Effect of a comfort scale compared with a pain numerical rate scale on opioids consumption in postanaesthesia care unit: the COMFORT study.

BACKGROUND: The way that pain is assessed in the PACU could impact on postoperative pain and analgesic consumption. However, there is currently no evidence to support this speculation. The authors hypothesised that using a comfort scale reduces postoperative opioid consumption when compared with a standard numerical rating scale (NRS) to evaluate pain in the PACU. METHODS: In this cluster-randomised trial, patients were assessed using either a comfort scale (comfort group) or a pain NRS (NRS group). The primary outcome was the opioid consumption in the PACU. The main secondary outcomes were postoperative pain, nausea and vomiting, length of stay in the PACU, and satisfaction. RESULTS: Of 885 randomised patients, 860 were included in the analysis. Opioid consumption in the PACU was comparable in the comfort and NRS groups (median [interquartile range [IQR] 0 (0-5) vs 0 (0-6); P=0.2436), irrespective of the type of surgical procedure. The majority of patients did not need any postoperative opioid (59% in the comfort group and 56% in the NRS group, P=0.2260). There was no difference in postoperative pain, nausea and vomiting, time to reach an Aldrete score ≥9 after extubation, and global satisfaction. CONCLUSIONS: Using a comfort scale to assess pain in the PACU did not spare any opioid compared with use of a standard NRS. Further studies focusing on patients at risk of increased postoperative opioid consumption are necessary. CLINICAL TRIAL REGISTRATION: NCT05234216.

Acupuncture Provides Short-Term Functional Improvements and Pain Relief for Patients After Knee Replacement Surgery: A Systematic Review and Meta-analysis.

The impact of acupuncture on knee function and pain intensity following knee replacement remains controversial. Therefore, we categorized the postsurgery recovery period into 3 phases: short-term (≤2 weeks), intermediate-term (2 weeks-3 months), and long-term (>3 months), and then assessed the effectiveness of acupuncture in improving function and alleviating pain at different stages following knee replacement. This meta-analysis included randomized controlled trials that compared acupuncture intervention with either no treatment or a sham group after knee replacement. Six databases were searched from inception to December 31, 2023, including PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and 2 Chinese databases (Chinese National Knowledge Infrastructure and WanFang Data). A total of 23 studies comprising 1,464 participants were included. Significant improvement of active range of motion was observed on day 7 and week 2 after operation. Lower pain intensity at rest was noted in patients receiving acupuncture in short-term periods after operation (12 hours, day 1, day 2, day 5, and week 2). A reduction in pain intensity during movement with acupuncture was observed on postoperative day 1 and day 7. Auricular acupuncture did not show not significant effectiveness in improving range of motion and pain intensity. For conventional acupuncture, the combination of distal and local point selection was found to be the most effective. Early application of acupuncture, in conjunction with physical therapy, starting before postoperative day 1 or day 2, was recommended. Further high-quality researches are warranted to validate the findings in this meta-analysis. PERSPECTIVE: This article demonstrates that acupuncture has short-term effects (≤2 weeks) on improving active range of motion and reducing pain during rest and during movement following knee replacement surgery. The findings support the early application of acupuncture in hospital settings after knee replacement. REGISTRATION ID: The study was registered on PROSPERO (CRD42024503479).

Effects of anterior quadratus lumborum block versus erector spinae plane block on postoperative acute pain in percutaneous nephrolithotomy: a prospective, observational study.

BACKGROUND: The study aimed to compare the pain-relieving effectiveness of anterior quadratus lumborum block (QLB3) and erector spinae plane block (ESPB), both of which have been documented to provide relief during abdominal surgery. METHODS: This prospective observational study, conducted between February and July 2023, included 96 patients who had undergone percutaneous nephrolithotomy (PCNL). Patients were divided into three groups: QLB3, ESPB, and control (no block) and received the corresponding nerve block in the preanesthetic room for regional block. Cumulative morphine consumption during the initial 24 h after PCNL, numerical rating scale resting/movement scores, intraoperative remifentanil usage, rescue analgesic requirements, time when the first analgesic was requested, and postoperative nausea and vomiting scores were documented and compared between the groups. RESULTS: Total median morphine consumption in the first 24 h postoperatively was similar in the QLB3 and ESPB groups but higher in the control group (QLB3, 7 mg [(Q1-Q3) 7-8.5]; ESPB, 8 mg [6.5-9]; control, 12.5 [10-17]; P < 0.001). Similarly, median intraoperative remifentanil consumption did not differ between the block groups but was higher in the control group (QLB3, 1082 µg [IQR 805.5-1292.7]; ESPB, 1278 µg [940.2-1297.5]; control, 1561 µg [1315-2068]; P < 0.001). The number of patients receiving rescue analgesic medication was similar in the block groups but higher in the control group (QLB3, n = 9 [30%]; ESPB, n = 14 [46.7%]; control, n = 21 [70%]; P = 0.008). CONCLUSIONS: QLB3 and ESPB were adequate and comparable in providing postoperative analgesia as part of multimodal analgesia after PCNL. TRIAL REGISTRATION: The study was registered on ClinicalTrials.gov (Identifier: NCT05822492).

Exploration of the mechanism underlying the therapeutic effect of electroacupuncture at chengshan acupoint on post-hemorrhoidectomy anal pain: Insights from the mAChRs/IP3-Ca2+-CaM signaling pathway.

OBJECTIVE: In the context of postoperative anal pain, understanding the intricate mechanisms and effective interventions is paramount. This study investigates the role of Muscarinic Acetylcholine Receptors (mAChRs) and the IP3-Ca2+-CaM signaling pathway in a rat model of postoperative anal pain, exploring the potential analgesic effects of electroacupuncture. METHODS: Comprehensive approaches involving mechanical sensitivity assays, Western blotting, immunohistochemistry, and intracellular calcium concentration measurement were used. RESULTS: The authors found elevated mAChRs expression in the postoperative pain model. Antagonizing mAChRs reduced pain sensitivity and attenuated the IP3-Ca2+-CaM pathway. Remarkably, electroacupuncture treatment further mitigated pain, potentially by suppressing this signaling cascade. INTERPRETATION: These findings reveal a novel connection between mAChRs and the IP3-Ca2+-CaM pathway in postoperative anal pain and suggest electroacupuncture as a promising avenue for pain relief through these mechanisms, offering insights into innovative strategies for postoperative pain management.

The effect of intraoperative methadone on postoperative opioid requirements in children undergoing orchiopexy: A randomized clinical trial.

BACKGROUND: Children undergoing outpatient surgery are at risk of inadequate postoperative pain control. Methadone has a long duration of action and an intraoperative dose may provide stable analgesia throughout the postoperative period. Intraoperative methadone has been shown to improve pain control in adolescents but its use for postoperative pain in pediatric patients undergoing outpatient surgery has not been studied before. Therefore, we conducted a double-blind randomized placebo-controlled trial to investigate the effects of a single dose of intraoperative methadone in children aged less than 5 years undergoing orchiopexy for undescended testis. METHODS: A total of 68 children were randomized to receive either methadone (0.1 mg/kg) or isotonic saline following induction of anesthesia. Exclusion criteria included preterm birth, previous scrotal surgery, and parents' inability to consent. Primary outcomes were opioid requirements (first primary outcome) and pain intensity in the post-anesthesia care unit. Secondary outcomes included episodes of desaturation and time until readiness to discharge from the post-anesthesia care unit, sleep on the first postoperative night, pain intensity, and opioid requirements at home until the evening on the first postoperative day. Follow-up was 4 days. RESULTS: Sixty children completed the study (age, mean ± SD, 26.2 ± 13.9 months), 29 children received methadone, and 31 children received placebo. Eighteen children required opioids in the post-anesthesia care unit, five children in the methadone group (proportion = 0.17, 95% confidence interval (CI): 0.07, 0.36) compared to thirteen patients in the placebo group (0.42, 95% CI: 0.26, 0.60) (mean difference = -0.24 and 95% CI: -0.03, -0.47) (p = 0.037). Five children in the methadone group (0.17, 95% CI: 0.03, 0.31) versus ten in the placebo group (0.32, 95% CI: 0.16, 0.49) had a face, legs, activity, cry, consolability score of ≥5 in the post-anesthesia care unit (mean difference = -0.15, 95% CI: -0.36, 0.06) (p = .179). More children in the placebo group woke up due to pain the first night following surgery (seven children vs. one child). The methadone group had a longer stay in the post-anesthesia care unit. There were no differences between the two groups regarding the other secondary outcomes. CONCLUSION: A single dose of intraoperative methadone reduces short-term postoperative opioid requirements in children after orchiopexy for nondescended testes but prolongs the duration of their stay in the post-anesthesia care unit.

[Pain relief after abdominal oncologic surgery. Evaluation of the effectiveness and safety of a fixed combination of diclofenac and orphenadrine]. / Obezbolivanie posle abdominal'nykh onkokhirurgicheskikh vmeshatel'stv. Otsenka effektivnosti i perenosimosti fiksirovannoi kombinatsii diklofenaka i orfenadrina.

OBJECTIVE: Evaluation of the analgesic, opioid-sparing, anti-inflammatory and adverse effects of the diclofenac and orphenadrine (Neodolpasse) fixed combination for analgesia in the postoperative period of surgical cancer patients. MATERIAL AND METHODS: A randomized, single-center, prospective, comparative study evaluated two analgesic regimens in 40 cancer patients undergoing various open cavity surgeries, including extensive combined interventions associated with the resection of 3 or more organs. The study was conducted following the transfer from the ICU to the surgical department during the early activation period, within the first two postoperative days. In the first group N (n=20), "Neodolpasse" (a fixed combination of 75 mg Diclofenac and 30 mg Orphenadrine) was administered as an infusion, twice daily. In the second group K (n=20) analgesia was performed with ketoprofen as an intravenous infusion at a daily dose of 200 mg. Patients in both groups received scheduled prolonged epidural analgesia with 0.2% ropivacaine, and when the severity of pain in a visual analogue scale (VAS) increased to more than 40 mm, so an additional dose of 100 mg tramadol was administered intramuscularly. Daily measurments of blood creatinine level and C-reactive protein were taken, postoperative blood loss was accounted for, as well as postoperative complications according to the Clavien-Dindo classification. RESULTS: The comparative analysis of the indicators of pain syndrome severity showed that the patients in group N exhibited a more pronounced analgesic effect, so on the second postoperative day 30% of patients reported moderate pain (from 50 to 60 mm on the pain scale), on the third day - 15%, and by the fourth day - all 100% of patients experienced pain of low intensity. The additional analgesia with tramadol in group N was required twice less than in the comparison group, and such adverse effects as nausea, drowsiness, and weakness were significantly more common in the ketoprofen group. In both groups, the average blood creatinine level did not exceed permissible values, and the C-reactive protein was elevated at all stages of the study but tended to decrease by the fourth day. The analysis of postoperative complications according to the Clavien-Dindo scale at the time of discharge did not reveal a direct correlation between the occurred complications and the use of NSAIDs. Adverse effects such as anastomotic failure, gastrointestinal complications, or other hemorrhagic manifestations were not recorded. CONCLUSION: The inclusion of Neodolpasse into multimodal analgesic regimens resulted in the most pronounced analgesic and opioid-sparing effects in surgical cancer patients using laparotomy access. Additionally, the application of short courses of nonsteroidal anti-inflammatory drugs (NSAIDs) was associated with a favorable safety profile.

Understanding the role of intraoperative hypothermia in perioperative opioid requirements in immediate implant-based breast reconstruction.

BACKGROUND: The relationship between perioperative temperatures and postoperative pain is unknown. The present study investigated the relationship of intraoperative hypothermia and perioperative opioid requirements after immediate implant-based breast reconstruction. METHODS: A retrospective chart review was conducted on patients undergoing immediate implant-based breast reconstruction from 2019-2023. Patients were classified into the hypothermic group (majority of procedure <36.0 °C) or normothermic group (majority of procedure ≥36.0 °C). Cumulative inpatient opioid requirements (morphine milli-equivalents [MMEs]) and frequency of patients requiring "high-dose opioids" (≥100 MMEs) were collected and compared between the groups. RESULTS: In total, 536 patients (835 breasts) were included, among whom 135 (25.1%) were hypothermic. The hypothermic group had lower mean intraoperative (88.4 vs. 99.1 MMEs, P = 0.007) and postoperative (45.6 vs. 56.8 MMEs, P = 0.006) than the normothermic group. Mean (B = 14.6, P = 0.004) and nadir (B = 10.4, P = 0.038) intraoperative temperatures directly predicted higher opioid requirements while higher percentages of the procedure time spent under 36 °C (B = -27.6, P = 0.004) predicted lower opioid requirements. The hypothermic group was associated with 66% decreased odds of requiring high-dose opioids after adjusting for differences in patient and operative characteristics (P = 0.007). CONCLUSION: Hypothermia is associated with decreased perioperative opioid requirements. Future studies should further investigate ideal temperature thresholds for warming protocols to minimize postoperative pain.

Local ketorolac infiltration for postoperative pain in open trigger finger surgery: a randomized controlled trial.

BACKGROUND: Multimodal analgesia is crucial for effective postoperative pain management in minor hand surgeries, enhancing patient satisfaction. The use of local wound infiltration with Ketorolac as an adjuvant pain management strategy is proposed for open trigger finger release surgery. This study aims to compare pain scores and functional outcomes between local wound infiltration with Ketorolac and oral non-steroidal anti-inflammatory drugs. METHODS: This study is a double-blind, parallel design, randomized controlled trials. Sixty-nine patients underwent trigger finger surgery between December 2021 and October 2022 were randomized into one of three groups: oral Ibuprofen alone group, local Ketorolac alone group and local Ketorolac with oral Ibuprofen group. The assessment included postoperative numeric rating scale (NRS) pain score, Disabilities of the Arm, Shoulder, and Hand (DASH) score, grip strength, mobility of proximal interphalangeal (PIP) joint. and complications. RESULTS: NRS pain scores during movement of the operated fingers were significantly lower at 6 h in local Ketorolac alone group and local Ketorolac with oral Ibuprofen group compared to oral Ibuprofen alone group. However, there were no significant differences between the groups in postoperative DASH scores, grip strength, mobility of PIP joints, and complications. CONCLUSIONS: Local infiltration of Ketorolac as an adjunct in postoperative pain management has been shown to provide superior analgesia during finger movement within the initial 6 h following trigger finger surgery, in comparison to oral NSAIDs. CLINICAL TRIAL REGISTRATION: Thaiclinicaltrials.org identifier: TCTR20210825002. Registered 25/08/2021. https://www.thaiclinicaltrials.org/show/TCTR20210825002.

Liposomal Bupivacaine via an Adductor Canal Block Compared to a Peripheral Nerve Catheter and No Block After Total Knee Arthroplasty: A Retrospective Analysis.

Background As total knee arthroplasty is one of the most common surgeries in the United States, it is important to identify regional anesthesia methods that optimize patient recovery. This study evaluates the effectiveness of adductor canal (AC) blocks with liposomal bupivacaine (LB) compared to other regional anesthesia techniques. We hypothesized that patients receiving single-shot (SS) AC blocks with LB would have lower postoperative opioid consumption compared to other groups. Methods A retrospective cohort analysis was conducted on patients from a single institution between January 2014 and December 2021. The primary outcome assessed was postoperative opioid use, with secondary outcomes including postoperative pain scores and hospital length of stay. Results The final analysis included 280 patients: 41 received an SS AC block with plain local anesthetic, 76 received a peripheral nerve catheter (PNC) with continuous ropivacaine, 79 received an SS AC block with LB, and 84 received no block. In fully adjusted models, postoperative opioid consumption on day one was significantly lower in the SS AC block with LB group compared to the no block group (b = 23.2, SE = 5.7, p < 0.0001), the PNC group (b = 15.5, SE = 5.7, p = 0.01), and the SS AC block with plain local anesthetic group (b = 18.9, SE = 6.9, p = 0.01). Additionally, hospital length of stay was significantly reduced in the LB group compared to the no block group (b = 1.5, SE = 0.3, p < 0.0001), the PNC group (b = 1.1, SE = 0.3, p < 0.0001), and the SS AC block with plain local anesthetic group (b = 1.5, SE = 0.3, p < 0.0001). Conclusions Patients who received an AC block with LB had higher pain scores on postoperative day 0 (POD0) but required less opioid medication on postoperative day 1 (POD1) and had a shorter hospital stay compared to patients who received other types of AC blocks or no block.

A Clinical Study of Anterior Abdominal Wall Hernias and Its Management: A Medical College Experience.

Objective We aim to evaluate the various risk factors contributing to the occurrence of anterior abdominal wall hernias and assess the various surgical modalities. Materials and methods This prospective observational research was conducted between 2022 and 2024 at a tertiary care health center, involving 100 participants with an anterior abdominal wall hernia diagnosis aged over 14 years. The study excluded patients under 14 years with bleeding diathesis, inherited coagulopathies, inguinal or femoral hernias, or recurrent ventral hernias. Participants underwent detailed clinical examinations and biochemical evaluations and underwent a primary ultrasonography (USG)/contrast-enhanced computed tomography (CECT) to determine defect size. Risk factors were documented, including age, gender, occupation, body mass index (BMI), comorbidities, previous surgery history, multiparity, smoking, chronic straining due to constipation or benign prostatic hyperplasia (BPH), malnutrition, chronic steroid use, chronic renal failure, and chronic liver disease. The surgical procedure was determined by the same surgical team for all cases. Standard antibiotic prophylaxis and preoperative painting/draping protocols were followed in all cases. Intraoperatively, intraoperative time (in hours) was documented. Postoperative parameters included pain, hematoma formation, seroma formation, surgical site infections (SSIs), and early recurrence. These intra- and postoperative findings constituted the primary outcome parameters. Secondary outcome parameters included hospital stay duration and time taken to return to work. Data analysis was performed using Statistical Package for the Social Sciences (SPSS) version 16 (IBM SPSS Statistics, Armonk, NY) software. Results The study analyzed the occurrence of ventral hernias in 100 patients, with the fourth decade having the highest occurrence (n=42 (42%)). The majority of the participants were male (female: n=47 (47%), male: n=53 (53%)). The majority of the participants were laborers, and 24% (n=24) were office workers. The study found that hypertension, diabetes mellitus, and chronic obstructive pulmonary disease were risk factors for hernias. Other risk factors included obesity, previous history of surgery, multiparity, smoking, chronic straining, malnutrition, and chronic steroid use. The most common type of ventral hernia was umbilical hernia (n=33 (33%)), followed by paraumbilical hernias (n=30 (30%)), and incisional hernias (n=20 (20%)). Of the 100 patients, 74% underwent open hernia repair, with the mean operation time being minimal in cases managed with laparoscopic repair (2.5±0.67 hours). Postoperative pain was highest with the Rives-Stoppa (RS) repair with component separation group. The incidence of surgical site infection was the maximum among cases of open anatomical repair (41.7%), followed by RS repair (31.3%), while it was the minimum in laparoscopic repair (3.7%). Early recurrence was lower in the laparoscopic group (n=1 (3.7%)). Conclusion The study highlights risk factors for abdominal wall hernia and management approaches. Understanding these is crucial for identifying and preventing recurrence. Surgeons must choose the right surgical approach based on patient health and symptoms to achieve desired outcomes and minimize complications. In addition, surgical expertise, availability of resources, and knowledge of what works best for the surgeon constitute important determinants of surgical outcomes.

Effect of sublingual fast-dissolving piroxicam premedication on postoperative pain experience in mandibular molars with non-vital pulp: a randomized double-blind controlled trial.

BACKGROUND: The aim of this trial was to evaluate the effect of a preoperative, single dose sublingual fast-dissolving piroxicam (20 mg) compared to placebo on postoperative pain at rest (POP), on biting (POPB) and on percussion (POPer) after single-visit endodontic treatment of asymptomatic mandibular molars with non-vital pulp. METHODS: Seventy patients randomly received either piroxicam or placebo 1 h before treatment (n = 35). Patients recorded their pain (POP and POPB) level 6 h, 12 h, 24 h, 48 h, 72 h and 7 days postoperatively using an 11-point numerical rating scale; POPer was assessed after 7 days. Resuce-analgesic intake (RAI) and flare-up incidence (FUI) were recorded. Data were statistically analyzed. RESULTS: Both groups had similar baseline characteristics (P > 0.05). Piroxicam showed less POP intensity and incidence than placebo at 6, 12 and 24 h, less POPB intensity and incidence at all timepoints, less POPer intensity and incidence and less RAI (p > 0.05), but similar FUI (P > 0.05). A significant rise in pain compared to baseline occurred with placebo from 6 to 72 h for POP and to 7 days with POPB (p > 0.05); such rise was not detected with piroxicam. POPB showed higher pain intensity than POP at all time points (p < 0.05). No swelling or adverse effects occured. CONCLUSIONS: A preoperative single dose of sublingual fast-dissolving piroxicam can be effective in reducing spontaneous pain up to 24 h, stimulated pain up to 7 days, and RAI incidence in asymptomatic mandibular molars with non-vital pulp; it can prevent rise in POP and POPB postoperatively. Stimulated postoperative pain can be more severe and longer lasting than spontaneous pain. TRIAL REGISTRATION: Clinicaltrials.gov ID: NCT03998826 (2019).

The Factors Impacting on Patient-Reported Outcomes After Bicruciate-Stabilized Total Knee Arthroplasty for Varus Knee Osteoarthritis.

Background: The aim of this study was to investigate the factors affecting patient-reported outcomes after bicruciate-stabilized total knee arthroplasty (BCS TKA) in patients. Methods: We retrospectively examined 122 knees with primary varus knee osteoarthritis that underwent BCS TKA. This study analyzed preoperative, intraoperative, and postoperative predictors of patient satisfaction and persistent postsurgical pain following BCS TKA at 1 year after surgery. We evaluated persistent postsurgical pain using Knee Injury and Osteoarthritis Outcome Score (KOOS) pain subscale and patient satisfaction using a visual analog scale. Results: The univariate analysis showed a significant negative correlation between the KOOS pain subscale and three factors: the preoperative central sensitization inventory (CSI) score, medial joint laxity at 90° flexion, and acute postsurgical pain. Patient satisfaction was significantly positively correlated with lateral joint laxity at 90° flexion and postoperative extension angle. Acute postsurgical pain had a significant negative correlation with patient satisfaction. The multiple regression analysis revealed preoperative CSI score and medial joint laxity at 90° flexion influenced patients' KOOS pain subscale responses. Only lateral joint laxity at 90° flexion had an impact on patient satisfaction. Conclusions: The acquisition of adequate soft tissue balance according to the concept of BCS TKA and preoperative central sensitization syndrome affects the clinical outcomes in BCS TKA.

Reliability and validity of the pressure algometer in predicting gynecological surgery pain.

OBJECTIVE: The purpose of this study was to determine the reliability and validity of the pressure algometer in predicting gynecological surgery pain. We looked into the predictive value of preoperative pain sensitivity to gynecological pain and the relationship between preoperative pressure pain threshold (PPT), pressure pain tolerance (PTO), and postoperative pain outcomes. METHODS: Reliability test: We recruited 60 volunteers at Nantong University. For three consecutive days, two examiners measured the pain sensitivity of each participant using a pressure algometer. Its test-retest and intra-rater reliability were assessed using the intraclass correlation coefficient (ICC). Validity test: We selected patients who underwent gynecological surgery in a hospital for the validity test. Before surgery, we assessed the patient's pain sensitivity to various stimuli. To determine the relationship between preoperative pain sensitivity and postoperative pain, we collected postoperative Numerical Rating Scale (NRS) and sufentanil consumption data. RESULTS: The algometer revealed a high test-retest and intra-rater reliability. According to the calculation of Youden's index, there was a 73.1% chance of patients with moderate to severe postoperative pain having a PTO <6.22 N, and patients with PTO <6.22 N had an 87.5% probability of moderate to severe postoperative pain. CONCLUSIONS: The pressure algometer has a high degree of accuracy in measuring the PPT and PTO of normal healthy individuals, making it a reliable tool for quantifying pain sensitivity. PTO can be used to predict the occurrence of moderate to severe postoperative pain.

Comparison of the Effect of Scalp Block With Ropivacaine vs. Ropivacaine and Clonidine on Postoperative Pain in Patients Undergoing Craniotomy Surgery Under General Anesthesia.

Introduction Clonidine, an α2 agonist known for its hypotensive and analgesic effects, has proven beneficial in various routes of administration such as oral, intravenous, and local infiltration. Scalp blocks enhance hemodynamic stability during surgery and reduce intraoperative opioid requirements compared to controls in numerous studies. Additionally, they are effective in managing postoperative pain, resulting in reduced opioid consumption. Research has shown that clonidine can enhance and prolong the effects of intrathecal, epidural, and peripheral nerve blocks (e.g., brachial plexus, peribulbar). Here, we investigated the impact of adding clonidine at a dose of 1 µg/kg to scalp blocks performed with 0.5% ropivacaine for supra-tentorial craniotomy Material and methods This study was conducted on 60 patients under the American Society of Anesthesiologists (ASA) grade I and II who were scheduled for elective supratentorial craniotomy. Patients were divided into two equal groups of 30 and received a scalp block following general anesthesia. Patients in Group A (n=30) received a scalp block of 0.5% ropivacaine plus 1 ml of normal saline (total 21 cc). Patients in Group B (n=30) received a scalp block of 0.5% ropivacaine and clonidine (1 µg/kg) combined with 0.5 ml of normal saline (total 21 cc). Blood pressure, heart rate, peripheral oxygen saturation (SpO2), visual analog score, Ramsay sedation score, duration of analgesia, and analgesia requirement in the first 24 hours were recorded from baseline and postoperatively. Results The duration of first rescue analgesia for Group A was 4.30 ± 1.5 hours and that of Group B was 9.10 ± 1.4 hours. Duration of analgesia was significantly prolonged in patients receiving ropivacaine with clonidine for scalp nerve block. The amount of tramadol given in the first 24 hours in Group A, 62.50 ± 25.00 mg, was high compared to Group B, 57.14 ± 18.89 mg. The mean arterial blood pressure differed significantly in both groups at 30 minutes, 1 hour, 3 hours, and 12 hours after scalp block postoperatively and lower in Group B. Although changes in pulse rate, and SpO2 were not statistically significant in both groups, patients were hemodynamically stable and did not require any ionotropic support. Ramsay sedation score and visual analog score postoperatively were not significant. There were no significant adverse effects noted in any groups. Conclusion Our study concluded that administering clonidine at a dosage of 1 µg/kg, in combination with 0.5% ropivacaine for scalp nerve block procedures, significantly extends the duration of analgesia and enhances its quality, all while maintaining stable hemodynamic parameters.

The Impact of Preoperative Combined Pectoserratus and/or Interpectoral Plane (Pectoralis Type II) Blocks on Opioid Consumption, Pain, and Overall Benefit of Analgesia in Patients Undergoing Minimally Invasive Cardiac Surgery: A Prospective, Randomized, Controlled, and Triple-blinded Trial.

OBJECTIVE: Acute postoperative pain remains a major obstacle in minimally invasive cardiac surgery (MICS). Evidence of the analgesic benefit of chest wall blocks is limited. This study was designed to assess the influence of combined pectoserratus plane block plus interpectoral plane block (PSPB + IPPB) on postoperative pain and the overall benefit of analgesia compared with placebo. DESIGN: A prospective, randomized, triple-blinded study was conducted. SETTING: The setting was the operating room and intensive care unit of a university hospital. PARTICIPANTS: A total of 60 patients undergoing elective right-lateral MICS were enrolled. INTERVENTIONS: Patients were randomly assigned to preoperative PSPB + IPPB with 30 mL of ropivacaine 0.5% or saline. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was total intravenous morphine milligram equivalents administered in the first 24 hours after extubation. Secondary endpoints included the Overall Benefit of Analgesia Score (OBAS) at 24 hours after extubation and repeated Visual Analogue Scale (VAS). Values for intravenous morphine milligram equivalents administered in the first 24 hours after extubation were significantly lower (median [interquartile range]: 4.2 mg [2.1 - 7.9] v 8.3 mg [4.2 - 15.7], p = 0.025; mean difference: 6.7 mg [0.94 - 12 mg], p = 0.024, Cohen's d: 0.64 [0.09 - 1.2]). Moreover, OBAS at 24 hours and VAS after extubation were significantly lower (4.0 [3.0 - 6.0] v 7.0 [3.0 - 9.0], p = 0.043; 0.0 cm [0.0 - 2.0] v 1.5 cm [0.3 - 3.0], p = 0.030). VAS did not differ between groups at later points. CONCLUSIONS: Preoperative PSPB + IPPB reduced 24-hour postextubation opioid consumption, pain at extubation, and OBAS. Given its low risk and expedient placement, it could be a helpful addition to MICS protocols. Future studies should evaluate these findings in multicenter settings and further elucidate the optimal timing of block placement.

Present and Future of Pharmacological Management for Acute Moderate-to-Severe Postoperative, Traumatic, or Musculoskeletal Pain in Europe: A Narrative Review.

Acute moderate-to-severe pain is common after surgery, trauma, or musculoskeletal injury, but its management remains suboptimal. Current single-agent treatments are limited by safety concerns, narrow therapeutic windows, and abuse potential, leaving substantial unmet needs. Here, we aimed to review guidelines for the management of acute moderate-to-severe post-surgical, trauma-related, or musculoskeletal pain in adults and discuss existing and potential future analgesics in this setting. We searched PubMed to identify relevant guidelines and existing analgesics for acute pain. To identify compounds in development, we searched ClinicalTrials.gov and the European Union Clinical Trials Register. Guidelines universally recognize the limitations of single-agent analgesics (particularly those with a single mechanism of action [MoA]) and recommend a multimodal approach as an established standard for acute pain. The benefit-risk profiles of traditional treatments, including paracetamol (acetaminophen), nonsteroidal anti-inflammatory drugs, selective cyclooxygenase-2 inhibitors, and opioids, can be improved by combining agents targeting different pain pathways. In multimodal approaches, lower doses of constituent agents can be used to achieve the same or superior analgesic effects relative to the individual agents. In some cases, novel formulations and co-crystal technology offer enhanced physicochemical and pharmacokinetic properties over individual agents. Lastly, initiatives to increase patient awareness and education around pain management may improve treatment satisfaction and quality of life, and hasten recovery. In conclusion, management of acute moderate-to-severe pain remains inadequate. Multimodal analgesics may offer advantages over traditional single-agent treatments (that often have a single MoA) for acute moderate-to-severe post-surgical, trauma-related, or musculoskeletal pain in adults. Multimodal analgesics, combined with patient education initiatives and non-pharmacological measures, when necessary, offer promise in addressing unmet needs in this setting.

Pharmacological differences in postoperative cutaneous sensitivity, pain at rest, and movement-induced pain in laparotomized mice.

Postoperative pain management is challenging. We used mice with a transverse laparotomy to study tactile allodynia measured by the von Frey test, pain at rest measured by facial pain expressions detected by an artificial intelligence algorithm, and movement-induced pain measured by reductions in exploratory activity. The standard analgesics morphine and ibuprofen induced distinct patterns of outcome-dependent effects. Whereas morphine was more effective in reversing pain at rest compared to tactile allodynia, it was unable to alter movement-induced pain. Ibuprofen showed comparable effects across the three outcomes. Administered together, the compounds induced synergistic effects in the three aspects of postoperative pain, mirroring the known advantages of multimodal analgesia used in clinical practice. We explored the impact of neuroimmune interactions using a neutrophil depletion strategy. This reversed pain at rest and movement-induced pain, but did not alter cutaneous sensitivity. Non-peptidergic (IB4+) and peptidergic (CGRP+) nociceptors are segregated neuronal populations in the mouse. We tested the effects of gefapixant, an antitussive drug targeting non-peptidergic nociceptors through P2X3 antagonism, and olcegepant, an antimigraine drug acting as a CGRP antagonist. Both compounds reversed tactile allodynia, while only gefapixant reversed pain at rest, and none of them reversed movement-induced pain. In conclusion, tactile allodynia, pain at rest, and movement-induced pain after surgery have different pharmacological profiles, and none of the three aspects of postoperative pain can predict the effects of a given intervention on the other two. Combining these measures provides a more realistic view of postoperative pain and has the potential to benefit analgesic development.

Superior hypogastric nerve plexus (SHNP) block for pain management after minimally invasive gynecology surgeries: A prospective randomized controlled trial.

OBJECTIVES: Our study aimed to evaluate the effect of superior hypogastric nerve plexus (SHNP) block in postoperative pain management in the first 24 h after minimally invasive gynecological (MIG) surgeries. METHODS: We conducted a double-blinded, randomized controlled trial in the Department of Obstetrics and Gynecology at a tertiary care centre from May 1, 2023 to September 30, 2023 in women undergoing major MIG surgeries. At the completion of the surgery, women were randomized to the intervention group who received SHNP block with ropivacaine 10 mL (0.75%) before port removal, whereas no intervention was taken in the control group. The extubation time was noted, and the pain score was assessed after 1, 2, 6, 12, and 24 h of extubation in the postoperative period using the visual analog scale (VAS). Statistical analysis was done, with a significance level of 0.05, to test the differences between the two groups. RESULTS: A total of 64 patients were randomly allocated to intervention and control groups. The median pain score was lower at 1 and 2 h post-extubation and comparable between the two groups at 6, 12, and 24 h. The surrogate markers that is need for additional analgesia and duration of stay did not differ significantly in the two groups, with P-values of 0.08 and 0.943, respectively. CONCLUSION: Although the SHNP group experienced considerably lower immediate postoperative pain levels in the initial hours following extubation, the impact of this benefit remains uncertain in the longer postoperative period. The effectiveness of this modality for pain control needs further study, particularly at later postoperative hours.

Comparison of postoperative pain in robotic and laparoscopic myomectomy: a retrospective cohort study.

Gynecologic surgery with minimally invasive method using robotic or laparoscopic techniques has gained popularity for reducing perioperative discomfort and length of hospital stay. However, the debate over postoperative pain superiority between traditional laparoscopy and robotic surgery persist. This study compared the postoperative pain of patients within 24 h of robotic (RM) and laparoscopic myomectomy (LM). This retrospective cohort study included 24 and 53 patients who underwent RM and LM, respectively, between January 2019 and July 2023. The primary outcomes were the postoperative pain levels of patients within 24 h and the use and dosage of postoperative analgesia. Additional perioperative analgesia, including long-acting non-steroidal anti-inflammatory drugs (Dynastat) and abdominal nerve block, was also recorded. The secondary outcomes were blood loss and hospitalization duration. The patient characteristics were similar between the groups. Factors that could potentially increase pain, such as the number of ports (p < 0.0001), additional procedures (p = 0.0195), operative time (p < 0.0001), number of myomas (p = 0.0057), and the largest myoma size (p = 0.0086), were significantly higher in the RM group than in the LM group. However, there were no significantly different in the postoperative visual analog scale pain scores, use and dosage of ketorolac and opioid, and use of Dynastat and nerve block between the groups. Hospitalization duration and intraoperative blood loss were similar between the groups. RM and LM offer comparable postoperative pain outcomes, emphasizing the importance of patient-specific factors in decision-making regarding myomectomy techniques.