Verbal Rating Scale Pain Scores Research Articles

Ketamine Compared With Morphine for Out-of-Hospital Analgesia for Patients With Traumatic Pain

Pain is a common out-of-hospital symptom among patients, and opioids are often prescribed. Research suggests that overprescribing for acute traumatic pain is still prevalent, even when limits restricting opioid prescriptions have been implemented. Ketamine hydrochloride is an alternative to opioids in adults with out-of-hospital traumatic pain. To assess the noninferiority of intravenous ketamine compared with intravenous morphine sulfate to provide pain relief in adults with out-of-hospital traumatic pain. The Intravenous Subdissociative-Dose Ketamine Versus Morphine for Prehospital Analgesia (KETAMORPH) study was a multicenter, single-blind, noninferiority randomized clinical trial comparing ketamine hydrochloride (20 mg, followed by 10 mg every 5 minutes) with morphine sulfate (2 or 3 mg every 5 minutes) in adult patients with out-of-hospital trauma and a verbal pain score equal to or greater than 5. Enrollment occurred from November 23, 2017, to November 26, 2022, in 11 French out-of-hospital emergency medical units. Patients were randomly assigned to ketamine (n = 128) or morphine (n = 123). The primary outcome was the between-group difference in mean change in verbal rating scale pain scores measured from the time before administration of the study drug to 30 minutes later. A noninferiority margin of 1.3 was chosen. A total of 251 patients were randomized (median age, 51 [IQR, 34-69] years; 111 women [44.9%] and 140 men [55.1%] among the 247 with data available) and were included in the intention-to-treat population. The mean pain score change was -3.7 (95% CI, -4.2 to -3.2) in the ketamine group compared with -3.8 (95% CI, -4.2 to -3.4) in the morphine group. The difference in mean pain score change was 0.1 (95% CI, -0.7 to 0.9) points. There were no clinically meaningful differences for vital signs between the 2 groups. The intravenous morphine group had 19 of 113 (16.8% [95% CI, 10.4%-25.0%]) adverse effects reported (most commonly nausea [12 of 113 (10.6%)]) compared with 49 of 120 (40.8% [95% CI, 32.0%-49.6%]) in the ketamine group (most commonly emergence phenomenon [24 of 120 (20.0%)]). No adverse events required intervention. In the KETAMORPH study of patients with out-of-hospital traumatic pain, the use of intravenous ketamine compared with morphine showed noninferiority for pain reduction. In the ongoing opioid crisis, ketamine administered alone is an alternative to opioids in adults with out-of-hospital traumatic pain. ClinicalTrials.gov Identifier: NCT03236805.

Peripheral Nerve Catheter Reduces Postoperative Opioid Consumption and Pain in Revision Total Knee Arthroplasty.

Patients undergoing revision total knee arthroplasty (rTKA) have historically received high doses of opioids during the perioperative period. As awareness of opioid use has heightened, opioid administration has continuously decreased. This study aimed to evaluate if peripheral nerve catheter (PNC) use in rTKA reduces opiate consumption while maintaining similar pain control and postoperative function levels. A retrospective review of 354 patients who underwent rTKA between July 2019 and January 2022 was conducted. Fifty total patients who received an adductor canal PNC were propensity-matched 1:1 to a control group of 50 patients that did not receive a PNC. To assess the primary outcome of opiate consumption, nursing documented opiate administration events were converted into morphine milligram equivalents per 24-hour interval. Postoperative pain and functional status were assessed using the verbal rating scale for pain and the Activity Measure for Post-Acute Care scores, respectively. Compared to the control group, the PNC group demonstrated significantly lower overall inpatient opiate consumption (98.68 ± 117.03 vs 176.69 ± 203.47 morphine milligram equivalents; 44.15% decrease, P= .021) and lower verbal rating scale pain scores at 60 to 72 hours postoperatively (4.85 ± 1.24 vs 5.83 ± 1.35; 16.81% decrease, P= .038). There was no significant difference in Activity Measure for Post-Acute Care scores postoperatively (raw score: 19.41 ± 3.61 vs 19.46 ± 3.18; 0.26% decrease, P= .952). Finally, the PNC cohort was significantly less likely to be readmitted within 90 days after surgery (0.0% vs 12.0%; P= .012). In rTKA patients, PNC can significantly reduce inpatient opioid consumption while maintaining a comparable functional recovery and superior pain control. Retrospective Cohort Study.

Effects of Dexamethasone on Postoperative Glycemic Control in Diabetic Patients Following Primary Total Joint Arthroplasty: A Retrospective Cohort Study

BackgroundConcerns regarding the effects of dexamethasone on diabetics' glucose control have stymied its use following total joint arthroplasty. This study aimed to evaluate the effects of 2 intravenous (IV) perioperative doses of dexamethasone on glucose levels, pain scores, and inpatient opioid consumption following total joint arthroplasty in diabetic patients. MethodsA retrospective review of 523 diabetic patients who underwent primary elective THA and 953 diabetic patients who underwent primary elective total knee arthroplasty (TKA) between May 6, 2020, and December 17, 2021 was conducted. Patients who received 1 dose (1D) of perioperative dexamethasone 10 mg IV were compared to patients who received 2 doses (2D). Primary outcomes included postoperative glucose levels, opioid consumption as morphine milligram equivalences, postoperative pain as Verbal Rating Scale pain scores, and postoperative complications. ResultsThe 2D TKA cohort had significantly greater average and maximum blood glucose levels from 24 to 60 hours compared to the 1D TKA cohort. The 2D THA cohort had significantly greater average blood glucose levels at 24 to 36 hours compared to the 1D THA cohort. However, the 2D TKA group had significantly reduced opioid consumption from 24 to 72 hours and reduced total consumption compared to the 1D TKA group. Verbal Rating Scale pain scores did not differ between cohorts for both TKA and THA at any interval. ConclusionAdministration of a second perioperative dose of dexamethasone was associated with increased postoperative blood glucose levels. However, the observed effect on glucose control may not outweigh the clinical benefits of a second perioperative dose of glucocorticoids.

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

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

Abstract No.: ABS2768: Comparison of pre-emptive ketamine nebulisation with intravenous ketamine for post-operative analgesia in children undergoing tonsillectomy: A randomised controlled trial

Background and Aims:Nebulised ketamine is a painless route of drug administration in children.This study aimed to compare the effectiveness of ketamine nebulisation as opposed to intravenous ketamine as premedication in childrenMethods:64 children aged 5-10 years, undergoing tonsillectomy were randomly allocated into 2 groups.Both groups received glycopyrrolate 5mcg/kg. First group received ketamine nebulisation (1mg/kg) 20minutes prior to the surgery and other group received intravenous ketamine (1mg/kg) just before shifting to operating room. Children were anaesthetised by standard technique using fentanyl 1 µg/kg, propofol 2mg/kg, atracurium 0.5mg/kg and sevoflurane. Postoperatively, pain score using verbal rating scale(VRS) was assessed immediately after shifting to post anaesthesia care unit (PACU)and after one hour and the time of first rescue analgesic requirement was noted. Children were also assessed for parental separation scores and levels of sedation using 5-point sedation scale preoperatively.Results:There was no difference in VRS pain score immediately after shifting to PACU but there was significant difference in the VRS pain score at one hour postoperatively (p<0.05).The mean time for rescue analgesia was significantly prolonged in ketamine nebulisation group (300±26.40min) in contrast to intravenous ketamine group (237.19±34.38min) (p<0.05). Nebulised and intravenous ketamine produced similar levels of sedation (score-2) and acceptable parental separation scores (score1,2) (table 1).Conclusion:Ketamine nebulisation (1mg/kg) administered before tonsillectomy significantly prolonged postoperative analgesia as opposed to intravenous ketamine with similar parental separation scores and sedation scores. Hence nebulisation can be used as an alternative route for administering ketamine.

A Comparative Study to Evaluate the Effect of Honey and Zinc Oxide Eugenol Dressing for the Treatment of Dry Socket: A Double-Blind Randomized Controlled Trial

Dry socket is a common postoperative complication secondary to any tooth extraction but is more commonly associated with mandibular third molars. Dry socket has been treated with various treatment modalities with different success rates. This study aimed to evaluate the effect of using honey and zinc oxide eugenol as an intra-socket medicament for the treatment of dry sockets. Ninety patients were divided into three groups as follows: Group 1 “honey”: 30 patients; Group 2 “zinc oxide eugenol”: 30 patients; and Group 3 “control”: 30 patients. Pre-medication and post-medication pain scores at different time intervals were measured on a verbal rating scale. The mean ages of the patients in each of the groups were as follows: Group 1: 44.26 ± 14.14; Group 2: 45.30 ± 18.08; and Group 3: 51.93 ± 9.75. As regards verbal rating scale pain scores, a significant difference was noted in patients that belonged to Groups 1 and 2, with an immediate reduction in post-medication pain scores. However, patients belonging to Group 3 reported pain and discomfort for over a week. The use of honey and zinc oxide eugenol resulted in significant immediate post-medication pain scores in patients as compared to the control group. Therefore, both honey and zinc oxide eugenol can be used as treatment options for dry socket patients.

Discontinuation of the liposomal delivery of bupivacaine has no effect on pain management after primary total knee arthroplasty : no effect on pain scores, opioid consumption, or functional status.

Liposomal bupivacaine (LB) as part of a periarticular injection protocol continues to be a highly debated topic in total knee arthroplasty (TKA). We evaluated the effect of discontinuing the use of LB in a periarticular protocol on immediate postoperative pain scores, opioid consumption, and objective functional outcomes. On 1 July 2019, we discontinued the use of intraoperative LB as part of a periarticular injection protocol. A consecutive group of patients who received LB as part of the protocol (Protocol 1) and a subsequent group who did not (Protocol 2) were compared. All patients received the same opioid-sparing protocol. Verbal rating scale (VRS) pain scores were collected from our electronic data warehouse and averaged per patient per 12-hour interval. Events relating to the opiate administration were derived as morphine milligram equivalences (MMEs) per patient per 24-hour interval. The Activity Measure for Post-Acute Care (AM-PAC) tool was used to assess the immediate postoperative function. A total of 888 patients received Protocol 1 and while 789 received Protocol 2. The mean age of the patients was significantly higher in those who did not receive LB (66.80 vs 65.57 years, p = 0.006). The sex, BMI, American Society of Anesthesiologists physical status score, race, smoking status, marital status, operating time, length of stay, and discharge disposition were similar in the two groups. Compared with the LB group, discontinuing LB showed no significant difference in postoperative VRS pain scores up to 72 hours (p > 0.05), opioid administration up to 96 hours (p > 0.05), or AM-PAC scores within the first 24 hours (p > 0.05). The control of pain after TKA with a multimodal management protocol is not improved by the addition of LB compared with traditional bupivacaine. Cite this article: Bone Joint J2021;103-B(6 Supple A):102-107.

Randomised controlled trial of a microneedle patch with a topical anaesthetic for relieving the pain of dental injections

ObjectivesTo determine whether a microneedle patch combined with 5% topical lidocaine reduces dental injection pain more than a patch without microneedles combined with 5% topical lidocaine. MethodsThis proof of principle randomised, two-treatment, double-blind, crossover split-unit design study in 16 healthy participants investigated levels of perceived pain from 3 increasing pain provoking challenges, when topical 5% lidocaine dental gel was applied to the oral mucosa with a microneedle patch and a patch with no microneedles, prior to infiltration with local anaesthesia on 2 visits. Pain was assessed by visual analogue scale (VAS) and 4-point verbal rating scale (VRS). Results15 participants completed the study. Mean pain scores, lower at buccal sites, increased in both groups across challenges 1−3: Test palatal 5.1, 11.9, 26.8; buccal 0.7, 2.8, 18.3; Control palatal 12.3, 18.7, 39.5; buccal 4.0, 6.9, 30.6. The microneedle patch plus lidocaine significantly lowered VAS pain scores at both sites for all challenges, the biggest mean difference seen palatally after challenge 3 (12.7, p < 0.001). VRS pain scores were also significantly reduced for test compared to control for all 3 challenges (p = 0.014). Buccal scores favoured the microneedle patch, significantly for pain challenge 3 (p = 0.025). No adverse events occurred. ConclusionsPrior oral application of a microneedle patch combined with 5% topical lidocaine gel reduced the pain experienced from dental infiltration. Microneedle patch use in the dental setting offers the prospect of improving degree and depth of anaesthesia from topically applied anaesthetic gel, without itself causing any pain. Clinical SignificanceDental injections are associated with fear and anxiety. Application of a microneedle patch, combined with topical anaesthetic, to the oral mucosa prior to delivery of the injection reduces the pain from this dental procedure. This novel technique may allay patients’ apprehension of local anaesthesia and improve quality of life outcomes.

Adductor Canal Blocks Reduce Inpatient Opioid Consumption While Maintaining Noninferior Pain Control and Functional Outcomes After Total Knee Arthroplasty

BackgroundThe use of perioperative adductor canal blocks (PABs) continues to be a highly debated topic for total knee arthroplasty (TKA). Here, we evaluate the effect of PABs on immediate postoperative subjective pain scores, opioid consumption, and objective functional outcomes. MethodsOn December 1, 2019, an institution-wide policy change was begun to use PABs in primary elective TKAs. Patient demographics, immediate postoperative nursing documented pain scores, opioid administration events, and validated physical therapy functional scores were prospectively collected as part of the standard of care and retrospectively queried through our electronic data warehouse. A historical comparison cohort was derived from consecutive patients undergoing TKA between July 1, 2019 and November 30, 2019. Results405 primary TKAs received PABs, while 789 patients were in the control cohort. Compared with controls, average verbal rating scale pain scores were lower among PAB recipients from 0-12 hours (2.42 ± 1.60 vs 2.05 ± 1.60; <.001) and 24-36 hours (4.92 ± 2.00 vs 4.47 ± 2.27; <.01). PAB recipients demonstrated significantly lower opioid consumption within the first 24 hours (44.34 ± 40.98 vs 36.83 ± 48.13; P < .01) and during their total inpatient stay (92.27 ± 109.81 vs 77.52 ± 123.11; <.05). AM-PAC scores within the first 24 hours were also higher for PABs (total scores: 20.28 ± 3.06 vs 20.71 ± 3.12; <.05). ConclusionWhile the minimal clinically important differences in pain scores and functional status were comparable between both cohorts, patients demonstrated a significant reduction in overall inpatient opiate consumption after the introduction of PABs. Surgeons should consider these findings when evaluating for perioperative pain management, opioid-sparing, and rapid discharge protocols.

Discontinuation of Intraoperative Liposomal Bupivacaine in Primary THA Does Not Clinically Change Postoperative Subjective Pain, Opioid Consumption, or Objective Functional Status

BackgroundThere is debate regarding the benefit of liposomal bupivacaine (LB) as part of a periarticular injection (PAI) in total hip arthroplasty (THA). Here, we evaluate the effect of discontinuing intraoperative LB PAI on immediate postoperative subjective pain, opioid consumption, and objective functional outcomes. MethodsOn July 1, 2019, an institutional policy discontinued the use of intraoperative LB PAI. A consecutive cohort that received LB PAI and a subsequent cohort that did not were compared. All patients received the same opioid-sparing protocol. Nursing documented verbal rating scale pain scores were averaged per patient per 12-hour interval. Opiate administration events were converted into morphine milligram equivalences per patient per 24-hour interval. The validated Activity Measure for Postacute Care (AM-PAC) tool was used to evaluate functional outcomes. ResultsSix hundred thirty eight primary THAs received LB followed by 939 that did not. In the non-LB THAs, BMI was higher (30.06 vs 29.43; P < .05). Besides marital status, the remaining baseline demographics were similar between the two cohorts (P > .05). The non-LB THA cohort demonstrated a marginal increase in verbal rating scale pain scores between 12 to 24 hours (4.42 ± 1.70 vs 4.20 ± 1.87; P < .05) and 36 to 48 hours (4.49 ± 1.72 vs 4.21 ± 1.83; P < .05). There was no difference in inpatient opioid administration up to 96 hours postoperatively (P > .05) or AM-PAC functional scores within the first 24 hours (P > .05). ConclusionA small statistical, but not clinically meaningful, difference was observed in subjective pain scores with LB PAI discontinuation. Opioid consumption and postoperative AM-PAC functional scores were unchanged after LB PAI discontinuation.

Pain relief after more than 24 hours of preoperative skin traction in patients with intertrochanteric fractures: A retrospective comparative cohort study

AimThe primary aim of the study was to investigate pain relief after more than 24 h of preoperative skin traction (because of delay in surgery due to comorbidities and system issues) in patients with intertrochanteric fractures. MethodWe performed a retrospective comparative cohort study of 56 patients who underwent intramedullary nailing for the treatment of intertrochanteric fractures and who had waited for surgery for more than 48 h after admission due to comorbidities or system issues. Preoperative therapy was randomly selected with a ratio of one to two and patients classified as skin traction (n = 18) or no traction (n = 38). The Verbal Rating Scale (VRS) was used to assess pain at 12–60 h post-admission. ResultsThere was no significant difference in VRS at 12 h after admission (1.1 ± 1.0 vs. 0.8 ± 0.9, p = 0.73), but patients who received skin traction had a lower VRS pain score at 24–60 h after admission compared to those with no traction (24 h, 0.4 ± 0.8 vs. 1.1 ± 1.0, p < 0.05; 36 h, 0.2 ± 0.5 vs. 0.9 ± 0.9, p < 0.05; 48 h, 0.2 ± 0.4 vs. 0.8 ± 0.9, p < 0.05; 60 h, 0.2 ± 0.4 vs. 0.9 ± 0.9, p < 0.05). ConclusionSkin traction for patients with intertrochanteric fractures for more than 24 h preoperatively resulted in a lower VRS pain score. Therefore, more than 24 h of preoperative skin traction for patients with intertrochanteric fractures may give effective pain relief in situations where surgery is delayed.

Effect of High-Intensity Laser Treatments on Chronic Pain Related to Osteoarthritis in Former Professional Athletes: A Case Series

Background: We evaluated the use of a new higher intensity 42 Watt cold laser for treating chronic pain related to osteoarthritis (OA) in former NFL football players. Methods: 39 consenting former NFL football players with OA underwent 1-3 treatment sessions lasting 10-20 min with a 42 Watt FDA-approved high-intensity cold laser (Phoenix thera-lase, Dallas, TX) at a wavelength of 1275 nm. We recorded their pain verbal rating scale (VRS) score at rest and with activity before and after each treatment using an 11-point VRS with 0=no pain to 10=worst pain imaginable. In addition, we assessed the duration of the painrelieving effect produced by each laser treatment, as well as its effects on other OA-related symptoms. Results: The chronic pain scores were significantly reduced both at rest and with activity after each treatment. Baseline VRS pain scores were 3.5 ± 2.9 at rest and 6.0 ± 2.6 with activity. After the initial treatment, the pain scores were reduced to 1.2 ± 1.8 (p<0.01) at rest and to 2.0 ± 2.0 (p<0.01) with activity. The overall beneficial effect was 7.2 ± 1.8 on a scale from 0=no relief to 10=complete relief, and the duration of the beneficial effect lasted 1-3 weeks in 64% of the players treated. Finally, 90% of the players would recommend the laser treatment to their colleagues. Conclusion: High-intensity cold laser treatments reduced chronic OA-related pain in former NFL football players by ~67% at rest and with activity and the beneficial effect typically persisted for 1 week or longer after 1-3 treatments in the majority of these chronic pain patients.

5% NaHCO3 Is Appropriate for Skin Cleaning With Central Venous Catheters

ObjectivesThe purpose of this study was to compare the effects of skin cleaning with 5% NaHCO3 to 75% alcohol on the removal of skin grease and pain of patients with central venous catheters (CVC). Materials and MethodsThis was a randomized, controlled, single-blinded and prospective study. From January-September 2015, 143 consecutive patients who met the inclusion and exclusion criteria and who underwent elective cardiovascular surgery with placement of a CVC were selected. Patients were randomly divided into 2 groups according to the disinfection preparation procedure: experimental group (n = 60), in which 5% NaHCO3 and distilled water solution at 40-45°C were used, and the control group (n = 66), in which 75% alcohol was used. Main outcome measures were verbal rating scale pain score, satisfaction and bacterial count after 2 minutes of iodine disinfection. ResultsThe verbal rating scale pain scores were lower in the experimental group than in the control group (P < 0.001). In the control group, 4.5% of patients and 43% of nurses were satisfied with 75% alcohol cleaning before disinfection procedure, compared to 74% and 78%, respectively, in the experimental group. The bacterial count did not show any difference between these 2 groups after iodine disinfection (P = 0.455). ConclusionsCleaning of the CVC before disinfection with 5% NaHCO3 and distilled water at 40-45°C alleviated pain and improved patient and nurse satisfaction compared with using 75% alcohol.

Comparison of pre treatment with Ondansetron and Lignocaine over Pain on Etomidate Injection. A double blind prospective non randomised study

Background: Etomidate is the preferred induction agent in patient with Cardiac disease due to its cardiac vascular stability. It can cause severe pain during IV administration which can produce increased stress response. Various methods have been tried to reduce the pain of etomidate injection with variable success. Lignocaine pre-treatment which is extensively used to reduce the pain of propofol injection is also used to reduce the pain of etomidate injection. Materials And Methods: This nonrandomised double blind, study was done after getting ethical clearance from university ethical committee. After informed consent 40 patients of both sexes aged between 18 to 65 years of ASA physical status 1, 2 & 3, who were posted for various elective surgical procedure planned under general anaesthesia were enrolled for the study.. They were not given any premedication. On arriving to Operating room (OR) 20G IV cannula inserted on dorsum of both hands and both flushed with100ml of normal saline. Venous drainage was occluded with elastic band in the both hands at midarm. In one hand 2ml of 1% lignocaine followed by 1 ml (2 mg ) of Etomidate is Injected and pain is assessed by Verbal rating scale(VRS). After one minute in other hand 2 ml (8mg) ondansetron injected followed by 1 ml (2 mg ) of Etomidate and pain is assessed. Statistical analysis: Non-Parametric test-Wilcoxon Sign Ranks Test is used to compare both drugs .Analysis is perfomed using SPSS Version22. Results: A total number of 40 patients (male=57.50%, female=42.50%).The mean age of patient was 42.85, The mean VRS pain score of etomidate after pre-administration of intravenous lignocaine (Drug A) was 1.58, which was lower compared to pre-administration of ondansetron(Drug )2.43. Conclusion: This study illustrates that pre-treatment with intravenous lignocaine significantly reduces the pain on injection of etomidate compare to ondansetron. (P value<0.001).

A randomized placebo-controlled trial to evaluate a novel noninjectable anesthetic gel with thermosetting agent during scaling and root planing in chronic periodontitis patients.

Aim:To study the efficacy of a noninjectable anesthetic gel with a thermosetting agent in the reduction of pain during scaling and root planing (SRP) in untreated chronic periodontitis patients.Materials and Methods:This study is a randomized, double-masked, split-mouth, placebo-controlled trial. Thirty patients were enrolled who underwent SRP in a split-mouth (right side/left side) manner. Before commencement of SRP, both quadrants on each side were isolated and had a randomized gel (either placebo or test gel) placed in the periodontal pockets for 30 s. The pain was measured using numerical rating scale (NRS) and verbal rating scale (VRS).Results:The median NRS pain score for the patients treated with the anesthetic test gel was 1 (range: 0-4) as opposed to 5 (range: 3-7) in the placebo treated patients. The mean rank of pain score using NRS in test gel was 16.18 as compared to 44.82 in placebo treated sites. Hence, significant reduction in pain was found in test gel as compared to placebo using NRS (P < 0.001). The VRS showed that the majority of patients reported no pain or mild pain with a median of 1 as compared to placebo treated sites with a median of 2 suggestive of moderate pain.Conclusions:The NRS and VRS pain scores showed that the side treated with anesthetic gel was statistically more effective than the placebo in reducing pain during SRP.

Contemporary Pain Management in Elderly Patients After Hip Fracture Surgery: Cross-sectional Analyses at Baseline of a Randomized Controlled Trial.

Adequate pain management following hip fracture surgery reduces length of stay, reduces incidence of delirium, promotes recovery, and improves mobility. Previous research suggests that hip fracture pain is undertreated in some patient subgroups, and that hypovitaminosis D can further aggravate pain which could hinder active rehabilitation. We provide a cross-sectional analysis of the baseline characteristics of participants in the REVITAHIP study with the aim of documenting pain intensity and its associations after hip fracture and to explore the characteristics of people who report higher levels of pain. We analyzed the baseline characteristics with a focus on pain scores in patients admitted with a hip fracture (undergoing surgery) to 3 teaching hospitals over New South Wales, Australia, between January 2011 and April 2013. Patients were evaluated using the Verbal Rating Scale (VRS). Secondary measures including 25-hydroxyvitamin D levels at baseline, hip fracture subtype, type of surgical intervention, quality of life score, and cognitive and mobility status were correlated with the VRS using the Pearson correlation, ANOVA, and regression analysis. The 218 participants had a mean age of 83.9±7.2 years and 77.1% were women of whom 16.0% had a Mini Mental State Examination score of ≤23 of 30. The mean and SD VRS pain score was 3.5±2.3. More than half (61.9%, n=113) had VRS≥3 and 18.1% (n=52) had VRS≥5. Using the EuroQOL pain subscore, 78.1% had moderate pain or discomfort and 7.9% had extreme pain or discomfort. Using a multivariate regression model, postoperative VRS was significantly higher in persons with a higher comorbidity count, those previously living independently alone, and surgical fixative modality with hemiarthroplasty. Overall, the levels of pain reported by this cohort are acceptable although approximately 10% to 15% had higher than reasonable levels of pain. This study provides an insight into pain assessment and management by identifying certain patient subtypes who are vulnerable to undertreatment of pain.

Study protocol for a double blind, randomised, placebo-controlled trial of continuous subpectoral local anaesthetic infusion for pain and shoulder function following mastectomy: SUB-pectoral Local anaesthetic Infusion following MastEctomy (SUBLIME) study.

IntroductionOver 16 000 mastectomies are performed in England and Wales annually. Acute postoperative pain and nausea are common. The most frequently occurring long-term complications are chronic pain (up to 50%) and reduced shoulder function (reported at 35%). Regional techniques that improve acute postoperative pain relief may reduce the incidence of these complications. This study assesses the effectiveness of a 24-hour continuous local anaesthetic in the subpectoral plane in improving postoperative pain and quality of life in patients undergoing mastectomy.Methods and analysisThis is a randomised, double blind, placebo-controlled, two-centre, parallel group trial in women undergoing mastectomy with or without axillary involvement. One hundred and sixty participants will be randomised in a 1:1 ratio to receive either 0.25% levobupivacaine or 0.9% saline by subpectoral infusion postoperatively for 24 h. All participants will be provided with an intravenous morphine patient-controlled analgesia (PCA) system. Participants will be followed-up for 24 h in hospital and at approximately 14 days and 6 months postoperatively. Joint primary outcome measures are total morphine consumption and total pain score (captured via patient-recorded visual analogue scale (VAS) 4 hourly) during the first 24 h postoperatively. Primary statistical analysis of total pain is based on the area under the curve of pain versus time graph. Secondary outcomes include PCA attempts in first 24 h; VAS pain scores and shoulder function by goniometry at 24 h, 14 days (approximately) and 6 months; Verbal Rating Scale pain scores in first 24 h; Brief Pain Inventory and Oxford Shoulder Score at 6 months; duration of hospital stay; incidence of postoperative nausea and vomiting; cost-effectiveness.Ethics and disseminationThe study is approved by the South West England Research Ethics Committee (12/SW/0149).Resultswill be published in a peer-reviewed journal and presented at local, national and international scientific meetings.Trial registrationISRCTN46621916. EudraCT 2011-005775-16.

Superiority of 5% NaHCO3 for preoperative hair removal in patients undergoing coronary artery bypass graft surgery with a limb vein: a randomized controlled trial†.

Compared with a dry environment with talcum powder, a wet, alkaline environment with NaHCO3 solution is better for hair removal, as it can soften and expand the hair, decrease the friction and shear forces on the skin, and make hair removal easier and more efficient. The purpose of this study was to compare the effects of a preoperative skin preparation of 5% NaHCO3 with that of talcum powder for softening hair in patients undergoing coronary artery bypass graft (CABG) surgery with the saphenous vein. A prospective randomized, single-blinded, controlled study was established. Between March 2012 and June 2013, 120 patients who met the inclusion and exclusion criteria underwent elective CABG surgery with the saphenous vein in our hospital. The same doctor obtained the saphenous vein of each patient by a uniform method. CABG surgery was performed through an open or endoscopic technique, according to each patient's condition. Patients were divided into two groups of 60 patients each, according to whether the preoperative skin preparation procedure was performed with a 5% solution of NaHCO3 at 45-50°C (experimental group) or with talcum powder (control group). Main outcome measures were the incision inflammation rate, skin preparation time, presence of shaving-induced macroscopic haemorrhagic spots, verbal rating scale (VRS) pain score and satisfaction. Neither group had any evidence of incision inflammation. The average (mean ± standard deviation) skin preparation time of the experimental group was shorter than that of the control group (5.58 ± 1.52 vs 9.74 ± 1.23 min, P < 0.001). Three patients in the experimental group and 17 in the control group had shaving-induced macroscopic haemorrhagic spots after skin preparation (P = 0.001). The VRS pain scores were different between the two groups (P < 0.001). In the control group, 40% of patients and 37% of nurses were satisfied with the skin preparation procedure, compared with 95 and 90%, respectively, in the experimental group (both P < 0.001). Hair softening with a 5% NaHCO3 solution protected the skin integrity, alleviated pain and improved patient satisfaction to a greater extent than talcum powder. Nurses found the 5% NaHCO3 solution to be more convenient and less time-consuming to use.

Ultrasound-guided single injection infraclavicular brachial plexus block using bupivacaine alone or combined with dexmedetomidine for pain control in upper limb surgery: A prospective randomized controlled trial

Background:Dexmedetomidine, is a selective α2-adrenoceptor agonist that is used as an adjuvant mixed with local anesthetics during regional anesthesia. This study was designed to test the efficacy of adding dexmedetomidine to bupivacaine during placement of infraclavicular brachial plexus blockade (ICB).Methods:Sixty adult patients were divided into 2 equal groups of 30 subjects each. Patients in Group I received an ICB using 30 mL of 0.33% bupivacaine and Group II patients received 30 mL of 0.33% bupivacaine mixed with 0.75 μg/kg of dexmedetomidine. The following brachial plexus nerve block parameters were assessed: block success rate, sensory onset time and duration, motor block onset time and duration, analgesic pain scores using the verbal rating scale (VRS) for pain, duration of analgesia, and amount of supplemental intravenous (IV) morphine required.Results:There was a statistically significant shorter time to onset of sensory blockade (13.2 vs 19.4 min, P=0.003), longer duration of sensory block (179.4 vs 122.7 min, P=0.002), shorter onset time to achieve motor block (15.3 vs 22.2 min, P=0.003), longer duration of motor block (155.5 vs 105.7 min, P=0.002), lower VRS pain scores, prolonged analgesia (403 vs 233 min, P=0.002), and lower morphine rescue requirements for 48 h after surgery (4.9 (0–8.0) vs 13.6 mg (4.0–16.0) mg, P=0.005). All patients recovered without evidence of sensory or motor deficit.Conclusion:Adding dexmedetomidine to bupivacaine during the placement of an ICB provides: (1) enhancement of onset of sensory and motor blockade, (2) prolonged duration of analgesia, (3) increases duration of sensory and motor block, (4) yields lower VRS pain scores, and (5) reduces supplemental opioid requirements.

The Use of Prolonged Peripheral Neural Blockade After Lower Extremity Amputation

Phantom limb syndrome (PLS) is common after limb amputations, involving up to 90% of amputees. Although many different therapies have been evaluated, none has been found to be highly effective. Therefore, we evaluated the efficacy of a prolonged perineural infusion of a high concentration of local anesthetic solution in preventing PLS. A perineural catheter was placed immediately before or during surgery in 71 patients undergoing lower extremity amputation. A continuous infusion of 0.5% ropivacaine was started intraoperatively at 5 mL/h using an elastomeric (nonelectronic) pump, and continued for 4 to 83 days after surgery. PLS was evaluated on the first postoperative day and then 1, 2, 3, and 4 weeks, and 3, 6, 9, and 12 months after surgery. To evaluate the presence and severity of PLS while the patient was receiving the ropivacaine infusion, it was discontinued for 6 to 12 hours before each assessment period (i.e., until the sensation in the extremity returned). The severity of phantom limb and stump pain was assessed using a 5-point verbal rating scale (VRS), with 0 = no pain to 4 = intolerable pain, and "phantom" sensations were recorded as present or absent. If the VRS score was >1 or significant phantom sensations were present, the ropivacaine infusion was immediately restarted at 5 mL/h. If the VRS score remained at 0 to 1 and the patient had not experienced phantom sensations for 48 hours, the infusion was permanently discontinued and the catheter was removed. Median duration of the local anesthetic infusion was 30 days (95% confidence interval, 25-30 days). On postoperative day 1, 73% of the patients complained of severe-to-intolerable pain (visual analog scale >2). However, the incidence of severe-to-intolerable phantom limb pain was only 3% at the end of the 12-month evaluation period. At the end of the 12-month period, the percentage of patients with VRS pain scores were 0 = 84%, 1 = 10%, 2 = 3%, 3 = 3%, and 4 = none. However, phantom limb sensations were present in 39% of patients at the end of the 12-month evaluation period. All patients were able to manage the elastomeric catheter infusion system at home. Use of a prolonged postoperative perineural infusion of ropivacaine 0.5% seems to be an effective therapy for the treatment of phantom limb pain and sensations after lower extremity amputation.