Postoperative Pain Management in Enhanced Recovery Pathways

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.

Effectiveness of intravenous administration of a combination of sufentanil and esketamine on post-cardiac surgery pain management and depression: a randomized controlled trial

Background

Cardiac surgery often results in significant postoperative pain, which can lead to complications and prolonged recovery. Pain and depression are closely linked, with effective pain management potentially reducing the risk of depression. Combining sufentanil, an opioid, with esketamine, a medication with both analgesic and antidepressant effects, may improve pain control and mood in postoperative patients. While promising in other surgeries, their effects in cardiac surgery remain unclear. This study explores how sufentanil and esketamine work together to manage pain and reduce depression after cardiac surgery.

Methods

A randomized controlled clinical trial was conducted from January 2021 to December 2023, involving 104 patients who underwent cardiac surgery. Patients [aged 61-64 years, body mass index (BMI) <30 kg/m2, American Society of Anesthesiologists (ASA) I-II, the snoring, tiredness, observed apnea, high blood pressure, body mass index, age, neck circumference, and male gender (STOP-Bang) score <3] were randomly assigned to a control group (n=52) receiving 2.5 µg/kg sufentanil or an experimental group (n=52) receiving 2.0 µg/kg sufentanil with 2 mg/kg esketamine via a central venous catheter for 48 h postoperatively. Exclusion criteria included allergies to fentanyl or etomidate, central nervous system diseases, recent opioid use, liver/kidney failure, or severe respiratory conditions. Outcome measures included patient-controlled intravenous analgesia (PCIA) pump usage, pain scores, clinical indicators, depressive symptoms, adverse events, and satisfaction levels.

Results

The experimental group had significantly fewer PCIA pump button presses (2.41±0.72) than the control group (6.20±1.31) (P<0.001). Visual analog pain scores were lower in the experimental group at multiple postoperative time points (P<0.05). Hamilton Depression Rating Scale (HAMD) scores were significantly lower in the experimental group (7.52±4.24) compared to the control group (13.84±2.76) (P<0.05), as were Hamilton Anxiety Rating Scale (HAMA) scores (8.84±2.13 vs. 12.64±3.25, P<0.05). Heart rate and mean arterial pressure were higher at postoperative time points T2, T3, and T4 in the experimental group (P<0.05), but no difference was observed at T1 (P>0.05) (T1 =4 h, T2 =8 h, T3 =24 h, T4 =48 h post-surgery). Oxygen saturation showed no significant difference between groups (P>0.05). Adverse reactions occurred in 13.46% of the experimental group and 19.23% of the control group, with no statistically significant difference (P>0.05). Patient and surgeon satisfaction scores were uniformly high on a five-point scale (both groups had median =5).

Conclusions

The combined administration of sufentanil and esketamine effectively managed pain and significantly reduced depressive symptoms in post-cardiac surgery patients. The experimental group demonstrated reduced PCIA usage and improved clinical indicators. These findings provide valuable insights for enhancing postoperative recovery and addressing both pain management and psychological well-being.

Trial Registration

Chinese Clinical Trial Registry; identifier: ChiCTR2400092428.

Optimization of Postoperative Opioids Use Following Spine Surgery

PURPOSE OF REVIEW

The present investigation evaluated the use of opioids for postoperative pain relief in spinal surgery patients.

RECENT FINDINGS

Pain management is a crucial component of postoperative care that greatly impacts patient outcomes. Postoperative pain management has been shown to allow for earlier mobility, discharge, and return to normal life. Opioids are the standard treatment for postoperative pharmacologic pain relief, but they are associated with the same adverse effects that pain management strives to mitigate. Opioids are associated with a large side effect profile, including a higher risk of various postoperative complications. Opioids are potentially highly addictive and postoperative use is associated with dependence, tolerance, and the current opioid epidemic. Some studies indicate that there are similar surgical outcomes amongst patients independent of whether opioids were prescribed opioids for pain relief.

CONCLUSION

Opioids should only be recommended for postoperative pain management under strict guidance and supervision from physicians. All 50 states have acute pain guidelines in place limiting opioid prescribing. One of the strategies of reducing postoperative opioid consumption is the emphasis on opioid alternatives that should be actively considered and explored prior to resorting to opioids. There are pharmacological and non-pharmacological options available for pain relief that can provide similar levels of analgesia as prescription opioid without unwanted effects such as tolerance and dependency. Proper assessment of patient history and risk factors can aid physicians in tailoring a pain management regimen that is appropriate for each individual patient. More research into efficacy and safety of alternative treatments to opioids is warranted.

The Effect of Music Therapy on Postoperative Pain and Agitation During Septorhinoplasty: A Blinded Clinical Trial

Background and Aims

It has been shown that patients who need surgery, such as septorhinoplasty candidates, suffer from unbearable pain during and after surgery. One of the main considerations of the surgeons for these patients is making them experience a pleasant, comfortable, and painless intervention during septorhinoplasty utilizing nonpharmacological or pharmacological approaches. This study aimed to investigate the antianxiety and analgesic effects of listening to music as a nonpharmacological method in patients undergoing septorhinoplasty with general anesthesia.

Methods

In this randomized controlled clinical trial study, 80 patients who were candidates for septorhinoplasty were randomly categorized into the case (with music) and control groups (without music) from May to September 2022. STATA Version 14.0 (StataCorp) was used for the statistical analysis of the acquired data. Pain perception and agitation were evaluated using the Visual Analog Scale (VAS) and Sedation-Agitation Scale (SAS), respectively, and compared between the two groups during the early postoperative period.

Results

Although the baseline SAS score in the two groups was similar, findings showed a significantly lower score in the intervention group in recovery units (t-test 4.30, p < 0.001). The mean VAS was 0.8 ± 1.18 and 1.87 ± 1.13 in the intervention and control groups, respectively (p < 0.001). The satisfaction level of those patients in the intervention group was demonstrated during the procedure of the intervention. However, there was no significant difference between the control and intervention groups for hemodynamic parameters.

Conclusion

Music therapy during surgical procedures can postoperatively simplify the optimized postsurgical outcomes for patients undergoing septorhinoplasty. Trial Registration: Iranian Registry of Clinical Trials (IRCT20210307050609N2).

Surgeon-Guided Fluoroscopic Erector Spinae Plane Block (ESPB) versus Anesthetist-Guided Ultrasonic ESPB for Perioperative Analgesia in Lumbar Fusion Surgery- a Prospective Randomized Control Study

Study designProspective, randomized control study.ObjectiveTo assess the safety and efficacy of fluoroscopy-guided vs ultrasound-guided Erector Spinae Plane Block (ESPB) for perioperative analgesia in lumbar fusion surgery.Materials and Methods66 patients requiring single-level lumbar fusion were randomized into 2 groups. One group had fluoroscopy-guided ESPB by the surgeon (Fluoro-ESPB group) and the other group had Ultrasound-guided ESPB by the anesthetist (USG-ESPB). Demographic details, intraoperative parameters (perioperative total opioid consumption, muscle relaxants used, heart rate, blood pressure), and postoperative parameters (VAS score, alertness, satisfaction score) were recorded and analyzed.ResultsDuring the initial 48 hours following the surgery, both groups provided good perioperative analgesia, and reported very low and comparable postoperative pain scores (VAS scale). The mean VAS score was 2.7 ± 0.5 in the Fluoro-ESPB group and 2.7 ± 0.5 in the USG-ESPB group (P = 0.91). The average time taken to deliver the block in the Fluoro-ESPB group (3.01 ± 0.97 mins) was significantly less than in the USG-ESPB group (4.74 ± 1.49 mins) (P = 0.00). The total perioperative opioid consumption (TOC), total intraoperative muscle relaxant consumption, and intraoperative blood loss were similar in both groups (Fluoro- ESPB, USG ESPB) (P > 0.05). The postoperative MOASS score was consistently high across both groups. The satisfaction scores were high and comparable (P = 0.403).ConclusionThe fluoroscopy-guided ESPB is a safe and effective alternative to the traditional ultrasound-guided technique. It can be performed by the surgeon, reducing overall procedure time, and improving workflow.

Patient experience of discharge opioid analgesia and care provision following spine surgery: A mixed methods study

Background

Perioperative opioid stewardship programs are increasingly being introduced to guide responsible use around the time of surgery to reduce opioid-related harm to patients. However, patient experiences of perioperative opioid stewardship programs are underexplored.

Methods

We designed a mixed methods study to explore patients' experiences of perioperative opioid stewardship in the post-operative period following spine surgery. We performed evaluative action research, combining quality improvement and ethnographic methodologies. Our quantitative methods were retrospective medical record review and targeted survey research. Our qualitative methods were online focus groups. The quantitative data were analysed using descriptive statistics, chi-square, and rank sum testing. The focus group data underwent inductive thematic analysis.

Results

Our spine surgery cohort for the four-month study period included 101 patients. The median total discharge opioid dispensed was 75 mg [interquartile range 75-150 mg], with 30% of patients prescribed modified release opioids on discharge. A subset of patients (N = 14) participated in the online focus groups. The key themes that emerged from these sessions were (1) Supportive care delivery and rescue mechanisms were universally important to patient participants, providing great reassurance during their recovery; (2) Participants commonly believed opioid analgesia had an important role in recovery following spine surgery. Some patients were keen to dispose of surplus opioids whilst others intended to retain them; (3) Opioid analgesia access was variable, but established community prescriber relationships were important for post-discharge opioid re-prescription, and (4) The key future improvement suggestions included routine post-discharge contact and enhanced communication options back to the hospital if needed.

Discussion and conclusions

Our mixed methods approach provided rich insights into the pain and opioid analgesia experiences of patients following spine surgery. These insights are useful when seeking to optimise perioperative opioid stewardship programs including better meeting the needs of patient consumers. Limitations included potential response and selection bias for the online focus groups towards younger, higher socioeconomic status patients.

Predictive Clinical Factors of Pain-Related Quality of Recovery Following Elective Gastrointestinal and Hepato-Pancreato-Biliary Surgery: An Observational Study in Norway

Purpose

This observational cohort study aimed to identify predictive factors associated with pain-related quality of recovery among patients undergoing elective gastrointestinal and hepato-pancreato-biliary surgery.

Patients and Methods

This study involved a secondary analysis of the data collected from five hospitals across all healthcare regions in Norway to validate the Norwegian version of the Quality of Recovery-15 (QoR-15NO). The sample consisted of 268 adult patients who underwent elective gastrointestinal and hepato-pancreato-biliary surgery between September 2021 and May 2022. Data were collected using QoR-15NO upon admission for surgery and on the first postoperative day, and surgery severity was classified using the Surgical Outcome Risk Tool. A linear mixed model and multivariate linear regression were used to investigate associations between postoperative scores and possible predictive clinically relevant factors.

Results

The results of this study showed that postoperative pain was significantly associated with age, gender, severity of surgery, and changes from pre- to postoperative status. Younger patients, compared to older patients (b=0.23, 95% CI: [0.03, 0.41]), female patients (b=-0.61, 95% CI: [-1.19, -0.04]), patients undergoing minor and intermediate surgeries compared to major surgeries (b=0.96, 95% CI: [0.00, 1.92]) all reported higher levels of postoperative pain. There was a significant decline in QoR post-surgery due to increased pain severity (b=-1.91, 95% CI: [-2.33, -1.50]; p <0.001). No clinically significant associations were found between ASA physical status, surgery duration, and pain-related QoR.

Conclusion

This study identified age, gender, and surgery severity as key predictors of postoperative pain. Younger and female patients and those undergoing minor surgeries are at higher risk for severe postoperative pain. Proactive approaches for minor surgeries and tailored pain management for younger patients and females might enhance recovery and postoperative pain outcomes. Thus, future research should focus on the long-term effects of individualized pain management and additional strategies for high-risk patient groups.

Intraoperative Sleep Spindle Activity and Postoperative Sleep Disturbance in Elderly Patients Undergoing Orthopedic Surgery: A Prospective Cohort Study

Purpose

This study aimed to investigate the relationship between intraoperative sleep spindle activity and postoperative sleep disturbance (PSD) in elderly orthopedic surgery patients.

Patients and Methods

In this prospective observational cohort study, we collected intraoperative electroencephalography (EEG) data from 212 elderly patients undergoing orthopedic surgery from May 2023 to December 2023. We used the Athens Insomnia Scale to assess sleep quality on postoperative day (POD) 1 and POD 3 and analyzed the correlation between intraoperative sleep spindle activity and PSD through logistic regression.

Results

The incidence of PSD was 65.6% on POD 1 and 41.9% on POD 3. On the first day, there were no significant differences in intraoperative sleep spindle characteristics between PSD and non-postoperative sleep disturbance (non-PSD) patients. However, by the third day, PSD patients showed lower sigma power compared to non-PSD patients, as well as lower spindle density in the bilateral frontopolar (Fp1/Fp2) and bilateral temporal (F7/F8) channels, with shorter average spindle duration (P < 0.05). Multivariate logistic regression analysis suggested that the average spindle density in F7/F8 channels (OR 0.543, 95% CI 0.375-0.786; P = 0.001) was an independent risk factor for PSD on POD 3. Furthermore, Mini-Mental State Examination (MMSE) could independently predict PSD on POD 1 (OR 0.806, 95% CI 0.656-0.991; P = 0.041) and POD 3 (OR 0.701, 95% CI 0.562-0.875; P = 0.002). Pain on movement and at rest were independently associated with PSD on POD 1 (OR 1.480, 95% CI 1.200-1.824; P < 0.001) and POD 3 (OR 1.848, 95% CI 1.166-2.927; P = 0.009), respectively.

Conclusion

Intraoperative mean spindle density in the F7/F8 channels was an independent risk factor for PSD on POD 3 in elderly patients undergoing orthopedic surgery. MMSE and postoperative pain also independently increased the risk of PSD.

Comparison of nalbuphine and dezocine for postoperative analgesia in elderly patients undergoing laparoscopic radical gastric cancer surgery

OBJECTIVE

Gastric cancer is a prevalent and significant malignancy that occurs throughout the world, with a particularly pronounced impact on the elderly population. This study aims to compare the efficacy of nalbuphine and dezocine in managing pain following laparoscopic radical gastrectomy.

METHOD

Elderly patients undergoing laparoscopic radical gastrectomy were divided into a nalbuphine (n=50) group and a dezocine (n=50) group according to their anesthesia agent. Anesthesia methods included preoperative intravenous administration of either 0.15 mg/kg nalbuphine or 0.1 mg/kg dezocine, followed by continuous propofol infusion during surgery. Pain and sedation levels were assessed using the VAS and Ramsay Sedation Scale. Secondary indicators included postoperative pain indicators, hemodynamic parameters, recovery time, and adverse anesthetic reactions.

RESULTS

There were no significant differences in baseline data between the two groups, including gender, age, body weight, ASA classification, gastric cancer stage, and surgery duration (all P > 0.05). The nalbuphine group showed superior postoperative pain management compared to the dezocine group, with lower VAS, RSS, inflammatory levels (SP and IL-6) and stress response indicators (all P < 0.05). The nalbuphine group also had shorter awakening time, higher awakening quality, shorter surgery time, and earlier extubation time. Furthermore, the incidence of adverse events was lower in the nalbuphine group.

CONCLUSION

Nalbuphine provides better postoperative pain relief and was associated with fewer adverse events in elderly patients undergoing laparoscopic radical gastrectomy. These findings suggest that nalbuphine is a safer and more effective analgesic option in this clinical context.

Evolving Toward Non-narcotic Perioperative Enhanced Recovery After Surgery and Opioid-Free Analgesia in the Management of Postoperative Pain

Opioid medications are commonly employed for perioperative and postoperative pain management. However, these medications can negatively impact the body's innate pain management system, specifically the action of beta-endorphins. By impairing the function of mu-opioid receptors and inhibiting the release of beta-endorphin, opioids may exacerbate and prolong postoperative pain. Additionally, opioid use is associated with numerous side effects, including nausea, vomiting, constipation, excessive sedation, clouded sensorium, dizziness, respiratory depression, and addiction, all of which may impede postoperative patient recovery and outcome quality. The purpose of this article is to explore the intricate relationship between opioid medications and endogenous beta-endorphins, examine nonopioid modalities for postoperative pain control, and elucidate the applications of non-narcotic perioperative enhanced recovery after surgery protocols in improving patient outcomes.

Capabilities Toward Intravenous Patient-Controlled Analgesia: A Cross-Sectional Study of Registered Nurses Working in Two Tertiary Hospitals in China and Thailand

BACKGROUND

An increased interest has been observed in the wide use of intravenous patient-controlled analgesia (IV-PCA) to control acute postoperative pain in both China and Thailand. The safety and efficacy of IV-PCA in patient care requires competent and capable staff nurses. This study aimed to appraise the capabilities of Thai and Chinese registered nurses regarding IV-PCA as a guide to develop educational programs.

METHOD

A descriptive cross-sectional survey was conducted with 203 Chinese and 270 Thai registered nurses. An anonymous self-report questionnaire addressing 6 domains of capabilities toward IV-PCA was used to collect the data. Descriptive and inferential statistics were employed to analyze the data.

RESULTS

The study found that the mean percentage scores (MPS) of the overall capability on IV-PCA of the Thai and Chinese nurse participants were 55.5 (mean [M] = 57.3, standard deviation [SD] = 4.9) and 62.6 (M = 58.7, SD = 13.0), respectively, which indicated very low and low levels. Barriers to the use and care of patients receiving IV-PCA after surgery according to the Thai and Chinese nurse participants included a lack of knowledge and systematic training regarding IV-PCA and a lack of first-hand experience in providing care for IV-PCA patients.

CONCLUSION

The study results call for intensive and effective training and education concerning all domains for registered nurses involved with patients receiving IV-PCA.

Identifying risk factors for postoperative ileus following open abdominal aortic aneurysm repair

BACKGROUND

Postoperative ileus (POI) is a common complication following major abdominal surgery. The majority of the data available regarding POI after abdominal surgery is from the gastrointestinal and urological literature. These data have been extrapolated to vascular surgery, especially with regard to enhanced recovery programs for open abdominal aortic aneurysm (AAA) surgery. However, vascular patients are a unique patient population and extrapolation of gastrointestinal and urological data may not necessarily be appropriate. Therefore, the purpose of this study was to delineate the prevalence and risk factors of POI in patients undergoing open AAA surgery.

METHODS

This was a retrospective, single-institution study of patients who underwent open AAA surgery from January 2016 to July 2023. Patients were excluded if they had undergone nonelective repairs or had expired within 72 hours of their index operation. The primary outcome was rates of POI, which was defined as the presence of two or more of the following after the third postoperative day: nausea and/or vomiting, inability to tolerate oral food intake, absence of flatus, abdominal distension, or radiological evidence of ileus.

RESULTS

A total of 123 patients met study criteria with an overall POI rate of 8.9% (n = 11). Patients who developed a POI had a significantly lower body mass index (24.3 kg/m2 vs 27.1 kg/m2; P = .003), were more likely to undergo a transperitoneal approach (81.8% vs 42.0%; P = .022), midline laparotomy (81.8% vs 37.5%; P = .008), longer total clamp times (151.6 minutes vs 97.7 minutes; P = .018), greater amounts of intraoperative crystalloid infusion (3495 mL vs 2628 mL; P = .029), and were more likely to return to the operating room (27.3% vs 3.6%; P = .016). Proximal clamp site was not associated with POI (P=.463). Patients with POI also had higher rates of postoperative vasopressor use (100% vs 61.1%; P = .014) and greater amounts of oral morphine equivalents in the first 3 postoperative days (488.0 ± 216.0 mg vs 203.8 ± 29.6 mg; P = .016). Patients who developed POI had longer lengths of stay (12.5 days vs 7.6 days; P < .001), a longer duration of nasogastric tube decompression (5.9 days vs 2.2 days; P < .001), and a longer period of time before diet tolerance (9.1 days vs 3.7 days; P < .001). Of those who developed a POI (n = 11), four (36.4%) required total parental nutrition during the admission.

CONCLUSIONS

POI is a morbid complication among patients undergoing elective open AAA surgery that prolongs hospital stay. Patients at risk for developing a POI are those with a lower body mass index, as well as those who had an operative repair via a transperitoneal approach, midline laparotomy, longer clamp times, larger amounts of intraoperative crystalloid infusion, a return to the operating room, postoperative vasopressor use, and higher amounts of oral morphine equivalents. These data highlight important perioperative opportunities to decrease the prevalence of POI.

Effect of oxycodone versus fentanyl for patient-controlled intravenous analgesia after laparoscopic hysteromyomectomy: a single-blind, randomized controlled trial

A single-blind, randomized controlled trial comparing oxycodone and fentanyl for patient-controlled intravenous analgesia (PCIA) after laparoscopic hysteromyomectomy found comparable pain relief between the two groups. The study included 60 participants, with NRS scores for pain at rest and when moving showing no significant differences between oxycodone and fentanyl groups at various time points postoperatively. Self-rating depression scale scores were also similar between the groups at 48 h. However, patients' satisfaction with PCIA was higher in the oxycodone group, with 73.3% reporting being very satisfied compared to 36.7% in the fentanyl group. Additionally, the oxycodone group had fewer incidences of headaches within 48 h postoperatively compared to the fentanyl group. These findings suggest that oxycodone may offer comparable pain relief, higher patient satisfaction, and fewer headaches for patients undergoing laparoscopic hysteromyomectomy compared to fentanyl, making it a suitable option for postoperative pain management in this population.Clinical trial registration number The study was registered with CHICTR.org, ChiCTR2100051924.

Comparative Review of Postoperative Analgesic Use After Total Hip Replacement: Opioids Versus Non-opioids

Total hip replacement (THR) is a common surgical procedure aimed at alleviating pain and improving function in patients with hip joint pathology. Effective postoperative pain management is crucial for patient recovery, satisfaction, and overall outcomes. This narrative review examines the comparative efficacy, safety, and implications of using opioids versus non-opioid analgesics in managing postoperative pain following THR. Opioids, while effective for severe pain, pose significant risks such as addiction, tolerance, and adverse effects. Non-opioid analgesics, including non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and regional anesthesia techniques, offer alternatives with potentially fewer side effects. This review synthesizes current evidence from clinical trials, observational studies, and expert guidelines to provide a comprehensive understanding of the benefits and drawbacks of each analgesic approach. The goal is to inform clinical decision-making and optimize pain management strategies for THR patients, balancing efficacy and safety.

Effect of transcranial direct current stimulation and narrow-band auditory stimulation on the intraoperative electroencephalogram: an exploratoratory feasibility study

Introduction

During general anesthesia, frontal electroencephalogram (EEG) activity in the alpha frequency band (8-12 Hz) correlates with the adequacy of analgesia. Transcranial direct current stimulation (tDCS) and auditory stimulation, two noninvasive neuromodulation techniques, can entrain alpha activity in awake or sleeping patients. This study evaluates their effects on alpha oscillations in patients under general anesthesia.

Methods

30 patients receiving general anesthesia for surgery were enrolled in this two-by-two randomized clinical trial. Each participant received active or sham tDCS followed by auditory stimulation or silence according to assigned group (TDCS/AUD, TDCS/SIL, SHAM/AUD, SHAM/SIL). Frontal EEG was recorded before and after neuromodulation. Patients with burst suppression, mid-study changes in anesthetic, or incomplete EEG recordings were excluded from analysis. The primary outcome was post-stimulation change in oscillatory alpha power, compared in each intervention group against the change in the control group SHAM/SIL by Wilcoxon Rank Sum testing.

Results

All 30 enrolled participants completed the study. Of the 22 included for analysis, 8 were in TDCS/AUD, 4 were in TDCS/SIL, 5 were in SHAM/AUD, and 5 were in SHAM/SIL. The median change in oscillatory alpha power was +4.7 dB (IQR 4.4, 5.8 dB) in SHAM/SIL, +2.8 dB (IQR 1.5, 8.9 dB) in TDCS/SIL (p = 0.730), +5.5 dB in SHAM/AUD (p = 0.421), and -6.1 dB (IQR -10.2, -2.2 dB) in TDCS/AUD (p = 0.045).

Conclusion

tDCS and auditory stimulation can be administered safely intraoperatively. However, these interventions did not increase alpha power as administered and measured in this pilot study.

Acupoint Stimulation for Pain Control in Enhanced Recovery After Surgery: Systematic Review and Meta-Analysis

Introduction: Postoperative pain control is a challenge in enhanced recovery after surgery (ERAS). The current study reviewed the efficacy and safety of incorporating acupoint stimulation for postoperative pain control in ERAS. Methods: Ten databases for relevant randomized controlled trials (RCTs) published in English or Mandarin Chinese were searched from 1997 to 2022. The quality of each article was appraised using the Cochrane Collaboration Risk of Bias Criteria and the modified Jadad Scale. The primary outcome was pain control, measured using the visual analog scale 24 h after surgery. Results: Eleven trials met the eligibility criteria and were included in the study. Acupoint stimulation was found more effective than control treatments in terms of pain intensity (standardized mean difference [SMD] -0.94; 95% confidence interval [CI] -1.35 to -0.53), analgesic drug consumption (SMD -1.87; 95% CI -2.98 to -0.75), postoperative nausea (PON; SMD 0.31; 95% CI 0.13 to 0.73), postoperative vomiting (POV; SMD 0.57; 95% CI 0.11 to 2.92), and PON and POV (PONV; SMD 0.29; 95% CI 0.16 to 0.53). The Zusanli (ST36) and Neiguan (PC6) were the most-used acupoints in the included trials (8/11). The reported adverse reaction was only one case of bruising. Discussion: Acupoint stimulation improved pain control in patients undergoing ERAS more than control treatments. The findings provide an evidence-based premise for incorporating acupoint stimulation into ERAS strategies. More rigorous RCTs are needed in the future.

Pain Neuroscience Education in elective surgery patients: study protocol for a randomised controlled trial

BACKGROUND

Pain Neuroscience Education (PNE) consists of an educational strategy that seeks to understand the biological processes of pain and how to control it. The main objective of this study will be to evaluate the impact of PNE on outcomes related to the postoperative period. The hypothesis is that the intervention may positively influence postoperative recovery, contributing to pain control, clinical indications, acceptance and consumption of analgesics and other pharmacological drugs that contribute to its control, as well as psychological aspects, such as anxiety, depression and pain catastrophising.

METHODS AND ANALYSIS

This will be an open, parallel, multicentre and randomised controlled clinical trial. A total of 100 participants aged between 18 and 59 years of age, of both genders, who are going to have elective general surgery will be evaluated. The intervention group will participate in a preoperative pain neuroscience educational session and also receive usual preoperative care, while the control group receives usual preoperative care as well. The educational session will last 30 min and consists of a video (5:20 min), a questionnaire about the content, time for participants to express their beliefs, thoughts and doubts. Participants will be evaluated preoperatively and there will be one postintervention evaluation. The intensity and characteristics of pain and anxiety are evaluated as primary outcomes. As secondary outcomes, pain catastrophising and depression are taken into account.

ETHICS AND DISSEMINATION

The project was approved by the Research Ethics Committee of the Faculty of Ceilandia, the Research Ethics Committee of the Institute of Strategic Health Management of the Federal District and the Research Council of the Hospital of Brasília-Rede Dasa (CAAE: 28572420.3.0000.8093). Recruitment began in June of 2023. All participants were included in the study only after their written consent. All data obtained will be analysed and distributed through publication in journals and at scientific events.

TRIAL REGISTRATION NUMBER

Brazilian Registry of Clinical Trials (ReBEC) (RBR-23mr7yy).

Comparison of Effectiveness and Safety of Oxycodone Hydrochloride and Fentanyl for Post-operative Pain Following Total Hip Arthroplasty: A Randomized Triple-Blind Trial

Background

Total hip replacement (THR) is frequently associated with intense post-surgical pain. Effective pain management is of crucial importance to improving patient's condition and increasing his/her satisfaction in the post-operative time.

Objectives

This study aimed to compare the analgesic effect and safety of oxycodone and fentanyl after THR.

Methods

Seventy-two cases scheduled for elective THR were included in this randomized, triple-blind trial. The patients were equally randomized into 2 groups: Fentanyl group (50 ug of fentanyl) and oxycodone group (oxycodone 4 mg). Drugs were received 20 min prior to the end of the operation.

Results

Post-operative visual analog scale (VAS) measurements at rest and movement at the post-anesthesia care unit (PACU) and in the ward, 2 h, 4 h, and 8 h post-operatively exhibited a significantly reduced value in the oxycodone group compared to the fentanyl group (P-value < 0.05). Time to first rescue for analgesia was delayed significantly in the oxycodone compared to the fentanyl group (P-value < 0.001). Fentanyl consumption (ug) in the 1st post-operative 12 h, 24 h, and 48 h decreased significantly in the oxycodone group compared to the fentanyl group (P-value < 0.001). Post-operative nausea, vomiting, headache, and pruritus were matched between the 2 groups (P > 0.05).

Conclusions

A bolus dose of 4 mg of oxycodone provided superior analgesic efficacy than 50 ug fentanyl as evidenced by significantly lower pain score, delayed onset to first request for analgesia, and the smaller amount of fentanyl consumption at 12, 24, and 48 h post-total hip arthroplasty compared to fentanyl. The incidence of adverse events was comparable between the 2 groups.

Variation in Intraoperative Opioid Administration by Patient, Clinician, and Hospital Contribution

Importance

The opioid crisis has led to scrutiny of opioid exposures before and after surgical procedures. However, the extent of intraoperative opioid variation and the sources and contributing factors associated with it are unclear.

Objective

To analyze attributable variance of intraoperative opioid administration for patient-, clinician-, and hospital-level factors across surgical and analgesic categories.

Design, Setting, and Participants

This cohort study was conducted using electronic health record data collected from a national quality collaborative database. The cohort consisted of 1 011 268 surgical procedures at 46 hospitals across the US involving 2911 anesthesiologists, 2291 surgeons, and 8 surgical and 4 analgesic categories. Patients without ambulatory opioid prescriptions or use history undergoing an elective surgical procedure between January 1, 2014, and September 11, 2020, were included. Data were analyzed from January 2022 to July 2023.

Main Outcomes and Measures

The rate of intraoperative opioid administration as a continuous measure of oral morphine equivalents (OMEs) normalized to patient weight and case duration was assessed. Attributable variance was estimated in a hierarchical structure using patient, clinician, and hospital levels and adjusted intraclass correlations (ICCs).

Results

Among 1 011 268 surgical procedures (mean [SD] age of patients, 55.9 [16.2] years; 604 057 surgical procedures among females [59.7%]), the mean (SD) rate of intraoperative opioid administration was 0.3 [0.2] OME/kg/h. Together, clinician and hospital levels contributed to 20% or more of variability in intraoperative opioid administration across all analgesic and surgical categories (adjusting for surgical or analgesic category, ICCs ranged from 0.57-0.79 for the patient, 0.04-0.22 for the anesthesiologist, and 0.09-0.26 for the hospital, with the lowest ICC combination 0.21 for anesthesiologist and hosptial [0.12 for the anesthesiologist and 0.09 for the hospital for opioid only]). Comparing the 95th and fifth percentiles of opioid administration, variation was 3.3-fold among anesthesiologists (surgical category range, 2.7-fold to 7.7-fold), 4.3-fold among surgeons (surgical category range, 3.4-fold to 8.0-fold), and 2.2-fold among hospitals (surgical category range, 2.2-fold to 4.3-fold). When adjusted for patient and surgical characteristics, mean (square error mean) administration was highest for cardiac surgical procedures (0.54 [0.56-0.52 OME/kg/h]) and lowest for orthopedic knee surgical procedures (0.19 [0.17-0.21 OME/kg/h]). Peripheral and neuraxial analgesic techniques were associated with reduced administration in orthopedic hip (51.6% [95% CI, 51.4%-51.8%] and 60.7% [95% CI, 60.5%-60.9%] reductions, respectively) and knee (48.3% [95% CI, 48.0%-48.5%] and 60.9% [95% CI, 60.7%-61.1%] reductions, respectively) surgical procedures, but reduction was less substantial in other surgical categories (mean [SD] reduction, 13.3% [8.8%] for peripheral and 17.6% [9.9%] for neuraxial techniques).

Conclusions and Relevance

In this cohort study, clinician-, hospital-, and patient-level factors had important contributions to substantial variation of opioid administrations during surgical procedures. These findings suggest the need for a broadened focus across multiple factors when developing and implementing opioid-reducing strategies in collaborative quality-improvement programs.

A review on wound management strategies in enhanced recovery after craniotomy: An in-depth analysis of their influence on patient recovery and surgical outcomes

Craniotomy, an essential neurosurgical operation, poses distinct difficulties in the realm of post-operative care, specifically with regard to the management of wounds. Efficient wound management is critical in order to optimize the surgical outcomes, reduce complications and facilitate a speedier recovery. The purpose of this comprehensive review was to assess contemporary wound management approaches as they pertain to improved recovery following craniotomy. This was achieved by contrasting conventional methods with more recent and innovative techniques and analysing the effects of these approaches on patient recovery and surgical results. An exhaustive literature search was undertaken, comprising narrative reviews, clinical studies, peer-reviewed articles and expert opinions. The emphasis was on the evolution of wound management strategies and techniques utilized after cranial section, as well as their contributions to patient recovery. The analysis reveals that while conventional wound management methods, including suturing and antiseptics, continue to be essential, innovative strategies such as negative pressure wound therapy, skin adhesives and advanced pain management protocols are becoming increasingly recognized. It has been demonstrated that these novel approaches improve recovery by decreasing the incidence of infections, enhancing patient comfort and producing superior cosmetic results. Nevertheless, obstacles continue to endure, including patient-specific variables, technological and financial considerations and the enduring consequences of recovery. Thus the treatment of wounds during craniotomy recuperation necessitates an integrated strategy that incorporates conventional techniques alongside contemporary advancements. Progress in this domain necessitates the customization of approaches to suit the unique requirements of each patient, the resolution of identified obstacles and an emphasis on ongoing investigation and interdisciplinary cooperation. The ever-changing terrain of wound management approaches underscores the ever-changing character of neurosurgical treatment and the continuous endeavour to enhance patient results following cranial resection.

A Retrospective Comparison of Clinical Efficacy between Multimodal Analgesia and Patient-Controlled Epidural Analgesia in Patients Undergoing Total Knee Arthroplasty

Background and Objectives: Adequate pain management during early rehabilitation is mandatory for improving the outcomes of patients undergoing total knee arthroplasty (TKA). Conventional pain management, mainly comprising opioids and epidural analgesia, may result in certain adverse effects such as dizziness, nausea, and motor blockade. We proposed a multimodal analgesic (MA) strategy involving the use of peripheral nerve block (NB), periarticular injection (PAI), and intravenous patient-controlled analgesia (IVPCA). This study compared the clinical efficacy and adverse effects of the proposed MA strategy and patient-controlled epidural analgesia (PCEA). Materials and Methods: We enrolled 118 patients who underwent TKA under spinal anesthesia. The patients followed either the MA protocol or received PCEA after surgery. The analgesic effect was examined using a numerical rating scale (NRS). The adverse effects experienced by the patients were recorded. Results: A lower proportion of patients in the MA group experienced motor blockade (6.45% vs. 22.98%) compared to those in the PCEA group on the first postoperative day. Furthermore, a lower proportion of patients in the MA group experienced numbness (18.52% vs. 43.33%) than those in the PCEA group on the first postoperative day. Conclusions: The MA strategy can be recommended for reducing the occurrence of motor blockade and numbness in patients following TKA. Therefore, the MA strategy ensures early rehabilitation while maintaining adequate pain relief.

Temporal trends and patterns in initial opioid prescriptions after hospital discharge following colectomy in England over 10 years

BACKGROUND

While opioid analgesics are often necessary for the management of acute postoperative pain, appropriate prescribing practices are crucial to avoid harm. The aim was to investigate the changes in the proportion of people receiving initial opioid prescriptions after hospital discharge following colectomy, and describe trends and patterns in prescription characteristics.

METHODS

This was a retrospective cohort study. Patients undergoing colectomy in England between 2010 and 2019 were included using electronic health record data from linked primary (Clinical Practice Research Datalink Aurum) and secondary (Hospital Episode Statistics) care. The proportion of patients having an initial opioid prescription issued in primary care within 90 days of hospital discharge was calculated. Prescription characteristics of opioid type and formulation were described.

RESULTS

Of 95 155 individuals undergoing colectomy, 15 503 (16.3%) received opioid prescriptions. There was a downward trend in the proportion of patients with no prior opioid exposure (opioid naive) who had a postdischarge opioid prescription (P <0.001), from 11.4% in 2010 to 6.7% in 2019 (-41.3%, P <0.001), whereas the proportions remained stable for those prescribed opioids prior to surgery, from 57.5% in 2010 to 58.3% in 2019 (P = 0.637). Codeine represented 44.5% of all prescriptions and prescribing increased by 14.5% between 2010 and 2019. Prescriptions for morphine and oxycodone rose significantly by 76.6% and 31.0% respectively, while tramadol prescribing dropped by 48.0%. The most commonly prescribed opioid formulations were immediate release (83.9%), followed by modified release (5.8%) and transdermal (3.2%). There was a modest decrease in the prescribing of immediate-release formulations from 86.0% in 2010 to 82.0% in 2019 (P <0.001).

CONCLUSION

Over the 10 years studied, there was a changing pattern of opioid prescribing following colectomy, with a decrease in the proportion of opioid-naive patients prescribed postdischarge opioids.

Association of Reported Nonsteroidal Anti-Inflammatory Drug (NSAID) Adverse Drug Reactions With Opioid Prescribing After Total Joint Arthroplasty

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are indicated for postoperative pain management, but use may be precluded by the report of adverse drug reactions (ADRs). The effect of NSAID ADR labeling on opioid prescribing after total joint arthroplasty (TJA) is unknown.

OBJECTIVE

To assess the association between NSAID ADRs and postoperative opioid prescribing after TJA, a common surgical procedure.

METHODS

We performed a retrospective cohort study of adults who underwent total joint (knee or hip) replacement in a single hospital network between April, 1, 2016, and December 31, 2019. Demographic information, clinical and surgical characteristics, and prescription data were obtained from the electronic health record. We studied the association between reported NSAID ADRs and postoperative opioid prescribing in a propensity score-matched sample over 1 year of follow-up.

RESULTS

NSAID ADRs were reported by 9.6% of the entire cohort (n = 584/6091). NSAID ADR was associated with 41% higher odds of receipt of opioid prescriptions at 181 to 365 days after hospital discharge (95% confidence interval: 13%-75%) in a propensity score-matched sample. Over 98% of individuals received an opioid prescription at the time of hospital discharge, with no difference in overall median opioid dose prescribed by NSAID ADR status. However, more patients with NSAID ADRs (7.6% vs 4.7%) received cumulative opioid doses ≥ 750 morphine milligram equivalents (MME) at discharge (P = .004).

CONCLUSION

Reported NSAID ADR was associated with increased risk for prolonged receipt of opioids at 181 to 365 days postoperatively. Patients with NSAID ADRs more frequently received cumulative opioid doses ≥ 750 MME at discharge after TJA. Clarification and evaluation of reported NSAID ADRs may be particularly beneficial for surgical patients at high risk for prolonged receipt of opioids.

An In-Depth Analysis of Providers and Services of Cancellation in Anesthesia Reveals a Complex Picture after Systemic Analysis

The variances in operating room (OR) cancellation rates between different service lines and operators within these service lines were assessed by reviewing the electronic medical record (EMR) covering 34,561 cases performed by 199 OR operators in 2018. We assumed that cancellations would differ between different service lines, but the between-operators variance was minimal within the service line. We hypothesized that most variability would be secondary to patient-specific (weekdays, time of year, and national holidays), seasonal and administrative issues. Of 4165 case cancellations, the majority (73.1%) occurred before the patient arrived at the hospital. A total of 60% of all cancellations were within gastroenterology, interventional cardiology, and orthopedics. Cancellation rate variability between surgeons operating within the same service line greatly varied between services from very homogenous to very diverse across providers. The top reasons for cancellation were: date change, canceled by a patient, or "no show". The highest cancellation rates occurred on Mondays and Tuesdays, in January and September, and during weeks associated with national holidays. In summary, cancellation variability must be analyzed at the level of individual specialties, operators, and time variability.