The analgesic efficacy of ultrasound-guided transversus abdominis plane block vs. local anesthetic infiltration technique in major gynecologic surgery: A randomized controlled trial

Background and Aim

Transversus abdominis plane (TAP) block and local anesthetic infiltration (LAI) technique are used as part of the multimodal analgesic regimen after abdominal surgery. Postoperative opioid consumption and analgesic efficacy was compared using TAP and LAI techniques in patients undergoing gynecologic surgery in a randomized, controlled clinical trial.

Material and Methods

Total of 135 patients scheduled for major gynecological surgeries were allocated into three groups: group T received bilateral TAP block with bupivacaine 0.25%; group I received LAI with 0.25% bupivacaine with epinephrine 5 μ/mL in the peritoneum and abdominal wall, and group C was control group. Anesthesia and postoperative analgesia were standardized. Outcome measures were cumulative and rescue tramadol consumption, numerical rating score (NRS) for pain and side effects in post-anesthesia care unit (PACU) at 4, 8, 12 hours postoperatively.

Results

Tramadol consumption, need for rescue analgesia, and NRS for pain between three groups at 4, 8, and 12 hours postoperatively had no statistically significant difference (P < 0.05). In PACU, median tramadol consumption used for rescue analgesia between group T (15 (15-30)) and group C (30 (15-45)) (P = 0.035), and between group T (15 (15-30)) and group I (30 (15-52)) was statistically significant (P = 0.034). In PACU, the percentage of patients having NRS >4 on movement in group C (72%) compared to group T (46.5%) and group I (46.5%) was significant (P = 0.034). No statistically significant difference was observed in the incidence of side effects among study groups (P > 0.05).

Conclusion

Except for the immediate postoperative period, neither TAP block nor LAI had added benefit to the multimodal analgesia regimen in patients undergoing gynecological surgeries.

Mapping Levels of Palliative Care Service Development in Malaysian Public Hospitals Using the WHO Public Health Model of Palliative Care

INTRODUCTION AND OBJECTIVES

This national audit involving Ministry of Health (MOH) Hospitals aimed to map out the levels of development of palliative care services and essential palliative medication availability in Malaysia.

MATERIALS AND METHODS

An online survey coupled with manual follow up was conducted throughout all MOH hospitals in Malaysia. Data collected described elements of the palliative care service(PCS) based on the WHO public health model. Data was computed using a novel matrix to determine three key indices which were the 1) palliative care development score (PCDS), 2)essential medications availability score (EMAS) and 3) opioid availability score (OAS). These scores then allowed mapping of PCS according to scores of 1-4 (1=least developed, 4=most developed).

FINDINGS

Out of all 140 MOH hospitals 88.6% (124) completed the PCDS survey, 120(85.7%) for the EMAS survey and 140 (100%) for the OAS survey. A total of 32(25.8%) hospitals had formal PCS with 8(25%) having resident palliative physicians (RPP), 8(25%) visiting palliative physicians(VPP) and 16(50%) no palliative physician (NPP). Out of these services, 17 (53%) had dedicated palliative care beds. In the PCDS survey, hospitals with PCS had significantly higher mean PCDS of 2.59 compared to 1.02 for non-PCS hospitals (P<0.001). The EMAS survey showed 109(90.8%) hospitals had EMAS of four and the OAS survey showed that 135(96.4%) hospitals had oral morphine available.

CONCLUSION

This study shows that palliative care service development in MOH hospitals is still very limited however, majority of MOH hospitals in Malaysia have all the essential medications and oral morphine available.

Availability and Use of Essential Opioid Analgesics in Sub-Saharan Africa: A Scoping Review Protocol

Introduction

The treatment of acute, peri-operative, and chronic pain by healthcare practitioners and health systems requires appropriate access to and availability of essential opioid medications. While opioids are often oversupplied and overprescribed in high-income countries, there are significant inequities as many low- and middle-income countries (LMICs) experience severe shortages. In fact, while the richest 10% in the world reside in countries receiving almost 90% of all available opioids, 50% of the poorest in the world reside in countries receiving just 1% of all available opioids.Understanding the social, economic, cultural, and regulatory barriers to access essential opioid analgesics in LMICs is critical in delineating and prioritizing appropriate interventions. We aim to conduct a scoping review on the availability and usage of essential opioid analgesics in LMICs, specifically in sub-Saharan Africa, to identify barriers, themes, and knowledge gaps.

Materials and Methods

We will utilize the framework for conducting scoping reviews by Arksey and O'Malley. We will perform the search for articles in 3 electronic databases (i.e., SCOPUS, PubMed, Embase) and relevant gray literature. Only articles in English will be included. There will be no restriction on the publication period. All articles will directly involve either the availability and/or the use of essential opioid analgesics. Studies will be restricted to focus on sub-Saharan Africa. We will use a tailored extraction frame to extract relevant information from published articles that meet our inclusion criteria. We will analyze the data using both descriptive statistics and thematic analysis on the main study questions.

Ethics and Dissemination

Since we will not be collecting primary data, formal ethical approval is not required.Our study findings will be disseminated through abstracts, conference presentations, and peer-reviewed publications.

Highlights

50 percent of the poorest in the world reside in countries receiving just 1 percent of all available opioidsThere is a paucity of data analyzing the inequitable distribution of essential opioid analgesics worldwideOur scoping review will identify barriers, themes, and knowledge gaps on the availability and use of essential opioids in SSAIt will identify areas for further research and potential policy initiatives.

Effective pain management as part of palliative care for persons living with HIV/AIDS in a developing country: a qualitative study

AIM AND OBJECTIVES

The aim of this research was to explore and understand nurses' experiences of managing pain for persons living with human immune virus/ acquired immune deficiency syndrome receiving palliative care at home in Botswana.

BACKGROUND

Community palliative and hospice care in Africa and Botswana were developed for persons with end-stage acquired immune deficiency syndrome and other terminal illnesses being cared for at home. As antiretro viral therapies extend the lives of persons living with human immune virus/acquired immune deficiency syndromes, there is an increase in the chronic conditions associated with human immune virus/acquired immune deficiency syndrome. Despite a strong demand for care of persons living with human immune virus/acquired immune deficiency syndromes and other chronic illnesses, little is known about Botswanan community nurses' capacity to manage community-based end-of-life care for persons living with human immune virus/acquired immune deficiency syndromes.

DESIGN

A qualitative study approach guided by van Manen's interpretive analysis was undertaken.

METHODS

Data were collected using semi-structured interviews that were audio-recorded, transcribed and analysed using qualitative interpretive analysis. Thirteen nurses from 12 health districts in Botswana were recruited to the study using purposeful sampling.

RESULTS

Participants identified that pain management was a significant issue. A lack of nurses' ability to advocate effectively for patients because of a lack of relevant skills and knowledge and poor availability of appropriate analgesics was a limiting factor along with doctors' reluctance to prescribe opioids to effectively manage pain.

CONCLUSION

Lack of resources coupled with lack of training for nurses has a negative impact on palliative care and the delivery of care services to persons living with human immune virus/acquired immune deficiency syndromes in Botswana.

RELEVANCE TO CLINICAL PRACTICE

Being attentive and listening to the nurses' voices in the provision of palliative care at home is an essential element in identifying the challenges they encounter. Lack of adequate palliative care training and a chronic shortage of resources have serious implications for the delivery of home-based palliative care in Botswana.

Opioid availability and palliative care in Nepal: influence of an international pain policy fellowship

Globally, cancer incidence and mortality are increasing, and most of the burden is shifting to low- and middle-income countries (LMICs), where patients often present with late-stage disease and severe pain. Unfortunately, LMICs also face a disproportionate lack of access to pain-relieving medicines such as morphine, despite the medical and scientific literature that shows morphine to be effective to treat moderate and severe cancer pain. In 2008, an oncologist from Nepal, one of the poorest countries in the world, was selected to participate in the International Pain Policy Fellowship, a program to assist LMICs, to improve patient access to pain medicines. Following the World Health Organization public health model for development of pain relief and palliative care, the Fellow, working with colleagues and mentors, has achieved initial successes: three forms of oral morphine (syrup, immediate-release tablets, and sustained-release tablets) are now manufactured in the country; health-care practitioners are receiving training in the use of opioids for pain relief; and a new national palliative care association has developed a palliative care training curriculum. However, long-term implementation efforts, funding, and technical assistance by governments, philanthropic organizations, and international partners are necessary to ensure that pain relief and palliative care become accessible by all in need in Nepal and other LMICs.