Designing the ideal perioperative pain management plan starts with multimodal analgesia

Research progress on the impact of opioids on the tumor immune microenvironment (Review)

Opioids have been extensively used in cancer pain management because they can significantly improve the quality of life of patients with advanced cancer. However, recent evidence suggests that opioids can also modulate the tumor immune microenvironment by interacting with opioid receptors on immune cells, potentially regulating tumor progression and efficacy of cancer treatments. Notably, morphine can exhibit a dose-dependent effect on tumor immunity in pancreatic cancer and renal cell models, with lower doses potentially promoting tumor migration and invasion of pancreatic cancer cells, whereas higher doses shows the effect of inhibiting migration and invasion through distinct molecular pathways. The present review therefore comprehensively explored the mechanisms by which opioids can regulate the tumor immune microenvironment, focusing on their effects on immune cells, oxidative stress and angiogenesis. It also examined the interactions between opioids and other analgesics, along with their potential impact on immune modulation. All relevant articles and materials were retrieved from PubMed using the key words 'opioids', 'immune system', 'T cells', 'monocytes', 'macrophages', 'lymphocytes', 'natural killer cell', 'immunotherapy', 'immune cell function' and 'dose dependent effect'. The immunosuppressive effects of opioids, particularly through the µ-opioid receptor, can suppress the activity of natural killer cells, impair antigen presentation and promote the function of regulatory T cells (Tregs). These effects may contribute to tumor progression and metastasis. The severity of these immunosuppressive effects appears to be dose-dependent and can vary among different tumor types. There is evidence to suggest that tumors with higher immune responsiveness will experience more pronounced suppression, including the reduction of tumor angiogenesis, resulting in a decrease in tumor volume and decrease in tumor metastases. Furthermore, the combination of opioids with other analgesics, such as non-steroidal anti-inflammatory drugs, has the potential to exacerbate immunosuppression, which can in turn increase the risk of infections. Therefore, although opioids are essential for pain management in patients with cancer, their potential to modulate the immune microenvironment and promote tumor progression requires careful consideration. Clinicians should evaluate the advantages and disadvantages of opioids, especially regarding emerging immunotherapies, to minimize their potential negative effects on the outcomes of cancer treatments. Future studies are recommended to prioritize the development of strategies that optimize pain management whilst preserving immune function, such as receptor-specific opioid formulations or adjunctive therapies targeting immunosuppressive pathways.

Opioid therapy vs. Multimodal analgesia in head and neck cancer (OPTIMAL-HN): Results of a randomized clinical trial

BACKGROUND

Radiation-induced mucositis (RIM) pain confers substantial morbidity for head and neck cancer (HNC) patients undergoing radiotherapy (RT) or chemoradiotherapy (CRT). With no well-established standard treatment, OPTIMAL-HN aimed to demonstrate the non-inferiority of multimodal analgesia (MMA; analgesic medications with different mechanisms of action) to opioid analgesia alone.

METHODS

OPTIMAL-HN (ClinicalTrials.gov identifier: NCT04221165) was an open-label, non-inferiority, randomized clinical trial. We enrolled HNC patients receiving curative-intent RT/CRT and experiencing moderate ≥ 4/10 RIM pain. We randomized 1:1, stratified by RT vs. CRT, to opioids alone (standard arm) or MMA (pregabalin, acetaminophen, naproxen, and opioids if required). The primary endpoint was mean pain score (range: 0-10) during the last week of RT. Secondary endpoints included mean weekly opioid use, duration of opioid requirement, quality of life, weight loss, and toxicity. All analyses were pre-specified, including testing for superiority if non-inferiority was demonstrated.

RESULTS

Forty-nine patients were enrolled, 25 in the opioid analgesia arm and 24 in the MMA arm. Median follow-up was 4.2 months. The primary endpoint, mean pain score during the last 7 days of RT, was 5.1 (95 % confidence interval [CI]: 4.1-6.1) in the opioid arm and 4.9 (95 % CI: 3.8-5.9) in the MMA arm (non-inferiority p = 0.039, superiority p = 0.72). Analyzing all pain scores from enrollment to 6-weeks post-RT, MMA demonstrated both non-inferiority and superiority compared to opioids alone (non-inferiority p = 0.0024, superiority p < 0.001). One patient in the MMA arm was admitted with acute kidney injury, possibly related to the analgesic regimen. Arms were similar for all other secondary endpoints.

CONCLUSIONS

MMA demonstrates non-inferiority to opioid analgesia alone in managing RIM pain during the last week of RT and superiority when analyzing the post-RT time period. MMA should, therefore, be considered an effective mode of analgesia for HNC patients receiving RT.

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Implementation of an Integrated Pediatric Perioperative Pain Pathway: A Quality Improvement Initiative

Purpose: A quality improvement initiative was developed, implemented, and evaluated to improve pediatric postsurgical pain management and reduce hospital length of stay. Methods: An interdisciplinary working group developed the novel integrated pediatric perioperative pain (IP3) pathway adhering to the 3P approach to pain management. Preoperative psychological intervention, patient and caregiver education, standardized medication ordersets, and early identification of increased pain were the focus. Length of stay, opioid consumption, and achievement of physiotherapy goals were compared pre- and postpathway for children undergoing posterior spinal instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS). Results: The prepathway (n = 34) and postpathway (n = 29) groups were well matched for age, gender, weight, number of levels fused, and socioeconomic status. Postpathway, length of stay in the intensive care unit (pre 1.06 days and post 0.76 days, p ≤ 0.01) and length of hospital stay (pre 6.24 days and post 5.11 days, p ≤ 0.01) significantly decreased. Standardized physiotherapy goals were achieved earlier postpathway implementation. Day of surgery postoperative opioid consumption was reduced in the postpathway group. Discussion: Implementation of the IP3 pathway resulted in significant improvement in pain management for children undergoing major orthopedic surgery. Shortened hospital stay, earlier achievement of physiotherapy goals, and reduced initial opioid consumption were realized. Future efforts will focus on applying this pathway to other pediatric surgeries, optimizing surgical scheduling, and enhancing staff education.

Effectiveness of Interventions to Reduce Opioid Use After Orthopaedic Surgery: A Systematic Review of Randomised Controlled Trials

BACKGROUND

The prescribing of opioids to patients for postoperative pain can lead to persistent opioid use. This review investigated the effectiveness of interventions aimed at reducing opioid use in patients after orthopaedic surgery.

METHODS

Electronic databases were searched from inception to November 2023. We included randomised controlled trials investigating interventions aimed at reducing opioid use after orthopaedic surgery. Two reviewers conducted the screening and data extraction and assessed the risk of bias (Cochrane Risk of Bias tool) and certainty of evidence (GRADE). The primary outcome was the mean daily dose of opioid analgesic medications in the medium term (1-3 months after randomisation). Results were pooled in a meta-analysis using a random-effects model where appropriate (e.g. I2 < 50%) or summarised narratively.

RESULTS

The search yielded 17,471 records, of which 39 trials were included. High heterogeneity meant that most comparisons could not be pooled. The mean daily dose was lower with multimodal analgesia interventions than with placebo/no intervention/usual care or active control in the medium term. No between-group differences were found between other pharmacological or non-pharmacological interventions and either placebo/no intervention/usual care or active control at the medium-term time point. The certainty of evidence ranged from low to moderate.

CONCLUSIONS

Multimodal analgesic interventions may reduce opioid use compared with placebo/no intervention/usual care or active control in the medium term. However, the high heterogeneity and low certainty of evidence means it is uncertain which interventions are effective in reducing opioid use after orthopaedic surgery.

Decoding behaviour change techniques in opioid deprescribing strategies following major surgery: a systematic review of interventions to reduce postoperative opioid use

BACKGROUND AND OBJECTIVES

METHODS: A structured search strategy encompassing databases including MEDLINE, Embase, CINAHL Plus, PsycINFO and Cochrane Library was implemented from inception to October 2023. Included studies focused on interventions targeting opioid reduction in adults following major surgeries. The risk of bias was evaluated using Cochrane risk-of-bias tool V.2 (RoB 2) and non-randomised studies of interventions (ROBINS-I) tools, and Cohen's d effect sizes were calculated. BCTs were identified using a validated taxonomy.

RESULTS

22 studies, comprising 7 clinical trials and 15 cohort studies, were included, with varying risks of bias. Educational (n=12), guideline-focused (n=3), multifaceted (n=5) and pharmacist-led (n=2) interventions demonstrated diverse effect sizes (small-medium n=10, large n=12). A total of 23 unique BCTs were identified across studies, occurring 140 times. No significant association was observed between the number of BCTs and effect size, and interventions with large effect sizes predominantly targeted healthcare professionals. Key BCTs in interventions with the largest effect sizes included behaviour instructions, behaviour substitution, goal setting (outcome), social support (practical), social support (unspecified), pharmacological support, prompts/cues, feedback on behaviour, environmental modification, graded tasks, outcome goal review, health consequences information, action planning, social comparison, credible source, outcome feedback and social reward.

CONCLUSIONS

Understanding the dominant BCTs in highly effective interventions provides valuable insights for future opioid tapering strategy implementations. Further research and validation are necessary to establish associations between BCTs and effectiveness, considering additional influencing factors.

PROSPERO REGISTRATION NUMBER

CRD42022290060.

Optimizing Peripheral Nerve Block Placement in Hip Surgery: A Cadaveric Study Mapping the Posterior Cutaneous Innervation

Optimizing analgesia after hip surgery enables more rapid recovery. However, peripheral nerve blocks (PNBs) often fail to provide adequate pain relief in the posterolateral hip as they typically target the lateral cutaneous nerve of the thigh (LCNT). This study aimed to map the nerves innervating the posterolateral hip through analysis of anatomy textbooks (n = 5) and cadaveric dissections (n = 13). The subcostal (SCN), iliohypogastric (IHN), and ilioinguinal (IIN) nerves were identified as key contributors to innervating the posterolateral hip. The optimal site for ultrasound-guided PNBs to target these three nerves was identified at the "75/25" landmark: 75% horizontally along the 12th rib and 25% vertically down to the iliac crest. Ultrasound-guided dye injections in cadavers (n = 6) showed that while the "75/25" landmark effectively stained the SCN (6/6) and IHN (4/6), it inconsistently stained the IIN (2/6). A second injection in the posterolateral hip stained branches of the IHN (4/6) and IIN (4/6) but not the SCN (1/6), suggesting the IHN and IIN are the dominant nerves in the posterolateral hip. These findings recommend a more distal injection at the "100/75" landmark to consistently block the IHN and IIN, thereby optimizing postoperative analgesia after hip surgery.

Intravenously Administered Nonsteroidal Anti-Inflammatory Drugs in Clinical Practice: A Narrative Review

Intravenously administered nonsteroidal anti-inflammatory drugs (NSAIDs) constitute a crucial component of multimodal analgesia strategies in surgical settings. This narrative review aims to provide an up-to-date evaluation of the efficacy, safety, and clinical use of intravenous (IV) NSAIDs for perioperative pain management in adults and children. The NSAIDs and selective COX-2 inhibitors (coxibs) approved in Europe for the short-term symptomatic treatment of acute, moderate perioperative pain via IV infusion in adults and/or children have been influenced by US and global guidelines and practice: the drugs primarily reviewed here are ibuprofen, ketorolac, ketoprofen, naproxen, paracetamol, and acetylsalicylic acid. Furthermore, intravenous ibuprofen is authorized for the short-term symptomatic treatment of fever. In contrast to intravenous ketoprofen, intravenous ibuprofen is authorized for administration to children over 6 years of age or weighing more than 20 kg. Overall, IV ibuprofen had a more favorable profile with regard to peri- and postoperative opioid sparing and pain relief. Oral ibuprofen and IV ibuprofen have similar levels of efficacy, although IV ibuprofen has a shorter onset of action and is required in patients who are unable to take oral medications. The frequency of significant adverse events appears to be similar for ibuprofen and paracetamol. Systematic reviews and meta-analyses report that intravenous NSAIDs reduce postoperative opioid consumption by approximately 20-60%, improving pain management with fewer opioid-related side effects. In indications in infants, the choice of medication is limited, and the oral route is not always feasible; IV formulations of ibuprofen are preferred in this setting. Topics for further research should include head-to-head trials of IV NSAIDs.

The Effect of Obesity on Postoperative Analgesia Practices and Complications Following Endoscopic Sinus Surgery: A Propensity Score-Matched Cohort Study

BACKGROUND

Despite growing concern regarding over-prescription of narcotic pain medication following ambulatory surgery, little is known about the analgesic prescribing practices following endoscopic sinus surgery (ESS) in obese patients in comparison to non-obese patients.

OBJECTIVE

To compare the rates of opioid versus non-opioid prescriptions, the need for steroids, and post-operative adverse events between obese and non-obese adult patients undergoing ESS.

METHODS

Using TriNetX Live database, we identified all patients aged ≥18 years who underwent ESS (n = 1303) between 2014 and 2022 across several healthcare institutions across the state of Tennessee. We 1:1 propensity score-matched obese (BMI ≥ 30 kg/m2) and non-obese (18.5 kg/m2 ≤ BMI < 30 kg/m2) cohorts for age, gender, race, and comorbidities including asthma, nicotine dependence, and sleep apnea. Rates of prescriptions and post-operative adverse events between cohorts were analyzed using risk ratios (RR) and confidence intervals (CI).

RESULTS

A toal of 532 obese patients were compared to 532 propensity score-matched non-obese patients in the first 14 post-operative days following ESS. The obese cohort was significantly more likely to be prescribed analgesics generally (RR = 1.72; 95% CI = 1.20-2.47), non-opioid analgesics (RR = 1.73; 95% CI = 1.19-2.50), and opioid analgesics (RR = 1.64; 95% CI = 1.14-2.36) than non-obese patients. There was no difference in rates of antibiotic or antiemetic prescription, prednisone/methylprednisolone, dexamethasone, ED visits, critical care service, epistaxis, transfusion, anemia, revision sinus surgery, mechanical ventilation, CPAP, or inhalation airway treatments.

CONCLUSION

Obese patients undergoing ESS were significantly more likely to be prescribed non-opioid and opioid analgesia in the first 14 days post-operatively compared to non-obese patients. There were no differences in post-operative adverse events or other prescriptions. Otolaryngologists should be aware that obese patients are at increased risk of opioid induced airway obstruction and steroid induced hyperglycemia, especially in patients with comorbid sleep apnea or diabetes. Emphasis on non-opioid analgesics and multimodal pain management should be advocated for this population.

Relationship of opioid tolerance to patient and wound factors, and wound micro-environment in patients with open wounds

OBJECTIVE

Opioid tolerance is a criterion for opioid use disorder, which is currently an epidemic in the US. Individuals with open wounds are frequently administered opioids; however, the phenomenon of opioid tolerance has not been examined in the context of wounds. The purpose of this exploratory study was to compare patient/wound factors, wound microbiome and inflammatory mediators between individuals who were opioid-tolerant versus those who were not opioid-tolerant.

METHOD

Patients with acute open wounds were enrolled in this cross-sectional study. All study data were collected before and during a one-time study dressing change.

RESULTS

The study included a total of 385 participants. Opioid-tolerant participants were significantly younger (p<0.0001); had higher levels of depression (p=0.0055) and anxiety (p=0.0118); had higher pain catastrophising scores (p=0.0035); reported higher resting wound pain (p<0.0001); had a higher number of wounds of <30 days' duration (p=0.0486); and had wounds with lower bacterial richness (p=0.0152) than participants who were not opioid-tolerant. A backward elimination logistic regression model showed that four predictors-resting wound pain, age, bacterial richness and depression-were the most important variables in predicting opioid-tolerance status.

CONCLUSION

These findings provide the first insights into the phenomenon of opioid tolerance in the context of open wounds. This study provides findings from which to guide hypothesis-driven research in the future.

Efficacy of Intraoperative Paracetamol and Nefopam Infusions in Addition to Transversus Abdominis Plane Block in Kidney Transplant Recipients

Background and Objectives: Kidney transplantation (KT) is an important treatment modality for renal failure. However, moderate-to-severe pain often occurs in KT recipients. Multimodal analgesia using combined analgesic measures has been recommended to enhance postoperative recovery. This retrospective study explored the additional analgesic efficacy of paracetamol and nefopam infusions in living-donor KT recipients who received a transversus abdominis plane (TAP) block. Materials and Methods: Consecutive living-donor KT recipients at our institute between January 2020 and March 2022 were divided into groups that received a TAP block with paracetamol and nefopam infusions (Group TA) or a TAP block without analgesics (Group T) during surgery. Following propensity-score (PS) matching, 103 patients were included in each group. Postoperative pain intensity assessed using the visual analog scale (VAS), opioid consumption via patient-controlled analgesia (PCA) devices over 24 h, and postoperative outcomes were compared between the two groups. Results: VAS pain intensity at rest was lower in group TA than in group T at 1 and 6 h after surgery [1 h: 29 (15-41) vs. 41 (29-51) mm, p < 0.001; 6 h: 32 (23-43) vs. 40 (32-54) mm, p < 0.001]. The VAS pain intensity during coughing was lower in group TA [1 h: 46 (30-58) vs. 59 (48-69) mm, p < 0.001; 6 h: 51 (40-63) vs. 60 (45-71) mm, p < 0.001]. Moreover, PCA consumptions during the first 6 h and between 6-24 h post-surgery was significantly lower in group TA. Other postoperative outcomes did not differ between the two groups. Conclusions: Multimodal analgesia with intraoperative paracetamol and nefopam infusions improved postoperative pain control in living-donor KT recipients who received a preoperative TAP block. Our findings demonstrate the efficacy of paracetamol and nefopam infusions in KT recipients.

Effects of pharmacological therapy on sleep quality in a postoperative setting: A systematic review of randomized controlled trials

Background and Aims

Postoperative sleep disturbances are associated with delayed recovery and increased incidences of complications. This systematic review aims to determine the impact of perioperative pharmacological therapies on postoperative sleep quality in the hospital.

Material and Methods

We searched MEDLINE, MEDLINE ePubs and In-Process Citations (Daily), Embase Classic + Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and PubMed for randomized controlled trials (RCTs) from inception to May 2022, with continued literature surveillance until August 2023. Studies included consisted of noncardiac surgical patients aged ≥18 years with postoperative sleep in the hospital. The primary outcome was improvement in postoperative sleep outcomes such as sleep quality, duration, efficiency, architecture, and insomnia ratings after pharmacological treatment. Additional outcomes included postoperative pain scores and opioid consumption.

Results

The search strategy yielded 21 studies (n = 3276), and 18 reported improved sleep outcomes using eight validated sleep measurement tools. Eight of 10 studies using dexmedetomidine via patient-controlled analgesia or intravenous infusion reported better sleep quality versus controls. Opioids (nalbuphine, tramadol plus sufentanil), nonopioids (zolpidem, midazolam, pregabalin), propofol total intravenous anesthesia (TIVA), S-ketamine, and ropivacaine nerve blocks were superior to controls in enhancing postoperative sleep quality. Eleven studies (52%) which included the combination of dexmedetomidine with opioids reported concurrent improvements in postoperative pain and sleep. Dexmedetomidine also decreased postoperative opioid analgesia consumption.

Conclusions

Evidence for the effects of perioperative pharmacological approaches on postoperative sleep are limited. High-quality RCTs of adequate power and methodology on the effects of pharmacology interventions on postoperative sleep are warranted.

Multimodal Analgesia Approach in Acute Low Back Pain Management: A Phase III Study of a Novel Analgesic Combination of Etoricoxib/Tramadol

INTRODUCTION

Pain and disability management are crucial for a speedy recovery. Combining analgesics with different mechanisms of action provides greater pain relief with lower doses, promoting efficient multimodal analgesia. This study evaluated the efficacy and safety between two fixed-dose combinations (FDC): etoricoxib/tramadol compared to paracetamol/tramadol for the management of acute low back pain (LBP) in a 7-day treatment.

METHODS

We conducted a phase IIIb, prospective, randomized, and multicenter study in patients with acute LBP treated with etoricoxib 90 mg/tramadol 50 mg (one packet of granules diluted in 100 ml of water, once a day [QD], for 7 days) or paracetamol 975 mg/tramadol 112.5 mg (one tablet of 325 mg/37.5 mg, three times a day [TID], for 7 days) to assess the efficacy (in terms of pain and disability improvement) and safety.

RESULTS

One hundred and twenty-four patients were randomized to receive either etoricoxib/tramadol QD (n = 61) or paracetamol/tramadol TID (n = 63). From the magnitude of change in pain evaluations, differences were observed between the treatment groups at 3 [p = 0.054, CI 95% - 0.648 (- 0.010 to 1.306)] and 5 days (p = 0.041). The proportion of patients with a 30% reduction in Visual Analogue Scale (VAS) score was statistically significant when comparing the treatment groups on the third day of follow-up [p = 0.008, CI 95% 0.241 (0.061-0.421)]. An improvement in LBP's disability to perform activities of daily routine (Oswestry and Roland-Morris questionnaires) was observed in both treatment groups. A total of 79 adverse events (AEs) (38 [48.1%] with etoricoxib/tramadol and 41 [51.9%] with paracetamol/tramadol) were reported. The most frequent AEs were nausea (17.7%) and dizziness (16.4%).

CONCLUSIONS

The results show the clinical benefits of etoricoxib/tramadol FDC, such as the sparing effect of tramadol dose per day, early therapeutic response rate compared with paracetamol/tramadol; which translates into faster pain relief, better adherence, less tramadol drug dependency, and a reduction of related AEs incidence.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT04968158.

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.

Multitarget ligands that comprise opioid/nonopioid pharmacophores for pain management: Current state of the science

Chronic pain, which affects more than one-third of the world's population, represents one of the greatest medical challenges of the 21st century, yet its effective management remains sub-optimal. The 'gold standard' for the treatment of moderate to severe pain consists of opioid ligands, such as morphine and fentanyl, that target the µ-opioid receptor (MOP). Paradoxically, these opioids also cause serious side effects, including constipation, respiratory depression, tolerance, and addiction. In addition, the development of opioid-use disorders, such as opioid diversion, misuse, and abuse, has led to the current opioid crisis, with dramatic increases in addiction, overdoses, and ultimately deaths. As pain is a complex, multidimensional experience involving a variety of pathways and mediators, dual or multitarget ligands that can bind to more than one receptor and exert complementary analgesic effects, represent a promising avenue for pain relief. Indeed, unlike monomodal therapeutic approaches, the modulation of several endogenous nociceptive systems can often result in an additive or even synergistic effect, thereby improving the analgesic-to-side-effect ratio. Here, we provide a comprehensive overview of research efforts towards the development of dual- or multi-targeting opioid/nonopioid hybrid ligands for effective and safer pain management. We reflect on the underpinning discovery rationale by discussing the design, medicinal chemistry, and in vivo pharmacological effects of multitarget antinociceptive compounds.

A randomised comparison of transverse abdominal plane block versus thoracic epidural analgesia on postoperative opioid consumption for colorectal enhanced recovery after surgery programme (OPIATE study)

BACKGROUND

The transverse abdominis plane block is increasingly being used as a less-invasive alternative to thoracic epidural analgesia for effective pain management. This study aimed to compare transverse abdominis plane block with opioid-based thoracic epidural analgesia in terms of postoperative opioid consumption.

METHODS

Patients in the thoracic epidural analgesia group received a continuous infusion of 0.1% levobupivacaine with 2mcg/ml of fentanyl, while those in the transverse abdominis plane group received 6-hourly boluses of 0.4ml/kg of 0.25% levobupivacaine. The primary objective was to compare the average fentanyl consumption, measured as intravenous fentanyl equivalents, over 72 hours.

RESULTS

Data of 35 patients were analysed. Fentanyl consumption at the end of 72 hours was significantly lower in the transverse abdominis plane group (median [interquartile range] 495 mcg (255, 750), and mean (95% confidence interval) 717.35mcg (403.54-1031.16)) compared to the thoracic epidural analgesia group (median [interquartile range] 760mcg (750, 760), and mean (95% confidence interval) 787mcg (746.81-827.19)) with a p value of 0.010. Pain scores at rest and during movement were comparable between the groups (p > 0.05). However, the median pain scores during movement were significantly lower in the thoracic epidural analgesia group at 60 and 72 hours (p ⩽ 0.05).

CONCLUSION

Multimodal analgesia with transverse abdominis plane resulted in lower opioid consumption over 72 hours compared to thoracic epidural analgesia.

Prevalence and Effect of Cannabinoids in Pain Management for Hand Pathologies

BACKGROUND

Cannabinoids are a diverse group of compounds under investigation for various medical purposes, including analgesia. Given the evolving landscape of cannabinoid use, we aimed to analyze their prevalence and effect in pain management among urban orthopedic hand patients.

METHODS

An electronic survey was administered to 122 new patients presenting to the orthopedic hand clinic of a major urban academic hospital. Demographic data, numerical rating scale pain scores, cannabinoid usage, and other concomitant pain regimens were recorded.

RESULTS

Approximately half of the new patients were dissatisfied with current pain management for their hand pathology. Prescription (Rx) and over-the-counter (OTC) pain medications were used by 58% (71/122) of patients, while cannabinoids were used by 15% (18/122) of patients. Compared with pre-usage pain scores, both cannabinoids and Rx/OTC medications induced significant reductions in pain associated with patients' hand pathologies (Cannabinoid: Δ4.4, P = .002; Rx/OTC: Δ3.0, P < .001). Cannabinoids induced a larger analgesic effect, but this difference was not statistically or clinically significant (P = .06). Subjectively, cannabinoid users either preferred their cannabinoid over Rx/OTC medications or liked both equally. Opioid use was higher among cannabinoid users (22.2% vs 12.5%), although this was not statistically significant (P = .28).

CONCLUSION

Approximately 15% of new urban hand patients use cannabinoids for pain control, and these compounds have similar analgesic efficacy in hand pathologies as Rx/OTC medications. Cannabinoids are equally liked or preferred relative to traditional medications in this cohort, and they may play an important role in pain management for hand patients.

Improving perioperative acetaminophen administration for safer and cost-effective multimodal analgesia in pediatric surgery: A QI initiative

BACKGROUND

The use of acetaminophen in the perioperative period has emerged as an attractive option for providing safer and cost-effective analgesia in children.

AIMS

The primary aim of our project was to increase the use of acetaminophen (both oral and intravenous) in the perioperative period from a baseline of 39.5% to 50% for all surgical patients within 24 months. The secondary aim was to increase the use of enteral acetaminophen from 10% to 52.5% during the same period.

METHODS

A multidisciplinary team was formed, and model for improvement was chosen as the QI methodology. The primary measure was the total percentage of surgical patients receiving any form of perioperative acetaminophen, while our secondary measure was the percentage use of oral acetaminophen administration. We also tracked the average maximum PACU (Post Anesthesia Care Unit) pain scores and the percentage of patients receiving IV opioids. Multiple interventions were conducted, including education, increasing the availability of acetaminophen, and optimizing the electronic medical record (EMR). Monthly data was collected using an automated report in the EMR.

RESULTS

We successfully achieved our goal, increasing the use of acetaminophen from 39.5% to 70% within four months. Despite some fluctuations, by the end of 24 months, we not only met but surpassed our goal, with 63% of patients receiving perioperative acetaminophen. Similarly, the usage of oral acetaminophen increased from a baseline of 10% to 78%. Our average maximum PACU pain scores improved from 5.4 to 5.2, and the percentage of patients receiving rescue opioids decreased from 15.4 to 13.1.

CONCLUSION

We successfully achieved and sustained our goals of improving acetaminophen use for our surgical patients without worsening pain scores or worsening use of intravenous opioids. Future directions include further refining our strategies and exploring additional opportunities to optimize pain management in pediatric perioperative settings.

Comparison of Hemodynamic and Recovery Profile Between Segmental Thoracic Spinal and General Anesthesia in Upper Abdominal and Breast Surgeries: A Systematic Review and Meta-Analysis

Segmental thoracic spinal anesthesia (STSA) has been described primarily as case reports for performing upper abdominal and thoracic surgeries in significant respiratory comorbid patients. A few comparative studies have recently evaluated the technique as an advantageous alternative to general anesthesia (GA). However, there is no systematic evaluation and comparison of the techniques. The present systematic review evaluated the hemodynamic, comfort, and satisfaction of patients undergoing abdominal and thoracic surgeries under STSA and GA. PubMed, CENTRAL, Google Scholar Advanced, and citation tracking were performed to find suitable articles that compared STSA and GA. The primary objective-related data were hypotension and bradycardia. The secondary objective-related data in the context of postoperative nausea vomiting (PONV), pain, rescue analgesics, sedation requirement, satisfaction, and comfort were assessed. Meta-analysis was performed for dichotomous data on hypotension, bradycardia, and PONV; odds ratio (OR) and 95% confidence interval (CI) were reported. Data of 394 patients from six studies were evaluated. Patients undergoing upper abdominal and breast surgeries under STSA had significantly higher odds of hypotension (Fixed-Effect Model OR 12.23, 95% CI 2.81-53.28; I2 =0%, and the Random Effects Model OR 12.01, 95% CI 2.75-52.52; I2 =0%) and bradycardia (Fixed-Effect Model OR 10.95, 95% CI 2.94-40.74, I2 =0%, and the Random Effects Model OR 9.97, 95% CI 2.61-38.08; I2 =0%) but lower odds of PONV (Fixed-Effect Model OR 0.24, 95% CI 0.13-0.43; I2 =0%, and the Random Effects Model OR 0.24, 95% CI 0.13-0.45; I2 =0%). Most of the patients undergoing STSA were given intravenous sedation to overcome anxiety and discomfort. Overall, patient satisfaction was on par with GA. However, few surgeons were unenthusiastic about the technique while performing axillary clearances due to bothering twitches from cautery. STSA led to early post-anesthesia care unit (PACU) discharge and provided better pain control, lowering the need for rescue analgesics and opioid consumption in the first 24-hour postoperative period. STSA is associated with very high odds of hypotension and bradycardia as compared to GA. On the other hand, STSA demonstrated superior pain control, reduced opioid requirements, shorter PACU stays, and significantly reduced risk of PONV. Nevertheless, STSA patients mostly require sedation to make the patient comfortable.

Optimizing Pain Management in Emergency Departments: A Comprehensive Review of Current Analgesic Practices

Effective pain management in Emergency Departments (EDs) is vital for improving patient comfort and clinical outcomes. This review provides a comprehensive analysis of current pain management practices in ED settings, focusing on the challenges and opportunities for optimization. The review examines pharmacologic and non-pharmacologic pain management strategies, evaluating their effectiveness and identifying inconsistencies and gaps in current practices. Key challenges in the ED environment include time constraints, variability in clinical protocols, and the need to address diverse patient needs, including those of paediatric, geriatric, and chronic pain patients. The review highlights the importance of standardized pain assessment tools and protocols to improve consistency in pain management. Innovations, such as technological advances and multimodal approaches, are explored for their potential to enhance pain management practices. Recommendations address identified challenges, including improved training for ED staff, the development of evidence-based protocols, and the integration of multimodal pain management strategies. By addressing these areas, the review aims to contribute to the development of more effective and uniform pain management practices in emergency care, ultimately leading to better patient outcomes and experiences. This review emphasizes the need for ongoing research and adaptation of best practices to meet the evolving needs of patients in emergency settings.

Optimizing Regional Anesthesia for Cancer Patients: A Comprehensive Review of Current Practices and Future Directions

Regional anesthesia has emerged as a pivotal component in the perioperative management of cancer patients, offering several advantages over traditional general anesthesia. By providing targeted pain relief and minimizing systemic exposure to opioids, regional anesthesia reduces the risk of opioid-related side effects and enhances postoperative recovery. Regional anesthesia may positively influence oncological outcomes by attenuating the surgical stress response and preserving immune function, potentially reducing cancer recurrence and metastasis. This review comprehensively explores the current practices and benefits of regional anesthesia in the oncology setting, including various techniques such as nerve blocks, epidural anesthesia, and spinal anesthesia. It examines the challenges associated with its application in cancer patients, including technical difficulties and patient-related factors. It evaluates the existing evidence regarding its impact on cancer progression and patient survival. Additionally, the review discusses future directions in the field, emphasizing the need for personalized anesthesia strategies, further research into the long-term effects of regional anesthesia on cancer outcomes, and the development of innovative approaches to enhance its efficacy and safety. By addressing these areas, this review aims to provide a thorough understanding of how to optimize regional anesthesia for cancer patients, ultimately contributing to improved perioperative care and better long-term outcomes.

A Single Dose of Intrathecal Morphine Without Local Anesthetic Provides Long-Lasting Postoperative Analgesia After Radical Prostatectomy and Nephrectomy

PURPOSE

Pain after open urological procedures is often intense. The aim of the study was to compare the efficacy of intrathecal morphine with systemic analgesia approaches.

DESIGN

Prospective, randomized, single-blind controlled study.

METHODS

Patients undergoing open prostatectomy or nephrectomy were randomly divided into the intervention group or the control group. Patients in the intervention group received morphine 250 mcg in 2.5 mL saline intrathecally. Anesthesia was identical in both groups. All patients were admitted to the intensive care unit (ICU) postoperative and received paracetamol 1 g intravenously every 6 hours and diclofenac 75 mg intramuscularly every 12 hours. If postoperative pain exceeded four on the numeric rating scale, morphine 10 mg was administered subcutaneously. Pain intensity, time to first dose of morphine, morphine doses, and side effects were recorded.

FINDINGS

In total, 41 patients were assigned to the intervention group and 57 to the control group. The time to administration of the first dose of morphine was significantly (P < .001) longer in the intervention group when compared to controls. This observation was also noted individually for patients undergoing nephrectomy (36.86 hours vs 4.06 hours) and prostatectomy (33.13 hours vs 4.5 hours). Many patients did not need opioids after surgery in the intervention group (nephrectomy 72% vs 3%, prostatectomy 75% vs 4.5%, P < .001). There was no significant difference in the incidence of side effects.

CONCLUSIONS

The results of our study confirmed that preoperative intrathecal morphine provides long-lasting analgesia and reduces the need for postoperative systemic administration of opioids. Adverse effects are minor and comparable between groups.

Efficacy of Multimodal Analgesia with Transversus Abdominis Plane Block in Comparison with Intrathecal Morphine and Intravenous Patient-Controlled Analgesia after Robot-Assisted Laparoscopic Partial Nephrectomy

Background: Robot-assisted laparoscopic partial nephrectomy (RAPN) for renal tumor treatment provides ergonomic advantages to surgeons and improves surgical outcomes. However, moderate-to-severe pain is unavoidable even after minimally invasive surgery. Despite the growing interest in multimodal analgesia, few studies have directly compared its efficacy with intrathecal morphine, a traditional opioid-based analgesic. Methods: We retrospectively investigated the efficacy of multimodal analgesia compared with that of intrathecal analgesia and intravenous patient-controlled analgesia (IV-PCA) in patients who underwent transperitoneal RAPN at our institute between 2020 and 2022. Among the 334 patients who met the inclusion criteria, intrathecal analgesia using morphine 200 µg was performed in 131 patients, and multimodal analgesia, including transversus abdominis plane block and intraoperative infusion of paracetamol 1 g and nefopam 20 mg, was administered to 105 patients. The remaining 98 patients received postoperative IV-PCA alone. Results: As the primary outcome, the area under the curve of pain scores over 24 h was significantly lower in the intrathecal analgesia and multimodal analgesia groups than in the IV-PCA group (89 [62-108] vs. 86 [65-115] vs. 108 [87-126] h, p < 0.001). Cumulative opioid requirements were also significantly lower in the intrathecal analgesia and multimodal analgesia groups at 24 h after surgery (p < 0.001). However, postoperative nausea and vomiting were significantly increased in the intrathecal analgesia group (27.5% vs. 13.3% vs. 13.3%, p = 0.005). Conclusions: Multimodal analgesia with a transversus abdominis plane block is an efficient analgesic method with fewer adverse effects compared to other analgesic methods. Our findings suggest the efficacy and safety of a multimodal approach for opioid-sparing analgesia after RAPN in the current opioid epidemic.

Adductor Canal Block Versus Femoral Nerve Block for Postoperative Pain Management in Anterior Cruciate Ligament Reconstruction: A Prospective Interventional Study

Background A common knee joint disorder is injury to the anterior cruciate ligament (ACL), which often requires surgery. Proper pain control after the surgery facilitates fast recovery and prevents chronic pain. To provide analgesia for knee procedures, the use of opioids, non-steroidal anti-inflammatory medications, and regional techniques are commonly employed. This study aims to evaluate the efficacy of adductor canal block (ACB) and femoral nerve block (FNB) for postoperative pain management after anterior cruciate ligament reconstructions (ACLRs). Methodology This prospective interventional study included 30 participants scheduled for patellar graft ACLR. They were assigned into groups, i.e., ACB and FNB, with 15 patients each. The evaluation occurred one day before the operation, and all surgical procedures were performed using spinal anesthesia. During the postoperative period, a 10-point visual analog scale (VAS) was utilized to quantify pain intensity at the end of the surgery and at various intervals after the surgery. Patients with a VAS score greater than 4 received either FNB or ACB using bupivacaine 0.125%. Duration of analgesia time, power of quadriceps muscle, and neurologic complications were documented. Results No statistically significant value was observed in the mean duration of analgesia between the patients in ACB (348.33 minutes) and the patients in FNB (363.06 minutes). No motor block was observed in 12 patients who received ACB, while only four patients had a motor-sparing effect among those who received FNB. No neurological adverse effects were observed in the study participants. Conclusions ACB provides an equal duration of analgesia similar to FNB, and ACB significantly spares motor strength and maintains higher quadriceps power than FNB.

Dexmedetomidine Versus Fentanyl on Time to Extubation in Patients with Morbid Obesity Undergoing Laparoscopic Sleeve Gastrectomy

Background

Sleeve gastrectomy (SG) is an effective method for managing obesity. While opioids are used for their hemodynamic stability and their ability to reduce intraoperative stress, they also have reported side effects. Dexmedetomidine (DEX), an α2 adrenergic receptor agonist, is noted for its analgesic and anesthetic-sparing effects, leading to a higher quality of recovery.

Objectives

The study aims to compare the effects of fentanyl and dexmedetomidine (DEX) on the recovery of morbidly obese patients following laparoscopic sleeve gastrectomy (SG).

Methods

This randomized, double-blind study involved 64 patients, equally divided into two groups. The Dexmedetomidine group (Group D) received an intravenous (IV) loading dose of dexmedetomidine (1 μg/kg) over 15 minutes before anesthesia induction, followed by a 10 mL saline 0.9% infusion over 60 seconds during induction. Post-intubation, dexmedetomidine was administered at 0.5 μg/kg/h. The Fentanyl group (Group F) received a volume-matched saline 0.9% IV over 15 minutes pre-induction and fentanyl (1 μg/kg) diluted in 10 ml saline 0.9% IV over 60 seconds during induction. After intubation, a continuous fentanyl infusion was maintained at a rate of 1 μg/kg/hr.

Results

Extubation time was significantly shorter in the Dexmedetomidine group (Group D) at 8.25 ± 2.7 minutes compared to the Fentanyl group (Group F) at 10.47 ± 2.17 minutes, with a P-value of 0.001. Intraoperative heart rate and mean arterial blood pressure were also significantly lower in Group D than in Group F. Visual analogue scale (VAS) pain scores were significantly lower in Group D compared to Group F upon arrival at the post-anesthesia care unit and at 2 hours postoperatively (P-value < 0.05). Additionally, the morphine dose consumed in the first 12 hours after surgery was significantly lower in Group D (5.75 ± 2.20 mg) compared to Group F (8 ± 2.38 mg), with a P-value of 0.001.

Conclusions

For morbidly obese patients undergoing laparoscopic sleeve gastrectomy, dexmedetomidine (DEX) proves to be an effective anesthetic choice. It not only reduces extubation time but also lowers early postoperative visual analogue scale (VAS) pain scores and opioid consumption within the first 12 hours following surgery.

Implementation of an Ultrasound-Guided Regional Anesthesia Program in the Emergency Department of a Community Teaching Hospital

STUDY OBJECTIVE

We sought to initiate an emergency department (ED)-based ultrasound-guided regional anesthesia (UGRA) program in our community teaching hospital system. Here, we present our development process and protocol. We also sought to assess the types, indications, and associated adverse event rates for the UGRA procedures in this study.

METHODS

We conducted a retrospective analysis of prospectively collected quality assurance data from a case series of patients who underwent an UGRA procedure in the ED. In August 2020, we developed an UGRA program for our community teaching hospital and its 2 affiliated freestanding EDs. For quality assurance purposes, we tracked all UGRA procedures performed in the ED, and we specifically assessed adverse events using structured follow-up. We subsequently obtained approval from our institutional review board to perform chart reviews of the patients in our dataset to abstract additional data and formally perform a research study. We determined the frequency with which different UGRA procedures were performed, and we calculated the adverse event rate.

RESULTS

Between August 24, 2020, and July 15, 2022, a total of 18 different sonographers performed and documented 229 UGRA procedures on 206 unique patients. This included 28 different types of procedures. Follow-up after disposition was successful in 82.0% of patients. In 2 cases, the patient reported no pain relief at all from the procedure, but no patients reported complications related to the procedure.

CONCLUSION

We successfully initiated a robust ED-based UGRA program in our community teaching hospital system. Among patients with successful follow-up, no adverse events were identified.

Sacroplasty for Sacral Insufficiency Fractures: Narrative Literature Review on Patient Selection, Technical Approaches, and Outcomes

Sacral insufficiency fractures commonly affect elderly women with osteoporosis and can cause debilitating lower back pain. First line management is often with conservative measures such as early mobilization, multimodal pain management, and osteoporosis management. If non-operative management fails, sacroplasty is a minimally invasive intervention that may be pursued. Candidates for sacroplasty are patients with persistent pain, inability to tolerate immobilization, or patients with low bone mineral density. Before undergoing sacroplasty, patients' bone health should be optimized with pharmacotherapy. Anabolic agents prior to or in conjunction with sacroplasty have been shown to improve patient outcomes. Sacroplasty can be safely performed through a number of techniques: short-axis, long-axis, coaxial, transiliac, interpedicular, and balloon-assisted. The procedure has been demonstrated to rapidly and durably reduce pain and improve mobility, with little risk of complications. This article aims to provide a narrative literature review of sacroplasty including, patient selection and optimization, the various technical approaches, and short and long-term outcomes.

Efficacy of erector spine plane block in two different approaches to lumbar spinal fusion surgery: a retrospective pilot study

Background

Erector spine plane block (ESPB) has been widely used in spinal surgery, although there are variable data about its efficacy.

Objectives

This study aimed to evaluate the efficacy of ESPB in elective lumbar spinal fusion surgery patients with two different surgical approaches.

Materials and methods

Retrospectively, 45 elective lumbar transpedicular fusion (TPF) surgery patients undergoing open surgery with different approaches [posterior transforaminal fusion approach (TLIF) or combined posterior and anterior approach (TLIF+ALIF)] were divided into 2 groups: general anesthesia (GA, n = 24) and general anesthesia combined with ESPB (GA + ESPB, n = 21). The primary outcome was to analyze the efficacy of ESPB in two different surgical approaches in terms of pain intensity in the first 48 h. Secondary: Fentanyl-free patients and opioid consumption in the first 24 h postoperatively. Comparative analysis was performed (SPSS® v. 28.0) (p < 0.05).

Results

Out of 45 patients (27 female), 21 received GA + ESPB and 24 received GA. The average age was 60.3 ± 14.3 years. Chronic back pain before the operation was registered in 56% of patients. ESPB was performed in 17 TLIF and in 4 TLIF+ALIF patients. ESPB significantly reduced pain intensity at rest in both surgical approaches 48 h after surgery (p < 0.05). The need for postoperative fentanyl infusion was significantly lower in the group treated with GA + ESPB in both surgical approaches than in those who only received GA (29% vs. 77% in TLIF and 0% vs. 80% in TLIF+ALIF); p = 0.01 and p = 0.004. Additionally, we observed that ESPB provides a good analgesic effect for up to 6.8 ± 3.2 h in the TLIF and 8.9 ± 7.6 h in the TLIF+ALIF approaches. Consequently, ESPB reduced the initiation of the fentanyl compared to GA alone, with a mean difference of 3.2 ± 4.2 h in the TLIF subgroup (p = 0.045) and 6.7 ± 5.3 h in TLIF +ALIF (p = 0.028). Only in the TLIF+ALIF approach, ESPB reduced the total fentanyl consumption compared to those with GA (1.43 ± 0.45 mg/24 h vs. 0.93 ± 0.68 mg/24 h; p = 0.015).

Conclusion

ESPB significantly reduced pain at rest after surgery, the number of patients requiring immediate postoperative fentanyl analgesia, and total fentanyl consumption in both surgical approaches, particularly in TLIF+ALIF. However, the application of ESPB does not always provide completely sufficient analgesia.

Efficacy and Safety of Erector Spinae Plane Block Versus Thoracolumbar Interfascial Plane Block in Patients Undergoing Spine Surgery: A Systematic Review and Meta-analysis

OBJECTIVES

As 2 novel peripheral nerve blocks, the erector spinae plane block (ESPB) and thoracolumbar interfascial plane (TLIP) block can relieve postoperative pain in spinal surgery. This systematic review and meta-analysis aimed to determine the efficacy and safety of ESPB versus TLIP block in patients undergoing spine surgery.

METHODS

An extensive search of English online databases, including PubMed, Web of Sciences, Embase, Medline, and Cochrane Central Register of Controlled Trials, and Chinese online databases like Wanfang Data, CNKI, and CQVIP until March 31, 2023, with no language restrictions, was performed. This systematic review and meta-analysis are based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and have been registered on PROSPERO (International Prospective Register of Systematic Reviews) with registered ID: CRD42023420987.

RESULTS

Five studies involving 457 patients were eligible for inclusion in this study. Compared with TLIP block, ESPB had lower postoperative opioid consumption at postoperative 48 hours (standard mean difference =-1.31, 95% CI:-2.54 to -0.08, P =0.04, I2 =80%) and postoperative pain score at postoperative 24 hours (standard mean difference =-0.72, 95% CI=-1.43 to -0.02, P =0.04, I2 =95%) in patients undergoing spine surgery. Complications associated with ESPB and TLIP block were not reported in the included studies.

DISCUSSION

ESPB and TLIP block are 2 novel and effective block methods. Patients receiving ESPB had lower postoperative opioid consumption and postoperative pain scores compared with patients receiving TLIP block; there was no statistically significant difference's between the 2 groups in intraoperative opioid consumption, adverse events, and rescue analgesia.

Enhancing Pain Management for Open Inguinal Hernia Repair With a Novel Long-Acting Bupivacaine Drug Device (Xaracoll®) in Multimodal Pain Control: A Quality Improvement Initiative to Reduce Post-Operative Opioid Prescribing

Background Xaracoll® is a Food and Drug Administration (FDA) approved Type 1 Bovine collagen-based bupivacaine hydrochloride (HCl) implant developed to provide postoperative pain management for up to 24 hours after open inguinal hernia repair in adults. This retrospective review examined the efficacy of Xaracoll® in the management of postoperative pain compared to injectable Bupivacaine. Methods This retrospective study examines 54 patients who underwent unilateral open inguinal hernia repair by a single surgeon over three years. The control group consisted of 36 patients who received injectable Bupivacaine as the local anesthetic. Eighteen patients received the Xaracoll® drug device intra-operatively following the FDA-approved manufacturer's guidelines. Intra-operative analgesics administered and quantified by oral morphine equivalents (OME), opioid administration for pain control postoperatively, opioid prescriptions upon discharge, postoperative pain scores, and turnaround time (TAT) were compared. Results The use of Xaracoll® in inguinal hernia repair is associated with a decrease in the rate of opioid administration in the post-anesthesia care unit (PACU) (22.2% vs. 52.8%; p = 0.043). In addition, patients requiring opioids in the outpatient setting needed significantly less OME in the Xaracoll® group compared to the control group (52.50 vs. 136.15; p < .001). Conclusion This study demonstrates compelling evidence that Xaracoll® is a useful analgesia adjuvant for inguinal hernia repair, significantly reducing the need for opioids in the PACU and decreasing doses of opioid medications upon discharge. Xaracoll® is effective in minimizing postoperative pain and opioid medication dosages upon discharge as part of a multimodal approach to pain and improving patient experience. Further research is warranted to evaluate Xaracoll®'s role in pain control in the PACU and on discharge.

Rates and risk factors for persistent opioid use after cardiothoracic surgery: A cohort study

BACKGROUND

This study's aim was to estimate potential risk factors for persistent opioid use after cardiothoracic surgery.

METHODS

This study included participants in the McGill University Health Centre clinical trial (2014 to 2016). Provincial medical services, prescription claims, and medical charts data were linked. Persistent opioid use was defined as an initial peri-operative opioid dispensation followed by an opioid dispensation between 91 and 180 days postdischarge. Multivariable Cox Proportional Hazards models were used to assess factors associated with persistent opioid use.

RESULTS

A cohort of 815 patients (mean age: 68.9 [standard deviation = 8.9]) was assembled, of which 8.2% became persistent opioid users. Factors such as higher Charlson Comorbidity Index (adjusted hazard ratio: 3.4, 95% confidence interval: 1.1-10.6), history of diabetes (adjusted hazard ratio: 2.1, 95% confidence interval: 1.3-3.4), substance and alcohol abuse (adjusted hazard ratio: 16.3, 95% confidence interval: 5.3-49.5), and radiotherapy (adjusted hazard ratio: 2.4, 95% confidence interval: 1.5-4.1) were associated with a higher hazard of persistent opioid use. Previous opioid use (adjusted hazard ratio: 1.7, 95% CI: 1.0-2.8), daily peri-operative opioid dose (adjusted hazard ratio: 2.3, 95% confidence interval: 1.5-3.7), having an opioid dispensation 30 days pre-admission (adjusted hazard ratio: 1.7, 95% confidence interval: 1.0-2.8), and pre-admission analgesic use (adjusted hazard ratio: 1.7, 95% confidence interval: 1.0-2.8), were also associated with an increased hazard of persistent use. Being prescribed multimodal analgesia at discharge (adjusted hazard ratio: 0.54, 95% confidence interval: 0.32-0.92) was associated with a 46% decreased hazard of developing persistent opioid use.

CONCLUSION

Multiple patient- and medication-related characteristics were associated with an increased hazard of persistent opioid use.

Perioperative Management Conundrum for a Case With Multiple Commonly Used Drug Hypersensitivity

Perioperative hypersensitivity reactions vary from mild to potentially fatal anaphylaxis, resulting in significant morbidity and mortality. Most of the perioperative hypersensitivity and allergic reactions are attributed to antibiotics, antiseptic solutions, latex, and opioids. In the current thrust for opioid-free anesthesia, owing to its multiple advantages, paracetamol and nonsteroidal antiinflammatory agents play a significant role in multi-modal pain and inflammatory response management. Nearly nine out of ten individuals experience postoperative pain, one-third experience postoperative nausea and vomiting, and one-fourth experience fever, irrespective of surgery and type of anesthesia, often as an inflammatory response. While perioperative hypersensitivity reactions are common, a patient allergic to multiple commonly used drugs for the treatment of pain, fever, acid-peptic disorder, and nausea and vomiting is scarce. Such cases pose a great challenge in perioperative management. A 14-year-old male child with a traumatic foot drop planned for tibialis posterior tendon transfer developed an allergic reaction with mild fever following an injection of Ranitidine and Ondansetron in the preoperative area. Surgery was deferred and was investigated for allergy profile testing for commonly used drugs, which showed high IgE levels and moderate to severe hypersensitivity for diclofenac and paracetamol. The patient was operated on after one month under spinal anesthesia, avoiding ranitidine, ondansetron, diclofenac, and paracetamol. The following morning, he developed a high-grade fever (102.3° F), which did not resolve with conservative measures. Hypersensitivity and allergic reactions to NSAIDs are reported in the literature. While there are multiple drugs available as NSAIDs, cross-sensitivity or allergy to other drugs within the same group, and even chemically related groups, is also another possibility that needs to be considered while managing such patients. Mefenamic acid controlled the fever, and the child was discharged home after 48 hours of observation. However, the case posed a great perioperative management dilemma; the present report intends to highlight and discuss it.

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.

Novel Techniques for Musculoskeletal Pain Management after Orthopedic Surgical Procedures: A Systematic Review

Effective postoperative pain management is critical for recovery after orthopedic surgery, but often remains inadequate despite multimodal analgesia. This systematic review synthesizes evidence on innovative modalities for enhancing pain control following major orthopedic procedures. Fifteen randomized controlled trials and comparative studies evaluating peripheral nerve blocks, local anesthetic infiltration, cryotherapy, transcutaneous electrical stimulation, adjunct medications, and other techniques are included. Thematic analysis reveals that peripheral nerve blocks and local anesthetic infiltration consistently demonstrate reduced pain scores, opioid consumption, and side effects versus conventional analgesia alone. Oral multimodal medications also show promise as part of opioid-sparing regimens. Adjunctive approaches like cryotherapy, music, and dexmedetomidine require further research to optimize protocols. Despite promising innovations, critical knowledge gaps persist regarding comparative effectiveness, optimal interventions and dosing, combination strategies, cost-effectiveness, and implementation. High-quality randomized controlled trials using standardized protocols are essential to guide the translation of enhanced multimodal regimens into clinical practice. This review provides a framework for pursuing research priorities and advancing evidence-based postoperative pain management across orthopedic surgeries.

Ketamine for postoperative pain treatment in spinal surgery: Systematic review with meta-analysis and trial sequential analysis

AIM

We aimed to assess the beneficial and harmful effects of perioperative pain treatment with ketamine in patients undergoing spinal surgery.

METHODS

We searched Medline, Embase, and CENTRAL from inception until 15 February 2023 for randomised clinical trials comparing ketamine with placebo or no intervention in patients undergoing spinal surgery. The primary outcomes were cumulative opioid consumption at 24 h postoperatively and serious adverse events. We adhered to recommendations of the Cochrane Collaboration and performed meta-analysis, Trial Sequential Analysis (TSA) to assess the risks of random errors, risk of bias assessment to evaluate the risks of systematic errors, and used the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

We included a total of 28 randomised clinical trials enrolling 2110 participants providing data for our pre-defined outcomes. Twenty-three trials enrolled adult participants and 5 trials enrolled paediatric participants. Three trials were at low risk of bias. Meta-analysis and TSA of trials including adults showed that ketamine versus placebo or no intervention seemed to reduce the cumulative 24-h opioid consumption (mean difference -17.57 mg; TSA-adjusted 95% confidence interval, -24.22 to -10.92; p < .01; low certainty of evidence), and there was no evidence of a difference of ketamine versus placebo or no intervention on the risk of serious adverse events (risk ratio 2.16; 96.7% confidence interval, 0.35 to 13.17; p = .36; very low certainty of evidence).

CONCLUSION

In adults undergoing spinal surgery, ketamine may reduce cumulative 24-h opioid consumption. Ketamine may increase the occurrence of serious adverse events, but the evidence was very uncertain.

Advances in Anesthesia for Shoulder Surgery: A Comprehensive Review of Dexmedetomidine-Enhanced Interscalene Brachial Plexus Block

Surgical procedures on the shoulder pose distinctive challenges in managing pain during the perioperative period, underscoring the importance of exploring innovative anesthesia techniques. This comprehensive review article delves into integrating dexmedetomidine, an alpha-2 adrenergic agonist, within interscalene brachial plexus blocks for shoulder surgery. The review initiates by underscoring the pivotal role of effective anesthesia in shoulder surgery and elucidates the rationale behind investigating dexmedetomidine as an adjunct. It meticulously examines the anatomy and physiology of the brachial plexus, emphasizing its critical significance in shoulder surgery. Furthermore, the article expounds on dexmedetomidine's mechanisms of action and pharmacokinetics, encompassing its safety profile and potential side effects. The conventional interscalene brachial plexus block techniques, along with their limitations and challenges, are discussed, laying the foundation for the integration of dexmedetomidine. The review subsequently delves into exploring the role of dexmedetomidine in regional anesthesia, covering previous studies, mechanisms of action, and the potential advantages of incorporating it into nerve blocks. The review's core concentrates on the practical application of dexmedetomidine-enhanced interscalene brachial plexus blocks. This includes discussions on administration techniques, dosage guidelines, and compelling evidence supporting its utilization. Clinical scenarios where this approach proves most advantageous are thoroughly explored, comparing its effectiveness with traditional techniques in terms of pain control and patient outcomes. A comprehensive examination of relevant clinical trials and case studies highlights the evidence supporting its efficacy. The review also underscores safety considerations associated with dexmedetomidine. It proposes strategies for mitigating risks to ensure patient safety. Insights into future directions and research are provided, encompassing ongoing studies, areas necessitating further investigation, and potential refinements in technique. Finally, the article summarizes key findings, emphasizing the practicality of dexmedetomidine-enhanced interscalene brachial plexus blocks in shoulder surgery and its far-reaching implications for clinical practice and patient care.

Non-Surgical Treatments of Trigeminal Neuralgia from the Perspective of a Pain Physician: A Narrative Review

Trigeminal neuralgia (TN) is a unilateral disorder characterized by electric shock-like pain, abrupt onset and termination, and limited to one or more branches of the trigeminal nerve. Various therapeutic modalities for TN have been introduced. We searched for literature indexed in PubMed, Medline, and the National Library of Medicine and reviewed all relevant articles on non-surgical treatments for TN. Published studies were reviewed with no restrictions on date; reviews, clinical trials, animal studies, retrospective studies, and cases were included. Carbamazepine and oxcarbazepine are the recommended first-line pharmacotherapies. Interventional treatments should be considered when pharmacotherapy is insufficient or withdrawn because of adverse effects.

Optimal ropivacaine concentration for ultrasound-guided erector spinae plane block in patients who underwent video-assisted thoracoscopic lobectomy surgery

Background

An ultrasound-guided erector spinae plane block (ESPB) has emerged as an effective way to control postoperative pain and may be a good alternative way to an epidural block. However, relevant research on the appropriate concentration of local anesthetics for an ESPB remains scarce.

Aims

This study aimed to investigate the optimal concentration of ropivacaine for an ESPB in patients undergoing video-assisted thoracoscopic surgery (VATS).

Methods

A total of 68 patients who underwent a VATS lobectomy were enrolled. An ipsilateral ultrasound-guided ESPB was performed with three different ropivacaine concentrations as a local anesthetic: 0.189% (G1), 0.375% (G2), and 0.556% (G3). The total amount of perioperative remifentanil administered, patient-controlled analgesia (PCA) applied, and rescue drugs for postoperative analgesia during the 24 h after surgery were acquired, and numeric rating scale (NRS) scores were obtained.

Results

The total amount of intraoperative remifentanil administered was 7.20 ± 3.04 mcg/kg, 5.32 ± 2.70 mcg/kg, and 4.60 ± 1.75 in the G1, G2, and G3 groups, respectively. G2 and G3 had significantly lower amounts of remifentanil administered than the G1 group (P = 0.02 vs. G2; P = 0.003 vs. G3). The G3 group needed more inotropes than the G1 and G2 groups in the perioperative period (P = 0.045). The NRS scores, PCA, and rescue drug were not significantly different in the three groups.

Conclusion

The optimal concentration of ropivacaine recommended for an ESPB was 0.375%, which was effective in controlling pain and reducing the intraoperative opioid requirements with minimal adverse reactions such as hypotension.

Opioid-Based vs Opioid-Free Anesthesia in Breast Cancer Surgery

Introduction

Breast cancer is the most widely recognized malignant growth in ladies in India and accounts for 14% of all tumors in women. Modified radical mastectomy (MRM) is a surgery done for breast cancer. It leads to about 30% chances of postoperative nausea and vomiting (PONV) and 40% pain in the immediate postoperative period.

Objectives

Changes in blood pressure after intubation, waiting time for postoperative pain medication, and possibility of adverse effects.

Methodology

After the approval of ethical committee, the study was conducted in the procedure and possible complications associated with the procedure were explained to patients. Written informed consent was obtained from each patient.

Result and Conclusion

We conclude that opioid-free anesthesia is "more effective in reducing the incidence of postoperative nausea and vomiting, produces stable hemodynamics, and reduces incidence of side effects when compared with opioid-based general anesthesia in patients undergoing breast cancer surgeries."

Real-World Evidence on the Efficacy and Tolerability of Tramadol/Dexketoprofen (TRAM/DKP) Fixed-Dose Combination for the Management of Acute Non-surgical Pain in Asian Patients: A Multicentre Retrospective Case Series

INTRODUCTION

Multimodal analgesia is key in the effective management of acute pain. Previous clinical trials have demonstrated good results with the use of a fixed-dose combination (FDC) of tramadol 75 mg and dexketoprofen 25 mg (TRAM/DKP) in acute pain management. However, there is a dearth of real-world evidence on the efficacy and safety of this combination in the management of acute non-surgical pain, especially among Asian patients. The case series reported herein investigates the real-world experiences of physicians and Asian patients with the use of TRAM/DKP FDC in the management of acute non-surgical pain.

METHODS

Data were collected retrospectively on 11 Asian patients across multiple hospitals who had received a short course of TRAM/DKP FDC for acute non-surgical orthopaedic and non-orthopaedic pain. Data on baseline characteristics, medical history, treatment regimen, clinical outcomes, and patient satisfaction were compiled and shared at a peer-to-peer expert meeting in October 2022.

RESULTS

All patients experienced a reduction in pain intensity and were very satisfied with pain management, with a mean satisfaction score of 4.3/5. Five patients (range: 63-74 years) experienced mild adverse events, including nausea, vomiting, and dizziness, which resolved with no need for additional treatment in the majority of cases. No serious adverse events were recorded.

CONCLUSION

Asian patients with acute non-surgical orthopaedic and non-orthopaedic pain achieved good pain control with TRAM/DKP FDC. The regimen was well tolerated, and patients reported high levels of satisfaction with the outcomes, indicating that TRAM/DKP FDC is an effective choice for the control of acute non-surgical pain in Asian patients.

Comparison between costotransverse foramen block and thoracic paravertebral block for VATS pulmonary resection: A randomized noninferiority trial

STUDY OBJECTIVE

The present study assessed whether costotransverse foramen block (CTFB) is noninferior to thoracic paravertebral block (TPVB) for postoperative analgesia in video-assisted thoracoscopic surgery (VATS) pulmonary resection.

DESIGN

Single-center, double-blinded, randomized, non-inferiority trial.

SETTING

Operating room and intensive care unit or ward in a tertiary hospital.

PATIENTS

Patients aged 20 to 80 years with American Society of Anesthesiology physical status 1 to 3 scheduled for elective VATS pulmonary resection.

INTERVENTIONS

Sixty patients were randomly allocated 1:1 to receive CTFB or TPVB using 15 mL aliquots of 0.5% ropivacaine at the T4-5 and T6-7 intercostal levels immediately after the induction of general anesthesia.

MEASUREMENTS

The primary outcome was the area under the curve (AUC) of numeric rating scale (NRS, 0 to 10) during 24 h postoperatively (noninferiority limit was 24; NRS 1 per hour). The secondary outcomes included postoperative opioid consumption, rescue analgesic use, postoperative nausea and vomiting, pulmonary function, dermatomal spread of the blockade, and quality of recovery.

MAIN RESULTS

Forty-seven patients were included for final analysis. The difference between the mean 24-h AUCs of NRS in the CTFB (34.25 ± 16.30, n = 24) and TPVB (39.52 ± 17.13, n = 23) groups was -5.27 (95% confidence interval [CI], -15.09 to 4.55), with the upper limit of 95% CI being far below the predefined noninferiority margin of 24. There was no significant difference in the dermatomal spread of the blockades between the groups, as both reached the upper and lower most levels of T3 and T7 (median). Additionally, there were no significant differences in other secondary outcomes between the two groups.

CONCLUSIONS

The analgesic effect of CTFB was noninferior to that of TPVB during 24 h postoperatively in VATS pulmonary resection. Moreover, CTFB may offer potential safety benefits by keeping the tip of the needle far from the pleura and vascular structure.

Benefits of PECS Block as Part of the Enhanced Recovery After Surgery (ERAS) Protocol for Breast Cancer Surgery in an Asian Institution: A Retrospective Cohort Study

INTRODUCTION

Regional analgesia techniques have been increasingly used for post-operative pain management following mastectomy. We aim to evaluate analgesic benefits of pectoral nerve (PECS2) block incorporated as part of the enhanced recovery after surgery (ERAS) protocol in patients undergoing mastectomy in University Malaya Medical Centre, Malaysia.

MATERIAL AND METHODS

A single centre, cohort study evaluating 335 women who have undergone unilateral mastectomy between January 2017 and March 2020 in Malaysia. Regional anaesthesia were given pre-operatively via ultrasound guided pectoral and intercostal nerves block (PECSII).

RESULTS

Utilization of regional anaesthesia increased from 11% in 2017 to 43% in 2020. Types and duration of surgeries were comparable. Opiod consumption was 3 mg lower in those who had PECS2 block ((27 [24-30] mg), in comparison with those who received general anaesthesia only (30 [26-34] mg), p < 0.001, and length of stay was half a day shorter in the regional anaesthesia group and these were statistically significant. However, pain score (2 [1-3]; 2 [1-3], p=0.719) and post-operative nausea and vomiting (PONV) (32.6-32.5%, p = 0.996) were similar.

CONCLUSION

This study highlights the importance of PECS2 block as a component of ERAS protocol for mastectomy in an Asian hospital. This study also inferred that patients may be safely discharged within 24 h of surgery and therefore, same day surgery may be feasible in selected group of patients undergoing mastectomy and this could imply overall cost benefits.

Psychological Survivorship in Head and Neck Cancer

Survivorship for head and neck cancer patients presents unique challenges related to the anatomic location of their disease. After treatment, patients often have functional impairments requiring additional care and support. In addition, patients may have psychological challenges managing the effect of the disease and treatment. Routine screening is recommended for the identification of psychological conditions. This article reviews the latest research on key psychological conditions associated with head and neck cancer. It discusses risk factors for the development of each condition and provides recommendations for the management of patients who may present with psychological concerns.

Effect of bilateral ultrasound-guided erector spinae plane block on postoperative pain after open lumbar spinal surgery: a double-blind, randomized controlled trial

PURPOSE

The peripheral nerve blocks (PNB) are an important part of the multimodal analgesia for reducing postoperative pain, opioids consumption and its side effects. A new PNB, Erector spinae plane block (ESPB), has been revealed postoperative analgesic effect in various surgical procedures such as breast, thoracic and abdominal surgery, with the limitation of the studies for spine surgery. We aimed to evaluate the analgesic effect of ultrasound-guided bilateral erector spinae plane block (ESPB) after open lumbar spinal surgery.

METHODS

A double-blind, randomized controlled trial was conducted. Sixty-two patients undergoing posterior lumbar spinal surgery were randomly allocated into two groups. The ESPB group (n = 31) received ultrasound (US)-guided bilateral ESPB using 20 ml of 0.375% bupivacaine with adrenaline 5 mcg/ml per side. The control group (n = 31) received no intervention. The same postoperative analgesia regimen was applied by oral acetaminophen 10-15 mg/kg every 6 h, naproxen 250 mg twice daily, and intravenous (IV) morphine via patient-controlled analgesia (PCA) device. The postoperative morphine consumption, numerical pain score (NRS) and the side effects were recorded.

RESULTS

The bilateral ESPB group reduced the 24 h-morphine consumption by 42.9% (P < 0.001), decreased overall pain score at rest by 1.4 points (P = 0.02), and decreased overall pain score on movement by 2.2 points (P < 0.001). No severe complications related to the block technique or morphine used occurred.

CONCLUSION

The US-guided bilateral ESPB demonstrated the effectiveness for postoperative analgesia management after open lumbar spinal surgery regarding reduced opioid consumption and pain score without any serious complications.

The Shouldice Method: an expert's consensus

BACKGROUND

Hernia repairs are a commonly performed surgical procedure and the Shouldice Repair of inguinal hernias has been well described before in terms of its outcomes. However, the purpose of this paper was to understand what experts from Shouldice Hospital consider to be the essential steps to the Shouldice Method.

METHODS

Utilizing a Delphi Methodology, surgeons at Shouldice Hospital who are considered content experts, provided their answers on what is essential to the Shouldice Method. The median, interquartile range, and percent agreement from the responses as well as the Delphi's overall Cronbach's Alpha were determined. All Delphi items were ranked on a five-point Likert scale and consensus was reached when Cronbach's Alpha was ≥ 0.8. The items from the survey that ranked as 5-completely agree or 4-partially agree by ≥ 80% of participants on the five-point Likert scale were included in the final framework.

RESULTS

The final consensus for the Shouldice Method included 39 items with 7 overarching steps: preoperative preparation of the patient, anesthetic component, incision and nerve identification, treatment of the cremasteric muscles, hernia identification and treatment, reconstruction of the posterior wall, and post-operative management of patients.

CONCLUSION

The results of this consensus provide a step-by-step approach to the Shouldice Method, as well as information that is timely and can be utilized by surgeons incorporating non-mesh hernia repairs into their practice.

Effect of Immature Rubus occidentalis on Postoperative Pain in a Rat Model

Background and Objectives: This study aimed to identify the analgesic properties of immature Rubus occidentalis extract (iROE) using a postoperative-pain rat model. We also aimed to compare the analgesic effects of iROE to those of mature R. occidentalis extract (mROE) and examine the proinflammatory cytokine response and associated underlying mechanisms. Materials and Methods: In adult male Sprague Dawley rats, acute postoperative pain was induced through plantar hind-paw incisions. After the plantar incisions were made, the rats were intraperitoneally administered with normal saline or various doses of iROE and mROE to investigate and compare the analgesic effects of iROE and mROE. The mechanisms underlying iROE-induced analgesia were investigated via post-incisional administration of yohimbine, dexmedetomidine, prazosin, naloxone, atropine, or mecamylamine, followed by iROE. Mechanical withdrawal threshold (MWT) evaluations with von Frey filaments were carried out at different time points. Serum levels of tumor necrosis factor α, interleukin (IL)-1β, and IL-6 were measured to assess inflammatory responses. Multivariate analysis of variance (MANOVA) and linear mixed-effects model (LMEM) analysis were used to analyze the analgesic effect data. Results: The MWTs demonstrated significant increases in iROE in a dose-dependent manner up to 2 h after the plantar incisions were made. An LMEM analysis demonstrated that iROE yielded a significantly greater analgesic effect than mROE, but there was no significant difference between the two according to MANOVA. Dexmedetomidine enhanced the MWT-confirmed iROE response, while yohimbine and naloxone diminished it. Administration of iROE significantly attenuated the post-incisional increases in serum IL-1β and IL-6 levels. Conclusions: The iROE demonstrated analgesic and anti-inflammatory effects in a rat model of incisional pain, which were more pronounced than those associated with mROE. The analgesic activity of iROE may be associated with α₂-adrenergic and opioid receptors.

Effects of a Multimodal Approach Using Buprenorphine with/without Meloxicam on Food Intake, Body Weight, Nest Consolidating Behavior, Burrowing Behavior, and Gastrointestinal Tissues in Postoperative Male Mice

Distress affects animal welfare and scientific data validity. There is a lack of reports on the effects of multimodal analgesic approaches in mice. In this study, under the hypothesis that a multimodal analgesic protocol using buprenorphine with meloxicam has analgesic effects, we evaluated the effects of a multimodal analgesic protocol using buprenorphine with meloxicam on the well-being of mice during analgesic administration by changing the dosage of meloxicam. A total of 42 Slc:ICR male mice were categorized into nonsurgical and surgical groups (7 mice per group) and treated with an anesthetic (isoflurane) and analgesics (buprenorphine ± meloxicam). Analgesics were administered for 48 h after treatment. Buprenorphine (subcutaneous; 0.1 mg/kg/8 h) and meloxicam (subcutaneous; 0, 2.5, or 5 mg/kg/24 h) were administered twice. Body weight, food intake, nest consolidation score, and latency to burrow were evaluated. A significant decrease in food intake was observed 24 h after treatment, while a significant increase was observed 48 h post-treatment in all groups. Body weight showed a decreasing trend but was not significantly reduced. Furthermore, stomach, duodenum, and jejunum tissues showed no morphological abnormalities. Significant differences in burrow diving scores and the latency to burrow were observed between some groups, but these were not regarded as a consequence of the surgery and/or the meloxicam dose. When buprenorphine and meloxicam were combined, administering up to 5 mg/kg/day of meloxicam for 48 h to male mice after abdominal surgery had no significant negative effects on any tested parameters. In conclusion, a multimodal analgesic protocol of buprenorphine with meloxicam is among the options for increasing well-being in mice following abdominal surgery.

Pharmacologic Pain Management Trends among Adults Hospitalized with Cellulitis: An Evidence-Based Practice Project

BACKGROUND

Nurses commonly administer opioids, following "as needed" order sets, to patients hospitalized for acute pain conditions like cellulitis. Practice guidelines recommend limiting opioid administration for acute pain management. At two hospitals in the Pacific Northwest, an opioid stewardship committee was formed to align with best practice.

AIMS

The main objective was to describe changes to inpatient rates of opioid and non-opioid administration following implementation of evidence-based opioid stewardship efforts.

DESIGN

Observational, retrospective, evidence-based practice project.

SETTINGS

One 200-bed and one 680-bed hospital in Washington State.

PARTICIPANTS/SUBJECTS

Data were included from patients aged 18 years or older hospitalized for cellulitis.

METHODS

Demographic and pain-related data were extracted from the electronic health record (n = 4,523 encounters) guided by the symptom management framework. The proportion of patients receiving opioid or non-opioid medications before and after implementation of evidence-based practice opioid stewardship interventions was calculated descriptively. A logistic regression tested factors related to administration of an opioid medication.

RESULTS

The proportion of patients receiving an opioid decreased following opioid stewardship efforts while those receiving non-opioid analgesics remained stable. Factors significantly influencing inpatient opioid administration were: average inpatient pain score, pre-hospital opioid prescription, length of stay, and year of hospitalization.

CONCLUSIONS

Analgesic administration treating painful, acute cellulitis at two hospitals in the Pacific Northwest included opioid and non-opioid medications. The proportion of patients receiving opioids decreased following best practice opioid stewardship actions. Opportunities may exist for nurses to collaborate with providers to improve inpatient analgesic administration practices.