Total Morphine Research Articles

Clinical Decision Support to Increase Emergency Department Naloxone Coprescribing: Implementation Report

Abstract Background Coprescribing naloxone with opioid analgesics is a Centers for Disease Control and Prevention (CDC) best practice to mitigate the risk of fatal opioid overdose, yet coprescription by emergency medicine clinicians is rare, occurring less than 5% of the time it is indicated. Clinical decision support (CDS) has been associated with increased naloxone prescribing; however, key CDS design characteristics and pragmatic outcome measures necessary to understand replicability and effectiveness have not been reported. Objective This study aimed to rigorously evaluate and quantify the impact of CDS designed to improve emergency department (ED) naloxone coprescribing. We hypothesized CDS would increase naloxone coprescribing and the number of naloxone prescriptions filled by patients discharged from EDs in a large health care system. Methods Following user-centered design principles, we designed and implemented a fully automated, interruptive, electronic health record–based CDS to nudge clinicians to coprescribe naloxone with high-risk opioid prescriptions. “High-risk” opioid prescriptions were defined as any opioid analgesic prescription ≥90 total morphine milligram equivalents per day or for patients with a prior diagnosis of opioid use disorder or opioid overdose. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used to evaluate pragmatic CDS outcomes of reach, effectiveness, adoption, implementation, and maintenance. Effectiveness was the primary outcome of interest and was assessed by (1) constructing a Bayesian structural time-series model of the number of ED visits with naloxone coprescriptions before and after CDS implementation and (2) calculating the percentage of naloxone prescriptions associated with CDS that were filled at an outpatient pharmacy. Mann-Kendall tests were used to evaluate longitudinal trends in CDS adoption. All outcomes were analyzed in R (version 4.2.2; R Core Team). Implementation (Results) Between November 2019 and July 2023, there were 1,994,994 ED visits. CDS reached clinicians in 0.83% (16,566/1,994,994) of all visits and 15.99% (16,566/103,606) of ED visits where an opioid was prescribed at discharge. Clinicians adopted CDS, coprescribing naloxone in 34.36% (6613/19,246) of alerts. CDS was effective, increasing naloxone coprescribing from baseline by 18.1 (95% CI 17.9‐18.3) coprescriptions per week or 2,327% (95% CI 3390‐3490). Patients filled 43.80% (1989/4541) of naloxone coprescriptions. The CDS was implemented simultaneously at every ED and no adaptations were made to CDS postimplementation. CDS was maintained beyond the study period and maintained its effect, with adoption increasing over time (τ=0.454; P<.001). Conclusions Our findings advance the evidence that electronic health record–based CDS increases the number of naloxone coprescriptions and improves the distribution of naloxone. Our time series analysis controls for secular trends and strongly suggests that minimally interruptive CDS significantly improves process outcomes.

Lidocaine Patches After Cesarean Sections: A Randomized Control Trial

ObjectivesLidocaine patches are a common topical analgesic therapy but have not been thoroughly investigated in the surgical or obstetric literature. We sought to investigate the impact of adding topical lidocaine patches to routine post-cesarean pain management on patients’ post-cesarean pain scores and opioid use. Study DesignThis is a prospective randomized subject blinded controlled trial of patients undergoing cesarean delivery at a single institution. Individuals were excluded if they had three or more cesarean sections, abdominoplasty, history of abdominal hernia repair with mesh, active polysubstance use, or history of opiate use disorder with current medication-assisted treatment. Patients were randomized via a 1:1 randomization scheme to a placebo patch or lidocaine patch. Baseline maternal characteristics were collected. The primary outcome was mean visual analog pain scores (0-10). Our secondary outcome was total morphine equivalents used over the post-operative hospital stay. Pre- and post-study surveys were performed to evaluate subject's prior analgesia use (including opioids) and patient experience in the study. ResultsA total of 100 patients were randomized and 93 had complete data for analysis (46 placebo group, 47 treatment group). Groups had similar baseline characteristics (age, BMI, ethnicity, surgical time, and estimated blood loss). Mean maximum post-operative pain score by visual analog scale did not differ between placebo or lidocaine patch groups on post-operative day 1 (p=0.3), day 2 (p=0.9), day 3 (p=0.07), or day 4 (p=0.09). Mean post-operative pain score by visual analog scale did not differ between placebo or lidocaine patch groups on post-operative day 1 (p=0.7), day 2 (p=0.6), day 3 (p=0.2), or day 4 (p=0.5). In the post-study survey, 0% of the respondents in the lidocaine patch group reported disruption of their care and 63% reported desired use of lidocaine patch in the future. ConclusionsThe addition of lidocaine patches did not significantly decrease the maximum or average post-operative pain scores via visual analog scale after cesarean sections. More research is needed into non-opioid pain management strategies in the post-operative period in obstetric care.

The role of prescribed controlled substance acquisition as potential triggers of opioid overdose: A case-crossover study

Background: The role of prescribed opioids and benzodiazepines as risk factors for opioid overdose are well established, however, their role as potential ‘triggers’ of opioid overdose has not been formally investigated. Objective: The objective of this study was to evaluate the temporal relationship between controlled substance acquisition and opioid overdose utilizing a case-crossover design. Methods: This study utilized Arkansas statewide data between 2014 and 2020. Prescription Drug Monitoring Program (PDMP) data were used to assess controlled substance acquisition and fatal and non-fatal opioid overdose were assessed using linked death certificate, inpatient discharge, and emergency department (ED) data. All persons residing in Arkansas who experienced an opioid overdose or had ≥ 1 Arkansas PDMP prescription fill(s) were included. Controlled substance characteristics were described in the 7 days prior to overdose and compared to the controlled substance characteristics in 11 weekly (7-day) control windows prior to overdose. Binary controlled substance variables indicating presence or absence of: any controlled substance, opioid, benzodiazepine, stimulant, sedative, carisoprodol, opioid and benzodiazepine, and opioid and benzodiazepine and carisoprodol were created. Additionally, total morphine milliequivalents were calculated for each time window. Conditional logistic regression models were estimated and adjusted odds ratios for each controlled substance characteristic after accounting for other controlled substance, and prior overdose, and clinical characteristics derived from ED and inpatient data are reported. Results: A total of 2,818,135 individuals with ≥1 Arkansas PDMP record(s) (45.10 % male; 39.94 mean age) were included, of which 28,670 (1.02 %) experienced ≥1 opioid overdose. There was a significant association between opioid overdose and the acquisition of a controlled substance (OR=1.785; p < 0.001), opioid (OR=1.992; p < 0.001), benzodiazepine (OR=1.379; p < 0.001), carisoprodol (OR=1.744; p < 0.001), opioid and benzodiazepine (OR=2.203; p < 0.001), and opioid and benzodiazepine and carisoprodol (OR=2.503; p < 0.001), in the 7 days prior to an opioid overdose event. Conclusion: Controlled substance prescription acquisition, particularly opioids in combination with carisoprodol and/or benzodiazepines, are potential triggers of opioid overdose.

Comparison of combined deep and superficial serratus anterior block with thoracic paravertebral block for postoperative pain in patients undergoing video-assisted thoracoscopic surgery.

Thoracic paravertebral block (TPVB) is a well-established procedure for the management of postoperative pain in patients undergoing video-assisted thoracic surgery (VATS). In recent years, there have been studies suggesting that fascial plane blocks may be an alternative to TPVB. The objective of our study was to determine the efficacy of combined deep and superficial serratus anterior block (C-SAPB) as an alternative to TPVB in the management of postoperative analgesia in VATS. The patients were divided into two groups: the TPVB group and the C-SAPB group. Both groups were administered the same dose of local anesthetics. Multimodal analgesia was achieved for the groups. The primary outcome measure was visual analog scale (VAS) pain scores recorded within the first 48 h of the postoperative period in each group. The secondary outcomes were analgesic requirement, rescue analgesics, complications rate, and postoperative patient satisfaction. Thirty patients with C-SAPB and 30 patients with TPVB were analysed. VAS rest and VAS coughing scores were similar between the groups (p > 0.05). Demographic and side effect conditions, total morphine use, additional analgesic needs, vital parameters, block procedure time, and patient satisfaction were also similar between the groups (p > 0.05). Additionally, although block application times were comparable, the time was slightly shorter in C-SAPB. Similar analgesic efficacy was observed between C-SAPB and TPVB. TPVB maintains its place among the first choices in VATS. The efficacy of C-SAPB is comparable to that of TPVB. While the duration of C-SAPB application is not a significant factor, the brief nature of the procedure and its straightforward administration suggest that it may be an effective method.

Intraoperative Factors Affecting Pain Management and Postoperative Narcotic Use in Cranial Vault Remodeling: A Retrospective Review

Perioperative pain control in open cranial vault reconstruction (CVR) poses significant challenges. Narcotic use may confound signs of neurological deterioration and cause medication-induced complications. Previous studies have shown improved health outcomes in CVR with reduced narcotic use. The purpose of this study was to investigate the relationship between modifiable intraoperative factors on postoperative narcotic use. A retrospective cohort study was performed on 237 patients with craniosynostosis who presented to a tertiary pediatric hospital over a 10-year period for open CVR. There was a statistically significant relationship between total fluid volume infused intraoperatively (mL/kg) and total morphine equivalents (MEs, mL/kg) given throughout hospitalization (P&lt; 0.001). Longer operative times were associated with greater total hospitalization ME (P ≤ 0.006) and total intraoperative blood products transfused (P ≤ 0.001). Patients who received drains were given significantly higher total hospitalization ME compared with those who did not (P&lt; 0.001). Patients who received postoperative nonsteroidal anti-inflammatory drugs required significantly fewer total ME compared with children who did not (P&lt; 0.005) and patients who received intraoperative tranexamic acid were less likely to require postoperative blood transfusion (P&lt; 0.001). Postoperative nonsteroidal anti-inflammatory drug use is associated with decreased narcotic requirements during the immediate postoperative period whereas increased fluid requirements intraoperatively, longer operative durations, and drain placement are associated with higher narcotic use. Modifying intraoperative factors like these may lead to decreased postoperative pain, thus limiting narcotic use for patients, and improving overall outcomes.

Efficacy and safety of 4-hydroxy-2-methyl-N-(5-methyl-2-thiazolyl)-2H-1, 2-benzothiazin-3-carboxamide 1,1-dioxide, a rapid-acting meloxicam formulation, for analgesia after orthopaedic surgery under general anaesthesia: a randomized controlled trial.

Postoperative pain management is one of the most challenging treatments after orthopaedic surgery, and improved medical treatment options are urgently needed. This study aimed to evaluate the efficacy and safety of 4-hydroxy-2-methyl-N-(5-methyl-2-thiazolyl)-2H-1, 2-benzothiazin-3-carboxamide 1,1-dioxide (QP001) for moderate to severe pain following orthopaedic surgery. This randomized clinical trial enlisted patients experiencing moderate to severe pain following orthopaedic surgery in 20 hospitals in China. We allocated randomly 132 participants to receive 30mg QP001 and 66 participants to receive 0.9% saline pre-surgery. The primary efficacy outcome was the total morphine consumption within 24h. The total morphine consumption in the QP001 group, versus placebo group, was significantly lower over the following 24h [12.53 (10.51) vs. 26.13 (13.98), P < 0.001]. The total morphine consumption in the QP001 group, versus placebo group, was also significantly decreased over the following 48h (P < 0.001). The QP001 group, versus placebo, showed a significant decrease in the effective pressing times of the analgesic pump, morphine relief analgesia ratio over the 24h and 48h periods and the area under the curve for pain intensity-time as well as a significant prolonged in the time of first pressing the analgesic pump and the time of first morphine rescue analgesia (P < 0.001). The QP001 groups, versus placebo, show no significant difference in adverse events, but the incidence of adverse drug reactions decreased (59.4% vs. 75.8%, P = 0.023). QP001 provides analgesia and reduces opioid consumption in patients with moderate to severe pain after orthopaedic surgery, with a favorable safety profile.

Enhancing analgesia in acute renal colic pain: a randomized controlled trial of gabapentin adjunct to ketorolac-based regimen.

Renal colic is characterized by severe pain that is highly disabling. Gabapentin, an antiepileptic medication, is often recommended as a first-line therapy for neuropathic pain. However, its effectiveness in managing somatic pain, which is defined as the result of activity by pain receptors in the deep tissues, such as renal colic pain, is not as well-established. A phase 3 randomized clinical trial was conducted to evaluate the adjuvant analgesic effects of gabapentin on acute renal colic pain. Eligible patients participated in the study via random allocation to the control or gabapentin groups using the block randomization method. All patients received a shared regimen of ketorolac and rescue morphine as the conventional analgesic treatment for renal colic pain. Gabapentin was added as an adjuvant analgesic for the gabapentin group. A total of 63 individuals with an average age of 41.35 ± 13.08, were enrolled and completed the study. At the time of admission, there were no significant differences between the baseline characteristics of two groups, with exception of weight. The gabapentin group showed a significantly higher percentage of patients with pain severity of less than 5 after 60 and 90 min, as well as a significantly lower percentage of morphine rescue requirement and total morphine intake (mg) and mg/kg. In cases of acute renal colic, gabapentin significantly decreases both the amount of morphine required and the degree of pain, indicating that it may be a useful adjutant to standard analgesic regimens. Treatment regimens that include gabapentin may help individuals manage their pain and become less reliant on opioids. https://irct.behdasht.gov.ir/trial/56066, identifier: IRCT20200322046833N2.

Examining Disparities in Regional Anesthesia Utilization, Opioid Prescriptions, and Pain Scores Among Patients Who Received Primary or Revision Total Knee Arthroplasty at a Veterans Affairs Medical Center: A Retrospective Cohort Study.

Total knee arthroplasty (TKA) is one of the most performed surgical operations in the United States. Managing postoperative pain after TKA is of vital importance, as it is positively associated with outcome measures related to recovery of function and quality of life. Two commonly used methods to control postoperative pain are regional anesthesia (RA), consisting of a single or a combination of peripheral nerve and epidural blocks, and pain medication, such as opioids. Our retrospective analysis sought to better understand whether revision versus primary TKA impacted previously discovered disparities in perioperative pain management and use of RA at the Atlanta Veterans Affairs Health Care System (AVAHCS). Before data collection, we hypothesized that revision TKA would have a higher proportion of Black and older patients and that revision TKA patients would have lower postoperative pain scores. This was a retrospective analysis of AVAHCS patients who underwent elective unilateral primary or revision TKA surgery between 2014 and 2020. After application of our exclusion criteria, data from 562 patients were analyzed. Data collected included demographics information, type of RA used, and pain scores. Statistical analyses included chi-square test, t-tests, multiple logistic regression, and multiple linear regression, as appropriate to the outcomes of interest. Revision TKA patients were more likely to be Black (P = .018) and younger (P = .023 for <50 years of age group, P = .006 for 50 to 64 years of age compared to the >65 years group). Black patients, compared to White patients, had significantly higher pain scores at baseline (P = .0086) and at 24 hours postsurgery (P = .0037). Older patients (≥50 years old) had significantly higher baseline pain scores (P = .021 for the 50 to 64 years group, P < .01 for the >65 years group) and significantly lower first postanesthesia care unit pain scores (P < .05). Black race (P < .01) and age > 65 years (P < .01) were associated with a significant decrease in total oral morphine equivalents (OME) prescribed at discharge. None of the predictor variables-race, age, type of surgery (primary versus revision), baseline, and first postanesthesia care unit pain scores-were significantly associated with the use of RA in our cohort. Sociodemographic disparities in pain management have been reported in all healthcare systems, including the VAHCS. This moderately sized retrospective study, conducted at a single veterans affairs site, yielded several noteworthy findings. One finding of particular interest was that, despite Black patients reporting higher baseline and 24-hour postoperative pain scores, they were prescribed fewer opioids at discharge. Our results highlight the presence of clinically significant disparities in perioperative TKA pain management, emphasizing the need for continuous investigation and focused mitigation efforts among Veterans.

Opioid Prescribing Trends Among Workers' Compensation Patients Undergoing Foot and Ankle Surgery.

The purpose of this study was to evaluate opioid usage and prescribing trends among workers' compensation (WC) patients who underwent foot or ankle operative procedures compared with a control group. A retrospective review was conducted for WC and non-WC patients who underwent foot or ankle procedures in a single academic orthopaedic surgery practice. Outcome measures were total morphine milligram equivalents (MME) and number of opioid prescriptions. A total of 118 patients were identified, including 51 patients in the WC group and 67 in the non-WC group. After index surgery, 67% (34 of 51) of WC patients had 2 or more additional opioid prescriptions compared to 39% (26 of 67) of non-WC patients (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.4-6.7; P = .003). Collectively, there were greater prescriptions of oxycodone MME (P = .002) and hydrocodone MME (P = .07) in the WC cohort. Workers' compensation patients seem to be prescribed and consume opioids at a higher rate postoperatively. It is important for treating physicians to be aware of these trends, and discussions with patients regarding expected opioid use when planning surgical intervention may be beneficial. Physicians may need to set expectations preoperatively and suggest there are limits on the amount of opioids that can safely be prescribed. Level III, Retrospective cohort study, Prognostic.

Clavipectoral fascial plane block versus superficial cervical plexus block for fracture clavicle surgery: a randomized clinical trial

Background &amp; objective: Both, the clavipectoral fascial plane block as well as superficial cervical plane block have been utilized as a regional anesthesia technique for clavicular fracture surgery. We compared the efficacy and safety of clavipectoral plane block with superficial cervical plexus block for intraoperative and postoperative pain relief in clavicular fracture surgery under general anesthesia (GA). Methodology: This double-blinded randomized controlled trial included 84 patients, aged between 21 and 60 y, ASA classification I and II, with fracture clavicle, either isolated or part of other trauma, undergoing fracture clavicle fixation. The patients were divided into two groups. The first group received a clavipectoral fascial plane block and the other received a superficial cervical plane block. The visual analogue scale (VAS) scores were recorded as primary outcome, while the patients’ hemodynamics, time to first rescue analgesic, and total morphine consumption were the secondary outcomes at post-anesthesia care unit (PACU) then every 2 h in the ward till 8 h. Results: Compared to the superficial cervical plexus block the clavipectoral plane block was superior in analgesia and more effective during surgical dissection and intraoperative manipulations with a clinically and statistically significant difference all the time from PACU to 8 h postoperatively. The heart rate and arterial blood pressure were much more stable in the clavipectoral group. Also, time to first rescue analgesic was more in the clavipectoral group than in the superficial cervical block. Total morphine consumption was significantly less in the clavipectoral group than in the superficial cervical group. Conclusion: Clavipectoral plane bock is superior to superficial cervical block in fracture clavicle surgeries regarding efficacy and safety. Postoperative pain, measured by VAS, was less with clavipectoral plane block, with more hemodynamic stability and less opioid consumption postoperatively. Abbreviations: PACU - post-anesthesia care unit; CFP - Clavipectoral fascial plane; SCP - Superficial cervical plexus Keywords: Clavipectoral Plane Bock; Fracture Clavicle; Pain, Postoperative; Superficial Cervical Plexus Block Citation: Sayed AG, Abdelmoez WA, Ali OM, Elshafeey AE. Clavipectoral fascial plane block versus superficial cervical plexus block for fracture clavicle surgery: a randomized clinical trial. Anaesth. pain intensive care 2024;28(5):945−950; DOI: 10.35975/apic.v28i5.2573 Received: April 03, 2024; Reviewed: May 13, 2024; Accepted: July 02, 2024

Ultrasound-guided transversalis fascia plane block or transversus abdominis plane block for recovery after caesarean section: A randomised clinical trial.

Caesarean section is a widely performed surgical procedure that often results in moderate-to-severe postoperative pain. If left untreated, this pain can lead to short-term and long-term consequences. Transversalis fascia plane (TFP) block and transversus abdominis plane (TAP) block are among the regional anaesthesia techniques employed for managing pain after a caesarean section. We aimed to compare the impact of these two blocks on the quality of recovery in patients undergoing elective caesarean section under spinal anaesthesia. A single-centre, double-blind, randomised trial. Operating room, postanaesthesia recovery unit, and ward in a tertiary hospital. Ninety-three patients (ASA 2 to 3) were recruited. After exclusion, 79 patients were included in the final analysis: 40 in the TFP block group and 39 in the TAP block group. After surgery, participants received either TFP block (20 ml 0.25% bupivacaine for each side) or TAP block (20 ml 0.25% bupivacaine for each side). The primary outcome was the difference in obstetric quality of recovery 11-Turkish (ObsQoR-11T) scores between groups. Secondary outcomes included pain scores, opioid consumption and incidence of opioid-related complications. The mean ObsQoR-11T score was higher in the TFP block group compared with the TAP block group (97.13 ± 6.67 points vs. 87.10 ± 9.84 points, respectively; P < 0.001). The pain scores in the TFP block group were slightly lower between postoperative 4 and 24 h. The mean total morphine consumption was 15.08 ± 2.21 mg in the TFP block group and 22.21 ± 3.04 mg in the TAP block group ( P < 0.001). More patients required rescue analgesia between 4 and 8 h in the TAP block group [2.00 (5.00%) vs. 9.00 (23.08%), P = 0.02]. No significant differences were observed between groups in terms of opioid-related side effects. TFP block used for analgesic purposes yielded a better quality recovery period than TAP block and also reduced opioid consumption. Clinicaltrials.gov (NCT05999981). http://links.lww.com/EJA/B6 .

A pilot study of precision treatment for patients with lung cancer pain by Longteng Tongluo recipe using serum genomics.

To investigate the efficacy of Longteng Tongluo recipe (, LTTL) combined with three-step analgesia for the treatment of lung cancer pain, and the changes in serum miRNA expressions before- and after treatment with LTTL and its correlation with lung cancer pain. The possible mechanism underlying LTTL effects on the treatment of lung cancer pain was conducted. The pilot study was conducted at the oncology ward of the Yueyang Hospital and the Longhua Hospital between March 2018 and October 2019. A prospective, single-blind, placebo controlled, randomized clinical trial of LTTL or placebo combined with three-step analgesia treatments were administered to 24 cancer pain patients diagnosed with lung cancer. Analgesic efficacy was investigated as the primary outcome. Equivalent morphine consumption and numerical rating scale (NRS) scores were used as the secondary outcome. In the present study, we utilized deep sequencing techniques to compare the differential miRNA expressions in serum samples obtained from two groups: the lung cancer pain treatment group (LTTL + three-step analgesia) and the control group (placebo + three-step analgesia). Next, we employed the target prediction database to investigate the target genes for differential miRNA expressions and Gene Ontology (GO) analysis along with Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis to examine the roles and the major biochemical and signaling pathways related to the differentially expressed target genes, respectively. LTTL treatment significantly reduces the NRS score (P = 0.021) as compared to those before treatment, along with significant reductions in the total morphine equivalent consumption (P = 0.007) and the average daily equivalent morphine consumption (P = 0.003) as opposed to the control group. The expressions of 31 miRNAs differed considerably between the two groups of patients (≥ 2 times up-modulated or down-regulated between these groups, P<0.05). For instance, the miRNAs expression levels for patients before treatment (has-miR-2110 and has-miR-7d-3p) were significantly enhanced as compared to the healthy people, after LTTL treatment, the expressions of miR-2110 and miR-7d-3p in patients with lung cancer pain reduced significantly. Studies show that the above two miRNAs were significantly associated with lung cancer pain, which could mediate lung cancer pain. Furthermore, we identified 355 genes as potential targets of the 31 differentially expressed miRNAs. Pathway enrichment analyses using KEGG and GO analysis indicated that these target genes may play a crucial role in the development and modulation of lung cancer pain. LTTL demonstrated a discernible impact on alleviating lung cancer pain and its mechanism of action may be related to the downregulation of has-miR-2110 and has-miR-7d-3p expressions. This pilot study provides support for further exploration of LTTL in patients with lung cancer pain.

Does postoperative low-dose duloxetine provide analgesic effect and lower morphine consumption after primary total knee arthroplasty? A prospective, double-blind, randomized controlled trial.

Duloxetine as an adjunct analgesic has shown effective results in trials of patients undergoing total knee arthroplasty (TKA). However, the regimen has not been standardized. We, therefore, evaluated the analgesic efficacy of low-dose duloxetine after TKA. We conducted a double-blind, randomized controlled trial of patients undergoing unilateral primary TKA, comparing 30 mg/d of duloxetine for 6 weeks as an additive medication for pain control to modern multimodal analgesia after TKA. The primary outcome measure was a visual analogue scale (VAS) for pain at rest, during walking, and at night at 24 h, 72 h, 2 weeks, 6 weeks, and 12 weeks after the operation. Secondary outcomes were morphine consumption, adverse events, and functional outcomes: Oxford Knee Score, Knee injury and Osteoarthritis Outcome Score (KOOS). Mean VAS for pain at rest, during walking, and at night at 24 h, 72 h, 2 weeks, 6 weeks, and 12 weeks showed no significant differences between the two groups, except a significantly lower mean VAS at night at 2 weeks in the duloxetine group. Mean total morphine consumption (0-72 h) was 33% less in the duloxetine group (6.8 ± 5.7 vs. 10.2 ± 7.3 mg, p = 0.04). There were no significant differences in adverse events and functional outcomes except better KOOS symptoms at 6 and 12 weeks in the duloxetine group. Low-dose duloxetine could reduce postoperative morphine consumption and improve KOOS symptoms at 6 and 12 weeks with good tolerability. However, it did not significantly reduce pain at rest or during walking. Low-dose duloxetine can be considered an addition to contemporary multimodal pain management after TKA. Therapeutic Level I.

Liposomal Bupivacaine Does Not Decrease Postoperative Pain in Patients with Intracapsular Femoral Neck Fracture Treated with Hemiarthroplasty: HEAT-A Randomized, Controlled Trial.

Liposomal bupivacaine (LB) is a long-lasting local anesthetic agent that was developed for use in the surgical setting to help manage postoperative pain. The objective of this study was to evaluate the effect of LB on postoperative pain, function, and overall hospital course in patients with intracapsular hip fractures who were treated with hip hemiarthroplasty. This was a single-center, randomized prospective double-blinded study of 50 patients with an isolated intracapsular femoral neck fracture who were treated with hip hemiarthroplasty from 2018 to 2022. The study group consisted of 25 patients who were treated with intraoperative LB and bupivacaine hydrochloride injections, while the control group consisted of 25 patients who were treated with intraoperative bupivacaine hydrochloride injections only. Primary outcomes were a visual analog scale (VAS) score for pain, total morphine milligram equivalents (MME), delirium, and time to ambulation with physical therapy. No significant differences between the study and control groups were found in any of the outcomes measured. Most notably, there were no differences in the average postoperative pain score (VAS, 2.26 versus 2.7; p = 0.34), total MME used postoperatively (11.73 versus 9.98 MME; p = 0.71), and postoperative day of discharge (4.00 versus 3.88 days; p = 0.82). The results of our study suggest that use of LB is not associated with substantially improved postoperative pain or function or with a shorter hospital course following hip hemiarthroplasty for a femoral neck fracture. Given the higher cost of LB compared with standard postoperative pain modalities, it is worth questioning its use in the setting of geriatric hip fractures. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Intrathecal Drug Delivery System in Prepontine Cistern for Patients with Intractable Craniofacial Cancer Pain: A Multicenter Retrospective Study.

Patients with craniofacial cancer frequently suffer from severe pain. The traditional intrathecal, oral, or intravenous analgesics could only provide insufficient pain relief with many side effects. Thus, a more effective analgesia approach is required. This study aimed to investigate the safety and efficacy of placing the catheter of an intrathecal morphine pump in the prepontine cistern for the treatment of craniofacial cancer pain. We performed a retrospective study of patients with primary or metastatic craniofacial cancer pain who received the catheter placement of an intrathecal morphine pump into the prepontine cistern in eleven medical centers from September 2019 to December 2023. Friedman test and pairwise signed-rank test were used to evaluate the difference in numeric rating scale (NRS) scores, the number of breakthrough pain episodes, dose of intrathecal morphine, and dose of systemic morphine equivalents (oral, patch, intravenous) from preoperative period to postoperative days 1, 7, and 30. P values were corrected for multiple comparisons using Bonferroni test. The study included 33 patients. The median (interquartile range [IQR]) of NRS scores at days 1, 7, and 30 postimplant were 2.0 (1.0-3.5), 2.0 (1.0-2.0), and 1.0 (1.0-2.0), respectively, which was significantly lower than that before surgery (median, 8.0; IQR, 7.0-10.0; all P < .001). Compared to baseline number/d of breakthrough pain episodes (median, 6.0; IQR, 4.5-10.0), there was a progressive decrease in the number/d of breakthrough pain episodes at day 1, day 7, and day 30 postimplant, and the median (IQR) were 1.0 (0.0-3.0), 2.0 (0.0-3.0), and 0.0 (0.0-1.2), respectively (all P < .001). Approximately 78.8% and 96.7% of patients reported pain relief >50% at days 1 and 30 postimplant, respectively. Compared with that at day 1 postimplant, the proportion of patients with a pain relief rate >75% at day 30 postimplant also increased with continued intrathecal treatment. Compared to the dose of baseline systemic morphine equivalents (median, 228 mg.d-1; IQR, 120-408 mg.d-1), the dose of systemic morphine equivalents reduced significantly from 0(0-120) mg.d-1 at day 1 postimplant (P = .001), to 0 (0-0) mg.d-1 at days 7 and 30 postimplant (both P < .001). Few patients reported perioperative adverse events, including nausea, constipation, hypotension, urinary retention, dry mouth, headache, and sedation. No severe adverse events occurred. Placing the catheter tip of an intrathecal morphine pump into the prepontine cistern could effectively relieve refractory craniofacial cancer pain with an extremely low total morphine dose requirement and few adverse events. This procedure could be considered in patients with severe refractory craniofacial cancer pain.

Persistent Opioid Use After Hospital Admission From Surgery in New Zealand: A Population-Based Study.

Persistent opioid use (POU) is common after surgery and is associated with an increased risk of mortality and morbidity. There have been no population-based studies exploring POU in opioid-naïve surgical patients in New Zealand (NZ). This study aimed to determine the incidence and risk factors for POU in opioid-naïve patients undergoing surgery in all NZ hospitals. We included all opioid-naïve patients who underwent surgery without a concomitant trauma diagnosis and received opioids after discharge from any NZ hospital between January 2007 and December 2019. Patients were considered opioid naïve if no opioids had been dispensed to them or if they did not have a prior diagnosis of an opioid-use disorder up to 365 days preceding the index date. The primary outcome was the incidence of POU, defined a priori as opioid use after discharge between 91 and 365 days. We used a multivariable logistic regression to identify risk factors for POU. We identified 1789,407 patients undergoing surgery with no concomitant diagnosis of trauma; 377,144 (21.1%) were dispensed opioids and 260,726 patients were eligible and included in the analysis. Of those included in the final sample, 23,656 (9.1%; 95% confidence interval [CI], 9.0%-9.2%) developed POU. Risk factors related to how opioids were prescribed included: changing to different opioid(s) after discharge (adjusted odds ratio [aOR], 3.21; 95% CI, 3.04-3.38), receiving multiple opioids on discharge (aOR, 1.37; 95% CI, 1.29-1.45), and higher total oral morphine equivalents (>400 mg) (aOR, 1.23; 95% CI, 1.23-1.45). Conversely, patients who were coprescribed nonopioid analgesics on discharge had lower odds of POU (aOR, 0.91; 95% CI, 0.87-0.95). Only small differences were observed between different ethnicities. Other risk factors associated with increased risk of POU included undergoing neurosurgery (aOR, 2.02; 95% CI, 1.83-2.24), higher comorbidity burden (aOR, 1.90; 95% CI, 1.75-2.07), preoperative nonopioid analgesic use (aOR, 1.65; 95% CI, 1.60-1.71), smoking (aOR, 1.44; 95% CI, 1.35-1.54), and preoperative hypnotics use (aOR, 1.35; 95% CI, 1.28-1.42). Approximately 1 in 11 opioid-naïve patients who were dispensed opioids on surgical discharge, developed POU. Potentially modifiable risk factors for POU, related to how opioids were prescribed included changing opioids after discharge, receiving multiple opioids, and higher total dose of opioids given on discharge. Clinicians should discuss the possibility of developing POU with patients before and after surgery and consider potentially modifiable risk factors for POU when prescribing analgesia on discharge after surgery.

233. UTILITY OF SINGLE TRANSHIATAL CHEST DRAINAGE AFTER MINIMALLY INVASIVE OESOPHAGECTOMY: A PROPENSITY-SCORE MATCHED STUDY OF FEASIBILITY

Abstract Background The routine placement of intercostal chest drains remains common practice following minimally invasive oesophagectomy (MIO). Chest drains may contribute to increased post-operative pain and morbidity. The aim of this study was to compare the outcomes of transhiatal chest drain with intercostal chest drain. We analysed use of analgesia, length of hospital stay, and postoperative pulmonary morbidity following MIO. Methods This was a retrospective case-control study of patients undergoing elective MIO at a quaternary centre in Western Australia between September 2016 and September 2023. To reduce confounding, propensity score matching was performed. All patients were identified from a prospectively maintained database. In patients undergoing MIO with exclusive transhiatal drainage, a 19 French Blake’s drain was advanced through the hiatus into the right pleural cavity and positioned adjacent to the anastomosis. Results Thirty patients were included in the study, fifteen of whom had exclusively transhiatal drain placement. Mean total daily oral morphine dose equivalent was significantly lower in the transhiatal drain group (58mg+/-35.8) compared with intercostal drain group (100.8mg+/-64.0) on day 1 (p=0.04). There is no statistically significant difference between the total oral morphine use on days 3 (p=0.44) and 6 (p=0.97). No significant difference was observed in reintervention rate (p=1.00), length of stay (p=0.78) or postoperative pulmonary complications (p=1.00). Conclusion The results of this study suggest that transhiatal drain placement following MIO is associated with a reduction in post-operative pain and no increase in pulmonary complications or length of stay. Larger, prospective studies are needed to further evaluate the safety of single transhiatal chest drain placement following MIO.

Sedation and analgesia in the trauma intensive care unit of Inkosi Albert Luthuli Central Hospital - the effect of anti-retroviral therapy: A retrospective chart analysis.

Adequate access to antiretrovirals (ARV) has improved the longevity and quality of life of people living with the human immunodeficiency virus(HIV). Antiretrovirals are known to cause multiple drug-drug interactions. It was noted clinically that patients on ARVs appeared to be more difficult to sedate. This begs the question of the clinical impact of these drug interactions, should clinicians adjust sedative dosages when managing patients on ARVs? This study aimed to investigate the presence of and measure the differences in sedation and analgesic utilisation between polytrauma patients on ARVs and those not on ARVs. This retrospective observational chart review included consecutive adult polytrauma patients admitted to the Trauma ICU IALCH between January 2016 and December 2019. HIV status and ARV use was documented. The total sedation per drug utilised at 24, 48 and 72-hour interval was calculated and tabulated accordingly. Drug utilisation was compared to ARV status. A total of 216 adult polytrauma patients were included in the study. A total of 44 patients were HIV positive and 172 were HIV negative. Of the HIV positive patients 41 (93.2%) were on ARVs. Multiple comparisons were confirmed, however the primary analysis compared HIV negative patients with HIV positive patients on ARV. Total morphine, ketamine, midazolam and propofol doses were all numerically greater in patients on ARVs, although none of these reached statistical significance. The use of morphine rescue boluses during the first 72h of ICU admission and the doses of ketamine and propofol on ICU day 3 were significantly greater in those on ARVs. The data analysis showed that patients on ARVs required higher doses of some analgesia and sedation in ICU and lower doses of midazolam. This needs to be considered when sedating patients in a setting with a high HIV prevalence.

Efficacy of a Multimodal Surgical Site Injection for Postoperative Pain Control in Pediatric Patients With Cerebral Palsy Undergoing Hip Reconstruction: A Randomized Controlled Trial.

One in 4 children with cerebral palsy (CP) will undergo orthopaedic surgery during their childhood. Despite its ubiquity, postoperative pain control has been poorly studied in this patient population. Moreover, poor pain management has been associated with adverse surgical outcomes. Multimodal analgesic injections have been well studied in the adult population, demonstrating safety and efficacy in reducing postoperative pain and narcotic consumption, but this modality has not been studied in pediatric patients undergoing similarly complex procedures. The objective of this study was to evaluate the efficacy of a multimodal surgical site injection for postoperative pain control following operative management of hip dysplasia in patients with CP. After obtaining IRB approval, a multicenter, randomized double-blind placebo control trial was completed. Patients below 18 years old with a diagnosis of CP who were scheduled for varus derotation osteotomy (VDRO) of the proximal femur were randomized to receive a surgical-site injection with either a combination of ropivacaine (3mg/kg), epinephrine (0.5mg), and ketorolac (0.5mg/kg) (experimental group) or normal saline (control). All included patients had identical postoperative care, including immobilization, physical therapy, and standardized, multimodal postoperative pain control. Pain scores and narcotic consumption were recorded at regular intervals and compared between groups utilizing two-tailed t test or a nonparametric Mann-Whitney test for quantitative variables and a Fischer exact test for categorical variables. Thirty-four patients were included, evenly divided between study arms. There were no significant differences in demographic variables, gross motor function classification system (GMFCS), comorbidities, preoperative radiographic parameters, or concomitant surgeries between groups. Patients in the experimental group required significantly lower narcotic medications at all postoperative time points from PACU until hospital discharge compared with controls (0.41 ± 0.42 vs. 1.87 ± 2.05 total morphine mEQ/kg, P=0.01). Similarly, patients in the experimental group were found to have significantly lower pain scores throughout their hospital stays compared with controls (1.0 ± 0.6 vs. 2.4 ± 1.1 mean pain score, P<0.001). There were no significant differences in operative time, OR time, blood transfusion requirements or hospital length of stay between groups. There were no adverse medication reactions or injection site complications in either group. In patients with CP undergoing hip reconstruction, surgical-site injection with a multimodal analgesic combination improves pain control and reduces narcotic consumption in the early postoperative period with no observed adverse effects. Local multimodal analgesic injections should be adopted as part of standard multimodal pain control in this patient population for all osseous surgeries. Level I-therapeutic.

Anterior quadratus lumborum block provided superior pain control and reduced opioid consumption in kidney transplantation: A randomized controlled trial.

The research aimed to assess the effectiveness of inside-out anterior quadratus lumborum (QL3) block and local wound infiltration in managing postoperative pain and total morphine dosage following kidney transplantation. In this prospective, randomized, double-blind study; 46 end-stage renal disease patients undergoing kidney transplantation were randomly allocated into 2 groups: a QL group (n = 23) receiving 20 mL of 0.25% bupivacaine using the ultrasound-assisted inside-out technique before wound closure, while the local wound infiltration (LA) group (n = 23) receiving the same dose around the surgical wound and drain at the time of skin closure. The primary outcome measure was the numerical pain rating scale, with secondary outcomes including amount of morphine consumption at various postoperative time points (2nd, 4th, 6th, 12th, 18th and 24th hours). Patients in the QL group had significantly lower numerical rating scale scores at the 2nd and 4th hours, both at rest and during movement (P < .05). Although pain scores at rest and during movement at later time points were lower in the QL group compared to the LA group, these differences were not statistically significant. Cumulative morphine consumption at postoperative 4th, 6th, 12th, 18th and 24th hours was significantly lower in the QL group (P < .05). No patients experienced complications from the QL3 block. Ultrasound-assisted inside-out QL3 block significantly reduced postoperative pain levels at the 2nd and 4th hours, both at rest and during movement, and led to a reduction in cumulative morphine consumption from the 4th hour postoperatively, and persisting throughout the 24-hour period.