Systemic Analgesia Research Articles

Erector spinae plane block for minimally invasive thoracic surgery: a local audit and quality improvement project

Significant postoperative pain is common after minimally invasive thoracic surgery (MITS). This can be mitigated with regional anaesthesia in conjunction with systemic multimodal analgesia. The erector spinae plane block (ESPB), a recently established interfascial block, has demonstrated effective postoperative analgesia after thoracic surgery,1 with fewer risks compared with paravertebral block (PVB). The introduction of ESP catheters for continuous infusion or intermittent bolus administration of local anaesthetic can provide further analgesia in the postoperative period,2 however, sufficient data are lacking.

Comparison of erector spinae plane and paravertebral nerve blocks for postoperative analgesia in children after the Nuss procedure: study protocol for a randomized controlled non-inferiority clinical trial

BackgroundThoracic paravertebral block (TPVB) is a widely advocated regional technique for alleviating postoperative pain in children undergoing elective pectus excavatum repair. However, this technique is associated with some undesirable adverse events. Recently, the erector spinae plane block (ESPB) has been introduced as a practical alternative to the TPVB in thoracic surgery. This interfascial regional anesthesia technique interrupts pain sensation by injecting local anesthetics between the muscular layers of the thoracic wall. Several case series described it as an effective pain management technique following pectus excavatum repair. Therefore, this trial is designed to test the hypothesis that ESPB is non-inferior to TPVB in postoperative pain control after pectus excavatum repair.MethodsThis is a prospective randomized double-blind non-inferiority trial. A total of 40 patients aged 4 to 18 years undergoing Nuss surgery will be randomly assigned to receive pain treatment with either ESPB or TPVB. All patients will receive additional systemic multimodal analgesia with an intravenous patient-controlled analgesia pump and acetaminophen. The primary outcome is the pain intensity at rest, 24 h postoperatively. Secondary outcomes include accumulated morphine-equivalent consumption, postoperative pain scores, emergence agitation incidence, time of the first mobilization, time to first rescue analgesia, complications related to pain treatment, and morphine-related adverse events.DiscussionThis will the first randomized controlled trial to compare ESPB with TPVB for analgesia after pectus excavatum repair. This trial aims to provide important clinical evidence to elaborate on the analgesic mechanism of ESPB in children.Trial registrationClinicalTrials.govNCT05034601. This trial was prospectively registered.

Role of an Intercostobrachial Nerve Block in Alleviating Tourniquet Pain: A Randomized Clinical Trial.

IntroductionTourniquet pain may have cutaneous and ischemic components. It is questionable whether blockade of a sensory nerve will help reduce ischemic pain. In addition, complete anesthesia of the axilla in the intercostobrachial nerve (ICBN) distribution is challenging to execute, and ICBN blockade has an inherently higher failure rate because of its variable anatomic location and source of innervation. We sought to determine the utility of an ICBN block for the prevention of tourniquet pain.MethodsWe conducted a single-center randomized controlled trial at a major academic medical center involving patients scheduled to undergo distal upper extremity surgery under ultrasound-guided supraclavicular brachial plexus block. Forty patients were randomized to receive an additional ICBN block or no ICBN block, with 22 allocated to the intervention and 18 to control. We collected data on the incidence of tourniquet pain and systemic anesthetic requirements.ResultsInitial contingency analysis examining the relationship between ICBN block placement and the development of pain using the two-tailed Fisher exact test failed to show that the presence or absence of ICBN block was associated with the development of tourniquet pain. χ2 analysis failed to show that tourniquet time was significantly related to the development of tourniquet pain.ConclusionsThe overall incidence of tourniquet pain in the setting of a dense supraclavicular brachial plexus block for surgical anesthesia was low even without an ICBN block and even with tourniquet times greater than 90 min. Tourniquet pain was easily managed with small amounts of systemic analgesics.

Anatomical and Technical Considerations of the Hi-PAC (Hi-Volume Proximal Adductor Canal) Block: A Novel Motor-Sparing Regional Analgesia Technique for Below-Knee Surgeries.

Below-knee surgeries are among the most commonly performed orthopedic or plastic and reconstructive procedures. They are associated with significant postoperative pain despite the use of systemic analgesics. The regional analgesia (RA) technique has been proven beneficial for better patient outcomes when used as an adjunct to multimodal analgesia in the early postoperative period. However, apprehension of an acute compartment syndrome (ACS) can limit the administration of appropriate RA techniques in such surgeries, leading to more opioid consumption to meet the increasing analgesic demands. Many modifications in the RA related to techniques and the local anesthetic type, concentration, and volume have been described to tackle such situations. The ideal RA technique should provide procedure-specific analgesia below the knee joint without affecting motor power and/or causing any delay in diagnosing or treating ACS.The high-volume proximal adductor canal (Hi-PAC) block is a novel RA technique described as motor-sparing and procedure-specific for the below-knee surgeries. The Hi-PAC block, a single-injection technique, is administered in the proximal adductor canal targeting the saphenous nerve and depositing local anesthetics (LA) adjacent to the femoral artery below the vasoadductor membrane (VAM). By directly blocking the saphenous nerve and indirectly the sciatic nerve, it covers the entire innervation of the pain-generating components involved in the below-knee surgeries.This article describes the anatomical and technical considerations of the Hi-PAC block and provides background knowledge of the relevant anatomy and sonoanatomy for a better understanding of its intricacies.

Opioid Sparing Techniques for the Sports Medicine and Shoulder Procedures

Persistent opioid use after orthopedic surgery is a well-recognized complication, with as many as 20 percent of patients still consuming opiates at 180 days postoperative. The ongoing opioid epidemic has resulted in a three-fold increase in deaths attributed to prescription opioids from 2001 to 2016 and has reignited with the COVID-19 pandemic. Orthopedic surgeons are among the largest prescribers of opioid medications and must find ways to be responsible stewards of these drugs. We describe an environment of over prescription evidence-based methodology to provide patients with the appropriate relief without reliance on opiates, the historical mainstay of pain control. This is achieved by utilizing a multimodal approach consisting of education, as well as local, regional, and systemic analgesics.

Ultrasound-Guided Comparison of Psoas Compartment Block and Supra-Inguinal Fascia Iliaca Compartment Block for Pain Management in Pediatric Developmental Dysplasia of Hip Surgeries.

BackgroundThe aim of this study was to compare psoas compartment block (PCB) and supra-inguinal fascia iliaca compartment block (SFIB) in terms of pain management and the need for additional systemic analgesia in the perioperative phase of developmental dysplasia of the hip (DDH).Materials and MethodsSixty pediatric patients were randomized into the PCB group and the SFIB group. The Numeric Rating Scale (NRS) pain scores were used to assess postoperative pain during the initial 24 h after extubation. Sufentanil consumption, patient-controlled analgesia (PCA) demands, and complications were also recorded.ResultsThe NRS pain scores were significantly lower in the PCB group than in the SFIB group at 0, 4, 8, 12, and 24 h after extubation (all P < 0.01). Postoperatively, 13.8% of patients in the PCB cohort received additional administration of sufentanil, in contrast to 63.3% of the SFIB cohort (P < 0.01). In the PCB group, 0 (0-0) mcg/kg sufentanil was administered, while in the SFIB group 0.1 (0-0.2) mcg/kg (P < 0.01). In addition, the PCB group had fewer PCA demands than the SFIB group within the initial 24 h (P < 0.01). It took less operating time to achieve SFIB as compared to PCB (P < 0.01). No adverse events related to two techniques were recorded.ConclusionsPCB provided a better perioperative pain management in pediatric patients with the DDH surgeries compared to SFIB. It also reduced the need for supplementary systemic analgesia.

Regional anesthesia techniques and postoperative delirium: systematic review and meta-analysis.

Postoperative delirium is a frequent occurrence in the elderly surgical population. As a comprehensive list of predictive factors remains unknown, an opioid-sparing approach incorporating regional anesthesia techniques has been suggested to decrease its incidence. Due to the lack of conclusive evidence on the topic, we conducted a systematic review and meta-analysis to investigate the potential impact of regional anesthesia and analgesia on postoperative delirium. PubMed, Embase, and the Cochrane central register of Controlled trials (CENTRAL) databases were searched for randomized trials comparing regional anesthesia or analgesia to systemic treatments in patients having any type of surgery. This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We pooled the results separately for each of these two applications by random effects modelling. Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to evaluate the certainty of evidence and strength of conclusions. Eighteen trials (3361 subjects) were included. Using regional techniques for surgical anesthesia failed to reduce the risk of postoperative delirium, with a relative risk (RR) of 1.21 (95% CI: 0.79 to 1.85); P=0.3800. In contrast, regional analgesia reduced the relative risk of perioperative delirium by a RR of 0.53 (95% CI: 0.42 to 0.68; P<0.0001), when compared to systemic analgesia. Post-hoc subgroup analysis for hip fracture surgery yielded similar findings. These results show that postoperative delirium may be decreased when regional techniques are used in the postoperative period as an analgesic strategy. Intraoperative regional anesthesia alone may not decrease postoperative delirium since there are other factors that may influence this outcome.

Effectiveness of a Brief Hypnotic Induction in Third Molar Extraction: A Randomized Controlled Trial (HypMol)

Third molar extraction is a painful treatment for patients, and thus, it can be used to investigate the effects of analgesics on pain. Hypnosis can help to reduce pain and to decrease the intake of postoperative systemic analgesics. In this study, the effectiveness of a brief hypnotic induction for patients undergoing third molar extractions was investigated. Data were collected from 33 patients with third molar extractions on the right and left sides. Patients received 2 different types of pain interventions in this monocentric randomized crossover trial. Third molar extraction was conducted on 1 side with reduced preoperative local anesthetics and an additional brief hypnotic induction (Dave Elman technique). The other side was conducted with regular preoperative local anesthetics without a brief hypnotic induction (standard care). Intake of postoperative systemic analgesics was allowed in both treatments. Patients’ expectations about hypnosis were assessed at baseline. The primary outcome was the area under the curve with respect to ground of pain intensity after the treatment. Secondary outcomes were the amount of postoperative analgesics consumed and the preferred treatment. There was no evidence that the area under the curve with respect to ground of pain differed between the 2 interventions (controlling for gender), but the patients’ expectations affected the effectiveness of the brief hypnotic induction. This means that patients with high expectations about hypnosis benefit more from treatment with reduced preoperative local anesthetics and additional brief hypnotic induction. PerspectiveHypnosis is used as a treatment to reduce pain in general and dental settings. In this study, additional a brief hypnotic induction with reduced preoperative local anesthetic use did not generally reduce posttreatment pain after third molar extraction more than regular local anesthetics. The expectation of the patients about the effectiveness of hypnosis affected the effectiveness of the brief hypnotic induction so that patients with high expectations had a larger benefit from a brief hypnotic induction than patients with low expectations.

Кардіопротективні властивості торакальної паравертебральної блокади в гострому періоді закритої торакальної травми різного ступеня тяжкості

Вступ. Адекватність аналгезії при тяжкій закритій торакальній травмі (ЗТТ) забезпечується регіонарними методами знеболювання, одним із яких є торакальна паравертебральна блокада (ТПБ), яка вже довела свою ефективність. Проте не наведені дослідження впливу ТПБ на перебіг саме ушкодження серця після ЗТТ. Мета. Виявлення впливу ТПБ, проведеної в гострому періоді ЗТТ, на перебіг первинних і вторинних травматичних ушкоджень серця. Матеріали та методи. Контрольоване проспективне нерандомізоване дослідження засновано на аналізі лікування 82 постраждалих із ЗТТ: 70 (85,4 %) чоловіків, 12 (14,6 %) жінок, віком 53 (45, 65) роки. Групи сформовані за тяжкістю ЗТТ, де у підгрупах («a», «b») порівнювалася ефективність системної аналгезії (нестероїдні протизапальні засоби (НПЗЗ) та опіоїд) і ТПБ, проведеної у гострому періоді й надалі упродовж 4–5 діб. 1-ша групa — Injury Severity Score (ISS) — 16,0 ± 4,4 бала, APACHE II — 11,7 ± 3,6; 2-га група — ISS — 17,1 ± 3,9 бала, APACHE II — 13,8 ± 4,1; 3-тя група — ISS — 18,5 ± 4,9 бала, APACHE II — 14,5 ± 2,3. Результати. ЗТТ (ISS — 18 (14, 20) балів) із контузійним ушкодженням легенів І і ІІ ступеня у 62 (76 %) постраждалих (у 22 % виявлено на 1-шу добу, у 79 % — на 2-гу — 3-тю добу) ускладнювалася струсом чи забоєм серця до 70 % спостережень, післятравматичною міокардіо­дистрофією у ранньому та відновлювальному періодах — майже в усіх постраждалих. На електрокардіограмі (ЕКГ) — субендокардіальні та субепікардіальні зміни, пробіжки тахікардії, екстрасистоли, неспецифічні зміни кінцевої частки шлуночкового комплексу, ознаки інфаркту міокарда травматичного походження, а також і ІІ типу через крововтрату (у 2 пацієнтів). Не виявлено різниці ЕКГ-ознак між гемодинамічно стабільними і нестабільними пацієнтами. Застосування НПЗЗ та опіоїду (n = 43, підгрупи «а») достатньою мірою не усувало біль і гіпоксемію, зберігався периферичний вазоспазм (загальний периферичний судинний опір (ЗПСО) — 1987 ± 159 дин/с · см2), тахікардія (86 ± 13 уд · хв–1), зменшення роботи серця (серцевий індекс (СІ) — 2,71 ± 0,27 л/м2 · хв). Застосування ТПБ (n = 39, підгрупи «b») одразу знижувало біль на 68 ± 7 %, забезпечувало ліпше SрО2 95,6 ± 1,7 % проти 94,1 ± 1,5 % та РаО2/FіО2 340 ± 25 проти 312 ± 50 у підгрупах «а», що поєднувалось зі зменшенням тахікардії (80 ± 7 уд · хв–1) та периферичного судинного опору (ЗПСО — 1692 ± 157 дин/с · см2; p = 0,01) при одночасному сприятливому збільшенні продуктивності серцевої діяльності (СІ — 3,1 ± 0,17 л/м2 · хв). На 5-ту добу на фоні ТПБ РаО2/FiО2 був вищий, ніж у підгрупах «а» — 380 ± 28 % проти 362 ± 27 %; SрО2 — 96,8 ± 0,7 % проти 95,1 ± 1,1 % (p = 0,02). Висновки. ТПБ, проведена одразу в гострому періоді ЗТТ через усунення болю і гіпоксемії, має кардіопротекторну дію, що виявляється в антиаритмічному та протиішемічному ефектах, запобігаючи ускладненому перебігу струсу чи забою серця, зменшуючи прояви первинної і вторинної посттравматичної міокардіодистрофії.

Impact of Ultrasound-Guided Femoral Nerve Block on Ease of Positioning for Spinal Anesthesia in Patients with Femoral Fracture

Background: Spinal anesthesia is commonly used for orthopedic surgeries. The most important issue to improve outcome is patient cooperation to have a proper position for reducing pain during spinal anesthesia procedure. However, any change in position is painful which leads to sympathetic activation, tachycardia and hypertension, which may put patients with ischemic heart disease at risk. Peripheral nerve block is a safe and reliable alternative to systemic analgesia. Using the ultrasound-guided method reduces local anesthetics’ amount and side effects. Methods: In this study, 53 patients who came to the operating room with femoral fracture as candidates for spinal anesthesia were enrolled and received ultrasound-guided Femoral Nerve Block (FNB) (10 ml Lidocaine 1.5%). Before and after receiving the nerve block, the patients were asked about the severity of their pain using the Numerical Rating Scale (NRS). Both groups of patients and physicians were asked about their satisfaction according to a 5-point Likert scale. Results: Mean pain intensity in the NRS score at the time of admission to the operating room was 7.6±0.8, which was reduced to 1.8±1.5 after blockade. In this study, 39 (73.5%) patients were very satisfied (Likert scale 5), 10 (18.8%) were satisfied (Likert scale 4), 2 (3.7%) had no opinion (Likert scale 3), 2 (3.7%) were not satisfied (Likert scale 2), and no one was very dissatisfied (Likert scale 1). There was significant difference in physician’s satisfaction. Conclusion: Ultrasound-guided nerve block is a safe and effective method to be used for positioning during spinal anesthesia procedure.

Alternative pain management via endocannabinoids in the time of the opioid epidemic: Peripheral neuromodulation and pharmacological interventions.

The use of opioids in pain management is hampered by the emergence of analgesic tolerance, which leads to increased dosing and side effects, both of which have contributed to the opioid epidemic. One promising potential approach to limit opioid analgesic tolerance is activating the endocannabinoid system in the CNS, via activation of CB1 receptors in the descending pain inhibitory pathway. In this review, we first discuss preclinical and clinical evidence revealing the potential of pharmacological activation of CB1 receptors in modulating opioid tolerance, including activation by phytocannabinoids, synthetic CB1 receptor agonists, endocannabinoid degradation enzyme inhibitors, and recently discovered positive allosteric modulators of CB1 receptors. On the other hand, as non-pharmacological pain relief is advocated by the US-NIH to combat the opioid epidemic, we also discuss contributions of peripheral neuromodulation, involving the electrostimulation of peripheral nerves, in addressing chronic pain and opioid tolerance. The involvement of supraspinal endocannabinoid systems in peripheral neuromodulation-induced analgesia is also discussed. LINKED ARTICLES: This article is part of a themed issue on Advances in Opioid Pharmacology at the Time of the Opioid Epidemic. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v180.7/issuetoc.

Thoracic regional anesthesia and the impact on ventilation.

Thoracic surgical incisions can be associated with intense pain or discomfort. Postoperative thoracic pain may be multifactorial in origin. Inadequate analgesia causes respiratory dysfunction. Adequate analgesia preserves pulmonary function and may hasten recovery. Intravenous opioids are widely used but sufficient analgesia is seldom achieved in doses that permit safe spontaneous ventilation. Thoracic regional anesthesia provides profound analgesia, is opiate sparing and has minimal depressant effects on ventilation. Thoracic regional anesthesia is both an effective alternative to systemic analgesics or can be used as part of a multimodal analgesic technique.

The quality and continuity of systemic postoperative analgesia: a single center two-stage follow-up study

The aim of two prospective 1-month follow-up studies was to assess and compare the quality and continuity of postoperative systemic analgesia in Departments of Anaesthesiology and Surgery I and II, as well as adherence to prescribed plan of analgesia with respect to the effect of postoperative analgesia guidelines adopted in 2018. The studies included 94 (2016) and 80 (2018) patients who were operated under general anaesthesia, transferred to post-anaesthetic care unit (PACU), then to surgical wards and received systemic analgesia postoperatively. Comparison was based on adherence to postoperative analgesia plan during patient transfer. Recommendations for multimodal postoperative analgesia were given by the anaesthesiologist in 35.1% (ketoprofen + opioid) and 40.4% (paracetamol + opioid) in 2016 vs. 91.3% of cases in 2018, p &lt; 0.001. Comparing 2016 to 2018, adherence to planned analgesia in PACU, % of cases was 35.1% vs. 92.5% for paracetamol (p &lt; 0.001), 30.9% vs. 80% for ketoprofen (p &lt; 0.001) and 75.5% vs. 72.5% for pethidine (p = 0.649). Adherence to planned analgesia after transfer to Department of Surgery I, % of cases was 3.3% vs. 80% for paracetamol (p &lt; 0.001), 1.7% vs. 22% for ketoprofen (p &lt; 0.001) and 61.7% vs. 20% for pethidine (p &lt; 0.001). Adherence to planned analgesia after transfer to Department of Surgery II, % of cases was 0% vs. 10% for paracetamol (p = 0.059), 61.8% vs. 73.3% for ketoprofen (p = 0.325) and 29.4% vs. 13.3% for pethidine (p = 0.12), respectively. In conclusion, patients receive recommended systemic analgesia in PACU. Implementation of guidelines in Department of Surgery I resulted in 42% reduction of opioid and 76%increase of paracetamol use. Adherence to recommended analgesia in Department of Surgery II remains low.

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.

Chest Wall Nerve Blocks for Cardiothoracic, Breast Surgery, and Rib-Related Pain.

Perioperative analgesia in patients undergoing chest wall procedures such as cardiothoracic and breast surgeries or analgesia for rib fracture trauma can be challenging due to several factors: the procedures are more invasive, the chest wall innervation is complex, and the patient population may have multiple comorbidities increasing their susceptibility to the well-defined pain and opioid-related side effects. These procedures also carry a higher risk of persistent pain after surgery and chronic opioid use making the analgesia goals even more important. With advances in ultrasonography and clinical research, regional anesthesia techniques have been improving and newer ones with more applicationshave emerged over the last decade. Currently in cardiothoracic procedures, para-neuraxial and chest wall blocks have been utilized with success to supplement or substitute systemic analgesia, traditionally relying on opioids or thoracic epidural analgesia. In breast surgeries, paravertebral blocks, serratus anterior plane blocks, and pectoral nerve blocks have been shown to be effective in providing pain control, while minimizing opioid use and related side effects.Rib fracture regional analgesia options have also expanded and continue to improve. Advances in regional anesthesia have tremendously improved multimodal analgesia and contributed to enhanced recovery after surgery protocols. This review provides the latest summary on the use and efficacy of chest wall blocks in cardiothoracic and breast surgery, as well as rib fracture-related pain and persistent postsurgical pain.

Intraoperative ultrasound-guided serratus anterior plane catheter for postoperative analgesia after breast surgery in a morbidly obese patient

Inter-fascial plane blocks play a great role as part of the multimodal analgesic regimen for breast surgery. Fascial plane blocks are effective for immediate analgesia, but their use for prolonged postoperative analgesia is not yet explored. We present a hybrid technique of successful placement of intraoperative ultrasound-guided deep serratus anterior plane (SAP) catheter for continuous postoperative analgesia in a morbidly obese patient undergoing breast surgery. A sexagenarian morbidly obese female patient with left carcinoma breast was posted for modified radical mastectomy. The deep serratus anterior fascial plane was more than 9 cms deep and was poorly visualized. Hence, intraoperative catheter was placed under ultrasound guidance and used effectively for 5 days. The static and dynamic pain scores were <4 at all-time points with local anesthetics and nonopioid systemic analgesics. We observed that intraoperative ultrasound-guided SAP catheter can be effectively used for continuous postoperative analgesia in morbidly obese patients undergoing breast surgery.

Effectiveness of pericapsular nerve group block with ultrasonography in patients diagnosed with hip fracture in the emergency department.

Hip fractures (HF) are among the most common fractures present in the emergency department and are very painful. Pericapsular nerve group block (PENG) is a new regional anesthesia technique developed for analgesia in total hip arthroplas-ties. We aimed to determine the effectiveness of PENG block used to reduce pain in patients with HF in the emergency department. This single-center, randomized, and prospective study was carried out in the emergency department. The patients in-cluded in the study were selected according to the suitability of the personnel who will perform the procedure. The sealed envelope system was used for randomization. Statistical analysis was performed with 39 patients (18 patients in the PENG group, 21 patients in the control group). Thir-teen (33.3%) of the patients were female and 26 (66.7%) were male. The mean age was 75.3. At rest post-procedure, the mean Numeric Rating Scale (NRS) scores of the patients at the 30th min, 2nd, 6th, and 24th h were 1.78±1.83, 0.00±0.00, 0.00±0.00, and 1.28±1.41 in the PENG group. On the other hand, it was 3.38±1.86, 0.05±0.22, 2.86±2.37, and 4.95±1.47 in the control group, respectively. The mean NRS scores of the patients at 15° elevation of the leg at the 30th min, 2nd, 6th, and 24th h were 3.06±1.80, 0.06±0.24, 0.22±0.43, and 2.44±1.50 in the PENG group and it was 5.24±1.81, 1.05±0.92, 4.29±2.35, and 7.14±1.24 in the control group, respectively. PENG block can reduce pain and the need for systemic analgesics as a practical option in patients with HF.

Ropivacaine: A Review on the Pharmacological Features, Therapeutic Efficacy and Side-effects When used for Caudal Epidural Analgesia

Inadequate post operative pain treatment can lead to clinical and psychological changes, as well as increased morbidity, mortality, and financial burden, all of which can influence quality of life. A review of the pharmacological characteristics, therapeutic efficacy in delivering postoperative analgesia, and side-effects of Ropivacaine is presented in this article. Motor blockade is an unwanted effect during the post operative period. The fear of side-effects and hemodynamic instability caused by the most of the analgesic drugs are the challenges faced in providing effective post operative analgesia in children. Ropivacaine has lesser cardiotoxic effects, lesser motor blockade and minimal side-effects as compared to bupivacaine. These properties make it a promising drug for pediatric caudal analgesia and forms a cost-effective method by decreasing the requirement of systemic analgesics, morbidity and improving the life quality postoperatively.

Assessment of Intercostal Nerve Block Analgesia for Thoracic Surgery

The use of intercostal nerve block (ICNB) analgesia with local anesthesia is common in thoracic surgery. However, the benefits and safety of ICNB among adult patients undergoing surgery is unknown. To evaluate the analgesic benefits and safety of ICNB among adults undergoing thoracic surgery. A systematic search was performed in Ovid MEDLINE, Ovid Embase, Scopus, and the Cochrane Library databases using terms for ICNB and thoracic surgery (including thoracic surgery, thoracoscopy, thoracotomy, nerve block, intercostal nerves). The search and results were not limited by date, with the last search conducted on July 24, 2020. Selected studies were experimental or observational and included adult patients undergoing cardiothoracic surgery in which ICNB was administered with local anesthesia via single injection, continuous infusion, or a combination of both techniques in at least 1 group of patients. For comparison with ICNB, studies that examined systemic analgesia and different forms of regional analgesia (such as thoracic epidural analgesia [TEA], paravertebral block [PVB], and other techniques) were included. These criteria were applied independently by 2 authors, and discrepancies were resolved by consensus. A total of 694 records were selected for screening. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Data including patient characteristics, type of surgery, intervention analgesia, comparison analgesia, and primary and secondary outcomes were extracted independently by 3 authors. Synthesis was performed using a fixed-effects model. The coprimary outcomes were postoperative pain intensity (measured as the worst static or dynamic pain using a validated 10-point scale, with 0 indicating no pain and 10 indicating severe pain) and opioid consumption (measured in morphine milligram equivalents [MMEs]) at prespecified intervals (0-6 hours, 7-24 hours, 25-48 hours, 49-72 hours, and >72 hours). Clinically relevant analgesia was defined as a 1-point or greater difference in pain intensity score at any interval. Secondary outcomes included 30-day postoperative complications and pulmonary function. Of 694 records screened, 608 were excluded based on prespecified exclusion criteria. The remaining 86 full-text articles were assessed for eligibility, and 20 of those articles were excluded. All of the 66 remaining studies (5184 patients; mean [SD] age, 53.9 [10.2] years; approximately 59% men and 41% women) were included in the qualitative analysis, and 59 studies (3325 patients) that provided data for at least 1 outcome were included in the quantitative meta-analysis. Experimental studies had a high risk of bias in multiple domains, including allocation concealment, blinding of participants and personnel, and blinding of outcome assessors. Marked differences (eg, crossover studies, timing of the intervention [intraoperative vs postoperative], blinding, and type of control group) were observed in the design and implementation of studies. The use of ICNB vs systemic analgesia was associated with lower static pain (0-6 hours after surgery: mean score difference, -1.40 points [95% CI, -1.46 to -1.33 points]; 7-24 hours after surgery: mean score difference, -1.27 points [95% CI, -1.40 to -1.13 points]) and lower dynamic pain (0-6 hours after surgery: mean score difference, -1.66 points [95% CI, -1.90 to -1.41 points]; 7-24 hours after surgery: mean score difference, -1.43 points [95% CI, -1.70 to -1.17 points]). Intercostal nerve block analgesia was noninferior to TEA (mean score difference in worst dynamic panic at 7-24 hours after surgery: 0.79 points; 95% CI, 0.28-1.29 points) and marginally inferior to PVB (mean score difference in worst dynamic pain at 7-24 hours after surgery: 1.29 points; 95% CI, 1.16 to 1.41 points). The largest opioid-sparing effect of ICNB vs systemic analgesia occurred at 48 hours after surgery (mean difference, -10.97 MMEs; 95% CI, -12.92 to -9.02 MMEs). The use of ICNB was associated with higher MME values compared with TEA (eg, 48 hours after surgery: mean difference, 48.31 MMEs; 95% CI, 36.11-60.52 MMEs) and PVB (eg, 48 hours after surgery: mean difference, 3.87 MMEs; 95% CI, 2.59-5.15 MMEs). In this study, single-injection ICNB was associated with a reduction in pain during the first 24 hours after thoracic surgery and was clinically noninferior to TEA or PVB. Intercostal nerve block analgesia had opioid-sparing effects; however, TEA and PVB were associated with larger decreases in postoperative MMEs, suggesting that ICNB may be most beneficial for cases in which TEA and PVB are not indicated.

Persistent opioid use in cataract surgery pain management and the role of nonopioid alternatives.

Cataracts are a leading cause of preventable blindness globally. Although care varies between developing and industrialized countries, surgery is the single effective approach to treating cataracts. From the earliest documented primitive cataract removals to today's advanced techniques, cataract surgery has evolved dramatically. As surgical techniques have developed, so have approaches to surgical pain management. With current cataract surgical procedures and advanced technology, anesthesia and intraoperative pain management have shifted to topical/intracameral anesthetics, with or without low-dose systemic analgesia and anxiolysis. Despite this, pain and discomfort persist in some patients and are underappreciated in modern cataract surgery. Although pain management has progressed, opioids remain a mainstay intraoperatively and, to a lesser extent, postoperatively. This article discusses the evolution of pain management in cataract surgery, particularly the use of opioids and the associated risks as well as how ophthalmology can have a positive impact on the opioid crisis.