Systemic Multimodal Analgesia Research Articles

Battle of the Blocks: Which Pain Management Technique Triumphs in Gender-Affirming Bilateral Mastectomies?

Gender-affirming mastectomy, performed on transgender men and non-binary individuals, frequently leads to considerable postoperative pain. This pain can significantly affect both patient satisfaction and the overall recovery process. The study examines the efficacy of four analgesic techniques pectoral nerve (PECS) 2 block, erector spinae plane (ESP) block, thoracic wall local anesthesia infiltration (TWI), and systemic multimodal analgesia (SMA) in managing perioperative pain, with special consideration for the effects of chronic testosterone therapy on pain thresholds. A retrospective analysis was conducted on patients aged 18 - 45 who underwent gender-affirming bilateral mastectomies at a New York City community hospital. The study compared intraoperative and post-anesthesia care unit (PACU) opioid consumption, postoperative pain scores, the interval to first rescue analgesia, and total PACU duration among the four analgesic techniques. The study found significant differences in intraoperative and PACU opioid consumption across the groups, with the PECS 2 block group showing the least opioid requirement. The PACU morphine milligram equivalent (MME) consumption was highest in the SMA group. Postoperative pain scores were significantly lower in the PECS and ESP groups at earlier time points post-surgery. However, by postoperative day 2, pain scores did not significantly differ among the groups. Chronic testosterone therapy did not significantly impact intraoperative opioid requirements. The PECS 2 block is superior in reducing overall opioid consumption and providing effective postoperative pain control in gender-affirming mastectomies. The study underscores the importance of tailoring pain management strategies to the unique physiological responses of the transgender and non-binary community. Future research should focus on prospective designs, standardized block techniques, and the complex relationship between hormonal therapy and pain perception.

Prolonged blockade of the sciatic nerve in the treatment of pain in patients with chronic limb-threatening ischemia: prospective longitudinal clinical study

BACKGROUND: Systemic multimodal analgesia does not always relieve ischemic pain, and the side effects of its components may be intolerable in patients with comorbid and physically debilitation with chronic limb-threatening ischemia (CLTI). An alternative effective and safe method of pain relief for patients with CLTI is needed.
 OBJECTIVE: To evaluate the efficacy and safety of prolonged popliteal sciatic nerve block in patients with CLTI at the stages of treatment.
 MATERIALS AND METHODS: A prospective clinical study was performed in 31 patients with CLTI. Pain intensity was assessed by a numerical rating scale at the stages of treatment: (1) on admission, (2) presence of systemic multimodal analgesia (paracetamol, ketoprofen, tramadol, and morphine), (3) after catheter insertion to the popliteal sciatic nerve and prolonged nerve block with 0.5% ropivacaine solution, (4) after revascularization without anesthesia, (5) after revascularization in the presence of nerve blockade, and (6) upon discharge. Catheter insertion was performed under ultrasound control and neurostimulation. Pain intensity, frequency of insomnia, and forced lowering of the limb, need for narcotic analgesics, and patient satisfaction with treatment were assessed.
 RESULTS: Regional block before surgery provided better pain relief than systemic multimodal analgesia (p 0.001) and reduced the need for narcotic analgesics (p 0.001). Insomnia was observed less frequently with prolonged blockade of the sciatic nerve than with systemic multimodal analgesia (p 0.05), as well as forced lowering of the limb (p 0.05). Revascularization of the lower extremity has an analgesic effect; however, pain relief is required for most patients. Pain relief through sciatic nerve block at all stages of CLTI treatment, sleep normalization, and freedom from forced posture improved the quality of life and satisfaction with treatment. No complications associated with the regional blockade were recorded.
 CONCLUSION: Prolonged popliteal sciatic nerve block effectively relieves pain in patients with CLTI, is safe, and can be an alternative to systemic anesthesia.

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.

Preoperative Paravertebral Block and Chronic Pain after Breast Cancer Surgery: A Double-blind Randomized Trial.

The effectiveness of paravertebral block in preventing chronic pain after breast surgery remains controversial. The primary hypothesis of this study was that paravertebral block reduces the incidence of chronic pain 3 months after breast cancer surgery. In this prospective, multicenter, randomized, double-blind, parallel-group, placebo-controlled study, 380 women undergoing partial or complete mastectomy with or without lymph node dissection were randomized to receive preoperative paravertebral block with either 0.35 ml/kg 0.75% ropivacaine (paravertebral group) or saline (control group). Systemic multimodal analgesia was administered in both groups. The primary endpoint was the incidence of chronic pain with a visual analogue scale (VAS) score greater than or equal to 3 out of 10, 3 months after surgery. The secondary outcomes were acute pain, analgesic consumption, nausea and vomiting, chronic pain at 6 and 12 months, neuropathic pain, pain interference, anxiety, and depression. Overall, 178 patients received ropivacaine, and 174 received saline. At 3 months, chronic pain was reported in 93 of 178 (52.2%) and 83 of 174 (47.7%) patients in the paravertebral and control groups, respectively (odds ratio, 1.20 [95% CI, 0.79 to 1.82], P = 0.394). At 6 and 12 months, chronic pain occurred in 104 of 178 (58.4%) versus 79 of 174 (45.4%) and 105 of 178 (59.0%) versus 93 of 174 (53.4%) patients in the paravertebral and control groups, respectively. Greater acute postoperative pain was observed in the control group 0 to 2 h (area under the receiver operating characteristics curve at rest, 4.3 ± 2.8 vs. 2.9 ± 2.8 VAS score units × hours, P < 0.001) and when maximal in this interval (3.8 ± 2.1 vs. 2.5 ± 2.5, P < 0.001) but not during any other interval. Postoperative morphine use was 73% less in the paravertebral group (odds ratio, 0.272 [95% CI, 0.171 to 0.429]; P < 0.001). Paravertebral block did not reduce the incidence of chronic pain after breast surgery. Paravertebral block did result in less immediate postoperative pain, but there were no other significant differences in postoperative outcomes.

Adductor canal block with or without added magnesium sulfate following total knee arthroplasty: a multi-arm randomized controlled trial

PurposePostoperative analgesia following total knee arthroplasty (TKA) often includes intrathecal opioids, periarticular injection (PAI) of local anesthetic, systemic multimodal analgesia, and/or peripheral nerve blockade. The adductor canal block (ACB) provides analgesia without muscle weakness and magnesium sulphate (MgSO4) may extend its duration. The purpose of this trial was to compare the duration and quality of early post-TKA analgesia in patients receiving postoperative ACB (± MgSO4) in addition to standard care.MethodsElective TKA patients were randomized to: 1) sham ACB, 2) ropivacaine ACB, or 3) ropivacaine ACB with added MgSO4. All received spinal anesthesia with intrathecal morphine, intraoperative PAI, and multimodal systemic analgesia. Patients and assessors remained blinded to allocation. Anesthesiologists knew whether patients had received sham or ACB but were blinded to MgSO4. The primary outcome was time to first analgesic (via patient-controlled analgesia [PCA] with iv morphine) following ACB. Secondary outcomes were morphine consumption, side effects, visual analogue scale pain scores, satisfaction until 24 hr postoperatively, and length of stay.ResultsOf 130 patients, 121 were included. Nine were excluded post randomization: four were protocol violations, three did not meet inclusion criteria, and two had severe pain requiring open label blockade. There were no differences in the median [interquartile range] time to first PCA request: sham, 310 min [165–550]; ropivacaine ACB, 298 min [120–776]; and ropivacaine ACB with MgSO4, 270 min [113–780] (P = 0.96). Similarly, we detected no differences in resting pain, opioid consumption, length of stay, or associated side effects until 24 hr postoperatively.ConclusionWe found no analgesic benefit of a postoperative ACB, with or without added MgSO4, in TKA patients undergoing spinal anesthesia and receiving intrathecal morphine, an intraoperative PAI, and multimodal systemic analgesia.Trial registrationwww.clinicaltrials.gov (NCT02581683); registered 21 October 2015.

Continuous erector spinae plane block versus thoracic epidural analgesia in video-assisted thoracic surgery: a study protocol for a prospective randomized open label non-inferiority trial

BackgroundThoracic epidural analgesia is considered the gold standard for pain relief in video-assisted thoracoscopic surgery. This neuraxial technique blocks pain sensation by injecting a local anesthetic agent in the epidural space near the spinal cord to block spinal nerve roots. Recently, the erector spinae plane block has been introduced as a practical alternative to the thoracic epidural. This interfascial regional anesthesia technique interrupts pain sensation by injecting a local anesthetic agent in between the muscular layers of the thoracic wall. Several case series and three RCTs described it as an effective pain management technique in video-assisted thoracoscopic surgery (Scimia et al., Reg Anesth Pain Med 42:537, 2017; Adhikary et al., Indian J Anaesth 62:75–8, 2018; Kim, A randomized controlled trial comparing continuous erector spinae plane block with thoracic epidural analgesia for postoperative pain management in video-assisted thoracic surgery, n.d.; Yao et al., J Clin Anesth 63:109783, 2020; Ciftci et al., J Cardiothorac Vasc Anesth 34:444–9, 2020).The objective of this study is to test the hypothesis that a continuous erector spinae plane block incorporated into an opioid-based systemic multimodal analgesia regimen is non-inferior in terms of the quality of postoperative recovery compared to continuous thoracic epidural local anesthetic-opioid analgesia in patients undergoing elective unilateral video-assisted thoracoscopic surgery.MethodsThis is a prospective randomized open label non-inferiority trial. A total of 90 adult patients undergoing video-assisted thoracoscopic surgery will be randomized 1:1 to receive pain treatment with either (1) continuous erector spinae plane block plus intravenous patient-controlled analgesia with piritramide (study group) or (2) continuous thoracic epidural analgesia with a local anesthetic-opioid infusate (control group). All patients will receive additional systemic multimodal analgesia with paracetamol and non-steroidal anti-inflammatory drugs. The primary endpoint is the quality of recovery as measured by the Quality of Recovery-15 score. Secondary endpoints are postoperative pain as Numerical Rating Score scores, length of hospital stay, failure of analgesic technique, postoperative morphine-equivalent consumption, itching, nausea and vomiting, total operative time, complications related to surgery, perioperative hypotension, complications related to pain treatment, duration of bladder catheterization, and time of first assisted mobilization > 20 m and of mobilization to sitting in a chair.DiscussionThis randomized controlled trial aims to confirm whether continuous erector spinae plane block plus patient-controlled opioid analgesia can equal the analgesic effect of a thoracic epidural local anesthetic-opioid infusion in patients undergoing video-assisted thoracoscopic surgery.Trial registrationNetherlands Trial Register NL6433. Registered on 1 March 2018. This trial was prospectively registered.

Epidural analgesia in patients with thrombocytopenia. Clinical case

The article presents a clinical case of a 25-year-old patient with progressive diffuse B-cell lymphoma with lesions of the S2 nerve root, accompanied by pain syndrome that is not relieved by systemic multimodal analgesia using opioids, antiepileptic and non-steroidal anti-inflammatory drugs. Polyneuropathy, secondary immunodeficiency, thrombocytopenia grade IV refractory to platelet concentrate transfusion, Guillain-Barre syndrome, impaired the somatic status and intensified the pain syndrome. Local anesthetics epidural port was successfully implanted to improve quality of analgesia. As a result of prolonged epidural infusion of 0.2% ropivacaine with titration rate from 4 to 7 ml/hour depending on the severity of the pain syndrome, that significantly improved patients quality of life was achieved by reducing the intensity of pain and increasing duration of night sleep. In the early postoperative and long-term follow-up periods (14 days), there were no hemorrhagic and infectious complications associated with the use of the epidural port.

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

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

C-reactive protein as marker of post-operative analgesic quality after primary total knee arthroplasty.

To study the correlation between the level of C-reactive protein (CRP) and the severity of pain in the post-operative period with primary total knee arthroplasty and to conduct a comparative assessment of these indicators with various methods of pain relief. The primary hypothesis of the investigation was that post-operative CRP level is likely to be correlated with the severity of post-operative pain after total knee arthroplasty. The secondary points were the evaluation of CRP and pain syndrome in the groups, as well as the identification of the correlation between the level of CRP and the method of analgesia. Peri-operative levels of CRP and pain syndrome (10-point visual analogue scale) studied 160 patients with grade III gonarthrosis who have underwent primary total knee arthroplasty under conditions of subarachnoid anaesthesia in the period from years 2017 to 2019. Depending on the method of post-operative analgesia, patients were divided into five groups: group 1 had only systemic multimodal analgesia (SMA, n = 56), group 2 were treated with the epidural analgesia (EDA, n = 20), group 3 had local high-volume infiltration anaesthesia (LHVIA, n = 20), group 4 were getting LHVIA with a wound catheter (LHVIAc, n = 48), and group 5 had a single blockade of the femoral nerve (FNB, n = 16). A direct strong correlation was obtained between the level of CRP and the severity of pain syndrome in the knee joint during movement in four to six hours after surgery (n = 160, Kendall coefficient τ = 0.230, p = 0,000) and on the first post-operative day (n = 160, τ = 0.21, p = 0.001). The increase in CRP (the difference between pre-operative and post-operative CRP levels) also was positively correlated with the severity of pain in the post-operative period (n = 160, τ = 0.257, p = 0.000 and τ = 0.187, p = 0.001, respectively). CRP level significantly has increased in the post-operative period (p = 0,000). The lowest CRP indicators in the first post-operative day were recorded during the infiltrative anaesthesia (3rd and 4th groups);, the highest were during the administration of SMA group (1st group). The results confirm the correlation between the level of CRP and the severity of pain syndrome in the early post-operative period after total knee arthroplasty, its dependence on the method of analgesia, and allow to use it as a criterion for evaluating of the effectiveness of analgesia.

Postoperative Analgesia after Total Knee Arthroplasty: a Comparative Analysis of Current Treatment Techniques Effectiveness

The objective of the study was to evaluate the effectiveness and safety of high-volume local infiltration and epidural analgesic techniques after primary total knee arthroplasty versus standard systemic multimodal analgesia in the context of the postoperative analgesia protocols.Materials and Methods. A single-center randomized comparative study included 84 patients who, from august 2017 to august 2018, underwent a primary total knee arthroplasty. Depending on the method of postoperative analgesia, we randomized patients into 3 groups. Group A consisted of 32 patients who received intraoperative infiltration of periarticular tissues with 0.2% solution of ropivacaine in combination with adrenaline and subsequent bolus injection of a local anesthetic solution via a catheter inserted into the wound. Group B included patients who received epidural analgesia with a constant infusion of a 0.2% solution of ropivacaine (n = 28). In patients of group C, neither regional nor local analgesia techniques were used for postoperative analgesia (n = 24). All patients received standard systemic multimodal analgesia using nonsteroidal anti-inflammatory drugs and tramadol. The pain intensity was measured by vas when the patient was motionless, and during knee flexion (before surgery, after surgery on resolution of motor block and during the initial postoperative 24 h), side-effects were recorded.Results. The patients of Group C, during knee flexion in the postoperative period, reported the highest pain scores (6 (5; 8) during the initial postoperative 12 h and 6 (5; 6) during the initial postoperative 24 h). Severe pain, resistant to therapy and requiring the administration of narcotic analgesics (morphine 1.0 mg), was noted in 5 (15.6%) patients in group A and in 10 (41.6%) in group C, in contrast to patients of group B, where no pain was recorded in any patient, p = 0.056, p = 0.037 and p0.0001. Hypotension was observed only in group B in 6 (22%) patients. Intra-articular and other infectious complications among all patients were not recorded.Conclusion. High-volume local infiltration analgesia as a modality of postoperative analgesia is not inferior in the effectiveness to the epidural analgesia, does not require strict monitoring and is accompanied by a lower incidence of side-effects and complications, which can make it the procedure of choice in multimodal analgesia schemes for total knee arthroplasty.

Pain treatment in open liver resection, systemic multimodal analgesia vs epidural analgesia: A randomized controlled trial(data from Oslo-Comet study)

Pain treatment in open liver resection, systemic multimodal analgesia vs epidural analgesia: A randomized controlled trial(data from Oslo-Comet study)

Pain treatment in open liver resection, systemic multimodal analgesia vs epidural analgesia: a randomized controlled trial(data from Oslo-Comet study)

Background: Epidural analgesia (EA) is commonly provided to treat pain following major abdominal surgery. There is a discussion on the efficacy and safety of EA compared with other kinds of patient controlled analgesia. The aim of our study was to evaluate systemic multimodal analgesia including Intravenous Patient Controlled Analgesia (IV-PCA) vs EA in patients undergoing liver resection by open laparotomy. Our hypothesis is that IV-PCA is non-inferior to EA. Methods: Patients were randomized to ketobemidon based IV-PCA in combination with fixed doses of ketorolac, or EA. Both groups received a single dose of dexamethasone and paracetamol 1 g 4 qid. Primary outcome measure was overall pain intensity during the days 1-5 and scores on day 0 and 1 using numeric rating scale (NRS). Secondary endpoints included hospital length of stay, complications and side-effects. Results: A total of 143 patients were included. Overall pain intensity was similar between the groups and with mean NRS < 2,(p=0.31). On postoperative day 0 and 1 the EA group showed somewhat better pain relief, but thereafter IV-PCA was superior. Total opioid reduction and removal of the infusion pumps were achieved earlier in the IV-PCA group while opioid side-effects were more frequent in the EA group. Hospital stay was shorter in the IV-PCA group (median 74 vs 104h,p<0.001) Conclusion: Overall,IV-PCA demonstrated effective postoperative analgesia non-inferior to EA with a trend towards less side-effects and significantly shorter hospital length of stay.

SPINAL ANESTHESIA AS A PART OF ANAESTHESIOLOGIC SUPPORT IN FAST TRACK LAPAROSCOPIC COLON SURGERIES

The objective: to assess the efficiency of spinal analgesia as a part of anaesthesiologic support in laparoscopic colon surgeries within fast track programs. Subjects and methods: 60 patients who had laparoscopic colon surgeries within fast track programs were divided into 2 groups. In Group 1 ( n = 30), peri-operative analgesia was provided through intrathecal administration of 10.0–12.5 mg of bupivacaine and 200 mcg of morphine. In Group 2 ( n = 30), the systemic multi-modal analgesia was provided (nonsteroidal anti-inflammatory drugs, opioids). Results. The maximum intensity of pain at rest within 24 hours after surgery was assessed as 2 (2−3) scores as per the digital rating scale in Group 1 and 5 (4−6) scores in Group 2 ( p < 0.0001). The intensity of pain by the first verticalisation made 3 (2−5) scores in Group 1 and 6 (6−7) scores in Group 2 ( p < 0.0001). Intra-operative consumption of phentanyl, frequency of post-operative nausea, vomit and need for extra pain relief were much lower in Group 1. Conclusion. Intrathecal administration of 10.0−12.5 mg of bupivacaine and 200 mcg of morphine as a part of anaesthesiologic support in laparoscopic colon surgeries provides effective peri-operative analgesia and promotes the implementation of fast track programs in this type of interventions.

The addition of epidural local anesthetic to systemic multimodal analgesia following lumbar spinal fusion: a randomized controlled trial

This randomized trial aimed to evaluate the effects of adding continuous epidural analgesia with a bupivacaine and hydromorphone solution to systemic multimodal analgesia following one- or two-level lumbar spinal fusion. Thirty-nine patients undergoing lumbar spinal fusion, stratified for sex and one- or two-level fusion, were randomized to receive a continuous postoperative epidural infusion of either 0.1% bupivacaine with 15μg·mL(-1) hydromorphone (LA group) or 0.9% saline (NS group) at 6mL·hr(-1) for 48hr through an epidural catheter placed intraoperatively. All patients received a standardized postoperative multimodal analgesia regimen. Patients, healthcare providers, and research staff were blinded. The primary outcome measure was cumulative opioid consumption (oral morphine equivalent) during the first 48hr postoperatively. The mean (SD) cumulative opioid consumption 48hours postoperatively was 249.3 (143.3) mg in the NS group and 184.7 (208.1)mg in the LA group (mean difference 64.6mg; 95% confidence interval -54.3 to 183.5; P=0.27). There were no adverse events in either group. Continuous epidural infusion combined with systemic multimodal analgesia resulted in a mean reduction in 48-hr cumulative opioid consumption of 64.6mg (95% confidence interval -54.3 to 183.5) following one- or two-level lumbar spinal fusion. This estimate of effect is imprecise, and the routine use of continuous epidural analgesia in this surgical population is not yet warranted. This trial was registered at www.clinicaltrials.gov : NCT00644111.

Recovery after orthopedic surgery

Ambulatory surgery continues to expand in scope and volume. Part of this development is supported by improvements in anesthesia care, especially in the realm of postoperative analgesia, which is often outlasted by the pain. The purpose of this review is to outline methods of increasing the duration of postoperative pain control. There have been recent advances in the use of perineural catheters for the performance of continuous nerve blocks, the use of adjuvants to extend the duration of single dose blocks, methods to improve the technical performance of blocks, systemic multimodal analgesia, and novel or experimental agents. The ideas and findings described in this review are taken from the most recent literature and show promise of aiding in the continued improvement of patient care through their dissemination and refinement by further research. Of the modalities reviewed in current use, the continuous perineural catheter combined with systemic multimodal analgesics represents the best combination of safety and efficacy to provide prolonged postoperative analgesia.

Interpleural analgesia following hepatic resection

We read with interest the publication by Weinberg et al. [1] comparing the use of interpleural analgesia and patient controlled analgesia following hepatic resection. As the authors state, the use of a levobupivacaine infusion using an interpleural catheter has been previously described for postoperative analgesia, but not in the context of liver resection. Levobupivacaine is metabolised in the liver by CYP3A4 isoform and CYP1A2 isoform [2]. Although the metabolism of levobupivacaine may not be significantly affected following cholecystectomy [3] or renal surgery [4], a similar assumption cannot be made about levobupivacaine following hepatic resection. Hepatic metabolism of drugs may be affected by two mechanisms following hepatic resection. Although it is relatively safe to excise up to 70% of healthy liver parenchyma during hepatectomy [5], the capacity to manage the potential increased workload of metabolising levobupivacaine may be substantially impaired. Furthermore, the use of a Pringle manoeuvre to reduce hepatic venous blood loss renders the liver transiently ischaemic [6], which may additionally impair postoperative metabolic function. We believe confirmation of safe postoperative levobupivacaine serum levels needs to be demonstrated before interpleural techniques can be recommended. We also question the statement by the authors that ‘derangements in coagulation after hepatic resection have favoured systemic multimodal analgesia in preference to neuraxial techniques as the preferred method for effective delivery of postoperative analgesia in many institutions’. Numerous publications have confirmed the safety of peri-operative neuraxial blockade [7, 8]. Not only does this method provide excellent postoperative analgesia, it also contributes significantly to the intra-operative central venous pressure manipulation that is widely used to reduce blood loss during hepatic resection [9]. Using this technique a median blood loss of 100 ml can readily be achieved, avoiding postoperative coagulopathy and reducing the frequency of blood transfusion [10]. The avoidance of blood transfusion has been demonstrated to reduce the incidence of peri-operative liver impairment, which probably translates to a significant increase in long-term overall survival [5]. No external funding and no competing interests declared. Previously posted at the Anaesthesia Correspondence website: http://www.anaesthesiacorrespondence.com.

Risk factors for postoperative anxiety in adults.

We identified risk factors for postoperative anxiety and quantified their effect on 712 adults between 18 and 60 years of age (ASA I-III physical status) undergoing elective surgery under general anaesthesia, neural blockade or both. The measuring instruments were a structured questionnaire, a pain visual analogue scale, the McGill Pain Questionnaire, the State-Trait Anxiety Inventory, the Montgomery-Asberg Depression Rating Scale, a Self-Reporting Questionnaire-20, and a Self-Perception of Future Questionnaire. Multivariate conditional regression modelling taking into account the hierarchical relationship between risk factors revealed that postoperative anxiety was associated with ASA status III (OR = 1.48), history of smoking (1.62), moderate to intense postoperative pain (OR = 2.62) and high pain rating index (OR = 2.35), minor psychiatric disorders (OR = 1.87), pre-operative state-anxiety (OR = 2.65), and negative future perception (OR = 2.20). Neural block anaesthesia (OR = 0.72), systemic multimodal analgesia (OR = 0.62) and neuroaxial opioids with or without local anaesthesia (OR = 0.63) were found to be protective factors against postoperative anxiety.

Urinary tract infection in patients with rheumatoid arthritis.

Urinary tract infection in patients with rheumatoid arthritis.