The changing role of non-opioid analgesic techniques in the management of postoperative pain

Consensus statement on pain management for pregnant patients with opioid use disorder from the Society for Obstetric Anesthesia and Perinatology, Society for Maternal-Fetal Medicine, and American Society of Regional Anesthesia and Pain Medicine

Pain management in pregnant and postpartum people with an opioid use disorder requires a balance among the risks associated with opioid tolerance, including withdrawal or return to opioid use, considerations around the social needs of the maternal-infant dyad, and the provision of adequate pain relief for the birth episode that is often characterized as the worst pain a person will experience in their lifetime. This multidisciplinary consensus statement from the Society for Obstetric Anesthesia and Perinatology, the Society for Maternal-Fetal Medicine, and the American Society of Regional Anesthesia and Pain Medicine provides a framework for pain management in obstetrical patients with opioid use disorder. The purpose of this consensus statement is to provide practical and evidence-based recommendations and is targeted to healthcare providers in obstetrics and anesthesiology. The statement is focused on prenatal optimization of pain management, labor analgesia and postvaginal delivery pain management, and postcesarean delivery pain management. Topics include a discussion of nonpharmacologic and pharmacologic options for pain management, medication management for opioid use disorder (eg, buprenorphine, methadone), considerations regarding urine drug testing and other social aspects of care for maternal-infant dyads, and a review of current practices. The authors provide evidence-based recommendations to optimize pain management while reducing risks and the complications associated with opioid use disorder in the peripartum period. Ultimately, this multidisciplinary consensus statement provides practical and concise clinical guidance to optimize pain management for people with opioid use disorder in the context of pregnancy to improve maternal and perinatal outcomes.

Additive effect of a single intravenous dose of acetaminophen administered at the end of laparoscopic hysterectomy on postoperative pain control with nefopam and fentanyl-based patient-controlled analgesia: a double-blind, randomized controlled trial

BACKGROUND

Acetaminophen is a widely used analgesic for postoperative pain management. However, data on its combined use with nefopam for managing postoperative pain following laparoscopic hysterectomy are limited. This study evaluated the effects of a single intravenous dose of acetaminophen combined with fentanyl- and nefopam-based patient-controlled analgesia (PCA) in patients undergoing laparoscopic hysterectomy.

METHODS

In this prospective, double-blind, randomized controlled trial, 84 patients were randomized to receive either 1 g of intravenous acetaminophen (treatment group, n = 42) or normal saline (control group, n = 42) at the end of surgery. All patients received fentanyl and nefopam via PCA, postoperatively. PCA consumption, pain scores at rest, and postoperative nausea and vomiting (PONV) scores were assessed at 1, 6, and 24 h postoperatively. Patient satisfaction and opioid-related side effects were also evaluated. The primary outcome was the total PCA consumption within the first 24 h.

RESULTS

No significant difference in 24-h PCA consumption was observed between the control and treatment groups (27.9 ± 16.6 vs. 26.4 ± 11.2, P = 0.623). The pain scores at rest measured at 1, 6, and 24 h after surgery were also not significantly different between the two groups. There were no differences in the satisfaction scores, PONV scores, rescue analgesic use, adverse effects, or length of hospital stay between the groups.

CONCLUSIONS

A single intraoperative dose of intravenous acetaminophen, combined with nefopam- and fentanyl-based PCA, did not significantly reduce analgesic requirements, pain scores at rest, or opioid-related side effects compared with placebo in laparoscopic hysterectomy patients.

TRIAL REGISTRATION

ClinicalTrials.gov (Identifier: NCT03644147 | August 21, 2018).

Is perioperative use of a combination of pregabalin and naproxen superior to naproxen only in reducing pain in ankle fractures? A prospective, randomized, multicenter study

PURPOSE

To compare the analgesic efficacy, adverse effects, and long-term functional outcomes of perioperative naproxen alone versus naproxen with pregabalin for treating pain in ankle fractures.

METHODS

This study included 70 patients who underwent operative fixation of rotatory ankle fractures. Group A received naproxen 500 mg only, and Group B received naproxen 500 mg with pregabalin 75 mg 2-hour before surgery and 12 hourly for 14 days thereafter. The minimal clinically important difference of the visual analog scale (VAS) for pain was set at 1.8 out of 10. VAS for pain, opioid consumption, and any adverse effects were recorded for 3 days postoperatively. VAS for pain was checked at 2- and 6-weeks and 3- and 6-months, and functional outcomes were measured at 3- and 6-months postoperatively.

RESULTS

Sixty-three patients (33 and 30 in groups A and B, respectively) completed the 6-month follow-up. Demographic data were similar between groups. VAS for pain did not significantly differ between the groups at any timepoint up to 6 months (P ≥ 0.520), with 95% confidence intervals consistently within 1.8. No significant differences were observed between groups in opioid consumption and functional outcomes (P ≥ 0.211). In group B, dizziness at 48-hour and somnolence at 72-hour were significantly predominant (P ≤ 0.05).

CONCLUSION

Our study demonstrated comparable pain reduction between two groups following operative fixation of rotatory ankle fractures. However, side effects, including dizziness and somnolence, were predominant in Group B between 48 and 72 h.

Consensus Statement on Pain Management for Pregnant Patients with Opioid-Use Disorder from the Society for Obstetric Anesthesia and Perinatology, Society for Maternal-Fetal Medicine, and American Society of Regional Anesthesia and Pain Medicine

Pain management in pregnant and postpartum people with an opioid-use disorder (OUD) requires a balance between risks associated with opioid tolerance, including withdrawal or return to opioid use, considerations around social needs of the maternal-infant dyad, and the provision of adequate pain relief for the birth episode that is often characterized as the worst pain a person will experience in their lifetime. This multidisciplinary consensus statement between the Society for Obstetric Anesthesia and Perinatology (SOAP), Society for Maternal-Fetal Medicine (SMFM), and American Society of Regional Anesthesia and Pain Medicine (ASRA) provides a framework for pain management in obstetric patients with OUD. The purpose of this consensus statement is to provide practical and evidence-based recommendations and is targeted to health care providers in obstetrics and anesthesiology. The statement is focused on prenatal optimization of pain management, labor analgesia, and postvaginal delivery pain management, and postcesarean delivery pain management. Topics include a discussion of nonpharmacologic and pharmacologic options for pain management, medication management for OUD (eg, buprenorphine, methadone), considerations regarding urine drug testing, and other social aspects of care for maternal-infant dyads, as well as a review of current practices. The authors provide evidence-based recommendations to optimize pain management while reducing risks and complications associated with OUD in the peripartum period. Ultimately, this multidisciplinary consensus statement provides practical and concise clinical guidance to optimize pain management for people with OUD in the context of pregnancy to improve maternal and perinatal outcomes.

Comparison of the postoperative effects of the erector spinae plane block and local infiltration analgesia in patients operated with lumbotomy surgery incision: Randomized clinical study

BACKGROUND

Our aim was to observe the effects of local infiltration analgesia (LIA) or erector spinae plane block (ESPB) methods, which we applied preemptively in patients who were scheduled for surgery with a lumbotomy surgical incision and on intraoperative remifentanil consumption, and to compare the postoperative numerical rating scale (NRS), morphine demand, consumption, and pain degrees.

METHODS

Sixty American Society of Anesthesiologists I to III patients aged 18 to 75 years who were due to be operated on with a lumbotomy surgical incision were included in the study. The present study was conducted via prospective, randomized controlled, double-blind trials. After the induction of standard anesthesia, LIA was applied to 30 patients and ESPB was applied to 30 patients preemptively. The dose of remifentanil consumed in the intraoperative period was measured, and the hemodynamic parameters were measured every 5 minutes. Morphine bolus treatment with the postoperative patient-controlled analgesia and rescue analgesia with paracetamol were planned for the patients. Postoperative morphine and additional analgesia consumption, NRS, hemodynamic parameters, and complications were recorded for 48 hours.

RESULTS

There was no difference between the groups in terms of demographic and hemodynamic data. The mean consumption of remifentanil was measured as 455 ± 165.23 µg in the intraoperative ESPB group and 296.67 ± 110.59 µg in the LIA group, and a statistical difference was observed (P = .001). In the postoperative follow-ups, the ESPB group drug consumption and NRS score averages were significantly lower at all times (P = .01; patient-controlled analgesia-morphine, 41.93 ± 14.47 mg vs 57.23 ± 15.5 mg and additional analgesic-paracetamol: 2.1 ± 1.06 vs 4.27 ± 1.14 g). The mean duration of additional analgesic intake of the groups was 10.6 ± 8.1 in the LIA group, while it was 19.33 ± 8.87 in the ESPB group, a significant difference. The patient satisfaction questionnaire was also significantly in favor of ESPB (P = .05).

CONCLUSIONS

In conclusion, it has been shown that the intraoperative LIA method is more effective in terms of remifentanil consumption and in controlling pain in operations performed with a flank incision, but the ESPB method provides longer and more effective pain control in postoperative follow-ups.

Fast Track versus Conventional Perioperative Care Protocols in Paediatric Intestinal Stoma Closure ‒ A Randomised Study

BACKGROUND

It is still unclear to what extent fast-track (FT) surgery is applicable in paediatric surgery. The aim of the study was to compare the outcome between FT and conventional perioperative care protocols in paediatric intestinal stoma closure to assess the safety for future application.

MATERIALS AND METHODS

This study was a prospective randomised study. Twenty-six paediatric patients who underwent intestinal stoma closure from December 2019 to March 2021 were divided into two groups: group A, conventional methods and Group B FT protocol. The FT protocol included minimal pre-operative fasting, no pre-operative bowel preparation, no routine intraoperative use of nasogastric tube, drain tube, urinary catheter, early post-operative enteral feeding, early mobilisation, non-opioid analgesics and prophylactic use of anti-emetic. Total length of post-operative hospital stays and complications between these two groups were compared.

RESULTS

No significant differences were found between the two groups regarding anastomotic leak (nil in both groups), wound infection (7.7% in Group A vs. 0% in Group B; P = 1.0) and wound dehiscence (7.7% in Group A vs. 0% in Group B; P = 1.0). No significant differences were found in post-operative length of stay (median 5, interquartile range [IQR] 4-9 in Group A and median 6, IQR 4-7 in Group B, P = 0.549) and time to appearance of bowel function (passage of stool) (median 2 days in both groups; P = 0.978).

CONCLUSIONS

FT surgery was comparable to the conventional method in terms of complication and thus can reduce unnecessary interventions.

Patient and dentist perspectives on collecting patient reported outcomes after painful dental procedures in the National Dental PBRN

BACKGROUND

Dental Patient Reported Outcomes (PROs) relate to a dental patient's subjective experience of their oral health. How practitioners and patients value PROs influences their successful use in practice.

METHODS

Semi-structured interviews were conducted with 22 practitioners and 32 patients who provided feedback on using a mobile health (mHealth) platform to collect the pain experience after dental procedures. A themes analysis was conducted to identify implementation barriers and facilitators.

RESULTS

Five themes were uncovered: (1) Sense of Better Care. (2) Tailored Follow-up based on the dental procedure and patient's pain experience. (3) Effective Messaging and Alerts. (4) Usable Digital Platform. (5) Routine mHealth Integration.

CONCLUSION

Frequent automated and preferably tailored follow-up messages using an mHealth platform provided a positive care experience for patients, while providers felt it saved them time and effort. Patients thought that the mHealth questionnaires were well-developed and of appropriate length. The mHealth platform itself was perceived as user-friendly by users, and most would like to continue using it.

PRACTICAL IMPLICATIONS

Patients are prepared to use mobile phones to report their pain experience after dental procedures. Practitioners will be able to close the post-operative communication gap with their patients, with little interruption of their workflow.

Reduced side effects and improved pain management by continuous ketorolac infusion with patient-controlled fentanyl injection compared with single fentanyl administration in pelviscopic gynecologic surgery: a randomized, double-blind, controlled study

BACKGROUND

A combination of opioids and adjunctive drugs can be used for intravenous patient-controlled analgesia (PCA) to minimize opioid-related side effects. We investigated whether two different analgesics administered separately via a dual-chamber PCA have fewer side effects with adequate analgesia than a single fentanyl PCA in gynecologic pelviscopic surgery.

METHODS

This prospective, double-blind, randomized, and controlled study included 68 patients who underwent pelviscopic gynecological surgery. Patients were allocated to either the dual (ketorolac and fentanyl delivered by a dual-chamber PCA) or the single (fentanyl alone) group. Postoperative nausea and vomiting (PONV) and analgesic quality were compared between the two groups at 2, 6, 12, and 24 h postoperatively.

RESULTS

The dual group showed a significantly lower incidence of PONV during postoperative 2-6 h (P = 0.011) and 6-12 h (P = 0.009). Finally, only two patients (5.7%) in the dual group and 18 (54.5%) in the single group experienced PONV during the entire postoperative 24 h and could not maintain intravenous PCA (odds ratio: 0.056, 95% CI [0.007, 0.229], P < 0.001). Despite the administration of less fentanyl via intravenous PCA during the postoperative 24 h in the dual group than in the single group (66.0 ± 77.8 vs. 383.6 ± 70.1 μg, P < 0.001), postoperative pain had no significant intergroup difference.

CONCLUSIONS

Two different analgesics, continuous ketorolac and intermittent fentanyl bolus, administered via dual-chamber intravenous PCA, showed fewer side effects with adequate analgesia than conventional intravenous fentanyl PCA in gynecologic patients undergoing pelviscopic surgery.

Post-Procedure Analgesic Management

During the development of multimodal pain management protocols, practitioners need to consider the potential risks each treatment modality inherently carries in order to prevent or diminish harmful outcomes. As an example, the part dentists played in the early stages of the opioid epidemic in the United States of America should serve as a cautionary account. By understanding the roots of this crisis, as practitioners we are better equipped to implement the novel analgesic agents available today to optimize post-operative pain control while minimizing any risk of addiction and harm to our communities. It is therefore critical that our colleagues understand the variety of accessible options for pain management to assure that our profession is able to seek adequate and sustainable relief for our post-operative patients. This article will go in depth to explain the analgesic tools practitioners can implement for an effective low-risk protocol, including a combination of NSAIDS and acetaminophen approach, using long-acting local anesthetics such as Exparel, pregabalin, gabapentin, ketamine, dexmedetomidine, and corticosteroids, and enhanced recovery after surgery protocols.

Surgeon administered transversus abdominis plane block: anatomic principles and technique

The Transversus Abdominis Plane (TAP) block is a regional abdominal wall block that has been effectively used as an adjunct to alleviate postoperative pain. The ultrasound-guided TAP (USTAP) administered by anesthesiologists is the gold standard and has been effective for surgeries involving abdominal wall incisions. Recently, the TAP block has been administered by surgeons with the help of direct visualization during minimally invasive surgery. The surgeon-administered or laparoscopic-guided TAP block has been compared to the USTAP with no discernible difference in patient outcomes. Also, directly visualizing the injection in the surgeon-administered block can offset complications such as visceral injury and block failure (injectate in the wrong plane). This review explores the literature's surgeon-administered TAP blocks for minimally invasive surgery in the literature. In addition, the prerequisite anatomy of the anterolateral abdominal wall, various approaches, and other factors that influence the efficacy of the block are described to increase awareness of this analgesic tool among surgeons and achieve better postoperative pain management.

Comparative Evaluation of Postoperative Pain Scores and Opioid Consumption in Septorhinoplasty After Administration of Single-Dose Preemptive Paracetamol and Ibuprofen: A Randomized Controlled Trial

Introduction  Septorhinoplasty operates on the nose's bone and cartilage and is ensued by severe postoperative pain. Objective  The objective of this study is to evaluate the effects of preoperative administration of intravenous (IV) paracetamol and ibuprofen on postoperative pain scores in patients undergoing septorhinoplasty. Methods  A total of 150 patients undergoing septorhinoplasty were randomly assigned into 3 groups with 50 patients in each group. The control group (group A) was administered 100 ml saline solution; the paracetamol group (group B) was administered 1,000 mg of IV paracetamol in 100 ml of saline solution; and the ibuprofen group (group C) was administered 800 mg of IV ibuprofen in 100 ml of saline solution before surgery. Opioid analgesics were employed to achieve postoperative analgesia. Postoperative pain was evaluated using the visual analogue scale (VAS). Postoperative opioid consumption and adverse effects were also recorded for each patient. Results  In comparison with group A, the score in the VAS of groups B and C was statistically lower in all the time intervals ( p  < 0.05). In the 1 st and 6 th hours postoperatively, group C's score in the VAS in was lower than that of group B ( p  < 0.05). In the control group, total opioid consumption was highest in all time intervals ( p  < 0.05). In group C, total opioid consumption was significantly lower than in group B in the 0 to 6 and 6 to 12 hours intervals. ( p  < 0.05). Conclusion  The single-dose preemptive administration of ibuprofen has a more profound postoperative analgesic effect than paracetamol in the first 6 hours after septorhinoplasty. After the first 6 hours postsurgery, there is no difference between ibuprofen and paracetamol in terms of analgesic effect.

Efficacy of Transversus Abdominis Plane Block for Postoperative Analgesia in Different Lower Abdominal Surgeries in a Tertiary Care Hospital-Chengalpattu District

Background

Transversus abdominis plane (TAP) block is one of the novel approaches and an effective method for providing postoperative analgesia in patients undergoing lower abdominal surgeries.

Objectives

To evaluate the efficacy and routine usage of TAP block for postoperative analgesia in different lower abdominal surgeries.

Methods

It is a randomized, double-blind trial. Sixty patients undergoing lower abdominal surgeries in sub-arachnoid block with bupivicaine 0.5% were randomized to undergo TAP block (n = 30) using ropivacaine 0.375% as the study group. In the control group (n = 30), only the standard analgesic regimen (paracetamol 1 gm IV and tramadol 50 mg IV) was given. Postoperative pain was assessed using Visual Analogue Scale (VAS) at 30 min and 4, 8, 12, 16, 20, and 24 hrs. First analgesic request after TAP block was compared with a subsequent number of analgesics given postoperatively. Rescue analgesia given postoperatively at request after TAP block was paracetamol 1 gm IV and tramadol 50 mg IV.

Results

Patients who received TAP block had a significant reduction in postoperative pain scores at 30 min - 0 (0 - 1), 4 hrs - 0 (0 - 4), 8 hrs - 4 (3 - 5), 12 hrs - 1 (0 - 4), 16 hrs - 1 (1 - 2), 20 hrs -1 (0 - 2), 24 hrs -1 (0 - 1) with P-value < 0.05 in the first 24 hrs. TAP block also delayed the first rescue analgesic request (265 ± 24 min Vs. 66 ± 15 min with P-value < 0.005) and reduction in subsequent analgesic requirements in the first 24 hrs (1.04 ± 0.26 Vs. 2.3 ± 0.48 with P-value < 0.05).

Conclusions

TAP block holds a considerable part in postoperative analgesia. Highly effective for the first 24 hrs in patients undergoing different lower abdominal surgeries, it delays the first rescue analgesic request, decreases the subsequent analgesic requirement, and augments early mobilization, discharge, and cost-effectiveness.

Is Paracetamol Better than Diclofenac Sodium in Management of Postoperative Pain and Edema Following Major Maxillofacial Surgeries?

Introduction

Paracetamol is an optimal non-opioid analgesic and holds considerable advantages over NSAIDs in managing post-operative pain. Literature to date doesn't provide substantial documentation of it's efficacy and safety in major oral and maxillofacial surgeries. The study is designed to compare the effectiveness of intravenous paracetamol with diclofenac sodium for controlling post-operative pain and edema in major oral and maxillofacial surgeries.

Method

The double-blind randomised prospective study includes 140 healthy patients with ASA grades I and II. Patients were divided into Group A (1gm paracetamol) and B (75 mg diclofenac sodium), 70 patients each, undergoing similar surgical procedures. VAS and VRS were assessed for pain and thread method for measuring swelling. Mouth opening in space infections was measured with calliper and scale.

Results

Independent samples t-test and chi-square test showed longer pain-free interval, more interval between first and second dose, lesser number of doses required in Group A than Group B (p-value < 0.05). Independent samples t-test and Mann-Whitney test showed faster resolution of swelling in Group A (p-value < 0.05). Independent samples t-test showed lesser time taken for resolution of trismus in space infections in Group A (p-value < 0.05).

Discussion

Paracetamol 1 g was found to be an effective analgesic with less adverse effects. It is superior non-opioid analgesic in reducing the intensity of post-operative pain and swelling, also requires less number of doses than diclofenac sodium in major surgeries. Patients treated with paracetamol had better quality of life during post-operative period.

Patterns of Prescribing Postoperative Analgesic Medication After Thyroid Surgery: A Retrospective Cohort Study

Background

Mild-to-moderate postoperative pain is common after surgical procedures of the thyroid. Opioid analgesics have been commonly prescribed in such cases, but their use has been debated owing to concerns regarding the addictive nature of opioids. Recently, experts from the Endocrine Surgery Section of the American Head and Neck Society released a consensus document to limit the use of opioids as the first-line pain control medication after head and neck or endocrine procedures. However, differences in pain management prescriptions have been noted in many settings. This study aims to assess the post-thyroid surgery pain control medication prescription practices of head and neck and endocrine surgeons.

Methods

This study retrospectively reviewed the charts of 105 adult patients who underwent thyroid surgery (total thyroidectomy, thyroid lobectomy, or subtotal thyroidectomy) by head and neck or endocrine surgeons. The type of prescribed pain medication at hospital discharge postoperatively was then retrieved from each patient's discharge medication list. Descriptive statistics mean, standard deviations, frequencies, and percentages were computed, while the Chi-square test was applied to measure the significant differences among variables at a 5.00% significant level.

Results

An outpatient oral opioid, in the form combining paracetamol and codeine, was prescribed for 62 (59%) patients, whereas 43 (41%) were discharged on paracetamol only.

Conclusion

The use of opioids is the practice pattern for pain management among some head and neck or endocrine surgeons despite emerging evidence that supports the use of non-opioid and other alternative analgesic strategies in outpatient thyroid and parathyroid surgery. Further research and quality improvement interventions should be geared towards leading all health professionals to appropriate prescription practices to improve patient safety and reduce unnecessary opioid prescriptions.

Continuous Cold Flow Device Following Total Knee Arthroplasty: Myths and Reality

Background and Objectives: To assess the effect of continuous cold flow (CCF) therapy on pain reduction, opioid consumption, fast recovery, less perioperative bleeding and patient satisfaction in patients undergoing a total knee arthroplasty. Materials and Methods: Patients affected by knee osteoarthritis between September 2020 and February 2022 were enrolled in this case-control study. Patients were randomly divided into two groups (n = 50, each): the study group received postoperative CCF therapy while the control group was treated by cold pack (gel ice). The CCF device is a computer-assisted therapy with continuous cold fluid, allowing a selective distribution, constant and uniform, of cold or hot on the areas to be treated. In both groups, pre- and postoperative evaluations at 6, 24, 72 h and at the fifth day were conducted using Visual Analogic Scale (VAS), opioid consumption, passive range of motion, preoperative hematocrit, total blood loss by Gross formula, transfusion requirement and patient satisfaction questionnaire. Results: One hundred patients, 52 women (52%), were included in the study. Reduction of pain, opioid consumption and increase in passive range of movement were statistically significantly demonstrated in the study group on the first and third days. Patients were satisfied with adequate postoperative pain management due to CCF therapy (p = 0.01) and they would recommend this treatment to others (p = 0.01). Conclusions: A continuous cold flow device in the acute postoperative setting after total knee arthroplasty is associated with pain reduction and improving early movement. Patients were almost satisfied with the procedure. The management of perioperative pain control could improve participation in the early rehabilitation program as demonstrated by the increase in ROM, psychological satisfaction and reduction in opioid use.

Novel external oblique muscle plane block for blockade of the lateral abdominal wall: a pilot study on volunteers

PURPOSE

No reports have described techniques to efficiently anesthetize the lateral cutaneous branches of the entire abdomen. The aim of this study was to investigate an effective procedure for blocking the lateral cutaneous branches in the abdominal region. We sought to describe the sensory distribution of the previously described thoracoabdominal nerve block through perichondrial approach (TAPA) and the novel costal and lateral external oblique muscle plane (EXOP) blocks in healthy volunteers.

METHODS

This was a proof-of-concept pilot study that comprised ten volunteers with an American Society of Anesthesiologists Physical Status I. The participants underwent modified TAPA (M-TAPA), injection 2 of TAPA (injection into the anterior aspect of the 10th costal cartilage: I2-TAPA), costal EXOP, and lateral EXOP blocks with injection of 20 mL of ropivacaine 0.2% for each block. A pinprick test was performed one hour after injection and repeated at 30-min intervals until the effect of the nerve block disappeared.

RESULTS

The M-TAPA injection anesthetized the anterior branches from T6/7 to T11/12, whereas the I2-TAPA injection had no effect. Costal and lateral EXOP injections anesthetized the lateral cutaneous branches of T7-10 and T11-12, respectively.

CONCLUSION

The results of this pilot study in ten healthy volunteers indicate that novel EXOP blocks involving local anesthetic injection superficial to the external oblique muscle efficiently anesthetize the lateral cutaneous branches of the thoracoabdominal nerves. Our study shows that it may be anatomically plausible for the combined use of these blocks to anesthetize the entire abdominal wall.

Ketamine as a component of multimodal analgesia for pain management in bariatric surgery: A systematic review and meta-analysis of randomized controlled trials

Introduction

Anaesthesia in morbidly obese people is challenging with a high dose of opioid consumption. This systematic review and meta-analysis of randomised controlled trials (RCTs) summaries evidence comparing ketamine to placebo for pain management after bariatric surgery.

Methods

We used PRISMA 2020 and AMSTAR 2 guidelines to conduct this study. The random-effects model was adopted using Review Manager Version 5.3 for pooled estimates.

Results

Seven RCTs published between 2009 and 2021 were eligible, including a total of 412 patients (202 patients in the ketamine group and 210 patients in the control group). In the ketamine group total opioid consumption during the first 24 h postoperatively was reduced (mean difference, MD = −5.89; 95% CI [-10.39, −1.38], p = 0.01), lower pain score at 4 h (MD = −0.81; 95% CI [-1.52, −0.10], p = 0.03), pain score at 8 h (MD = −1.00; 95% CI [-1.21, −0.79], p < 0.01), and shorter hospital stay (MD = −0.10; 95% CI [-0.20, −0.01], p = 0.03). There was no significant difference between the two groups regarding duration of anaesthesia (MD = −3.42; 95% CI [-8.62, 1.82], p = 0.20), or sedation score (MD = −0.02; 95% CI [-0.21, 0.17], p = 0.84). As concern the postoperative complications, risks of postoperative nausea and vomiting(OR = 0.75; 95% CI [0.27, 2.04], p = 0.56), hallucinations (OR = 5.47; 95% CI [0.26, 117.23], p = 0.28), dizziness (OR = 1.05; 95% CI [0.14, 7.78], p = 0.96), and euphoria (OR = 5.77; 95% CI [0.65, 51.52], p = 0.12) were not different between the two groups either.

Conclusion

Ketamine could be an effective and safe technique for pain management following bariatric surgery. It reduces opioid consumption, postoperative pain, and hospital stay.

RegistrationThis review was registered in PROSPERO (CRD42022296484).

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This study comparing ketamine infusion or bolus with placebo when used with morphine, paracetamol or tramadol for pain management following bariatric surgery demonstrated that:

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Ketamine was associated with lower opioid consumption during the 24 h postoperatively.

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Ketamine decreased VAS scores at H4 and H8, and shorten the hospital stay.

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Ketamine ensure a similar duration of anaesthesia, postoperative sedation scores, PONV, and postoperative complications rate (hallucinations, headache, euphoria and dizziness).

Effect of Intravenous Paracetamol on Opioid Consumption in Multimodal Analgesia After Lumbar Disc Surgery: A Meta-Analysis of Randomized Controlled Trials

Background: Intravenous paracetamol, as an adjunct to multimodal analgesia, has been shown to successfully reduce opioid consumption after joint arthroplasty, abdominal surgery, and caesarean delivery. However, there are limited data on the opioid-sparing effect of intravenous paracetamol on lumbar disc surgery. Objectives: The aim of this study was to investigate the effectiveness and safety of intravenous paracetamol for reducing opioid consumption in lumbar disc surgery. The primary outcome was cumulative opioid consumption within 24 h postoperatively. Method: We followed the PRISMA-P guidelines and used GRADE to assess the quality of evidence. The review was registered in PROSPERO under the registration number CRD42021288168. Two reviewers conducted electronic searches in PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science (Clarivate Analytics). Randomized controlled trials (RCTs) that compared the postoperative opioid consumption of intravenous paracetamol with placebo in lumbar discectomy were included. Results: Five trials comprising a total of 271 patients were included. The overall opioid consumption within 24 h postoperatively was reduced [mean difference (MD), -10.61 (95% CI, -16.00 to -5.22) mg, p = 0.0001, I2 = 90%] in patients with intravenous paracetamol. Intravenous paracetamol significantly reduced the postoperative pain scores at 1 h [MD, -2.37 (95%CI, -3.81 to -0.94), p = 0.001, I2 = 82%], 2 h [MD, -3.17 (95%CI, -3.85 to -2.48), p < 0.00001, I2 = 38%], 6 h [MD, -1.75 (95%CI, -3.10 to -0.40), p = 0.01], 12 h [MD, -0.96 (95%CI, -1.77 to -0.15), p = 0.02], and 24 h [MD, -0.97 (95%CI, -1.67 to -0.27), p = 0.006] compared with the placebo. There were no differences in postoperative adverse effects. Conclusion: Intravenous paracetamol reduced postoperative opioid consumption and decreased postoperative pain scores without increasing adverse effects. The overall GRADE quality of the evidence was rated as low to moderate. Intravenous paracetamol appears to be an applicable option as an important part of multimodal analgesia for postoperative analgesia after lumbar disc surgery. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, CRD42021288168.

Effect of Anesthesia on Postoperative Pain in Patients after Septoplasty

The aim of the study was to assess acute pain syndrome in patients after septoplasty using different tactics of general anesthesia. All patients received local anesthesia with 2% procaine solution. In group 1 (95 patients), premedication with 2% promedol solution and 60 mg of ketorolac in the evening was used; group 2 (72 patients) was administered with fentanyl, propofol, cisatracuria besylate, tranexamic acid, atropine, and metoclopramide; and group 3 (89 patients) received atracuria besylate, sodium thiopental, nitrous oxide, and halothane. In groups 2 and 3, 100 mg of ketoprofen was administered intramuscularly in the evening on the day of surgery. Anterior tamponade was performed with parolon tampons in glove rubber. In groups 1 and 2, the tamponade was removed on day 2, and in group 3 it was removed 1 day after surgery. Pain syndrome was assessed on 1, 3, and 6 h and on days 1 and 2 after surgery. It was found that the scheme of anesthesia in group 2 is the most preferable, and the nasal tamponade must be removed on the 2nd day after the surgery.

A retrospective comparative study of local anesthesia only and local anesthesia with sedation for percutaneous endoscopic lumbar discectomy

It is still an unsolved problem to achieve both immediate intraoperative feedback and satisfactory surgical experience in percutaneous endoscopic lumbar discectomy under local anesthesia for lumbar disk herniation (LDH) patients. Herein, we compared the analgesic and sedative effects of local anesthesia alone and local anesthesia with conscious sedation in LDH patients during percutaneous endoscopic lumbar discectomy. Ninety-two LDH patients were enrolled and divided into the following groups: control group (Con Group), dexmedetomidine group (Dex Group), oxycodone group (Oxy Group), and dexmedetomidine + oxycodone group (Dex + Oxy Group). Various signs, including mean arterial pressure (MAP), heart rate (HR), pulse oximeter oxygen saturation (SpO₂) and Ramsay score, were compared before anesthesia (T1), working cannula establishment (T2), nucleus pulposus removal (T3), and immediately postoperation (T4). Clinical outcomes, including VAS score, operation time, hospitalization period, Macnab criteria, and SF-36 score, were also evaluated. The Dex + Oxy Group showed the most stable MAP and HR at T2 and T3 in all groups. The clinical outcomes, such as VAS, hospitalization period, Macnab criteria, and SF-36 score, have no significant differences among groups (p > 0.05). Local anesthesia combined with conscious sedation is a safe and effective method to improve the surgical experience and achieve satisfying clinical outcomes for LDH patients during percutaneous endoscopic lumbar discectomy.

The effect of preoperative oral magnesium oxide on the severity of postoperative pain among women undergoing hysterectomy

BACKGROUND

Magnesium sulfate has been reported to be effective in perioperative pain treatment and in blunting somatic, autonomic, and endocrine reflexes provoked by noxious stimuli. The pre-emptive analgesic effects of magnesium in reducing postoperative pain could be beneficial in abdominal and gynecologic surgeries.

OBJECTIVE

The aim of study was to compare the pre-emptive analgesic effects of oral magnesium oxide and naproxen for hysterectomy surgery.

METHODS

This study evaluated all patients who were candidates for hysterectomy in 2 months. The 64 patients were randomly divided into two groups using a random allocation sequence. The patients in the intervention and control groups received either magnesium oxide tablet (500 mg) or naproxen tablet (500 mg) orally half an hour before surgery, respectively. The severity of postoperative pain is assumed as a primary outcome which is evaluated using the visual analogue scale (VAS).

RESULTS

In this study, 64 patients were assessed. The results showed age, weight, systolic and diastolic blood pressure, and pulse rate of the patients in the two groups were not significantly different (p > 0.05). The mean score of pain intensity for these patients was significantly lower than the patients receiving naproxen (p-value: 0.03). Besides, more than one-quarter of patients in the magnesium oxide group (n = 9, 28.12%) received this analgesia with lower dose than the patients in the naproxen group (p-value: 0.03).

CONCLUSION

The results of this study showed that preoperative oral magnesium oxide had a significant effect on the severity of postoperative pain and consumption of postoperative analgesia.

Written Prescription for Over-the-Counter Nonopioid Pain Medications Does Not Increase the Likelihood of Use after Ambulatory Hand and Upper Extremity Surgery

Introduction  This study looked to determine how providing written prescriptions of nonopioids affected postoperative pain medication usage and pain control. Materials and Methods  Patients undergoing hand and upper-extremity surgery ( n = 244) were recruited after the implementation of a postoperative pain control program encouraging nonopioids before opioids. Patients were grouped based on procedure type: bone ( n = 66) or soft tissue ( n = 178). Patients reported postoperative medication consumption and pain control scores. Two-tailed t -tests assuming unequal variance were performed to look for differences in postoperative pain control and medication consumption between those who were and were not given written prescriptions for nonopioids. Results  For both soft tissue and bone procedure patients, a written prescription did not significantly affect patients' postoperative pain control or medication consumption. Regardless of receiving a written prescription, patients who underwent soft tissue procedures consumed significantly more daily nonopioids than opioids. Conclusion  Receiving written prescriptions for nonopioids may not have a significant effect on postoperative pain control or medication consumption. Patients undergoing soft tissue hand and upper extremity procedures may be more likely to consume more daily nonopioids than opioids postoperatively compared to bone procedure patients regardless of whether they receive a written prescription for nonopioids.

Analysis of in-hospital analgesic pharmacotherapy costs and regimen and impact on postoperative pain-related function in degenerative lumbar intervertebral disc disease

BACKGROUND

Pain medication may affect clinical and economic outcomes, and a detailed description of pain medication use is advocated in the literautre for better assessment of clinical outcomes of spine surgery, which otherwise clould be misleading.

OBJECTIVES

To analyze the impact of in-hospital analgesic pharmacotherapy after spine surgery on subjective quality of life and pain relief in patients with degenerative lumbar intervertebral disc disease (DLIVD), and also to analyze pharmacotherapy costs.

DESIGN

A single-center study included 50 patients with L5/S1 or L4/L5 DLIVD, eligible for spine surgery.

INTERVENTION

Neurosurgery for DLIVD.

MAIN ENDPOINTS

Outcomes in terms of postoperative pain and function were recorded prospectively using standardized questionnaires. Data for cost analysis and pharmcotherapy regimen were obtained retrospectively from case histories, doctors' request cards and hospital discharge summaries.

RESULTS

Mean total pharmacotherapy cost amounted to €453.42±49.09. Mean pharmacotherapy cost amounted to €314.76±54.21 preoperatively, and €138.66±25.54 postoperatively. The greatest improvement in function and quality of life was in patients treated with non-opioids.

CONCLUSION

This study supports the notion that analgesic pharmacotherapies could be differentiated in terms of overall impact on quality of life, and that pain-related distress might be the most relevant factor in this setting.

A Comprehensive Enhanced Recovery Pathway for Rotator Cuff Surgery Reduces Pain, Opioid Use, and Side Effects

BACKGROUND

Patients often have moderate to severe pain after rotator cuff surgery, despite receiving analgesics and nerve blocks. There are many suggested ways to improve pain after rotator cuff surgery, but the effects of adopting a pathway that includes formal patient education, a long-acting nerve block, and extensive multimodal analgesia are unclear.

QUESTIONS/PURPOSES

(1) Does adoption of a clinical pathway incorporating patient education, a long-acting nerve block, and preemptive multimodal analgesia reduce the worst pain during the first 48 hours after surgery compared with current standard institutional practices? (2) Does adoption of the pathway reduce opioid use? (3) Does adoption of the pathway reduce side effects and improve patient-oriented outcomes?

METHODS

From September 2018 to January 2020, 281 patients scheduled for arthroscopic ambulatory rotator cuff surgery were identified for this paired sequential prospective cohort study. Among patients in the control group, 177 were identified, 33% (58) were not eligible, for 11% (20) staff was not available, 56% (99) were approached, 16% (29) declined, 40% (70) enrolled, and 40% (70) were analyzed (2% [4] lost to follow-up for secondary outcomes after postoperative day 2). For patients in the pathway cohort, 104 were identified, 17% (18) were not eligible, for 11% (11) staff was not available, 72% (75) were approached, 5% (5) declined, 67% (70) enrolled, and 67% (70) were analyzed (3% [3] lost to follow-up for secondary outcomes after postoperative day 2). No patients were lost to follow-up for primary outcome; for secondary outcomes, four were lost in the control group and three in the pathway group after postoperative day 2 (p = 0.70). The initial 70 patients enrolled received routine care (control group), and in a subsequent cohort, 70 patients received care guided by a pathway (pathway group). Of the 205 eligible patients, 68% (140) were included in the analysis. This was not a study comparing two tightly defined protocols but rather a study to determine whether adoption of a pathway would alter patient outcomes. For this reason, we used a pragmatic (real-world) study design that did not specify how control patients would be treated, and it did not require that all pathway patients receive all components of the pathway. We developed the pathway in coordination with a group of surgeons and anesthesiologists who agreed to apply the pathway as much as was viewed practical for each individual patient. Patients in both groups received a brachial plexus nerve block with sedation. Major differences between the pathway and control groups were: detailed patient education regarding reasonable pain expectations with a goal of reducing opioid use (no formal educational presentation was given to the control), a long-acting nerve block using bupivacaine with dexamethasone (control patients often received shorter-acting local anesthetic without perineural dexamethasone), and preemptive multimodal analgesia including intraoperative ketamine, postoperative acetaminophen, NSAIDs, and gabapentin at bedtime, with opioids as needed (control patients received postoperative opioids but most did not get postoperative NSAIDS and no controls received gabapentin or separate prescriptions for acetaminophen). The primary outcome was the numerical rating scale (NRS) worst pain with movement 0 to 48 hours after block placement. The NRS pain score ranges from 0 (no pain) to 10 (worst pain possible). The minimum clinically important difference (MCID) [12] for NRS that was used for calculation of the study sample size was 1.3 [18], although some authors suggest 1 [13] or 2 [5] are appropriate; if we had used an MCID of 2, the sample size would have been smaller. Secondary outcomes included NRS pain scores at rest, daily opioid use (postoperative day 1, 2, 7, 14), block duration, patient-oriented pain questions (postoperative day 1, 2, 7, 14), and patient and physician adherence to pathway.

RESULTS

On postoperative day 1, pathway patients had lower worst pain with movement (3.3 ± 3.1) compared with control patients (5.6 ± 3.0, mean difference -2.7 [95% CI -3.7 to -1.7]; p < 0.001); lower scores were also seen for pain at rest (1.9 ± 2.3 versus 4.0 ± 2.9, mean difference -2.0 [95% CI -2.8 to -1.3]; p < 0.001). Cumulative postoperative opioid use (0-48 hours) was reduced (pathway oral morphine equivalent use was 23 ± 28 mg versus 44 ± 35 mg, mean difference 21 [95% CI 10 to 32]; p < 0.01). The greatest difference in opioid use was in the first 24 hours after surgery (pathway 7 ± 12 mg versus control 21 ± 21 mg, mean difference -14 [95% CI -19 to -10]; p < 0.01). On postoperative day 1, pathway patients had less interference with staying asleep compared with control patients (0.5 ± 1.6 versus 2.6 ± 3.3, mean difference -2.2 [95% CI -3.3 to -1.1]; p < 0.001); lower scores were also seen for interference with activities (0.9 ± 2.3 versus 1.9 ± 2.9, mean difference -1.1 [95% CI -2 to -0.1]; p = 0.03). Satisfaction with pain treatment on postoperative day 1 was higher among pathway patients compared with control patients (9.2 ± 1.7 versus 8.2 ± 2.5, mean difference 1.0 [95% CI 0.3 to 1.8]; p < 0.001). On postoperative day 2, pathway patients had lower nausea scores compared with control patients (0.3 ± 1.1 versus 1 ± 2.1, mean difference -0.7 [95% CI -1.2 to -0.1]; p = 0.02); lower scores were also seen for drowsiness on postoperative day 1 (1.7 ± 2.7 versus 2.6 ± 2.6, mean difference -0.9 [95% CI - 1.7 to -0.1]; p = 0.03).

CONCLUSION

Adoption of the pathway was associated with improvement in the primary outcome (pain with movement) that exceeded the MCID. Patients in the pathway group had improved patient-oriented outcomes and fewer side effects. This pathway uses multiple analgesic drugs, which may pose risks to elderly patients, in particular. Therefore, in evaluating whether to use this pathway, clinicians should weigh the effect sizes against the potential risks that may emerge with large scale use, consider the difficulties involved in adapting a pathway to local practice so that pathway will persist, and recognize that this study only enrolled patients among surgeons and the anesthesiologists that advocated for the pathway; results may have been different with less enthusiastic clinicians. This pathway, based on a long-lasting nerve block, multimodal analgesia, and patient education can be considered for adoption.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Ropivacaine continuous wound infusion after mastectomy with immediate autologous breast reconstruction: A retrospective observational study

Continuous wound infusion usually provides postoperative analgesia as a multimodal analgesia with systemic opioid use. When continuous wound infusion of local anesthetics (LA) supports successful postoperative analgesia without systemic opioid use, the side effects of opioid can be reduced. Nevertheless, continuous wound infusion after mastectomy with immediate autologous breast reconstruction leads to concerns about wound healing. This study evaluated analgesic effects and wound healing conditions of continuous wound infusion of LA compared with opioid-based, intravenous patient-controlled analgesia (IV PCA) in mastectomy with immediate autologous breast reconstruction.This retrospective observational study included females, aged between 33 and 67 years, who underwent mastectomy with immediate autologous breast reconstruction. Sixty-five patients were enrolled. The eligible patients were placed into 2 groups for managing postoperative pain, one used continuous wound infusion with 0.5% ropivacaine (ON-Q, n = 32) and the other used a fentanyl-based IV PCA (IV PCA, n = 33). Using the electronic medical record system, the postoperative recovery profiles were examined over 5 days using a visual analogue scale (VAS), incidence of postoperative nausea and vomiting (PONV), incidence of sleep disturbance, frequency of rescue analgesic use, analgesia-related adverse events, length of hospital stay, and degree of patient satisfaction. The condition of the surgical wound was observed for 1 year after surgery.The primary endpoint was the intensity of pain at 6 hours after surgery. The VAS was comparable between the groups (P > .05). Although recovery profiles and the degree of patient satisfaction were similar between the groups, the incidence of PONV was significantly lower in the ON-Q group than in the IV PCA group on the day of surgery and postoperative day 1. No patients had severe wound complications. The satisfaction score of analgesia in the ON-Q group was comparable with that of the patients in the IV PCA group.This study demonstrates that single use of continuous wound infusion showed comparable analgesia with fentanyl-based IV PCA in patients who underwent mastectomy with immediate autologous breast reconstruction. Furthermore, the continuous infusion of LA directly on the surgical site did not significantly affect wound healing.

Bowel dysfunction after elective spinal surgery: etiology, diagnostics and management based on the medical literature and experience in a university hospital

BACKGROUND

Bowel dysfunction after spinal surgery is often underestimated and if not treated in a timely manner can lead to undesirable surgical interventions or fatal complications. The current medical literature primarily focuses on bowel dysfunction as a result of spinal injury.

OBJECTIVE

The purpose of this review is to explore this topic in evaluating current evidence regarding the causes of acute bowel dysfunction after elective spinal surgery, primarily the thoracolumbar spine. Since available evidence for recommendations of treatment is scarce, an interdisciplinary management approach for treatment of bowel dysfunction following spinal surgery is also formulated.

MATERIAL AND METHODS

An extensive literature search was carried out on PubMed. Keywords that were used in the search included bowel dysfunction, obstruction, postoperative ileus, spinal surgery, spinal fusion, constipation, opioid-induced constipation, colonic pseudo-obstruction, ischemic colitis, immobility-induced bowel changes, epidural anesthesia and diet. Relevant studies were chosen and included in the review. The treatment approach used in the spine center of a university hospital was included.

RESULTS

Current research mainly focuses on investigating the nature and symptomatology of chronic bowel dysfunction after spinal cord injury. Emphasis on the acute phase of bowel dysfunction in patients after elective spinal surgery is lacking. The comorbidities that exacerbate bowel dysfunction postoperatively are well-defined. There has been refinement and expansion of the pharmacological and nonpharmacological treatment that could be implemented. Enough evidence exists to provide sufficient care.

CONCLUSION

Management of acute bowel dysfunction after spinal surgery requires a comprehensive and individualized approach, encompassing comorbidities, behavioral changes, medications and surgery. Close supervision and timely treatment could minimize further complications. Research is required to identify patients who are at a higher risk of developing bowel dysfunction after specific spinal procedures.

Adjuvant Drugs for Peripheral Nerve Blocks: The Role of Alpha-2 Agonists, Dexamethasone, Midazolam, and Non-steroidal Anti-inflammatory Drugs

Adjuvant drugs for peripheral nerve blocks are a promising solution to acute postoperative pain and the transition to chronic pain treatment. Peripheral nerve blocks (PNB) are used in the brachial plexus, lumbar plexus, femoral nerve, sciatic nerve, and many other anatomic locations for site-specific pain relief. However, the duration of action of a PNB is limited without an adjuvant drug. The use of non-opioid adjuvant drugs for single-shot peripheral nerve blocks (sPNB), such as alpha-2 agonists, dexamethasone, midazolam, and non-steroidal anti-inflammatory drugs, can extend the duration of local anesthetics and reduce the dose-dependent adverse effects of local anesthetics. Tramadol is a weak opioid that acts as a central analgesic. It can block voltage-dependent sodium and potassium channels, cause serotonin release, and inhibit norepinephrine reuptake and can also be used as an adjuvant in PNBs. However, tramadol's effectiveness and safety as an adjuvant to local anesthetic for PNB are inconsistent. The effects of the adjuvants on neurotoxicity must be further evaluated with further studies to delineate the safety in their use in PNB. Further research needs to be done. However, the use of adjuvants in PNB can be a way to help control postoperative pain.

The administration of the opioid buprenorphine decreases motivational error signals

While opioid addiction has reached pandemic proportions, we still lack a good understanding of how the administration of opioids interacts with cognitive functions. Error processing - the ability to detect erroneous actions and correct one's behaviour afterwards - is one such cognitive function that might be susceptible to opioidergic influences. Errors are hypothesised to induce aversive negative arousal, while opioids have been suggested to reduce aversive arousal induced by unpleasant and stressful stimuli. Thus, this study investigated whether the acute administration of an opioid would affect error processing. In a double-blind between-subject study, 42 male volunteers were recruited and received either 0.2 mg buprenorphine (a partial µ-opioid receptor agonist and κ-opioid receptor antagonist) or a placebo pill before they performed a stimulus-response task provoking errors. Electroencephalograms (EEG) were recorded while participants performed the task. We observed no group differences in terms of reaction times, error rates, and affective state ratings during the task between buprenorphine and control participants. Additional measures of adaptive control, however, showed interfering effects of buprenorphine administration. On the neural level, decreased Pe (Error Positivity) amplitudes were found in buprenorphine compared to control participants following error commission. Further, frontal delta oscillations were decreased in the buprenorphine group after all responses. Our neural results jointly demonstrate a general reduction in error processing in those participants who received an opioid before task completion, thereby suggesting that opioids might have indeed the potential to dampen motivational error signals. Importantly, the effects of the opioid were evident in more elaborate error processing stages, thereby impacting on processes of conscious error appraisal and evidence accumulation.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION AND RELEVANCE

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

Impact of Auricular Neurostimulation in Patients Undergoing Colorectal Surgery with an Enhanced Recovery Protocol: A Pilot Randomized, Controlled Trial

BACKGROUND

Narcotics are the cornerstone of postoperative pain control, but the opioid epidemic and the negative physiological and psychological effects of narcotics implore physicians to utilize nonpharmacological methods of pain control.

OBJECTIVE

This pilot study investigated a novel neurostimulation device for postoperative analgesia. We hypothesized that active neurostimulation would decrease postoperative narcotic requirements.

DESIGN

This was a placebo-controlled, double-blinded trial.

SETTINGS

This trial was conducted at an academic medical center and a Veterans Affairs hospital.

PATIENTS

This trial included adult patients who underwent elective bowel resection between December 2016 and April 2018.

INTERVENTIONS

Patients were randomly assigned to receive an active or inactive (sham) device, which was applied to the right ear before surgery and continued for 5 days.

MAIN OUTCOME MEASURES

The primary outcome was total opioid consumption. The secondary outcomes included pain, nausea, anxiety, return of bowel function, complications, 30-day readmissions, and opioid consumption at 2 weeks and 30 days.

RESULTS

A total of 57 patients participated and 5 withdrew; 52 patients were included in the analysis. Twenty-eight patients received an active device and 24 received an inactive device. There was no difference in total narcotic consumption between active and inactive devices (90.79 ± 54.93 vs 90.30 ± 43.03 oral morphine equivalents/day). Subgroup analyses demonstrated a benefit for patients after open surgery (p = 0.0278). When patients were stratified by decade, those aged 60 to 70 and >70 years derived a benefit from active devices in comparison with those aged 30 to 40, 40 to 50, and 50 to 60 years old (p = 0.01092). No serious adverse events were related to this study.

LIMITATIONS

This study was limited by the small sample sizes.

CONCLUSIONS

No difference in opioid use was found with auricular neurostimulation. However, this pilot study suggests that older patients and those with larger abdominal incisions may benefit from auricular neurostimulation. Further investigation in these high-risk patients is warranted. See Video Abstract at http://links.lww.com/DCR/B452.ClinicalTrials.gov identifier: NCT02892513.

IMPACTO DE LA NEUROESTIMULACIN AURICULAR EN PACIENTES SOMETIDOS A CIRUGA COLORRECTAL CON UN PROTOCOLO DE RECUPERACIN MEJORADA UN ENSAYO PILOTO ALEATORIZADO Y CONTROLADO

ANTECEDENTES:Los narcóticos son la piedra angular del control del dolor postoperatorio, pero la epidemia de opioides y los efectos fisiológicos y psicológicos negativos de los narcóticos incentivan a los médicos a que utilicen métodos no farmacológicos de control del dolor.OBJETIVO:Este estudio piloto investigó un nuevo dispositivo de neuroestimulación para analgesia postoperatoria. Hipotetizamos que la neuroestimulación activa disminuiría los requerimientos narcóticos postoperatorios.DISEÑO:Este fue un ensayo doble ciego controlado con placebo.ESCENARIO:Esto se llevó a cabo en un centro médico académico y en un hospital de Asuntos de Veteranos (Veterans Affairs hospital).PACIENTES:Este ensayo incluyó pacientes adultos que se sometieron a resección intestinal electiva entre diciembre de 2016 y abril de 2018.INTERVENCIONES:Los pacientes fueron asignados al azar para recibir un dispositivo activo o inactivo (falso), que se aplicó al oído derecho antes de la cirugía y se mantuvo durante 5 días.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue el consumo total de opioides; los resultados secundarios incluyeron dolor, náusea, ansiedad, retorno de la función intestinal, complicaciones, reingresos a 30 días y consumo de opioides a 2 semanas y a 30 días.RESULTADOS:Participaron un total de 57 pacientes y 5 se retiraron; Se incluyeron 52 pacientes en el análisis. Veintiocho pacientes recibieron un dispositivo activo y 24 recibieron un dispositivo inactivo. No hubo diferencias en el consumo total de narcóticos entre los dispositivos activos e inactivos (90.79 ± 54.93 vs 90.30 ± 43.03 equivalentes de morfina oral [OME] / día). Los análisis de subgrupos demostraron un beneficio para los pacientes después de cirugía abierta (p = 0.0278). Cuando los pacientes se estratificaron por década, aquellos de 60-70 y > 70 años obtuvieron un beneficio de los dispositivos activos en comparación con los de 30-40, 40-50 y 50-60 años (p = 0.01092). No hubo eventos adversos graves relacionados con este estudio.LIMITACIONES:Este estudio estuvo limitado por los pequeños tamaños de muestra.CONCLUSIONES:No se encontró diferencia en el uso de opioides con la neuroestimulación auricular. Sin embargo, este estudio piloto sugiere que los pacientes mayores y aquellos con incisiones abdominales más grandes pueden beneficiarse de la neuroestimulación auricular. Está justificada la investigación adicional en estos pacientes de alto riesgo. Consulte Video Resumen en http://links.lww.com/DCR/B452. (Traducción-Dr. Jorge Silva Velazco).

Laparoscopic Sleeve Gastrectomy under Awake Paravertebral Blockade Versus General Anesthesia: Comparison of Short-Term Outcomes

AIMS

This study aimed at comparing the pre-, intra-, and early postoperative outcomes, between patients who underwent PVB vs general anesthesia (GA) during LSG. Follow-up of weight loss at least 1 year postoperatively was also evaluated.

METHODS

A cohort study was conducted by selecting all patients who underwent LSG under PVB and GA at Makassed General Hospital between 2010 and 2016. Demographic, social, pre-op health status, body mass index (BMI), operative time, postoperative pain and pain medication consumption, postoperative complications and length of hospital stay, all were studied. Follow-up weight loss was collected up to 5 years postoperatively. Data entry, management, and descriptive and inferential statistics were performed using SPSS.

RESULTS

A total of 210 participants were included in this study of which 48 constituted the PVB group and 162 patients composed the GA group. Both groups were similar in baseline demographic factors, with patients in PVB suffering from higher number and advanced stage of comorbidities than the GA group. Mean operative time was similar in between the two groups with 80 ± 20 min for PVB and 82 ± 18 min for GA group. Intraoperative complications were scarce among both study groups. GA group requested a second dose of analgesia earlier than PVB group. After at least 1 year postoperatively, the mean percentage of excess weight loss was 81.35 ± 15.5% and 77.89 ± 14.3% for the PVB and GA groups, respectively, P value 0.45.

CONCLUSION

Outcomes of LSG under both types of anesthesia (PVB alone and GA alone) were found to be comparable. However, the need for analgesia was significantly less in the PVB group compared to GA group.

Intra-articular use of analgesic/antinflammatory drugs in dogs and horses

Joint pain is a major cause of lameness in animals such as horses and dogs, and it may affect their athletic performance and quality of life. The intra-articular administration of analgesic/antinflammatory drugs is a common practice in veterinary medicine, for both lameness diagnosis and joint pain management. It is used either perioperatively, such as in animals undergoing arthroscopy/arthrotomy, and in osteoarthritic animals. However, evidence regarding efficacy and safety of each drug is limited, and controversies persist in these areas. In particular, it is often uncertain whether a defined treatment is effective by simply relieving the symptomatic pain associated with the joint disease, or whether it has a positive effect on the joint environment. Moreover, there is still much hesitation about treatments for joint diseases, related to the time of their application for the best outcome, and to any possible deleterious side effects. This article includes a review of the literature concerning the main analgesic/antinflammatory drugs used intra-articularly for managing acute and chronic joint pain/inflammation in dogs and horses. Three main issues for each class of drugs are considered, including clinical efficacy, pharmacokinetics, and local cytotoxic effects.

Assessment of Pain and Analgesic Use in Children Following Otologic Surgery

OBJECTIVE

To compare postoperative pain and analgesic use in children following transcanal endoscopic ear surgery (TEES) vs non-transcanal endoscopic ear surgery (non-TEES).

STUDY DESIGN

Prospective case series.

SETTING

Tertiary care center.

METHODS

Surveys using the Wong-Baker FACES Pain Rating Scale and recording the frequency and dosage of consumed analgesics were administered prospectively to caregivers of children undergoing otologic surgery between May 2018 to February 2020. Pain intensity and medication use were recorded twice daily for 6 days, starting on postoperative day 0. Mean pain scores and mean number of consumed analgesic doses were compared between groups.

RESULTS

Survey response rate was 57.9%. Among 53 patients who completed the survey, 35 (66.0%) underwent TEES and 18 (34.0%) underwent non-TEES. Mean pain ratings on postoperative days 0 and 1 were significantly lower among children undergoing TEES (2.2 and 2.1) vs non-TEES (4.0 and 4.1), P = .045 and P = .008, respectively (Mann-Whitney U test). The mean pain ratings across the 6 days were similar in TEES (1.7) and non-TEES (2.6) (P = .140, Mann-Whitney U test). The mean number of analgesic doses consumed per half-day over the 6 days was significantly lower among children undergoing TEES (0.3) vs non-TEES (0.6; P = .049, Mann-Whitney U test).

CONCLUSION

Postoperative pain following TEES and non-TEES in children was overall low. Children undergoing TEES had a small but statistically significant decrease in pain on postoperative days 0 and 1 and decreased use of pain medications compared to non-TEES.

Evaluation of the Effect of Erector Spinae Plane Block in Patients Undergoing Belt Lipectomy Surgery

BACKGROUND

The interest in and demand for post-bariatric surgery have increased along with the increase in obesity surgery. Belt lipectomy, during which a circular correction is made in the center of the trunk, is the most commonly performed among these surgical techniques. Postoperative pain is an important problem due to the size of the surgical site and stretched closure. In this study, it was aimed to evaluate the intraoperative and postoperative narcotic analgesic consumption, postoperative analgesic requirement, postoperative visual analog scale (VAS) scores, postoperative nausea and vomiting (PONV), and the first mobilization time in patients with and without erector spinae plane block (ESPB).

METHODS

The files of patients who had undergone belt lipectomy between 2016 and 2019 in our hospital were retrospectively reviewed. Patients who received ESPB were called group 1, and those who did not undergo ESPB were called group 2. Their demographic characteristics, intraoperative and postoperative narcotic and non-narcotic analgesic consumption, VAS scores, PONV, and the first mobilization times were recorded.

RESULTS

The files of a total of 51 patients, including 23 patients in group 1 and 28 patients in group 2, were reviewed. It was determined that intraoperative and postoperative narcotic analgesic consumption (p < 0.005), PONV (p < 0.005), and the first mobilization time (p < 0.005) were significantly lower in group 1 compared with group 2.

CONCLUSION

The use of the ESP block in belt lipectomy surgeries significantly reduces intraoperative and postoperative narcotic analgesic consumption and pain scores.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Developments in combined analgesic regimens for improved safety in postoperative pain management

Introduction: Fixed-dose combination analgesic regimens may be similarly effective to opioid monotherapy but with potentially less risk. A number of individualized combination regimens can be created, including nonopioid agents such as acetaminophen and nonsteroidal anti-inflammatory drugs, opioids, and adjunctive agents such as gabapentin, pregabalin, and muscle relaxants. Areas covered: When such combinations have a synergistic effect, analgesic benefits may be enhanced. Many combination analgesic regimens are opioid sparing, which sometimes but not always results in reduced opioid-associated side effects. Safety concerns for all analgesics must be considered but postoperative analgesia is typically administered for a brief period (days), reducing risks that may occur with prolonged exposure. Expert opinion: Judiciously considered combination analgesic regimens can be effective postoperative analgesics that reduce opioid consumption without compromising pain control, which are important factors for patient recovery and satisfaction. The specific combinations used must be based on the patient, the type and duration of the surgical procedure, and complementary mechanisms of action of the agents used. In opioid-sparing combination analgesic regimens, the short-term use of small doses of opioids in this setting may be helpful for appropriate patients.

Assessment of Factors Associated With Postoperative Pain After Photorefractive Keratectomy

PURPOSE

To define the factors that affect patient's self-assessed postoperative pain after photorefractive keratectomy (PRK).

METHODS

Patients who underwent PRK in 2016 were evaluated. Anonymized data collected included patient gender, age, and season at the time of surgery, ablation depth, surgeon status (attending vs. resident), topical tetracaine use, and subjective pain scores at postoperative days (PODs) 1 and 7. Average pain scores and amount of pain medication taken were analyzed for each of the previously mentioned variables.

RESULTS

Overall, 231 patients who underwent PRK were analyzed. The mean pain score and SD were 0.78 ± 1.87 on POD 1 and 0.03 ± 0.37 by POD 7. Patients who used topical tetracaine reported significantly higher pain on POD 1 and 7 compared with patients who did not use tetracaine (P < 0.001 and P = 0.038, respectively). No significant differences in pain scores were seen based on surgeon status, ablation depth, gender, and season. Patients who used topical tetracaine took a higher amount of oral pain medication (9.44 ± 6.01) compared with those who did not (7.02 ± 4.71) (P = 0.022).

CONCLUSIONS

Postoperative pain was significantly elevated in patients who used tetracaine on POD 1 and POD 7. These patients were also more likely to take oral pain medication than those who did not use topical tetracaine. Surgeon status, season, gender, and ablation depth showed no significant differences in subjective pain scores. Oral pain medication should be evaluated to assess efficacy and safety in inhibiting ocular pain after PRK.

The relationship between postoperative opioid consumption and the incidence of hypoxemic events following total hip arthroplasty: a post hoc analysis

Background

Postoperative opioid analgesia may cause respiratory depression. We assessed whether following total hip arthroplasty, placebo-adjusted reductions in morphine consumption at 48 hours with parecoxib (47.0%), propacetamol (35.1%) or parecoxib plus propacetamol (67.9%) translated into a reduction in hypoxemic events.

Methods

This was a post hoc analysis of a randomized, placebo-controlled, noninferiority study. Patients were randomly assigned to receive intravenous parecoxib (40 mg twice daily), propacetamol (2 g 4 times daily), parecoxib plus propacetamol (40 mg twice daily + 2 g 4 times daily) or placebo. Dose, date and time of morphine administration via patient-controlled analgesia were monitored throughout the study. In patients not receiving supplemental oxygen, peripheral blood oxygenation was assessed continuously for 48 hours after surgery. Hypoxemia was defined as peripheral oxygen saturation less than 90%. The times and oximeter readings of hypoxemic events were recorded. Pearson correlation coefficient was used to assess for correlations between cumulative morphine consumption at 48 hours and mean number of hypoxemic events.

Results

A significantly smaller proportion of patients who received the combined treatment with parecoxib and propacetamol had hypoxemia versus placebo (2.8% v. 13.2%, p < 0.05), and the mean number of hypoxemic events was significantly smaller for parecoxib (0.12), propacetamol (0.06) and parecoxib plus propacetamol (0.03) versus placebo (0.36; all p < 0.05). There was no correlation between the reduction in cumulative morphine consumption at 48 hours and the mean number of hypoxemic events in any treatment group (all p > 0.1).

Conclusion

Following total hip arthroplasty, a greater than 70% reduction in morphine consumption may be necessary to translate into a corresponding reduction in hypoxemic events.

Anterior approach of abdominal field block at linea semilunaris: A surgically assisted novel technique for postoperative analgesia in cesarean section

Context

Post Caesarean pain is described as moderate to severe. Although advances in the new analgesics techniques, no current standard exists for optimizing and managing. Taking into consideration of acute post Caesarean pain, this novel technique of surgically assisted anterior abdominal field block at linea semilunaris have proved considerable analgesic potential along with multimodal analgesia.

Aims

Although advances have been made in the understanding of the pathophysiology and in the development of new analgesics, patients still suffer from moderate-to-severe post-Cesarean pain. Taking into consideration the consequences of pain, this anterior approach to abdominal field block technique was performed to minimize acute pain experienced during post-Cesarean section.

Settings and Design

Prospective observational study design.

Materials and Methods

In the present study, a total of 120 parturients undergoing cesarean section (CS), after closure of uterine incision were included. We intraoperatively, under all asepsis, performed surgically assisted abdominal field block at linea semilunaris, by bilaterally injecting 20 mL 0.25% bupivacaine on each side, in addition to standard analgesic 100 mg diclofenac suppository. Each patient was assessed at 0, 4, 8, 12, and 24 h after surgery, by an independent observer for pain using NRS 0-10 and the time of the first demand for analgesic diclofenac paracetamol and its side effects.

Statistical Analysis Used

The entire data is statistically analyzed using Statistical Package for Social Sciences (SPSS ver. 21.0, IBM Corporation, USA) for MS Windows. The categorical variables were compared using Wilcoxon's signed-rank test.

Results

Of the total 120 patients, it is worth noting that none of the patients had severe or worst pain. The percentage of patients who did not require analgesia were (96.7%) at 4 h, (81.7%) at 8 h, (77.5%) at 12 h, and (90.8%) at 24 h. The mean analgesic consumption of paracetamol diclofenac on 4, 8, 12, 16, and 24 h after CS was significantly less. No patient required opioid supplementation. Patient satisfaction was high and was early ambulated.

Conclusions

There is considerable potential for anterior approach abdominal field block, (linea semilunaris block) to comprise an effective component of a multimodal regimen for post-Cesarean section analgesia and is easy to perform within limited resources.

Analgesic Efficacy of Erector Spinae Plane Block Compared with Intrathecal Morphine After Elective Cesarean Section: A Prospective Randomized Controlled Study

BACKGROUND

We aimed to assess the efficacy of ultrasound-guided bilateral erector spinae plane block (ESPB) compared to intrathecal morphine (ITM) for analgesia after elective cesarean delivery under spinal anesthesia.

METHODS

In total, 140 parturients scheduled for elective cesarean section under spinal anesthesia were randomly allocated into two equal groups. The ESPB-group received 10 mg hyperbaric bupivacaine intrathecally through spinal anesthesia, followed by an ESPB at the ninth thoracic transverse process with 20 mL of 0.5% bupivacaine immediately after the operation. The ITM-group received 10 mg hyperbaric bupivacaine with 100 mcg morphine intrathecally through spinal anesthesia, followed by a sham block at the end of the surgery. The visual analogue scale (VAS) score for pain at several postoperative time points, total opioid consumption, and time to the first analgesic request were evaluated. Statistical analysis was performed with the independent t-test and linear mixed-effects models. The Kaplan-Meier estimator and the log-rank test were used to compare the primary and secondary outcomes of the groups.

RESULTS

No significant differences were observed between the groups regarding patient characteristics; in the post-operative period (0-24 hrs), VAS scores (at rest) were, on average, 0.25 units higher in the ITM group. The total tramadol consumption in the first 24 hrs was significantly higher in the ITM group than in the ESPB group (101.71 ± 25.67 mg vs 44 ± 16.71 mg, respectively). The time to the first analgesic request was 4.93±0.82 hrs in the ITM group and 12±2.81 hrs in the ESPB group. Patient satisfaction did not differ significantly.

CONCLUSION

ESPB has a successful postoperative analgesic effect and may limit opioid consumption in parturients undergoing elective caesarean delivery.

Haemodynamic and analgesic control in a perioperative opioid-free approach to bariatric surgery - A case report

New approaches to bariatric surgery aim to achieve stress-free anaesthesia with sympathetic stability to protect organs and provide sufficient tissue perfusion, analgesia and rapid emergence. Opioid-free and multimodal approaches to anaesthesia provide intra- and post-operative sedation and analgesia, particularly advantageous in morbidly obese patients, but their feasibility and efficacy are still disputed. We describe the case of a female patient proposed for laparoscopic bariatric surgery, conducted under an opioid-free anaesthesia protocol, the haemodynamic, ventilatory and analgesic control, and intra- and post-operative monitoring and complications.

Intravenous Patient-controlled Analgesia Versus Thoracic Epidural Analgesia After Open Liver Surgery: A Prospective, Randomized, Controlled, Noninferiority Trial

OBJECTIVE

We conducted a randomized, controlled, noninferiority trial to investigate if intravenous, multimodal, patient-controlled analgesia (IV-PCA) could be noninferior to multimodal thoracic epidural analgesia (TEA) in patients undergoing open liver surgery.

SUMMARY BACKGROUND DATA

The increasing use of minimally invasive techniques and fast track protocols have questioned the position of epidural analgesia as the optimal method of pain management after abdominal surgery.

METHODS

Patients operated with open liver resection between February 2012 and February 2016 were randomly assigned to receive either IV-PCA enhanced with ketorolac/diclofenac (IV-PCA, n = 66) or TEA (n = 77) within an enhanced recovery after surgery protocol. Noninferiority would be declared if the mean pain score on the numeric rating scale (NRS) for postoperative days (PODs) 0 to 5 in the IV-PCA group was no worse than the mean pain score in the TEA group by a margin of <1 point on an 11-point scale (0-10).

RESULTS

The primary endpoint, mean NRS pain score was 1.7 in the IV-PCA group and 1.6 in the TEA group, establishing noninferiority. Pain scores were lower in the TEA group on PODs 0 and 1, but higher or equal on PODs 2 and 5. Postoperative hospital stay was significantly shorter for patients in the IV-PCA group (74 vs 104 h, P < 0.001). The total opioid consumption during the first 3 days was significantly lower in the IV-PCA group.

CONCLUSIONS

IV-PCA was noninferior to TEA for the treatment of postoperative pain in patients undergoing open liver resection.

Effect of preemptive analgesia with ibuprofen in the control of postoperative pain in dental implant surgeries: A randomized, triple-blind controlled clinical trial

BACKGROUND

Preemptive analgesia has as its basic principle the administration of analgesics before the onset of painful stimuli, in order to reduce or prevent postoperative pain, but this question is little explored in implantology. Thus, this study was conducted in order to evaluate the clinical efficacy of ibuprofen in pain prevention after unit implant surgery.

MATERIAL AND METHODS

For this triple-blind, parallel, placebo-controlled and randomized clinical trial, 54 insertion surgeries of unitary implants were performed. Two groups have received two different protocols 1 hour before surgery: Ibuprofen group (IBU) 600 mg of ibuprofen; and (2) placebo group (maize starch). The intensity of the pain was evaluated through the visual analogue scale (VAS) in 6 times (1, 6, 12, 24, 48 and 72 hours after the surgery). Patients were instructed to take 750 mg of paracetamol as rescue medication, if necessary. The occurrence and the intensity of pain were analyzed by means of an analysis of variance ANOVA with repeated measurements using the general linear model procedure.

RESULTS

The IBU group had significantly lower VAS scores overall (IBU = 0.30, ± 0.57; placebo = 1.14, ± 1.07; p<0.001) and at all times in the intra, intergroup comparisons and time/group interaction than the placebo group (p<0.001). The use of rescue medication was significantly lower and the postoperative time was longer in the IBU group compared to placebo (p = 0.002).

CONCLUSIONS

The single use of ibuprofen was found to be significantly superior in reducing pain after unit implant surgery compared to placebo. Key words:Analgesia, dental implants, pain, surgery, oral.

Comparison of tramadol versus tramadol with paracetamol for efficacy of postoperative pain management in lumbar discectomy: A randomised controlled study

PURPOSE

Despite developments in the treatment of pain, the availability of new drugs or increased knowledge of pain management, postoperative pain control after different surgeries remains inadequate. We aimed to compare the postoperative analgesic efficacy of tramadol versus tramadol with paracetamol after lumbar discectomy.

DESIGN, SETTING, PARTICIPANTS

Sixty patients undergoing lumbar discectomy were randomly assigned into two groups.

METHODS

Patients in Group T (n = 30) received tramadol (1 mg/kg), and patients in Group TP (n = 30) received tramadol (1 mg/kg) with paracetamol (1 g) 30 minutes before the end of surgery and paracetamol was continued during the postoperative period at 6 hours intervals for the first 24 hours. Patient-controlled analgesia with tramadol was used during the postoperative period.

MAIN OUTCOME MEASURES

Duration, postoperative pain scores, Ramsay sedation scores, analgesic consumption, and side effects were recorded in all patients during the postoperative period. Continuous random variables were tested for normal distribution using the Kolmogorov-Smirnov test, than Student's t-test was used for means comparisons between groups. For discrete random variables chi-square tests and McNemar test was used.

RESULTS

Demographic data, mean duration of anaesthesia and surgery were similar in both groups. Postoperative pain scores were significantly higher in Group T than Group TP at 5; 15; 20; and 30 minutes (P = .021, P = .004, P = .002, P = .018). Late postoperative pain scores were similar. Total tramadol consumption in Group T (106.12 ± 4.84 mg) was higher than Group TP (81.20 ± 2.53) during the 24 hours postoperative period. However, continuing the paracetamol at 6 hours interval did not change late postoperative pain scores.

CONCLUSION

The administration of tramadol with paracetamol was more effective than tramadol alone for early acute postoperative pain therapy following lumbar discectomy. Therefore, while adding paracetamol in early pain management is recommended, continuing paracetamol for the late postoperative period is not advised.

Patterns in Opioid Prescription for Patients Operatively Treated for Ankle Fractures Following Implementation of 2017 Ohio Opioid Prescriber Law

Background

The purpose of this study was to report patterns of opioid prescription for patients treated operatively for ankle fractures after implementation of the 2017 Ohio Opioid Prescriber Law in comparison to the previous year.

Methods

A total of 144 patients operatively treated for isolated ankle fractures during two 6-month periods, January 2017 to July 2017 (pre-law) and January 2018 to July 2018 (post-law), were retrospectively identified. Preoperative and postoperative patient narcotic use was reviewed using a legal prescriber database. Total number of prescriptions, quantity of pills, and morphine milligram equivalents (MMEs) per patient prescribed during the 90-day postoperative period were compared between those treated before and those treated after implementation of the Ohio prescriber law.

Results

The average number of opioid prescriptions prescribed per patient in the 90-day postoperative period was 2.3 in the pre-law group and 2.1 in the post-law group (P = .625). The average MMEs prescribed per patient dropped from 942.4 MME pre-law to 700.5 MME post-law (P = .295). Differences in the average number of pills per prescription pre- and post-law (49.7 vs 36.2) and average MME per prescription (382.1 mg vs 275.2 mg) were statistically significant (P < .001 and P = .016, respectively).

Conclusion

Following the implementation of the 2017 Ohio Opioid Prescriber Law, there was a downward trend in the number of pills per prescription and MMEs per prescription in patients operatively treated for isolated ankle fractures. The presence of a downward trend in the quantity of opioids prescribed in this patient cohort suggests the effectiveness of the state law.

Level of Evidence

Level III, comparative study.