Efficacy of Bilateral Erector Spinae Block in Patients Undergoing Posterior Spine Fusion Surgeries: A Comparative Randomised Controlled Trial

Introduction During spine surgeries, various levels of tissue injury can result in varying hemodynamic responses and significant postoperative pain. Perioperative pain management is essential to controlling hemodynamic responses and postoperative pain management. Erector spinae plane (ESP) blocks can help alleviate this pain by blocking the dorsal rami of the spinal nerve. This study aims to evaluate the efficacy of ESP by assessing the perioperative opioid requirement, hemodynamic parameters, and visual analogue score (VAS) during the postoperative period. Methods In this study, 56 patients underwent elective posterior spine fusion surgeries under conventional anaesthesia and were allocated into two groups: 28 patients were included in the conventional group (Group C) and 28 patients in the ESP group (Group E). Group C patients received 20 ml of 0.9% sodium chloride (NaCl) on each side, and Group E patients received 20 ml of 0.25% bupivacaine + 4 mg dexamethasone on each side under ultrasound sonography guidance. Postoperative pain was assessed using the VAS score. The hemodynamic parameters during the intraoperative period, the time for the first opioid analgesia requirement until 24 hours in the postoperative period, and the amount of cumulative opioid consumption during the perioperative period were observed. Results Postoperative VAS was lower in Group E (P < 0.001). There were significant differences in hemodynamic parameters: heart rate (P < 0.045), systolic blood pressure (P < 0.002), diastolic blood pressure (P < 0.003), and mean arterial pressure (P < 0.002) at the time of incision in Group E. Intraoperative opioid requirements at the time of incision (P < 0.036), 60th minutes (P < 0.023), 120th minutes (P < 0.023), and postoperative opioid requirements at the first hour (P < 0.001), sixth hour (P < 0.004), 14th hour (P < 0.025), 20th hour (P < 0.009), and 24th hour (P < 0.025) had lower opioid requirements in Group E than Group C. Conclusion ESP block is a more site-specific dorsal rami block with a better perioperative hemodynamic profile, a part of multimodal analgesia intraoperatively, and excellent postoperative analgesia with fewer postoperative opioid requirements in multilevel spine fusion surgeries.

A Good Response to Nonsteroidal Antiinflammatory Drugs Does Not Discriminate Patients With Longstanding Axial Spondyloarthritis From Controls With Chronic Back Pain

OBJECTIVE

To compare the response to nonsteroidal antiinflammatory drugs (NSAIDs) in patients with longstanding axial spondyloarthritis (axSpA) and controls with back pain (nonspondyloarthritis [non-SpA]).

METHODS

Consecutive outpatients with chronic back pain (axSpA or non-SpA), were prospectively recruited. Any previous NSAIDs were withdrawn 2 days before study start (baseline). Back pain was assessed using a numerical rating scale (NRS; range 0-10) starting at 2 hours after baseline and several times thereafter up to 4 weeks. "Any response" to NSAIDs was defined as improvement of back pain on the NRS > 2 units, and "good response" as improvement > 50%, compared to baseline.

RESULTS

Among 233 patients included, 68 had axSpA (29.2%) and 165 had non-SpA back pain (70.8%). The mean age was 42.7 (SD 10.7) vs 49.3 (SD 11.1) years, symptom duration 15.1 (SD 11.1) years vs 14.6 (SD 11.9) years, and pain score 5.9 (SD 2.3) vs 6.3 (SD 2.0), respectively. Overall, of patients with axSpA or non-SpA back pain, 30.9% vs 29.1% of patients showed any response and 23.5% vs 16.4% of patients showed a good response after 4 weeks, respectively (P value not significant). No differences were found in the rapidity of response or between subgroups of patients based on demographics, including different stages of axSpA.

CONCLUSION

No major differences in the response to NSAIDs were found between patients with axSpA and those with non-SpA with longstanding chronic back pain. The item in the Assessment of SpondyloArthritis international Society classification criteria on "response to NSAIDs" needs more study.

Are There Racial Disparities in Perioperative Pain? A Retrospective Study of a Gynecological Surgery Cohort

PURPOSE

The purpose of this study was to examine whether racial disparities exist in immediate postoperative pain scores and intraoperative analgesic regimens in a single surgical cohort.

DESIGN

A single-center, retrospective analysis.

METHODS

This retrospective study of a single surgical cohort was conducted via chart review of the existing electronic health record. A total of 203 patients who underwent minimally invasive hysterectomy were included in the analysis. Three initially reviewed patient records were excluded from the final analysis due to the small size of their racial cohorts (two Asian or Pacific Islander and one Native American). The White patients (n = 103) and Black patients (n = 100) were compared for differences in pain scores in the postanesthesia care unit (PACU). The patients' intraoperative analgesic regimens were also compared.

FINDINGS

There were no significant differences between races in the postoperative pain scores in the PACU or in the analgesia administered by the anesthesia provider intraoperatively.

CONCLUSIONS

In this specific population, there was no evidence of racial disparities in postoperative pain or intraoperative analgesia administration. Further research is needed to understand the unique factors of the perioperative period, to see if the absence of disparities in this study is repeated in other cohorts, and to mitigate any disparities that are found.

Discrepancy Between Reported and Calculated Pain Reduction in Patients With Spinal Cord Stimulation Therapy and Lack of Agreement Between Patient Satisfaction and Degree of Pain Relief

OBJECTIVES

This study aimed to determine agreement between reported percentage pain reduction (RPPR) and calculated percentage pain reduction (CPPR) in patients with percutaneous spinal cord stimulation (SCS) implants, and to correlate RPPR and CPPR with patient satisfaction. We also sought to determine which patient-reported outcome measures are most improved in patients with SCS.

MATERIALS AND METHODS

Fifty patients with percutaneous spinal cord stimulator implants with a mean follow-up of 51.1 months were interviewed and surveyed to assess their pain level, impression of degree of pain relief, satisfaction with the therapy, and desire to have the device again. Baseline pain level was obtained from their preimplant records.

RESULTS

Overall, RPPR was found to be 53.3%, whereas CPPR was 44.4%. Of all patients, 21 reported <50% pain reduction; however, most of these (12/21, 57%) were satisfied with the outcome of therapy. In terms of individual improvement in outcomes, activities of daily life was the most improved measure at 82%, followed by mood, sleep, medication use, and health care utilization at 74%, 62%, 50%, and 48%, respectively.

CONCLUSIONS

RPPR appears to be a complex outcome measure that may not agree with CPPR. Overall RPPR is greater than the CPPR. On the basis of our data, these independently valid measures should not be used interchangeably. A 50% pain reduction threshold is not a requisite for patient satisfaction and desire to have the device again. Activities of daily living was the most improved measure in this cohort, followed by mood, sleep, medication usage, and decrease in health care utilization.

Perioperative Analgesia and Patients' Satisfaction in Spinal Anesthesia for Cesarean Section: Fentanyl Versus Morphine

Perioperative analgesia for cesarean section aims to ensure the mother's comfort, facilitate a smooth surgical experience, and promote a successful recovery. One-hundred-ninety patients were enrolled in a randomized double-blind study designed to assess the quality of perioperative analgesia, level of satisfaction, and incidence of adverse reactions in elective cesarean section under spinal anesthesia when fentanyl or morphine was added to bupivacaine. Two treatment groups comprising 173 subjects were compared in the per-protocol analysis: F (fentanyl, standard dose 25 μg) and M (morphine, standard dose 100 μg). Numerical pain scores were recorded perioperatively for 72 h (both at rest and on mobilization), with overall postoperative satisfaction and analgesic-related side effects. The patients in the morphine group had significantly better pain management (Mann-Whitney U test, p < 0.001) and higher level of satisfaction (Mann-Whitney U test, p < 0.001). The latter was related to the greater need for rescue medication in the fentanyl group (OR = 4.396; p = 0.019). On the other hand, fentanyl had significantly fewer non-life-threatening side effects, such as high-intensity pruritus (Mann-Whitney U test, p < 0.001), nausea (OR = 0.324; p = 0.019), vomiting and dizziness upon first mobilization (OR = 0.256; p < 0.001). It remains for future clinical trials to help establish doses that will tilt the scale to one side or the other.

Service availability and readiness for hip fracture care in low- and middle-income countries in South and Southeast Asia

Aims

The aim of this study was to describe the current pathways of care for patients with a fracture of the hip in five low- and middle-income countries (LMIC) in South Asia (Nepal and Sri Lanka) and Southeast Asia (Malaysia, Thailand, and the Philippines).

Methods

The World Health Organization Service Availability and Readiness Assessment tool was used to collect data on the care of hip fractures in Malaysia, Thailand, the Philippines, Sri Lanka, and Nepal. Respondents were asked to provide details about the current pathway of care for patients with hip fracture, including pre-hospital transport, time to admission, time to surgery, and time to weightbearing, along with healthcare professionals involved at different stages of care, information on discharge, and patient follow-up.

Results

Responses were received from 98 representative hospitals across the five countries. Most hospitals were publicly funded. There was consistency in clinical pathways of care within country, but considerable variation between countries. Patients mostly travel to hospital via ambulance (both publicly- and privately-funded) or private transport, with only half arriving at hospital within 12 hours of their injury. Access to surgery was variable and time to surgery ranged between one day and more than five days. The majority of hospitals mobilized patients on the first or second day after surgery, but there was notable variation in postoperative weightbearing protocols. Senior medical input was variable and specialist orthogeriatric expertise was unavailable in most hospitals.

Conclusion

This study provides the first step in mapping care pathways for patients with hip fracture in LMIC in South Asia. The previous lack of data in these countries hampers efforts to identify quality standards (key performance indicators) that are relevant to each different healthcare system.

A Systematic Review and Meta-Analysis Comparing the Effectiveness of Transversus Abdominis Plane Block and Caudal Block for Relief of Postoperative Pain in Children Who Underwent Lower Abdominal Surgeries

Background and Objectives: Postoperative pain after lower abdominal surgery is typically severe. Traditionally, in pediatric anesthesia, a caudal block (CB) has been used for pain management in these cases. Nowadays, a transversus abdominis plane block (TAPB) seems to be an effective alternative. However, which technique for perioperative analgesia is better and more effective remains unclear in children who undergo abdominal surgeries. The aim of this study was to compare the efficacy and safety of a TAPB and CB for pain management in children after abdominal surgery by conducting a meta-analysis of published papers in this area. Methods: We conducted a thorough search of PubMed, EMBASE, the Cochrane Library, and the Web of Science for randomized controlled trials (RCTs) that compared a TAPB and CB for pain management in children who had abdominal surgery. Two researchers screened and assessed all the information with RevMan5.3 used for this meta-analysis. Pain scores, the total dose of rescue analgesic given, the mean duration of analgesia, the intraoperative and postoperative hemodynamic conditions 24 h after surgery, and adverse events were compared. Results: 15 RCTs that involved a total of 970 pediatric patients were included in this study. The results of this meta-analysis showed that there were no significant differences between the 2 groups in terms of postoperative pain scores at 1 h (SMD = 0.35; 95% CI = -0.54 to 1.24; p = 0.44, I2 = 94%), 6 h (SMD = -0.10; 95% CI = -0.44 to -0.23; p = 0.55, I2 = 69%), 12 h (SMD = -0.02; 95% CI = -0.45 to -0.40; p = 0.93, I2 = 80%), and 24 h (SMD = -0.66; 95% CI = -1.57 to -0.25; p = 0.15, I2 = 94%); additional analgesic requirement (OR 0.25; 95% CI 0.09 to 0.63; p = 0.004, I2 = 72%); total dose of rescue analgesic given in 24 h (SMD = -0.37; 95% CI = -1.33 to -0.58; p = 0.44; I2 = 97%); mean duration of analgesia (SMD = 1.29; 95% CI = 0.01 to 2.57; p = 0.05, I2 = 98%); parents' satisfaction (SMD = 0.44; 95% CI = -0.12 to 1.0; p = 0.12; I2 = 80%); and intraoperative and postoperative hemodynamic conditions 24 h after the surgery and adverse events (SMD = 0.78; 95% CI = 0.22 to 2.82; p = 0.70; I2 = 62%). Compared to a CB, a TAPB resulted in a small but significant reduction in additional analgesic requirement after surgery (OR 0.25; 95% CI 0.09 to 0.63; p = 0.004). Conclusions: TAPBs and CBs result in similar efficient early analgesia and safety profiles in children undergoing abdominal surgeries. Moreover, no disparities were observed for adverse effects between TAPBs and CBs.

Unlocking the Optimal Analgesic Potential: A Systematic Review and Meta-Analysis Comparing Intravenous, Oral, and Rectal Paracetamol in Equivalent Doses

Paracetamol (acetaminophen) is an extensively used analgesic for acute and chronic pain management. Currently, paracetamol is manufactured for oral, rectal, and intravenous (IV) use. Research has shown varied results on the analgesic properties of IV paracetamol compared to oral and rectal paracetamol; however, research on the same doses of paracetamol is limited. Therefore, this review was constructed to explore the analgesic properties of IV paracetamol compared with oral and rectal paracetamol administered in equivalent doses. A broad and thorough literature search was performed on five electronic databases, including PubMed, ScienceDirect, Medline, Scopus, and Google Scholar. Statistical analysis of all outcomes in our review was then performed using the Review Manager software. Outcomes were categorized as primary (pain relief and time to request rescue analgesia) and secondary (adverse events after analgesia). An extensive quality appraisal was also done using the Review Manager software's Cochrane risk of bias tool. The literature survey yielded 2,945 articles, of which 12 were used for review and analysis. The pooled analysis for patients undergoing surgical procedures showed that IV paracetamol had statistically similar postoperative pain scores at two (mean difference (MD) = -0.14; 95% confidence interval (CI) -0.58-0.29; p = 0.51), 24 (MD = 0.09; 95% CI = -0.02-0.21; p = 0.12), and 48 (MD = 0.04; 95% CI = -0.08-0.16; p = 0.52) hours as oral paracetamol. Similarly, the data on time to rescue analgesia showed no considerable difference between the IV and oral paracetamol groups (MD = -1.58; 95% CI = -5.51-2.35; p = 0.43). On the other hand, the pooled analysis for patients presenting non-surgical acute pain showed no significant difference in the mean pain scores between patients treated with IV and oral paracetamol (MD = -0.35; 95% CI = -2.19-1.48; p = 0.71). Furthermore, a subgroup analysis of analgesia-related adverse events showed that the incidences of vomiting/nausea and pruritus did not differ between patients receiving IV and oral paracetamol (odds ratio (OR) = 0.71; 95% CI = 0.45-1.11; p = 0.13 and OR = 0.48; 95% CI = 0.18-1.29; p = 0.05, respectively). A review of information from two trials comparing equal doses of IV and rectal paracetamol suggested that the postoperative pain scores were statistically similar between the groups. IV paracetamol is not superior to oral or rectal paracetamol administered in equal doses. Therefore, we cannot recommend or refute IV paracetamol as the first-line analgesia for acute and postoperative pain.

Efficacy and safety of erector spinae plane block for postoperative analgesia in breast cancer surgery-A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

We aim to evaluate the analgesic efficacy and safety of erector spinae plane block (ESPB) for postoperative analgesia in breast cancer surgeries.

METHODS

PubMed, Web of Science, CBM, Embase, Cochrane, Wanfang, VIPP, and CNKI were searched to identify published eligible randomized controlled trials. The primary results were the postoperative 24 h morphine consumption and pain scores, while the secondary outcomes included pain scores at other times, press times of patient-controlled intravenous analgesia (PCIA), times to request for first rescue analgesia, the incidence of request for rescue analgesia, opioid-related complications, nerve blocks related complications and patient satisfaction.

RESULTS

We included 20 studies meeting the inclusion criteria, which involved 1293 participants. The morphine consumption and the pain scores during 24 h postoperatively were significantly decreased in the ESPB group versus the control group (p < 0.00001). Furthermore, ESPB also reduced pain scores at other time points, press times of PCIA, and times to first rescue analgesia requirement. Meanwhile, there was a lower incidence of postoperative nausea and vomiting, and skin pruritus in the ESPB group than in the control group.

CONCLUSIONS

Compared to general anesthesia alone, ESPB combined with general anesthesia can effectively reduce the postoperative pain intensity within 48 h and opioid consumption within 24 h after breast cancer surgery, and reduce the incidence of opioid and nerve blocks related complications.

Health-related quality of life in patients 40 years after diagnosis of an idiopathic scoliosis

AIMS

Only a few studies have investigated the long-term health-related quality of life (HRQoL) in patients with an idiopathic scoliosis. The aim of this study was to investigate the overall HRQoL and employment status of patients with an idiopathic scoliosis 40 years after diagnosis, to compare it with that of the normal population, and to identify possible predictors for a better long-term HRQoL.

METHODS

We reviewed the full medical records and radiological reports of patients referred to our hospital with a scoliosis of childhood between April 1972 and April 1982. Of 129 eligible patients with a juvenile or adolescent idiopathic scoliosis, 91 took part in the study (71%). They were evaluated with full-spine radiographs and HRQoL questionnaires and compared with normative data. We compared the HRQoL between observation (n = 27), bracing (n = 46), and surgical treatment (n = 18), and between thoracic and thoracolumbar/lumbar (TL/L) curves.

RESULTS

The mean time to follow-up was 40.8 years (SD 2.6) and the mean age of patients was 54.0 years (SD 2.7). Of the 91 patients, 86 were female (95%) and 51 had a main thoracic curve (53%). We found a significantly lower HRQoL measured on all the Scoliosis Research Society 22r instrument (SRS-22r) subdomains (p < 0.001) with the exception of mental health, than in an age-matched normal population. Incapacity to work was more prevalent in scoliosis patients (21%) than in the normal population (11%). The median SRS-22r subscore was 4.0 (interquartile range (IQR) 3.3 to 4.4) for TL/L curves and 4.1 (IQR 3.8 to 4.4) for thoracic curves (p = 0.300). We found a significantly lower self-image score for braced (median 3.6 (IQR 3.0 to 4.0)) and surgically treated patients (median 3.6 (IQR 3.2 to 4.3)) than for those treated by observation (median 4.0 (IQR 4.1 to 4.8); p = 0.010), but no statistically significant differences were found for the remaining subdomains.

CONCLUSION

In this long-term follow-up study, we found a significantly decreased HRQoL and capacity to work in patients with an idiopathic scoliosis 40 years after diagnosis.Cite this article: Bone Joint J 2023;105-B(2):166-171.

Comparison of Binaural Tone Music vs Patient Choice Music vs Midazolam on Perioperative Anxiety in Patients Posted for Surgery Under Spinal Anaesthesia: a Randomized Control Trial

Background Perioperative anxiety affects patients' hemodynamics by increasing stress levels, leading to delayed recovery. In this study, we compared the anxiety-reducing effect of music (patient choice and binaural tone music) with midazolam for perioperative anxiolysis in patients undergoing surgery under spinal anaesthesia. Methods After obtaining institutional ethical clearance and informed written consent, a total of 225 patients classified as ASA grades 1 and 2 (American Society of Anesthesiologists) were enrolled and randomised into three groups of 75 patients per group. Group A patients received research-selected music (binaural tone) via noise-cancelling headphones, Group B received intravenous midazolam (minimum of 1 mg to 2 mg maximum) as per clinical judgement, and Group C participants provided patient-preferred music via noise-cancelling headphones. The patient's perioperative anxiety was assessed using a visual analogue anxiety scale at regular time intervals. Results Anxiety scores were significantly reduced in the patient's choice music group (Group C) and binaural tone music group (Group A) as compared to the midazolam group (Group B). Postoperative pain scores were statistically significantly lower in Group C, followed by Group A and Group B. On comparing patient satisfaction scores, using numerical rating scores, 96% of patients in Group C achieved excellent scores with a p-value of 0.007. Conclusion Binaural tone music and patient choice music can be suitable alternatives to pharmacological therapies for perioperative anxiolysis.

Efficacy of electroacupuncture combined with intravenous patient-controlled analgesia after cesarean delivery: a randomized clinical trial

BACKGROUND

Electroacupuncture is a nonpharmacologic intervention for analgesia that is widely recognized as therapy for pain. However, the clinical efficacy of electroacupuncture combined with patient-controlled intravenous analgesia for postoperative analgesia after cesarean delivery remains unclear.

OBJECTIVE

This study aimed to assess the efficacy of electroacupuncture + patient-controlled intravenous analgesia for postoperative analgesia after cesarean delivery, determine the optimal frequency for the best analgesic effect, and explore the underlying mechanism of action.

STUDY DESIGN

This single-center, randomized, single-blinded, sham acupuncture controlled clinical trial was conducted at a tertiary university hospital in China. Female patients who underwent cesarean delivery and received fentanyl as patient-controlled intravenous analgesia for postoperative analgesia were enrolled. Patients were after surgery randomized to receive 2 Hz electroacupuncture treatment (n=53), 20/100 Hz electroacupuncture treatment (n=53), or sham electroacupuncture treatment (n=52) (controls). The 2 electroacupuncture groups received electroacupuncture treatment at 2 or 20/100 Hz at the ST36 and SP6 points, whereas, in the sham electroacupuncture group, sham electroacupuncture was performed at nonmeridian points with nonenergized electroacupuncture instruments. Of note, 4 electroacupuncture treatments were performed in all groups at 6, 12, 24, and 48 hours after surgery. The primary outcome was the number of analgesic pump compressions at 48 hours after surgery. The secondary outcomes included number of analgesic pump compressions at 6, 12, and 24 hours after surgery; pain scores at 6, 12, 24, and 48 hours after surgery; fentanyl consumption at 48 hours after surgery; interleukin 6 and procalcitonin levels at 12 and 48 hours after surgery; and time to first exhaust.

RESULTS

Overall, 174 primigravida women were included in the intention-to-treat analysis. The number of analgesic pump compressions and pain scores at all 4 time points and fentanyl consumption at 48 hours after surgery were significantly lower in the electroacupuncture treatment groups than in the sham electroacupuncture group (P<.001).

CONCLUSION

Electroacupuncture + patient-controlled intravenous analgesia had a significantly better analgesic effect than sham electroacupuncture + patient-controlled intravenous analgesia within 48 hours after surgery. Thus, electroacupuncture can be considered safe and effective and may improve the efficacy of patient-controlled intravenous analgesia for pain management after cesarean delivery. Electroacupuncture can be recommended as a routine complementary therapy for pain control after cesarean delivery.

Minimum volume of infiltrative anesthetic required for pain-free placement of mini-implants: a split-mouth clinical trial

OBJECTIVE

To determine the minimum volume of infiltrative anesthetic required for pain-free mini-implant placement in the maxillary buccal region by comparing the efficacy of 1.0 mL with 0.5 mL of 2% lignocaine with 1:200,000 epinephrine during mini-implant placement.

METHOD AND MATERIALS

This split-mouth study involved 19 healthy patients without systemic disease, recent history of allergy, or medications within the age group of 17 to 28 years belonging to both sexes requiring bilateral buccal mini-implants in the posterior maxilla. Lignocaine 2% with 1:200,000 epinephrine (0.5 mL and 1.0 mL) was randomly injected between the right and left side 30 minutes apart for each consecutive patient. Mini-implants were placed 5 minutes after the administration of the infiltrative anesthetic. The pain response was evaluated during mini-implant placement (T1), and 5 minutes (T2) and 10 minutes (T3) after mini-implant placement on both sides using a pain-rating scale. Descriptive statistics and a factorial repeated-measure analysis of variance were calculated for pain response, sex, and side of the jaw.

RESULTS

At T1, T2, and T3, 1.0 mL of anesthetic had a lesser pain score by 1.00, 1.00, and 0.58, respectively, compared to 0.5 mL, with 95% confidence intervals of 0.43 to 1.57 (P = .001), 0.49 to 1.51 (P = .000), and 0.08 to 1.08 (P = .024), respectively.

CONCLUSIONS

1.0 mL of 2% lignocaine with 1:200,000 epinephrine administered submucosally appears to provide better anesthesia than 0.5 mL during and after insertion of mini-implants. This study will help the operator administer the correct volume of infiltrative anesthetic thereby improving pain response, alleviating patient anxiety, and providing a better patient experience during and immediately after mini-implant placement.

Pain Control and Satisfaction With Peripheral Nerve Blocks for Upper Extremity Surgery

BACKGROUND

Regional anesthesia ("block") is an important component of upper extremity (UE) surgery pain control. However, little is known about patient experience related to perioperative opioid use. This study assessed patient-reported pain control and satisfaction with UE blocks and evaluated how opioid consumption impacted these outcomes before the block "wore off."

METHODS

A postoperative phone survey was administered to patients who underwent outpatient UE surgery at a surgery center for more than 16 months. It assessed pain scores (scale 1-10), satisfaction with block duration (scale 1-5), duration until return of UE function, and opioid consumption. Analyses used Mann-Whitney U tests, Fisher exact tests, and bivariate and multivariable linear and ordered logistic regressions to understand relationships between opioid use and outcomes.

RESULTS

A total of 509 patients (61%) completed the survey, and 441 (88%) were satisfied with block duration. Initial and final pain scores were significantly higher in patients who took opioids prior to the block wearing off (6 and 4.5, P = .04 and 3.5 and 2, P = .002, respectively). Although satisfaction with block duration was not different in group comparisons (ie, patients who premedicated vs those who did not), in a multivariable analysis, patients who premedicated with opioids had 78% increased odds of reporting the highest level of satisfaction compared with the lower 4 levels (P = .03).

CONCLUSIONS

Upper extremity blocks are associated with high overall patient satisfaction and postsurgical pain control. Premedicating before the block wears off may increase patient satisfaction with block duration even if pain is not notably impacted.

Analgesic Effects of a Novel Combination of Regional Anesthesia After Pediatric Cardiac Surgery: A Retrospective Cohort Study

OBJECTIVE

The objective of this study was to determine whether the use of regional anesthesia in children undergoing congenital heart surgery was associated with differences in outcomes when compared to surgeon-delivered local anesthetic wound infiltration.

DESIGN

A retrospective cohort study.

SETTING

At a single pediatric tertiary care center.

PARTICIPANTS

Pediatric patients who underwent primary repair of septal defects between January 1, 2018, and March 31, 2022.

INTERVENTIONS

The patients were grouped by whether they received surgeon-delivered local anesthetic wound infiltration or bilateral pectointercostal fascial blocks (PIFBs) and a unilateral rectus sheath block (RSB) on the side ipsilateral to the chest tube.

MEASUREMENTS AND MAIN RESULTS

Using overlap propensity score-weighted models, the authors examined postoperative opioid requirements (morphine milliequivalents per kilogram), pain scores, length of stay, and time under general anesthesia (GA). Eighty-nine patients were eligible for inclusion and underwent analysis. In the first 12 hours postoperatively, the block group used fewer morphine equivalents per kilogram versus the infiltration group, 0.27 ± 0.2 v 0.64 ± 0.42, with a weighted estimated decrease of 0.39 morphine equivalents per kilogram (95% CI -0.52 to -0.25; p < 0.001), and had lower pain scores, 3.2 v 1.6, with a weighted estimated decrease of 1.7 (95% CI -2.3 to -1.1; p < 0.001). The length of stay and time under GA also were shorter in the block group with weighted estimated decreases of 22 hours (95% CI -33 to -11; p = 0.001) and 18 minutes (95% CI -34 to -2; p = 0.03), respectively.

CONCLUSIONS

Bilateral PIFBs and a unilateral RSB on the side ipsilateral to the chest tube is a novel analgesic technique for sternotomy in pediatric patients. In this retrospective study, these interventions were associated with decreases in postoperative opioid use, pain scores, and hospital length of stay without prolonging time under GA.

Clinical results and patient-reported outcomes following robotic-assisted primary total knee arthroplasty : a multicentre study

Aims

The aim of this study was to report patient and clinical outcomes following robotic-assisted total knee arthroplasty (RA-TKA) at multiple institutions with a minimum two-year follow-up.

Methods

This was a multicentre registry study from October 2016 to June 2021 that included 861 primary RA-TKA patients who completed at least one pre- and postoperative patient-reported outcome measure (PROM) questionnaire, including Forgotten Joint Score (FJS), Knee Injury and Osteoarthritis Outcomes Score for Joint Replacement (KOOS JR), and pain out of 100 points. The mean age was 67 years (35 to 86), 452 were male (53%), mean BMI was 31.5 kg/m² (19 to 58), and 553 (64%) cemented and 308 (36%) cementless implants.

Results

There were significant improvements in PROMs over time between preoperative, one- to two-year, and > two-year follow-up, with a mean FJS of 17.5 (SD 18.2), 70.2 (SD 27.8), and 76.7 (SD 25.8; p < 0.001); mean KOOS JR of 51.6 (SD 11.5), 85.1 (SD 13.8), and 87.9 (SD 13.0; p < 0.001); and mean pain scores of 65.7 (SD 20.4), 13.0 (SD 19.1), and 11.3 (SD 19.9; p < 0.001), respectively. There were eight superficial infections (0.9%) and four revisions (0.5%).

Conclusion

RA-TKA demonstrated consistent clinical results across multiple institutions with excellent PROMs that continued to improve over time. With the ability to achieve target alignment in the coronal, axial, and sagittal planes and provide intraoperative real-time data to obtain balanced gaps, RA-TKA demonstrated excellent clinical outcomes and PROMs in this patient population.

Cite this article: Bone Jt Open 2022;3(7):589–595.

Predicting Post-Discharge Opioid Consumption After Total Hip and Knee Arthroplasty in the Opioid-Naïve Patient

BACKGROUND

Pain catastrophizing, anxiety, and depression are associated with poor outcomes after total hip (THA) and total knee (TKA) arthroplasty. The goal of this study is to determine the relationship between post-operative pain scores and opioid consumption; and the association among pre-operative measures of anxiety, depression, and pain catastrophizing and post-operative opioid consumption in patients undergoing THA and TKA.

METHODS

This is a single-institution prospective cohort study of 243 opioid-naïve patients undergoing elective, primary THA (n = 123) or TKA (n = 120) for osteoarthritis. Pre-operatively, patients completed the PROMIS-29 (Patient-Reported Outcomes Measures Information System; physical function/anxiety/depression/fatigue/sleep disturbance/social activities/pain interference/pain intensity) and Pain Catastrophizing Scale. Post-operatively, patients completed a weekly survey for 12 weeks determining morphine-milligram-equivalent (MME) opioid consumption, opioid cessation, and visual analog scale pain scores. Multivariable regression models determined the association between pre-operative scores and post-operative opioid consumption.

RESULTS

Mean (±standard deviation) total opioid consumption and duration was 75.1 ± 112.0 MME and 1.7 ± 1.7 weeks in THA and 384.7 ± 473.3 MME and 4.3 ± 3.5 weeks in TKA. Visual analog scale pain scores (0-100) after opioid cessation were 28.0 ± 22.9 in THA and 30.7 ± 25.8 in TKA. Multivariable regression showed that each unit increase in PROMIS-29 fatigue T-score was associated with 8.4 hours longer opioid usage in THA (P = .008) and 15.1 hours longer in TKA (P = .036), as well as 12.7 MME additional opioids in TKA (P = .027). There were no significant associations with other PROMIS-29 domains or the Pain Catastrophizing Scale.

CONCLUSION

Opioid use duration is different for THA and TKA and may correlate with pain scores. Only pre-operative fatigue was associated with post-operative opioid consumption. These findings should inform THA and TKA post-operative pain management pathways.

Transmuscular Quadratus Lumborum Block versus Infrainguinal Fascia Iliaca Nerve Block for Patients Undergoing Elective Hip Replacement: A Double-blinded, Pilot, Randomized Controlled Trial

Purpose

Transmuscular quadratus lumborum (TQL) block has been described as an effective option for postoperative analgesia in patients undergoing hip replacement with single injection described as providing analgesia for up to 24 h. We hypothesize that a TQL block, when compared to fascia iliaca block (FIB), will provide better analgesia and less motor block in the initial 24-h postoperative period.

Patients and Methods

Fifty patients undergoing elective hip replacement surgery, ASA I–III, were included in the study. Patients were randomized into two groups. Patients in group A received spinal anesthesia followed by FIB. Patients in group B received spinal anesthesia followed by TQLB. Postoperative pain scores and motor block were assessed at 6 and 24 hours. The primary outcome measure was 24 h total morphine consumption. Secondary outcome measures included pain score (VNS) and motor block (modified Bromage scale) at 6 and 24 h postoperatively.

Results

There was no statistical difference in morphine consumption between the two groups (p-value 0.699). There was no difference in pain scores at 6 h (p-value 0.540) or 24 h (p-value 0.383). There was no difference in motor block at 6 h (p-value 0.497) or at 24 h (p-value 0.773).

Conclusion

Transmuscular quadratus lumborum block along with spinal anesthesia for patients undergoing elective hip replacement surgery does not reduce opioid consumption or motor weakness when compared to fascia iliaca block. The results and conclusion apply to a dose of 20 mL of 0.25% bupivacaine used in each group.

Utility of unidimensional and functional pain assessment tools in adult postoperative patients: a systematic review

BACKGROUND

We aimed to appraise the evidence relating to the measurement properties of unidimensional tools to quantify pain after surgery. Furthermore, we wished to identify the tools used to assess interference of pain with functional recovery.

METHODS

Four electronic sources (MEDLINE, Embase, CINAHL, PsycINFO) were searched in August 2020. Two reviewers independently screened articles and assessed risk of bias using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist.

RESULTS

Thirty-one studies with a total of 12 498 participants were included. Most of the studies failed to meet the methodological quality standards required by COSMIN. Studies of unidimensional assessment tools were underpinned by low-quality evidence for reliability (five studies), and responsiveness (seven studies). Convergent validity was the most studied property (13 studies) with moderate to high correlation ranging from 0.5 to 0.9 between unidimensional tools. Interpretability results were available only for the visual analogue scale (seven studies) and numerical rating scale (four studies). Studies on functional assessment tools were scarce; only one study included an 'Objective Pain Score,' a tool assessing pain interference with respiratory function, and it had low-quality for convergent validity.

CONCLUSIONS

This systematic review challenges the validity and reliability of unidimensional tools in adult patients after surgery. We found no evidence that any one unidimensional tool has superior measurement properties in assessing postoperative pain. In addition, because promoting function is a crucial perioperative goal, psychometric validation studies of functional pain assessment tools are needed to improve pain assessment and management.

CLINICAL TRIAL REGISTRATION

PROSPERO CRD42020213495.

Interposition GraftJacket allografts for irreparable rotator cuff tears

AIMS

Long-term outcomes following the use of human dermal allografts in the treatment of symptomatic irreparable rotator cuff tears are not known. The aim of this study was to evaluate these outcomes, and to investigate whether this would be a good form of treatment in young patients in whom a reverse shoulder arthroplasty should ideally be avoided.

METHODS

This prospective study included 47 shoulders in 45 patients who underwent an open reconstruction of the rotator cuff using an interposition GraftJacket allograft to bridge irreparable cuff tears, between January 2007 and November 2011. The Oxford Shoulder Score (OSS), pain score, and range of motion (ROM) were recorded preoperatively and at one year and a mean of 9.1 years (7.0 to 12.5) postoperatively.

RESULTS

There was significant improvement in the mean OSS from 24.7 (SD 5.4) preoperatively to 42.0 (SD 6.3) at one year, and this improvement was maintained at 9.1 years (p < 0.001), with a score of 42.8 (SD 6.8). Similar significant improvements in the pain score were seen and maintained at the final follow-up from 6.1 (SD 1.6) to 2.1 (SD 2.3) (p < 0.001). There were also significant improvements in the ROM of the shoulder, and patient satisfaction was high.

CONCLUSION

The use of an interposition human dermal allograft in patients with an irreparable rotator cuff tear leads to good outcomes that are maintained at a mean of nine years postoperatively. Cite this article: Bone Joint J 2022;104-B(1):91-96.

Association Between Pain Intensity and Discontinuing Opioid Therapy or Transitioning to Intermittent Opioid Therapy After Initial Long-Term Opioid Therapy: A Retrospective Cohort Study

The purpose of this study was to evaluate changes in pain intensity among Veterans transitioning from long-term opioid therapy (LTOT) to either intermittent therapy or discontinuation compared to continued LTOT. Pain intensity was assessed using the Numeric Rating Scale in 90-day increments starting in the 90-day period prior to potential opioid transitions and the two ensuing 90-day periods after transition. Primary analyses used a 1:1 greedy propensity matched sample. A total of 29,293 Veterans switching to intermittent opioids and 5,972 discontinuing opioids were matched to Veterans continuing LTOT. Covariates were well balanced after matching except minor differences in baseline mean pain scores. Pain scores were lower in the follow up periods for those switching to intermittent opioids and discontinuing opioids compared to those continuing LTOT (0-90 days: Intermittent: 3.79, 95%CI: 3.76, 3.82; LTOT: 4.09, 95%CI: 4.06, 4.12, P < .0001; Discontinuation: 3.06, 95%CI: 2.99, 3.13; LTOT: 3.86, 95%CI: 3.79, 3.94, P = <.0001; 91-180 days: Intermittent: 3.76, 95%CI: 3.73, 3.79; LTOT: 3.99, 95%CI: 3.96, 4.02, P < .0001; Discontinuation: 3.01, 95%CI: 2.94, 3.09; LTOT: 3.80, 95%CI: 3.73, 3.87, P = <.0001). Sensitivity analyses found similar results. Discontinuing opioid therapy or switching to intermittent opioid therapy was not associated with increased pain intensity. PERSPECTIVE: This article evaluates the association of switching to intermittent opioid therapy or discontinuing opioids with pain intensity after using opioids long-term. Pain intensity decreased after switching to intermittent therapy or discontinuing opioids, but remained relatively stable for those continuing long-term opioid therapy. Switching to intermittent opioids or discontinuing opioids was not associated with increased pain intensity.

Comparing Pain Intensity Using the Numeric Rating Scale and Defense and Veterans Pain Rating Scale in Patients Revisiting the Emergency Department

Objective 

To determine the relationship between Numeric Rating Scale (NRS) and Defense and Veterans Pain Rating Scale (DVPRS) as pain intensity measures, we compared pain scores to sociodemographic and treatment data in patients revisiting the emergency department (ED).

Methods 

After Institutional Review Board approval, 389 adults presenting within 30 days of an index visit were enrolled. Pain scores were classified as follows: 0-3 (mild), 4-7 (moderate), and 8-10 (high). Data were analyzed using descriptive analysis. Wilcoxon rank-sum test measured the association of pain score with gender. Pain scales were correlated using Spearman correlation coefficient. Pain scale association with opioid treatment was tested via ordinal logistic regression controlling for gender, home opioid use, and if ED revisit was for pain.

Results 

Average patient age was 49. Most patients were African American (68.4%), male (51.2%), and returned for pain (67.0%). As continuous measures, both scales were positively correlated with each other (p<0.0001). Pain score severity categories were distributed differently between the two scales (p=0.0085), decreasing by 8% in patients reporting high pain severity when using DVPRS. For both scales, the proportion of patients (1) administered opioids (p=0.0009 and p≤0.0001, respectively) and (2) discharged with opioids (p=0.0103 and p=0.0417, respectively) increased with pain severity. Discharge NRS (p=0.0001) (OR=3.2, 1.780-5.988) and DVPRS pain score categories (p<0.0001) (OR=2.7, 95% CI=1.63-4.473) were associated with revisits for pain. 

Conclusions

Our findings demonstrate a link between NRS and administration of opioid medications and suggest that DVPRS may better differentiate between moderate and high levels of pain in the ED setting.

Liposomal bupivacaine addition versus standard bupivacaine alone for colorectal surgery: a randomized controlled trial

Aim: This study evaluated use of liposomal bupivacaine (LB) versus standard bupivacaine (SB) alone in quadratus lumborum (QL) blocks for laparoscopic colorectal surgery. Materials & methods: In this prospective, randomized controlled trial, patients received QL1 blocks with either LB (40 ml 0.125% SB plus 20 ml of LB) or SB (60 ml of 0.25% SB) with 30 ml per side. Opioid usage, pain scores, side effects and other medications were recorded. Results: For 78 patients (38 LB; 40 SB), all parameters were similar between groups, except that the LB group had a higher 48 h need for metoclopramide. Conclusion: LB provided no analgesic benefit over SB alone for QL blocks. Clinical Trials registration number: NCT03702621.

Comparison of Regional Anesthesia Timing on Pain, Opioid Use, and Postanesthesia Care Unit Length of Stay in Patients Undergoing Open Reduction and Internal Fixation of Ankle Fractures

Regional nerve blocks are an effective method of managing acute pain associated with surgery. The relative benefit of preoperative versus postoperative peripheral nerve blocks is not entirely clear. The primary aim of this study was to determine differences in pain scores in patients undergoing preoperative block versus postoperative block versus no block. We hypothesized that patients receiving preoperative blocks would have reduced pain scores and decreased opioid use in the immediate postoperative period. We conducted a retrospective cohort analysis of 302 consecutive patients undergoing unilateral open reduction and internal fixation of ankle fracture under general anesthesia. We identified 3 groups: preoperative block, postoperative block, or no block. Data obtained from our electronic medical records included demographic information, postanesthesia care unit length of stay, pain scores obtained preoperatively, upon arrival to the postanesthesia care unit, and upon discharge from the postanesthesia care unit as well as intraoperative and postanesthesia care unit opioid utilization. Patients receiving preoperative block had significantly lower pain scores, less intraoperative or postanesthesia care unit opioid use, and shorter postanesthesia care unit dwell time compared with patients receiving postoperative block or no block. Preoperative popliteal sciatic and adductor canal blocks in patients undergoing ankle fracture surgery appears to be more effective than either postoperative block or no block.

Reduction of opioid utilization after vaginal delivery with an electronic health record intervention

BACKGROUND

The national epidemic of opioid misuse has focused its attention on postpartum analgesic usage. Adequate pain control achieved with nonopioid pain medications and conservative measures could reduce the number of opioid pain medications available for misuse and diversion. Interventions that decrease inpatient opioid use after delivery could reduce the potential for chronic dependence in postpartum women. Modification of preloaded electronic order sets to decrease opioid administration has successfully reduced opioid use following a major abdominal surgery, including cesarean delivery. However, interventions to reduce opioid use following vaginal delivery are not well described.

OBJECTIVE

We aimed to evaluate the effect of removing opioid medications from postpartum order sets on medication usage following vaginal delivery.

STUDY DESIGN

We performed a retrospective cohort study of women undergoing a singleton vaginal delivery at an academic tertiary care center. Our institution removed opioid medications from postpartum order sets in April 2018. We compared the following 2 delivery cohorts: the "preintervention" cohort (April 2016-March 2018) and the "postintervention" cohort (June 2018-July 2018). The primary outcome was postpartum opioid use. The secondary outcomes were nonopioid analgesic use and discharge with an opioid prescription. We compared the demographic and obstetrical data, self-reported pain scores, and postpartum analgesic usage between groups. We determined that a minimum of 138 patients would be needed in each group to identify a 20% decrease in opioid usage (α=.05; β=.2).

RESULTS

We analyzed 276 subjects: 138 in the preintervention group and 138 in the postintervention group. The postintervention group was older and more likely to have an operative vaginal delivery. Otherwise, groups had similar demographic and obstetrical characteristics. Postpartum opioid use decreased from 56% in the preintervention group to 16% in the postintervention group, a 71% reduction (P<.001). The incidence of severe pain score (>7) was similar between groups with a median occurrence of 1 (interquartile range, 0-4) for both (P=.7). The number of opioid discharge prescriptions among those receiving inpatient opioids was significantly lower in the postintervention group than in the preintervention group (18% vs 38%, respectively), a 53% decrease (P<.001).

CONCLUSION

Removal of opioids from the postpartum order set was associated with lower rates of opiate usage following vaginal delivery in a single center without changing the frequency of severe pain scores. This simple intervention has the potential to reduce opioid exposure.

Pelvic pain: What are the symptoms and predictors for surgery, endometriosis and endometriosis severity

BACKGROUND

Chronic pelvic pain (CPP) is a common condition which significantly impacts the quality of life and wellbeing of many women. Laparoscopy with histopathology is recommended for investigation of pelvic pain and identification of endometriosis with concurrent removal. Never-the-less, the association between endometriosis and pelvic pain is challenging, with endometriosis identified in only 30-50% of women with pain.

AIMS

To explore the predictors for undergoing surgery, for identifying endometriosis and endometriosis severity in a cohort of women with CPP.

MATERIALS AND METHODS

This study forms part of the Persistent Pelvic Pain project, a prospective observational cohort study (ANZCTR:ACTRN12616000150448). Women referred to a public gynaecology clinic with pain were randomised to one of two gynaecology units for routine care and followed for 36 months with 6-monthly surveys assessing demographics, medical history, quality of life, and pain symptoms measured on a Likert scale. Operative notes were reviewed and endometriosis staged.

RESULTS

Of 471 women recruited, 102 women underwent laparoscopy or laparotomy, of whom 52 had endometriosis (n = 37 stage I-II; n = 15 Stage III-IV). Gynaecology unit, pelvic pain intensity and lower parity were all predictors of surgery (odds ratio (OR) 0.342; 95% CI 0.209-0.561; OR 1.303; 95% CI: 1.079-1.573; OR 0.767; 95% CI: 0.620-0.949, respectively). There were no predictors identified for endometriosis diagnosis and the only predictor of severity was increasing age (OR 1.155; 95% CI: 1.047-1.310).

CONCLUSIONS

Gynaecology unit and pain intensity were key predictors of undergoing laparoscopy; however, pain severity did not predict endometriosis diagnosis or staging. These findings indicate the need to review current frameworks guiding practice toward surgery for pelvic pain.

Influence of interpretation of pain scores on patients' perception of pain: A prospective study

Background and Aims:

Assessment of pain using pain scales is essential. In the Numeric Rating Scale (NRS), patients are asked to score their pain intensity on a scale from 0 to 10 (10- worst pain). This requires some abstract thinking by the patient, also the pain scores (PS) may not essentially communicate the patients’ need for more analgesia. We planned a study to evaluate the change in patients’ self-assessed PS after understanding clinical interpretation of the NRS.

Methods:

This prospective study was registered after approval from our hospital ethics board. Sample size estimated for the trial was 360 patients. All postoperative patients were recruited after informed consent. Patients having prolonged stay in Intensive Care Unit (more than 48 h), or those who underwent emergency surgeries were excluded. During Acute Pain Service (APS) rounds, patients were asked to rate their PS on the NRS. This was followed by a briefing about the clinical interpretation of the scale, and the patients were asked to re score their pain using the same scale. The change in pain severity was compared using Chi-square test.

Results:

Following explanation, a change in severity was seen for PS at rest [X² (9, N- 360) = 441, P < 0.001] and at movement [X² (9, N- 360) = 508, P < 0.001]. Overall, a change in PS severity was seen in 162 patients (45%). A decrease and an increase in the severity of pain was seen in 119 and 41 patients respectively.

Conclusion:

Explaining the clinical interpretation of PS on a NRS does lead to a change in patients’ self-assessed PS.

Pain and Interoceptive Awareness Outcomes of Chronic Pain Patients With Spinal Cord Stimulation

OBJECTIVES

Meditation has been shown to improve outcomes for chronic pain by increasing patients' awareness of their own bodies. Some patients have an innate ability to leverage their mind-body connection, and this interoceptive awareness may aid them in garnering pain relief. We explored whether spinal cord stimulation (SCS) patients with greater innate awareness had better outcomes.

MATERIALS AND METHODS

We contacted 30 thoracic SCS patients with baseline and postoperative pain, psychological, and disability outcomes to complete the Multidimensional Assessment of Interoceptive Awareness (MAIA) survey. MAIA distinguishes between beneficial and maladaptive aspects of the perception of body sensations via six positive subscales (noticing, attention regulation, emotional awareness, self-regulation, body listening, and trusting) and two negative subscales (not distracting, not worrying). MAIA subscales and positive/negative groups were correlated with percentage change in Numerical Rating Scale (NRS), Oswestry Disability Index (ODI), Beck's Depression Inventory (BDI), Pain Catastrophizing Scale (PCS), and McGill Pain Questionnaire (MPQ).

RESULTS

Patients included 14 males/16 females with a mean age of 58. At a mean follow-up of 14.13 months (range 6-26), NRS, ODI, BDI, PCS, and MPQ showed improvements. Positive traits correlated with improvements in pain (MAIA-self regulation with NRS-worst [p = 0.018], NRS-least [p = 0.042], NRS-average [p = 0.006], NRS-current [p = 0.001]; MAIA-body listening with MPQ-total [p = 0.016] and MPQ-sensory [p = 0.026]). Improvement in PCS-total was associated with higher scores in noticing (p = 0.002), attention regulation (p = 0.017), emotional awareness (p = 0.039), and trusting (p = 0.047). PCS-rumination correlated with MAIA-positive total (p = 0.012). In contrast, better attention regulation signified less improvement in ODI (p = 0.043) and MPQ affective (p = 0.026).

CONCLUSIONS

Higher interoceptive awareness in SCS patients correlated with greater improvement following the procedure, particularly with regards to pain relief and pain catastrophizing. These findings suggest that patients with better mind-body connections may achieve greater pain relief following SCS in this patient population, thereby aiding providers in determining who may benefit from this intervention.

A Single Centre Randomised Control Study to Assess the Impact of Pre-Operative Carbohydrate Loading on Women Undergoing Major Surgery for Epithelial Ovarian Cancer

Objective

Historically, patients have fasted before elective surgery to ensure an empty stomach to avoid aspiration. A fasting-induced catabolic state however may adversely influence recovery after surgery. Our study was designed to test the effect of oral carbohydrate loading on clinical parameters in patients undergoing major surgery for advanced-stage ovarian cancer.

Methods

A double-blinded single-centre randomised trial was designed to recruit 110 patients with advanced-stage epithelial ovarian cancer undergoing either primary surgery, or neoadjuvant chemotherapy prior to debulking surgery. Following written informed consent, the patients were randomised into two groups. Group 1 received the carbohydrate drink (intervention) and group 2 received flavoured water (placebo). The quantity of fluid in both groups was 800ml the night before the surgery and 400ml two hours before the induction of anaesthesia. The primary endpoint of the study was the Length of Hospital Stay (LoHS); the secondary parameters assessed were pain scores, nausea and vomiting scores, bowel function, and postoperative complication rate.

Results

Between March 2009 and December 2011, 80 patients were randomised and 75 completed the study. A decision was made to close the trial early as a change in routine clinical practice meant that patients were admitted on the day of surgery rather than a day before. Analysis of the data revealed that there were no significant differences between the study groups in terms of LoHS and other clinical parameters.

Conclusion

In this single-center study, which failed to recruit the planned number of patients, we were unable to demonstrate that oral carbohydrate intake pre-operatively has significant impact on the recovery process or the length of hospitalisation postoperatively. Future studies should examine all aspects of an Enhanced Recovery Program after Surgery as a package as compared to a single element to enhance patient outcome.

Intravenous Versus Oral Acetaminophen in Outpatient Cystoscopy Procedures: Retrospective Comparison of Postoperative Opioid Requirements and Analgesia Scores

PURPOSE

To assess if the choice of acetaminophen formulation (intravenous vs oral) when administered preoperatively for ambulatory cystoscopy procedures is associated with differences in anesthetic outcomes.

METHODS

Medical records of adult patients undergoing ambulatory cystoscopy procedures at an outpatient procedural center from July 1, 2014, through November 30, 2017, were abstracted. The association between anesthetic outcomes (severe pain, rescue opioids, postoperative nausea, and vomiting) and acetaminophen formulation was assessed. Propensity-adjusted analyses were performed using inverse probability of treatment weighting to account for potential confounders.

RESULTS

During the study time frame, there were 611 intravenous and 2955 oral acetaminophen administrations for cystoscopy procedures. Postoperative bladder spasms were a major contributor to severe pain and complicated 1036 cases, with similar rates between intravenous (N = 183, 29.9%) and oral (N = 853, 28.9%) formulations, P = .625. After adjusting for bladder spasms, intravenous acetaminophen was associated with longer anesthesia recovery (estimate 5.2 [95% CI 0.5-9.9] minutes, P = .030), use of rescue opioids (odds ratio 1.33 [1.07-1.66], P = .012), and postoperative nausea and vomiting (1.40 [1.02-1.93], P = .037), but not severe pain (1.07 [0.81-1.40], P = .640).

CONCLUSION

Preoperative intravenous acetaminophen compared to oral acetaminophen for ambulatory cystoscopy procedures was not associated with better anesthetic outcomes. Bladder spasms were a major contributor to postoperative pain.

A Comparison of Conventional Intravitreal Injection Method vs InVitria Intravitreal Injection Method

Purpose

To compare use of the conventional intravitreal injection method to the InVitria intravitreal injection device. Three outcome measures were studied: patient comfort, speed of injection and cost-effectiveness.

Patients and Methods

A prospective review of 58 patients was undertaken. Patients scored their perceived pain for each part of the conventional injection method using visual analogue scales (VAS), which allows pain to be scored from 0 (no pain) to 100. The same 58 patients scored their perceived pain for each part of the injection process with the InVitria on their follow-up visit. The procedure was timed in both settings and cost to the Trust was analysed.

Results

Pain scores when the InVitria was used were lower than when the conventional method was used for all aspects of the intravitreal injection procedure, in particular, when comparing insertion of drape/speculum (mean score 57.56) to insertion the InVitria (mean score 16.50), needle entry (mean score 37.76 to 27.86) and removal of the drape/speculum (mean score 38.72) to removal of the InVitria (11.07). The reduction in pain scores was statistically significant for all aspects of the procedure, except the initial instillation of drops. The InVitria was an average of 1 minute and 32 seconds faster than the conventional method. Use of the InVitria in place of the conventional method provides an annual saving of £24,300 to the Trust based on the number of injections currently performed.

Conclusion

The introduction of the InVitria in the Newcastle Eye Centre has had a positive impact on patient comfort, time and cost to the Trust.

Ultrasound-Guided Pecto-Intercostal Fascial Block for Postoperative Pain Management in Cardiac Surgery: A Prospective, Randomized, Placebo-Controlled Trial

OBJECTIVE

To explore the effect of pecto-intercostal fascial plane block (PIFB) on postoperative opioid requirements, pain scores, lengths of intensive care unit and hospital stays and incidence of postoperative delirium in cardiac surgical patients.

DESIGN

Single- center, prospective, randomized (1:1), quadruple- blinded, placebo-controlled trial.

SETTING

Single center, tertiary- care center.

PARTICIPANTS

The study comprised 80 adult cardiac surgical patients (age >18 y) requiring median sternotomy.

INTERVENTION

Patients were randomly assigned to receive ultrasound-guided PIFB, with either 0.25% bupivacaine or placebo, on postoperative days 0 and 1.

MEASUREMENTS AND MAIN RESULTS

Of the 80 patients randomized, the mean age was 65.78 ± 8.73 in the bupivacaine group and 65.70 ± 9.86 in the placebo group (p = 0.573). Patients receiving PIFB with 0.25% bupivacaine showed a statistically significant reduction in visual analog scale scores (4.8 ± 2.7 v 5.1 ± 2.6; p < 0.001), but the 48-hour cumulative opioid requirement computed as morphine milligram equivalents was similar (40.8 ± 22.4 mg v 49.1 ± 26.9 mg; p = 0.14). There was no difference in the incidence of postoperative delirium between the groups evaluated using the 3-minute diagnostic Confusion Assessment Method (3/40 [7.5%] v 5/40 [12.5%] placebo; p = 0.45).

CONCLUSION

Patients who received PIFB with bupivacaine showed a decline in cumulative opioid consumption postoperatively, but this difference between the groups was not statistically significant. Low incidence of complications and improvement in visual analog scale pain scores suggested that the PIFB can be performed safely in this population and warrants additional studies with a larger sample size.

The serratus anterior plane block for analgesia after thoracic surgery: A meta-analysis of randomized controlled trails

BACKGROUND

The serratus anterior plane (SAP) block is a newer method that can be used in patients undergoing thoracic surgeries. The postoperative analgesia efficacy of SAP blocks for thoracic surgery remains controversial. We conduct a meta-analysis to evaluate the analgesia of SAP blocks after thoracic surgery.

METHODS

We searched PubMed, Embase, EBSCO, the Cochrane Library, Web of Science, and CNKI for randomized controlled trials (RCTs) regarding the postoperative pain control of a SAP block on thoracic surgery. All of the dates were screened and evaluated by two researchers and meta-analysis was performed using RevMan5.3 software.

RESULTS

A total of 8 RCTs involving 542 patients were included. The meta-analysis showed statistically significant differences between the two groups with respect to postoperative pain scores at 2 h (standardized mean difference [Std.MD] = -1.26; 95% confidence interval [CI] = -1.66 to -0.86; P < .0001); 6 h (SMD = -0.50; 95%CI = -0.88 to -0.11; P = .01); 12 h (SMD = -0.63; 95%CI = -1.10 to -0.16; P = .009); 24 h (SMD = -0.99; 95%CI = -1.44 to -0.51; P < .0001); postoperative opioid consumption at 24 h (SMD = -0.83; 95%CI = -1.10 to -0.56; P < .00001); and postoperative nausea and vomiting (PONV) rates (RR = 0.39; 95% CI = 0.21-0.73; P = .003).

CONCLUSION

The SAP block can play an important role in the management of pain after thoracic surgery by reducing both pain scores and 24-h postoperative opioids consumption. In addition, there is fewer incidence of PONV in the SAP block group.

Clinical analgesic efficacy of pectoral nerve block in patients undergoing breast cancer surgery: A systematic review and meta-analysis

BACKGROUND

Breast cancer is the most commonly diagnosed cancer in women, and more than half of breast surgery patients experience severe acute postoperative pain. This meta-analysis is designed to examine the clinical analgesic efficacy of Pecs block in patients undergoing breast cancer surgery.

METHODS

An electronic literature search of the Library of PubMed, EMBASE, Cochrane Library, and Web of Science databases was conducted to collect randomized controlled trials (RCTs) from inception to November 2018. These RCTs compared the effect of Pecs block in combination with general anesthesia (GA) to GA alone in mastectomy surgery. Pain scores, intraoperative and postoperative opioid consumption, time to first request for analgesia, and incidence of postoperative nausea and vomiting were analyzed.

RESULTS

Thirteen RCTs with 940 patients were included in our analysis. The use of Pecs block significantly reduced pain scores in the postanesthesia care unit (weighted mean difference [WMD] = -1.90; 95% confidence interval [CI], -2.90 to -0.91; P < .001) and at 24 hours after surgery (WMD = -1.01; 95% CI, -1.64 to -0.38; P < .001). Moreover, Pecs block decreased postoperative opioid consumption in the postanesthesia care unit (WMD = -1.93; 95% CI, -3.51 to -0.34; P = .017) and at 24 hours (WMD = -11.88; 95% CI, -15.50 to -8.26; P < .001). Pecs block also reduced intraoperative opioid consumption (WMD = -85.52; 95% CI, -121.47 to -49.56; P < .001) and prolonged the time to first analgesic request (WMD = 296.69; 95% CI, 139.91-453.48; P < .001). There were no statistically significant differences in postoperative nausea and vomiting and block-related complications.

CONCLUSIONS

Adding Pecs block to GA procedure results in lower pain scores, less opioid consumption and longer time to first analgesic request in patients undergoing breast cancer surgery compared to GA procedure alone.

Value of ultrasound-guided transforaminal nerve block in the treatment of lumbar disc herniation

Objective

This study was performed to investigate the effectiveness and safety of ultrasound-guided transforaminal nerve block in the treatment of lumbar disc herniation.

Methods

Sixty patients who underwent treatment for protrusion of a lumbar intervertebral disc in Wangjing Hospital from January 2016 to December 2017 were divided into the study group and the control group. The visual analog scale (VAS) pain scores, the Japanese Orthopaedic Association (JOA) scores of the lumbar vertebra, PRI (pain rating index), and PPI (present pain intensity) were recorded at 30 minutes, 1 week, and 3 months after the operation.

Results

There were significant differences in the VAS, JOA, PRI, and PPI scores between the study group and control group.

Conclusion

Ultrasound guidance can improve the efficacy and safety of transforaminal nerve block in the treatment of lumbar disc herniation and shorten the operative duration.

A Novel Opioid-Sparing Pain Management Protocol Following Total Hip Arthroplasty: Effects on Opioid Consumption, Pain Severity, and Patient-Reported Outcomes

BACKGROUND

Opioid prescriptions and subsequent opioid-related deaths have increased substantially in the past several decades. Orthopedic surgery ranks among the highest of all specialties with respect to the amount of opioids prescribed. We present here the outcomes of our opioid-sparing pain management pilot protocol for total hip arthroplasty (THA).

METHODS

A retrospective study was conducted to assess outcomes before and after the implementation of an opioid-sparing pain management protocol for THA. Patients were divided into 2 cohorts for comparison: (1) traditional pain management protocol and (2) opioid-sparing pain management protocol. The Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, pain severity using a Visual Analog Scale, and inpatient morphine milligram equivalents (MMEs) per day were compared between the 2 cohorts.

RESULTS

No statistically significant difference was observed in Hip Disability and Osteoarthritis Outcome Score for Joint Replacement between the 2 cohorts at any time point (P > .05). Although there was a significant decrease in pain scores over time (P < .01), there was no statistically significant difference in the rates of change between the 2 pain management protocols at any time point (P = .463). Inpatient opioid consumption was significantly lower for the opioid-sparing cohort in comparison to the traditional cohort (14.6 ± 16.7 vs 25.7 ± 18.8 MME/d, P < .001). Similarly, the opioid-sparing cohort received significantly less opioids than the traditional cohort during the post discharge period (13.9 ± 24.2 vs 80.1 ± 55.9 MME, P < .001).

CONCLUSION

The results of this study suggest that an opioid-sparing protocol reduces opioid consumption and provides equivalent pain management and patient-reported outcomes during the 90-day THA episode of care relative to a traditional opioid-based regimen. These findings may help decrease the risk of adverse events associated with postoperative opioid use and provide a means of decreasing the opioid footprint in clinical practice.

Trajectory analysis for postoperative pain using electronic health records: A nonparametric method with robust linear regression and K-medians cluster analysis

Postoperative pain scores are widely monitored and collected in the electronic health record, yet current methods fail to fully leverage the data with fast implementation. A robust linear regression was fitted to describe the association between the log-scaled pain score and time from discharge after total knee replacement. The estimated trajectories were used for a subsequent K-medians cluster analysis to categorize the longitudinal pain score patterns into distinct clusters. For each cluster, a mixture regression model estimated the association between pain score and time to discharge adjusting for confounding. The fitted regression model generated the pain trajectory pattern for given cluster. Finally, regression analyses examined the association between pain trajectories and patient outcomes. A total of 3442 surgeries were identified with a median of 22 pain scores at an academic hospital during 2009-2016. Four pain trajectory patterns were identified and one was associated with higher rates of outcomes. In conclusion, we described a novel approach with fast implementation to model patients' pain experience using electronic health records. In the era of big data science, clinical research should be learning from all available data regarding a patient's episode of care instead of focusing on the "average" patient outcomes.

Association Between Pain Scores and Successful Spinal Cord Stimulator Implantation

INTRODUCTION

Determining reduction in pain score during spinal cord stimulation (SCS) trial is important prior to permanent SCS implantation. However, this association remains elusive. We investigate the association between post-SCS pain scores and successful permanent SCS implants.

MATERIALS AND METHODS

This IRB-approved, retrospective study identified patients who underwent SCS trials and implantation. Predictive modeling with nonparametric regression and margins plot analysis was used to determine the threshold for post-SCS trial pain scores associated with successful permanent SCS implant (defined as >50% pain relief). Nonparametric sensitivity and specificity analysis was performed. p < 0.05 was considered significant.

RESULTS

Eighty-eight patients with SCS trials were retrospectively identified (57.95% female, median age 52.5 ± 15.5 years). Of the total cohort, 79% had successful permanent SCS implantation. Post-SCS trial pain scores less than or equal to 4.9 had greater than 50% probability of a successful permanent SCS implant (97.14% sensitivity, 44.44% specificity, ROC = 0.71). Post-SCS trial pain scores between 4 and 7 were associated with a significantly higher probability of a successful SCS implant among patients without spine surgery compared with those with a history of spine surgery. Compared with males, females with pain scores between 5 and 7 had a higher probability of a successful SCS implant.

CONCLUSION

Low pain scores after SCS trial are predictive of successful SCS implants with high sensitivity. Males and surgical patients with higher pain scores had a lower probability of successful SCS implant than their counterparts. Larger studies are needed to further elucidate this relationship.

Pain measurement and critical review of analgesic trials: pain scores, functional pain measurements, limits and bias of clinical trials

Randomized clinical trials designed to assess analgesic agents and/or techniques used for postoperative pain control have several limitations, which are addressed in this article. Efficacy of analgesics cannot be limited to the evaluation of pain intensity or the amount of opioid rescue medication, but it also means to evaluate parameters such as the delay and duration of the effect, the number of patients with satisfactory pain control, and side effects. Because combination of analgesics is the standard of care in clinical practice, its value also needs to be documented. Eventually, analgesic treatments have to be considered in the settings of postoperative supportive care and enhanced recovery programmes after surgery.

Postoperative pain and comfort scores: Do they correlate?

Research on the nocebo effect has shown that some words can hurt. Pain is defined as ‘unpleasant’ and ‘associated with actual or potential tissue damage’. So, a sensation described as ‘pain’ may function as a negative suggestion or nocebo communication. This can lead to pain being experienced or exacerbated where it would not have been otherwise. The nocebo effect has also been implicated as adversely affecting the pain experience during the assessment of pain postoperatively. Words that avoid this potential nocebo effect such as ‘comfort’ may represent a more satisfactory alternative. We therefore aimed to determine whether ‘comfort’ and ‘pain’ scores correlate when assessing patients postoperatively at the same timepoint. Patients were questioned before routine post-anaesthesia rounds to rate their pain and comfort levels, with the sequence of questions randomised. Patients were asked to rate pain and comfort on a 0–10 verbal numerical rating scale, where 0 represents ‘no pain’ or ‘no comfort’ and 10 ‘worst pain’ or ‘most comfort’ imaginable, respectively. To provide a clinically relevant correlation of approximately 0.7 between pain and inverted comfort scores, a sample size of 100 would provide adequate precision (95% confidence interval (CI) 0.58–0.79). A P-value of <0.05 was considered significant. We recruited 100 patients. A positive correlation of 0.62 was found between pain and inverted comfort scores (95% CI 0.47–0.72; P<0.0001). The question sequence of asking about pain or comfort did not affect either score. Comfort and pain scores are moderately correlated. This finding represents a first step in validating comfort scores and suggests that they could be considered a suitable alternative to pain scores when assessing patients postoperatively. As comfort is not an exact antonym to pain, caution is required when using these measures interchangeably.

Preemptive Oral Acetaminophen for Women Undergoing Total Laparoscopic Hysterectomy

OBJECTIVE

To decrease hospital expenses by administering oral acetaminophen rather than intravenous (IV) acetaminophen to women who undergo laparoscopic hysterectomy.

DESIGN

A quality improvement project using a between-groups, pre-/postimplementation design for women undergoing total laparoscopic hysterectomy. Retrospective chart review was used to compare data of women who received intraoperative IV acetaminophen before implementation versus women who received oral acetaminophen after implementation. Pain scores and opioid consumption in morphine equivalents were recorded at four time points.

SETTING/LOCAL PROBLEM

A 369-bed hospital in the southeastern United States, where, in 2016, nearly $260,000 was spent on perioperative IV acetaminophen for all operating room cases.

PARTICIPANTS

Women between the ages of 18 and 55 years scheduled to have total laparoscopic hysterectomy were included. Excluded were women with a history of chronic pain, opioid use, or liver pathology; women with a contraindication to nonsteroidal anti-inflammatory drugs; and women whose procedures were converted from laparoscopic to open.

INTERVENTION/MEASUREMENTS

Women were instructed to take oral acetaminophen the day before surgery in divided doses, with 1 g every 6 hours, for a total dose of 3 g. On the day of surgery, women received the final 1-g dose of oral acetaminophen.

RESULTS

There were no significant differences between groups for pain scores or total opioids received before implementation (mean = 3.28, standard deviation = 2.05) compared with after implementation (mean = 3.65, standard deviation = 1.63; t [18] = -.043, p = .674). The preimplementation cost per individual was $30.03 for 1 g of IV acetaminophen, and the postimplementation cost was $0.36 for 2 500-mg oral acetaminophen tablets, a 98.8% relative cost decrease per woman.

CONCLUSION

Replacing IV acetaminophen with preemptive oral acetaminophen has the potential to save money without compromising care.

Efficacy of exercise for improving functional outcomes for patients undergoing total hip arthroplasty: A meta-analysis

BACKGROUND

The objective of this meta-analysis was aimed to illustrate the functional outcomes of exercise for total hip arthroplasty (THA) patients.

METHODS

In July, 2018, a systematic computer-based search was conducted in PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews, and Google database. Data on exercise for functional outcomes for THA patients were retrieved. The primary endpoint was walking speed. Other outcomes included physical activity scale, Harris hip score, pain scores, abduction strength, and the length of hospital stay. After testing for publication bias and heterogeneity between studies, data were aggregated for random-effects models when necessary.

RESULTS

Ten clinical studies with 441 patients were ultimately included in the meta-analysis. Compared with the control group, exercise was associated with an increase of the walking speed by 0.15 m/s than control group (weighted mean difference [WMD] 0.15; 95% confidence interval [CI] 0.08, 0.22; P = .000). Also, exercise group could also increase Harris hip score (WMD 8.49; 95% CI 5.19, 11.78; P = .000) and abduction strength than control group (WMD 9.75; 95% CI 5.33, 14.17; P = .000). What is more, exercise has a beneficial role in reducing the pain scores (WMD -1.32; 95% CI -2.07, -0.57; P = .001) and the length of hospital stay (WMD -0.68; 95% CI -1.07, -0.29; P = .001) than the control group. However, there was no significant difference between the physical activity scale (WMD -2.13; 95% CI -6.31, 2.05; P = .317).

CONCLUSIONS

Compared with control group in the management of THA, postoperative exercise has a better pain relief and clinical outcomes. Considering the beneficial of the postoperative exercise, we take a positive attitude toward use exercise for patients with THA.

Influence of preoperative opioid use on postoperative outcomes and opioid use after arthroscopic rotator cuff repair

BACKGROUND

Recent orthopedic research has questioned the effect of opioid use on surgical outcomes. This study investigated this in the context of arthroscopic rotator cuff repair. We hypothesized that preoperative opioid use would be associated with inferior outcomes and greater postoperative opioid requirements.

METHODS

A database query identified adult patients with full-thickness or partial-thickness supraspinatus tears surgically treated between 2011 and 2015. Preoperative and postoperative outcomes scores (active range of motion [AROM], American Shoulder and Elbow Surgeons [ASES], Constant scores, Simple Shoulder Test [SST], and visual analog scale [VAS] for pain) and postoperative opioid use were retrospectively recorded. Patients with less than 2 years of follow-up data at the time of the retrospective review were contacted for prospective ASES, SST, and VAS data collection.

RESULTS

A total of 200 patients, 44 of whom received opioids preoperatively, were identified for inclusion. Patients prescribed preoperative opioids had consistently inferior preoperative and postoperative outcomes scores; however, the magnitudes of improvement were not significantly different between groups. Postoperatively, patients in the preoperative opioid group received 1.91 (95% confidence interval, 1.31-2.78) times more opioids over a postoperative course of treatment that was 2.73 (95% confidence interval, 1.62-4.59) times longer. In addition to having a greater proportion of women, this group also had significantly higher rates of certain comorbidities, including back pain, depression, degenerative joint disease, and chronic pain conditions.

CONCLUSIONS

All patients demonstrated significant improvements in outcomes scores after surgical repair that were not significantly different between groups. However, patients taking opioids preoperatively did not ultimately reach the same level of functionality and had substantially greater opioid requirements postoperatively.

PROMIS Physical Function for prediction of postoperative pain, narcotics consumption, and patient-reported outcomes following minimally invasive transforaminal lumbar interbody fusion

OBJECTIVEThis study aimed to determine if the preoperative Patient-Reported Outcomes Measurement Information System, Physical Function (PROMIS PF) score is predictive of immediate postoperative patient pain and narcotics consumption or long-term patient-reported outcomes (PROs) following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).METHODSA prospectively maintained database was retrospectively reviewed. Patients who underwent primary, single-level MIS TLIF for degenerative pathology were identified and grouped by their preoperative PROMIS PF scores: mild disability (score 40-50), moderate disability (score 30-39.9), and severe disability (score 20-29.9). Postoperative pain was quantified using the visual analog scale (VAS), and narcotics consumption was quantified using Oral Morphine Equivalents. PROMIS PF, Oswestry Disability Index (ODI), 12-Item Short-Form Health Survey, Physical Component Summary (SF-12 PCS), and VAS back and leg pain were collected preoperatively and at 6-week, 3-month, 6-month, and 12-month follow-up. Preoperative PROMIS PF subgroups were tested for an association with demographic and perioperative characteristics using 1-way ANOVA or chi-square analysis. Preoperative PROMIS PF subgroups were tested for an association with immediate postoperative pain and narcotics consumption in addition to improvements in PROMIS PF, ODI, SF-12 PCS, and VAS back and leg pain by using linear regression controlling for statistically different demographic characteristics.RESULTSA total of 130 patients were included in this analysis. Patients were grouped by their preoperative PROMIS PF scores: 15.4% had mild disability, 63.8% had moderate disability, and 20.8% had severe disability. There were no significant differences among the subgroups in terms of age, sex, smoking status, and comorbidity burden. Patients with greater disability were more likely to be obese and to have workers' compensation insurance. There were no differences among subgroups in regard to operative levels, operative time, estimated blood loss, and hospital length of stay. Patients with greater disability reported higher VAS pain scores and narcotics consumption for postoperative day 0 and postoperative day 1. Patients with greater preoperative disability demonstrated lower PROMIS PF, ODI, SF-12 PCS, and worse VAS pain scores at each postoperative time point.CONCLUSIONSPatients with worse preoperative disability, as assessed by PROMIS PF, experienced increased pain and narcotics consumption, along with less improvement in long-term PROs. The authors conclude that PROMIS PF is an efficient and accurate instrument that can quickly assess patient disability in the preoperative period and predict both short-term and long-term surgical outcomes.

Intracameral lidocaine as supplement to classic topical anesthesia for relieving ocular pain in cataract surgery

AIM

To evaluate safety, efficacy, and patient adherence of intracameral lidocaine as supplement of classic topical anesthetic drops in cataract surgery.

METHODS

A prospective and controlled trial including a large cohort of 1650 individuals suffering with bilateral cataract not complicated, in program by phacoemulsification surgery, were randomly assigned to 2 different groups for the type of anesthesia received, 0.4% oxybuprocaine hydrochloride (INN) drops, and INN drops associated to intracameral 1% lidocaine hydrochloride monohydrate. At the end of surgery, tables were assigned to each patient indicating the degree of pain (0-3) felt during the operation.

RESULTS

Thirty-two percent of patients in group 1 declared to have not felt any pain against the 77% of patients in group 2. Fifty-nine percent of patients in group 1 complained about only a slight discomfort against 20% of group 2 patients. Only a small percentage of patients in group 1 (5%) admitted severe pain, while no patient in group 2 admitted severe pain. Four patients of group 2 reported an episode of transient amaurosis, lasting several hours after surgery.

CONCLUSION

Intracameral administration of lidocaine is a simple and secure method able to increase the analgesia during the cataract surgery, eliminating the discomfort and increasing also the cooperation of the patients during the steps of manipulation.

The efficacy of thoracic paravertebral block for thoracoscopic surgery: A meta-analysis of randomized controlled trials

BACKGROUND

The efficacy of thoracic paravertebral block for thoracoscopic surgery remains controversial. We conduct a systematic review and meta-analysis to explore the impact of thoracic paravertebral block on thoracoscopic surgery.

METHODS

We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through August 2018 for randomized controlled trials (RCTs) assessing the effect of thoracic paravertebral block on thoracoscopic surgery. This meta-analysis is performed using the random-effect model.

RESULTS

Six RCTs involving 300 patients are included in the meta-analysis. Overall, compared with control group for thoracoscopic surgery, thoracic paravertebral block results in significantly reduced pain scores within 6 hours (Std. MD = -2.15; 95% CI = -3.67 to -0.62; P = .006), postoperative anesthesia consumption during 48 hours (Std. MD = -1.81; 95% CI = -3.05 to -0.58; P = .004), and hospital stay (Std. MD = -1.19; 95% CI = -2.13 to -0.26; P = .01), but has no important impact on pain scores at 24 hours (Std. MD = -1.10; 95% CI = -2.77-0.57; P = .20), and 48 hours (Std. MD = -1.25; 95% CI = -2.86-0.36; P = .13).

CONCLUSIONS

Thoracic paravertebral block can substantially enhance pain management for thoracoscopic surgery.

Efficacy of the Stellate Ganglion Block Through the Lateral Approach Using Ultrasonogram and Fluoroscopy

OBJECTIVE

Stellate ganglion (SG) block can provide pain relief in sympathetically mediated painful conditions. SG block at the sixth cervical (C6) vertebra level through lateral approach under the ultrasonogram (USG) guidance is very safe but may spare the fibres supplying the upper limb. When the drug is given at the C6 subfascially, it spreads along the cervical sympathetic chain, blocking the head/neck and upper limb. In this study, we assessed the efficacy of the SG block given at the C6 level after confirming the subfascial needle position under USG and downward spread of dye under fluoroscopy.

METHODS

Ten patients with sympathetically mediated painful conditions belonging to the American Society of Anesthesiologists (ASA) Class I and II and aged between 18 and 60 years were included in the study. The SG was approached laterally under the USG guidance, and the dye was injected after confirming the subfascial needle position. A downward spread of dye was confirmed on fluoroscope, and 4 mL of 0.25% of bupivacaine with 40 mg of methylprednisolone was injected. Patients were assessed in terms of the pain relief, an increase in axillary temperature and adverse events after 30 minutes. A statistical analysis was done with Student's t-test and paired samples t-test.

RESULTS

There was a statistically significant reduction in the post-block pain scores with the rise in temperature in the ipsilateral arm (p=0.000). The dye spread was observed from the fourth cervical vertebra to the first thoracic vertebra in all patients. Transient hoarseness was seen in 20% of patients, and the sensation of a lump was seen in 10% of patients.

CONCLUSION

We conclude that SG can be blocked effectively and safely through the lateral approach at the C6 level under ultrasonogram and fluoroscopic guidance.

Bisphosphonate Use in Pediatric Oncology for Pain Management

The use of bisphosphonates for pain control in children with cancer is not extensively studied. We retrospectively evaluated 35 children with cancer treated with intravenous bisphosphonates for pain management at a single institution from 1998 through 2015. We analyzed pain scores and opioid and adjuvant medication consumption before bisphosphonate administration, daily for 2 weeks, and at 3 and 4 weeks after administration. We also determined the time interval between diagnosis and first administration of bisphosphonates and duration of life after bisphosphonate administration. Mean pain scores were 2.45 (±2.96) and 0.75 (±1.69) before and 14 days after bisphosphonate administration, respectively ( P = .25), and morphine equivalent doses of opioids were 5.52 (±13.35) and 5.27 (±9.77), respectively ( P = .07). Opioid consumption was significantly decreased at days 4 to 8, days 11 to 12, and week 3 after first bisphosphonate administration. The median duration of life after first bisphosphonate administration was 80 days, indicating its use late in the course of treatment. Bisphosphonates did not significantly improve pain outcomes at 2 weeks, but opioid consumption was reduced at several time points during the first 3 weeks. The use of bisphosphonates earlier in the course of pediatric oncological disease should be evaluated in prospective investigations.

Intraoperative Infiltration of Liposomal Bupivacaine vs Bupivacaine Hydrochloride for Pain Management in Primary Total Hip Arthroplasty: A Prospective Randomized Trial

BACKGROUND

Pain management after total hip arthroplasty is well studied. Nevertheless, there is no consensus regarding the "cocktail" to use in periarticular infiltration (PAI). Liposomal bupivacaine (LB) is a slow release local anesthetic that can be infiltrated during surgery. In this study, we compared LB to bupivacaine hydrochloride (HCL).

METHODS

Between September 2014 and March 2016, 181 patients were screened for this prospective randomized trial. A total of 107 patients were enrolled and studied. Patients were separated into LB and control groups. LB group (50) received PAI with LB and bupivacaine HCL with epinephrine and the control group (57) received PAI with bupivacaine HCL and epinephrine. Patient morphine equivalent consumption, pain score estimated on visual analog scale, time to first ambulation greater than 20 feet, time to discharge, drug-related side effects, and patient falls were documented. Data were collected up to 72 hours postoperation.

RESULTS

There was no significant difference in morphine equivalent consumption in any of the 12-hour time blocks, up to 72 hours. No patient falls were documented in either group. Time to first ambulation greater than 20 feet, ambulation same day as surgery, time to discharge, and drug-related side effects were not significantly different between groups.

CONLCUSION

Intraoperative PAI with LB did not result in significant differences in postoperative opioid consumption, pain scores, opioid-related side effects, time to first ambulation, and length of stay up to 72 hours following total hip arthroplasty compared to a control group.