Superior Analgesia Research Articles

Sufentanil Combined with Nalbuphine via Patient-Controlled Intravenous Analgesia After Cesarean Section: A Retrospective Evaluation.

PurposeThis retrospective study evaluated the efficacy, opioid consumption, and safety profile of two patient-controlled intravenous analgesia (PCIA) regimens (sufentanil combined with nalbuphine vs sufentanil alone) after cesarean section (CS).Patients and MethodsParturients (n = 1808) received sufentanil combined with nalbuphine (SN group) or sufentanil alone (S group) as PCIA after CS. The primary outcome was the numeric rating scale (NRS) pain score with movement (NRS-M) at 24 h after CS. Secondary outcomes were NRS scores at rest (NRS-R) at 24 and 48 h after CS, NRS-M at 48 h after CS, cumulative PCIA bolus times, and opioid consumption during the first 24 and 48 h postoperatively, which was measured in morphine-equivalent doses.ResultsThe population comprised 993 and 815 subjects in the SN and S groups, respectively. At 24 and 48 h after CS, the respective NRS-M scores of the SN group (4.62, 3.37) were each significantly lower than those of the S group (5.18, 4.01; P < 0.01 for both). The corresponding NRS-S scores were similarly lower in the SN group (0.96, 0.19) than in the S group (2.05, 0.92; P < 0.01 for both). After adjusting for covariates, the SN group still had lower NRS-M than the S group at 24 h after CS (estimate adjusted = 0.565, P < 0.001). The PCIA bolus times were significantly lower in the SN group than in the S group. The rates of bradycardia and respiratory depression were lower in the SN group than in the S group. However, the rates of dizziness and postoperative hypotension were slightly higher in the SN group, and those of nausea/vomiting were comparable.ConclusionCompared with sufentanil alone, sufentanil combined with nalbuphine for PCIA provided superior analgesia in parturient women after CS.

Analgesic effect of intravenous versus intraperitoneal dexmedetomidine as an adjuvant to intraperitoneal bupivacaine (0.125%) in laparoscopic cholecystectomy: a randomized, double blind, interventional study

Background and Aims: Laparoscopic cholecystectomy has emerged as a gold standard technique for gall bladder stones. The aim of the present study was to compare the analgesic effect of intravenous (IV) vs intraperitoneal (IP) dexmedetomidine as an adjuvant to intraperitoneal (IP) bupivacaine in laparoscopy. Methods: A prospective, randomized, double blind, interventional study was conducted on 100 patients undergoing laparoscopic cholecystectomy where they were divided into following 2 groups: Group A: Patients received IV 1µg/kg dexmedetomidine diluted to 30 ml with normal saline over 10 min and 40 ml of 0.125% bupivacaine IP after removal of gall bladder. Group B: Patients received IV 30 ml of normal saline and 1µg/kg IP dexmedetomidine in 40 ml of 0.125% IP bupivacaine after removal of gall bladder. The primacy outcome was noted as a difference in mean duration for need of first rescue analgesia. The total consumption of analgesic in first 24hours was recorded and compared between the two groups. Results: Both the groups were comparable in terms of demographic profile and intraoperative hemodynamic parameters with no statistical difference. Comparison of time to first analgesic requirement between the two groups showed statistically significant results with unpaired t test The time of first rescue analgesia in Group A was 151.80 min ± 76.624. and in Group B was 94.80min ± 21.499. The total analgesic requirement in 24 hours in Group A was 136.64 ± 31.251 and in Group B was 144.12 ± 21.49. Conclusion: In our study we concluded that intravenous dexmetomidine provided superior analgesia as compared to intraperitoneal dexmetomidine when used as an adjuvant with Bupivacaine intraperitoneally.

Regional anesthesia in trauma patients: a quality improvement study.

Traumatic injury is associated with severe pain that is often inadequately managed. Opioids remain the mainstay of pain management in this population because of their ease of use. However, opioids have significant side effects including nausea, delirium, and respiratory depression. Regional anesthesia has been demonstrated in the perioperative setting to provide superior analgesia with fewer side effects and a reduced length of stay. Similarly, regional anesthesia has been shown to improve morbidity for extremity fractures and dislocations when introduced early. This was a prospective cohort quality improvement study evaluating the use of earlier and more consistent regional anesthesia procedures in 28 consecutive trauma patients at a large Canadian trauma center. In this quasi-experimental before and after study, we identified all trauma patients with an ISS < 15 that would have been candidates for a peripheral nerve block and compared them to the study population that received a regional anesthesia nerve block within 24h of admission. The introduction of a multidisciplinary pain program into our level 1 regional trauma center resulted in a decrease in pain severity and opioid consumption of 55% and 61%, respectively, after 24h of admission. Length of stay in the emergency department decreased (11.5 ± 6.9 vs. 4.9 ± 4.4h; p < 0.01) while hospital length of stay did not (338 ± 276 vs. 285 ± 205h; p = 0.4). This quality improvement proof-of-principle study reveals the potential advantages for regional anesthesia, such as decreased emergency department use, opioid consumption, and pain severity. Further randomized trials are necessary, however, to describe a direct benefit from peripheral nerve blockade on reducing length of stay for trauma patients.

Meperidine-Ketorolac Combination Provides Better Analgesia than Meperidine Alone in Postoperative Patients.

Our study objective was to assess if multi-modal analgesia with meperidine-ketorolac combination provides superior analgesia or reduces opioid requirement following surgery compared to Meperidine alone. Double-blind randomized controlled trial. Postoperative pain control in orthopedic ward after spinal anesthesia. American Society of Anesthesiology (ASA) risk I or II (ASA I/II) patients who had lower limb implant surgery (88) at our center from September 2014 to July 2015. Patients were randomly assigned to receive either 1 mg/kg of intravenous (IV) meperidine and 30 mg of IV ketorolac (treatment group) or 1 mg/kg of IV meperidine (control group) post-surgery, administered every hour for the first 6 hours during the first 24 hours post-surgery. In addition, patients received intravenous meperidine on an 'as needed basis' during the first 24 hours of the postoperative period. Outcomes were time-to-first analgesia request postoperatively; cumulative opioid dose in first 24 hours post-surgery; frequency of side effects; and patient satisfaction with pain relief using a Likert scale. Numerical rating scale (NRS) pain scores hourly for the first 6 hours, then the 8th, 12th, 16th, 18th and 24th hour post-surgery were assessed. There was a significant delay in time of first request for analgesia (460 min vs 225 min; P=0.03) and a reduction in opioid consumption in 24 hours (299 mg vs 325 mg; P=0.01) in the meperidine/ketorolac group compared with the meperidine alone group which were both statistically significant. Patient satisfaction with pain relief was better in the treatment group (P=0.01). Additionally, there were fewer side effects in the treatment group than in the control group but this was not statistically significant. Adding ketorolac to meperidine reduced postoperative pain, reduced patient daily opioid requirement, increased patient satisfaction with pain relief, without increasing the frequency of side effects. Therefore, IV ketorolac addition to opioids may be a reasonable option in multimodal analgesic protocol.

Pericapsular nerve group (PENG) block for hip arthroscopy: a randomized, double-blinded, placebo-controlled trial

IntroductionArthroscopic hip surgery is associated with significant postoperative pain. Femoral nerve blocks have been shown to improve postoperative analgesia at the expense of quadriceps weakness. The pericapsular nerve group (PENG)...

Comparison of the Analgesic Effect of Subcutaneous Bupivacaine Infiltration and Intravenous Diclofenac vs. Intravenous Diclofenac Monotherapy After Inguinal Hernioplasty: A Retrospective Study.

BackgroundPostoperative pain is a significant problem encountered by patients after a surgical intervention, and there is a crucial need for effective postoperative pain control. The studies have shown that multimodal analgesia and wound infiltration are effective ways to reduce this pain and have a substantial role in the reduction of postoperative medications requirement. This study aimed to evaluate the effect of subcutaneous infiltration of bupivacaine hydrochloride and intravenous (IV) diclofenac as postoperative pain relief in adults undergoing inguinal hernia repair.MethodsA single-center retrospective study included 104 patients aged 18-65 undergoing unilateral inguinal herniorrhaphy at the selected hospital. The patients were in two groups of 52 each. Group A received a 75 mg dose of IV diclofenac plus a subcutaneous injection of 10 mL of bupivacaine hydrochloride (HCl) 0.5% while Group B only received the IV diclofenac without the bupivacaine injection. The postoperative pain was assessed at one, two, three, six, and 12 hrs after the operation using the visual analog scale (VAS), which exhibited a range of pain from zero (no pain) to 10 (extreme pain).ResultsOf a total of 104 patients, 92% of patients were male. The patients' mean age was 36 ± 11 years, and the mean body mass index (BMI) was 22 ±3 kg/m2. American Society of Anesthesiologists physical class I was similar in both groups (90.4% versus 84.6%). Patients in Group A had significantly lower VAS pain scores at one, two, three, six, and 12 hrs after the operation and a longer emergence time than Group B (all p-values were < 0.001). Subcutaneous bupivacaine infiltration and IV diclofenac were also found to be an effective analgesic technique in open hernia repair with mesh (p-value < 0.001 for all).ConclusionSubcutaneous injection of bupivacaine combined with IV diclofenac provides superior analgesia to monotherapy intravenous diclofenac after inguinal hernia repair.

Comparative evaluation of fentanyl and magnesium sulphate as an adjuvant to 0.375% bupivacaine in ultrasound guided supraclavicular brachial plexus block

Supraclavicular block helps in achieving good anaesthesia along with complete muscle relaxation while providing hemodynamic stability and excellent post-operative analgesia. The addition of opioids to local anaesthetics injected during brachial plexus block has been shown to decrease the post-operative systemic analgesic requirements. This study was designed to compare the effectiveness of addition of MgSO (150 mg) and Fentanyl (50 micrograms) to 0.375% bupivacaine with placebo in supraclavicular brachial plexus block.A prospective double-blind randomised controlled study was conducted comprising of 75 patients undergoing upper limb surgeries under ultrasound guided supraclavicular brachial plexus block. Patients were randomized into one of the three groups (n=25) and designated as Group P (20ml of 0.375% Bupivacaine only), Group M (150 mg Magnesium sulphate with Bupivacaine) and Group F (50 micrograms Fentanyl with Bupivacaine). The primary purpose of the studywasto compare the onset and quality of sensory as well as motor blockade in all three groups. The onset time (in minutes) of sensory as well as motor blockade was significantly shorter in group P (p&amp;#60;0.001). Mean duration of sensory blockade (7.65±1.05 hours) and motor blockade (8.17±1.17 hours) was longest in group F when compared to group M and group P (p&amp;#60;0.001). Percentage of patients requiring rescue analgesia were significantly less in group F (16%) than group M (32%) and group P (80%) respectively (p&amp;#60;0.001). The mean time prior to administration of rescue analgesia in groups F, M and P were 14.21±4.29, 9.86±1.49 and 8.50 ±2.37 hours respectively (p&amp;#60;0.001).Although the additives delay the onset of action of local anaesthetic agents in brachial plexus block, Fentanyl as an adjuvant provided superior analgesia when compared to Magnesium sulphate as well as placebo with respect to duration of motor and sensory blockade. In addition, patients who received fentanyl as an adjuvant, required lesser rescue analgesia in the post-operative period.

Pain levels and patient comfort after lower limb arthroplasty comparing i.v. patient-controlled analgesia, continuous peripheral nerve block and neuraxial analgesia: a retrospective cohort analysis of clinical routine data

BackgroundInsufficient pain control after lower limb arthroplasty results in delayed recovery and increased risk for pain chronicization. The ideal kind of analgesia is still discussed controversially. We conducted a retrospective analysis of single-center routine data from a German university hospital, including patients receiving either total hip (THA) or knee arthroplasty (TKA).MethodsAll patients received general anesthesia. Patients undergoing THA received either continuous epidural ropivacaine infusion (0.133%, Epi) or patient-controlled analgesia (PCA) with the Wurzburg Pain Drip (tramadol, metamizole and droperidol, WPD) or with piritramide (Pir). After TKA, patients received either continuous femoral nerve block (ropivacaine 0.2%, PNB) or Pir.ResultsThe analyzed cohort comprised 769 cases. Use of WPD after THA (n = 333) resulted in significantly reduced Numeric Rating Scale (NRS) values at rest, compared to Epi (n = 48) and Pir (n = 72) (.75 [IQR 1.14] vs. 1.17 [1.5], p = .02 vs. 1.47 [1.33], p < .0001) as well as maximum NRS scores (2.4 [1.7] vs. 3.29 [1.94], p < .001 vs. 3.32 [1.76], p < .0001). Positive feedback during follow-up visits was significantly increased in patients with a WPD PCA (p < .0001), while negative feedback (senso-motoric weakness/technical problems/nausea/dizziness/constipation) was particularly increased in Epi patients and lowest in those with WPD (p < .0001). After TKA, Pir (n = 131) resulted in significantly reduced NRS values at rest, compared to PNB (n = 185) (1.4 [1.4] vs. 1.6 [1.68], p = .02). Positive feedback was increased in patients with a Pir PCA in comparison with PNB (p = .04), while negative feedback was increased in PNB patients (p = .04). Overall, WPD presented with the lowest rate of any complications (8.7%), followed by Pir (20.2%), PNB (27.6%) and Epi (31.3%) (p < .001).ConclusionsIn the assessed population, the use of a WPD PCA after THA offered better pain control and patient comfort in comparison with continuous epidural or piritramide-based analgesia. After TKA, the use of a Pir PCA provided superior analgesia and a lower complication rate compared to continuous PNB.

Comparison of Efficacy and Safety of Transdermal Buprenorphine Patch and Conventional Analgesics in Intra-capsular Femur Neck Fracture Post Hemiarthroplasty.

One of the most common fractures in the elderly population is a fracture of the neck of femur. Effective post-operative analgesia is a major challenge. Age-related co-morbidities restrict the choice of analgesics. The purpose of this study was to compare the efficacy and safety of transdermal buprenorphine [TDB] patch and conventional analgesics following hemiarthroplasty for intra-capsular fracture neck of femur. This was a prospective, randomized control study done in 60 patients undergoing hemiarthroplasty for intra-capsular fracture neck of femur over a period of 2years. Patients were randomized in 2 groups. Group A received a combination of IV paracetamol and tramadol for first 48h followed by oral formulation. In Group B patients, a transdermal buprenorphine patch of 5mcg/h was applied at the beginning of surgery and was continued 2weeks post-operative.Pain score by VAS was observed both at rest and on movement and followed up till 14days post-operative. Primary target was to maintain a VAS ≤ 4. Rescue analgesic was given if the VAS was ≥ 6. Secondary targets were number of rescue analgesics required, adverse reactions and complications if any. Group B had significantly lower pain scores at rest and during movement [p value 0.0012 to ≤ 0.0001], so was rescue analgesia requirement. No significant side effects were seen in TDB group. TDB patch is safe and provides superior analgesia and compliance as compared to conventional analgesics in the post-operative period in proximal femur fracture surgeries.

Dexmedetomidine as an Adjuvant to Ropivacaine in Ultrasound Guided Brachial Plexus Block Using Supraclavicular Parasagittal Approach for Upper Limb Orthopedic Surgeries

Background: Brachial plexus block is a key technique in anesthesiologist’s practice. Ropivacaine is a long acting local anaesthetic, Dexmedetomidine has been included as an adjuvant to enhance block duration.&#x0D; Aim: To elucidate the effect of addition of Dexmedetomidine to Ropivacaine in ultrasound guided parasagittal supraclavicular brachial plexus approach with respect to duration of analgesia, onset and duration of sensorimotor blockade.&#x0D; Methods: A randomized single blinded prospective clinical study was conducted among Forty patients of 20-50yrs, ASA Grade I and II, weighing &gt;60kgs scheduled for elective upper limb orthopedic surgeries. Group RN received 25ml of 0.75% ropivacaine with 1ml normal saline, Group RD received 25ml of 0.75% ropivacaine with 1mcg/kg dexmedetomidine diluted to 1ml. Analgesic efficacy, sensorimotor blockade was determined.&#x0D; Statistical Analysis: Demographic and hemodynamic data was analyzed using student t-test. Unpaired t-test was used to analyze onset, duration of sensorimotor blockade and analgesic duration. Results were statistically significant if p-value &lt;0.05. P-value &lt;0.001 was considered highly significant.&#x0D; Results: Analgesic duration was prolonged in Group RD rather than Group RN (646.82 +/- 21.56min vs 484.78 +/- 15.52min). Group RD had rapid onset of sensory (7.4 +/- 1.02min vs 9.9 +/- 1.16min) and motor blockade (10.25 +/- 1.13min vs 13.28+/- 1.22min). Duration of sensory (536.62 +/- 9.61min vs 413.79 +/- 15.61min) and motor blockade (430.13 +/- 11.68min vs 298.12 +/- 15.36min) was enhanced in Group RD.&#x0D; Conclusion: Adding Dexmedetomidine to Ropivacaine provided superior analgesia along with rapid onset and longer duration of sensorimotor blockade.

Comparison of hydromorphone and butorphanol for management of pain in equine patients undergoing elective arthroscopy: a randomized clinical trial

ObjectiveTo compare the effects of hydromorphone and butorphanol in horses undergoing arthroscopy and describe the pharmacokinetics of hydromorphone in anesthetized horses. Study designRandomized controlled clinical trial. AnimalsA total of 40 adult horses admitted for elective arthroscopy. MethodsHorses were randomly assigned to be administered intravenous hydromorphone (0.04 mg kg–1; group TxH; n = 19) or butorphanol (0.02 mg kg–1; group TxB; n = 21) prior to surgery as part of a standardized anesthetic protocol. Pain was scored by two observers unaware of group assignment using the Equine Utrecht University Scale for Facial Assessment of Pain (EQUUS-FAP) and a composite pain scale (CPS) prior to surgery (baseline), 2 hours (P2) and 4 hours (P4) following recovery from anesthesia. Blood samples were collected at various time points for determination of plasma hydromorphone concentration using liquid chromatography–tandem mass spectrometry. Data were analyzed with a mixed-effect model. ResultsMedian (range) baseline EQUUS-FAP was 1.2 (0.0–4.0) with no effect of group, time points or interaction. Baseline CPS was similar between groups. Group TxH baseline CPS was 2.5 (0.0–10.0), increased at P2 [4.5 (0–10.0); p = 0.046] and returned to baseline values at P4 [3.0 (0.0–11.0)]. Group TxB baseline CPS was 2.0 (0.0–8.0), increased at P2 [3.5 (0.0–11.0); p = 0.009] and P4 [5.0 (0.0–11.0); p < 0.001]. Pharmacokinetic terminal half-life was 774 ± 82.3 minutes, area under the curve was 1362 ± 314 ng minutes mL–1, clearance was 30.7 ± 7.23 mL minute–1 kg–1 and volume of distribution at steady state was 884 ± 740 mL kg–1. ConclusionsHydromorphone, but not butorphanol, decreased CPS back to baseline at P4 after recovery. Clinical relevanceHydromorphone may provide superior postoperative analgesia compared with butorphanol in horses undergoing arthroscopy.

Efficacy of ultrasound-guided erector spinae plane block versus paravertebral block for postoperative analgesia in single-port video-assisted thoracoscopic surgery: a retrospective study.

Thoracic paravertebral block (TPVB) is an analgesic method recommended in the enhanced recovery after surgery (ERAS) protocol and proven successful in thoracoscopic surgery. The study aimed to investigate whether the erector spinae plane block (ESPB) administered single-injection in uniportal video-assisted thoracoscopic surgery (VATS) can be an alternative to TPVB as an analgesic method. In this study, American Society of Anesthesiologists (ASA) physical status class I-II-III patients aged between 18-70 years who underwent thoracoscopic wedge resection surgery were analyzed retrospectively; 136 patients in the ESPB group and 114 patients in the TPVB group were included in the study. Postoperative cumulative morphine consumption numerical rating scale (NRS) scores were compared at 1, 6, 12, and 24 hours after surgery at rest and during coughing between the groups. Also, rescue analgesia requirements, postoperative nausea, vomiting and other complications were evaluated. The mean cumulative morphine consumption in the postoperative 24 hours was 20.06 mg in the ESPB group and 11.35 mg in the TPVB group. A statistically significant difference was observed between groups in terms of total morphine consumption in the postoperative 24 hours (P<0.001). NRS score was significantly lower in the TPVB group at postoperative 6th and 24th hours during coughing (P=0.003 and P=0.034, respectively) and at 24th hour at rest (P=0.008) than ESPB group. Median NRS scores at rest were low (<4) in both groups. There was no significant difference between the groups in terms of postoperative pulmonary complications as atelectasis and length of hospital stay (LOS) (P=0.643 and P=0.867 respectively). Ultrasound (US)-guided single-injection TPVB provided superior analgesia in patients undergoing single-port VATS than ESPB. In addition to this, TPVB showed more opioid sparing by reducing morphine consumption.

Analgesic efficacy of preoperative ultrasound transversal abdominal plane block for open hysterectomy

Transversus abdominis plane (TAP) block is a promising technique in post-operative pain relief, following various types of surgeries with an incision on the anterio-lateral abdominal wall. Our randomized, prospective, control trial evaluates its peri-operative analgesic effectiveness for total abdominal hysterectomy (AH) via Pfannenstiel approach. Forty-six women, admitted for intervention, were randomized. A group with an application of bilateral, preincisional TAP block with ropivacaine (n = 23) versus a control group (n = 23) were formed. The post-operative pain relief for all the participants consisted of a mono-component, patient-controlled morphine analgesia. The amount of total 24 h morphine consumption and intraoperative fentanyl use was calculated. Pain at rest and in motion was assessed on a Verbal Numeric Scale (VNS). The incidence of post-operative nausea and vomiting was registered. TAP block with ropivacaine reduced the 24 h post-operative cumulative morphine requirements. The morphine consumption of the TAP block group (14.5 mg ± 4 mg) was statistically significantly lower than the control one (21.7 mg ± 6.8 mg). TAP block decreased the intraoperative use of fentanyl and the post-operative VNS scores at rest and in motion. The groups did not demonstrate any difference in the incidence of nausea and vomiting after surgery. TAP block was not associated with any complications. Our study showed that TAP block effectively leads to superior analgesia in patients undergoing total AH.

A prospective, randomized clinical study for evaluation of pregabalin for post-operative analgesia in infraumbilical surgeries

Background: Preemptive analgesia is about the administration of an analgesic agent before the initiation of noxious stimulus, aiming of preventing sensitization of the neural system to successive stimulus that could intensify pain perception. Pregabalin is derivative of gabapentinoid which exhibits analgesic properties. Aims and Objectives: This clinical study designed to evaluate the effectiveness of pregabalin for post-operative analgesia in infraumbilical surgeries. Materials and Methods: This prospective clinical study was conducted in a medical college hospital of central India after obtaining approval from institutional ethics committee and informed written consent from the selected patients over the period of 1 year. A total of 60 patients between the ages of 20 and 40 years of ASA Grade I/II were randomly assigned into two groups (n=30, each) using an online randomization tool. Patients in Group P received oral Pregabalin 150 mg and Group D received oral Diazepam 10 mg, 1 h before induction of anesthesia. Both the groups uniformly received Tablet Paracetamol 1 gm, 2 h after completion of surgery. Patients experiencing pain with visual analogue scale (VAS) score ≥3, were injected Inj. Tramadol 100 mg, as rescue analgesia. Outcome variables such as need for rescue analgesia, sedation, VAS score, and other adverse events were noted at time intervals of 2, 4, 6, 12, and 24 h. Results: The mean VAS scores in patients of Group P were significantly lower than Group D (P&lt;0.0001), over 24 h of post-operative period. In Group P, rescue analgesic Inj. Tramadol was given after 12.33±3.47 h as compared to 3.47±8.19 h in Group D (P&lt;0.0001) with total need of 133.56±49.27 mg and 210.73±63.35 mg over 24 h in patients of Groups P and D, respectively (P&lt;0.0001). Conclusion: Pregabalin 150 mg in pre-operative period provides superior post-operative analgesia and considerably reduces need of rescue analgesia postoperatively.

A comparison between thoracic epidural analgesia and rectus sheath catheter analgesia after open midline major abdominal surgery: randomized clinical trial.

BackgroundRectus sheath catheter analgesia (RSCA) and thoracic epidural analgesia (TEA) are both used for analgesia following laparotomy. The aim was to compare the analgesic effectiveness of RSCA with TEA after laparotomy for elective colorectal and urological surgery.MethodsPatients undergoing elective midline laparotomy were randomized in a non-blinded fashion to receive RSCA or TEA for postoperative analgesia at a single UK teaching hospital. The primary quantitative outcome measure was dynamic pain score at 24 h after surgery. A nested qualitative study (reported elsewhere) explored the dual primary outcome of patient experience and acceptability. Secondary outcome measures included rest and movement pain scores over 72 h, functional analgesia, analgesia satisfaction, opiate consumption, functional recovery, morbidity, safety, and cost-effectiveness.ResultsA total of 131 patients were randomized: 66 in the RSCA group and 65 in the TEA group. The median (interquartile range; i.q.r.) dynamic pain score at 24 h was significantly lower after TEA than RSCA (33 (11–60) versus 50.5 (24.50–77.25); P = 0.018). Resting pain score at 72 h was significantly lower after RSCA (4.5 (0.25–13.75) versus 12.5 (2–13); P = 0.019). Opiate consumption on postoperative day 3 (median (i.q.r.) morphine equivalent 17 (10–30) mg versus 40 (13.25–88.50) mg; P = 0.038), hypotension, or vasopressor dependency (29.7 versus 49.2 per cent; P = 0.023) and weight gain to day 3 (median (i.q.r.) 0 (−1–2) kg versus 1 (0–3) kg; P = 0.046) were all significantly greater after TEA, compared with RSCA. There were no significant differences between groups in other secondary outcomes, although more participants experienced serious adverse events after TEA compared with RSCA, which was also the more cost-effective.ConclusionsTEA provided superior initial postoperative analgesia but only for the first 24 h. By 72 hours RSCA provides superior analgesia, is associated with a lower incidence of unwanted effects, and may be more cost-effective.

Implementation and Postoperative Management of Continuous Adductor Canal Catheters for Total Knee Arthroplasty to Reduce Surgical Backlog Related to the COVID-19 Pandemic: An Acute Pain Service Nursing Perspective and Educational Resource

PurposeIn response to the surgical backlog created by the COVID-19 pandemic and to spare valuable hospital resources, we developed and implemented a continuous adductor canal catheter (CACC) program for total knee arthroplasty (TKA) patients. CACC's offer superior analgesia, decrease opioid use, and increase patient satisfaction while simultaneously promoting a decreased length of hospital stay and even same day discharges. The implementation of analgesia protocols using continuous peripheral nerve catheters and isometric pumps has been described for other surgical procedures and populations; however, the role of the Acute Pain Service Nurse (APS RN) in the implementation of such a program has not been described. DesignAn best practice initiative for TKA patients receiving CACC was developed and implemented for patients recovering both in the hospital and at home. MethodsWe describe the development and implementation of a CACC program for TKA patients in response to the surgical backlog created by the COVID-19 pandemic from the perspective of the APS RN. We provide a detailed narrative description of our postoperative assessment and experience, and offer practical insights for the postoperative care of these patients. We share the educational resources and assessment tools we developed to ensure consistent, safe, and effective clinical management of CACC patients in the hospital and at home. FindingsCACCs via elastomeric pumps have been shown to offer significant advances to pain control following TKA, decrease opioid use, enable earlier discharge, and improve patient satisfaction, all of which we observed unequivocally in our patients. In our experience, implementation of a daily telephone follow up by an APS RN for discharged TKA patients with a CACC was crucial for patient safety, patient satisfaction, and reducing emergency phone calls and emergency room visits. ConclusionsWe anticipate this description will provide an invaluable educational resource for other Acute Pain Service programs as similar outpatient peripheral nerve catheter programs are developed in response to the pandemic.

Over View of Oliceridine Newer Opioid Analgesic

Pain relief requires a balance between adequate analgesia and risk of adverse effects. Opioids remain the cornerstone for managing moderate to severe pain, but are associated with opioid-induced respiratory depression (OIRD) and gastrointestinal complications. Opioids exert their analgesic effects predominantly via G-protein signaling, however, adverse effects including OIRD are mediated by the β-arrestin pathway. Oliceridine is the first of a new class of biased opioid agonists that preferentially activate G-protein signaling over β-arrestin, which would theoretically improve analgesia and reduce the risk of adverse effects. Oliceridine is approved by the Food and Drug Administration (FDA) for the treatment of moderate to severe acute pain. The efficacy of Oliceridine was mainly established in two randomized controlled Phase III clinical trials of patients experiencing moderate to severe pain after bunionectomy (APOLLO-1) and abdominoplasty (APOLLO-2). The results of the APOLLO studies demonstrate that Oliceridine, when administered via patient-controlled analgesia (PCA) demand boluses of 0.35mg and 0.5mg, provides superior analgesia compared to placebo, and is equianalgesic to PCA morphine 1mg demand boluses, without significant difference in the incidence of respiratory complications. However, these studies were designed to evaluate analgesic efficacy, and it is still uncertain if Oliceridine has a better safety profile than conventional opioids. Although several post hoc analyses of pooled data from the trials reported that Oliceridine was associated with lower OIRD and gastrointestinal complications compared to morphine, prospective studies are needed to elucidate if biased agonists such as Oliceridine reduce the risk of adverse effects compared to conventional opioids

Abstract No. : ABS0107 : Ultrasound guided lower thoracic erector spinae plane block for postoperative analgesia following gynaecologic oncology surgery - A randomised controlled trial

Background and Aims:Erector spinae plane (ESP) block is a relatively novel block which provides local and visceral analgesia for abdominal surgery. The present study is aimed to assess the efficacy of ESP block for postoperative analgesia following major open gynaecologic oncology surgery.Methods:Sixty female patients posted for elective open gynaecologic oncology surgeries were enroled in this prospective, double blind study and randomised to B and C group. Group B patients received general anaesthesia plus ultrasound guided bilateral ESP block at T9 level at the end of surgery while group C patients received general anaesthesia only. Primary outcome was postoperative visual analogue scale (VAS) scores. Secondary outcomes were time to first rescue analgesic, 24 hours tramadol consumption, and side effects. Chi square and student t tests were used and P < 0.05 was considered significant.Results:Postoperative pain scores were lower in B group compared to C group at rest and on movement . Time to first rescue analgesic was prolonged in B group (8.10 ± 1.48 hours) as compared to C group (0.7 ± 0.38 hours) [P < 0.0001]. Total 24 hours tramadol consumption was less in B group (68 ± 48.55 mg) than C group (210 ± 52.65 mg)(table 1) [P < 0.0001].Conclusion:Ultrasound guided ESP block with general anaesthesia provides superior postoperative analgesia compared to general anaesthesia alone following major gynaecologic oncology surgeries without any side effects. It can be used as an alternative to epidural analgesia.Table 1Comparison of variables in different routes of ketamine administrationVariableGroup intravenous-ketamineGroup nebulised-ketamine P Age mean (years)7.56±1.277.41±1.14>0.05Weight mean (kg)25.34±4.7125.09±2.97>0.05Parental Separation scores (median)11>0.05Sedation (median) 5-point sedation score22>0.05Verbal rating scale pain score (median) Immediate00>0.05 1 h- post-operatively210.04Time for 1st rescue analgesic (min)237.19±34.38 min300±26.396 minP<0.001

Evaluation of the postoperative morphine-sparing effect of oral premedicants used as pre-emptive analgesics in breast-conserving cancer surgeries: A randomised placebo-controlled trial.

Background and Aims:Breast cancer surgeries are associated with both nociceptive and neuropathic pain, requiring strong analgesics. We aimed to evaluate the postoperative morphine-sparing effect of pre-emptive oral premedication with tramadol versus pregabalin in patients undergoing breast-conserving cancer surgeries (BCCS).Methods:This prospective, randomised, placebo-controlled trial was carried out at tertiary care centre on 90 patients undergoing BCCS randomised into three groups of 30 each. Group C received placebo, Group T received tramadol 100 mg and Group P received pregabalin 75 mg as oral premedication, 1 hour before surgery. General anaesthesia was administered. Postoperatively morphine 1 mg.h-1 through intravenous PCA was started at a visual analogue scale score ≥4. Total morphine consumption in 24 hours was calculated and its sparing effect was evaluated as the primary outcome.Results:The median with interquartile range (IQR) of total postoperative morphine consumed in 24 hours, was found to be 22 mg (IQR 0-25.77), 15 mg (IQR 0-16) and 17.50 mg (IQR 0-19.25) in groups C, T, P respectively, (P = 0.000, 0.003, 0.060). The median duration of analgesia in group C was 5.40 hours (IQR 3.30-11.40), 11.6 hours (IQR 9.30-24.0) in group T and 8.60 hours (IQR 6.97-16.27) in group P (P value C/T = 0.000, C/P = 0.007, T/P = 0.002). The postoperative side effects were comparable.Conclusion:Oral tramadol 100 mg and oral pregabalin 75 mg as premedication reduced the 24 hours postoperative morphine requirement as compared to placebo in BCCS. However, tramadol 100 mg provided superior analgesia for longer duration than pregabalin 75 mg and was associated with more side effects.

351 Oral Opioids vs Patient Controlled Analgesia: Efficacy of Analgesia Post Lung Resection and Association with Postoperative Bronchoscopy and Bronchial Aspiration – a Single Center Observational Retrospective Study

Abstract Aim Respiratory complications arising from disrupted evacuation of bronchopulmonary secretions are frequently encountered following anatomical lung resections. In cases refractory to mucolytics and chest physiotherapy, definitive management usually entails bronchoscopic aspiration. Pain is an important precipitating factor for sputum retention impeding mucociliary clearance and productive cough. Opioids remain the mainstay of postoperative analgesia but can also promote retention of secretions due to their anti-tussive properties and ventilatory depression. In this study, we aimed to review the efficacy of oral opioids against patient-controlled analgesia (PCA) in immediate post-operative period. We further explored if use of PCA predisposed to post-operative bronchoscopy. Method A retrospective case note analysis was conducted for all 329 patients undergoing lung resections (lobectomy, wedge resection, segmentectomy, pneumonectomy, metastasectomy both via thoracotomy and VATS approach) between May 2016 and December 2019 in a Thoracic Surgery Unit under a single consultant surgeon. Results Of the 329 patients undergoing lung resections, 46.8% patients received oral opioids and remaining 53.1% received PCA for immediate postoperative pain management. Pain scores at rest were documented for 48.02% patients – scores calculated at 10.39+/-8.7 hours after completion of surgery were 1.023+/-0.754 for the PCA cohort and 0.904+/-0.756 for patients receiving oral opioids (p = 0.131). 13 patients were noted to undergo bronchoscopy to aid in secretion clearance. Univariate analysis failed to establish a correlation between use of PCA and incidence of post-operative bronchoscopy (p = 0.603). Conclusions PCA is not associated with significant sputum retention necessitating bronchoscopic aspiration. It, however, does not offer superior analgesia for static pain compared to oral opioids.