A double-blinded, placebo-controlled, randomized study to evaluate the efficacy of perioperative dextromethorphan compared to placebo for the treatment of postoperative pain: a study protocol.

BACKGROUND: Pain management is a critical component of comprehensive postsurgical care, as it influences patient safety and outcomes, and inadequate control has been associated with the development of chronic pain syndromes. Despite recent improvements, the management of postoperative pain following total knee arthroplasty (TKA) remains a challenge. The use of opioid-sparing, multimodal analgesic regimens has broad support, but there is a paucity of high-quality evidence regarding optimal postoperative protocols and novel approaches are needed. Dextromethorphan stands out among both well-studied and emerging pharmacological adjuncts for postoperative pain due its robust safety profile and unique pharmacology. The purpose of this study is to evaluate the efficacy of multi-dose dextromethorphan for postoperative pain control following TKA. METHODS: This is a single-center, multi-dose, randomized, double-blinded, placebo-controlled trial. A total of 160 participants will be randomized 1:1 to receive either 60 mg oral dextromethorphan hydrobromide preoperatively, as well as 30 mg 8 h and 16 h postoperatively, or matching placebo. Outcome data will be obtained at baseline, during the first 48 h, and the first two follow-up visits. The primary outcome measure will be total opioid consumption at 24 h postoperatively. Secondary outcomes related to pain, function, and quality of life will be evaluated using standard pain scales, the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) questionnaire, the Patient-Reported Outcomes Measurement Information System (PROMIS-29) questionnaire, and clinical anchors. DISCUSSION: This study has a number of strengths including adequate power, a randomized controlled design, and an evidence-based dosing schedule. As such, it will provide the most robust evidence to date on dextromethorphan utilization for postoperative pain control following TKA. Limitations include not obtaining serum samples for pharmacokinetic analysis and the single-center study design. TRIAL REGISTRATION: This trial has been registered on the National Institute of Health's ClinicalTrials.gov (NCT number: NCT05278494). Registered on March 14, 2022.

Peripheral Nerve Block Utilization is Associated With Decreased Postoperative Opioid Consumption and Shorter Length of Stay Following Total Knee Arthroplasty.

Background: This study aims to examine differences in postoperative complications and opioid consumption associated with perioperative peripheral nerve block (PNB) utilization during primary total knee arthroplasty (TKA). Methods: The Premier Healthcare Database was queried for adult patients who underwent primary, elective TKA from 2015 to 2020. Patients who received a femoral or adductor canal PNB were compared to patients who did not. PNB utilization was trended from 2015 to 2020. Univariate and multivariate regression analyses were performed to assess differences in the 90-day risk of postoperative complications between groups. The average inpatient opioid consumption in morphine milligram equivalents was assessed as a function of length of stay. Results: Overall, 609,991 patients were included. PNB utilization increased from 9.29% in 2015 to 30.3% in 2020. After controlling for confounders, the PNB cohort was more likely to have same-day discharge (adjusted odds ratio [aOR] 1.88) and had a decreased risk of periprosthetic joint infection (aOR 0.87), pulmonary embolism (aOR 0.81), and respiratory failure (aOR 0.78). However, there was an increased risk of seroma (aOR 1.75) and hematoma (aOR 1.22) associated with PNB utilization. Lower average overall opioid exposure was seen in the PNB cohort vs no-PNB cohort (82.1 ± 194.7 vs 89.4 ± 214.1 morphine milligram equivalents, P < .001). Conclusions: PNB utilization during primary TKA is associated with a shorter length of stay and decreased risk of multiple postoperative complications, as well as reduced postoperative opioid consumption. These data provide evidence in support of the safety and efficacy of this emerging practice. However, the clinical relevance of an increased risk of seroma and hematoma formation may warrant further investigation.

A Survey of Current Preferences of Plastic Surgeons Regarding the Assessment and Reduction of Preoperative Patient Anxiety.

BACKGROUND: Preoperative anxiety is a common phenomenon in plastic surgery that has been associated with numerous negative patient outcomes. Little is known about the preferences of plastic surgeons regarding management of patient preoperative anxiety OBJECTIVE: To determine the preferences of plastic surgeons regarding the assessment and reduction of adult preoperative patient anxiety in their primary practice setting. METHODS: The membership of the American Council of Academic Plastic Surgeons (ACAPS) was surveyed using an anonymous, online questionnaire from April to June of 2020. RESULTS: A total of 100 participants from a membership of 532 responded (19%). The majority of respondents (63%) did not formally assess patient anxiety but supported the use of standardized scales to measure anxiety (57%). Most plastic surgeons preferred patient education (81%), family member presence (69%), and visit from the anesthesiologist (54%) to reduce patient anxiety. Plastic surgeons also allocated the most responsibility to anesthesiologists (63%) and plastic surgeons (62%) to reduce preoperative anxiety. DISCUSSION: Most plastic surgeon members of ACAPS did not assess their patients' anxieties preoperatively but appeared willing to use anxiety scales. Plastic surgeons also supported several measures to reduce anxiety, especially patient education, family member preferences, and anesthesiologist visits. Although plastic surgeons appeared to hold multiple parties responsible to manage preoperative anxiety, they held themselves and anesthesiologists most responsible. Future studies are needed to determine whether these views cohere with those of other healthcare providers and whether these preferences change for pediatric patients. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Addition of Intrathecal Morphine for Postoperative Pain Management in Pediatric Spine Surgery: A Meta-analysis.

STUDY DESIGN: Meta-analysis. OBJECTIVE: The objective of this study was to determine whether adjunctive intrathecal morphine (ITM) reduces postoperative analgesic consumption following pediatric spine surgery. SUMMARY OF BACKGROUND DATA: Previous studies that have tested supplemental ITM to manage pain after pediatric spine surgery have been limited by small sample sizes. METHODS: A comprehensive search of PubMed, Web of Science, Clinicaltrials.gov, and the Cochrane Central Register of Controlled Trials was performed for clinical trials and observational studies. Time to first analgesic demand, postoperative analgesic use, pain scores, and complication data were abstracted from each study. Mean difference (MD) and 95% confidence interval (CI) were used to compare continuous outcomes and odds ratios (OR) and 95% CI were used for dichotomous outcomes. RESULTS: A total of 5 studies, including 3 randomized controlled trials and 2 retrospective chart reviews, containing 636 subjects, were incorporated into meta-analysis. Subjects that were administered ITM in addition to postoperative analgesics (ITM group) were compared with those receiving postoperative analgesics only (control group). In the ITM group, time to first analgesic demand was longer (MD, 8.79; 95% CI, 4.20-13.37; P<0.001), cumulative analgesic consumption was reduced at 24 hours (MD, -0.40; 95% CI, -0.56 to -0.24; P<0.001), and cumulative analgesic consumption was reduced at 48 hours (MD, -0.43; 95% CI, -0.59 to -0.27; P<0.001). Neither postoperative pain scores at 24 hours (P=0.16) nor 48 hours (P=0.18) were significantly different between ITM and control groups. Rates of respiratory depression, nausea, vomiting, and pruritus were not different between groups (all Ps>0.05). CONCLUSIONS: Addition of ITM in pediatric spine surgery produced a potent analgesic effect in the immediate postoperative period. Patients administered ITM did not request opiates as early as control and consumed fewer opiates by the second postoperative day. Furthermore, use of ITM did not increase complications such as respiratory depression, nausea, vomiting, or pruritus.

Attitudes of Spine Surgeons Regarding Management of Preoperative Anxiety: A Cross-sectional Study.

STUDY DESIGN: This is a cross-sectional study. OBJECTIVE: To investigate spine surgeons' attitudes regarding preoperative anxiety measurement, management, and responsibility. SUMMARY OF BACKGROUND DATA: The vast majority of patients scheduled for spine surgery experience preoperative anxiety. However, there are currently no consensus guidelines for measure or management of preoperative anxiety in spinal operations. MATERIALS AND METHODS: An anonymous questionnaire was sent online to spine surgeons of AO Spine North America to capture their views regarding preoperative anxiety. RESULTS: Of 69 complete responses, most respondents were male (n=66, 95.7%), orthopedic surgeons (n=52, 75.4%), and practicing at an academic setting (n=39, 56.5%). Most spine surgeons practiced for at least 20 years (n=52, 75.4%), operated on 100-300 patients per year (n=48, 69.6%), and were attending physicians (n=61, 88.4%). Most did not measure preoperative anxiety (n=46, 66.7%) and would not use a rating scale to measure it (n=38, 55.1%). However, most would discuss it if mentioned by the patient (n=40, 58.0%). Other spine surgeons measured anxiety verbally (n=22, 31.9%) or with a rating scale or survey (n=6, 8.7%). Although preferences for preoperative anxiety management varied, most respondents used patient education (n=54, 78.3%) and permitting family members' presence (n=36, 52.2%) to reduce patient anxieties. Spine surgeons held themselves, anesthesiologists, and patients most responsible to manage preoperative anxiety. CONCLUSIONS: The majority of spine surgeons surveyed did not regularly measure preoperative anxiety, but would discuss its management if the subject was broached by the patient. Spine surgeons relied on a variety of methods to manage a patient's anxiety, but most preferred preoperative education and permitting the presence of family members. Responsibility for controlling preoperative anxiety was chiefly allocated to surgeons, anesthesiologists, and patients. Future avenues for research may include developing a preoperative anxiety measurement scale and management protocol specific to spine surgery. LEVEL OF EVIDENCE: Level IV.

Intrathecal Morphine in Spine Surgery: A Meta-analysis of Randomized Controlled Trials.

STUDY DESIGN: Meta-analysis of randomized controlled trials (RCTs). OBJECTIVE: The aim of this study was to evaluate the effectiveness of intrathecal morphine (ITM) in reducing postoperative pain and opioid analgesic consumption following spine surgery. SUMMARY OF BACKGROUND DATA: The use of ITM following adult spine surgery is of particular interest because of the ease of access to the thecal sac and the potential to provide adequate analgesia at low doses. However, previous studies of ITM have been limited by small sample sizes and conflicting results. METHODS: A comprehensive search of PubMed, Web of Science, Clinicaltrials.gov, and the Cochrane Central Register of Controlled Trials for prospective RCTs was performed by two independent reviewers. Postoperative opioid consumption, pain scores, and complications were documented from the identified studies. Standard mean differences (SMDs) were applied to continuous outcomes and odds ratios were determined for dichotomous outcomes. RESULTS: Eight RCTs involving 393 subjects met inclusion criteria and were included in this meta-analysis. Patients receiving ITM (ITM group) as an adjunct to postoperative opioid analgesic were compared to patients receiving postoperative opioids only (control group). Postoperative morphine equivalent consumption was significantly lower during the first 24 hours postoperative in the ITM group (P < 0.001). Pain scores were similarly lower in the first 24 hours following spine surgery in those who received ITM (P < 0.001). In patients administered ITM, a greater percentage experienced pruritus (P < 0.001). Respiratory depression was solely encountered in the ITM group (P = 0.25). There were no significant differences between the ITM and control groups in terms of sedation (P = 0.18), nausea (P = 0.67), vomiting (P = 0.62), or length of stay (P = 0.13). CONCLUSION: In patients undergoing spine surgery, use of ITM significantly reduced opioid analgesic consumption and Visual Analogue Schores pain scores compared to controls within the first 24 hours postoperatively. High-quality, follow-up RCTs with large sample sizes are recommended to determine the potential of supplementary ITM in spine surgery and complete the side effects profile. LEVEL OF EVIDENCE: 1.

Bilateral ultrasound-guided continuous ilioinguinal-iliohypogastric block for pain relief after cesarean delivery.

We present three cases in which continuous ilioinguinal-iliohypogastric nerve block with 0.2% ropivacaine, together with oral ibuprofen, was used to provide analgesia after cesarean delivery. The catheters were placed under ultrasound guidance in the plane between the internal oblique and transversus abdominis muscles on both sides of the abdomen. Numeric pain rating was used for the assessment of postoperative pain. Low pain scores, minimal use of supplemental opioid, and the absence of nausea and vomiting suggests that continuous ilioinguinal-iliohypogastric nerve blockade deserves further study as a possible component of multimodal analgesia after cesarean delivery.

Pediatric airway and esophageal profiles with acoustic reflectometry.

Acoustic reflectometry is a technique by which the dimensions of a cavity can be estimated in the form of an area-distance profile. We conducted a pilot study to obtain the acoustic reflectometry (AR) images associated with breathing tube (endotracheal tube, ETT) placement (inner diameter 4.5-6 mm) and positioning in 21 (n = 21) children, aged 2-12 yr. Characteristic AR profiles, as previously noted in adults, were obtained for tracheal and esophageal intubations in children. Both types of profiles showed constant area throughout the ETT length, followed distally by either a rapid area increase (tracheal) or an area decrease to a near zero value (esophageal). Relative to a tracheal profile, a bronchial intubation exhibits a decrease in area distal to the carina position. With deeper ETT insertion, abutment of the ETT against the bronchial wall can occur, with a possible profound area decrease. The occurrence of ETT abutment in children and neonates, and its possible AR detection and treatment, is discussed.