Postoperative pain, analgesia, and recovery-bedfellows that cannot be ignored

The Analgesic Efficacy of the Single Erector Spinae Plane Block with Intercostal Nerve Block Is Not Inferior to That of the Thoracic Paravertebral Block with Intercostal Nerve Block in Video-Assisted Thoracic Surgery

This monocentric, single-blinded, randomized controlled noninferiority trial investigated the analgesic efficacy of erector spinae plane block (ESPB) combined with intercostal nerve block (ICNB) compared to that of thoracic paravertebral block (PVB) with ICNB in 52 patients undergoing video-assisted thoracic surgery (VATS). The endpoints included the difference in visual analog scale (VAS) scores for pain (0–10, where 10 = worst imaginable pain) in the postanesthetic care unit (PACU) and 24 and 48 h postoperatively between the ESPB and PVB groups. The secondary endpoints included patient satisfaction (1–5, where 5 = extremely satisfied) and total analgesic requirement in morphine milligram equivalents (MME). Median VAS scores were not significantly different between the groups (PACU: 2.0 (1.8, 5.3) vs. 2.0 (2.0, 4.0), p = 0.970; 24 h: 2.0 (0.8, 3.0) vs. 2.0 (1.0, 3.5), p = 0.993; 48 h: 1.0 (0.0, 3.5) vs. 1.0 (0.0, 5.0), p = 0.985). The upper limit of the 95% CI for the differences (PACU: 1.428, 24 h: 1.052, 48 h: 1.176) was within the predefined noninferiority margin of 2. Total doses of rescue analgesics (110.24 ± 103.64 vs. 118.40 ± 93.52 MME, p = 0.767) and satisfaction scores (3.5 (3.0, 4.0) vs. 4.0 (3.0, 5.0), p = 0.227) were similar. Thus, the ESPB combined with ICNB may be an efficacious option after VATS.

Differential synaptic mechanism underlying the neuronal modulation of prefrontal cortex, amygdala, and hippocampus in response to chronic postsurgical pain with or without cognitive deficits in rats

Chronic Postsurgical Pain (CPSP) is well recognized to impair cognition, particularly memory. Mounting evidence suggests anatomic and mechanistic overlap between pain and cognition on several levels. Interestingly, the drugs currently used for treating chronic pain, including opioids, gabapentin, and NMDAR (N-methyl-D-aspartate receptor) antagonists, are also known to impair cognition. So whether pain-related cognitive deficits have different synaptic mechanisms as those underlying pain remains to be elucidated. In this context, the synaptic transmission in the unsusceptible group (cognitively normal pain rats) was isolated from that in the susceptible group (cognitively compromised pain rats). It was revealed that nearly two-thirds of the CPSP rats suffered cognitive impairment. The whole-cell voltage-clamp recordings revealed that the neuronal excitability and synaptic transmission in the prefrontal cortex and amygdala neurons were enhanced in the unsusceptible group, while these parameters remained the same in the susceptible group. Moreover, the neuronal excitability and synaptic transmission in hippocampus neurons demonstrated the opposite trend. Correspondingly, the levels of synaptic transmission-related proteins demonstrated a tendency similar to that of the excitatory and inhibitory synaptic transmission. Furthermore, morphologically, the synapse ultrastructure varied in the postsynaptic density (PSD) between the CPSP rats with and without cognitive deficits. Together, these observations indicated that basal excitatory and inhibitory synaptic transmission changes were strikingly different between the CPSP rats with and without cognitive deficits.

Identification of individuals at risk for postoperative cognitive dysfunction (POCD)

Postoperative cognitive dysfunction (POCD) is common, occurring in around 10-54% of individuals within first few weeks after surgery. Although the majority of POCD is less commonly persistent later than 3 months following surgery, the condition increases length of stay (LOS), mortality and long-term cognitive decline, raising the need for a broad screening to identify individuals at risk for POCD during the perioperative period. In this narrative review, we summarize preoperative, intraoperative and postoperative risk factors for POCD reported in last 5 years and discuss neuropsychological tools and potential biomarkers and time points for assessment that might be suitable for clinical use. We aim to provide crucial information for developing a strategy of routine screening for POCD, which may assist with better identification of at-risk individuals for early interventions. Very importantly, the utilization of a standardized strategy may also allow higher consistency and comparability across different studies.

SCFAs Ameliorate Chronic Postsurgical Pain-Related Cognition Dysfunction via the ACSS2-HDAC2 Axis in Rats

Patients with chronic postsurgical pain (CPSP) frequently exhibit comorbid cognitive deficits. Recent observations have emphasized the critical effects of gut microbial metabolites, like short-chain fatty acids (SCFAs), in regulating cognitive function. However, the underlying mechanisms and effective interventions remain unclear. According to hierarchical clustering and 16S rRNA analysis, over two-thirds of the CPSP rats had cognitive impairment, and the CPSP rats with cognitive impairment had an aberrant composition of gut SCFA-producing bacteria. Then, using feces microbiota transplantation, researchers identified a causal relationship between cognitive-behavioral and microbic changes. Similarly, the number of genera that generated SCFAs was decreased in the feces from recipients of cognitive impairment microbiota. Moreover, treatment with the SCFAs alleviated the cognitive-behavioral deficits in the cognitively compromised pain rats. Finally, we observed that SCFA supplementation improved histone acetylation and abnormal synaptic transmission in the medial prefrontal cortex (mPFC), hippocampal CA1, and central amygdala (CeA) area via the ACSS2 (acetyl-CoA synthetase2)-HDAC2 (histone deacetylase 2) axis. These findings link pain-related cognition dysfunction, gut microbiota, and short-chain fatty acids, shedding fresh insight into the pathogenesis and therapy of pain-associated cognition dysfunction.

Efficiency and safety of erector spinae plane block in percutaneous nephrolithotomy: a meta-analysis based on randomized controlled trials

OBJECTIVES

To pool the data of published studies using the meta-analysis method to provide a high level evidence for the use of ESPB in pain control after PCNL.

METHODS

Two main stream databases, Pubmed and Embase, were used to identify potentially included studies. Primary outcomes included pain visual analogue scale (VAS) at different time points, intraoperative fentanyl use, time to first rescue analgesia and total tramadol or paracetamol consumption. Secondary outcome was defined as side effects of nausea and vomiting.

RESULTS

Fourteen studies were identified after database searching and 6 studies were included in the quantitative analysis. Overall, ESPB could significantly reduce the postoperative short-time (1-2h) and long-time (24h) VAS values (MD: -1.35, 95%CI: -1.71, -1.00 for short-time and MD: -0.39, 95%CI: -0.61, -0.17 for long-time) without significant heterogeneity. When it came to other primary outcomes, ESPB still showed its advantages in less intraoperative fentanyl use and total tramadol/paracetamol consumption, and longer time to first rescue analgesia. Complications were similar between groups (OR:0.90, 95%CI:0.38-2.14).

CONCLUSIONS

ESPB was an efficient and safe procedure for postoperative pain management in PCNL. More RCTs with larger sample size are still needed.

The efficacy and safety of paravertebral block for postoperative analgesia in renal surgery: A systematic review and meta-analysis of randomized controlled trials

Background

Paravertebral block (PVB) has been widely used in postoperative analgesia, especially in thoracic and breast surgery. However, the efficacy and safety of PVB for analgesia after renal surgery remains uncertain. Therefore, this study aimed to determine the postoperative analgesic efficacy and safety of PVB in renal surgery.

Methods

PubMed, Web of Science, Embase, and the Cochrane Library databases were systematically searched up to December 20, 2021. All randomized controlled trials (RCTs) evaluating the postoperative analgesic efficacy of PVB in renal surgery were collected. The meta-analysis was performed using RevMan 5.4 and Stata/MP 14.0 software.

Results

A total of 16 RCTs involving 907 patients were included in the meta-analysis. Ten studies investigated patients under percutaneous nephrolithotomy (PCNL), and six studies were done for patients under other renal surgery (nephrectomy or pyeloplasty). Compared with control groups (no block, sham block, or other nerve blocks), meta-analysis showed that PVB reduced 24-hour postoperative opioid consumption significantly (SMD = −0.99, 95%CI: −1.60–0.38, p = 0.001, I² = 92%) and reduced pain scores at various time points within 24 h at rest and 1 h, 4 h, and 24 h at movement after renal surgery, furthermore, PVB prolonged the time to first postoperative analgesic requirement (SMD = 2.16, 95%CI: 0.94–3.39, p = 0.005, I² = 96%) and reduced the incidence of postoperative additional analgesia (OR = 0.14, 95%CI: 0.06∼0.33, p < 0.00001, I² = 50%). Subgroup analysis revealed that the postoperative analgesia effect of PVB was more significant in PCNL, and the use of bupivacaine for PVB seemed to have a better performance. Besides, there was no difference in the incidence of postoperative nausea, vomiting, and itching between PVB and control groups.

Conclusion

This study indicates that PVB may provide effective postoperative analgesia in patients under renal surgery, especially PCNL patients. Moreover, PVB is a safe analgesic method without significant analgesia-related complications.

Effects of Electroacupuncture on Gastrointestinal Motility Function, Pain, and Inflammation via Transient Receptor Potential Vanilloid 1 in a Rat Model after Colonic Anastomoses

Background. Complications after colon surgery are a major obstacle to postoperative recovery. The purpose of this study was to investigate the effect of electroacupuncture (EA) at Zusanli (ST36) on gastrointestinal motility in rats after colonic anastomosis and the mechanism of transient receptor potential vanillin 1 (TRPV1) channel in regulating gastrointestinal motility, pain, and inflammation. Methods. The rats were randomly divided into six groups, including the control, model, EA, sham-EA, capsaicin, and capsaicin+EA groups, with preoperative capsaicin pretreatment and EA treatment at ST36 acupoint after surgery. Rats were treated using EA at ST36 or sham acupoints after surgery for 5 days. Capsaicin was intraperitoneally injected into rats 3 hours before surgery. Gastrointestinal motility was assessed by measuring the gastric residue, small intestinal propulsion in vivo, contractile tension, and frequency of isolated muscle strips in vitro. The mechanical withdrawal threshold (MWT) of abdominal incision skin and spontaneous nociceptive scores were observed and recorded in rats after colon anastomosis. The expressions of TRPV1, substance P (SP), neurokinin 1 (NK1) receptor, nuclear factor kappa-B (NF-κB), interleukin- (IL-) 6, L-1β, and tumor necrosis factor- (TNF-) α were determined. Results. Compared with the model group, electroacupuncture at ST36 point could significantly reduce the residual rate of stomach in rats after operation and increase the propulsive force of the small intestine and the contraction tension of the isolated smooth muscle. Electroacupuncture also increased postoperative day 3 MWT values and decreased postoperative spontaneous nociception scores. In addition, electroacupuncture treatment downregulated the expressions of IL-6, IL-1β, TNF-α, TRPV1, NF-κB, SP, and NK1 receptors in the colon tissue of rats after colonic anastomosis. Conclusions. Our study showed that electroacupuncture at ST36 acupoint could improve gastrointestinal motility in rats after colonic anastomosis and relieve intestinal inflammation and pain. The mechanism may be to inhibit the activation of NF-κB and SP/NK1 receptor signaling pathways by inhibiting TRPV1.

Finding the vulnerable postoperative population: A two-step cluster analysis of the PAIN-OUT registry

BACKGROUND

Identifying predictors of poor postoperative outcomes is crucial for planning personalized pain treatments. The aim of this study was to examine pain outcomes using cluster analysis in N=2,678 patients from the PAIN-OUT registry at first postoperative day.

METHODS

Indicator variables of the clustering analysis assessed multiple domains, such as clinical and surgical conditions, analgesic-anesthetic variables, desire for more pain treatment and outcome variables of the International Pain Outcome Questionnaire (IPO) summarized as factor scores.

RESULTS

Two-step cluster identified the three-cluster solution as the optimal. Two empirical groups (C1 and C2) included patients with good postoperative outcomes discriminated by peripheral nerve block use, while the other cluster (C3) grouped patients with the worst outcomes, where all patients desired more pain treatment. C3 comprised about 20% of the participants, mostly lower limb, abdominal and spine procedures. The best predictors of belonging to C3 included younger age, being male, preoperative opioid use, bone and fracture reduction procedures, institution, number of comorbidities and morphine equivalents in the recovery room.

CONCLUSIONS

IPO factor scores can be used to select pain outcomes phenotypes in large clinical databases. Most of the predictors were present before the recovery period so perioperative planning should focus in the preoperative and intraoperative periods.

Injectable electrospun fiber-hydrogel composite sequentially releasing clonidine and ropivacaine for prolonged and walking regional analgesia

Rationale: Peripheral nerve block is a traditional perioperative analgesic method for its precise pain control and low systemic toxicity. However, a single low dose of local anesthetic merely provides a few hours of analgesia, and high dose results in irreversible toxicity, whereas continuous infusion of anesthetics is expensive and complicated. Therefore, it is necessary to develop a long-acting and sensory-selective local anesthetic for safe perioperative analgesia. Methods: An injectable composite comprising ropivacaine-loaded poly (ε-caprolactone) electrospun fiber and clonidine-loaded F127 hydrogel (Fiber-Rop/Gel-Clo composite) was developed for long-acting and walking regional analgesia with barely one dose. The peripheral nerve blockade effect of the composite was evaluated in a rat sciatic nerve block model. Also, the biodegradability and biosafety of the composite was evaluated. Results: The preferentially released Clo from the hydrogel rapidly constricted the peripheral arterial vessels, reducing the blood absorption of Rop and thus enhancing the local Rop accumulation at the injection site. The subsequently sustainable release of Rop from the fiber, significantly prolonged the sciatic nerve block of rats. Remarkably, an amazing sensorimotor segregation effect was achieved, as the sensory blockade (32.0 ± 1.4 h) lasted significantly longer than the motor blockade (20.3 ± 0.9 h). Additionally, the Fiber-Rop/Gel-Clo composite presented good biodegradability and biosafety in vivo. Conclusions: Our designed Fiber-Rop/Gel-Clo composite with minimal invasion, prolonged synergistic analgesia, and strikingly sensorimotor segregation effect, posted a promising prospect for regional long-term walking analgesia in clinical treatment.

Local effects of natural alkylamides from Acmella oleracea and synthetic isobutylalkyl amide on neuropathic and postoperative pain models in mice

Neuropathic and postoperative pain are clinical conditions that impair the patient's quality of life. The current pharmacotherapy of both painful states is ineffective and accompanied by several side effects. In order to develop new therapeutics targets, the secondary metabolites of plants have been extensively studied. Acmella oleracea ("jambu") is a native plant from the Amazon region and rich in alkylamides, bioactive compounds responsible for inducing anesthetic and chemesthetic sensations. We previously demonstrated that the intraplantar administration of an hexanic fraction (HF) rich in alkylamides from jambu and the synthetic isobutylalkyl amide (IBA) at 0.1 μg/20 μL can promote antinociceptive and anti-inflammatory effects. Thus, this study aimed to evaluate the local effect of HF and IBA (0.1 μg/20 μL) on neuropathic (partial sciatic nerve ligation, PSNL) and postoperative pain (plantar incision surgery, PIS) models in mice. Seven days after the PSNL, the mechanical (von Frey test) and cold (acetone-evoked evaporative cooling) allodynia, and digital gait parameters were analyzed. The intraplantar HF and IBA treatments attenuated the mechanical and cold allodynia as well as the static (max. Contact and print area) and dynamic (stand duration) parameters of digital gait analyses. On the day after PIS, the mechanical allodynia, heat hyperalgesia (hot plate, 52 ± 0.1°C), and spontaneous nociception scores were evaluated. Topical treatment with HF reduced the mechanical allodynia, heat hyperalgesia, and spontaneous nociception scores. In contrast, IBA treatment only partially reduced the mechanical allodynia. In summary, the local treatment with HF was effective on both neuropathic and postoperative pain, as opposed to IBA, which only had an effect on neuropathic pain.

Analgesic and Sedative Effects of Different Doses of Dexmedetomidine Combined with Butorphanol in Continuous Analgesia after a Cesarean Section

Objective

The present study is designed to study the analgesic and sedative effect of different doses of dexmedetomidine combined with butorphanol in continuous analgesia after a cesarean section.

Methods

A total of 60 puerperae undergoing a cesarean section recruited from a single center were divided into three groups according to the postoperative continuous analgesia protocol: control group (100 mL of normal saline containing 10 µg/kg fentanyl and 0.25 mg of palonosetron, 2 mL/h for continuous analgesia for 48 h), DB1 group (100 mL of normal saline containing 1.0 µg/kg dexmedetomidine, 4 mg of butorphanol, 10 µg/kg fentanyl, and 0.25 mg of palonosetron, 2 mL/h for continuous analgesia for 48 h), and DB2 group (100 mL normal saline containing 2.0 µg/kg dexmedetomidine, 4 mg of butorphanol, 10 µg/kg fentanyl, and 0.25 mg of palonosetron, 2 mL/h for continuous analgesia for 48 h). We compared the blood pressure, heart rate, oxygen saturation, VAS score, Ramsay score, and adverse reactions of puerperae among the three groups after surgery.

Results

The baseline data all have no significant difference in the three groups (p > 0.05). Compared with those in the control group, the systolic blood pressure, diastolic blood pressure, heart rate, and VAS score of the puerperae in the DB1 group and DB2 group were significantly decreased at 6, 24, and 48 h (P < 0.05), while the Ramsay scores of the puerperae in DB1 group and DB2 group were significantly increased at 6, 24, and 48 h (p < 0.05). At the same time, the systolic blood pressure, diastolic blood pressure, heart rate, and VAS score of the puerperae in the DB2 group were significantly lower than those in the DB1 group (P < 0.05), while the Ramsay scores of the puerperae in DB2 group were significantly higher than those in the DB1 group (P < 0.05). Also, there is no significant difference in oxygen saturation and adverse reactions of puerperae among the three groups after surgery (p > 0.05).

Conclusion

Dexmedetomidine combined with butorphanol can improve the analgesic and sedative effects in continuous analgesia after a cesarean section, and the analgesic and sedative effects of dexmedetomidine in the high-dose group are better than those in the low-dose group.

Anesthetic Effect of the Fascia Iliaca Compartment Block with Different Approaches on Total Hip Arthroplasty and Its Effect on Postoperative Cognitive Dysfunction and Inflammation

Objective

The objective of this article is to make a comparison of the anesthetic effects of the inside and outside fascia iliaca compartment block (FICB) in total hip arthroplasty (THA) and to study the effect of the different approaches of the FICB on postoperative cognitive dysfunction (POCD) and serum inflammatory cytokines in THA patients.

Methods

A total of 60 patients who received THA treatment from January 2021 to December 2021 were divided into two groups, namely, Inside group (inside approach of the FICB) and Outside group (outside approach of the FICB), according to the different approaches of the FICB. Forty-eight hours after surgery, we compared the use of ropacaine dosage, visual analogue scale (VAS) score, the use of patient-controlled analgesia (PCA), mini-mental state examination (MMSE) score, the incidence of POCD, and the serum levels of IL-1, IL-6. Secondary indicators include surgical indicators and the quality of anesthesia cannula.

Results

The ratio of re-fix the catheter, intubation time, and the use of ropacaine dosage at 48 h after surgery in the Outside group were significantly higher than that in the Inside group (p &lt; 0.05), while the depth of cannulation in the Outside group was significantly lower than that in the Inside group (p &lt; 0.05). VAS scores were comparable between the Inside and the Outside groups, except at 24 h after surgery. The use of PCA from 24 to 48 h after surgery in the Outside group was significantly higher than that in the Inside group (p &lt; 0.05). The MMSE score and the incidence of POCD in the Outside group were higher than that in the Inside group. At the same time, the serum IL-1β levels at 1 and 6 h after surgery and the serum IL-6 levels at 1, 6, 24, and 48 h after surgery in the Outside group were significantly higher than that in the Inside group (p &lt; 0.05).

Conclusion

Compared with the outside approach of the FICB, the inside approach of the FICB has better anesthetic effect, better postoperative analgesia, fewer postoperative analgesics, lower incidence of POCD, and lower serum cytokines during the treatment of THA patients.

The duration of chronic low back pain is associated with acute postoperative pain intensity in lumbar fusion surgery: a prospective observational study

BACKGROUND

Pre-existing chronic pain has been associated with severe postoperative pain. In this study, we sought to prospectively analyse the association between the duration of chronic low back pain and the intensity of acute postoperative pain after lumbar fusion surgery.

METHODS

A total of 330 patients who underwent lumbar fusion surgery were divided into three groups (chronic low back pain less than 1 year, one to 5 years, and more than 5 years) based on the duration of chronic pain. On the first postoperative day, the maximum pain scores of each patient were recorded during the day and at night. Bivariate correlation and logistic regression were performed to identify relationships between acute postoperative pain and related variables (age, sex, smoking history, body mass index, operation history, duration of surgery, level of preoperative pain, aetiology of back pain, Self-rating Anxiety Scale, Self-rating Depression Scale, FRAIL scale, and duration of chronic low back pain). If the postoperative pain score was > 3 when the patient reported was at rest, the patients were treated with postoperative intravenous self-controlled analgesia or rescue analgesics if necessary.

RESULTS

There was an association between severe acute postoperative pain and the duration of chronic low back pain. In terms of VAS day, multivariable logistic regression showed the duration of chronic low back pain was not statistically significant (OR = 2.48, 95% CI: 0.900 to 6.828, p = 0.0789). The result is uncertain because the confidence interval included the null after controlling for SAS, SDS, BMI, and aetiology of back pain. In terms of VAS night, patients with a duration of chronic low back pain of more than 5 years were more likely having moderate to severe acute postoperative pain (VAS > 3) compared to patients with a duration of chronic low back pain less than 1 year (OR = 3.546, 95% CI: 1.405 to 8.95, p = 0.0074). Hospital stay, the pain score on the day of discharge and the pain score after 3 months displayed no significant difference among the three groups (P > 0.05). However, the need for postoperative rescue analgesics was different among the three groups (P < 0.05).

CONCLUSION

The longer the duration of chronic pain was, the higher the incidence of moderate to severe acute postoperative pain was and the greater the amount of analgesics required after surgery.

TRIAL REGISTRATION

This study was registered at the Chinese Clinical Trial Registration Center ( http://www.chictr.org.cn/index.aspx , clinical trial number: ChiECRCT20200165, date of registration: July 6, 2020).

Application of Ultrasound-Guided Transversus Abdominis Plane Block Combined with Nalbuphine Patient-Controlled Intravenous Analgesia in Postoperative Analgesia After Laparotomy: A Randomized Controlled Trial

Introduction

Pain is a common postoperative complication. The ideal postoperative analgesia is awake, safe, mobile, and without side effects. The objective of this study is to provide new ideas for postoperative analgesia by observing the safety and analgesic effect of different analgesic methods in patients undergoing laparotomy after surgery.

Methods

Patients, who underwent laparotomy between September 2019 and December 2020, were randomly divided into three groups: group S received sufentanil, group N received nalbuphine, group T + N received postoperative bilateral transversus abdominis plane block (TAPB) and nalbuphine. The primary outcomes included visual analog scale (VAS) score and the use of postoperative analgesic pump. Secondary outcomes included quality of life recovery (QoR-15) scale score and incidence of postoperative adverse reactions.

Results

Compared with group S and N, there were significant differences in the resting VAS score within 48 h after surgery, dynamic VAS score within 12 h after surgery, the first compression time, and cumulative use of patient-controlled intravenous analgesia (PCIA) drugs at 24 h in group T + N (P < 0.05). The QoR-15 score within 48 h after surgery in group T + N was significantly higher than group N (P < 0.05). The first exhaust time and the incidence of nausea and vomiting in group T + N were significantly lower than those in group N (P < 0.05).

Conclusions

Sufentanil PCIA and nalbuphine PCIA have equivalent analgesic effects, while TAPB combined with nalbuphine PCIA can ensure a good analgesic effect, thereby reducing the incidence of adverse reactions.

Comparison of Supraclavicular Regional Nerve Block Versus Infraclavicular Regional Nerve Block in Distal Radial Open Reduction and Internal Fixation: A Retrospective Case Series

Background

The management of pain in patients undergoing open reduction and internal fixation (ORIF) of distal radius fractures (DRFs) remains an area of debate for anesthesiologists due to a variety of block options and no definitive superior technique among these modalities. In this retrospective case series, we compare the efficacy of supraclavicular versus infraclavicular regional nerve blocks for surgical patients undergoing distal radial ORIF operations to determine if one approach was superior.

Methodology

This retrospective case series included patients undergoing ORIF of a DRF at a tertiary academic medical center between April 28, 2016, and August 23, 2021. In total, 54 patients undergoing ORIF of a DRF provided written consent for the nerve block(s) on the day of surgery. Of these 54 patients, 54 (100%) underwent primary procedures. Of the 54 primary ORIF patients, 28 (52%) received the supraclavicular block, while 26 (48%) received the infraclavicular nerve block.

Results

The infraclavicular and supraclavicular groups did not significantly differ regarding age, gender, American Society of Anesthesiologists, weight, or body mass index. The primary (intraoperative opioid use) and secondary (postoperative opioid use, postoperative nausea and vomiting in the post-anesthetic care unit, highest and average pain scores, and time to discharge) outcomes data were included in the study. The infraclavicular and supraclavicular groups did not significantly differ in any of the assessed outcomes except for time to discharge.

Conclusions

The supraclavicular block approach for distal radius ORIF offers an effective and non-inferior alternative to the infraclavicular block approach concerning effective analgesia and safety.

Evaluation of Preoperative Sleep Quality and Factors Affecting Pain Intensity of Patients Hospitalized in Surgical Services

PURPOSE

The aim of this study was to determine the preoperative sleep quality and pain intensity of patients hospitalized in the surgical services of a university hospital, and to evaluate the relationship between sleep quality and pain intensity and the factors affecting it.

DESIGN

The study was a descriptive cross-sectional study.

METHODS

The study was conducted on 139 patients over the age of 18 who were hospitalized in the surgical services of Eskişehir Osmangazi University Health Practice and Research Hospital between March 1, 2019 and July 31, 2019, and agreed to participate in the study. The "Visual Analog Scale for Pain (VASP)" was used to evaluate the pain intensity of the patients, and the "Visual Analog Sleep Scale (VASS)" to determine the quality of sleep.

FINDINGS

The sleep quality of women, those who had sleep problems before hospitalization and those who had sleep problems in the preoperative period was worse (P <.001). Patients who had a companion and had sleep problems in the preoperative period had higher pain levels (P <.001 for each). As the pain levels of the patients increased, their sleep quality deteriorated (P <.001). Multiple linear regression analysis revealed that for each unit increase in the variable of having sleep problems in the preoperative period increases the VASS score by 180.422 points and the VASP score by 1.788. Being a woman increased the VASS score by 91.469 points, and the presence of a companion increased the VASP score by 1.644 points.

CONCLUSIONS

The preopertive sleep quality and pain intensity of surgery patients were interrelated. Having sleep problems in the preoperative period affected both the sleep quality and pain intensity of the patients. While female gender affected the sleep quality of the patients hospitalized in surgical services, the presence of a companion was found to affect the severity of pain.

Evaluation of Different Pain-Control Procedures for Post-cardiac Surgery: A Systematic Review and Network Meta-Analysis

Objective

To identify superior pain-control procedures for postoperative patients who undergo cardiac surgeries.

Methods

Literature searches were conducted in globally recognized databases, including MEDLINE, EMBASE and Cochrane Central, to identify randomized controlled trials (RCTs) investigating pain-control procedures after cardiac surgeries. The parameters evaluating analgesic efficacy and postoperative recovery, namely, the pain score and ICU stay, were quantitatively pooled and estimated using Bayesian methods. The values of the surface under the cumulative ranking (SUCRA) probabilities regarding each parameter were calculated to enable the ranking of various pain-control procedures. Node-splitting analysis was performed to test the inconsistency of the main results, and the publication bias was assessed by examining the funnel-plot symmetry.

Results

After a detailed review, 13 RCTs containing 7 different procedures were included in the network meta-analysis. After pooling the results together, an erector spinae plane block (ESPB) and a local parasternal block (LPB) plus target-controlled infusion (TCI) presented the best analgesic effects for reducing pain at rest (SUCRA, .47) and during movement (SUCRA, .52), respectively, while the former also achieved the shortest ICU stay (SUCRA, .48). Moreover, the funnel-plot symmetries showed no inconsistencies or obvious publication bias in the current study.

Conclusions

The current evidence indicates that ESPB is a potential superior analgesic strategy for post-cardiac surgery patients. To verify this conclusion further, it is imperative to obtain more high-quality evidence and conduct relevant investigations in the future.

A guide to regional analgesia for Total Knee Arthroplasty

Regional analgesia has been introduced successfully into the postoperative pain management after total knee arthroplasty, reducing pain scores, opioid use and adverse effects.

Combination of regional analgesia techniques is associated with better pain management and lower side effects than single regional techniques.

Adductor canal block provides good analgesia and considerably lower detrimental effect in muscular strength than femoral nerve block, enhancing surgical recovery.

Infiltration techniques may have equivalent analgesic effect than epidural analgesia and peripheral nerve blocks, however there should be awareness of dose dependent toxicity.

Novel long-acting local anesthetics role for regional analgesia is still to be determined, and will require larger randomized trials to support its advantage over traditional local anesthetics.

Cite this article: EFORT Open Rev 2021;6:1181-1192. DOI: 10.1302/2058-5241.6.210045

Dexmedetomidine-soaked nasal packing can reduce pain and improve sleep quality after nasal endoscopic surgery: a double-blind, randomized, controlled clinical trial

STUDY OBJECTIVE

Bilateral endoscopic nasal surgery is usually associated with pain and sleep disturbance. The aim of this study was to evaluate the effects of dexmedetomidine-soaked nasal packing on analgesia and improvement of sleep quality in patients undergoing this surgery.

METHOD

Eighty patients were enrolled and randomly allocated into 4 groups. At the end of surgery, dexmedetomidine-soaked nasal packings were applied to three groups with a dosage of 1 μg kg^-1 (D1), 2μg kg^-1 (D2), 4 μg kg^-1 (D4) and normal saline-soaked nasal packing (NS) was applied to a fourth group. The primary outcome was postoperative pain scores using a visual analog scale (VAS) recorded at six time points: before the surgery (T1); 2 h (T2), 8 h (T3), 24 h (T4), 48 h (T5) after surgery; and at the moment of nasal packing removal (T6). Secondary outcomes were postoperative sleep status evaluated by the Pittsburgh sleep quality index (PSQI) and subjective sleep quality value (SSQV). Factors affecting sleep, hemodynamic changes, and adverse events were also recorded.

RESULTS

Compared with the NS group, dexmedetomidine-soaked nasal packing significantly relieved postoperative pain and improved sleep quality. The effect was similar between D2 and D4, which was greater than in D1. However, D2 was associated with fewer adverse events.

CONCLUSIONS

Dexmedetomidine-soaked nasal packing not only offers effective analgesia but also improves postoperative sleep quality in patients undergoing bilateral endoscopic nasal surgery. Taking effect and adverse events into consideration, a dosage of 2μg kg^-1 may be optimal.

TRIAL REGISTRATION

www.chictr.org.cn/index.aspx (ChiCTR1900025692) Retrospectively registered 5 September 2019.

Effect of Different Modes of Administration of Dexmedetomidine Combined with Nerve Block on Postoperative Analgesia in Total Knee Arthroplasty

INTRODUCTION

Dexmedetomidine (DEX) as a nerve block adjuvant can significantly prolong analgesia. However, whether perineural or systemic administration of DEX is more beneficial in patients undergoing total knee arthroplasty (TKA) has not been thoroughly investigated. To this end, we evaluated the effects of perineural and systemic DEX administration on postoperative analgesia in patients undergoing TKA surgery.

METHODS

We randomly assigned patients undergoing TKA under general anesthesia combined with femoral nerve block and sciatic nerve block to one of three groups: (1) ropivacaine plus perineural dexmedetomidine (DP): 0.25% ropivacaine 40 mL plus 0.5 μg/kg dexmedetomidine; (2) ropivacaine plus systemic dexmedetomidine (DS): 0.25% ropivacaine 40 mL plus systemic 0.5 μg/kg dexmedetomidine; (3) control group (C): 0.25% ropivacaine 40 mL.

RESULTS

The average length of time until patients first experienced postoperative pain was significantly longer in the DP group (26.0 h [22.0-30.0 h]) than in the DS group (22.4 h [18-26.8 h]) and the control group (22.9 h [19.5-26.3 h], P = 0.001). For this result there was no significant difference between the DS and the control group. Compared with the DS and control groups, patients in the DP group had lower resting visual analogue scale (VAS) scores at 24, 48, and 72 h after surgery (P < 0.05). VAS activity scores at 12, 24, and 48 h after surgery in the DP group were lower than those in the DS and control groups, with a statistically significant difference (P < 0.05). Compared with the DS and control groups, the amount of postoperative opioids in the DP group was also significantly reduced, and the number of people needing postoperative rescue analgesia was significantly lower, with a statistical difference (P < 0.05). Meanwhile, the sleep satisfaction of patients in the DP group on the first night after surgery and the satisfaction with pain control at 72 h after surgery were both higher than those in the DS group and control group (P < 0.05).

CONCLUSIONS

Perineural administration of DEX can significantly prolong the interval until patients report pain for the first time after TKA, relieve postoperative pain, reduce postoperative opioid dosage, and improve postoperative sleep quality and satisfaction with pain control.

TRIAL REGISTRATION

The trial was registered at the Chinese Clinical Trial Registry, identifier ChiCTR1900025808.

Developing consensus on core outcome domains for assessing effectiveness in perioperative pain management: results of the PROMPT/IMI-PainCare Delphi Meeting

ABSTRACT

Postoperative pain management is still insufficient, leading to major deficits, including patient suffering, impaired surgical recovery, long-term opioid intake, and postsurgical chronic pain. Yet, identifying the best treatment options refers to a heterogeneous outcome assessment in clinical trials, not always reflecting relevant pain-related aspects after surgery and therefore hamper evidence synthesis. Establishing a core outcome set for perioperative pain management of acute pain after surgery may overcome such limitations. An international, stepwise consensus process on outcome domains ("what to measure") for pain management after surgery, eg, after total knee arthroplasty, sternotomy, breast surgery, and surgery related to endometriosis, was performed. The process, guided by a steering committee, involved 9 international stakeholder groups and patient representatives. The face-to-face meeting was prepared by systematic literature searches identifying common outcome domains for each of the 4 surgical procedures and included breakout group sessions, world-café formats, plenary panel discussions, and final voting. The panel finally suggested an overall core outcome set for perioperative pain management with 5 core outcome domains: physical function (for a condition-specific measurement), pain intensity at rest, pain intensity during activity, adverse events, and self-efficacy. Innovative aspects of this work were inclusion of the psychological domain self-efficacy, as well as the specific assessment of pain intensity during activity and physical function recommended to be assessed in a condition-specific manner. The IMI-PROMPT core outcome set seeks to improve assessing efficacy and effectiveness of perioperative pain management in any clinical and observational studies as well as in clinical practice.

Study on the Effect of Different Doses of Hydromorphone on the Time Response and Postoperative Analgesia of Ropivacaine in Ultrasound-Guided Suprailiac Fascia Inguinal Block

OBJECTIVE

To investigate the effects of different doses of hydromorphone under the guidance of ultrasound on ropivacaine blocking the superior inguinal iliac fascia and postoperative analgesia.

METHODS

From January 2020 to June 2021, 90 American Society of Anesthesiologists (ASA) I-II patients undergoing elective total hip arthroplasty (THA) were selected and randomly divided into 3 groups, 30 patients in each one. Ultrasound-guided superior inguinal iliac fascia block was performed in the patients of the 3 groups before operation. The L group: 0.3% ropivacaine 30 ml; the H1 group: 0.3% ropivacaine + 25 μg/kg hydromorphone 30 ml; the H2 group: 0.3% ropivacaine + 50 μg/kg hydromorphone 30 ml. The time until the occurrence of pain, pain intensity, sufentanil remedial dose, the number of PCIA presses, and effective times were compared among the 3 groups. The VAS and Ramsay scores of 3 groups were recorded at 12 h, 24 h, 36 h, and 48 h after operation.

RESULTS

The time from the end of surgery to the appearance of pain in the H2 group was higher than that in the H1 group and the L group, and the time in the H1 group was higher than that in the L group (P < 0.05). The VAS score in the H2 group was lower than that in the H1 group and the L group, and the VAS score in the H1 group was lower than that in the L group (P < 0.05). The VAS scores of 12 h, 24 h, 36 h, and 48 h after operation in the H2 group were lower than those of the H1 group and the L group, and the H1 group was lower than the L group (P < 0.05). The Ramsay scores at 12 h, 24 h, 36 h, and 48 h after operation in the H2 group and the H1 group were higher than those in the L group (P < 0.05), and the difference was not statistically significant in the H2 group and the H1 group (P > 0.05). The remedial dosage of sufentanil, times of PCIA compression, and effective times in the H2 group were lower than those in the H1 group and the L group, and the level in the H1 group was lower than that in the L group (P < 0.05). The incidence rates of adverse reactions in the L group, the H1 group, and the H2 group were 13.33%, 23.33%, and 30.00%, respectively. There was no significant difference in the incidence rate of adverse reactions among the 3 groups (P > 0.05).

CONCLUSION

25 μg/kg and 50 μg/kg hydromorphone used in the ultrasound-guided superior inguinal iliac fascia block can enhance the time effect of ropivacaine and improve analgesic effects, with good safety. In addition, time effect and analgesic effect of 50 μg/kg hydromorphone in enhancing ropivacaine were more obvious.

Evaluation of functional parameters, patient-reported outcomes and workload related to continuous urinary bladder irrigation after transurethral surgery

Background

Continuous saline bladder irrigation (CBI) is a common procedure after transurethral surgery and to treat gross hematuria. We conducted this study to gather data on parameters of CBI, medical staff’s work load associated with CBI monitoring, patients’ feeling of safety and of patients’ impairments during CBI.

Methods

We observed CBI taking place after transurethral surgery for a 2–9-hour period. Patients were asked to rank how safe they felt, general impairments and impaired mobility. Irrigation parameters and complications were documented at least every 30 minutes. The staff’s workload was evaluated through the frequency of visits and presence time.

Results

The patients’ mobility was notably reduced with an average of 10.5%±16.7% of time spent outside of bed, pain was low (mean 0.60±1.15). Patients felt very safe with CBI (8.8±1.9), hardly impaired overall (3.8±3.0), but restricted in mobility (5.9±2.8). Pain was associated with general impairment and impaired mobility. Clot retention occurred in 5 patients. Average irrigation speed was 9.46±8.69 mL/min (0 to 86.7 mL/min). Urine bags were emptied on average every 2.2±1.2 hours. Patients were visited by medical personnel 1 to 11 times.

Conclusions

CBI remains an improvable procedure in terms of the irrigation process itself to prevent complications, the patients’ feeling of safety and comfort during CBI and the amount of work associated with its monitoring. We have provided parameters for the implementation of more individualized CBI monitoring.

Trial registration

German Clinical Trial Registry; DRKS00023707; Registered retrospectively November 25 2020, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00023707

Intrathecal Injection of GRIP-siRNA Reduces Postoperative Synaptic Abundance of Kainate Receptor GluK2 Subunits in Rat Dorsal Horns and Pain Hypersensitivity

The mechanisms underlying postoperative pain differ from the inflammatory or neuropathic pain. Previous studies have demonstrated that intrathecal α-amino-3-hydroxy-5-methy-4-isoxazole propionate (AMPA) -kainate (KA) receptor antagonist inhibits the guarding pain behavior and mechanical hyperalgesia, indicating a critical role of spinal KA receptors in postoperative pain hypersensitivity. However, how the functional regulations of spinal KA receptor subunits are involved in the postoperative pain hypersensitivity remains elusive. Therefore, in the current study, we investigated the synaptic delivery of spinal KA receptor subunits and the interaction between KA receptor subunits and glutamate receptor-interacting protein (GRIP) during the postoperative pain. Our data indicated that plantar incision induced the synaptic delivery of GluK2, but not GluK1 or GluK3 in ipsilateral spinal cord dorsal horns. The co-immunoprecipitation showed an increased GluK2 -GRIP interaction in ipsilateral dorsal horn neurons at 6 h post-incision. Interestingly, Intrathecal pretreatment of GRIP siRNA increased the paw withdrawal thresholds to mechanical stimuli and decreased the cumulative pain scores in the paws ipsilateral to the incision at 6 h post-incision. Additionally, Intrathecal pretreatment of GRIP siRNA reduced the synaptic abundance of GluK2 in ipsilateral spinal dorsal horn at 6 h after plantar incision. In general, our data have demonstrated that the GluK2- GRIP interaction-mediated synaptic abundance of GluK2 in dorsal horn neurons plays an important role in the postoperative pain hypersensitivity. Disrupting the GluK2- GRIP interaction may provide a new approach for relieving postoperative pain.

Postoperative Pain Mediates the Association Between Peripheral Nerve Blocks and Postoperative Sleep Following Lower Extremity Arthroplasty

OBJECTIVES

Despite substantial research showing the bidrectional relationship between sleep and pain, there remains a dearth of research examining the role of perioperative pain management interventions in mitigating postoperative sleep disturbances. This secondary analysis of a prospective observational multisite study examined the association between peripheral nerve block (PNB) use during total knee or total hip arthroplasty (TKA/THA) procedures and postoperative pain and sleep outcomes.

MATERIALS AND METHODS

Adult patients undergoing TKA or THA procedures were recruited from 2 tertiary care facilities. Average pain and sleep disturbance scores were collected preoperatively and at 1- and 2-week postoperatively. Participants were not randomized to receive PNB. Postoperative outcomes were compared based on receipt of PNB during surgery. Structural equation modeling path analysis was utilized to model multiple co-occurring relationships, including mediation pathways between perioperative pain management approaches, pain, and postoperative sleep outcomes.

RESULTS

Of the 197 participants, 53% received PNB. Mediation analyses indicated that PNB was indirectly associated with 1-week sleep disturbance via its effects on 1-week pain intensity (β=-0.02, 95% confidence interval [CI] -0.04, -0.001, P=0.04). In addition, PNB was indirectly associated with 2-week sleep disturbance, via its effects on 1-week pain intensity and 1-week sleep disturbance (β=-0.04, 95% CI -0.07, -0.02, P=0.04). Lastly, PNB was indirectly associated with 2-week pain intensity via its effects on 1-week pain intensity (β=-0.10, 95% CI -0.19, -0.02, P=0.02).

CONCLUSIONS

Receipt of PNB during TKA or THA was found to be associated with improved 1-week postoperative pain intensity, which in turn was found to be associated with lower sleep disturbances at both 1- and 2-week postoperative time points. Multimodal opioid sparing pain management interventions, capable of improving postoperative sleep, are vital to improving recovery and rehabilitation following arthroplasty.

Pre-surgical heart-rate variability strongly predicts less post-operative pain in patients with epilepsy

OBJECTIVES

Post-operative pain is a common clinical problem after surgery, yet its predictors are inconsistent and unclear. This study examined whether pre-surgical vagal cardiac efferent nerve activity, indirectly indexed by heart rate variability (HRV), predicts patients' pain after epileptic surgery.

METHODS

Using a prospective design, HRV was measured at rest during 5 min in n = 30 patients, prior to undergoing epileptic surgery. Post-operative pain was assessed every 8 h during the first 2 days after surgery, and our analyses focused on the worse pain level. We used multiple regression analyses and statistically considered several confounders (age, surgical duration, and analgesics during various surgical phases).

RESULTS

Multiple HRV indexes strongly and inversely predicted post-operative pain, with high-frequency HRV (HF-HRV) being the strongest predictor (r = -0.81, p < 0.001). In a hierarchical multiple regression, HF-HRV accounted for an additional and significant 18% of the variance in post-operative pain, after statistically considering effects of age, surgical duration and effects of two anaesthetics.

CONCLUSIONS

Pre-surgical HF-HRV independently, strongly and inversely predicts post-operative pain. These results are in line with a neuromodulatory role of the vagus nerve in pain and have clinical implications for predicting and managing post-operative pain.

Laparoendoscopic single-site adrenalectomy versus multi-port laparoendoscopic adrenalectomy: A systemic review and meta-analysis

Background

To investigate the outcomes of laparoendoscopic single-site adrenalectomy (LESS-A) compared to multi-port laparoendoscopic adrenalectomy (m-LA).

Methods

Studies comparing LESS-A with m-LA were identified from PubMed, Embase, and Cochrane Library before June 2020. Post-operative pain, resumption outcomes, and perioperative outcomes were analyzed. We conducted meta-analyses using the Mantel-Haenszel method with random-effects model. Subset analyses were conducted according to peritoneal and retroperitoneal approaches. A small study effect was illustrated using funnel plots and Egger's test.

Results

One randomized controlled trial (RCT) and nineteen retrospective cohort studies involving 1554 patients were included for analyzed. Pooled analysis showed that LESS-A had significantly lower postoperative pain scores (MD −0.77, 95%CI −1.45 to −0.10) and less pain medication used (RR 0.74, 95%CI 0.60 to 0.91) compared to m-LA. Besides, LESS-A had significantly shorter hospital stays (MD −0.75, 95%CI −1.18 to −0.33), shorter duration of oral intake resumption (MD −0.33, 95%CI −0.60 to −0.06), and better cosmetic satisfaction (SMD 1.15, 95%CI 0.21 to −2.09). As for perioperative outcomes, LESS-A led to significant longer operative time (MD 13.43, 95%CI 4.08 to 22.77). No significant differences were observed in terms of the remaining perioperative outcomes.

Conclusions

LESS-A is associated with less post-operative pain and quicker recovery duration. However, the longer operative time of LESS-A compared with m-LA is a drawback.

•

Multi-port laparoscopic adrenalectomy (m-LA) is widely used for treatment of benign adrenal tumor.

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Laparoscopic single-site adrenalectomy (LESS-A) had significant less post-operative pain and less pain medication consumption comparing with m-LA.

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LESS-A had better resumption outcomes, including shorter hospital stay and quicker post-operative oral intake.

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LESS-A offer better cosmetic satisfaction.

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Longer operative time is a drawback of LESS-A.

Carbenoxolone has the potential to ameliorate acute incision pain in rats

Carbenoxolone (CBX) is primarily used to relieve various types of neuropathic and inflammatory pain. However, little is known concerning the role of CBX in acute pain and its functional mechanisms therein and this was investigated in the present study. Rats underwent toe incision and behavioral tests were performed to assess mechanical hypersensitivity. The expression levels of pannexin 1 (Px1) and connexin 43 (Cx43) were detected using western blot analysis 2, 4, 6 or 24 h after toe incision, and the expression of TNF-α, IL-1β and P substance (SP) was determined by ELISA; Px1 and Cx43 expression was also examined by immunofluorescence staining. At 2, 6 and 12 h post-toe incision, the postoperative pain threshold was significantly reduced, which was subsequently recovered at 2 and 6 h post-surgery following pretreatment with CBX or pannexin 1 mimetic inhibitory peptide. CBX reduced Px1 levels at 4 and 24 h post-incision. However, Cx43 levels were reduced by CBX as little as 2 h post-surgery. Furthermore, CBX not only distinctly decreased the levels of Px1 and Cx43, but also reduced the co-localization of Px1 or Cx43 with glial fibrillary acidic protein, 2 h after incision. It was also observed that the protein levels of inflammatory makers (IL-1β, SP and TNF-α) showed a tendency to decline at 2, 4, 6 and 24 h after incision. Collectively, the expression of Px1 and Cx43 in astrocytes may be involved in pain behaviors diminished by CBX, and CBX potentially reduces acute pain by decreasing Px1 and Cx43 levels. Px1 and Cx43 from spinal astrocytes may serve important roles in the early stages and maintenance of acute pain, while preoperative injection of CBX has the potential to relieve hyperalgesia.

An Evaluation of the Effect of Catheter-Directed Continuous Infusion of Local Anesthetic by Elastomeric Pump on Opioid Usage Following Donor Kidney Nephrectomy

BACKGROUND

Postoperative pain management following donor nephrectomy can prove challenging for immediate discharge on postoperative day 1 or 2. Although the standard for pain control is utilization of opioids, this increases the risk of postoperative ileus and, if continued inappropriately, increases excess opioids circulating in the community. One strategy that proposes to limit postoperative opioids in kidney donors is the continuous infusion of local anesthetics (CILA), though the effect on patient outcomes is unclear.

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of postoperative CILA to decrease opioid usage in kidney donors who undergo laparoscopic nephrectomy.

METHODS

A retrospective analysis was conducted of kidney donors who underwent laparoscopic nephrectomy and received CILA (CILA group) compared with kidney donors who received standard-of-care (SOC) postoperative analgesia. The primary outcome was the mean total oral morphine equivalents (OMEs) administered following surgery.

RESULTS

A total of 176 kidney donors were evaluated, 88 in each group. The mean OME administered in the CILA group was significantly higher than in the SOC group: 194.8 versus 133.5 mg (P = 0.003). Mean total postoperative administration of acetaminophen was also increased in the CILA group: 3736.9 versus 2611.6 mg (P = 0.0041). Mean length of stay following surgery was higher in the kidney donors who received CILA, whereas return to bowel function, time to ambulation, and pain scores were not significantly different.

CONCLUSION AND RELEVANCE

This report demonstrated that CILA is not an effective modality to reduce opioid utilization or improve recovery in kidney donors following laparoscopic nephrectomy.

The effect of preoperative sublingual buprenorphine on postoperative pain after lumbar discectomy: A randomized controlled trial

Background

Lumbar discectomy is one of the most common surgical procedures performed to manage pain caused by the protrusion of an intervertebral disc. Postoperative pain management can be challenging and might lead to increased intake of opioids. Objective: The aim of this study was to determine the effect of preoperative sublingual buprenorphine on severity of pain after lumbar disc surgery and postoperative intake of morphine.

Methods

This Randomized clinical trial study was performed on 78 patients who were selected for lumbar discectomy surgery. Patients were randomly divided into two groups of 39 patients, each. Patients in the buprenorphine and placebo group received 2 mg buprenorphine sublingual, and placebo 1 h before surgery. Severity of pain, nausea, vomiting and pruritus and intake of opioids in the two groups were evaluated and recorded 1, 6, 12 and 24 h after surgery. Data were analyzed using SPSSv21.

Results

There was a significant difference in pain score in buprenorphine group at 1, 6, 12, and compared with placebo (P < 0.005). In the control group, the use of analgesics was more than the buprenorphine group. In the first hours after surgery (1–6 h), the incidence of nausea in the buprenorphine group was significantly lower than of the control group (P < 0.05). However, at 12 and 24 h, this difference was not observed, p > 0.05. There was no significant difference in incidence of side effects (nausea, vomiting, pruritus) in the two groups (P > 0.05).

Conclusion

Sublingual buprenorphine in postoperative pain management is an effective and low dose drug. Due to its simpler administration, it is recommended to relief postoperative pain after lumbar disc surgery.

•

Lumbar discectomy is one of the most common surgical procedures performed to manage pain.

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Postoperative pain management can be challenging and might lead to increased intake of opioids.

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Sublingual buprenorphine in postoperative pain management is an effective and low dose drug.

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It is recommended to relief postoperative pain after lumbar disc surgery.

TNF-α - mediated peripheral and central inflammation are associated with increased incidence of PND in acute postoperative pain

Background

Acute postoperative pain plays an important role in the perioperative neurocognitive disorders (PND). The pathogenesis of PND is still unknown, but it is generally believed that peripheral and central nervous system inflammation play an important role, and acute postoperative pain is also thought to aggravate postoperative inflammatory response. The aim of the present study is to explore the effect of acute postoperative pain on peripheral and central nervous system inflammation and related cognitive impairment behaviour in elderly rats after surgery.

Methods

Rats were assigned into four groups: control, surgery for internal fixation for tibial fracture, surgery with analgesia using intraperitoneal morphine, and morphine without surgery. Pain was assessed by the Subjective Pain Scale. The spatial memory of rats was assessed by the Morris water maze (delayed matching task) from the second day to the seventh day after surgery (POD2-POD7). In part of the rats, the pro-inflammatory cytokines TNF-α in plasma, the medial prefrontal cortex (mPFC), and the hippocampus were determined by ELISA on the POD2. The activation of microglia and the expression of c-Fos in the hippocampal CA1 regions and mPFC were detected by the immunohistochemical method on the POD2.

Results

Acute postoperative pain and spatial memory impairment occurred after operation, and postoperative analgesia could significantly improve the both parameters. Additionally, on the POD2, the levels of TNF-α in plasma, hippocampus and mPFC were significantly increased, while the activation of microglia cells and the expression c-Fos in the hippocampal CA1 regions and mPFC were significantly increased. And postoperative analgesia with morphine significantly inhibited the above reactions.

Conclusion

Our data suggest that acute postoperative pain increases the incidence of perioperative neurocognitive disorders. Peripheral and central nervous system inflammation may be involved in this cognitive impairment. And reducing the intensity of acute postoperative pain may be one of the main preventive strategies for PND.

Effects of Transcutaneous Electrical Acupoint Stimulation (TEAS) on Postoperative Recovery in Patients with Gastric Cancer: A Randomized Controlled Trial

Purpose

Transcutaneous electrical acupoint stimulation (TEAS) is an innovative choice for postoperative pain management. However, the safety and effectiveness of this traditional Chinese medicine (TCM) therapy for patients who underwent gastrectomy is largely unknown. So, the purpose of this study is to evaluate the safety and effectiveness of TEAS for patients who underwent gastrectomy.

Patients and Methods

We recruited 96 patients with gastric cancer from May 2019 to November 2019; 82 patients were enrolled, and 81 patients completed. Patients were randomly assigned to TEAS group (TG) received TEAS on postoperative day (POD) 1–3 or control group (CG) at a 1:1 ratio. The primary outcomes were pain score and consumption of analgesics. The secondary were the time of first postoperative flatus and defecation, frequency of postoperative nausea, vomiting, distention, diarrhea, comfort of semi-fluid diet, Clavien-Dindo grade (C-D grade) and length of postoperative day. We performed hematological analysis to explore the possible mechanisms.

Results

Overall, 81 patients were enrolled included in the analysis. Compared with CG, pain scores in TG were lower on POD 1–5 (average: 2.55±0.21 vs 3.10±0.42, P<0.001), and the use rate of opioids was lower (43.9 vs 75.0, P=0.004); time of first postoperative flatus (55.63±16.74 vs 72.60±20.92, P<0.001) and defecation (72.20±16.24 vs 95.78±17.75, P<0.001) were shorter; the frequency of nausea were fewer (1.88±1.09 vs 2.58±0.77, P=0.029) and patients were more comfortable with semi-fluid diet (7.63±0.63 vs 6.93±0.69, P<0.001); among the hematologic results, β-endorphin (β-End), interleukin-2 (IL-2), motilin (MTL) on POD 3, POD 5 were lower, 5-hydroxytryptamine (5-HT), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α) were higher. And no adverse event was reported.

Conclusion

TEAS can relieve postoperative pain and promote the recovery of gastrointestinal function. Consequently, it can be an adjunctive therapy to enhance postoperative recovery for patients after gastrectomy.

Acupuncture for Rehabilitation After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: There is an increasing interest in acupuncture for promoting post-operative rehabilitation, but the effectiveness of acupuncture for rehabilitation after total knee arthroplasty (TKA) remains controversial.

Objective: This study aims to investigate the effect of acupuncture on rehabilitation after TKA.

Methods: Database searches of PubMed, EMBASE, CINAHL, and China National Knowledge Infrastructure (CNKI) were conducted to obtain articles published until August 2020. All identified articles were screened, and data from each included study were extracted independently by two investigators. Meta-analysis was performed to examine the effects of acupuncture on pain, range of knee motion, function, and nausea/vomiting after TKA.

Results: A total of nine randomized clinical trials were included according to the inclusion and exclusion criteria in this review. Compared with routine treatment, acupuncture combined with routine treatment showed a significantly greater pain reduction at 8, 12, 24, and 48 h post-operatively after TKA. Meanwhile, we found that the acupuncture groups showed a significant function improvement and a lower percentage of nausea/vomiting in comparison with the control groups after operation. However, acupuncture groups demonstrated no statistically significant improvement in post-operative pain at 4 h, 7 days, 14 days, and more than 21 days, and no significant difference in range of knee motion was observed between the acupuncture groups and control groups after surgery.

Conclusions: Acupuncture, as a supplementary treatment after TKA, could improve function and reduce nausea/vomiting. However, the effect of acupuncture on pain relief may be mainly achieved within post-operative 48 h, and it had no efficacy in improving range of knee motion. More large-scale and high-quality studies are warranted.

A Randomized Controlled Trial of Music for Pain Relief after Arthroplasty Surgery

PURPOSE

Effective pain management for patients undergoing orthopedic surgery, using pharmacological and nonpharmacological strategies, is essential. This pilot study evaluated music as an adjuvant therapy with prescribed analgesics to reduce acute pain and analgesic use among patients undergoing arthroplasty surgery.

DESIGN

Prospective randomized controlled trial of 50 participants scheduled for arthroplasty surgery at a large university-affiliated hospital.

METHODS

Participants were randomly assigned to treatment (music and analgesic medication; n = 25) or control (analgesic medication only; n = 25) groups. The intervention consisted of listening to self-selected music for 30 minutes, three times per day postoperatively in hospital and for 2 days postdischarge at home. Participants rated pain intensity and distress before and after music listening (treatment group) or meals (control group). Analgesic medication use was assessed via medical records in hospital and self-report logs postdischarge.

RESULTS

Forty-seven participants completed the study. Participants who listened to music after surgery reported significantly lower pain intensity and distress in hospital and postdischarge at home. There were no statistically significant differences in analgesic medication use after surgery between groups.

CONCLUSIONS

Study findings provide further evidence for the effectiveness of music listening, combined with analgesics, for reducing postsurgical pain, and extend the literature by examining music listening postdischarge. Music listening is an effective adjuvant pain management strategy. It is easy to administer, accessible, and affordable. Patient education is needed to encourage patients to continue to use music to reduce pain at home during the postoperative recovery period.

Intrathecal Oxytocin Improves Spontaneous Behavior and Reduces Mechanical Hypersensitivity in a Rat Model of Postoperative Pain

The first few days post-surgery, patients experience intense pain, hypersensitivity and consequently tend to have minor locomotor activity to avoid pain. Certainly, injury to peripheral tissues produces pain and increases sensitivity to painful (hyperalgesia) and non-painful (allodynia) stimuli. In this regard, preemptive pharmacological treatments to avoid or diminish pain after surgery are relevant. Recent data suggest that the neuropeptide oxytocin when given at spinal cord level could be a molecule with potential preemptive analgesic effects, but this hypothesis has not been properly tested. Using a validated postoperative pain model (i.e. plantar incision), we evaluated in male Wistar rats the potential preemptive antinociceptive effects of intrathecal oxytocin administration measuring tactile hypersensitivity (across 8 days) and spontaneous motor activity (across 3 days). Hypersensitivity was evaluated using von Frey filaments, whereas spontaneous activity (total distance, vertical activity episodes, and time spent in the center of the box) was assessed in real time using a semiautomated open-field system. Under these conditions, we found that animals pretreated with spinal oxytocin before plantar incision showed a diminution of hypersensitivity and an improvement of spontaneous behavior (particularly total distance and vertical activity episodes). This report provides a basis for addressing the therapeutic relevance of oxytocin as a potential preemptive analgesic molecule.

The role of regional analgesia in personalized postoperative pain management

Pain management plays a fundamental role in enhanced recovery after surgery pathways. The concept of multimodal analgesia in providing a balanced and effective approach to perioperative pain management is widely accepted and practiced, with regional anesthesia playing a pivotal role. Nerve block techniques can be utilized to achieve the goals of enhanced recovery, whether it be the resolution of ileus or time to mobilization. However, the recent expansion in the number and types of nerve block approaches can be daunting for general anesthesiologists. Which is the most appropriate regional technique to choose, and what skills and infrastructure are required for its implementation? A multidisciplinary team-based approach for defining the goals is essential, based on each patient's needs, and incorporating patient, surgical, and social factors. This review provides a framework for a personalized approach to postoperative pain management with an emphasis on regional anesthesia techniques.

Infraclavicular nerve block reduces postoperative pain after distal radial fracture fixation: a randomized controlled trial

Background

It is unclear whether regional anesthesia with infraclavicular nerve block or general anesthesia provides better postoperative analgesia after distal radial fracture fixation, especially when combined with regular postoperative analgesic medications. The aim of this study was to compare the postoperative analgesic effects of regional versus general anesthesia.

Methods

In this prospective, observer blinded, randomized controlled trial, 52 patients undergoing distal radial fracture fixation received either general anesthesia (n = 26) or regional anesthesia (infraclavicular nerve block, n = 26). Numerical rating scale pain scores, analgesic consumption, patient satisfaction, adverse effects, upper limb functional scores (Patient-Rated Wrist Evaluation, QuickDASH), health related quality of life (SF12v2), and psychological status were evaluated after surgery.

Result

Regional anesthesia was associated with significantly lower pain scores both at rest and with movement on arrival to the post-anesthetic care unit; and at 1, 2, 24 and 48 h after surgery (p ≤ 0.001 at rest and with movement). Morphine consumption in the post-anesthetic care unit was significantly lower in the regional anesthesia group (p<0.001). There were no differences in oral analgesic consumption. Regional anesthesia was associated with lower incidences of nausea (p = 0.004), and vomiting (p = 0.050). Patient satisfaction was higher in the regional anesthesia group (p = 0.003). There were no long-term differences in pain scores and other patient outcomes.

Conclusion

Regional anesthesia with ultrasound guided infraclavicular nerve block was associated with better acute pain relief after distal radial fracture fixation, and may be preferred over general anesthesia.

Trial registration

Before subject enrollment, the study was registered at ClinicalTrials.gov (NCT03048214) on 9th February 2017.

Challenges in optimising recovery after emergency laparotomy

Standardised peri-operative care pathways for patients undergoing emergency laparotomy or laparoscopy for non-traumatic pathologies have been shown to be inadequate and associated with high morbidity and mortality. Recent research has highlighted this problem and showed that simple pathways with 'rescue' interventions have been associated with reduced mortality when implemented successfully. These rescue pathways have focused on early diagnosis and surgery, specialist surgeon and anaesthetist involvement, goal-directed therapy and intensive or intermediary postoperative care for high-risk patients. In elective surgery, enhanced recovery has resulted in reduced length of stay and morbidity by the application of procedure-specific, evidence-based interventions inside rigorously implemented patient pathways based on multidisciplinary co-operation. The focus has been on attenuation of peri-operative stress and pain management to facilitate early recovery. Patients undergoing emergency laparotomy are a heterogeneous group consisting mostly of patients with intestinal perforations and/or obstruction with varying levels of comorbidity and frailty. However, present knowledge of the different pathophysiology and peri-operative trajectory of complications in these patient groups is limited. In order to move beyond rescue pathways and to establish enhanced recovery for emergency laparotomy, it is essential that research on both the peri-operative pathophysiology of the different main patient groups - intestinal obstruction and perforation - and the potentially differentiated impact of interventions is carried out. Procedure- and pathology-specific knowledge is lacking on key elements of peri-operative care, such as: multimodal analgesia; haemodynamic optimisation and fluid management; attenuation of surgical stress; nutritional optimisation; facilitation of mobilisation; and the optimal use and organisation of specialised wards and improved interdisciplinary collaboration. As such, the future challenges in improving peri-operative patient care in emergency laparotomy are moving from simple rescue pathways to establish research that can form a basis for morbidity- and procedure-specific enhanced recovery protocols as seen in elective surgery.

Upregulation of spinal glucose-dependent insulinotropic polypeptide receptor induces membrane translocation of PKCγ and synaptic target of AMPA receptor GluR1 subunits in dorsal horns in a rat model of incisional pain

It is unclear whether glucose-dependent insulinotropic polypeptide receptor (GIPR) signaling plays an important role in spinal nociception. We hypothesized that the spinal GIPR is implicated in central sensitization of postoperative pain. Our data showed that the cumulative pain scores peaked at 3 h, kept at a high level at 1 d after incision, gradually decreased afterwards and returned to the baseline values at 5 d after incision. Correspondingly, the expression of GIPR in spinal cord dorsal horn peaked at 1 d after incision, and returned to the baseline value at 5 d after incision. The double-labeling immunofluorescence demonstrated that spinal GIPR was expressed in dorsal horn neurons, but not in astrocyte or microglial cells. At 1 d after incision, the effects of intrathecal saline, GIPR antagonist (Pro3)GIP on pain behaviors were investigated. Our data showed that at 30 min and 60 min following intrathecal treatments of 300 ng (Pro3)GIP, the cumulative pain scores were decreased and paw withdrawal thresholds to mechanical stimuli were increased when compared to those immediately before intrathecal treatments. Accordingly, at 30 min after intrathecal injections, the membrane translocation levels of PKCγ and the GluR1 expression in postsynaptic membrane in ipsilateral dorsal horns to the incision were significantly upregulated in rats with intrathecal saline injections, as compared to normal control group. At 30 min after intrathecal treatment, (Pro3)GIP inhibited the membrane translocation levels of PKCγ and the GluR1 expression in postsynaptic membrane in ipsilateral dorsal horns. Our study indicates that upregulation of spinal GIPR may contribute to pain hypersensitivity through inducing membrane translocation level of PKCγ and synaptic target of AMPA receptor GluR1 subunits in ipsilateral dorsal horns of rats with plantar incision.

A survey of postoperative pain treatments and unmet needs

More than 300 million patients undergo surgery worldwide each year. Pain associated with these procedures is associated with short- and long-term negative sequelae for patients, healthcare providers, and healthcare systems. The following chapter is a review of the reality of postoperative pain management in everyday clinical routine based on survey- and registry-derived data with a focus on care in adults. Between 30% and up to 80% of patients report moderate to severe pain in the days after surgery. Structures, processes, and outcomes vary widely between hospitals and indicate gaps between evidence-based findings and practice. Pain assessment is not effectively implemented in many hospitals and should consider cultural differences. Few data exist on the situation of pain management in low- and middle-income countries, indicating lack of resources and available medication in many of these areas. Certain types of surgery as well as demographic and clinical factors are associated with increased risk of severe postoperative pain.

Involvement of Interleukin-10 in Analgesia of Electroacupuncture on Incision Pain

Objective

Postincision pain often occurs after surgery and is an emergency to be treated in clinic. Electroacupuncture (EA) is a Chinese traditional treatment widely used to cure acute or chronic pain, but its mechanism is not clear. Interleukin-10 (IL-10) is a powerful anti-inflammatory cytokine that shows neuroprotective effects in inflammation and injury in the CNS. The present study attempts to reveal that IL-10 is crucial for EA analgesia on postincision pain.

Methods

A model of incision pain was established in C57BL/6J mice. The pain threshold was detected by behavioral test, and the expression of IL-10 and its receptor was detected by an immunohistochemical method. C-fiber-evoked field potentials were recorded by in vivo analysis.

Results

The mechanical allodynia induced by paw incision was significantly inhibited by pretreatment of EA in mice. Intrathecal injection of IL-10 neutralizing antibody (2 µg/10 µL) but not intraplantar injection (10 µg/10 µL) reversed the analgesia of EA. The upregulations of IL-10 mRNA and protein were induced by EA at 6 h and 1 d after incision, respectively. Spinal long-term potentiation (LTP), a substrate for central sensitization, was also suppressed by EA with IL-10. IL-10 recombinant protein (1 µg/10 µL, i.t.) mimicked the analgesia of EA on mechanical allodynia and inhibition on the spinal LTP. Posttreatment of EA after incision also transitorily relieved the mechanical allodynia, which can be blocked by spinal IL-10 antibody. IL-10 and its receptor, IL-10RA, are predominantly expressed in the superficial spinal astrocytes.

Conclusions

These results suggested that pretreatment of EA effectively prevented postincision pain and IL-10 in spinal astrocytes was critical for the analgesia of EA and central sensitization.

Current Status and Future Directions of Pain-Related Outcome Measures for Post-Surgical Pain Trials

Background: Clinical trials remain vital in order to: A) develop new treatment interventions, and also, B) to guide optimal use of current interventions for the treatment and prevention of acute and chronic postsurgical pain. Measures of pain (e.g. intensity and relief) and opioid use have been validated for the settings of postsurgical pain and continue to effectively guide research in this field..

Methods: This narrative review considers needs for innovation in postsurgical pain trial outcomes assessment.

Results: Future improvements are needed and include: A) more widespread measurement of movement-evoked pain with validation of various procedure-relevant movemen-tevoked pain maneuvers; B) new validated analytical approaches to integrate early postoperative pain scores with opioid use; and, C) closer attention to the measurement of postoperative opioid use after hospital discharge. In addition to these traditional measures, consideration is being given to the use of new pain-relevant outcome domains that include: 1) other symptoms (e.g. nausea and vomiting), 2) recovery of physiological function (e.g. respiratory, gastrointestinal, genitourinary and musculoskeletal), 3) emotional function (e.g. depression, anxiety) and, 4) development of chronic postsurgical pain. Also, there is a need to develop pain-related domains and measures for evaluating both acute and chronic post-operative pain. Finally, evidence suggests that further needs for improvements in safety assessment and reporting in postsurgical pain trials is needed, e.g. by using an agreed upon, standardized collection of outcomes that will be reported as a minimum in all postsurgical pain trials.

Conclusions: These proposed advances in outcome measurement methodology are expected to improve the success by which postsurgical pain trials guide improvements in clinical care and patient outcomes.