acute pain and the total area of dysaesthesia.

Introduction of an enhanced recovery program for young adults undergoing posterior spinal fusion surgery for idiopathic scoliosis: a single-centre pilot study evaluating short term outcomes

Background: The large surgical incision and extensive tissue trauma in posterior spinal fusion for adolescent idiopathic scoliosis causes severe acute postoperative pain. Furthermore, posterior spinal fusion is associated with a risk of persistent postsurgical pain. Six months after posterior spinal fusion, the incidence of persistent postsurgical pain is as high as 22% of the patients. Optimizing pain management therefore remains crucial, but challenging. Objective: The study objective is to design and implement an enhanced recovery pathway for patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion integrating all aspects of biopsychosocial care. Its outcomes are assessed, including its effect on postoperative pain and early mobilization. Design and settings: A prospective cohort study was performed at the Antwerp University Hospital. Methods: In December 2019, a prospective cohort study was set up in which an enhanced recovery pathway substitutes more than the patient controlled intravenous analgesia containing morphine postoperatively. This pathway consists of m/eHealth based psychological screening questionnaires, patient education, early mobilization, and a multimodal analgesia protocol consisting of preemptive gabapentin, an intraoperatively given single dose of methadone (0.2 mg kg-1), non-steroidal anti-inflammatory drugs, and acetaminophen. Results: We treated 25 adolescents (10 males and 15 females) with the developed enhanced recovery pathway with a mean age of 16.5 years (range 12-22). The mean number of spinal levels fused was 10 (range 6-13). Mean numerical rating scale scores were 4.17 at postoperative day 1, 4.46 at postoperative day 2, and 3.74 at postoperative day 3 in enhanced recovery pathway treated patients. Mean bladder catheterization duration was 3.04 days and enhanced recovery pathway patients stayed in the hospital for an average of 7.4 days. Conclusions: Using an enhanced recovery pathway for patients undergoing posterior spinal fusion could not only reduce the acute and chronic opioid consumption and its side effects, but could also result in less postoperative pain, shorter hospital stay and higher patient satisfaction. Further reevaluation and improvement focused on these variables will likely further improve the effectiveness of enhanced recovery pathways. Trial registration: ClinicalTrials.gov NCT04038229.

The cost-effectiveness analysis of analgesic treatment options for postoperative pain following laparotomy surgeries.

Postoperative pain control remains unsatisfactory. Patients who underwent laparotomy may have moderate to severe acute postoperative pain. Comparative cost-effectiveness of the following postoperative pain treatment options remains to be investigated: patient-controlled intravenous analgesia (PCIA) with flurbiprofen therapy, flurbiprofen monotherapy, parecoxib monotherapy, or dezocine monotherapy. To provide a cost-effectiveness analysis (CEA) of four analgesic regimens for patients with postoperative pain following laparotomy surgeries. Patients with postoperative pain following laparotomy were retrospectively reviewed from a postoperative pain management database created by pharmacists, and divided into four groups according to analgesic regimens. The clinical outcomes were visual analogue scale (VAS) scores and the incidence of adverse drug events. The CEA was conducted by developing a decision tree model based on retrospective data. The maximum incremental cost-effectiveness ratio (ICER) of the four regimens was used as the willingness-to-pay (WTP) value. Meanwhile, the uncertainty of the base-case results was examined by one-way and probabilistic sensitivity analyses. A total of 677 patients were included in the retrospective study. PCIA with flurbiprofen therapy had the lowest VAS scores at 6, 24, 48h postoperatively. Based on the base-case results, PCIA plus flurbiprofen was the optimal regimen with the highest effectiveness, while flurbiprofen monotherapy had the lowest cost. PCIA plus flurbiprofen was the optimal regimen even with a WTP value of 0 dollars. PCIA plus flurbiprofen therapy was the optimal regimen. Parecoxib monotherapy was more cost-effective than flurbiprofen monotherapy. The findings may guide the selection of postoperative pain management.

Racial inequities in opioid use disorder management: can the anesthesiologist improve outcomes?

Racial inequities in opioid use disorder management: can the anesthesiologist improve outcomes?

Postoperative Analgesic Efficacy of Intraoperative Pectoral Nerve Block for Modified Radical Mastectomy: a Double-Blind Prospective Randomised Interventional Study.

Severe acute postoperative pain following breast surgery increases the risk of persistent pain and affects the recovery of patients. Recently, pectoral nerve (PECs) block has gained significance as a regional fascial block that can provide adequate postoperative analgesia. This study aimed to evaluate the safety and efficacy of PECs II block, which was given intraoperative under direct vision after performing modified radical mastectomy for breast cancer patients. This prospective randomised study was comprised of a PECs II group (n = 30) and a control group (n = 30). Group A patients received 25ml of 0.25% bupivacaine for PECs II block intraoperatively after the surgical resection was done. Both groups were compared with respect to the demographic and clinical parameters, total intraoperative fentanyl dose, total duration of surgery, postoperative pain score (Numerical Rating Scale) and the analgesic requirement, postoperative complications, postoperative duration of hospital stay, and the outcome. Intraoperative PECs II block was not associated with any increase in the duration of surgery. The postoperative pain scores were significantly higher in the control group till 24h after the surgery, and so was the postoperative analgesic requirement. Patients in the PECs group were found to have rapid recovery and decreased postoperative complications. Intraoperative PECs II block is not only safe, time-saving procedure but also significantly reduces the postoperative pain and analgesic requirement in breast cancer surgeries. It is also associated with a faster recovery, decreased postoperative complications, and better patient satisfaction.

Prevalence and Factors Associated with Acute Postoperative Pain after Emergency Abdominal Surgery

Objective: This study aimed to assess the prevalence and associated factors of acute postoperative pain after emergency abdominal surgery in the first 24 postoperative hours among adult patients. Methods: An institutional-based cross-sectional study was conducted on adult patients undergoing emergency abdominal surgery at the University of Gondar Comprehensive Specialized Hospital from March 1 to May 30, 2020. Data were collected by delivering questionnaires through interviews and reviewing the patients’ charts. Data were entered into Epi Info software, version 7.2, and analyzed by SPSS version 20. Logistic regression was applied to point out independent risk factors for postoperative acute pain. Variables with a p-value of &lt; 0.05 were taken as significant. Results: 165 patients participated in the study with a response rate of 98.2%. Among these, 75.8% [95% CI: (69.8%, 82.3%)] of patients experienced moderate to severe acute postoperative pain. Female gender [AOR:3.9, 95%CI: (1.22,12.5)], preoperative anxiety[AOR:4.4,95%CI:(1.74,11.1)],moderate to severe preoperative pain[AOR:5.79,95%CI:(2.08,16.1)], and incision length ≥10cms [AOR: 4.86, 95%(CI:1.88,12.5)], were significantly associated with moderate to severe acute postoperative pain. Conclusions and Recommendations: The prevalence of immediate postoperative pain following emergency abdominal surgery was found to be high in this study. Acute postoperative pain was substantially linked to the female sex, preoperative anxiety, preoperative pain, and an incision length of ≥10 cm. The prevalence of moderate-to-severe acute postoperative pain as well as the factors that contribute to it can be used to develop particular preventive strategies to reduce patient suffering.

Network meta-analysis of the analgesic effectiveness of regional anaesthesia techniques for anterior cruciate ligament reconstruction.

Anterior cruciate ligament reconstruction can cause moderate to severe acute postoperative pain. Despite advances in our understanding of knee innervation, consensus regarding the most effective regional anaesthesia techniques for this surgical population is lacking. This network meta-analysis compared effectiveness of regional anaesthesia techniques used to provide analgesia for anterior cruciate ligament reconstruction. Randomised trials examining regional anaesthesia techniques for analgesia following anterior cruciate ligament reconstruction were sought. The primary outcome was opioid consumption during the first 24 h postoperatively. Secondary outcomes were: rest pain at 0, 6, 12 and 24 h; area under the curve of pain over 24 h; and opioid-related adverse effects and functional recovery. Network meta-analysis was conducted using a frequentist approach. A total of 57 trials (4069 patients) investigating femoral nerve block, sciatic nerve block, adductor canal block, local anaesthetic infiltration, graft-donor site infiltration and systemic analgesia alone (control) were included. For opioid consumption, all regional anaesthesia techniques were superior to systemic analgesia alone, but differences between regional techniques were not significant. Single-injection femoral nerve block combined with sciatic nerve block had the highest p value probability for reducing postoperative opioid consumption and area under the curve for pain severity over 24 h (78% and 90%, respectively). Continuous femoral nerve block had the highest probability (87%) of reducing opioid-related adverse effects, while local infiltration analgesia had the highest probability (88%) of optimising functional recovery. In contrast, systemic analgesia, local infiltration analgesia and adductor canal block were each poor performers across all analgesic outcomes. Regional anaesthesia techniques that target both the femoral and sciatic nerve distributions, namely a combination of single-injection nerve blocks, provide the most consistent analgesic benefits for anterior cruciate ligament reconstruction compared with all other techniques but will most likely impair postoperative function. Importantly, adductor canal block, local infiltration analgesia and systemic analgesia alone each perform poorly for acute pain management following anterior cruciate ligament reconstruction.

Ultrasound-guided, continuous erector spinae plane (ESP) block in minimally invasive thoracic surgery—comparing programmed intermittent bolus (PIB) vs continuous infusion on quality of recovery and postoperative respiratory function: a double-blinded randomised controlled trial

BackgroundMinimally invasive thoracic surgery (MITS) has been shown to reduce postoperative pain and contribute to better postoperative quality of life as compared to open thoracic surgery (Bendixen et al., Lancet Oncol 17:836–44, 2016). However, it still causes significant post-operative pain. Regional anaesthesia techniques including fascial plane blocks such as the erector spinae plane block (ESP) have been shown to contribute to post-operative pain control after MITS (Finnerty et al., Br J Anaesth 125:802–10, 2020). Case reports relating to ESP catheters have described improved quality of pain relief using programmed intermittent boluses (PIB) instead of continuous infusion (Bendixen et al., Lancet Oncol 17:836–44, 2016). It is suggested that larger, repeated bolus dose may provide superior pain relief, possibly because of improved spread of the local anaesthetic medications (Ilfeld and Gabriel, Reg Anesth Pain Med 44:285–86, 2019). Evidence for improved spread of local anaesthetic may be found in one study which demonstrated that PIB increased the spread of local anaesthetic medication compared to continuous infusions for continuous paravertebral blocks, which are another type of regional anaesthesia technique for the chest wall (Hida et al., Reg Anesth Pain Med 44:326–32, 2019). Similarly, regarding labour epidural analgesia, the weight of evidence is in favour of PIB providing better pain relief compared with continuous infusion (Onuoha, Anesthesiol Clin 35:1–14, 2017).Since fascial plane blocks, such as ESP, rely on the spread of local anaesthetic medication between muscle layers of the chest wall, intermittent boluses may be particularly useful for this group of blocks. However, until recently, pumps capable of providing automated boluses in addition to patient-controlled boluses were not widely available. To best of our knowledge, there are no randomised controlled trials comparing continuous infusion versus intermittent bolus strategies for erector spinae plane block for MITS in terms of patient centred outcomes such as quality of recovery.MethodsThis trial will be a prospective, double-blinded, randomised controlled superiority trial. A total of 60 eligible patients will be randomly assigned to receive an intermittent bolus regime of local anaesthetic vs a continuous infusion of local anaesthetic. The medication will be delivered via an ultrasound-guided erector spinae plane block catheter which will be inserted by an anaesthesiologist while the patient is under general anaesthetic before their MITS surgery begins. The primary outcome being measured is the Quality of Recovery (QoR-15) score between the two groups 24 h after surgery. Secondary outcomes include respiratory testing of maximal inspiratory volume measured with a calibrated incentive spirometer, area under the curve for Verbal Rating Score for pain at rest and on deep inspiration versus time over 48 h, total opioid consumption over 48 h, QoR-15 score at 48 h and time to first mobilisation.DiscussionDespite surgical advancements in thoracic surgery, severe acute post-operative pain following MITS is still prevalent. This study will provide new knowledge and possible recommendations about the efficacy of programmed intermittent bolus regimen of local anaesthetic vs a continuous infusion of local anaesthetic via an ultrasound-guided erector spinae plane catheter for patients undergoing MITS.Trial registrationThis trial was pre-registered on ClinicalTrials.gov Identifier: NCT05181371. Registered on 6 January 2022. All item from the World Health Organization Trial Registration Data set have been included.