Standard Multimodal Analgesia Research Articles

ERECTOR SPINAE PLANE BLOCK FOR MINIMALLY INVASIVE MITRAL VALVE SURGERY HAS NO IMPACT ON POSTOPERATIVE OUTCOMES: A DOUBLE-BLIND, PROSPECTIVE RANDOMIZED PLACEBO-CONTROLLED TRIAL

<h3>Objective</h3> Compared to traditional sternotomy, minimally invasive mitral valve surgery (MIMVS) using video-assisted thoracoscopy has been shown to result in an increased incidence of moderate to severe acute postoperative pain.1 The Erector Spinae Plane (ESP) block, a novel fascial plane block, may be an useful and safe option for postoperative analgesia in MIMVS.2 As randomized trials in this field are sparse, we hypothesized that an intermittent ESP block with ropivacaine 0.5% (intervention group) compared to normal saline 0.9% (control group) is effective in reducing postoperative pain after MIVMS.3 <h3>Design & Methods</h3> PPThis single center, double-blind, prospective, randomized, placebo-controlled trial was approved by the local Ethics Committee (S62638 June 4th 2019, EudraCT 2019-001125-27). The trial was supported by the EACTA Research Grant 2020. Primary endpoint was postoperative 24h morphine consumption. Based on pilot data and to have an 80% power to show a 25% reduction in 24h morphine consumption in the intervention-group compared to the control-group, 64 patients had to be randomized (1:1 ratio). A pre-planned sample size recalculation was performed after inclusion of 32 patients. Multiple secondary endpoints were evaluated up to 30-days postoperatively including postoperative pain scores, midaxillary sensory block, rescue treatments for pain and hospital length of stay.3 <h3>Results</h3> Sample size recalculation revealed the need to recruit 4 additional patients in each group. 72 patients were randomized between July 2nd 2019 and November 4th 2021. Regarding our primary outcome, 2 patients in the intervention-group could not be assessed due to reintubation and ischemic cerebral event. In the control-group, we observed 2 epileptic seizures requiring unblinding of the randomization to start appropriate treatment. There were no differences in baseline or procedural characteristics. The median (IQR) 24h morphine consumption was not different between the intervention- and control-group: 41mg [30;55] vs 37mg [29;50], p=0.70, respectively (Table 1). Mean numerical rating scale values for pain showed no significant differences between groups (Figure 1). The number of morphine boli requested each hour by the patient, sensory block, rescue treatments for pain and hospital length of stay were comparable (Figure 2 & Table 1). <h3>Conclusion</h3> In the current placebo-controlled trial following MIMVS, we were unable to demonstrate any benefit from the addition of an intermittent ESP-block to a standard multimodal analgesia regimen.

Lumbar Erector Spinae Plane Block for Total Hip Arthroplasty Comparing 24-Hour Opioid Requirements: A Randomized Controlled Study.

Design Prospective, randomized, controlled trial. Patients. Sixty-three adult patients with an American Society of Anesthesiologists Status I–III who are undergoing elective primary total hip arthroplasty. Interventions. Patients were randomized to the control group (no block) or the ESPB group (preoperative ultrasound-guided lumbar ESPB). Intraoperatively, all patients received spinal anesthesia with moderate sedation. Postoperatively, patients received a standardized multimodal analgesia protocol. Measurements. The primary outcome was cumulative opioid consumption at 24 hours postoperatively. Secondary outcomes included cumulative opioid consumption at 8 hours and through 48 hours postoperatively and pain scores at 24 and 48 hours post surgery. Main Results. Thirty-one patients were randomized to the control group (spinal alone) and 32 patients to the ESPB group. The median opioid requirement in the first 8 hours after surgery was higher in the control group (28 mg of oral morphine equivalents (OME) versus 5 mg of OME in the ESPB group) (p = 0.013). There was no statistically significant difference in opioid consumption between the groups at 24 hours (p = 0.153) or 48 hours (p = 0.357) postoperatively. There was no statistically significant difference in pain scores between the two groups through 24 hours (p = 0.143) or 48 hours (p = 0.617) after surgery. Conclusion Lumbar ESPB reduces opioid utilization during the first 8 hours postoperatively after total hip arthroplasty but not thereafter. Evaluating the use of either adding a local anesthetic adjunct to the ESPB or using longer-acting local anesthetic warrants further investigation.

Efficacy of ultrasound-guided single-injection erector spinae plane block for thoracoscopic wedge resection: a prospective randomized control trial

BackgroundDespite advances in minimally invasive thoracic surgery, patients remain at risk of adverse pulmonary events with suboptimal postoperative analgesia. Novel methods of regional analgesia are warranted. Our objective was to...

The association of Serratus Anterior Plane blocks with postoperative opioid use and analgesia following simple lumpectomy: a retrospective cohort analysis

BackgroundThe potential benefit of regional interventions for simple lumpectomy breast cancer surgeries has not been well investigated. Understanding which patients to not offer a regional intervention to can be just as important as knowing which would benefit. It is unclear whether fascial plane blocks, such as serratus anterior plane (SAP) block, should be routinely performed for less extensive breast surgeries. Therefore, our goal in this retrospective cohort study was to evaluate the association of integrating SAP blocks into a standard perioperative multimodal analgesia plan in patients undergoing simple lumpectomies (without node biopsies) with perioperative opioid consumption. As secondary outcomes, we also analyzed postoperative pain scores and post-anesthesia care unit (PACU) length of stay.MethodsThis was a single institution retrospective cohort study (surgical site infiltration only versus SAP block cohorts) assessing the association of SAP blocks to our outcomes of interest. In the adjusted analysis, we created matched cohorts using 1:1 (surgical site infiltration only: SAP block) propensity-score matching using nearest neighbor-matching without replacement. To compare the primary and secondary outcomes in the matched cohorts, we used the Wilcoxon signed rank test. A P-value of < 0.05 was considered statistically significant.ResultsThere were 419 patients included in the analysis, in which 116 (27.7%) received a SAP block preoperatively in addition to our standard perioperative analgesia plan. In an unadjusted analysis, no differences were seen in perioperative opioid consumption, PACU pain scores, and PACU length of stay. Among the matched cohorts, the median [quartile] perioperative opioid consumption in the surgical site infiltration only versus SAP block cohorts were 10 mg [10, 13.25 mg] and 10 mg [7, 15 mg], respectively (P = 0.16). No differences were seen in the other outcomes.ConclusionsIn this study, we evaluated the impact of SAP blocks on patients undergoing simple lumpectomies, which are relatively less involved breast surgeries. We concluded that routine use of preoperative regional anesthesia is not beneficial for these specific patients. Future studies should focus on identifying patients that would directly benefit from regional interventions.

Opioid-Sparing Effects of the Bupivacaine Pleural Catheter in Surgical Decompression of the Thoracic Outlet

Rib resection in thoracic outlet decompression can result in significant postoperative pain requiring high levels of opioid medications. We evaluated the impact of a bupivacaine infusing pleural catheter on postoperative pain and opioid usage in patients undergoing rib resection for thoracic outlet syndrome. We hypothesized that delivery of local anesthetic via the pleural catheter would improve postoperative pain control compared to standard multimodal analgesia, and that the use of the catheter would decrease opioid use during the index hospitalization and prescriptions for opioid pain medications at discharge. We conducted a single-center retrospective cohort study of 26 patients who underwent rib resection for thoracic outlet decompression. Primary outcome was opioid consumption during the index hospitalization, measured in morphine milligram equivalents (MME). Secondary outcomes were MME prescribed at discharge and pain scores during the index hospitalization before and after the pleural drain and pleural catheter were removed. Patients in the bupivacaine infusion pleural catheter group (n=11) had significantly lower MME usage during the index hospitalization (22.5 [1.9, 65.6] vs. 119.8 [76.5, 167.4]), and significantly lower MME prescribed at discharge (0 [0, 37.5] vs. 225 [183, 315]), compared to standard multimodal analgesia in controls (n=15). Only 3 patients in the bupivacaine pleural catheter group were discharged with any opioid prescriptions (27%), compared to 14 patients in the control group (93%). There was no difference in postoperative pain scores between groups before or after removal of the pleural drain, which was placed in all cases (P=0.31 and P=0.76, respectively). Intraoperative placement of a bupivacaine infusion pleural catheter significantly reduced opioid use during the index hospitalization and opioid prescribing at discharge. Anesthetic infusion pleural catheters should be the treatment modality of choice for postoperative pain management in patients undergoing thoracic outlet decompression.

Perioperative analgesic efficacy and safety of erector spinae plane block in posterior cervical spine surgery: a double-blinded, randomized controlled study

<h3>BACKGROUND CONTEXT</h3> Posterior cervical spine surgeries (PCSS) are typically open surgeries and entail significant postoperative pain. Current perioperative pain management in PCSS is reliant on multimodal analgesia. While perioperative epidural anesthetic infusion can be used in lumbar surgeries, this is not an option in the cervical spine. Pre-emptive regional analgesia through erector spinae plane block (ESPB) has shown significant perioperative analgesic benefits in lumbar spine surgeries. There are no such clinical studies in PCSS. <h3>PURPOSE</h3> To assess the safety and efficacy of ultrasound-guided ESPB for perioperative analgesia in PCSS. <h3>STUDY DESIGN</h3> Prospective, randomized controlled, double-blinded study. <h3>PATIENT SAMPLE</h3> This study included 86 patients requiring sub-axial PCSS with or without instrumentation randomized into two groups, those who underwent ESPB with multimodal analgesia (case) and those with only multimodal analgesia (control). <h3>OUTCOME MEASURES</h3> Demographic and surgical data (blood loss, duration of surgery, perioperative total opioid consumption, muscle relaxants used) were assessed. Postoperatively, the surgical site pain, alertness scale, satisfaction score, time to mobilization and complications were recorded. <h3>METHODS</h3> After anesthesia and prone position, case patients received ultrasound-guided ESPB at the T1 level using 15ml of 0.25% bupivacaine and 8mg dexamethasone bilaterally while the control patients received only standard postoperative multimodal analgesia. <h3>RESULTS</h3> Each group included 43 patients; the two groups were identical in demographic and surgical profile. The intraoperative opioid consumption (119.53±40.35 vs 308.6±189.78; p<0.001) in mcg), muscle relaxant usage (50.00±0.00 mg vs 59.53±3.75 mg, p<0.001), surgical duration (124.77±26.63/ 156.74±37.01 mins; p<0.01) and intraoperative blood loss (310.47±130.73 ml vs 429.77±148.50 ml; p<0.05) were significantly less in the ESPB group. In the postoperative period, the control group's pain score was significantly higher (p<0.001). The Modified Observer Alertness/Sedation Score (MOASS) score and satisfaction scores also showed significant differences between the case and control groups (p<0.001). The mean time required to ambulate (sitting/walking) was statistically less in cases (15.81±6.15/20.72±4.02 hours) when compared to controls (16.86±6.18/ 23.05±8.88 hours) (p<0.001). <h3>CONCLUSION</h3> In patients undergoing PCSS, ESPB is a safe and effective technique with better outcomes than standard multi-modal analgesia alone, in terms of reduced intraoperative opioid requirements and blood loss, better postoperative analgesia and early mobilization. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Analgesic efficacy of erector spinae plane blocks for lumbar spine surgery: a randomized double-blind controlled clinical trial

IntroductionErector spinae plane block has been proposed to reduce opioid use and improve pain relief with controversial results. This randomized clinical study aimed to assess the efficacy of erector spinae...

Orthopedic sleep and novel analgesia pathway: a prospective randomized controlled trial to advance recovery after shoulder arthroplasty.

Lack of sleep is associated with adverse effects on postsurgical pain and recovery. We hypothesized that a multimodal sleep pathway, including nonpharmacologic sleep hygiene interventions and the use of zolpidem and melatonin, could improve patient analgesia and sleep after total shoulder arthroplasty. We performed a prospective randomized controlled study in which patients undergoing anatomic and reverse total shoulder arthroplasty were treated with or without an interventional multimodal sleep pathway. This pathway included nursing-directed nonpharmacologic measures that promote sleep hygiene and pharmacologic interventions with low-dose zolpidem and melatonin at bedtime. All patients underwent a standardized multimodal analgesia protocol with scheduled acetaminophen, naproxen, and gabapentin, as well as a single-shot interscalene regional nerve block. This study enrolled 125 patients (64 in control group and 61 in interventional group) with similar demographic characteristics. The interventional group showed less oral morphine milligram equivalent (MME) consumption on postoperative day (POD) 0 (44.8±36.1 MMEs vs. 60.9±42.1 MMEs, P=.01) and showed a trend toward lower POD 0 visual analog scale pain scores (2.6±1.8 vs. 3.3±3.0, P=.06). Visual analog scale pain scores and MME consumption were similar on POD 1. The interventional group showed a longer objective sleep duration by quantitative wrist actigraphy (5.9±3.1 hours vs. 4.6±2.7 hours, P=.008), with better sleep quality assessed by the Leeds Sleep Evaluation Questionnaire (0-100 scale; 50.3±26.8 vs. 38.5±27.8, P=.01). The 2 groups showed similar satisfaction with pain management (89.2% vs. 79.6%, P=.16) and sleep management (82.1% vs. 76.8%, P=.48). There was no difference in the length of inpatient stay (32.2±14.8 hours vs. 34.1±12.8 hours, P=.44). In the setting of a regional and multimodal analgesia recovery plan for shoulder arthroplasty patients undergoing inpatient observation, the use of an interventional sleep pathway appears to be safe and beneficial, with improved analgesia, reduced opioid use, increased sleep duration, and improved reported sleep quality during the postoperative recovery period.

PD28-03 THE PENOSCROTAL APPROACH TO PENILE IMPLANTATION RESULTS IN INCREASED PENILE, NOT SCROTAL PAIN: IMPORTANT CONSIDERATIONS FOR PROSTHETIC UROLOGISTS

You have accessJournal of UrologyCME1 May 2022PD28-03 THE PENOSCROTAL APPROACH TO PENILE IMPLANTATION RESULTS IN INCREASED PENILE, NOT SCROTAL PAIN: IMPORTANT CONSIDERATIONS FOR PROSTHETIC UROLOGISTS Avery Braun, Daniel Swerdloff, Hira Chaudry, Alice Xiang, Michelle Chen, Martin Gross, and Jay Simhan Avery BraunAvery Braun More articles by this author , Daniel SwerdloffDaniel Swerdloff More articles by this author , Hira ChaudryHira Chaudry More articles by this author , Alice XiangAlice Xiang More articles by this author , Michelle ChenMichelle Chen More articles by this author , Martin GrossMartin Gross More articles by this author , and Jay SimhanJay Simhan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002576.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Increased postoperative scrotal pain following inflatable penile prosthesis (IPP) implantation is a principal argument of many detractors of the penoscrotal approach. However, there remains a paucity of work assessing severity, location and duration of pain following IPP surgery. We thoroughly characterize postoperative pain following penoscrotal IPP in patients managed with a standardized multimodal analgesia (MMA) protocol. METHODS: This is a single-center, prospective analysis of 98 virginal penoscrotal IPP patients utilizing MMA (a standardized protocol of acetaminophen, gabapentin, and NSAIDs) from 9/2019 to 9/2021. Patients with chronic pain, those ineligible for MMA, alternative surgical approaches, concomitant surgeries or infections were excluded. Follow-up was executed on POD 2, 7, 14, and 30 with a standard questionnaire (Figure 1A). Pain scores were stratified based by visual analogue score (VAS) to none/mild (VAS=0-3), moderate (VAS=4-6) & severe (VAS=>7). RESULTS: Pain locations/trends are found in Figure 1B. Most “area of most bother” following IPP was external to the scrotum throughout recovery (70% vs 30% POD2; 65% vs 35%, POD7; 62% vs 38% POD14; & 70% vs 30% POD30, p=<0.001) with only the penile shaft and glans significantly increasing in bother from 20% POD2; 28% POD7; 27% POD14; to 38% POD30 (p=0.023). Patients reporting no to mild pain increased from 23.1% to 70.4% while those reporting severe pain decreased from 46.2% to 11.1% from POD2 to 30 (p=0.05). In those with severe pain, “area of most bother” was incisional on POD2 (35.7%) and POD7 (37.5%), glanular on POD14 (50%) and on the shaft on POD30 (50%). 7/98 (7.1%) patients required narcotic refills and all experienced severe pain with higher average VAS scores compared to the rest of the cohort (7.0 vs 5.2 POD2, 7.3 vs 5.3 POD7, 7.0 vs 3.6 POD14, and 5.4 vs 2.3 POD30, p=0.019). CONCLUSIONS: We report a thorough assessment of the pain profile experienced by penoscrotal IPP recipients in the first postoperative month. While proponents of infrapubic and subcoronal approaches anecdotally postulate decreased postoperative pain due to reduced scrotal manipulation, we objectively demonstrate that most penoscrotal IPP patients complain of penile shaft and glans penis pain. Source of Funding: NA © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e499 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Avery Braun More articles by this author Daniel Swerdloff More articles by this author Hira Chaudry More articles by this author Alice Xiang More articles by this author Michelle Chen More articles by this author Martin Gross More articles by this author Jay Simhan More articles by this author Expand All Advertisement PDF DownloadLoading ...

Perioperative analgesic efficacy and safety of erector spinae plane block in posterior cervical spine surgery—a double blinded, randomized controlled study

Background contentPosterior cervical spine surgery (PCSS) are typically open surgeries and entail significant postoperative pain. Current perioperative pain management in PCSS is reliant on multimodal analgesia. While perioperative epidural anesthetic infusion can be used in lumbar surgeries, this is not an option in the cervical spine. Pre-emptive regional analgesia through erector spinae plane block (ESPB) has shown significant perioperative analgesic benefits in lumbar spine surgeries. There are no such clinical studies in PCSS. PurposeTo assess the safety and efficacy of ultrasound-guided ESPB for perioperative analgesia in PCSS. Study designProspective, randomized controlled, double-blinded study. Patient sampleEighty-six patients requiring sub-axial PCSS with or without instrumentation were randomized into two groups, those who underwent ESPB with multimodal analgesia (case) and those with only multimodal analgesia (control). Outcome measuresDemographic and surgical data (blood loss, duration of surgery, perioperative total opioid consumption, muscle relaxants used) were assessed. Postoperatively, the surgical site pain, alertness scale, satisfaction score, time to mobilization and complications were recorded. MethodsAfter anesthesia and prone position, case patients received ultrasound-guided ESPB at the T1 level using 15 ml of 0.25% bupivacaine and 8 mg Dexamethasone bilaterally while the control patients received only standard postoperative multimodal analgesia. ResultsThere were 43 patients in each group; the two groups were identical in demographic and surgical profile. The intraoperative opioid consumption (119.53±40.35 vs. 308.6±189.78; p<.001) in mcg), muscle relaxant usage (50.00±0.00 mg vs. 59.53±3.75 mg, p<.001), surgical duration (124.77±26.63/ 156.74±37.01 min; p<.01) and intraoperative blood loss (310.47±130.73 ml vs. 429.77±148.50 ml; p<.05) were significantly less in the ESPB group. In the postoperative period, the control group's pain score was significantly higher (p<.001). The Modified Observer Alertness/Sedation Score (MOASS) score and satisfaction scores also showed significant differences between the case and control groups (p<.001). The mean time required to ambulate (sitting/walking) was statistically less in cases (15.81±6.15/20.72±4.02 h) when compared to controls (16.86±6.18/ 23.05±8.88 h; p<.001). ConclusionIn patients undergoing PCSS, ESPB is a safe and effective technique with better outcomes than standard multimodal analgesia alone, in terms of reduced intraoperative opioid requirements and blood loss, better postoperative analgesia and early mobilization.

Postoperative analgesic efficacy of quadratus lumborum block in patients undergoing laparoscopic cholecystectomy: A retrospective study

Background: Patients undergoing laparoscopic cholecystectomy (LC) often complain of pain in the postoperative period despite intravenous analgesic administration. Systemic analgesia is also associated with side effects such as postoperative nausea and vomiting, thus adding to patient's discomfort. Posterior quadratus lumborum (QL) block has been studied to provide adequate analgesia in this set of patients. We retrospectively studied the efficacy of posterior QL block in LC patients and assessed them for chronic pain. Methods: Records of patients meeting inclusion criteria were taken. Standard multimodal analgesia as per the institute protocol was performed in all patients. Posterior QL block was performed under ultrasound guidance in test group, while control group received parenteral analgesia alone. Measurements: Static and dynamic Numeric Rating Scale (NRS) were measured at different time intervals during the first 24 postoperative h and time to rescue analgesia was noted. Assessment of chronic pain was done at the same time for all the patients. Side effect profile of both the groups was compared. Results: Static and dynamic pain scores were compared between block and control groups at immediate postoperative time period, 3 h, 12 h, and 24 h and statistically significant difference was noted with lower scores in test group as compared to control group at all four time points (P < 0.05). None of the patients in test group suffered chronic pain, while 33.3% patients in control group had chronic pain. Conclusion: Posterior QL block is an effective analgesia option for LC patients with less incidence of side effects. It should be performed more frequently as it is effective in reducing acute and probably chronic pain too in LC patients.

Efficacy of Transcutaneous Electrical Nerve Stimulation for Postoperative Pain, Pulmonary Function, and Opioid Consumption Following Cardiothoracic Procedures: A Systematic Review

Transcutaneous electrical nerve stimulation (TENS) is a minimally invasive method for treating pain. In the most recent review published in 2012, TENS was associated with increased pain relief following cardiothoracic surgery when compared to standard multimodal analgesia. The purpose of this systematic review and meta-analysis is to determine if adding TENS to current pain management practices decreases pain and analgesic use and improves pulmonary function for postcardiothoracic surgery patients. CINAHL, MEDLINE, Cochrane Database of Systematic Reviews, PubMed, and ClinicalTrials.gov were searched using specific keywords. Covidence was used to screen, select studies, and extract data by two independent reviewers. The Cochrane Risk of Bias tool assessed risk of bias. Visual analog scale (VAS) and pulmonary function data were exported for meta-analysis using a random effects model. The search yielded 38 articles. Eight randomized controlled trials met inclusion criteria for the literature review. Five studies were included in the meta-analysis of pain at 24, 48, and 72 hours postoperatively. Data were analyzed using the standard mean difference (SMD). TENS had a significant impact on VAS at rest (-0.76 SMD [95% confidence interval, CI=-1.06 to -0.49], p < 0.00001) and with coughing (-1.11 SMD [95%CI=-1.64 to -0.56], p < 0.0001). FEV1 improved after 72 hours (1.00 SMD [95%CI=0.66-1.35], p < 0.00001), as did forced vital capacity (1.16 SMD [95%CI=0.23-2.10], p=0.01). The addition of TENS therapy to multimodal analgesia significantly decreases pain following cardiothoracic surgery, increases the recovery of pulmonary function, and decreases the use of analgesics.

Erector spinae plane block reduces pain after laparoscopic cholecystectomy.

After laparoscopic cholecystectomy patients have moderate pain in the early postoperative period. According to several studies an erector spinae plane (ESP) block can be avaluable part of multimodal analgesia. Our intention was to evaluate how ESP block influences postoperative pain scores and opioid consumption after laparoscopic cholecystectomy. This single-blinded, prospective, randomized study included 60patients undergoing laparoscopic cholecystectomy to receive either bilateral ESP block at the Th7 level (n = 30) with 20 ml of 0.25% levobupivacaine plus dexamethasone 2 mg per side, or standard multimodal analgesia (n = 30). Patients from the standard multimodal analgesia group received tramadol 100 mg at the end of the procedure. Postoperative analgesia for both groups was acetaminophen 1 g/8 h i.v. and ketorolac 30 mg/8 h. Tramadol 1 mg/kg was arescue treatment for pain breakthrough (numeric rating scale/NRS ≥ 6) in both groups. Pain at rest was recorded at 10 min, 30 min, 2 h, 4 h, 8 h, 12 h and 24 h after surgery using NRS (0-10). An ESP block significantly reduced postoperative pain scores compared to standard multimodal analgesia after 10 min (p = 0.011), 30 min (p = 0.004), 2 h (p = 0.011), 4 h (p = 0.003), 8 h (p = 0.013), 12 h (p = 0.004) and 24 h (p = 0.005). Tramadol consumption was significantly lower in the ESP group 25.02 ± 56.8g than in the standard analgesia group 208.3 ± 88.1g (p < 0.001). An ESP block can provide superior postoperative analgesia and reduction in opioid requirement after laparoscopic cholecystectomy.

Вплив премедикації й знеболювання на стан тривоги і післяопераційної когнітивної функції при операціях на поперековому відділі хребта

Актуальність. Операції на поперековому відділі хребта можуть виконуватися як в умовах загальної (ЗА), так і спінальної анестезії (СА) та з різним режимом періопераційного знеболювання. Вплив цих двох факторів на емоційний і когнітивний стан пацієнтів залишається невизначеним. Мета дослідження: оцінити вплив премедикації та анестезії на передопераційну тривогу та післяопераційну когнітивну функцію при операціях на хребті. Матеріали та методи. Дослідження проведене на 254 пацієнтах віком 18–70 років, ASA I–II, яким виконувались планові оперативні втручання на поперековому відділі хребта. Пацієнти отримували спінальну або загальну внутрішньовенну анестезію та стандартне знеболювання (СЗ) або періопераційну мультимодальну аналгезію (ММА). СЗ включало парацетамол 1 г тричі на добу та морфін за необхідності та премедикацію феназепамом 0,5 мг. Пацієнти з ММА отримували додатково прегабалін 75 мг per os напередодні та у перші 3 доби післяопераційного періоду та парекоксиб 40 мг двічі на добу. Для оцінки тривоги використовували шкалу APAIS-A (Amsterdam Preoperative Anxiety and Information Scale частина Anxiety) та для оцінки когнітивних функцій — тест зв’язування чисел (ТЗЧ). Результати. Премедикація феназепамом та прегабаліном однаково впливала на рівень тривожності. Вірогідних відмінностей за APAIS-A не знайдено у пацієнтів жодної групи. ТЗЧ перед операцією вірогідно не відрізнявся між групами. На 3-тю добу після операції час за ТЗЧ у пацієнтів обох груп, які отримували СЗ та премедикацію феназепамом, був більшим за передопераційний рівень (у групі СА-СЗ — 87,3 ± 27,2 с проти 63,1 ± 16,3 с, р &lt; 0,05; у групі ЗА-СЗ — 92,1 ± 25,1 с проти 61,1 ± 18,5 с, р &lt; 0,05), а також більшим за аналогічні показники пацієнтів відповідних підгруп ММА (87,3 ± 27,2 с проти 57,4 ± 23,8 с, р &lt; 0,05, у групах спінальної анестезії та 92,1 ± 25,1 с проти 61,8 ± 19,8 с, р &lt; 0,05, у групах тотальної внутрішньовенної анестезії). Висновки. Введення у склад ММА прегабаліну забезпечує не тільки знеболюючий, але й протитривожний ефект, співставний з таким у бензодіазепінів. На відміну від прегабаліну, феназепам викликає зниження уваги та концентрації (до 3-ї доби). Режим премедикації та знеболювання, а не метод анестезії впливає на розвиток когнітивних змін у післяопераційному періоді.

Opioid Sparing Effects of the Bupivacaine Pleural Catheter in Surgical Decompression of the Thoracic Outlet

Rib resection in thoracic outlet decompression can result in significant postoperative pain requiring high levels of opioid medications. We evaluated the impact of a bupivacaine-infusing pleural catheter on postoperative pain and opioid usage in patients undergoing rib resection for thoracic outlet syndrome. We hypothesized that delivery of local anesthetic via the pleural catheter would improve postoperative pain control compared with standard multimodal analgesia, and that the use of the catheter would decrease opioid use during the index hospitalization and prescriptions for opioid pain medications at discharge. We conducted a single-center retrospective cohort study of 26 patients who underwent surgical thoracic outlet decompression. Primary outcome was opioid consumption during the index hospitalization, measured in morphine milligram equivalents (MME). Secondary outcomes were MME prescribed at discharge and pain scores during the index hospitalization before and after the pleural drain and pleural catheter were removed. Patients in the bupivacaine infusion pleural catheter group (n = 11) had significantly lower MME usage during the index hospitalization (median, 22.5; interquartile range [IQR], 1.9-65.6 vs 119.8; IQR, 76.5-167.4), and significantly lower MME prescribed at discharge (median, 0; IQR, 0-37.5 vs 225; IQR, 183-315]), compared with standard multimodal analgesia in controls (n = 15) (Table). Only three patients in the bupivacaine pleural catheter group were discharged with any opioid prescriptions (27%), compared with 14 patients in the control group (93%). There was no difference in postoperative pain scores between groups before or after removal of the pleural drain, which was placed in all cases (P = .31 and P = .76, respectively). Intraoperative placement of a bupivacaine infusion pleural catheter significantly reduced opioid use during the index hospitalization and opioid prescribing at discharge. Anesthetic infusion pleural catheters should be the treatment modality of choice for postoperative pain management in patients undergoing thoracic outlet decompression.

Evaluation of ultrasound-guided bilateral low thoracic erector spinae plane block for postoperative analgesia in cesarean delivery patients: a prospective, randomized, controlled clinical trial

BackgroundErector spinae plane block (ESPB) is a recently described block. In many reports, ESPB has been reported to provide effective postoperative analgesia in patients undergoing cesarean delivery (CD). Herein, we compared the effectiveness of ESPB and control group in postoperative analgesia in patients undergoing CD under spinal anesthesia. MethodsThis assessor-blinded, prospective, randomized, efficiency study was conducted in the postoperative recovery room and ward at a tertiary university hospital. Eighty-six patients ASA II–III were recruited. Following exclusion, 80 patients were randomized into two equal groups (block and control group). Standard multimodal analgesia was performed in the control group while ESPB block was performed in the intervention (ESPB) group. Opioid consumption was measured and pain intensity between groups was compared using Numeric Rating Scores (NRS). ResultsNRS was lower in Group ESPB at 3rd and 6th hours. There was no difference between NRS scores at other hours. Opioid consumption was lower in Group ESPB. ConclusionWhen added to multimodal analgesia, bilateral ultrasound guided low thoracic ESPB leads to improve the quality of analgesia in the first 24 hours in patients undergoing CD.

The Role of Truncal Blocks in Obstetric Anesthesia

This review provides a framework for managing post-cesarean delivery pain in the age of enhanced recovery after surgery (ERAS). In doing so, it highlights the role that truncal blocks play in obstetric anesthesia. The value of transversus abdominus plane block (TAP) and quadratus lumborum block (QLB) to optimize post-cesarean delivery pain is discussed. TAP block and QLB have been compared with each other and with controls, with and without neuraxial morphine. In the absence of neuraxial morphine, TAP block and QLB are superior to controls, but when intrathecal morphine is used, they do not provide additional benefit. There is indeed a role for truncal blocks in obstetric anesthesia. Both TAP block and QLB provide analgesia after cesarean delivery. They are not, however, universally beneficial; they are best incorporated when neuraxial morphine is not used, or to rescue pain not well-controlled with standard multimodal analgesia.

Transmuscular quadratus lumborum block reduces opioid consumption and prolongs time to first opioid demand after laparoscopic nephrectomy

BackgroundRobotic and hand-assisted laparoscopic nephrectomies are often associated with moderate to severe postoperative pain. The aim of the current study was to investigate the analgesic efficacy of the transmuscular quadratus...

Effectiveness, cost-effectiveness and safety of gabapentin versus placebo as an adjunct to multimodal pain regimens in surgical patients: protocol of a placebo controlled randomised controlled trial with blinding (GAP study)

IntroductionGabapentin is an antiepileptic drug currently licensed to treat epilepsy and neuropathic pain but has been used off-label to treat acute postoperative pain. The GAP study will compare the effectiveness,...

Postoperative Anesthesia Of Elderly And Senile Patients With Total Joint Replacement Of The Lower Extremities

Objective: To evaluate the efficacy and safety of patient-controlled analgesia through prolonged epidural analgesia after joint replacement of the lower extremities.&#x0D; Material and methods. We analyzed the postoperative period of 213 elderly and senile patients who were operated on for degenerative-dystrophic and traumatic injuries of the joints of the lower extremities. All patients underwent total joint replacement (164 - THA and 49 - TKA). The age of patients is from 65 to 90 years (average age was 78 ± 8 years) with a physical status of ASA 3 and above. All examined patients were divided into 2 groups. 63 patients comprised the main group, which in the postoperative period underwent patient-controlled analgesia (PCA) through prolonged epidural analgesia. The control group consisted of 150 patients, for the anesthesia of which in the postoperative period only standard systemic multimodal analgesia was used&#x0D; Conclusion. Patient-controlled analgesia is an alternative to traditional analgesic regimens. This method should be one of the main methods after surgical anesthesia for joint replacement of the lower limb in elderly and senile patients.