Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17:131-157. [PMID: 26827847 DOI: 10.1016/j.jpain.2015.12.008]

Knowledge, attitudes and practices of pain management among Taiwanese physicians in a reformed 2-year postgraduate training programme: a cross-sectional questionnaire survey

BACKGROUND

Taiwan implemented a reformed 6-year medical education in 2013, with a subsequent 2-year postgraduate training programme starting in August 2019. This study investigated the perceptions of acute and chronic pain management in postgraduate physicians.

METHODS

In late July 2023, a cross-sectional questionnaire survey was conducted of Taiwanese physicians who had almost completed their postgraduate 2-year or 1-year training and those who were starting a postgraduate programme in early August 2023. This survey evaluated their knowledge, attitude and clinical experience related to opioid-based pain management and their perceptions of the opioid crisis in the United States and Taiwan.

RESULTS

Of the 197 postgraduate physicians, 169 (85.8%) responded to the survey. Physicians who had received postgraduate 2-year (n = 48) and 1-year (n = 51) training had a deeper understanding of opioids (p < 0.001) and exhibited greater confidence in acute and chronic pain management (both p < 0.001) compared with those who were just starting a postgraduate programme (n = 70). Of the included physicians, 92 (54.4%) were aware of the ongoing opioid crisis in the United States, but only 28 (16.6%) disagreed with the notion of a current opioid problem in Taiwan. Approximately 27.8% had never heard of multimodal analgesia, and 86.4% expressed a need for further pain management education.

CONCLUSIONS

The postgraduate training programme in Taiwan provides enhanced knowledge of opioids and improves physicians' levels of confidence in acute and chronic pain management. However, only one-sixth of postgraduate physicians are aware that Taiwan does not have an opioid problem.

Evidence summary on pain management in thoracoscopic lung cancer surgery

Objective

The study aimed to systematically retrieve, evaluate and summarize evidence on perioperative pain management in adults undergoing thoracoscopic lung cancer surgery, to assist oncology nurses in improving pain assessment and management.

Methods

The research question was established using PIPOST model and a systematic search was conducted in English and Chinese databases, professional society websites and guideline platforms for literature published between January 2017 and December 2024. Included literature types comprised guidelines, systematic reviews, evidence summaries, expert consensus, and standards. After literature searching and screening in January 2025, the remaining guidelines were evaluated by four investigators, while other literature was assessed by two investigators. Evidence was then extracted and graded.

Results

Eighteen articles were included, comprising 5 systematic reviews, 3 guidelines, 2 clinical decisions, 4 evidence summaries, 3 expert consensus, and 1 standard. Twenty-five pieces of evidence across six topics were summarized, covering organizational management, high-risk patient assessment and preoperative education, pain assessment, intraoperative analgesia, multimodal pharmacological strategies, and non-pharmacological interventions.

Conclusions

This evidence summary highlights effective strategies for perioperative pain management in thoracoscopic lung cancer surgery, which could support oncology nurses in implementing comprehensive pain assessment, identifying high-risk patients, and applying diversified analgesic interventions.

Implementation of an opioid-sparing protocol utilizing liposomal bupivacaine and intravenous ketorolac for pain management after living kidney donation

BACKGROUND

Opioids are commonly used for management of post-operative pain in living kidney donors. Reducing exposure to opioids is desirable to minimize risk of dependence and potential side effects such as nausea, vomiting, and constipation which may delay discharge. Liposomal bupivacaine, ketorolac, and scheduled acetaminophen have all demonstrated efficacy for management of post-operative pain in this population.

AIM

To assess the efficacy and safety of an opioid-sparing protocol utilizing a multimodal pain management approach in living kidney donors post-nephrectomy.

METHODS

Single-center, retrospective chart review study examining 52 living kidney donors (26 pre-protocol implementation, 26 post-protocol implementation) from May 24^th, 2019 to September 27^th, 2023. Patients in the post-protocol group received intraoperative liposomal bupivacaine, hydromorphone PCA (until able to tolerate oral medications), 15 mg of intravenous ketorolac every 6 hours for 3 doses, and scheduled oral acetaminophen, in addition to oxycodone as needed for moderate to severe pain. The primary endpoint was oral morphine equivalent (OME) use within 48 hours post-surgery. Secondary endpoints include average daily pain scale within 48 hours post-surgery, length of stay (LOS) (days), and incidence of new acute kidney injury (AKI) or gastrointestinal (GI) bleed during admission per provider. Differences between the pre- and post-protocol implementation groups were compared utilizing the exact Wilcoxon test for continuous variables and either the Fisher’s Exact or χ² test for categorical variables.

RESULTS

Patients in the pre-protocol implementation group received more OME (mg) within 48 hours post-surgery when compared to the post-protocol group (median: 84.5 vs 69.0). The median of total OME over the course of admission was numerically greater the pre-protocol group (105.0 vs 69.0), and was significantly more per LOS (41.3 vs 25.7, P = 0.02). Average daily pain score was not statistically significantly different between the two groups on post-operative day 1 (median: 5.3 vs 4.4; P = 0.43) and post-operative day 2 (median: 4.7 vs 5.2; P = 0.96). No significant differences were found in provider-identified incidences of AKI or GI bleeding during admission. There was no difference in serum creatinine at the time of discharge between the two groups.

CONCLUSION

A multimodal, opioid-sparing pain management protocol was as effective for pain control and resulted in significantly less opioid daily exposure over LOS. No adverse events were found related to use of ketorolac in patients undergoing donor nephrectomy. Our findings suggest that an opioid-sparing protocol is both safe and effective at minimizing opioid exposure and managing post-operative pain within the first 48 hours post-surgery.

Correlation between dexmedetomidine and postoperative sleep quality in older patients undergoing intestinal surgery

OBJECTIVE

This study examined the correlation between dexmedetomidine and postoperative sleep quality in older patients following intestinal surgery.

METHODS

A total of 112 older patients were randomly assigned to receive either saline (Group A) or dexmedetomidine (Group B). Sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI) before surgery and on postoperative days 1, 3, 7 and 30. Urinary melatonin and cortisol levels were measured, and pain intensity was assessed using the Visual Analogue Scale (VAS) at various time points. Logistic regression analysis identified factors influencing postoperative sleep quality.

RESULTS

Both groups showed increased PSQI scores postoperatively, with Group A scoring higher than Group B. Group B exhibited a significantly lower incidence of sleep disorders on Days 1 and 3. Urinary melatonin levels decreased in both groups, with Group A showing lower levels, while cortisol concentrations increased, particularly in Group A. Higher VAS scores were also noted in Group A. Patients not receiving dexmedetomidine had a greater prevalence of sleep disorders. Logistic regression revealed dexmedetomidine dosage, gender and VAS scores at 24 h as significant factors affecting sleep quality.

CONCLUSIONS

Dexmedetomidine enhances postoperative sleep quality in older patients undergoing intestinal surgery by reducing cortisol levels, increasing melatonin production and effectively alleviating pain, thereby supporting better recovery outcomes.

Adjunctive Use of Gabapentinoids Increases Opioid Consumption Following One-Level to Three-Level Anterior Lumbar Interbody Fusion With Posterior Fixation: A Propensity Score-Matched Analysis

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To evaluate the impact of adjunctive gabapentinoid therapy on postoperative opioid consumption following one to three levels anterior lumbar interbody fusion (ALIF) with posterior fixation.

SUMMARY OF BACKGROUND DATA

Gabapentin and pregabalin are analogues of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) and are frequently used as adjuncts in multimodal anesthesia strategies for managing acute pain. However, the opioid-sparing effect of gabapentinoids in the context of spine surgery has yet to be consistently demonstrated.

MATERIALS AND METHODS

The PearlDiver database was queried from 2010 to 2021 for patients who underwent primary one to three levels ALIF with posterior fixation. Patients with opioid or gabapentinoid use within six months before index surgery were excluded. Patients with both gabapentinoid and opioid treatment were propensity score matched to patients with opioid-only treatment.

RESULTS

The propensity score-matching resulted in two equal groups of 2617 patients with and without adjunctive gabapentinoid treatment for pain management. Adjunctive use of gabapentinoids was associated with a modest 2.9% reduction in average morphine milligram equivalent (MME) per day [standardized mean difference (SMD): -1.33, 95% CI: -2.657 to -0.002, P =0.050]. However, this was accompanied by a 37.1% increase in the total duration of opioid prescriptions (SMD: 94.97, 95% CI: 56.976-132.967, P <0.001) and a 41.7% increase in total MME consumption per patient (SMD: 4817.23, 95% CI: 1864.410-7770.044, P =0.001). In addition, gabapentinoid use was associated with an increased risk of readmission due to pain [relative risk (RR): 1.10, 95% CI: 1.002-1.212, P =0.050] and the development of drug abuse (RR: 1.37, 95% CI: 1.016-1.833, P =0.046).

CONCLUSION

Despite the modest daily opioid-sparing effect observed, adjunctive gabapentinoid treatment appears to increase total opioid consumption due to prolonged opioid use and may compromise pain management in the context of ALIF with posterior fixation.

Optimization of carbon membrane performance in reverse osmosis systems for reducing salinity, nitrates, phosphates, and ammonia in aquaculture wastewater

This study investigates the performance of various types of carbon membranes in reverse osmosis systems aimed at reducing salinity, nitrates, phosphates, and ammonia in aquaculture wastewater. As sustainable aquaculture practices become increasingly essential, effective treatment solutions are needed to mitigate pollution from nutrient-rich effluents. The research highlights several carbon membranes types, including carbon molecular sieves, activated carbon membranes, carbon nanotube membranes, and graphene oxide membranes, all of which demonstrate exceptional filtration capabilities due to their unique structural properties. Findings reveal that these carbon membranes can achieve removal efficiencies exceeding 90 % for critical pollutants, thereby significantly improving water quality and supporting environmental sustainability. The study also explores the development of hybrid membranes and nanocomposites, which enhance performance by combining the strengths of different materials, allowing for customized solutions tailored to the specific requirements of aquaculture wastewater treatment. Additionally, operational parameters such as pH, temperature, and feed water characteristics are crucial for maximizing membrane efficiency. The integration of real-time monitoring technologies is proposed to enable prompt adjustments to treatment processes, thereby improving system performance and reliability. Overall, this research emphasizes the importance of interdisciplinary collaboration among researchers and industry stakeholders to drive innovation in advanced filtration technologies. The findings underscore the substantial potential of carbon membranes in tackling the pressing water quality challenges faced by the aquaculture sector, ultimately contributing to the sustainability of aquatic ecosystems and ensuring compliance with environmental standards for future generations.

Suzetrigine for moderate to severe acute pain

Suzetrigine (VX-548), 2-pyridinecarboxamide, 4-[[[(2R ,3S ,4S ,5R )-3-(3,4-difluoro-2-methoxyphenyl)tetrahydro-4,5-dimethyl-5-(trifluoromethyl)-2-furanyl]carbonyl]amino]-, or 4-[[(2R ,3S ,4S ,5R )-3-(3,4-difluoro-2-methoxyphenyl)-4,5-dimethyl-5-(trifluoromethyl)oxolane-2-carbonyl]amino]pyridine-2-carboxamide, is a selective voltage-gated sodium channel NaV1.8 blocker that was recently approved by FDA as a non-opioid analgesic to treat moderate to severe acute pain. It has a molecular formula C21H20F5N3O4 and a molecular weight of 473.4 g/mol. The molecule has a chiral tetrahydrofuran core (2R ,3S ,4S ,5R ) that is conjugated to a picolinamide ring via an amide linker at position 2, a 3,4-difluoro-2-methoxyphenyl group at position 3, a methyl group at position 4, and both a trifluoromethyl group and a methyl group at position 5.

Effect of epidural gelfoam soaked levobupivacaine with or without pethidine on postoperative analgesia after single-level lumbar laminectomy: Randomized controlled study

BACKGROUND

Postoperative pain following spine surgery remains a challenge for patients, surgeons and healthcare facilities. This study aimed to evaluate the postoperative analgesic efficacy of gelfoam soaked in pethidine combined with levobupivacaine, compared to gelfoam soaked in levobupivacaine alone in single-level lumbar laminectomy patients.

METHODS

This was a prospective, randomized, double blinded study. A total of 90 patients of either sex, aged 18 to 60 years with ASA class I or II planned for single-level lumbar laminectomy were randomly assigned into three equal groups: group A (levobupivacaine plus pethidine): epidural gelfoam soaked with 1 ml levobupivacaine 0.25 % plus 1 ml pethidine 50 mg, group B (levobupivacaine alone): epidural gelfoam soaked with 1 ml levobupivacaine 0.25 % plus 1 ml of 0.9 % sodium chloride; and group C (control group): epidural gelfoam soaked with 2 ml of 0.9 % sodium chloride. Total analgesic consumption, time to first rescue analgesic request, time to ambulate, postoperative VAS scores, vital signs and adverse effects were recorded.

RESULTS

Demographic and baseline patients' data were comparable among the 3 groups. Group B had lower total analgesic consumption, prolonged time to first rescue analgesia, earlier ambulation, and lower VAS scores in the first 24 h in compared to control group C. Significant differences were found between groups A and B in total analgesic consumption, time to first rescue analgesia, and VAS score in the first 24 h. However, no significant differences were found between the two groups regarding time of ambulation and average VAS scores 24 to 48 h after surgery. There were no significant differences in the occurrence of adverse effects among the 3 groups.

CONCLUSIONS

This study demonstrated that the addition of pethidine to epidural levobupivacaine in a gelfoam soaked form enhanced the postoperative analgesia in patients undergoing single-level lumbar laminectomy in terms of reduced total analgesic consumption, prolonged time to first rescue analgesia and lower postoperative pain scores.

Trends in Opioid and Gabapentinoid Utilization: A Time-Series Analysis Across 72 Countries From 2012 to 2023

PURPOSE

We compare trends in gabapentinoid and opioid utilization overall and by economic development category. We also sought to predict future trends and assess correlations in gabapentinoid and opioid utilization.

METHODS

We conducted a repeated cross-sectional analysis of retail prescriptions for 72 countries from Q1 2012 to Q3 2023. We measured standardized units/1000 population for gabapentinoid and opioid sales, stratified by development category, and used time-series models to predict trends for the following 3 years. Granger causality tests examined predictive relationships between gabapentinoid and opioid sales.

RESULTS

Global gabapentinoid annual sales rose by 114.5% from 2012 to 2022, with a higher increase in developing (180.9%) than developed economies (110.0%). In contrast, annual opioid sales declined globally by 25.4%, with a 27.9% decrease in developed and a 16.8% increase in developing economies. Assuming current trends persist over the following 3 years, gabapentinoid quarterly sales are forecasted to rise by 7.7% in developed and 18.6% in developing economies, while opioid quarterly sales are expected to decrease by 9.5% and increase by 15.1%, respectively. Granger causality tests indicated that gabapentinoids may predict opioid sales globally for the following year, but opioids did not predict gabapentinoid sales.

CONCLUSION

We evaluated the global trends in gabapentinoid and opioid sales, suggesting important differences in pain management practices across developed and developing economies. Our findings highlight the need to ensure the safe use of gabapentinoids and opioids while balancing proper pain management.

The Role of Gabapentin in Enhanced Recovery After Surgery (ERAS) for Patients Undergoing Abdominal Procedures, A Systematic Review and Meta-Analysis

Background and Aims

Postoperative pain management remains a significant challenge for patients undergoing abdominal surgery, with poorly managed pain adversely affecting recovery, leading to increased opioid use and associated side effects. Gabapentin, an anticonvulsant, has been proposed as an effective analgesic within enhanced recovery after surgery (ERAS) protocols to minimize opioid consumption and reduce postoperative nausea and vomiting (PONV). However, its role in perioperative pain management lacks consensus, necessitating a systematic review and meta-analysis.

Methods

A systematic review and meta-analysis of randomized controlled trials and observational studies were conducted, following PRISMA guidelines. Databases including PubMed, Scopus, and EMBASE were searched up to August 2024 using terms such as "gabapentin," "postoperative pain," and "ERAS." Studies involving gabapentin or pregabalin in abdominal surgery were included. Pain was assessed using the visual analog scale (VAS), opioid consumption was converted to morphine equivalents, and PONV rates were analyzed. Meta-analysis was performed using STATA 17 software with a random-effects model due to high clinical heterogeneity.

Results

Twenty-two studies with 1812 patients (909 in the gabapentin group and 903 in the control group) were included. Gabapentin significantly reduced postoperative pain (Hedges's g = -1.65, 95% CI: -2.34 to -0.97, p < 0.001) and opioid consumption (Hedges's g = -2.25, 95% CI: -4.29 to -0.20, p = 0.03). Gabapentin also significantly reduced PONV (log OR = -0.67, 95% CI: -1.25 to -0.09, p = 0.02). Adverse effects were mild, including sedation and dizziness.

Conclusion

Gabapentin demonstrates efficacy in reducing postoperative pain, opioid consumption, and PONV in patients undergoing abdominal surgery. Despite substantial heterogeneity across studies, the results suggest gabapentin as a valuable addition to ERAS protocols. Further research is necessary to optimize dosing strategies and address safety concerns, especially regarding sedation in vulnerable populations.

Impact of intraoperative ketorolac on postoperative pain in children undergoing adenotonsillectomy: a double blind, placebo-control trial

PURPOSE

Postoperative pain control following adenotonsillectomy in the pediatric population poses a great challenge to care providers. Multi-modal pain management regimes including NSAIDs such as intraoperative ketorolac usage has been purposed for many years. However, the effectiveness of ketorolac to reduce post-tonsillectomy pain and opioid-related side effects is controversial. The study was to evaluate the opioid-sparing effect of an intraoperative intravenous single dose of ketorolac in children undergoing adenotonsillectomy. We also assessed the effectiveness of perioperative ketorolac on alleviating the common adverse effects of opioid usage.

METHODS

With IRB approval, a total of 142 pediatric patients aged between 3 and 12 years undergoing elective adenotonsillectomy were randomized to receive either placebo or 0.5 mg/kg ketorolac intraoperatively with other pain management remaining the same. The primary outcomes were postoperative pain scores and postoperative rescue pain medication usage. Common postoperative anesthesia-related complications such as nausea, vomiting and postoperative rebleeding were assessed.

RESULTS

We found that ketorolac usage decreased the overall postoperative pain scores significantly (Max FLACC score 4.3 ± 2.6 for ketorolac vs. 5.9 ± 3.0 for placebo). However, intraoperative single-dose ketorolac administration did not reduce postoperative rescue opioid usage, nor decrease the rates of postoperative nausea and vomiting. We did not observe significant postoperative bleeding or other complications associated with ketorolac usage.

CONCLUSIONS

While intraoperative ketorolac usage reduces the overall postoperative pain score, it does not decrease the postoperative opioid consumption in our current practice regime. Ketorolac may be a good multi-modal pain management adjunct without increased postoperative complications such as rebleeding.

Intervention for hospitalized people with chronic pain and elevated risk for opioid-related harm: A pilot randomized controlled trial

BACKGROUND

The management of analgesia in people hospitalized with chronic pain and elevated risk for opioid-related harm is challenging. While opioid stewardship programs could provide guidance, their feasibility in this population has not been examined.

OBJECTIVES

To develop a case identification tool and evaluate the feasibility of an electronic medical record (EMR)-delivered opioid stewardship and pain intervention among hospitalized people with chronic pain and elevated risk for opioid-related harm.

METHODS

After developing and evaluating the operating characteristics of a case identification tool to identify people with chronic pain and elevated risk for opioid-related harm, hospitalized adults with chronic pain and elevated risk for opioid-related harm were randomized to an EMR-delivered opioid stewardship and pain intervention versus usual care. Primary outcomes were feasibility-based. Exploratory outcomes were pain-related clinical outcomes.

RESULTS

The case identification tool had a sensitivity of 88.9% and a specificity of 95.7%. The trial recruited 52/97 (54%) of potential participants who completed 52/52 (100%) potential assessments and of whom 45/52 (87%) were retained in the study at 4 weeks, demonstrating feasibility. On average, both treatment arms received 56% of the recommended guideline-concordant care and there was no significant difference in opioid and pain-related care in the two groups.

CONCLUSION

It is both feasible to develop an EMR-based tool to prospectively identify hospitalized people with chronic pain and elevated risk for opioid-related harm as well as recruit these individuals to an EMR-delivered opioid stewardship and pain intervention. Additional strategies to support the provision of guideline-concordant care may be warranted.

Management of postoperative pain in neonatal intensive care units in Japan

Neonatal postoperative pain management in Japan is not as standardized as bedside procedural pain, where evidence-based guidelines are widespread, which causes a knowledge gap. To identify postoperative pain management issues, we analyzed the anonymous survey online or by mail by neonatologists or head nurses in 89 Japan's neonatal intensive care units (levels III and IV). Although 79 units (88.8%) required recommendation for postoperative pain management, 11 units (12.4%) used a pain scale for pain assessment, 35 units (39.3%) had evaluated and recorded the pain assessment, 27 units (30%) had updated the postoperative pain management plan, less than bedside procedure, and 14 units (15.7%) had made a preoperative pain management plan. Pain management among neonatal nurses and neonatologists and pediatric surgeons and anesthesiologists have been in three units (3.4%) for preoperative, and in six units (6.7%), and postoperative pain management consult was provided in 15 units (16.9%), which means Initiatives at facilities are essential. We suggest evidence-based practical recommendations in Japan are necessary for neonates to minimize postoperative pain, enhance neonatal postoperative pain management knowledge, and provide consistent postoperative pain management appropriate to the neonates' condition by multidisciplinary collaboration among neonatal nurses, neonatologists, pediatric surgeons, and pediatric anesthesiologists.

Nursing care in ketamine infusions for pain control in adults: a scoping review protocol

OBJECTIVE

This scoping review will map the available evidence on nursing care provided to adults receiving ketamine infusion for pain management in hospitals and outpatient clinics.

INTRODUCTION

The use of intravenous ketamine infusions has increased in various contexts, particularly for pain management as part of a multimodal approach. Although ketamine is associated with a lower risk of hemodynamic disorders and respiratory depression, caution is advised due to its adverse effects. International guidelines on ketamine use in treatments for pain recommend that only a well-trained health care provider monitor patients who receive ketamine infusions. Nursing staff play a frontline role in ketamine administration and their responsibilities include preparation, administration, documentation, evaluation, management of adverse effects, and patient education.

INCLUSION CRITERIA

This review will consider available evidence on adults with acute or chronic pain; in hospitals or outpatient clinics; who are receiving nursing care provided before, during, and after intravenous ketamine infusions for pain management.

METHODS

This review will follow the JBI methodology for scoping reviews. Searches will be conducted in PubMed, Embase, LILACS, Scopus, Science Direct, and CINAHL (EBSCOhost). Gray literature searches will be conducted in OAIster and Social Science Research Network. There will be no restrictions on language or year of publication. Two reviewers will independently screen titles, abstracts, and full-text articles. Any disagreements will be resolved by a third reviewer. The results will be analyzed by frequency counts and presented in tables and figures, in a manner that aligns with the objective of the review.Details of this review project can be found in Open Science Framework: https:osf.io/txmz7.

Preparation, characterisation, and testing of reservoir-based implantable devices loaded with tizanidine and lidocaine

Multiple sclerosis is a chronic neuroimmunological disorder that causes progressive disability, primarily in young adults. It places a significant burden on healthcare systems due to high medication costs and long-term care needs. Implantable devices offer a promising alternative for delivering sustained drug doses in the treatment of chronic conditions. This study introduces a novel long-acting subcutaneous implant for dual-drug delivery: tizanidine (TZ) for spasticity management and lidocaine (LD) for post-insertion pain relief. Reservoir-type implants were developed with TZ in the core and LD in the shell. Two fabrication methods-direct compression and vacuum compression moulding (VCM)-were evaluated for TZ-loaded pellets (3 mm diameter, ~ 10 mm length) using TZ base and TZ hydrochloride. Pellets were encapsulated inside a biodegradable polycaprolactone (PCL) tubular membrane to control drug release. Direct compression pellets, made with poly(vinyl pyrrolidone) and hydroxypropyl-β-cyclodextrin, disintegrated quickly, releasing TZ over 20 days. VCM pellets, formulated with PCL or PCL/poly(ethylene glycol) (PEG), offered prolonged release: up to 200 days for TZ base and 80 days for TZ hydrochloride. Adding PEG accelerated TZ release, reducing duration to 20 days (TZ base) and 125 days (TZ hydrochloride). LD was incorporated into the PCL membrane, providing up to three days of sustained release. Physicochemical analysis confirmed formulation homogeneity and no covalent interactions. These findings highlight the potential of this implant system for MS-related spasticity management, supporting further research into long-acting implants to improve treatment adherence and patient outcomes.

Efficacy of erector spinae plane block for postoperative pain management: A meta-analysis and trial sequential analysis of randomized controlled trials

BACKGROUND

Postoperative pain remains a major problem across a wide range of surgical procedures. The efficacy and clinical utility of the Erector Spinae Plane Block (ESPB) in reducing postoperative pain remains uncertain.

OBJECTIVE

To evaluate the efficacy and safety of the ESPB compared with placebo or sham block in perioperative pain management.

EVIDENCE REVIEW

We searched PubMed, Embase, Web of Science, Scopus, and Cochrane CENTRAL for randomized controlled trials (RCTs) comparing ESPB to placebo or sham block in surgical patients. Primary outcomes included postoperative pain at 2 h, 6 h, 24 h, and 48 h, intraoperative and cumulative postoperative opioid consumption (24 h), and postoperative nausea and vomiting, pruritus, and block-related adverse events. Subgroup and sensitivity analyses, as well as meta-regressions, were performed to explore sources of heterogeneity. Trial sequential analysis (TSA) was used to assess the quantitative robustness of the available data. This review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under registration number CRD42024583633.

FINDINGS

Forty-three RCTs were included, with 1361 patients randomized to the Erector Spinae Plane Block group. ESPB reduced postoperative pain at 2 h (MD -1.46;95 % CI -1.98 to -0.94;p < 0.001;I2 = 91 %), 6 h (MD -1.23;95 % CI -1.64 to -0.83;p < 0.001;I2 = 89 %), 24 h (MD -0.47;95 % CI -0.67 to -0.28;p < 0.001;I2 = 78 %), and 48 h (MD -0.24;95 % CI -0.39 to -0.09;p = 0.002;I2 = 10 %). Also, intraoperative opioid consumption (MD -137.43 μg;95 % CI -208.73 to -66.13;p < 0.001;I2 = 100 %), 24 h cumulative opioid consumption (MD -25.62 mg;95 % CI -31.31 to -19.93;p < 0.001;I2 = 99 %), and incidence of postoperative nausea and vomiting (RR 0.56;95 % CI 0.44 to 0.72;p < 0.001;I2 = 16 %) were significantly lower in patients submitted to ESPB. No significant differences were found in postoperative pruritus (RR 0.62;95 % CI 0.35 to 1.10;p = 0.105;I2 = 27 %). Notably, no block-related adverse events were reported in any study. Certainty of evidence was rated as low to moderate for most outcomes. TSA suggested that no further trials are needed to assess ESPB efficacy in the analyzed outcomes, except for postoperative pruritus.

CONCLUSION

ESPB is a safe and effective regional anesthesia technique that significantly reduces postoperative pain and opioid consumption across various surgical procedures.

Injectable thermosensitive hydrogel based on hyaluronic acid and poloxamer for sustained bupivacaine release and prolonged analgesia

Local anesthetics are commonly used for postoperative pain relief but have limited effectiveness due to their short half-life and low molecular weight. Various sustained-release systems have been explored but face challenges such as low encapsulation efficiency in liposomes, rapid degradation and limited release durations of hydrogel, and difficulties with injectability in combined microsphere/hydrogel. This study presents a double cross-linked hydrogel (Bup/PO) made from aminated poloxamer 407 (P407) and oxidized hyaluronic acid (OHA), cross-linked via oxime bonds and hydrophobic interactions. Rheological analysis showed that the hydrogel exhibited temperature sensitivity, with a storage modulus of up to 10,000 Pa at 37 °C, significantly higher than pure P407. In vitro, the hydrogel provided sustained bupivacaine release for up to 8 days. In vivo, a rat sciatic nerve block model demonstrated that the Bup/PO hydrogel significantly extended the mechanical pain threshold for 32 h and thermal pain threshold for 48 h. The hydrogel was fully biodegradable within 21 days, with mild reversible inflammation and no neurotoxicity. This study introduces a double-cross-linking mechanism that improves hydrogel stability, mechanical properties, and drug release, offering a promising solution for long-term postoperative pain management and regional anesthesia.

The efficacy of liposomal bupivacaine in parasacral ischial plane block for pain management after total knee arthroplasty: a randomized controlled trial

BACKGROUND

Utilizing liposomal bupivacaine (LB) for postoperative analgesia post-total knee arthroplasty (TKA) is prevalent. However, its effectiveness in pain control, specifically in the parasacral ischial plane block (PIPB) post-TKA, remains unknown.

METHODS

This single-center, double-blinded, randomized controlled trial recruited patients scheduled for unilateral TKA. Forty-five patients were randomly assigned in a 1:1 ratio to receive 133 mg (Group A) or 266 mg (Group B) LB using the block randomization method. The PIPB effectiveness was assessed by evaluating changes in sensory and motor functions. The primary outcome was the cumulative area under the curve (AUC) of the Numerical Rating Scale (NRS) at rest within 72 h postoperatively. All patients were included in the analyses of analgesic efficacy, rehabilitation quality, and adverse events.

RESULTS

Between January 30, 2024, and May 1, 2024, 45 patients were enrolled and randomly assigned to Group A (n = 22) and Group B (n = 23). A significant between-group difference was observed in the NRS-AUC0-72 h at rest postoperatively (132.3 ± 19.7 vs. 97.3 ± 19.1, p = 0.001), but none was observed in NRS-AUC0-72 h during activity (p = 0.642). Kaplan-Meier survival analysis revealed significant between-group differences in the median onset times of sensory [60 vs. 35(min), p < 0.0001] and motor blocks [85 vs. 50(min), p < 0.0001]. The onset time of sensory block was notably shorter than that of motor block in both groups. No significant variance was observed in the median regression time for the sensory block. A significant between-group difference in the rescue analgesic dosage was observed on the first postoperative day [43.1 vs. 27.2(mg), p = 0.009], with no significant differences in the subsequent two days or the total amount. No significant between-group differences were found in adverse events or rehabilitation quality.

CONCLUSION

LB used in the PIPB was effective for analgesia at rest post-TKA, with 266 mg demonstrating superiority. Trial RegistrationThe randomized controlled trial was registered in the Chinese Clinical Trial Registry (https://www.chictr.org.cn/, No: ChiCTR2400079606).

Bibliometric analysis of multimodal analgesia research in the perioperative period: trends, contributions, and emerging areas (2013-2023)

Objectives

Multimodal analgesia (MA) is a cornerstone in perioperative pain management, enhancing pain relief and minimizing opioid consumption by targeting various pain pathways. This study conducts a bibliometric analysis of MA research from 2013 to 2023 to understand its development and impact on perioperative care.

Methods

A comprehensive literature search of the Web of Science Core Collection (WOSCC) was conducted, covering publications from January 2013 to December 2023. Data were analyzed using VOSviewer and other bibliometric tools to identify publication trends, key contributors, and emerging research themes.

Results

The analysis identified 1,939 studies on MA, with a notable increase in annual publications since 2020. The USA, China, and Canada were the leading contributors. Key terms like Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), Enhanced Recovery After Surgery (ERAS), and Patient-Controlled Analgesia (PCA) were frequently associated with MA. Significant journals included the Cureus Journal of Medical Science and Anesthesia and Analgesia. Influential authors such as Richard D. Urman and Henrik Kehlet were highlighted for their contributions. The research showed significant advancements and growing global interest in MA.

Conclusion

The study underscores the growing importance of MA in perioperative pain management, with significant contributions from leading countries and researchers. Future research should focus on optimizing pain management protocols, enhancing patient recovery, and reducing opioid dependency through MA.

Effect of listening to music on anxiety, pain, and cardiorespiratory parameters in cardiac surgery: A randomized clinical trial

PURPOSE

To evaluate the effect of listening to music on preoperative anxiety, postoperative pain (at rest and during coughing), and cardiorespiratory parameters in patients undergoing cardiac surgery.

DESIGN

Single-centered, randomized, parallel, superiority clinical trial.

METHODS

This study was carried out with 50 adult patients undergoing elective cardiac surgery randomly allocated at a 1:1 ratio to one of the groups, experimental (n = 25) or control (n = 25). The experimental group listened to music during the immediate preoperative period and on the first postoperative day. The control group received standard care. State-Trait Anxiety Inventory and Numeric Pain Rating Scale were used to collect data.

FINDINGS

The classical music significantly reduced preoperative state anxiety scores (p < 0.001; dCohen = 2.1), postoperative pain intensity at rest (p < 0.001; dCohen = 1.4) and during coughing (p < 0.001; dCohen = 1.3). There was also a statistically significant reduction in systolic (p = 0.001; dCohen = 0.9) and diastolic blood pressure (p = 0.01; dCohen = 0.6), heart rate (p < 0.001; dCohen = 2.5), respiratory rate (p < 0.001; dCohen = 1.4), and a significant increase in oxygen saturation (p < 0.001; dCohen = 1.2).

CONCLUSIONS

Listening to music had a significant impact on the evaluated outcomes, demonstrating its potential as a complementary intervention to pharmacological treatment for patients undergoing cardiac surgery.

IMPLICATIONS FOR CLINICAL PRACTICE

The findings reinforce the evidence that listening to music is a promising nursing intervention to be used in the perioperative period of cardiac surgeries, with the potential to promote well-being to patients and improve the quality of care provided.

Pericapsular Nerve Group Block with Periarticular Injection for Pain Management after Total Hip Arthroplasty: A Randomized Controlled Trial

PURPOSE

The purpose of this study was to compare the effectiveness of pericapsular nerve group (PENG) block with periarticular multimodal drug injection (PMDI) on postoperative pain management and surgical outcomes in patients who underwent total hip arthroplasty (THA). We hypothesized that PENG block with PMDI would exhibit superior effects on postoperative pain control after THA compared to PMDI alone.

MATERIALS AND METHODS

From April 2022 to February 2023, 58 patients who underwent THA were randomly assigned into two groups: PENG block with PMDI group (n=29) and PMDI-only group (n=29). Primary outcomes were postoperative numeric rating scale (NRS) at rest and during activity at 6, 24, and 48 hours postoperatively. Secondary outcomes were postoperative complications (nausea and vomiting), Richards-Campbell Sleep Questionnaire (RCSQ) score, length of hospital stay, Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index, Harris Hip Score (HHS), and total morphine usage after surgery.

RESULTS

There was no significant difference in postoperative pain for either resting NRS or active NRS. Postoperative nausea and vomiting, RCSQ score, length of hospital stay, WOMAC index, HHS, and total morphine usage exhibited no significant differences between the two groups.

CONCLUSION

Both groups showed no significant differences in postoperative pain and clinical outcomes, indicating that the addition of PENG block to PMDI does not improve pain management after applying the posterolateral approach of THA. PMDI alone during THA would be an efficient, fast, and safe method for managing postoperative pain. This article was registered with ClinicalTrials. gov (Gov ID: NCT05320913).

Pharmacology and Mechanism of Action of Suzetrigine, a Potent and Selective NaV1.8 Pain Signal Inhibitor for the Treatment of Moderate to Severe Pain

INTRODUCTION

There is a high unmet need for safe and effective non-opioid medicines to treat moderate to severe pain without risk of addiction. Voltage-gated sodium channel 1.8 (NaV1.8) is a genetically and pharmacologically validated pain target that is selectively expressed in peripheral pain-sensing neurons and not in the central nervous system (CNS). Suzetrigine (VX-548) is a potent and selective inhibitor of NaV1.8, which has demonstrated clinical efficacy and safety in multiple acute pain studies. Our study was designed to characterize the mechanism of action of suzetrigine and assess both nonclinical and clinical data to test the hypothesis that selective NaV1.8 inhibition translates into clinical efficacy and safety, including lack of addictive potential.

METHODS

Preclinical pharmacology and mechanism of action studies were performed in vitro using electrophysiology and radiolabeled binding methods in cells recombinantly expressing human NaV channels, human proteins, and primary human dorsal root ganglion (DRG) sensory neurons. Safety and addictive potential assessments included in vitro secondary pharmacology studies, nonclinical repeat-dose toxicity and dependence studies in rats and/or monkeys, and a systematic analysis of adverse event data generated from 2447 participants from phase 3 acute pain studies of suzetrigine.

RESULTS

Suzetrigine is selective against all other NaV subtypes (≥ 31,000-fold) and 180 other molecular targets. Suzetrigine inhibits NaV1.8 by binding to the protein's second voltage sensing domain (VSD2) to stabilize the closed state of the channel. This novel allosteric mechanism results in tonic inhibition of NaV1.8 and reduces pain signals in primary human DRG sensory neurons. Nonclinical and clinical safety assessments with suzetrigine demonstrate no adverse CNS, cardiovascular or behavioral effects and no evidence of addictive potential or dependence.

CONCLUSIONS

The comprehensive pharmacology assessment presented here indicates that suzetrigine represents the first in a new class of non-opioid analgesics that are selective NaV1.8 pain signal inhibitors acting in the peripheral nervous system to safely treat pain without addictive potential.

Global Research Trends in Postoperative Delirium and Its Risk Factors: A Bibliometric and Visual Analysis

PURPOSE

Postoperative delirium (POD) is one of the most frequent complications after surgery which is closely associated with many adverse outcomes, including high mortality and low quality of life. This study aims to carry out a bibliometric analysis of POD and its risk factors from 2012 to 2022 to reveal the research status and hot spots.

DESIGN

This study is a bibliometric and visualized analysis.

METHODS

Relevant publications between 2012 and 2022 were extracted from the Web of Science Core Collection database. CiteSpace software (v6.1. R2, Drexel University), VOSviewer software (v1.6.18, Leiden University), and the Online Analysis Platform of Literature Metrology were used to analyze research attributes. These publications were used to analyze research attributes, including countries, journals, institutions, authors, keywords, and burst detection, to predict trends and hot spots.

FINDINGS

We included a total of 1,324 related documents from 2012 to 2022. The literature on POD has increased significantly since 2016. The United States and Harvard University were the leading literature publishing country (436/1324, 32.9%) and institution (112/1324, 8.5%). Anesthesia and Analgesia was the most frequently published journal. Keywords analysis with VOSviewer revealed that the keywords could be divided into five clusters, including anesthesia techniques, cardiac surgery, risk factors, intraoperative anesthesia monitoring, and postoperative cognitive dysfunction. We included a total of 198 POD risk factors documents, and the literature on POD risk factors increased. The People's Republic of China and Harvard University were the leading literature publishing country (53/198, 26.8%) and institution (12/198, 6.1%). Elderly, hip surgery, frailty, postoperative pain, cardiac surgery, dementia, and depression are keywords that are risk factors for POD.

CONCLUSIONS

The number of literature on POD in the field of anesthesia has increased significantly. Risk factors and anesthesia techniques are still key areas of research. Encephalogram, the use of sedatives, and perioperative nursing may be the new research focus. Older adults, hip fractures, cardiac surgery, liver transplants, dementia, and depression are hot words in the field of POD risk factors.

Systematic review on postoperative opioid use and other outcomes after lobectomy for lung cancer in the U.S

OBJECTIVE

This systematic review summarizes literature on postoperative opioid use in lung cancer patients after lobectomy, focusing on opioid consumption, survival, recurrence, pain scores, length of stay, readmission, and in-hospital mortality.

METHODS

PubMed and Embase were searched from 1 January 1993, to 31 May 2024, for observational studies on U.S. lung cancer patients. Retrospective studies reporting the outcomes of interest were included, excluding pediatric populations, non-English publications, non-lung cancer studies, reviews, meta-analyses, economic modeling papers, or interventional studies.

RESULTS

Out of 683 identified articles, 22 studies met inclusion criteria, encompassing 77,315 patients. Commonly used opioids were morphine, hydromorphone, and fentanyl. Pain scores varied by surgical approach, with better control reported with video-assisted thoracoscopic surgery (VATS) and liposomal bupivacaine (LB). Longer hospital stays were linked to higher odds of persistent opioid use. Higher opioid doses were associated with decreased overall survival (OS) and recurrence-free survival.

CONCLUSIONS

The review highlights the complex relationship between postoperative opioid use and outcomes in lung cancer patients post-lobectomy. Alternatives like intercostal nerve blocks with LB and VATS can reduce opioid use and enhance recovery, emphasizing personalized pain management. Future research should focus on reducing opioid overprescription and patient education to minimize long-term use.

Methadone in the madness: a case series and review of methadone management in hospital settings

The management of patients on chronic methadone therapy for opioid use disorder presents unique pharmacological and psychosocial challenges in hospital settings. This case series discusses complexities such as methadone's variable pharmacokinetics, alternatives to oral methadone and conversion ratios. Additionally, it outlines the nuances around the psychosocial considerations of methadone therapy and addressing addiction-related behaviors without compromising patient dignity. The review calls for individualized care plans with uninterrupted opioid agonist therapy to meet the baseline opioid requirements and pro-active pain management plans. Enhanced clinician education and better real-world data to guide methadone management is important to improve outcomes for this vulnerable patient cohort.

Thoracic Epidural Analgesia Is Not Associated With Improved Survival After Pancreatic Surgery: Long-Term Follow-Up of the Randomized Controlled PAKMAN Trial

BACKGROUND

Perioperative thoracic epidural analgesia (EDA) and patient-controlled intravenous analgesia (PCIA) are common forms of analgesia after pancreatic surgery. Current guidelines recommend EDA over PCIA, and evidence suggests that EDA may improve long-term survival after surgery, especially in cancer patients. The aim of this study was to determine whether perioperative EDA is associated with an improved patient prognosis compared to PCIA in pancreatic surgery.

METHODS

The PAKMAN trial was an adaptive, pragmatic, international, multicenter, randomized controlled superiority trial conducted from June 2015 to October 2017. Three to five years after index surgery a long-term follow-up was performed from October 2020 to April 2021.

RESULTS

For long-term follow-up of survival, 109 patients with EDA were compared to 111 patients with PCIA after partial pancreatoduodenectomy (PD). Long-term follow-up of quality of life (QoL) and pain assessment was available for 40 patients with EDA and 45 patients with PCIA (questionnaire response rate: 94%). Survival analysis revealed that EDA, when compared to PCIA, was not associated with improved overall survival (OS, HR, 1.176, 95% HR-CI, 0.809-1.710, P = .397, n = 220). Likewise, recurrence-free survival did not differ between groups (HR, 1.116, 95% HR-CI, 0.817-1.664, P = .397, n = 220). OS subgroup analysis including only patients with malignancies showed no significant difference between EDA and PCIA (HR, 1.369, 95% HR-CI, 0.932-2.011, P = .109, n = 179). Similar long-term effects on QoL and pain severity were observed in both groups (EDA: n = 40, PCIA: n = 45).

CONCLUSIONS

Results from this long-term follow-up of the PAKMAN randomized controlled trial do not support favoring EDA over PCIA in pancreatic surgery. Until further evidence is available, EDA and PCIA should be considered similar regarding long-term survival.

Acute Pain Management in People With Opioid Use Disorder : A Systematic Review

BACKGROUND

Guidance on acute pain management among people with opioid use disorder (OUD) is limited.

PURPOSE

To synthesize evidence on the benefits and harms of acute pain interventions among people with OUD.

DATA SOURCES

APA PsycArticles, APA PsycInfo, APA PsycExtra, Allied and Complementary Medicine Database, CINAHL, Cochrane Library, Google Scholar, Ovid Embase, Ovid MEDLINE, PubMed, Scopus, and the Web of Science Core Collection through 7 July 2024.

STUDY SELECTION

Studies of any design that evaluated acute pain interventions among adults with OUD and included pain or OUD outcomes.

DATA EXTRACTION

Independent dual screening, single-investigator data extraction with verification, and dual quality and strength of evidence assessment.

DATA SYNTHESIS

Seventeen trials, 20 controlled observational studies, and 78 uncontrolled observational studies met eligibility criteria. Continuing use of buprenorphine during acute pain episodes may be associated with similar or improved pain-related outcomes versus discontinuing, based on cohort studies conducted primarily in perioperative settings. Single well-conducted randomized controlled trials in emergency department (ED) or perioperative settings in adults not prescribed medications for OUD suggest oral clonidine, intramuscular haloperidol and midazolam with intravenous (IV) morphine, and intraoperative IV lidocaine may improve pain outcomes and warrant study in diverse patient populations. Few studies evaluated methadone or the effect of interventions on OUD outcomes.

LIMITATIONS

Most evidence is observational and at risk of bias due to confounding. All studies were conducted in ED or hospital settings, most before widespread use of high-potency synthetic opioids or among non-U.S. populations using opium.

CONCLUSION

The overall evidence for pain outcomes in people with OUD is low. The effect of pain interventions on OUD outcomes is an important evidence gap.

PRIMARY FUNDING SOURCE

None. (Protocol registered a priori on Open Science Framework [https://osf.io/25hbs]).

Advances in Anesthesia Techniques for Postoperative Pain Management in Minimally Invasive Cardiac Surgery: An Expert Opinion

Minimally invasive cardiac surgery (MICS) often leads to severe postoperative pain. At present, multimodal analgesia schemes for MICS have attracted much attention, and the application of various chest wall analgesia techniques is becoming increasingly widespread. However, research on anesthesia techniques for postoperative pain management in MICS remains relatively limited at present. We searched for relevant literature and summarized recent related research in eight MICS techniques, including thoracic epidural anesthesia, spinal anesthesia, thoracic paravertebral plane block, erector spinae plane block, serratus anterior plane block, pectoral nerve block, intercostal nerve block, and parasternal block. This article provides an overview of the anatomy and procedures involved in these analgesic techniques, their mechanisms of action, and the latest clinical trial evidence. It also evaluates their progress in MICS, compares their advantages and disadvantages, and discusses practical challenges.

Outcome Indicators for Evaluating Interventions by Advanced Practice Nurses Specialising in Acute Pain: A Scoping Review

AIM

To identify outcome indicators to evaluate interventions delivered by advanced practice nurses specialising in acute pain as reported in the scientific literature.

DESIGN

Scoping review.

DATA SOURCES

Three databases (PubMed, Scopus and CINAHL) were systematically searched in December 2023 to identify studies published between 1996 and 2023.

REVIEW METHODS

Search results were managed through the Rayyan platform. Two review authors independently performed data selection and extraction, and a third reviewer resolved conflicts.

RESULTS

The search identified 1263 studies. After screening titles and abstracts, 14 full-text studies were selected for data extraction and analysis. These studies encompassed a variety of designs, including randomised controlled trials, cohort studies and observational studies. The outcome indicators used to evaluate advanced practice nurses' interventions in acute pain management were examined across three key dimensions: study population and setting, intervention and model of acute pain nurse care and quality-of-care assessment. The specific outcome indicators identified included 'pain score', 'side effects', 'analgesia prescription', 'non-pharmacological interventions', 'nurses' pain management knowledge', 'patient/parent education' and 'APN contact'.

CONCLUSION

This review underscores the growing and evolving role of advanced practice nurses (APNs) in acute pain management, highlighting the diversity of care models and interventions implemented across clinical settings. Key outcome indicators, such as 'pain score', 'side effects' and 'nursing staff's understanding of pain management', were identified, with certain indicators, like 'APN contact' and 'non-pharmacological interventions', more closely linked to the nurse-led approach.

IMPLICATIONS FOR THE PROFESSION

This scoping review underscores the importance of developing and evaluating outcome indicators to enhance the assessment of interventions provided by advanced practice nurses in acute pain management. While consensus on specific indicators has not yet been reached, this review highlights the need for further research to refine and standardise these indicators, thereby contributing to more uniform and comparative evaluations of care.

IMPACT

The identified outcome indicators can inform the evaluation of APN interventions in acute pain management, supporting efforts to optimise and standardise care. Further implementation and assessment of these indicators will be essential to enhance the quality and effectiveness of patient care.

REPORTING METHOD

The PRISMA extension for Scoping Review guidelines was used.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Barriers and Facilitators to Implementing Acute Pain Services at King Faisal Hospital Rwanda

Background: As a critical component of clinical care, every patient should have access to acute pain service (APS). Despite significant progress in its development, acute pain is under or inadequately treated, particularly in African countries. In addition, acute pain treatment and management has received insufficient clinical attention, resulting in inadequacies in postoperative pain relief, which has continued to be a significant challenge. Aims: This study aims to assess the knowledge, perceptions, and experiences of healthcare professionals about APS delivery at King Faisal Hospital Rwanda (KFH). Methods: Nine semistructured focus group discussions (FGDs) were conducted from April to May 2023. Participants were selected via random stratified sampling, and FGDs were conducted in internal medicine, anesthesia and the operating theater, obstetrics and gynecology, the intensive care unit, pediatrics, accident and emergency, medical doctors, physiotherapy, and the surgical ward departments at KFH. Results: Participants highlighted four key areas that can serve as either barriers or facilitators to implementing APS at KFH. These include healthcare provider skills and training; the development and implementation of standardized protocols; establishing a dedicated interdisciplinary APS team; and patient awareness and education. Conclusions: Having institutional systems in place, including standardized protocols, a dedicated team, and regular training opportunities, may help strengthen APS. Patient education and ensuring patients know their care options is another facilitator to improving APS.

Improving post-operative pain management after total hip and knee replacement in a special care unit: a best practice implementation project

INTRODUCTION

Post-operative pain is often underestimated (70% of surgical patients experience some degree of pain) and is insufficiently treated. This increases morbidity and mortality, mainly due to respiratory and thromboembolic complications, longer hospital stays, deterioration in quality of life, and occurrence of chronic pain.

OBJECTIVES

This study aimed to improve post-operative pain management in the first 4 hours after total hip and knee replacement by promoting best practices.

METHODS

This project used the JBI Evidence Implementation Framework. JBI's Practical Application of Clinical Evidence System (PACES) and Getting Research into Practice (GRiP) audit tools were used to collect data and develop implementation strategies, in line with identified barriers. The project was conducted in a special care unit in a primary hospital in Spain using a sample of 30 patients. Three phases of activity were followed: conducting a baseline audit, implementing improvement strategies, and conducting follow-up audits to assess intervention outcomes. The evaluation criteria used in the audits were derived from a JBI evidence summary on post-operative pain management.

RESULTS

The baseline audit identified five barriers: lack of nursing staff knowledge of appropriate pain assessment scales; lack of complete pain assessment record in the electronic nursing records; lack of staff confidence in evidence-based practice; lack of dedicated training time for staff; and low staff participation in consensus process. Strategies were formulated to address these barriers using JBI's GRiP method. Following implementation, compliance with all audit criteria significantly improved.

CONCLUSION

The strategies developed using the JBI Evidence Implementation Framework positively impacted compliance with best practices.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A339.

The Impact of Diclofenac Suppositories on Post-Cesarean Section Pain: A Systematic Literature Review

Background: Managing postoperative pain after Cesarean section is imperative, as acute postoperative pain is considered a risk factor for chronic postoperative pain. We investigated the role of diclofenac suppositories in postoperative pain management after Cesarean section. Methods: For this systematic review, we searched PubMed, Scopus, the Cochrane Library, Google Scholar, and two other clinical trial registers from database inception up to July 23 to July 26, 2024. We included randomized controlled trials and other studies in which diclofenac suppositories were administered as an intentional intervention. We excluded studies not reported in English and without a focus on the principal medicine (diclofenac suppository). Two researchers independently chose studies and assessed the risk of bias using RoB-2, following the PRISMA-2020 guidelines. Primary outcomes included pain severity or intensity measured with validated clinical scales. We synthesized the studies narratively. The PICO was used to generate the research question: Population-Cesarean section patients, Intervention-diclofenac suppository, Comparison-opioids, Outcome-lower pain scores and a reduced need for more pain medications, Research question-the effectiveness of diclofenac suppositories in preventing postoperative pain and reducing the consumption of pain medicines in Cesarean section patients. Findings: From an initial pool of 203 records, 20 records were selected for review. Notably, discrepancies in the study design and reporting were observed. This raised concerns about the consistency and reliability of the results obtained from the different studies. The visual analogue scale (VAS) emerged as the frequently used pain assessment tool. Diclofenac suppository was compared against other treatments under three categories: placebo, other nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids or opioid-like medicines. The findings revealed that diclofenac suppository was effective in reducing pain compared to placebo and hence, minimized the need for opioids. The concept of combining pain medicines for postoperative management, known as multimodal analgesia, was central to most of the studies. Interpretation: Combination of diclofenac suppositories with other pain relief medicines reduces the need for rescue pain medicines, which are usually opioids such as morphine, meperidine, or pentazocine. Clinical Implications: Patient satisfaction can be improved with these enhanced pain management strategies. Also, reliance on opioids for postoperative pain management and its related side effects will be reduced. This research reinforces the importance of multimodal analgesia in postoperative pain management. The findings also open pathways for further clinical trials to explore the appropriate combinations, dosages, and administration of NSAIDs for specific surgical populations and settings. Future research should focus on standardizing methodologies and addressing risk of bias to enhance reliability of findings related to diclofenac suppository and multimodal analgesia.

A Cross-Sectional Study on Current Perioperative Pain Management and Nurses' Pain Management Self-Efficacy in China's Interventional Department

Objective

To critically evaluate the present status of perioperative pain management among nurses in interventional departments as well as to delineate the factors influencing the self-efficacy of pain management to provide a foundation for enhancing perioperative pain management practices.

Methods

This was a descriptive cross-sectional study on 941 nurses from 24 Chinese provinces and municipalities. A questionnaire was conducted to examine the current pain management practices. Independent sample t-test and analysis of variance were used for inter-group comparison. Multiple linear regression analysis was done to analyze the influencing factors of pain management self-efficacy.

Results

About 76.5% of the nurses in the interventional departments had undergone pain management training; however, more than one-third (37.6%) had not in the past two years. Merely 4.9% of nurses expressed confidence that their knowledge in pain management was sufficient to meet the demands the clinical practice. The foremost three areas of pain management information desired by the nurses in the intervention department were pain psychology (79.6%), pharmacological pain treatment (78.1%), and non-pharmacological pain interventions (77.4%). A majority (57.6%) of the nurses failed to assess the patients' comprehension and perspectives of analgesia, elements contributing to pain exacerbation or alleviation, and the outcomes of analgesic measures. The cumulative score for the pain self-efficacy questionnaire among nurses in the intervention department was 63.95±21.83. Multiple linear regression analysis revealed that variables such as the acquisition of pain knowledge, the frequency of pain training in the past two years, the ratio of evaluation tools employed for assessment, the prevalent utilization of multi-dimensional evaluation instruments, and professional course studies in academia were determinants influencing pain management self-efficacy.

Conclusion

Perioperative pain management by interventional department nurses in China is unstandardized and lacks continuous education. Nursing administrators should create targeted training to boost pain assessment, prevention and treatment abilities.

Association of opioid utilization in the intensive care unit and opioid prescriptions at hospital discharge in opioid-naïve non-surgical patients who received enhanced oxygen therapy

PURPOSE

To evaluate the association between opioid utilization in community-based intensive care units and the continuation of opioid prescriptions at hospital discharge for non-surgical, opioid-naïve patients.

MATERIALS AND METHODS

This nested case-control study included adults without opioid prescriptions 45 days before hospital admission who had intensive care unit stays of 48 h or longer and received enhanced oxygen therapy. Patients were excluded if they had opioid allergies, cancer, in-hospital death, palliative care, major surgery, or substance use disorders. Opioid utilization was measured using cumulative oral morphine equivalents and average daily morphine equivalents during the intensive care unit stay. Multivariable regression models examined the association between opioid utilization and opioid prescription at discharge.

RESULTS

Among 260 patients, 33 patients (12.7 %) received opioid prescriptions at discharge. These patients had significantly higher cumulative morphine equivalents during their intensive care unit stay (cases: 3362.4, standard error 1102.5; controls: 1024.9, standard error 240.0; p = 0.002) and higher average daily morphine equivalents during their stay (cases: 129.8, standard error 36.9; controls: 61.2, standard error 10.7; p = 0.03). Patients who received more than 90 cumulative morphine equivalents during their intensive care unit stay had 6.63 times higher odds of receiving an opioid prescription at discharge (p < 0.001). Each additional 10 daily morphine equivalents increased the odds of discharge continuation by 3 % (p = 0.011).

CONCLUSIONS

Increased opioid utilization during intensive care unit stays was associated with higher odds of opioid prescriptions at discharge in opioid-naïve, non-surgical patients.

ABSTRACT KEY POINTS

Question: Does opioid use in community-based ICUs correlate with continued opioid prescriptions at discharge for opioid-naïve, non-surgical patients?

FINDINGS

This nested case-control study found that patients who received opioids during their ICU stay had a higher likelihood of being prescribed opioids at discharge. Specifically, those with cumulative opioid use >90 MME had 6.63 times higher odds of opioid continuation at discharge. Meaning: The study concludes that higher opioid use during ICU stays significantly increases the likelihood of opioid prescription continuation at hospital discharge for opioid-naïve, non-surgical patients.

Postoperative Pain in Vitreoretinal Surgery With Combined Regional-General Anesthesia Versus General Anesthesia: A Systematic Review and Meta-Analysis

PURPOSE

To investigate postoperative pain variations in vitreoretinal surgeries conducted with combined regional-general anesthesia or general anesthesia.

DESIGN

Systematic review and meta-analysis.

METHODS

A systematic search of the PubMed, Embase, and Cochrane Library databases was conducted to identify relevant randomized controlled trials published before December 26, 2023. Studies comparing vitreoretinal surgeries conducted under combined anesthesia to general anesthesia were included, while studies using only regional anesthesia were excluded. The quality of the studies was assessed using the Cochrane Collaboration risk of bias tool, and the results are presented as odds ratios or standardized mean differences (SMDs) with 95% confidence intervals (CIs). I2 statistic was calculated to assess heterogeneity. The primary outcomes in our study included the proportions of patients needing as-needed postoperative analgesics, dosage of as-needed postoperative analgesia medications, and time to the first demand for as-needed postoperative analgesia. The secondary outcomes included postoperative pain scores at 0.5, 1, 2, 4, 6, 12, 24 hours (h), duration of surgery and anesthesia, and percentage of patients experiencing postoperative nausea and vomiting.

RESULTS

A total of 19 randomized controlled trials involving 1314 patients were analyzed. Combined anesthesia was associated with lower proportions of patients needing as-needed postoperative analgesics (odds ratio, 0.218 95% CI, 0.114-0.418, I2 = 55.2%), reduced dosage of as-needed postoperative analgesia medications (SMD, -1.429, 95% CI, -2.395 to -0.462, I2 = 90.4%), and longer time to the first demand for as-needed postoperative analgesia compared with general anesthesia alone (SMD, 2.650, 95% CI, 1.169-4.132, I2 = 96.5%). The effect of additional regional anesthesia lasted for 6 h (0.5 h SMD, -1.471, 95% CI, -2.498 to -0.444, I2 = 90.5%; 1 h, -1.507, -2.309 to -0.705, 92.7%; 2 h -1.487, -2.300 to -0.674, 93.2%; 4 h -1.052, -1.708 to -0.396, 89.5%; 6 h -1.053, -1.932 to -0.174, 93.4%; 12 h -0.286, -0.648 to 0.076, 57.1%; 24 h -0.297, -0.624 to 0.029, 64.0%). Combined anesthesia decreased postoperative nausea and vomiting risk without affecting the surgical or anesthesia duration.

CONCLUSIONS

Combined anesthesia demonstrated additional postoperative analgesic effects versus general anesthesia only. Further research is needed to validate the results of our study and to identify vision-threatening complications.

Prolonged post-operative hydrocodone usage due to psychotropic drug interaction

OBJECTIVES

To explore pain outcomes in patients prescribed hydrocodone and psychotropic medications with or without CYP2D6 inhibition activity.

METHODS

Patients hospitalized for lower/limited upper extremity injuries who were prescribed hydrocodone alongside a psychotropic medication were considered for this study (n=224). A subset of these patients (n=178) was prescribed a psychotropic medication known to inhibit CYP2D6, while the remainder (n=46) were prescribed psychotropic medications without CYP2D6 inhibition activity. Patient demographics and pain outcomes were collected by electronic health record review and interviews.

RESULTS

Patients taking a psychotropic inhibitor of CYP2D6 exhibited longer duration of opioid use post-discharge (median 33 days [IQR 10-99]) compared with patients taking a psychotropic non-inhibitor (4 days [2-20], p<0.001). No significant differences were observed with in-hospital pain outcomes, including total dose of hydrocodone administered, duration of hydrocodone use, pain index scores, and the occurrence of common mild/moderate/severe hydrocodone side effects.

CONCLUSIONS

Patients prescribed at least one psychotropic inhibitor of CYP2D6 were more likely to continue using hydrocodone for up to 3 months following surgery. Knowledge of these critical drug-drug interactions could enhance clinical practice and improve patient outcomes. This study highlights negative post-operative pain outcomes in patients prescribed hydrocodone alongside a psychotropic inhibitor of CYP2D6. The results of this study indicate that patients taking psychotropic medications that inhibit CYP2D6 are at increased risk for prolonged hydrocodone use following orthopedic surgery.

Efficacy, safety, and pharmacokinetics of CPL-01, an investigational long-acting ropivacaine, in bunionectomy: Results of a phase 2b study

CPL-01 (ropivacaine extended-release injection) is formulated to safely provide postoperative analgesia and reduce opioid use. Participants undergoing unilateral distal first metatarsal bunionectomy with osteotomy were randomized to receive either CPL-01 (200 mg in Cohort 1, 300 mg in Cohort 2), ropivacaine HCl (50 mg in Cohort 1, 75 mg in Cohort 2), or volume-matched placebo into the surgical site prior to closure. Participants remained in an inpatient setting for 72 h to assess efficacy (Numeric Rating Scale [NRS] scores for pain with activity adjusted for opioid usage, and rescue medication usage), safety and pharmacokinetics. Seventy-three participants were randomized and treated, and 71 participants completed the study. Participants who received 300 mg CPL-01 had a mean (SD) area under the curve from 0 to 72 h (AUC0-72) of the NRS score with activity of 356.9 (132.82), which was lower than placebo, indicating less pain. Participants who received CPL-01 300 mg also had numerically lower mean total opioid consumption. CPL-01 was safe and well-tolerated, with no evidence of increased AEs in one group versus another. Infiltration of CPL-01 had no impact on wound or bone healing. CPL-01 showed predictable and consistent extended-release pharmacokinetics, with no indication of "dose-dumping." Ropivacaine HCl delivered 94.3-99.7 % of its ropivacaine dose in the first 24 h; the 300 mg CPL-01 dose delivered 38.5 %. While this Phase 2b study was small, results demonstrated the safety, efficacy, and extended-release characteristics of this long-acting ropivacaine formulation in this surgical model, supporting further development of CPL-01 in Phase 3 clinical studies.

Cannabinoids for Acute Postoperative Pain Management: A Systematic Review and Meta-Analysis of Clinical Trials

BACKGROUND

Poor acute postoperative pain control, coupled with the use of intravenous medications with a limited and unsafety efficacy spectrum, has led to new therapeutic alternative explorations to reduce adverse events while increasing its analgesic efficacy. There cannabinoids have been proposed as a useful control agent in post-surgical pain. Nevertheless, to date, there is no solid evidence to evaluate them. The current article sought to determine cannabinoids' effectiveness and safety in the aforementioned context.

METHODS

A systematic review of controlled clinical trials evaluated the efficacy and safety of cannabinoids for the treatment of acute postoperative pain. The study was structured under the Cochrane recommendations. Primary outcomes included: pain intensity reduction, the number and doses of rescue analgesics and adverse events.

RESULTS

Of 62 articles found, only five were included. Four of them presented high inter-observer agreement and 60% were classified as having a low risk of bias. When evaluating the objectives of each article, a disparity was found in the investigative methods and terms implemented. Due to the heterogeneity of methods, it was not possible to carry out meta-analytic evaluations and only qualitative evaluations were feasible.

CONCLUSIONS

Despite finding contradictory evidence in relation to the analgesic cannabis effect in the postoperative context, methodological disparities found in the included articles and the impossibility of performing collective quantitative analyses were more significant. Before concluding with the well-known sentence: "further intervention studies are necessary", this report has identified limitations and has proposed recommendations for the planning and execution of future cannabis clinical trials, which will support new and necessary evidence for stronger meta-analytic reviews.

SIGNIFICANCE

The management of severe pain after surgery, and the use of intravenous drugs with limited and potentially unsafe effectiveness, has led to the exploration of new treatment options to minimize side effects while improving pain relief. Cannabinoids have been suggested as a potential solution for managing post-surgical pain, but there is currently insufficient evidence to assess their effectiveness. The purpose of this article was to evaluate the effectiveness and safety of cannabinoids in this context.

Role of Gender and Race in Patient-Reported Outcomes and Satisfaction

Patient-reported outcomes and patient-reported outcome measures are important tools that pertain to a patient's health, quality of life, or functional status associated with clinical care. There are multiple measurement tools available to measure these outcomes. Recently, there has been an increased focus on understanding the role of demographic determinants such as gender, race and socioeconomic status (SES) on patient reported outcomes. Therefore, in this review, outcome domain tools to measure these domains and the roles of gender, race, and SES on outcomes are analyzed.

Prevention of Opioid Misuse and Abuse Through Effective Pain Management in Patients With Chronic Pain: An Umbrella Systematic Review

Chronic pain is a condition that frequently affects patients and communities. There are several treatment options available, including both pharmacological and non-pharmacological. Opioid prescriptions have increased over the past few years, and long-term use of opioids leads to an increased risk of opioid misuse and death due to overdose. This systematic review discusses the effective pain management options in chronic non-cancer pain patients that may help prevent opioid use and misuse. We searched PubMed, PubMed Central (PMC), Medical Literature Analysis and Retrieval System Online (MEDLINE), Multidisciplinary Digital Publishing Institute (MDPI), and Google Scholar for relevant literature. The different results were screened by the application of eligibility criteria, and 15 papers were finalized for review. These papers discussed the different pain management options, physician guidelines, and efforts to reduce opioid misuse, the importance of pill counting, and the involvement of multidisciplinary care teams in pain management. However, most of these papers were reviews over a short duration. The effects of emotions on chronic pain have been discussed along with the multidisciplinary pain rehabilitation treatment options that have improved patients' overall function. The reviewed research demonstrated positive outcomes of spinal cord stimulation in chronic low back pain, thereby reducing opioid use. However, further research is needed to explore more treatment options for chronic pain that can adequately reduce pain and prevent opioid use.

Enhanced rehabilitation after surgery: principles in the treatment of emergency complicated colorectal cancers - a narrative review

Enhanced Recovery After Surgery (ERAS) protocols are used in elective colorectal surgeries and have shown improved recovery for many patients. However, using these protocols in emergency colorectal surgery, especially in complicated cases of obstructive colorectal cancer, is still debated. This review examined the ERAS principles that can be adapted for emergencies. We reviewed the literature on applying ERAS principles in emergency colorectal cancer surgery. We analyzed key strategies used before, during, and after surgery. The aim of ERAS in emergency colorectal surgery is to reduce physical stress from urgent surgical conditions. Before surgery, the focus should be on early patient recovery, managing blood sugar levels, and providing patient education when possible. Minimally invasive techniques, careful fluid management, and effective pain relief during surgery are intraoperative key points. After surgery, early feeding, patient mobilization, and minimizing the use of medical devices are encouraged. Studies have shown that using ERAS in emergencies can lower mortality, reduce hospital stays, and influence patient recovery rates, although it may lead to higher initial costs. Still, following ERAS in emergencies is inconsistent due to logistical issues and patient health changes. More people are starting to recognize the benefits of ERAS in obstructive colorectal cancer surgery. Although there is less evidence compared to elective procedures, new studies suggest that organized steps for care can improve patient outcomes. Further research is needed to improve ERAS emergency protocols and identify patients suitable for this approach so that healthcare resources can be used better.

The analgesic effectiveness of auriculotherapy for acute postoperative pain: A systematic review and meta-analysis

BACKGROUND

Postoperative pain is a significant yet inadequately managed complication following surgery, and auriculotherapy to alleviate acute postoperative pain (APP) and reduce the use of opioids remains controversial.

METHODS

We searched the MEDLINE, Web of Science, Embase, Cochrane Library, CINAHL Complete, and ClinicalTrials.gov from inception to January 23, 2024 for all randomized controlled trials (RCTs) of auriculotherapy in the treatment of APP. The extracted data underwent risk of bias assessment, meta-analysis, subgroup analyses, sensitivity analysis, meta-regression analysis, and evidence rating.

RESULTS

A total of 24 studies involving 2131 patients were included in the meta-analysis. Low-quality evidence indicated that auriculotherapy was effective in reducing pain intensity at 24 [MD(95 %CI)=-0.64(-1.09, -0.19), I2=77 %, P＜0.01], 48 [MD(95 %CI)=-0.49(-0.97, 0.00), I2=71 %, P=0.05], and 72 [MD(95 %CI)=-0.80(-1.32, -0.28), I2=52 %, P＜0.01] hours after surgery, while moderate-quality evidence showed a decrease in total opioid consumption [MD(95 %CI)=-24.41 OME (-38.28, -10.54), I2=95 %, P＜0.01]. However, no significant effects were observed in reducing postoperative nausea or vomiting [RR(95 %CI)=0.61(0.32, 1.16), I2=71 %, P=0.13; RR(95 %CI)=0.32(0.09, 1.18), I2=71 %, P=0.09; RR (95 %CI)=0.34(0.11, 1.06), I2=28 %, P=0.06; for postoperative nausea and vomiting (PONV), postoperative nausea or postoperative vomiting respectively], with evidence ranging from moderate to very low. Additionally, two RCTs found that auriculotherapy could delay the time to the first request for analgesia.

CONCLUSIONS

The summary estimates indicate that auriculotherapy may be beneficial in reducing APP and opioid consumption in specific surgeries based on low-to-moderate quality evidence. However, high-quality RCTs are still further studied in different surgical populations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO database, CRD42024506989.

The Relationship of Perioperative Inadvertent Hypothermia with Anxiety and Comfort

The study aimed to investigate the relationship of perioperative inadvertent hypothermia with anxiety and thermal and general comfort in surgical patients. Inadvertent perioperative hypothermia occurs after surgery and affects many patient outcomes. However, the relationship between hypothermia and anxiety has been given little attention. The research is of descriptive type. A total of 117 surgical patients who met the inclusion criteria were sampled and divided into two groups: hypothermic (n = 54) and normothermic (n = 63). Patients undergoing surgery were monitored for body temperature, systolic and diastolic blood pressure, heart rate, pain intensity, anxiety (Numeric Rating Scale [NRS] and State Anxiety Scale [SAI]), and comfort (Perianesthesia Comfort Questionnaire) levels. The groups were similar in terms of descriptive characteristics (p > 0.05). Among the patients undergoing surgical intervention, 46.1% were hypothermic. Compared with the normothermic group, the hypothermic group had significantly lower body temperature until the second postoperative hour, lower thermal comfort score until the third postoperative hour, and higher heart rate and anxiety (NRS) score until the first postoperative day. Furthermore, there was a significant difference between the groups in terms of pain intensity up to the first 30 minutes after surgery (p < 0.05). Moreover, there was no significant difference between the groups in terms of pre and postoperative day one anxiety (SAI) and Periantesthesia Comfort Scale mean scores (p > 0.05). The study findings showed that hypothermia affected thermal comfort up to the first 3 hours after surgery, pain intensity up to the first 30 minutes, and heart rate and anxiety (NRS) levels up to the first day.

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

INTRODUCTION

Total knee arthroplasty (TKA) is one of the most performed surgical operations in the United States. Managing postoperative pain after TKA is of vital importance, as it is positively associated with outcome measures related to recovery of function and quality of life. Two commonly used methods to control postoperative pain are regional anesthesia (RA), consisting of a single or a combination of peripheral nerve and epidural blocks, and pain medication, such as opioids. Our retrospective analysis sought to better understand whether revision versus primary TKA impacted previously discovered disparities in perioperative pain management and use of RA at the Atlanta Veterans Affairs Health Care System (AVAHCS). Before data collection, we hypothesized that revision TKA would have a higher proportion of Black and older patients and that revision TKA patients would have lower postoperative pain scores.

MATERIALS AND METHODS

This was a retrospective analysis of AVAHCS patients who underwent elective unilateral primary or revision TKA surgery between 2014 and 2020. After application of our exclusion criteria, data from 562 patients were analyzed. Data collected included demographics information, type of RA used, and pain scores. Statistical analyses included chi-square test, t-tests, multiple logistic regression, and multiple linear regression, as appropriate to the outcomes of interest.

RESULTS

Revision TKA patients were more likely to be Black (P = .018) and younger (P = .023 for <50 years of age group, P = .006 for 50 to 64 years of age compared to the >65 years group). Black patients, compared to White patients, had significantly higher pain scores at baseline (P = .0086) and at 24 hours postsurgery (P = .0037). Older patients (≥50 years old) had significantly higher baseline pain scores (P = .021 for the 50 to 64 years group, P < .01 for the >65 years group) and significantly lower first postanesthesia care unit pain scores (P < .05). Black race (P < .01) and age > 65 years (P < .01) were associated with a significant decrease in total oral morphine equivalents (OME) prescribed at discharge. None of the predictor variables-race, age, type of surgery (primary versus revision), baseline, and first postanesthesia care unit pain scores-were significantly associated with the use of RA in our cohort.

CONCLUSIONS

Sociodemographic disparities in pain management have been reported in all healthcare systems, including the VAHCS. This moderately sized retrospective study, conducted at a single veterans affairs site, yielded several noteworthy findings. One finding of particular interest was that, despite Black patients reporting higher baseline and 24-hour postoperative pain scores, they were prescribed fewer opioids at discharge. Our results highlight the presence of clinically significant disparities in perioperative TKA pain management, emphasizing the need for continuous investigation and focused mitigation efforts among Veterans.

Patient Controlled Intravenous Analgesia with Oxycodone or Sufentanil After Hip Surgery: Study Protocol for a Multi-Centered, Randomized Controlled Trial

Background: Patient-controlled intravenous analgesia (PCIA) after hip surgery should be focused on sufficient analgesia, recovery, and the risk of adverse effects. Sufentanil PCIA offers effective analgesia but with obvious side effects. Oxycodone, a semi-synthetic opioid, is reported to have good analgesic effects with fewer adverse effects compared to strong opioids. We hypothesize that in hip surgery, compared with sufentanil PCIA, oxycodone PCIA in an equipotent dose to sufentanil could achieve similar postoperative analgesia while reducing the incidence of adverse effects associated with strong opioids. Methods: This multi-centered, randomized, controlled open-label clinical trial compares the efficacy of oxycodone and sufentanil for PCIA in hip surgery patients. Results: A total of 570 subjects will be randomly allocated in a 1:1 ratio into either the oxycodone group or sufentanil group. The primary outcome is the resting numerical rating scale (NRS) pain scores at 2 h after surgery. The secondary outcomes include the incidence of postoperative nausea and vomiting (PONV), NRS pain scores on movement, complications, mobilization time, length of hospital stay, total in-hospital cost, etc. Conclusions: This trial will provide evidence for the choice of PCIA in hip surgery by comparing the analgesic efficacy and side effects of oxycodone and sufentanil, serving as a foundation for postoperative pain management guidelines and recommendations. Trial Registration: Clinical Trials NCT03685188.

Impact of Individualized Comfort-Based Combined Anesthesia Protocol on Elderly Patients Undergoing Outpatient Oral Procedures

Aims/Background Anxiety, fear, and lack of confidence in surgical outcomes can lower the pain threshold of elderly patients. Developing individualized and comfortable anesthesia protocols is critical for optimizing outcomes in elderly patients undergoing oral procedures. This study aimed to investigate the impact of an individualized comfort anesthesia protocol on elderly patients with varying levels of dental anxiety undergoing complex tooth extraction. Methods A retrospective analysis was conducted on 210 elderly patients who underwent complex tooth extractions at the Comfort Oral Treatment VIP Center and Oral Surgery Department of Beijing Stomatological Hospital, Capital Medical University, between December 2022 and May 2024. Patients were categorized into three groups based on Corah's Dental Anxiety Scale: mild dental anxiety (Group G1, 72 cases), moderate dental anxiety (Group G2, 72 cases), and severe dental anxiety (Group G3, 66 cases). Corresponding anesthesia regimens were administered: 0.06 mg/kg, 0.08 mg/kg + 0.03 μg/kg/time, and 0.06 mg/kg + 0.05 μg/kg/time, respectively. Mean arterial pressure (MAP), bispectral index (BIS), and heart rate (HR) were measured at sedation onset (T1), after local anesthesia injection (T2), and at the end of tooth extraction (T3). Sedation onset time, recovery time, discharge time, and adverse reactions were also recorded. Results Repeated measures analysis of variance (ANOVA) revealed significant difference in BIS within groups over time (p < 0.001), with notable group-by-time interactions (p < 0.001) and significant within-group effects (p < 0.001). For MAP, there was a significant within-group effect (p < 0.001) and group-by-time effect (p < 0.001), while the time effect was not statistically significant (p = 0.302). HR demonstrated a significant within-group effect (p < 0.001) but no significant time effects (p = 0.278) and marginally non-significant group-by-time interactions (p = 0.052). Compared with Group G3, Groups G1 and G2 exhibited shorter sedation onset, recovery times, and discharge times (p < 0.001). Additionally, Group G3 had longer sedation onset and recovery times compared to Group G2 (p < 0.001). No significant difference in discharge times was observed between Groups G1 and G2 (p > 0.05). Among the adverse reactions, bradycardia and drowsiness were significantly more frequent in specific groups (p < 0.05). Conclusion An individualized comfort-based anesthesia protocol tailored to the levels of anxiety, fear, and anticipated pain effectively provides optimal sedative and anesthetic outcomes for elderly patients undergoing complex tooth extractions in outpatient settings. This approach exhibits significant benefits in sedation onset, recovery, and discharge times while minimizing adverse reactions, making it a practical and effective option for clinical application.

Disparities in Postoperative Pain Management: A Scoping Review of Prescription Practices and Social Determinants of Health

Background: Opioid analgesic therapy has been traditionally used for pain management; however, the variability in patient characteristics, complexity in evaluating pain, availability of treatment within facilities, and U.S. physicians overprescribing opioids have contributed to the current opioid epidemic. Despite large research efforts investigating the patterns of postsurgical pain management and influencing factors, it remains unclear how these overall trends vary across the varying sizes and available resources of academic hospitals, community hospitals, and outpatient surgery centers. The primary aim of this scoping review was to examine the patterns of contemporary postoperative pain management across healthcare settings, including academic medical centers, community hospitals, and outpatient surgery centers. Specifically, this study investigates how prescription practices for opioids, NSAIDs, and acetaminophen are influenced by patient demographics, including sex, race, gender, insurance status, and other social determinants of health (SDoH), to inform equitable and patient-centered pain management strategies. Methods: This study utilized The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) and was used as a reference checklist. The Arksey and O'Malley methodological framework was used to guide the review process. To ensure comprehensive coverage, searches were conducted across three major databases: PubMed, Embase, and Cochrane Library. Results: A total of 43 eligible studies were retained for analysis. The highest reported Healthy People 2030 category was Social and community context (n = 39), while the highest reported category of SDoH was age (n = 36). A total of 34 articles listed sex and age as SDoH. Additional SDoH examined were race/ethnicity (n = 17), insurance (n = 7), employment (n = 1), education (n = 4), and income (n = 1). This review suggests that there are significant gaps in the implementation of institution-specific, patient-centered, and equitable pain management strategies, particularly in academic hospitals, which our findings show have the highest rates of opioid and NSAID prescriptions (n = 26) compared to outpatient surgical centers (n = 8). Findings from our review of the literature demonstrated that while academic hospitals often adopt enhanced recovery protocols aimed at reducing opioid dependence, these protocols can fail to address the diverse needs of at-risk populations, such as those with chronic substance use, low socioeconomic status, or racial and ethnic minorities. Conclusions: Findings from this review are expected to have implications for informing both organizational-specific and nationwide policy recommendations, potentially leading to more personalized and equitable pain management strategies across different healthcare settings. These include guidelines for clinicians on addressing various aspects of postoperative pain management, including preoperative education, perioperative pain management planning, use of different pharmacological and nonpharmacological modalities, organizational policies, and transition to outpatient care.