Postoperative Pain Management Strategies Research Articles

Pain management for the neurosurgical patient in spinal procedures: overview of historic and new modalities

The potent pain-relieving properties of opioids come at a steep price. Their addictive nature and side effects raise critical concerns in managing pain after surgical spine procedures. Postoperatively, spinal surgeries often accompany acute intense pain, which presents a significant challenge in optimal recovery. This paper reviews the historical approach to pain management in spine surgeries and expands on the use of alternatives and novel agents with reduced addictive potential. Additionally showcasing individualized multimodal strategies for postoperative pain management beyond pharmacological approaches such as cognitive behavioral therapy (CBT), physical therapy, and transcutaneous electrical nerve stimulation (TENS). Given the global opioid addiction crisis, there is a growing need for a fundamental shift towards safer and effective alternatives. Transitioning beyond opioid-centric practices in spinal surgery can optimize pain relief while improving patient outcomes and minimizing risk.

Effect of an intravenous acetaminophen/ibuprofen fixed-dose combination on postoperative opioid consumption and pain after video-assisted thoracic surgery: a double-blind randomized controlled trial

BackgroundVideo-assisted thoracoscopic surgery (VATS) often induces significant postoperative pain, potentially leading to chronic pain and decreased quality of life. This study aimed to evaluate the acetaminophen/ibuprofen combination effectiveness in reducing analgesic requirements and pain intensity in patients undergoing VATS.Study designThis is a double-blinded randomized controlled trial.MethodsAdult patients scheduled for elective VATS for lung resection were randomized to receive either intravenous acetaminophen and ibuprofen (intervention group) or 100 mL normal saline (control group). Treatments were administered post-anesthesia induction and every 6 h for three cycles. The primary outcome was total analgesic consumption at 24 h postoperatively. Secondary outcomes were cumulative analgesic consumption at 2 and 48 h; analgesic-related side effects at 2, 24, and 48 h; quality of recovery at 24 h and 48 h postoperatively; pain intensity at rest and during coughing; and rescue analgesics use. Chronic postsurgical pain (CPSP) was assessed through telephone interviews 3 months postoperatively.ResultsThe study included 96 participants. The intervention group showed significantly lower analgesic consumption at 24 h and 48 h postoperatively (24 h: median difference: − 100 µg equivalent intravenous fentanyl [95% confidence interval (CI) − 200 to − 5 μg], P = 0.037; 48 h: median difference: − 140 μg [95% CI − 320 to − 20 μg], P = 0.035). Compared to the controls, the intervention group exhibited a significantly lower quality of recovery 24 h post-surgery, with no significant difference at 48 h. All pain scores except for coughing at 48 h post-surgery were significantly lower in the intervention group compared to the controls. No significant differences were observed between the groups in postoperative nausea and vomiting occurrence, hospital stay length, and CPSP.ConclusionPerioperative administration of acetaminophen/ibuprofen significantly decreased analgesic needs in patients undergoing VATS, providing an effective postoperative pain management strategy, and potentially minimizing the need for stronger analgesics.

Injectable Hydrogel Delivery System with High Drug Loading for Prolonging Local Anesthesia.

Peripheral nerve block is performed for precise pain control and lesser side effects after surgery by reducing opioid consumption. Injectable hydrogel delivery systems with high biosafety and moisture content have good clinical application prospects for local anesthetic delivery. However, how to achieve high drug loading and long-term controlled release of water-soluble narcotic drugs remains a big challenge. In this study, heterogeneous microspheres and an injectable gel-matrix composite drug delivery system are designed in two steps. First, heterogeneous hydrogel microspheres loaded with ropivacaine (HMS-ROP) are prepared using a microfluidic chip and in situ alkalization. An injectable self-healing hydrogel matrix (Gel) is then prepared from modified carboxymethylcellulose (CMC-ADH) and oxidized hyaluronic acid (OHA). A local anesthetic delivery system, Gel/HMS-ROP/dexmedetomidine (DEX), with long-term retention and drug release in vivo is prepared by combining HMS-ROP and Gel/DEX. The drug loading of HMS-ROP reached 41.1%, with a drug release time of over 160h in vitro, and sensory and motor blockade times in vivo of 48 and 36h, respectively. In summary, the sequential release and synergistic analgesic effects of the two anesthetics are realized using core-shell microspheres, DEX, and an injectable gel, providing a promising strategy for long-acting postoperative pain management.

Comparing Ureteral Catheterization's Impact on Flank Pain Post Ureteroscopic Stone Management

Background: Urolithiasis, or kidney stone disease, is a prevalent condition that poses significant challenges in urological practice. The management of ureteral stones, particularly through ureteroscopy, is a common intervention. The use of short-term ureteral catheterization as a postoperative pain management strategy following ureteroscopic stone removal has been a subject of debate, with limited evidence on its efficacy and necessity. Objective: This study aimed to evaluate the effectiveness of short-term ureteral catheterization in reducing postoperative flank pain compared to non-catheterization in patients undergoing uncomplicated ureterolithotripsy for the management of distal ureteral stones. Methods: A prospective, randomized, controlled trial was conducted at Liaquat National Hospital, Karachi, from January to July 2013, involving 60 patients aged 15-70 years with distal ureteral stones less than 1.0 cm. Patients were randomized into two groups: Group A received short-term ureteral catheterization, and Group B did not. The primary outcome measured was the reduction in mean pain score by at least 4 points from the baseline at every 6-hour interval for the first 24 hours post-procedure. Statistical analysis was performed using SPSS version 25, applying chi-square tests, independent sample t-tests, and Mann-Whitney tests, with a p-value of less than 0.05 considered significant. Results: Both groups demonstrated a significant reduction in pain scores at 12, 18, and 24 hours post-operation. However, there was no significant difference in pain reduction between the catheterized (Group A) and non-catheterized (Group B) groups, with p-values of 0.55 for efficacy in pain reduction. The mean age, stone size, and postoperative hospital stay did not significantly differ between the groups, indicating that short-term ureteral catheterization did not offer additional benefits in managing postoperative pain or recovery. Conclusion: Short-term ureteral catheterization following uncomplicated ureterolithotripsy does not significantly improve pain management compared to non-catheterization. This suggests that routine catheterization may be unnecessary, potentially leading to a paradigm shift in postoperative care for patients undergoing ureteroscopic stone removal. Future studies with larger sample sizes and long-term follow-up are needed to further validate these findings.

Severity and associated factors of postoperative pain in paediatric surgical patients aged 2 months-7 years at selected Addis Ababa Public Hospitals: a multicenter prospective longitudinal study.

Postoperative pain is a common and distressing consequence of surgery in children. It can lead to suffering, prolonged recovery, impaired physical functioning, and even chronic pain. Effective postoperative pain management is crucial for improving patient outcomes. However, several factors hinder the accurate assessment and management of pain in children, particularly in low-income countries. This study aims to evaluate the severity of postoperative pain in paediatric patients and identify its predictors. A longitudinal study was conducted on 235 paediatric surgical patients aged 2 months-7 years in Public Hospitals of Addis Ababa from January to April 2023. The primary outcome, pain severity, was assessed at three different times using a pain assessment tool. Cochran's q-test was used to compare postoperative pain incidences. The Generalized Estimating Equation was used to determine predictor variables' effects on pain severity over time. The study demonstrated the direction of association and significance using an AOR with a 95% CI at a P value of 0.05. The incidence of moderate to severe postoperative pain was 36.6% at 12 h, 20% at 24 h, and 10% at 36 h. Patients with preoperative pain and preoperative anxiety were more likely to experience moderate to severe postoperative pain [adjusted odds ratio (AOR)=3.41, CI=1.15, 10.00 and AOR=2.28, CI=1.219, 4.277, respectively). Intraoperative predictors of postoperative pain severity included longer duration of surgery (AOR=6.62, CI=1.90, 23.00) and major surgery (AOR=5.2, CI=2.11, 12.88). Postoperative pain severity was reduced in patients receiving multimodal analgesia (AOR=0.24; CI=0.091, 0.652) and in patients assessed frequently in the postoperative period (AOR=0.09; CI=0.022, 0.393). A significant portion of paediatric surgical patients in this study experienced high levels of postoperative pain, particularly within the first 24 h. The most influential factors affecting pain severity were postoperative pain management strategies and assessment practices.

Comparison of Pain Management Strategies to Reduce Opioid Use Postoperatively in Free Flap Breast Reconstruction: Pain Catheter versus Nerve Block in Addition to Refinements in the Oral Pain Management Regime.

Background Perioperative management in autologous breast reconstruction has gained focus in recent years. This study compares two pain management protocols in patients undergoing abdominal-based free flap breast reconstruction: a past protocol (PP) and a current protocol (CP)-both intended to reduce opioid consumption postoperatively. The PP entails use of a pain catheter in the abdominal wound and the CP consists of an intraoperative nerve block in addition to refinements in the oral pain management. We hypothesize that the CP reduces opioid consumption compared to PP. Methods From December 2017 to January 2020, 102 patients underwent breast reconstruction with an abdominal-based free flap. Two postoperative pain management strategies were used during the period; from December 2017 to September 2018, the PP was used which entailed the use of a pain catheter with ropivacaine applied in the abdominal wound with continuous distribution postoperatively in addition to paracetamol orally and oxycodone orally pro re nata (PRN). From October 2018 to January 2020, the CP was used. This protocol included a combination of intraoperative subfascial nerve block and a postoperative oral pain management regime that consisted of paracetamol, celecoxib, and gabapentin as well as oxycodone PRN. Results The CP group ( n = 63) had lower opioid consumption compared to the PP group ( n = 39) when examining all aspects of opioid consumption, including daily opioid usage in morphine milligram equivalents and total opioid usage during the stay ( p < 0.001). The CP group had shorter length of hospital stay (LOS). Conclusion Introduction of the CP reduced opioid use and LOS was shorter.

Analgesic efficacy of an opioid-free postoperative pain management strategy versus a conventional opioid-based strategy following laparoscopic radical gastrectomy: an open-label, randomized, controlled, non-inferiority trial

ObjectiveIn patients undergoing laparoscopic radical gastrectomy, the use of subcostal transversus abdominis plane block (STAPB) for completely opioid-free postoperative pain management lacks convincing clinical evidence.MethodsThis study included 112 patients who underwent laparoscopic radical gastrectomy at the 900TH Hospital of the Joint Logistics Support Force from October 2020 to March 2022. Patients were randomly divided into (1:1) continuous opioid-free STAPB (C-STAPB) group and conventional group. In the C-STAPB group, 0.2% ropivacaine (bilateral, 20 ml per side) was injected intermittently every 12 h through a catheter placed on the transverse abdominis plane for postoperative pain management. The conventional group was treated with a conventional intravenous opioid pump (2.5 μg/kg sufentanil and 10 mg tropisetron, diluted to 100 ml with 0.9% NS). The primary outcomes were the accumulative area under the curve of the numeric rating scale (NRS) score at 24 and 48 h postoperatively at rest and during movement. The secondary outcomes were postoperative recovery outcomes, postoperative daily food intake, and postoperative complications.ResultsAfter exclusion (n = 16), a total of 96 patients (C-STAPB group, n = 46; conventional group, n = 49) were included. We found there were no significant differences in the cumulative AUC of NRS score PACU-24 h and PACU-48 h between the C-STAPB group and conventional group at rest [(mean difference, 1.38; 95% CI, − 2.21 to 4.98, P = 0.447), (mean difference, 1.22; 95% CI, − 6.20 to 8.65, P = 0.744)] and at movement [(mean difference, 2.90; 95% CI, − 3.65 to 9.46; P = 0.382), (mean difference, 4.32; 95% CI, − 4.46 to 13.1; P = 0.331)]. The 95% CI upper bound of the difference between rest and movement in the C-STAPB group was less than the inferior margin value (9.5 and 14 points), indicating the non-inferiority of the analgesic effect of C-STPAB. The C-STAPB group had faster postoperative recovery profiles including earlier bowel movement, defecation, more volume of food intake postoperative, and lower postoperative nausea and vomiting compared to conventional groups (P < 0.001).ConclusionsAfter laparoscopic radical gastrectomy, the analgesic effect of C-STAPBP is not inferior to the traditional opioid-based pain management model.Trial registrationChiCTR2100051784.

Research progress on early postoperative pain management strategies after arthroscopic anterior cruciate ligament reconstruction

To summarize the early postoperative pain management strategies for anterior cruciate ligament reconstruction (ACLR), and to select a reasonable and effective pain management plan to promote functional rehabilitation after ACLR. The literature about the early postoperative pain management strategies of ACLR both domestically and internationally in recent years was extensiverly reviewed, and the effects of improving postoperative pain were reviewed. Currently, physical therapy and oral medication have advantages such as economy and simplicity, but the effect of improving postoperative pain is not satisfactory, often requires a combination of intravenous injection or intravenous pump, which is also a common way to relieve pain. However, in order to meet the analgesic needs of patients, the amount of analgesic drugs used is often large, which increases the incidence of various adverse reactions. Local infiltration analgesia (LIA), including periarticular or intra-articular injection of drugs, can significantly improve the early postoperative pain of ACLR, and achieve similar postoperative effectiveness as nerve block. LIA can be used as an analgesic technique instead of nerve block, and avoid the corresponding weakness of innervated muscles caused by nerve block, which increases the risk of postoperative falls. Many studies have confirmed that LIA can alleviate postoperative early pain in ACLR, especially the analgesic effects of periarticular injection are more satisfactory. It can also avoid the risk of cartilage damage caused by intra-articular injection. However, the postoperative analgesic effect and timeliness still need to be improved. It is possible to consider combining multimodal mixed drug LIA (combined with intra-articular and periarticular) with other pain intervention methods to exert a synergistic effect, in order to avoid the side effects and risks brought by single drugs or single administration route. LIA is expected to become one of the most common methods for relieving postoperative early pain in ACLR. Early pain after arthroscopic ACLR still affects the further functional activities of patients, and all kinds of analgesic methods can achieve certain effectiveness, but there is no unified standard at present, and the advantages and disadvantages of various analgesic methods need further research.

Safety of the immediate use of nonsteroidal anti-inflammatory drugs after adult craniotomy for tumor.

Poor pain control has a negative impact on postoperative recovery and patient satisfaction. However, overzealous pain management, particularly with opioids, can confound serial neurological assessments, increase morbidity, and predispose patients to long-term dependence. Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in treating postoperative pain and can limit opioid intake, but their use has been limited in patients undergoing craniotomy for brain tumor resection due to concerns of an increased hemorrhage risk. Herein, the authors aim to 1) address the safety of NSAID use in the immediate postoperative setting and 2) determine whether NSAID administration decreases opioid use following craniotomy for tumor resection in adult patients. The authors conducted a retrospective cohort study of patients 18 years and older with an estimated glomerular filtration rate ≥ 60 ml/min/body surface area who had undergone craniotomy for tumor resection at their institution between 2019 and 2021. NSAID use in the first 48 hours following surgery was recorded. Primary outcomes were postoperative hemorrhage requiring a return to the operating room before hospital discharge and within 30 days of surgery. Secondary outcomes were more-than-minimal hemorrhage that did not require reoperation, acute kidney injury, and total opioid use within 48 hours after craniotomy. Among 1765 reviewed patient records, 1182 were eligible for inclusion in this analysis. Amid these records were 114 patients (9.6%) who had received at least one dose of an NSAID within 48 hours of their craniotomy. Four (0.3%) patients experienced bleeding requiring a return to operating room, one of whom was from the NSAID-treated group (RR 3.12, 95% CI 0.33-29.77, p = 0.30). No significant difference in nonoperative intracranial hemorrhage (RR 1.34, 95% CI 0.54-3.35, p = 0.53), postoperative acute kidney injury, or clinically significant extracranial bleeding was found between the NSAID and no-NSAID groups. Patients in the NSAID group had significantly higher oral morphine equivalent use (median 68 vs 30, p < 0.001). Postoperative NSAID use following craniotomy for tumor resection was not associated with an increased risk of hemorrhage requiring a return to the operating room. The authors noted higher opioid use in the patients treated with NSAIDs, which may reflect underlying reasons for the decision to treat patients with NSAIDs in the immediate postoperative period. These data warrant further investigation of NSAIDs as a safe, opioid-sparing postoperative pain management strategy in patients with normal kidney function who are undergoing intracranial tumor resection.

Arthroscopy Association of Canada Position Statement on Opioid Prescription After Arthroscopic Surgery.

Despite the ongoing opioid epidemic, most patients are still prescribed a significant number of opioid medications for pain management after arthroscopic surgery. There is a need for consensus among orthopaedic surgeons and solutions to aid providers in analgesic strategies that reduce the use of opioid pain medications. This position statement was developed with a comprehensive systematic review and meta-analysis of exclusively randomized controlled trials (RCTs) to synthesize the best available evidence for managing acute postoperative pain after arthroscopic surgery. Position statement. The Embase, MEDLINE, PubMed, Scopus, and Web of Science databases were searched from inception until August 10, 2022. Keywords included arthroscopy, opioids, analgesia, and pain, and associated variations. We included exclusively RCTs on adult patients to gather the best available evidence for managing acute postoperative pain after arthroscopic surgery. Patient characteristics, pain, and opioid data were extracted, data were analyzed, and trial bias was evaluated. A total of 21 RCTs were identified related to the prescription of opioid-sparing pain medication after arthroscopic surgery. The following recommendations regarding noninvasive, postoperative pain management strategies were made: (1) multimodal oral nonopioid analgesic regimens-including at least 1 of acetaminophen-a nonsteroidal anti-inflammatory drug-can significantly reduce opioid consumption with no change in pain scores; (2) cryotherapy is likely to help with pain management, although the evidence on the optimal method of application (continuous-flow vs ice pack application) is unclear; (3) and (4) limited RCT evidence supports the efficacy of transcutaneous electrical nerve stimulation and relaxation exercises in reducing opioid consumption after arthroscopy; and (5) limited RCT evidence exists against the efficacy of transdermal lidocaine patches in reducing opioid consumption. A range of nonopioid strategies exist that can reduce postarthroscopic procedural opioid consumption with equivalent vocal pain outcomes. Optimal strategies include multimodal analgesia with education and restricted/reduced opioid prescription.

Prolonged Anesthesia Effects of Locally Administered Ropivacaine via Electrospun Poly(caprolactone) Fibrous Membranes.

Prolonged analgesia is important to safeguard the patient's comfort and safety during and after surgery in clinical practice. To meet the demand for prolonged analgesia, medical professionals often resort to increasing drug frequency, which may lead to poor patient compliance and serious complications due to drug overdose. Therefore, it is of great interest to develop controlled-release drug delivery systems for local anesthetics, enabling slow and controlled drug release to prolong the analgesic effect and minimize systemic toxicity. In this study, we utilized an electrospinning technique to fabricate nonwoven poly(caprolactone) (PCL) fibrous membranes loaded with Ropivacaine and performed proof-of-principle experiments on both in vitro drug release tests and in vivo animal tests, to further prolong the analgesic effect of Ropivacaine and improve postoperative local pain management and chronic pain treatment. Material characterization and in vitro drug release studies confirmed the feasibility of the Ropivacaine-loaded PCL fibrous membranes for sustained release. The drug loading content and drug loading efficiency of Ropivacaine-loaded fibrous membrane are 8.7 ± 0.3 wt% and 96 ± 3 wt%, respectively. Evaluation in an animal model demonstrated prolonged anesthesia effects along with excellent biocompatibility and stability. At 72 h, the cumulative release accounted for approximately 50% of the drug loading content. This study offers novel approaches and strategies for clinical postoperative pain management and chronic pain treatment, while providing new insights and directions for the design of local anesthetic controlled-release delivery systems.

Does Adding an IPACK Block to the Suprainguinal Fascia Iliaca Block Improve the Quality of Analgesia in Patients Undergoing Knee Arthroplasty under Spinal Anesthesia? A Retrospective Cohort Study.

Background and Objectives: Total knee arthroplasty (TKA) is a commonly performed orthopedic procedure, and is often accompanied by significant postoperative pain. The supra-inguinal fascia iliaca block (SIFIB), similar to an anterior lumbar plexus block, is frequently used in hip surgeries. The interspace between the popliteal artery and capsule of the posterior knee (IPACK) block is a regional anesthesia technique that targets the posterior innervation of the knee capsule. This retrospective study aimed to compare the analgesic effects of SIFIB and SIFIB + IPACK on patients undergoing TKA under spinal anesthesia. Materials and Methods: This retrospective study revealed the data collected from a tertiary hospital. Patient data were gathered for individuals who underwent unilateral TKA under spinal anesthesia during the period between 1 January 2023 and 1 September 2023. Inclusion criteria comprised patients falling within ASA class I-III, those following a standardized perioperative analgesia regimen, and individuals receiving opioids via a patient-controlled analgesia device (PCA) as part of their postoperative pain management strategy. Patients were grouped as SIFIB and SIFIB + IPACK according to the performed regional anesthesia technique. Results: In the study, the data of 88 patients in total, 61 in the SIFIB group and 27 in the IPACK group, were analyzed. The 24 h cumulative morphine consumption was similar in the SIFIB and SIFIB + IPACK groups (10.62 ± 6.58 mg vs. 12.55 ± 8.84 mg, respectively; p: 0.258). The NRS scores of the groups were similar in all time frames. Conclusions: Our study reveals that combining IPACK with SIFIB in the multimodal analgesia plan does not provide additional benefits in terms of postoperative opioid consumption and pain scores in patients undergoing unilateral THA under spinal anesthesia.

Comparison of Dexamethasone Versus Methylprednisolone With Bupivacaine in Transversus Abdominis Plane Block for Attenuation of Chronic Postoperative Abdominal Pain.

Background Opioids, which have well-known adverse effects such as drowsiness paralytic ileus and respiratory depression, were mostly utilised to treat postoperative pain in the past. The increased incidence of side effectshas led to a rise in interest in pain management techniques that spare opioids. Persistent abdominal pain following surgery has a major detrimental effect on patients' quality of life. While epidural analgesia is widely regarded as the gold standard to combat the pain that is present post abdominal surgeries, it is not devoid ofdrawbacks. The transversus abdominis plane (TAP) block has developed as a potentially effective treatment for severe abdominal pain. The TAP block acts on the neuro-fascial plane between the internal oblique and transversus abdominis muscles, which is innervated by spinal nerves from T6 to L1. Studies reveal that the addition of corticosteroids to bupivacaine in TAP blocks provides pain relief and improves the quality of life of the patient. Aims and objectives In this study, the effects ofbupivacaine and corticosteroids, particularly dexamethasone and methylprednisolone, on chronic abdominal pain following surgery are examined. Assessing the quality of pain relief is the primary objective. Methodology Thirty patients who had undergone abdominal surgery and had been having persistent abdominal pain for six to eight months thereafter and had attempted unsuccessfully to treat the pain with alternative pain relief methods participated in the study. They were divided into two groups at random. Dexamethasone and bupivacaine were given to patients in Group D while methylprednisolone and bupivacaine were given to patients in Group M for ultrasonography (USG)-guided bilateral TAP blocks. At various intervals up to 12 weeks after injection, the patient's pain levels were measured using the visual analogue score (VAS), and their quality of life was assessed using the quality-of-life score. Results Patients in Group M experienced significantly less pain than those in Group D at the fourth, sixth, and 12th weeks of treatment. Furthermore, in the fourth, sixth, and 12th weeks, patients in Group M reported a superior quality of life in comparison to those in Group D. Conclusion Patients with persistent postoperative abdominal pain receiving bupivacaine and methylprednisolone in an ultrasonography-guided TAP block experience more effective and long-lasting pain relief than those who receive bupivacaine and dexamethasone. The quality of life for patients may be enhanced by using corticosteroids to optimise postoperative pain management strategies and lessen the need for opioids, as this study highlights.

Analgesic efficacy of an opioid-free postoperative pain management strategy versus a conventional opioid-based strategy following open major hepatectomy: an open-label, randomised, controlled, non-inferiority trial

Convincing clinical evidence regarding completely opioid-free postoperative pain management using erector spinae plane block (ESPB) in patients undergoing open major hepatectomy (OMH) is lacking. Herein, we aimed to compare the postoperative analgesic efficacy of the visualised continuous opioid-free ESPB (VC-ESPB) and conventional intravenous opioid-based postoperative pain management in hepatocellular carcinoma (HCC) patients undergoing OMH. This open-label, randomised, controlled, non-inferiority trial enrolled patients with HCC undergone open major hepatectomy in Fujian Provincial Hospital and compared the postoperative analgesic efficacy of VC-ESPB (VC-ESPB group) and conventional intravenous opioid-based pain management regimen (conventional group). Patients were randomly assigned (1:1) to VC-ESPB group and conventional group. Patients were not masked to treatment allocation. The VC-ESPB group was treated with intermittent injections of 0.25% ropivacaine (bilateral, 30mL each side) given every 12h through catheters placed in the space of erector spinae and an opioid-free intravenous pump (10-mg tropisetron diluted to 100mL with 0.9% normal saline [NS]) for postoperative pain management. The conventional group did not receive ESPB and was treated with a conventional intravenous opioid-based pump (2.5-μg/kg sufentanil and 10-mg tropisetron diluted to 100mL with 0.9% NS). Patients in the VC-ESPB group underwent magnetic resonance imaging (MRI) to identify local anaesthetic diffusion after ESPB was performed under ultrasound guidance. The primary outcome was postoperative analgesic efficacy, which was indicated by the cumulative area under the curve (AUC) of the pain visual analogue scale scores (range, 0-10; a higher score indicates more pain) obtained at rest and at movement until 48h postoperatively after leaving the post-anaesthesia care unit (PACU). Herein, an AUC of 26.5 was set as the noninferiority margin, which needed to be satisfied for both cumulative AUCPACU-48h at rest and cumulative AUCPACU-48h at movement. Per protocol participants were included in primary and safety analyses. This trial was registered with ChiCTR.org.cn (ChiCTR1900026583). Between October 30, 2019, and May 1, 2023, 106 patients were enrolled and randomly assigned to the VC-ESPB group (n=53) and the conventional group (n=53). After the dropout (n=5), a total of 101 patients (VC-ESPB group, n=50; conventional group, n=51) were analysed. Both the level of cumulative AUCPACU-48h (at rest: 160.08±38.00 vs. 164.94±31.00; difference [90% CI],-4.861 [-16.308, 6.585]) and cumulative AUCPACU-48h (at movement: 209.64±28.98 vs. 212.59±33.11; difference [90% CI],-2.948 [-13.236, 7.339]) were similar between the VC-ESPB and control groups within the first postoperative 48h. The upper limit of the 90% CIs for the difference in cumulative ACUPACU-48h at rest and at movement did not reach the upper inferiority margin (26.5). During the first postoperative 48h, the rate of nonsteroidal anti-inflammatory drug rescue analgesia was similar between the VC-ESPB group and conventional group (n=16, 32.0% vs. n=11, 21.6%; P=0.236). Treatment-related death was not observed in the VC-ESPB group (n=0, 0%) and conventional group (n=0, 0%). In VC-ESPB group, local site paralysis (n=1, 2.0%) was observed in one patient and rash (n=1, 2.0%) was observed in another patient. One patient in the conventional group was observed with rash preoperatively (n=1, 2.0%). The VC-ESPB group had significantly lower rates of postoperative nausea (n=2, 4.0%, vs. n=9, 17.6%, P=0.028), vomiting (n=1, 2.0% vs. n=8, 15.7%, P=0.031) and lower incidence of major complications (n=4, 8.0% vs. n=6, 11.8%; P=0.033). This study demonstrates the noninferiority of VC-ESPB when compared with the conventional opioid-based approach for postoperative pain management after OMH, suggesting that it is feasible to achieve opioid-free postoperative pain management for OMH. The Joint Funds for the Innovation of Science and Technology, Fujian Province, China; the Youth Scientific Research Project of Fujian Provincial Health Commission; the Fujian Research and Training Grants for Young and Middle-aged Leaders in Healthcare; and the Key Clinical Specialty Discipline Construction Program of Fujian, China.

Efficacy of a continuous wound infiltration system for postoperative pain management in gynecologic patients who underwent single-port access laparoscopy for adnexal disease.

Single-port access (SPA) laparoscopy requires only one incision, unlike conventional laparoscopy. However, its umbilical incision is larger than that of conventional laparoscopy and can be vulnerable to postoperative pain. This study aimed to evaluate whether simultaneous use of a continuous wound infiltration (CWI) system and intravenous patient-controlled analgesia (IV PCA) effectively decreases surgical site pain in patients who underwent SPA laparoscopy due to gynecologic adnexal disease. A total of 371 patients who underwent SPA laparoscopy and who received IV PCA or CWI was retrospectively reviewed (combined group [CWI + IV PCA, n = 159] vs. PCA group [IV PCA only, n = 212]). To evaluate postoperative pain management, the numeric rating scale (NRS) pain score after surgery, total amount of fentanyl administered via IV PCA, and additional pain killer consumption were collected. The NRS scores at 12 h (1.90 ± 1.11 vs. 2.70 ± 1.08, p < 0.001) and 24 h (1.82 ± 0.82 vs. 2.11 ± 1.44, p = 0.026) after surgery were significantly lower in the combined group than in the PCA group. The total amount of PCA fentanyl was significantly smaller in the combined group than in the PCA group (p < 0.001). The total quantity of rescue analgesics was smaller in the combined group than in the PCA group (p < 0.05). Combined use of the CWI system and IV PCA is an effective postoperative pain management strategy in patient who underwent SPA laparoscopy for adnexal disease.

The efficacy of preoperative intravenous acetaminophen for laparoscopic extraperitoneal closure in children with inguinal hernia for The enhanced recovery after surgery: A prospective randomized study

PurposeA postoperative pain management strategy for the enhanced recovery after surgery (ERAS) protocol has recently become more important in pediatric surgery and growing attention is being paid to perioperative use of intravenous acetaminophen (IV-A). In laparoscopic extraperitoneal closure (LPEC) procedure, postoperative pain is still occurring and optimal analgesia remains unclear. We aimed to evaluate the efficacy of preoperative IV-A (pIV-A) for postoperative analgesia after LPEC in children. MethodsAfter approval of the ethics committee of our hospital (#2,018,131), 40 consecutive pediatric patients with unilateral inguinal hernia were randomized into two group (20 each) and received LPEC procedure with pIV-A (group-A) and without (group-C). The pain scale score (PSS), the frequency of the postoperative acetaminophen bolus use (FPAB) and school start day (SSD) were assessed. ResultsThe PSS and the FPAB are significantly lower in group-A compared to group-C on POD0 and POD1, indicating a significant reduction in pain in group-A at an early stage after the operation. In addition, SSD after LPEC operation was shorter in group-A compared to group-C. ConclusionOur results suggest that pIV-A for postoperative analgesia after LPEC in children is safe and useful for the ERAS.

Efficacy of opioid-sparing analgesia after median sternotomy with continuous bilateral parasternal subpectoral plane blocks

ObjectivesRegional anesthetic techniques, traditionally underutilized in cardiac surgery, may play a role in multimodal analgesia, effectively improving pain control and reducing opioid consumption. We investigated the efficacy of continuous bilateral ultrasound-guided parasternal subpectoral plane blocks following sternotomy. MethodsWe reviewed all opioid-naïve patients who underwent cardiac surgery via median sternotomy under our enhanced recovery after surgery protocol between May 2018 and March 2020. Patients were grouped based on postoperative pain management strategy–those who received standard Enhanced Recovery After Surgery (ERAS) multimodal analgesia alone (no nerve block group) versus those receiving ERAS multimodal analgesia plus continuous bilateral parasternal subpectoral plane blocks (block group). In the block group, parasternal subpectoral plane catheters were placed under ultrasound-guidance on each side of the sternum with initial 0.25% ropivacaine bolus, followed by continuous 0.125% bupivacaine infusions. Postoperative patient-reported numerical rating scale pain scores and opioid consumption in morphine milligram equivalents were compared through postoperative day 4. ResultsOf 281 patients included in the study, the block group comprised 125 (44%) patients. Although baseline characteristics, type of surgery, and length of stay were similar between groups, average numerical rating scale pain scores and opioid consumption were significantly lower in the block group through postoperative day 4 (all P values < .05). We also observed a 44% reduction in total opioid consumption after surgery in the block group (75.1 vs 133.1 MME; P = .001) and 1 less hospital day requiring opioids (4.2 vs 3 days; P = .001). ConclusionsContinuous bilateral parasternal subpectoral plane blocks may further reduce poststernotomy pain and opioid consumption within the context ERAS multimodal analgesia.

Comparative evaluation of visual analogue scale and pupillary diameter for post-operative pain: An observational study.

An objective understanding of pain guides the effectiveness of various postoperative pain management strategies. The measurement of pain by the visual analogue scale (VAS) is dependent on the individual's cognitive and emotional ability. Pupillary dilatation has been successfully used to measure pain in quantitative terms. The present study was conducted to study the correlation between VAS and pupillary diameter in the evaluation of postoperative pain. This observational study was carried out on 85 patients 18-65 years of age, scheduled for lower abdominal surgical procedures under general anaesthesia. Postoperative pain assessment was done using the VAS at 6 h, 12 h, 18 h and 24 h. In addition, the pupillary diameter of both eyes was measured simultaneously. Paired t-test and analysis of variance (ANOVA) were used to compare the data, and Pearson's correlation coefficient was calculated to assess the bivariate correlation between VAS score and pupillary diameter. Mean ± standard deviation (SD) of VAS scores at baseline, 6 h, 12 h, 18 h and 24 h postoperatively were 0, 4.88 ± 0.88, 3.39 ± 0.86, 2.19 ± 0.66 and 1.40 ± 0.49, respectively. Mean change was significant at all time intervals (P < 0.001). The mean ± SD change in average pupillary diameter was 0.59 ± 0.64, 0.44 ± 0.54, 0.22 ± 0.34 and 0.07 ± 0.22 mm, respectively, showing a significant change from baseline (P < 0.05). On overall evaluation, mean pupillary diameter showed a significant incremental trend with an increasing VAS score (P < 0.001). Change in pupillary diameter correlated well with the pain scores (VAS) and thus pupillary diameter can be chosen as an objective measurement of postoperative pain severity.

Evaluation of a pain management program for patients with median arcuate ligament syndrome

Median arcuate ligament syndrome is a complex disorder potentially caused by variation in the position of the median arcuate ligament. Symptomology involves chronic abdominal pain, nausea, and malnourishment. Pain management modalities and short-term outcomes for patients undergoing operative surgery for median arcuate ligament syndrome have yet to be fully evaluated. Our hospital implemented a pain management consultation program in 2017 focused on perioperative pain management. The objective of this study is to assess if the introduction of a pain management consultation program concurrent with median arcuate ligament syndrome surgery impacts patient outcomes and post-operative pain management strategies in these patients. De-identified data was collected retrospectively from our hospital's electronic medical records system, identifying median arcuate ligament syndrome patients and using International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes from September 2017 to August 2021. Patients were grouped into the "consultation" cohort if they had scheduled and attended a pre-operative pain consultation. Pre-operative and discharge medications, pain scores, and demographics were collected to evaluate if the initiative impacted outcomes. Median arcuate ligament syndrome patients who had a pre-operative pain management consultation had higher rates of pre-operative opioid (35.5%; p = 0.01) and non-opioid use (60.7%; p < 0.001). Patients without a pre-operative consultation that did not use opioids pre-operatively were more likely to be discharged on one or more opioids. Differences were also found for psychiatric medication at discharge (p < 0.001) with patients receiving pain consultation indicating higher percentages of use. Special consideration on prescribing pain medication should be part of discharge planning for median arcuate ligament syndrome patients. Addition of a pain management consultation can aid in these decisions.

Postoperative pain and pain management and neurocognitive outcomes after non-cardiac surgery: a protocol for a series of systematic reviews

BackgroundPostoperative delirium (POD) is common after non-cardiac surgery in older adults and can result in increased risk of adverse outcomes including postoperative cognitive dysfunction (POCD). Pain after surgery is also frequent and can persist as chronic postsurgical pain (CPSP). Evidence is inconsistent and controversial on whether acute and chronic postsurgical pain, and different postoperative pain management strategies (including opioid versus opioid-sparing strategies), is associated with the occurrence of POD and POCD. In this protocol, we propose a series of systematic reviews to answer the following research questions: In adults undergoing non-cardiac surgery, (1) is acute postsurgical pain associated with POD and/or POCD? (2) Are opioid-sparing/avoidance strategies of acute postoperative pain management associated with lower incidence and/or severity of POD and POCD, compared to predominantly opioid-based strategies? (3) Is CPSP associated with POCD? (4) Are opioid-sparing management strategies of CPSP associated with lower incidence and/or severity of POCD compared to standard of care or strategies not aiming at reduced opioid use?MethodsWe will search MEDLINE, EMBASE, Cochrane (CENTRAL), CINAHL, and PSYCHINFO. According to the research question, we will include cohort and case-control studies (questions 1 and 3) or randomized controlled trials and non-randomized studies (questions 2 and 4). The risk of bias will be assessed independently and in duplicate using the revised Cochrane risk-of-bias tool, the Newcastle-Ottawa Scale, and the Joanna-Briggs Institute critical appraisal checklist. Disagreements will be resolved by a third reviewer. Findings will be reported narratively, and where possible and appropriate, meta-analyses will be performed. Certainty of evidence will be assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. We will conduct the reviews in accordance with the guideline of the Preferred Reporting Items for Systematic Review and Meta-Analyses Protocols.DiscussionOur systematic reviews will summarize available evidence to date on the association of postoperative pain and its management strategies with the incidence of POD and POCD in non-cardiac surgery. We will evaluate the existing evidence and its limitations and inform the design of future interventional studies comparing the effects of different pain management strategies on postoperative neurocognitive outcomes.Systematic review registrationPROSPERO CRD42021192105