Severe Postoperative Pain Research Articles

Systematic Approaches to Optimize Opioid Prescribing in Surgical Patients

The opioid crisis has highlighted the urgent need to optimize pain management strategies in surgical settings, prompting a shift towards opioid-sparing therapies. While opioids are crucial for alleviating moderate to severe postoperative pain, their over prescription poses significant risks, including addiction and overdose. This paper examines the feasibility of achieving opioid-free surgical recovery, particularly for minor and minimally invasive procedures, with the goal of extending this practice to more invasive surgeries through enhanced recovery after surgery (ERAS) programs. It also considers the cultural factors that influence patient expectations regarding pain management in countries with lower opioid prescribing rates, such as Japan and Germany, emphasizing the need for tailored approaches in the United States. The study advocates for the exclusion of opioids at every stage of the perioperative experience, promoting opioid-free anesthesia and analgesia. A framework for optimizing opioid prescribing practices in surgical contexts is proposed, highlighting the vital roles of acute pain specialists and pharmacists in developing comprehensive pain management strategies. By incorporating multimodal analgesia techniques, including non-opioid medications and alternative therapies, healthcare providers can effectively mitigate the risks associated with opioids while ensuring adequate pain relief

Retrospective evaluation of postoperative analgesia efficacy of a new technique in anterior iliac crest bone graft harvesting: anterior iliac block

BackgroundIn reconstructive surgeries, iliac crest bone graft harvesting is commonly preferred. The pain experienced after surgery at the anterior iliac crest (AIC) donor site might be more intense compared to the pain at the primary surgical area where the graft is placed. To address this issue, we defined a novel technique called the anterior iliac block (AIB), which can provide analgesia with lower volumes. In this study, the effect of this technique for AIC bone greft harvesting was evaluated.MethodsPatients who were operated on and had AIC bone graft harvested included in this retrospective study. The study collected age, height, weight, ASA classification, and duration of surgery, information on the regional anesthesia technique, block performance, postoperative pain severity, opioid consumption, rescue analgesics used in the first postoperative 24 h.ResultsData from 16 patients were analyzed. The popliteal sciatic block was performed in eight patients, infraclavicular brachial plexus block in four patients, supraclavicular brachial plexus block in one patient, PENG block in one patient, and proximal adductor canal block in two patients two provide analgesia for primary surgery. The median morphine consumption at postoperative 24th hour was 3.5 mg, median NRS score was 1 at postoperative 1st hour, and 0 at postoperative 6th, 12th and 24th hours.ConclusionsThe study findings indicate that the AIB provides adequate analgesia for AIC graft harvesting in the first postoperative 24-hour period. It can be used as an adjuvant to the peripheric nerve block for the primary surgical site.Trial registrationNCT06295224.

Preoperative resting-state electrophysiological signals predict acute but not chronic postoperative pain.

The prevalence of postoperative pain is notably high among the elderly population, which poses significant challenges for their postoperative recovery. In this study, we aimed to identify preoperative predictors for acute and chronic postoperative pain in patients undergoing lumbar spinal surgery through a longitudinal investigation. We recruited 75 patients (mean age 68.29 ± 5.60 years) and collected their resting-state electroencephalography (EEG) data two hours before the surgery. The aperiodic and periodic signal components were extracted from the resting-state EEG using the Fitting Oscillations and One-Over-F algorithm. We also collected the preoperative pain ratings, demographic information and the Hospital Anxiety and Depression Scale from all patients. The postoperative pain ratings were collected ten times from Day 1 to Week 12 after surgery. We observed a high incidence of postoperative acute and chronic pain among older patients. Preoperative pain and peak alpha frequency in resting-state EEG were the primary predictors of acute postoperative pain. Although age is a significant predictor of chronic postoperative pain, its predictive performance is poor. Overall, our study provides valuable insights into the complex pattern of preoperative EEG features, preoperative pain and age in predicting postoperative pain at different stages. Our findings highlight the significance of exploring preoperative features to identify patients who are at a higher risk of developing severe postoperative pain, which can aid in the development of more personalized and effective pain management strategies. The heightened occurrence of postoperative pain among the elderly presents formidable obstacles to their recuperation. This study delves into identifying preoperative factors influencing acute and chronic postoperative pain. Our findings indicate that preoperative pain and peak alpha frequency are crucial predictors of acute postoperative pain. However, the predictive performance for chronic postoperative pain is limited, although age was a significant predictor of chronic postoperative pain. These insights contribute to the identification of patients at elevated risk for severe acute and chronic postoperative pain, offering valuable guidance for pre-surgical risk assessment.

Intraoperative Facet Joint Block Reduces Pain After Oblique Lumbar Interbody Fusion

Background: Oblique lumbar interbody fusion (OLIF) results in less tissue damage than in other surgeries, but immediate postoperative pain occurs. Notably, facet joint widening occurs in the vertebral body after OLIF. We hypothesized that the application of a facet joint block to the area of widening would relieve facet joint pain. The purpose of this study was to evaluate the analgesic effects of such injections on postoperative pain. Methods: This double-blinded, placebo-controlled study randomized patients into 2 groups. Patients assigned to the active group received an intra-articular injection of a compound mixture of bupivacaine and triamcinolone, whereas patients in the placebo group received an equivalent volume of normal saline solution injection. Back and dominant leg pain were evaluated with use of a visual analog scale (VAS) at 12, 24, 48, and 72 hours postoperatively. Clinical outcomes were evaluated preoperatively and at 6 months postoperatively with use of the Oswestry Disability Index (ODI) and VAS for back and dominant leg pain. Results: Of the 61 patients who were included, 31 were randomized to the placebo group and 30 were randomized to the active group. Postoperative fentanyl consumption from patient-controlled analgesia was higher in the placebo group than in the active group at up to 36 hours postoperatively (p < 0.001) and decreased gradually in both groups. VAS back pain scores were significantly higher in the placebo group than in the active group at up to 48 hours postoperatively. On average, patients in the active group had a higher satisfaction score (p = 0.038) and were discharged 1.3 days earlier than those in the placebo group. Conclusions: The use of an intraoperative facet joint block decreased pain perception during OLIF, thereby reducing opioid consumption and the severity of postoperative pain. This effect was also associated with a reduction in the length of the stay. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Opioid Use after Transforaminal Lumbar Interbody Fusion: A Comparison between Open and Minimally Invasive Surgery.

Opioids are medications frequently used in patients with moderate and severe chronic pain. Their pharmacologic profile allows their use in acute severe postoperative pain. However, due to their highly addictive profile, opioid misuse is considered a public health issue. Vertebral spine fusion, decompression, and instrumentation are often associated with acute, severe postoperative pain. The present study aims to compare postoperative opioid consumption in a group of patients who underwent open transforaminal lumbar interbody fusion (OTLIF) against a similar group of patients who underwent minimally invasive transforaminal lumbar interbody fusion (MTLIF). We present a quantitative, observational, analytical, and historical cohort study. After convenience sampling, we identified 45 patients, 34 of whom underwent OTLIF and 11 underwent MTLIF. The analysis was made after measuring the following variables: demographics, type of surgery, length of stay, pain control, opioid type, and opioid dose. Statistical methods were implemented according to the origin and behavior of the variable. We found a difference between significant and nonsignificant pain among the groups with less opioid consumption in the MTILF group. This difference was seen in the frequency and dosage during all observation periods. However, in the postoperative observation, the frequencies and dosages were equal between groups. According to linear regression, the type of surgery, radiculopathy, and radiculitis explain the significant postoperative pain in up to 50% of cases. Our study reveals a significant difference in opioid consumption between patients undergoing different surgical techniques. While these findings are valid for the studied population, the limitation in sample size highlights the need for further research. The implications of our findings on postoperative pain management and opioid use in spinal surgeries are significant and warrant continued investigation.

Comparative analysis of the effectiveness of quadratus lumborum and transversus abdominis muscle blocks for postoperative pain relief during laparoscopic robot-assisted total hysterectomy.

The purpose of this study was to compare and evaluate the analgesic effectiveness of quadratus lumborum block (QLB) and transversus abdominis plane bloc block (TAPB) after laparoscopic robot-assisted total hysterectomy. Materials and methods. A prospective study of female patients (n=101), with physical status ASA I-II, who underwent laparoscopic robot-assisted total hysterectomy under multicomponent general anesthesia. In random order, patients were randomized into three groups: the first group (CON, n=40) - control, where no blocks were performed, the second group (TAPB, n=30) - a blockade of the transverse abdominis muscle, the third group (QLB, n= 31) – blockade of the quadratus lumborum muscle was performed. After surgery, pain was assessed using a 10-point digital visual analogue scale, and postoperative nausea and vomiting were assessed. (PONV) Average arterial pressure and heart rate were recorded. Additionally, the next morning, a survey was conducted to assess the well-being and satisfaction of patients. Results. There were no differences between the groups in terms of demographic characteristics, duration of surgery, and analgesic consumption during the intraoperative period. The severity of postoperative pain was higher (p<0.05) in the control group than in the blockade groups. Both block groups demonstrated lower pain scores at all time points assessed. The latest need for analgesics was in the QLB group. Mean arterial pressure (MAP) values differed only in the first 2 hours after surgery between the CON and TAPB groups (p<0.05). PONV one hour after surgery was more observed in the control group and less in the QLB group (p<0.05). According to the results of a survey conducted on the day after surgery, the number of patients satisfied with the anesthesia and assistance provided in the recovery room in the groups with blockade (TAPB, QLB) was 2.1-5.3% higher (p>0.05). More patients from the QLB group (p<0.05) noted very good and good health, and most patients (p<0.05) from the CON and TAPB group noted satisfactory health. Conclusion. The use of interfascial blocks for postoperative pain relief (TAPB, QLB) after laparoscopic robot-assisted hysterectomy improves the quality of pain relief and the well-being of patients. Benefits of QLB include better pain relief, reduced incidence of PONV, and greater patient satisfaction. TARP has shown equally good results, and this method is easier to perform.

Chronic post-surgical pain after total knee arthroplasty: a narrative review.

Total knee arthroplasty (TKA) is an efficacious treatment for end-stage knee osteoarthritis, often accompanied by severe postoperative pain. In certain patients, this pain can persist for over 3months and is referred to as chronic post-surgical pain (CPSP). Postoperative persistent pain has emerged as a significant and noteworthy issue impacting patient quality of life following TKA. The etiology of CPSP after TKA is multifaceted. Peripheral or central sensitizations resulting from inflammatory reactions, nerve injury, and neurobiological mechanisms are the primary mechanisms contributing to chronic persistent pain after TKA. Preoperative, intraoperative, and postoperative factors can induce pain sensitization. Once CPSP occurs after TKA, it significantly hampers patient recovery with challenging treatment options. Currently, among the preventive and therapeutic strategies for chronic pain after TKA, it is widely believed that early comprehensive preventive treatment to prevent acute to chronic pain transition can substantially reduce the incidence of CPSP following TKA. In recent years, studies have investigated perioperative strategies aimed at reducing the occurrence of persistent pain after TKA. This article provides an overview of advancements in understanding the pathogenesis, high-risk factors, and preventive measures for chronic pain following TKA. We hope that this review will guide future research directions on CPSP after TKA while contributing to clinical perioperative pain management.

Efficacy of dexamethasone or clonidine as adjuvants in interscalene brachial plexus block for preventing rebound pain after shoulder surgery: a randomized clinical trial

BackgroundRebound pain is believed to involve both nociceptive pain due to insufficient analgesia and hyperalgesia induced by regional anesthesia. Adjuvant's addition could prevent rebound pain. This study aimed to determine if the addition of dexamethasone or clonidine to local anesthetic when performing interscalene block could prevent rebound pain. MethodsThis was a multicenter, prospective, parallel grouping, randomized clinical trial conducted with patients receiving a single injection of bupivacaine 0.375% in interscalene block ultrasound guided and general anesthesia for shoulder surgery were randomly assigned to either no additives (control), clonidine (30 mcg), or dexamethasone (4 mg). The primary outcome was rebound pain, defined as sudden onset of pain, moderate to severe intensity (VAS ≥7) without improvement with oral medication, followed by VAS pain at rest, required rescue analgesia, the occurrence of adverse events or complications, and satisfaction survey assessments between groups. Rebound pain and pain at rest were assessed 2, 4, 6, 12, 24, and 48 hours after the procedure. ResultsThe incidence of rebound pain was not statistically different between groups (p-value = 0.22), with an observed incidence of 41.2% (95% CI 25.9‒57.9), 28.6% (95% CI 16.7‒43.3), and 23.3% (95% CI 12.6‒37.6) in the control, dexamethasone, and clonidine groups, respectively. Additionally, there were no significant differences between the groups in time, from anesthetic blockade to first complaint of pain or the severity of postoperative pain. ConclusionThe administration of dexamethasone or clonidine as perineural adjuncts to local anesthesia in single-injection interscalene blocks did not significantly reduce the incidence of rebound pain.

Effect of pericapsular nerve block on the quality of recovery after shoulder arthroscopy.

Shoulder arthroscopy, a standard orthopedic procedure, often results in severe postoperative pain, leading to high opioid consumption and delayed recovery. Various analgesic methods, including peripheral nerve blocks, manage this pain. The pericapsular nerve group block is a relatively new technique whose efficacy in shoulder surgeries has yet to be extensively studied. This study aimed to assess the impact of the pericapsular nerve group block on postoperative recovery quality following shoulder arthroscopy, as measured by the Quality of Recovery-15 score. A randomized, prospective, controlled, multicenter study was conducted with 60 patients undergoing unilateral shoulder arthroscopy. Participants were allocated to either Group P (patients receiving the pericapsular nerve group block and multimodal analgesia) or Group C (patients receiving only multimodal analgesia). The primary outcome measured was the Quality of Recovery-15 score 24 hours post-surgery. Secondary outcomes included postoperative numeric rating scale scores, the requirement for rescue analgesia, time to first rescue analgesia, postoperative complications, the necessity for antiemetics, and patient satisfaction. The median Quality of Recovery-15 score was significantly higher in Group P compared to Group C (120±10 vs. 89±11; P<0.001). Additionally, Group P exhibited lower pain scores at rest and during movement, a decreased need for rescue analgesia, and an extended duration before the first rescue analgesia was required. Postoperative nausea and vomiting were less common in Group P, and patient satisfaction scores were notably higher in this group. The pericapsular nerve group block significantly enhances postoperative recovery quality, reduces pain and opioid consumption, and improves patient satisfaction without significant complications.

Intraoperative Methadone in Spine Surgery ERAS Protocols: A Systematic Review of the Literature.

Systematic review. To systematically review the use of intraoperative methadone in spine surgery and examine its effects on postoperative opioid use, pain, length of stay, and operative time. Spine surgery patients commonly have a history of chronic pain and opioid use, and as a result, they are at an increased risk of severe postoperative pain. While pure mu opioids remain the standard for acute surgical pain management, they are associated with significant short-term and long-term adverse events. Methadone presents an alternative to pure mu opioids which may improve postoperative management of pain following intraoperative use. A systematic review of MEDLINE, Embase, and Web of Science databases was conducted to review existing literature detailing operating time, postoperative pain, opioid usage, and hospital length of stay (LOS) following intraoperative methadone administration in spine surgery. Following screening of 994 articles and application of inclusion criteria, 8 articles were included, 4 of which were retrospective. Conventional spine surgery intraoperative analgesic strategies used as comparators for intraoperative methadone included hydromorphone, ketamine, and sufentanil. Considering patient outcomes, included studies observed that patients treated with intraoperative methadone had statistically similar or significantly reduced pain scores, opioid usage, and LOS compared with comparator analgesics. However, one study observed that intraoperative methadone used in a multimodal analgesia regimen strategy with ketamine resulted in a shortened LOS compared with the use of intraoperative methadone alone. Differences in operating time between cases that used intraoperative methadone and cases that used comparator analgesics were not statistically significant among included studies. Methadone may present an alternative option for both intraoperative and postoperative analgesia in spine surgery recovery protocols and may reduce postoperative pain, opioid use, and LOS while maintaining consistent operating time and reduced side effects of pure mu opioids. Level II.

Effects of Ketamine 0.5 mg/kgBW administration as preemptive analgesia on analgesia duration and the need for Fentanyl following hysterectomy surgery: a randomized controlled trial

INTRODUCTION: Hysterectomy is a surgical procedure with a high number of moderate to severe postoperative pain complications. Preemptive analgesia prevents central sensitization before surgery, hampering postoperative hyperesthesia. Ketamine is one of several preemptive analgesia available. This study aims to study the effects of ketamine 0.5 mg/kgBW administration as preemptive analgesia on analgesia duration and the need for fentanyl following hysterectomy surgery. MATHERIALS AND METHODS: This study is a double-blind randomized controlled trial experiment on two groups: the treatment group (n = 20) was given ketamine 0.5 mg/kgBW and the control group (n = 20). The duration was measured starting from surgery completion up to the need for additional fentanyl 25 µg analgesia through Patient Controlled Analgesia (PCA) within 24-hour periods following surgery. Numerical data statistical analysis was done using unpaired T-test and Mann—Whitney for normally distributed data and non-normally distributed data respectively. Categorical data statistical analysis was done using the Exact Fisher test. RESULTS: The mean time recorded until additional analgesia was needed in the treatment group was 246.00 ± 33.150 minutes and in the control group was 121.50 ± 23.792 minutes. The mean total 24-hour post-surgery additional analgesia was 82.50 ± 11.75 µg and 118.75 ± 11.10 µg for the treatment group and control group respectively. There were statistically significant differences in the duration of analgesia and the need for additional analgesia between the two subject groups (p &lt; 0.05). CONCLUSIONS: Administration of ketamine preemptive analgesia at a dose of 0.5 mg/kgBW resulted in longer analgesia duration and reduced the need for fentanyl as an additional analgesic in postoperative patients compared with no preemptive analgesia and showed no significant side effects.

Efficacy of Quadratus Lumborum Block Compared to Paravertebral Block on Pediatric Patients Undergoing Abdominal Surgery

Background: Abdominal surgery is a major procedure associated with severe postoperative pain in pediatric patients. Quadratus lumborum block (QLB) is considered an effective pain control in such cases. Paraverterbral block (PVB) is another option for postoperative pain management. The aim of this study was to compare the effectiveness of quadratus lumborum block with paravertebral block. Methods: This single-blind randomized controlled trial included 22 pediatric patients who underwent abdominal surgery at Sanglah Hospital, Denpasar between August – October 2022. Research subjects were divided into 2 treatment groups; group A consisted of general anesthesia combined with quadratus lumborum block and group B consisted of general anesthesia combined with paravertebral block. Duration of analgesia was recorded based on the time to analgesic rescue, FLACC pain scale at 0, 2, 4, 6, 12 and 24 hours and total opioid consumption 24 hours after surgery. Statistical analyses were performed using SPSS. Results: Eleven patients received QLB and PVB respectively. There was a significant difference in mean analgesia duration of 1287 ± 129.69 minutes compared to 750 ± 122.22 minutes (p &lt; 0.001) (CI 95%: 425.18 – 649.36), median FLACC pain scale at 12 (1 (IQR 2) vs 4 (IQR 1)) and 24 hours postoperative (1 (IQR 2) vs 3 (IQR 1)) between QLB and PVB (p &lt; 0.001 and p &lt; 0.007). Mean 24-hour postoperative opioid consumption was significantly lower in the QLB compared to the PVB. Conclusion: QLB has better effectiveness than PVB in pediatrics undergoing abdominal surgery.

Virtual Reality for Postoperative Pain Management: A Review of Current Evidence.

With the ongoing opioid crisis, there is a continued need to develop multimodal pain management strategies inclusive of non-pharmacological treatments. Virtual reality (VR) offers a non-invasive treatment approach for the management of acute and chronic pain including postoperative pain. The aim of this review is to describe the use of VR and its effect on pain-related outcome measures compared to routine care in various types of surgical procedures. Severe postoperative pain is associated with an increased risk of medical complications and may lead to the development of chronic pain. VR-based interventions are a form of distraction therapy that attenuates pain perception and have been shown to reduce activity in central pain-processing regions. In patients undergoing cardiac surgery, VR may reduce postoperative pain and improve physiological parameters such as heart rate and blood pressure. VR technology was found to have a high satisfaction rate in patients undergoing laparoscopic abdominal surgeries. Three-dimensional (3D) VR interventions may be useful for postoperative pain control in patients undergoing head and neck surgery. VR technology has revealed mixed results for postoperative pain control following orthopedic procedures although it has beneficial effects on functional outcomes during postoperative rehabilitation. In the pediatric population, VR is notable for its applicability in postoperative pain control and anxiety. VR technology is a novel, non-pharmacologic adjunct in the management of postoperative pain. Current studies are limited regarding therapy adaptations for the elderly population. High-quality randomized controlled trials are needed to establish the clinical effectiveness of VR-based therapies in the postoperative setting.

Management of Grade III Internal Hemorrhoids by HAL (Haemrriodal Artery Ligation) and Tikshna Kshara Application

This study aims to standardize a hybrid procedure to be used in internal Hemorrhoids (Arsha) without complication of post-operative bleeding and severe pain experienced by patients in other forms of surgical interventions. Methodology: A patient diagnosed with Grade III hemorrhoids visited outpatient department and after thorough discussion, evaluation and physical/local examination was advised to undergo Tikshana Kshara therapy along with HAL for redressal of symptoms presented as bleeding per rectum. The patient was sent for routine pre surgical investigations and pre-anesthetic checkup. A surgical plan was devised for the case using Vicryl 2-0 for HAL and Tikshana Apamarga Kshara for application on pile mass. A half slit proctoscope was used for visualization of each pile mass. Suture of 8 shape was taken at the base of each pile mass for ligation with Vicryl 2-0 and Tikshana Kshara was applied after that on each pile mass for 40 sec one after the another. Khasra was washed with Nimbu Swaras to prevent Atidagdta by Kshara. There was minimal bleeding at the time of suturing and colour of the pile masses changed immediately to Pakva Jamunphala varna. A standard Kshara prepared using Apamarga, Suddha Varga and Chitraka was used for application. Patient was kept under observation for post-operative care. Efficacy was assessed after 15 days of the procedure. Results: The procedure produced encouraging results with significant reduction in size pile masses. There was no post-operative pain or constipation. There was minimum to no post-operative bleeding or stenosis. Conclusion: This hybrid combination by usage of Vicryl 2-0 and Tikshana Kshara application shows promising results in management of G-III hemorrhoids with no to minimal complication and post-operative care. Patient can immediately get back to work with some precautions.

Chronic postoperative pain syndrome and its neuropathic component in long-term period of coronary artery bypass grafting

Background: Along with increased safety and quality of the early postoperative period, 6.9% of patients who undergo sternotomy experience chronic pain at the surgical site. The significance of this issue is underestimated, with a third of these patients developing a neuropathic component of chronic pain syndrome. Aim: To assess the severity of acute and chronic postoperative pain following sternotomy and to identify predictors of the neuropathic component of chronic pain syndrome. Materials and methods: Out of 115patients who underwent elective coronary artery bypass grafting (CABG) randomized according to method of anesthesia, two study groups were formed based on the results of a telephone survey: a general anesthesia group (GA, n=28) and a combined anesthesia group (CA, n=34). As part of the posthoc analysis, a logistic regression model was built to predict chronic neuropathic pain syndrome based on gender, age, anesthesia method, and factors assessing the severity of the perioperative period and myocardial impairment. Results: Chronic postoperative pain syndrome was identified in 25.8% of patients, with a neuropathic component confirmed in 19.4% of cases. Pain severity at rest in the GA and CA groups was 2.0 (1.0) and 3.0 (3.0) points on a numeric rating scale one hour after extubation, and 2.0 (2.0) and 2.0 (2.0) points by the end of the first postoperative day (p=0.193 and 0.610, respectively). The logistic regression model achieved an AUROC of 0,82 (95% CI 0,68–0,96) with c2(10)=10.62, p=0.39. Conclusions: Neuropathic pain was diagnosed in 19.4% of patients following CABG. The use of regional anesthesia and the severity of acute pain did not impact the development of neuropathic pain syndrome in the long-term period after surgery. The proposed model for predicting the neuropathic component of chronic pain syndrome after CABG requires further improvement.

Postoperative analgesic effectiveness of ultrasound-guided bilateral erector spinae plane block vs. rectus sheath block for midline abdominal surgery in a low- and middle-income country: a randomised controlled trial.

The use of erector spinae plane block and rectus sheath block for postoperative analgesia in midline abdominal procedures is becoming more common. However, the most effective and appropriate method remains unclear. We aimed to compare the postoperative analgesic effecacy of ultrasound-guided bilateral erector spinae plane blocks with rectus sheath blocks for midline abdominal surgery in a low- and middle-income country. We allocated randomly 72 patients aged 18-65 y undergoing midline abdominal surgery to an erector spinae plane block (n = 36) or a rectus sheath block (n = 36) utilising a prospective, parallel study design. Patients, care providers and outcome assessors were blinded to the interventions. The primary outcome measures were total postoperative analgesia consumption, postoperative pain severity and time to first rescue analgesic administration. Secondary outcomes included the incidence of postoperative complications and adverse events. Of 78 patients assessed for eligibility, six were excluded, leaving 72 for analysis. Patients allocated to erector spinae plane block had a lower mean (SD) postoperative opioid consumption compared with those allocated to rectus sheath block (3.5 (8.7) morphine milligram equivalents vs. 8.2 (2.8) morphine milligram equivalents, respectively; p = 0.003). Time to first analgesic request was greater in patients allocated to erector spinae plane block compared with those allocated to rectus sheath block (mean (95%CI) 16 (13-17) h vs. 12 (11-13) h, respectively; p < 0.001). There were no block-related complications in either group. Erector spinae plane blocks are more effective than rectus sheath blocks for the management of postoperative pain following midline abdominal surgery. Integration of erector spinae plane blocks into multimodal opioid-sparing analgesic strategies after midline abdominal surgeries may promote enhanced patient recovery in low-and middle-income countries.

Conceptual Study on the Effect of Palasha Gudavarti in Post-operative Pain Management of Anorectal Surgeries

Post-operative pain management is a crucial component of recovery, particularly following anorectal surgeries, where pain can significantly hinder healing. The prevalence of postoperative pain after 24 hours of surgery is 55.3%, after 48 hours is 34.7 % and of moderate to severe post-operative pain is 13 % after 24 hours, and 11.7% after 48 hours1 .Ano rectal pathology amenable to ambulatory surgery includes anal fissures, warts, fistulas, hemorrhoids,abscess and small neoplasms. Quick recovery after ano rectal surgery can be successful only with effective post-operative pain control. Acharya Sushruta recommends the use of Yashtimadhu siddha ghritha application over the operated area2 . Additionally , he advocates the application of shoolahara dravyas and vatahara dravyas processed with ghritha to the surgical site for effective pain relief. Planning a cost effective, reliable, time tested and technically simple management is the need of this modem era. The present study explores the possible analgesic, anti-inflammatory, and wound-healing properties of Palasha Gudavarti, offering an alternative approach to conventional pain management techniques.

The Impact of Pudendal Nerve Injection in Vaginal Surgery: A Secondary Analysis

Importance Evidence regarding the effect of pudendal nerve blockade during vaginal surgery is conflicting. Previous studies compared pudendal nerve blockade to either normal saline placebo injection or no injection, demonstrating small or no difference in pain outcomes. Studies investigating nerve blocks at the time of vaginal surgery have not evaluated the effect of infiltration of the space around the pudendal nerve. Objective The aim of the study was to determine whether intraoperative pudendal nerve injection (bupivacaine or normal saline) will result in improved pain scores and satisfaction compared with patients who receive no pudendal injection. Study Design We performed a secondary analysis of 2 randomized controlled trials investigating postoperative pain after vaginal reconstructive surgery, comparing the outcomes of the following 3 groups: control (no pudendal injection), intervention (bilateral pudendal nerve blockade), and placebo (bilateral normal saline pudendal injections). The primary outcome was postoperative pain scores. Secondary outcomes were opioid use, patient satisfaction, and postoperative complications. Linear mixed effects models were applied to outcomes, and treatment effects with 95% confidence intervals were estimated at each time point from the model. Results One hundred four patients who underwent vaginal surgery were included: 36 pudendal nerve block, 35 normal saline pudendal injection, and 33 no injection. The groups were well-matched. Linear mixed effects models demonstrated no significant differences between treatment groups for postoperative pain severity scores, opioid use, and patient-reported satisfaction at each time point. Conclusions Normal saline injection and no injection seem to have no clinically meaningful difference in effect, and either could reasonably serve as control for pudendal blockade during vaginal surgery.

The role of adjuvants in regional anesthesia: the postoperative analgesic effectiveness of dexamethasone vs. tramadol given as adjuvants to bupivacaine for ultrasound-guided supraclavicular block for upper extremity surgery—a prospective cohort study

BackgroundBrachial plexus block is used as a surgical anesthesia and analgesia for postoperative pain. Recently, the use of local anesthetics for regional nerve block has been enhanced by mixing them with a different class of drugs as adjuvants. These adjuvants of local anesthetics improved the quality and duration of nerve block and reduced the dose-dependent side effects of local anesthetics. However, the effectiveness of these adjuvants varies depending on the nature of the nerve block and the type of local anesthetics used. Therefore, we aimed to compare the postoperative analgesic effectiveness of dexamethasone vs. tramadol when used as adjuvants to bupivacaine for ultrasound-guided supraclavicular block in upper extremity surgery.MethodsUtilizing a prospective cohort study design, 126 consecutive patients who were undergoing upper extremity surgery with ultrasound-guided supraclavicular block were included. Patients were divided into three groups based on the preference of the responsible anesthetist to use adjuvants with bupivacaine for the block. The dexamethasone group (n = 42) were given 30 ml of 0.25% bupivacaine with 8 mg dexamethasone, the tramadol group (n = 42) were given 30 ml of 0.25% bupivacaine with 100 mg tramadol, and the non-adjuvant group (n = 42) were given 30 ml of 0.25% bupivacaine alone. The primary outcomes evaluated were postoperative pain severity using the numerical pain rating scale (NRS), the duration of analgesia, and the total postoperative analgesic consumption. Secondary outcomes included the incidence of postoperative complications.ResultA total of 126 patients were recruited and analyzed. There was no statistical difference in the demographic data among the groups. The postoperative NRS score was significantly reduced in the dexamethasone and tramadol group compared with the non-adjuvant group (p &amp;lt; 0.001). The NRS score in the dexamethasone group at 18 and 24 h was statistically much lower than in the tramadol and non-adjuvant group. The postoperative duration of analgesia was significantly prolonged in the dexamethasone (1,069 ± 316.99 min) group compared with the tramadol (617.02 ± 214.05 min) and non-adjuvant (434.17 ± 111.23 min) groups (p &amp;lt; 0.001). Patients in the non-adjuvant group had a significantly higher total analgesic consumption over 24 h. The dexamethasone group experienced significantly fewer incidences of nausea, with no differences in other complications among the groups.ConclusionThe addition of dexamethasone as an adjuvant to bupivacaine for ultrasound-guided supraclavicular block improves postoperative analgesia. We recommend the integration of dexamethasone as an adjuvant to local anesthetics during nerve blocks to enhance postoperative pain management after surgery.

Effect of Ultrasound-Guided External Oblique Intercostal Block on Postoperative Recovery After Subxiphoid Video-Assisted Thoracoscopic Thymectomy: A Randomized Controlled Trial.

Severe postoperative pain can occur after subxiphoid video-assisted thoracoscopic thymectomy (SVATT), affecting the quality of postoperative recovery. This study aimed to evaluate the effect of ultrasound-guided external oblique intercostal (EOI) block on recovery after SVATT. A total of 60 patients undergoing SVATT were randomly divided into the EOI group (group E, n = 30) and the control group (group C, n = 30). Group E underwent ultrasound-guided bilateral EOI block at the 6th rib level and was injected 20 mL of 0.375% ropivacaine on each side. Group C was injected with 20 mL of 0.9% saline at the same site. After the operation, both groups received a patient-controlled intravenous analgesic (PCIA) pump. The 15-item Quality of Recovery (QoR-15) scores were recorded at 24 hours before surgery (T0), 24 hours after surgery (T3), and 48 hours after surgery (T4). The sufentanil usage in the first 24 hours postoperatively, the remifentanil dosage during surgery, the time of first pressing PCIA, and the cases of rescue analgesia were recorded. The visual analog scale (VAS) scores of patients at 6 (T1), 12 (T2), 24 (T3), and 48 hours (T4) after an operation during rest and coughing were recorded. The dermatomes of the sensory plane, block complications in group E, and the incidence of other postoperative adverse reactions in both groups were also recorded. Compared with group C, the QoR-15 scores of patients were significantly higher at T3 and T4 in the group E. The VAS scores were significantly lower at T1, T2, and T3 during rest and coughing in the group E. The sufentanil usage in the first 24 hours postoperatively, the remifentanil dosage during surgery, and the cases of rescue analgesia were significantly lower in group E, and the time of first pressing PCIA was significantly increased in group E (all P < .05). Ultrasound-guided EOI block can be safely used in patients undergoing SVATT, which can improve the quality of postoperative recovery and reduce postoperative pain.