Ultrasound-Guided External Oblique Intercostal Plane Block for Postoperative Analgesia in Laparoscopic Sleeve Gastrectomy: A Prospective, Randomized, Controlled, Patient and Observer-Blinded Study.

PURPOSE: The external oblique intercostal plane (EOI) block is a novel block technique for anterolateral upper abdominal wall analgesia. The superficial nature of the external oblique intercostal plane allows it to be easily identified even in patients with obesity. The aim of this study was to test the hypothesis that EOI block would reduce IV morphine consumption within 24 h after laparoscopic sleeve gastrectomy. MATERIALS AND METHODS: Patients were randomly assigned to one of two groups: EOI block group and control group. The patients in the EOI block group received ultrasound-guided bilateral EOI block with a total of 40 ml 0.25% bupivacaine after anesthesia induction. The patients in the control group received no intervention. Postoperatively, all the patients were connected to an intravenous patient controlled analgesia (PCA) device containing morphine. The primary outcome of the study was IV morphine consumption in the first postoperative 24 h. RESULTS: The median [interquartile range] morphine consumption at 24 h postoperatively was significantly lower in the EOI block group than in the control group (7.5 [3.5 to 8.5] mg vs 14 [12 to 20] mg, p = 0.0001, respectively). Numerical rating scale (NRS) scores at rest and during movement were lower in the EOI block group than in the control group at 2, 6, and 12 h but were similar at 24 h. No block-related complications were observed in any patients. CONCLUSION: The results of the current study demonstrated that bilateral EOI block reduced postoperative opioid consumption and postoperative pain in patients with obesity undergoing laparoscopic sleeve gastrectomy. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT05663658.

Low Patient Weight and Long Intubation Time Are Key Factors for Pain during Colonoscopy.

Although the clinical usefulness of colonoscopy has been established, the procedure remains painful for many patients. This study was designed to clarify the factors predicting colonoscopy-related pain. We evaluated 283 consecutive patients who completed a first-ever, total colonoscopy without sedatives or analgesics. The severity of pain symptoms was evaluated by a numeric rating scale (NRS) in a questionnaire immediately after the colonoscopy. Patient backgrounds and endoscopic findings were analyzed to evaluate their association with pain. Out of 283 patients, 53 scored their pain 0-1 on the NRS while 48 scored it 6-10. We defined the colonoscopies of the former and latter patients as painless and painful, respectively, and compared the two. Multivariate analyses revealed that low body weight (OR 4.95, 95%CI 1.89-12.99) and longer intubation time (OR 3.63, 95%CI 1.46-9.03) were significant risk factors for painful colonoscopy. To identify factors contributing to the increased intubation time, we divided subjects into short- and long-intubation-time groups based on a median insertion time of 7 min. Older age (OR 2.28, 95%CI 1.31-3.98), previous abdominal surgery (OR 1.93, 95%CI 1.13-3.32) and findings of invasive cancer (OR 10.90, 95%CI 1.34-88.90) were significant factors for longer intubation time.

Somatosensory profiling of patients undergoing alcohol withdrawal: Do neuropathic pain and sensory loss represent a problem?

INTRODUCTION: Chronic heavy alcohol use is known to cause neurological complications such as peripheral neuropathy. Concerning the pathophysiology, few sural nerve and skin biopsy studies showed that small fibers might be selectively vulnerable to degeneration in alcohol-related peripheral neuropathy. Pain has rarely been properly evaluated in this pathology. The present study aims at assessing pain intensity, potential neuropathic characteristics as well as the functionality of both small and large nerve sensitive fibers. METHODS: In this observational study, 27 consecutive adult patients, hospitalized for alcohol withdrawal and 13 healthy controls were recruited. All the participants underwent a quantitative sensory testing (QST) according to the standardized protocol of the German Research Network Neuropathic Pain, a neurological examination and filled standardized questionnaires assessing alcohol consumption and dependence as well as pain characteristics and psychological comorbidities. RESULTS: Nearly half of the patients (13/27) reported pain. Yet, pain intensity was weak, leading to a low interference with daily life, and its characteristics did not support a neuropathic component. A functional impairment of small nerve fibers was frequently described, with thermal hypoesthesia observed in 52% of patients. Patients with a higher alcohol consumption over the last 2 years showed a greater impairment of small fiber function. DISCUSSION: Patients report pain but it is however unlikely to be caused by peripheral neuropathy given the non-length-dependent distribution and the absence of neuropathic pain features. Chronic pain in AUD deserves to be better evaluated and managed as it represents an opportunity to improve long-term clinical outcomes, potentially participating to relapse prevention.

Consistency between the 2016 ACR criteria and a previous diagnosis or hypothesis of fibromyalgia in a specialised referral clinic.

OBJECTIVES: Fibromyalgia (FM) is a complex syndrome whose hallmark features are chronic widespread pain, sleep disturbances, fatigue and cognitive dysfunctions. However, it is still difficult to apply validated diagnostic criteria. The aim of this study is to examine the accuracy of a previous diagnosis/diagnostic hypothesis of FM according to the 2016 ACR diagnostic criteria. METHODS: All of the patients newly referred to a private rheumatological clinic with the specific request for a consultation because if FM over an 18-month period were evaluated by means of a standardised protocol in order to determine whether they fulfilled the 2016 ACR diagnostic criteria for FM. They were initially divided into three groups: those with a previous diagnosis of FM (group 1), those with a physician's diagnostic hypothesis of FM (group 2) and those who personally hypothesised FM (group 3). They were subsequently classified as having FM, IFM (borderline scores) or not having FM (non-FM) on the basis of the 2016 ACR diagnostic criteria. RESULTS: The study involved 216 patients (25 males and 191 females): 112 in group 1, 49 in group 2, and 55 in group 3. Only 89 patients (41.2%) fulfilled the ACR criteria; 42 (19.44%) met the study protocol-defined scores for IFM; and 85 (39.35%) were diagnosed as not having FM. Only 50% of the patients with a previous diagnosis of FM fulfilled the ACR criteria, and just under 25% did not have FM. Almost 50% of the patients with a physician's diagnostic hypotheses of FM did not have FM, whereas 20% of the patients who personally hypothesised FM fulfilled the ACR criteria. GP scores and TPCs were significantly different (FM > IFM, FM > non-FM, and IFM > non-FM) as were WPI, SSS and PSD scores for FM > IFM group. Rheumatologists made the previous diagnosis in 92.85% of patients, 53.84% of whom met the ACR criteria and about 20% did not have FM; and as many as 37.5% of the patients with a previous diagnosis made by a non-rheumatologist did not have FM. The non-FM patients were given 84 alternative diagnoses, 78.5% of which referred to rheumatic diseases. One hundred and thirty-one patients had 86 closely pain-related co-morbidities, 94.1% of which were rheumatic diseases. CONCLUSIONS: Our findings confirm the inaccuracy of FM diagnoses and highlights the possibility that in everyday clinical practice, they are not always made with reference to very specific criteria and that there is a high risk of classifying non-FM patients as having FM. They also underline the importance of an accurate differential diagnosis. Separately classifying as IFM those patients who do not meet the ACR criteria, but have clinical findings indicating FM, may help to prevent their exclusion from specific treatment(s).

Pain assessment following open hemorrhoidectomy under local anesthesia versus saddle block: a multicenter randomized controlled trial.

BACKGROUND: There is disparity in evidence on pain assessment post open hemorrhoidectomy (OH) using local anesthesia and its use in developing countries compared to developed countries. Therefore, we conducted this study to assess the occurrence of postoperative pain following open hemorrhoidectomy under local anesthesia versus saddle block for uncomplicated 3rd or 4th degree hemorrhoids. METHODS: This was a prospective equivalence randomized, double blind controlled trial conducted from December 2021 to May 2022 among patients with primary uncomplicated 3rd or 4th degree hemorrhoids. Pain severity was assessed at 2, 4 and 6 h post open hemorrhoidectomy using visual analogue scale (VAS). Data was analysed using SPSS version 26 at a p < 0.05 as statically significant using visual analogue scale (VAS). RESULTS: We recruited 58 participants in this study who underwent open hemorrhoidectomy under local anesthesia or saddle block (29 participants per group). The sex ratio was of 1.15 of female to male and a mean age of 39 ± 13. VAS was found to be different at 2 h post OH compare to other time of pain assessment but not statically significant by area under the cover (AUC) (95% CI = 486-0.773: AUC = 0.63; p = 0.09) with a none significance by Kruskal-Wallis's test (p:0.925). CONCLUSION: Local anesthesia was found to be having a similar pain severity occurrence in post operative period among patients undergoing open hemorrhoidectomy for primary uncomplicated 3rd or 4th degree hemorrhoids. Close monitoring of pain in postoperative period is mandatory especially at 2 h to assess need of analgesia. TRIAL REGISTRATION: Pan African Clinical Trials Registry, PACTR202110667430356. Registered on 8th October, 2021.

Effects of Dexmedetomidine on Postoperative Pain and Recovery Time in Obese Patients.

Objective: The objective of this study is to investigate the effect of dexmedetomidine on postoperative pain and recovery time in obese patients. Methods: A total of 100 obese patients with body mass index (BMI) ≥ 30 kg/m2 who underwent laparoscopic sleeve gastrectomy under general anesthesia in our hospital from January 2019 to December 2021 were included and assigned into DEX group (dexmedetomidine group) and NS group (normal saline group). The bariatric surgery patients who were given normal saline pump were the NS group (n = 50), and the bariatric surgery patients who were given the dexmedetomidine pump were the DEX group (n = 50). The patients in the DEX group were given continuous intravenous infusion of dexmedetomidine before, during, and after induction of anesthesia at a dose of 0.4 µg. kg-1. h-1, 0.4 µg·kg-1. h-1, 0.2 µg·kg-1. h-1, respectively. The NS group was infused with the same volume of normal saline for the same time. The two groups of patients were treated with the same anesthesia induction and maintenance program. By comparing the operation, anesthesia, postoperative extubation, and recovery time of the two groups of patients, the effect of dexmedetomidine on the postoperative recovery time of obese patients was analyzed. Visual analogue scale (VAS) and adverse reactions were compared to analyze the effect of dexmedetomidine on postoperative pain in obese patients. Results: The operation, anesthesia, postoperative extubation, and recovery time of the DEX group were significantly lower than those of the NS group, whereas the VAS and adverse reactions were significantly lower than those in the NS group (P < 0.05). Conclusion: An appropriate dose of dexmedetomidine in bariatric surgery for morbidly obese patients can effectively shorten the recovery time and extubation time of patients, reduce postoperative pain and the incidence of adverse reactions, and is worthy of clinical application. Dexmedetomidine 2 µg/kg has promising anesthesia benefits in bariatric surgery of obese patients, can provide favorable analgesia and quality of recovery, help reduce the degree of stress response of patients, and does not increase the risk of adverse events. However, this study has certain limitations, so physicians should tailor the dosage according to the patient's physical condition in clinical practice.

Quadratus Lumborum Block with Laparoscopic Assisted Catheter Placement Technique in Donor Nephrectomy: A Preliminary Report.

Quadratus lumborum block (QLB) is a new fascial plane block that may be helpful for laparoscopic surgeries. In this present study, we aim to evaluate the analgesic efficacy of QLB in laparoscopic living related donor nephrectomy (LLRDN) applied continuously via a catheter that was placed under laparoscopic vision by the surgeon. Following the approval of the Clinical Research Ethics Committee of Istanbul University, Istanbul Medical Faculty (2019/1552), 9 study (Group QLB) and 26 control (Group M) patients that underwent LLRDN were enrolled in this retrospective study. All donors underwent left nephrectomy via transperitoneal laparoscopic approach. An epidural catheter was placed between the QL and psoas major (PM) fascial plane intraoperatively by the surgeon under laparoscopic direct vision, and bupivacaine 0.25% 20 mL was injected through the catheter. After the operation, for group QLB, we used a continuous infusion of bupivacaine 0.1% 7 mL/h over 24 hours. Group M patients received intravenous morphine patient controlled analgesia for 24 hours, postoperatively. Pain scores, total morphine consumption, and complications during the first 24 hours after surgery were recorded. During the first postoperative 24 hours, morphine requirement decreased by more than 70% in Group QLB (Group QLB: 5.11 ± 1.16 mg vs Group M: 16.8 ± 7.1 mg) (P < .0001). Postoperative Numeric Rating Scale (NRS) values at the 45th minute and first hour were both significantly lower in Group QLB than Group M (P < .01). This preliminary report showed that QL catheter placement technique provides good postoperative analgesia in patients undergoing LLRDN. However, further randomized controlled studies with extended patient numbers are required to test the efficacy of the technic.

[A prospective randomized controlled study of the difference between BPPV manual reduction and automatic device reduction].

Objective:To investigate the difference between manual reduction and automatic device reduction in the treatment of benign paroxysmal positional vertigo（BPPV）, and to provide evidence-based medicine for the clinical choice of BPPV treatment. Methods:Two hundred and two BPPV patients who came to the hospital for diagnosis and treatment were collected and divided into two groups by random number table method. Group A had 102 cases for manual reduction, and group B had 100 cases for automatic device reduction. Both groups were given the same medicine-assisted treatment. All patients were followed up 7 to 10 days after reduction treatment. To evaluate the differences in the overall effective rate of treatment, visual analog scale（VAS）, incidence of adverse reactions, treatment time were compared between the two groups. Results:The overall effective rate was 98.03% and 91.00% in group A and group B, respectively, group A was slightly higher than group B（P=0.027）; the difference in VAS scores before and after treatment: group A was 6（4） points, group B was 5（3） , group A is greater than group B（P=0.002）; adverse reaction rates in groups A and B were 4.90% and 8.00%, respectively, group B was slightly higher than group A（P=0.37）; treatment time: group A 6.0（1.0） min in group A and 8.0（2.0） min in group B, group A was significantly shorter than group B（P<0.01）. Conclusion:Both manual and fully automatic device reduction can effectively improve the clinical symptoms of BPPV patients, but for physicians with extensive clinical experience it is recommended to choose manual reduction.

Diagnostic office hysteroscopy; why is it still painful procedure despite the surgical experience and mini-hysteroscope?

AIM: To evaluate the effect of cervical canal features on pain during outpatient hysteroscopy performed by experienced surgeons using mini-hysteroscope. METHODS: A prospective observational study was conducted on 303 women undergoing diagnostic hysteroscopy without anesthesia. Pain intensity was evaluated using the visual analog scale (VAS) when the cervical canal was passed. The patients were divided into two groups according to the VAS score: painless or mild pain (VAS <4) and moderate or severe pain (VAS ≥ 4). The relationship between cervical canal characteristics (length, version, and flexion positions, history of cervical intervention, stenosis, synechiae), obstetric and gynecological history, preoperative anxiety level, procedure duration, and pain intensity was examined. RESULTS: Moderate pain (4 ≤ VAS < 7) was observed in 38% of patients (n = 117) and 14 patients (5%) experienced severe pain (VAS ≥ 7). In multivariate analysis, nulliparity (p = 0.01; OR, 4.6; 95% CI, 1.7-13.2), postmenopausal state (p = 0.02; OR, 2.2; 95% CI, 1.2-4.3), excessive flexion of the cervix and retroverted uterus (p <0.001; OR, 4.1; 95% CI, 2.0-8.5) were identified as risk factors for a painful procedure. Diagnostic hysteroscopy was successful in 98% of the patients. The pain was the primary cause of the failed hysteroscopy. CONCLUSION: In addition to nulliparity and postmenopausal status, unfavorable features of the cervical canal, such as the excessive flexion position of the cervix and uterine retroversion are significant causes of pain during outpatient hysteroscopy.

Asymptomatic inguinal hernia: does it need surgical repair? A systematic review and meta-analysis.

BACKGROUND: The aim of this review is to compare the outcomes of surgical repair versus watchful waiting in asymptomatic or minimally symptomatic inguinal hernias. METHODS: Preferred reporting items for systematic reviews and meta-analyses guidelines were employed. We analysed primary outcomes: pain, quality of life, pain during daily activities and visual analogue scale (VAS that measures pain at rest and on movement) and secondary outcomes: postoperative complications and recurrence. RESULTS: Pain and quality of life were not comparable due to differences in the parameters used in different articles. Pain interfering with normal daily activity was evaluated in one study and appears more favourable in the post-repair group respect to the watchful waiting (WW) group (5.1% versus 2.2%). VAS, measured in one study, at 6 months was more favourable in the surgery group (37% versus 44%). After 12 months the outcome was better in the control group than in the repair group (28% versus 30%). Conversion rate of the patient cohorts from watchful waiting to elective surgery was between 35.03% and 57.8%. The meta-analysis did not find significant statistical differences in the two groups examined for postoperative complications [RR = 0.95, 95% CI (0.50, 1.80), P = 0.88], as for hernia recurrence [RR = 1.01, 95% CI (0.50, 2.02), P = 0.98]. CONCLUSION: WW seems to be an acceptable option for the patient with asymptomatic or minimally symptomatic inguinal hernias. Delaying surgical repair until symptoms appear is safe. Acute hernia incarcerations are not particularly frequent. The incidence of chronic pain after the repair is high. Physicians must select patients carefully and explain to them the risks and benefits of surgery.

The Safety Profile of Liposomal Bupivacaine Use in Septorhinoplasty.

Objective: To evaluate the safety profile, including adverse drug reactions and operative complications, of liposomal bupivacaine (LB) use for local anesthesia during functional septorhinoplasty. Study Design: Retrospective review. Subject and Methods: A database query was conducted for patients >18 years of age who underwent septorhinoplasty from January 1, 2019, to August 1, 2020. Adverse drug reactions and postoperative outcomes were compared between patients who received locally administered LB and patients who received standard local anesthetic at the completion of the surgery. Results: A total of 95 cases were included in our data analysis. No significant differences were found in adverse reactions overall (6.3% vs. 3.1%, p = 0.51) or complications, including rate of infection (3.2% vs. 3.1%, p = 1), cartilage warping (1.6% vs. 0%, p = 1), graft resorption (0% vs. 0%, p = 1), septal hematoma (0% vs. 0%, p = 1), and need for revision surgery (4.8% vs. 3.1%, p = 1) between LB and control groups. Conclusion: LB demonstrated an acceptable safety profile when compared with standard local anesthetics during septorhinoplasty, with no significant difference in systemic or local adverse drug reactions or postoperative complications.

Early Stage Versus Late Stage Periarticular Injection during Unicompartmental Knee Arthroplasty for Postoperative Pain Relief: A Randomized Controlled Trial.

Controlling postoperative pain after unicompartmental knee arthroplasty (UKA) is essential to improve patient satisfaction and promote early recovery. The purpose of this study was to investigate the difference in clinical efficacy between early and late stage periarticular injection during UKA for postoperative pain relief. Eighty-four patients meeting the inclusion and exclusion criteria were randomly divided into the early stage periarticular injection group and late stage periarticular injection group by using a random number tables method. The difference between the two groups was that the early stage periarticular injection group received superficial injection before the joint incision, while the late stage periarticular injection group received superficial injection after implantation of the prosthesis. Deep injection and other perioperative conditions of the two groups were controlled identically. The primary outcome of the study was the recovery room immediate visual analog scale (VAS) at rest. The secondary outcomes were the postoperative VAS (at rest) at 3, 6, 9, 12, 18, 24, 48, 72, 96, and 120 hours, drug dosage of rescue analgesia, range of motion (ROM), and complications. The recovery room immediate VAS (at rest) in the early stage periarticular injection group was significantly lower than that of the late stage periarticular injection group (21 ± 24 vs. 32 ± 34 mm, p = 0.018), the average difference of the VAS reached the minimal clinically important difference. No statistically significant difference in postoperative drug dosage of rescue analgesia, ROM, and complications. Preemptive analgesia combined with the early stage periarticular injection can better alleviate postoperative pain than the late stage periarticular injection.

Hepatic Plexus Nerve Block for Microwave Ablation of Hepatic Tumors.

Seven patients underwent microwave ablation of hepatic tumors; during ablation, a hepatic nerve plexus block was used for pain control. The mean visual analog scale (VAS) score for pain (scale, 0-10) was 0.3 ± 0.5 (SD) at baseline and 2.5 ± 1.4, 2.6 ± 1.4, and 2.3 ± 0.9 at 1, 5, and 10 minutes during ablation. Two patients reported a VAS score of 4 or greater during ablation, which improved in both patients to a VAS score of 3 after one rescue sedation dose. The remaining patients required no additional sedation. No major complication occurred. No patient required conversion to general anesthesia.

Chronic Pain Following Fracture-Related Surgery: Posttraumatic Rather Than Postsurgical Origin Promotes Chronification-A Prospective Observational Study With 1-Year Follow-up.

BACKGROUND: Chronic posttraumatic/postsurgical pain (CPSP) is common after traumatic or surgical damage. Exposure to both trauma and surgery, with the potential for repeated bone and nerve damage, may increase the risk of CPSP after fracture-related surgery. But the (long-term) incidences of CPSP and neuropathic CPSP and the ensuing burdens are unknown. Therefore, the patients were prospectively assessed within 1 year, and the patient-specific characteristics were explored. METHODS: Between 2017 and 2018, 127 patients (age: 52.9 ± 17.1 years, male: 55.1%) with traumatic fractures needing osteosynthesis (extremities: 91.3%) were assessed posttrauma (before surgery), postsurgery at days 1 to 5, 6 weeks, 3 and 12 months. The primary outcomes are as follows: incidence at 3 and 12 months of CPSP (defined as pain intensity on a numerical rating scale [NRS: 0-10] ≥3), secondary exploration: neuropathic CPSP (NRS ≥3 and Douleur Neuropathique 4 interview [DN4i] score ≥3 [Douleur Neuropathique interview: 0-7]); burden: quality of life (QoL, the EuroQOL five dimensions questionnaire [EQ-5D-3L] descriptive system); and inter alia, the number of analgesics (trial registration: DRKS00011601). RESULTS: The incidence of CPSP was 57.1% (52/91, n/N) at 3 and 42.7% (35/82) at 12 months postsurgery, including neuropathic CPSP 7.7% (4/52) and 17.1% (6/35), respectively. Descriptively, posttraumatic higher pain intensity at rest (difference of 0.9 ± 1.8 NRS) and the need for more frequent analgesics (by 34.3%) were associated with CPSP a year after surgery compared to those without. As soon as week 6, these patients had developed descriptively a 15% more impaired QoL, with 25% more impairment after 1 year. The patients with CPSP presented with at least 1 neuropathic symptom 12 months later in 68.6% (24/35) of cases, mainly with an early posttraumatic occurrence (without fulfilling the definition of neuropathic CPSP). CONCLUSIONS: After early fracture-related surgery, high incidences of CPSP (43%) were prospectively observed 1 year postsurgery, up to approximately 1 in 5 patients who had neuropathic CPSP. At the same time, CPSP was accompanied with an impacted QoL and analgesic dependence, both indicating clinical relevance. Moreover, the high incidence and the early posttraumatic occurrence of more intense pain suggest that the initial fracture-related trauma, rather than the surgical trauma, may predominantly trigger CPSP at Y1 (1 year). Therefore, these exploratory results set the direction of required future research. A future clinical hypothesis might be: treat first what hurts first.

Acute postoperative pain in 23 procedures of gynaecological surgery analysed in a prospective open registry study on risk factors and consequences for the patient.

Effective perioperative pain management is essential for optimal patient recovery after surgery and reduces the risk of chronification. However, in clinical practice, perioperative analgesic treatment still needs to be improved and data availability for evidence-based procedure specific analgesic recommendations is insufficient. We aimed to identify procedures related with high pain scores, to evaluate the effect of higher pain intensity on patients and to define patient and intervention related risk factors for increased pain after standard gynaecological and obstetrical surgery. Therefore, we performed a prospective cross-sectional study based on the German registry for quality in postoperative pain (QUIPS). A cohort of 2508 patients receiving surgery between January 2011 and February 2016 in our tertiary referral centre (university departments of gynaecology and obstetrics, respectively) answered a validated pain questionnaire on the first postoperative day. Maximal pain intensity was measured by means of a 11-point numeric rating scale (NRS) and related to procedure, perioperative care as well as patient characteristics. The interventions with the highest reported pain scores were laparoscopic removal of ovarian cysts (NRS of 6.41 ± 2.12) and caesarean section (NRS of 6.98 ± 2.08). Factors associated with higher pain intensity were younger age (OR 1.75, 95% CI 1.65-1.99), chronic pain (OR 2.08, 95% CI 1.65-2.64) and surgery performed outside the regular day shift (OR 1.67, 95% CI 1.09-2.36). Shorter duration of surgery, peridural or local analgesic and preoperative sedation reduced postoperative pain. Patients reporting high pain scores (NRS ≥ 5) showed relevant impairment of daily activities and reduced satisfaction. Caesarean section and minimal invasive procedures were associated with the highest pain scores in the present ranking. Pain management of these procedures has to be reconsidered. Younger age, receiving surgery outside of the regular shifts, chronic pain and the surgical approach itself have a relevant influence on postoperative pain intensity. When reporting pain scores of 5 or more, patients were more likely to have perioperative complications like nausea or vomiting and to be impaired in mobilisation. Registry-based data are useful to identify patients, procedures and critical situations in daily clinical routine, which increase the risk for elevated post-intervention pain. Furthermore, it provides a database for evaluation of new pain management strategies.

A Novel Perioperative Multidose Methadone-Based Multimodal Analgesic Strategy in Children Achieved Safe and Low Analgesic Blood Methadone Levels Enabling Opioid-Sparing Sustained Analgesia With Minimal Adverse Effects.

BACKGROUND: Intraoperative methadone, a long-acting opioid, is increasingly used for postoperative analgesia, although the optimal methadone dosing strategy in children is still unknown. The use of a single large dose of intraoperative methadone is controversial due to inconsistent reductions in total opioid use in children and adverse effects. We recently demonstrated that small, repeated doses of methadone intraoperatively and postoperatively provided sustained analgesia and reduced opioid use without respiratory depression. The aim of this study was to characterize pharmacokinetics, efficacy, and safety of a multiple small-dose methadone strategy. METHODS: Adolescents undergoing posterior spinal fusion (PSF) for idiopathic scoliosis or pectus excavatum (PE) repair received methadone intraoperatively (0.1 mg/kg, maximum 5 mg) and postoperatively every 12 hours for 3-5 doses in a multimodal analgesic protocol. Blood samples were collected up to 72 hours postoperatively and analyzed for R-methadone and S-methadone, 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidene (EDDP) metabolites, and alpha-1 acid glycoprotein (AAG), the primary methadone-binding protein. Peak and trough concentrations of enantiomers, total methadone, and AAG levels were correlated with clinical outcomes including pain scores, postoperative nausea and vomiting (PONV), respiratory depression, and QT interval prolongation. RESULTS: The study population included 38 children (10.8-17.9 years): 25 PSF and 13 PE patients. Median total methadone peak plasma concentration was 24.7 (interquartile range [IQR], 19.2-40.8) ng/mL and the median trough was 4.09 (IQR, 2.74-6.4) ng/mL. AAG concentration almost doubled at 48 hours after surgery (median = 193.9, IQR = 86.3-279.5 µg/mL) from intraoperative levels (median = 87.4, IQR = 70.6-115.8 µg/mL; P < .001), and change of AAG from intraoperative period to 48 hours postoperatively correlated with R-EDDP (P < .001) levels, S-EDDP (P < .001) levels, and pain scores (P = .008). Median opioid usage was minimal, 0.66 (IQR, 0.59-0.75) mg/kg morphine equivalents/d. No respiratory depression (95% Wilson binomial confidence, 0-0.09) or clinically significant QT prolongation (median = 9, IQR = -10 to 28 milliseconds) occurred. PONV occurred in 12 patients and was correlated with morphine equivalent dose (P = .005). CONCLUSIONS: Novel multiple small perioperative methadone doses resulted in safe and lower blood methadone levels, <100 ng/mL, a threshold previously associated with respiratory depression. This methadone dosing in a multimodal regimen resulted in lower blood methadone analgesia concentrations than the historically described minimum analgesic concentrations of methadone from an era before multimodal postoperative analgesia without postoperative respiratory depression and prolonged corrected QT (QTc). Larger studies are needed to further study the safety and efficacy of this methadone dosing strategy.

[Pain in hospitalized pediatric patients in a third-level healthcare institution]. / Dolor en pacientes pediátricos hospitalizados en una institución de salud de tercer nivel.

In the hospital setting, pediatric patients can present painful conditions or undergo procedures that generate pain, therefore, recognizing their existence and carrying out a clinical approach to it should be a priority in health care teams. OBJECTIVE: To characterize the pain and its clinical-therapeutic approach in hospitalized patients in the general ward of a tertiary pediatric healthcare institution. PATIENTS AND METHOD: An observational, cross-sectional, and descriptive study conducted between August and October 2019. 187 patients were included. Study variables were sex, reason for hospita lization, treating specialty, chronic, current, and in the last 24 hours pain, intensity, maximum cause of pain, and analgesic prescription. The FLACC (Face, Legs, Activity, Cry, Consolability) scale was used in children aged between two months and three years, the revised Faces Pain Scale in children between four and eight years of age, and the self-reported Visual Analogue Scale was used in children from nine years of age onwards. After data analysis with descriptive statistics, differences between groups were calculated with the Chi-square test for qualitative variables, and non-parametric tests for comparison of groups with ordinal variables. RESULTS: 10.7% of the patients had chronic pain, without differences according to sex (p = 0.713). The prevalence of pain at the time of the evaluation was 38.5%, without differences according to sex (p = 0.419). Patients admitted for surgery and trau ma had a higher prevalence of pain (p = 0.034) and 53.5% of the children had an analgesic prescrip tion. CONCLUSION: the prevalence of pain in the hospitalized pediatric patients is high. Additionally, high use of non-opioid analgesia and a low prescription of opioid analgesics in the pediatric sphere is reported for the usual management of moderate and severe intensity pain.

The Effect of Ketamine on Acute and Chronic Wound Pain in Patients Undergoing Breast Surgery: A Meta-Analysis and Systematic Review.

INTRODUCTION: Perioperative use of ketamine has been discussed widely in many kinds of surgery. The aim of our study was to evaluate the short-term and long-term benefits and safety of ketamine after breast surgery. METHOD: We performed a quantitative systematic review. We included randomized controlled trials that compared intravenous administration of ketamine to a placebo control group, or compared bupivacaine in combination with ketamine to bupivacaine alone in thoracic paravertebral blocks or pectoral blocks among patients undergoing breast surgery. The primary outcome was postoperative pain intensity. Secondary outcomes included cumulative opioid consumption during the 0- to 24-hour postoperative period, the effect on postmastectomy pain syndrome, the effect on postoperative depression, and the adverse events associated with the use of ketamine. RESULTS: Thirteen randomized controlled trials with 1,182 patients were included for analysis. Compared with placebo, intravenous ketamine was effective in reducing wound pain intensity during the first 6 hours after surgery (weighted mean difference [WMD] -0.83; 95% confidence interval [CI] -1.65, -0.01; P = 0.048) and during the first 24 hours after surgery (WMD -0.65; 95% CI -0.95, -0.35; P < 0.001), and in decreasing opioid consumption (WMD -4.14; 95% CI -8.00, -0.29; P = 0.035) during the first 24 hours after surgery, without increasing the risks for gastrointestinal and central nervous system adverse events. Adding ketamine to bupivacaine in thoracic paravertebral blocks was also effective in reducing postoperative wound pain during the first 6 hours after surgery (WMD -0.59; 95% CI, -1.06, -0.12; P = 0.014) and during the first 24 hours after surgery (WMD -0.90; 95% CI -1.27, -0.53; P < 0.001), and in decreasing opioid consumption (WMD - 4.59; 95% CI -5.76, -3.42; P < 0.001) during the first 24 hours after surgery. Perioperative use of ketamine was associated with improved postoperative depression symptoms (standardized mean difference -0.80; 95% CI - 1.34, -0.27; P = 0.003) and less incidence of postmastectomy pain syndrome (relative risk 0.79; 95% CI 0.63, 0.99; P = 0.043). CONCLUSION: Ketamine is an effective and safe multimodal analgesic in patients undergoing breast surgery, administered both intravenously and when added to bupivacaine in paravertebral blocks. In addition, ketamine showed a long-term benefit for preventing postoperative depression and postmastectomy pain syndrome.

Outcomes of Expandable Interbody Devices in Lumbar Fusion: A Systematic Review and Meta-analysis.

STUDY DESIGN: This was a systematic review. OBJECTIVE: The objective of this study was to review radiographic, clinical, and surgical outcomes of expandable interbody device implantation following lumbar fusion. SUMMARY OF BACKGROUND DATA: Few studies have evaluated postsurgical outcomes of expandable implants following lumbar interbody fusion. METHODS: A systematic review was performed to identify studies investigating expandable intervertebral body devices in lumbar fusion. Radiographic parameters, fusion assessments, patient-reported outcomes (PROs), complications, and revision data were recorded. A comparison of expandable and static devices was performed using a meta-analysis. RESULTS: Eleven articles were included. Postoperative improvements for each radiographic parameters for expandable versus static device implantation ranged from: lumbar lordosis, +2.0 to +5.0 degrees (expandable) versus +1.0 to +4.4 degrees (static); segmental lordosis, +1.0 to +5.2 degrees (expandable) versus+1.1 to +2.3 degrees (static); disk height, +0.82 to +4.8 mm (expandable) versus +0.26 to +6.9 mm (static); foraminal height, +0.13 to +2.8 mm (expandable) versus and +0.05 to +3.0 mm (static). Fusion rates ranged from 72.1% at 6 months to 100% at terminal follow-up. Preoperative to final follow-up improvement for the various PROs assessed were: Oswestry Disability Index, -15.4 to -56.3 (expandable) versus -13.6 to -26.3 (static); Visual Analog Scale (VAS) Back, -3.2 to -6.0 (expandable) versus -3.1 to -4.1 (static); and VAS Leg, -2.9 to -7.1 (expandable) -3.0 versus -4.8 (static). Static cages had a reported complication rate ranging from 6.0% to 16.1% and a subsidence rate of 6.0%. Expandable cages had a reported complication rate that ranged from 0.0.% to 10.0% and a subsidence rate of 5.5%-10.0%. A meta-analysis demonstrated a statistically significant difference in the PRO Oswestry Disability Index, but not VAS Back, VAS Leg, or radiographic outcomes (disk height or foraminal height). CONCLUSION: There is no clear evidence for the use of expandable interbody devices over static devices.

Results at 3-year follow-up of totally extraperitoneal (TEP) hernia surgery with long-term resorbable mesh.

INTRODUCTION: Synthetic non-resorbable mesh is almost standard in hernia surgery. However, several studies have showed negative effects of permanent implants such as chronic inflammation and complications involving different organs bordering the mesh. Such complications can raise the risk of chronic post-operative pain (CPP). Recently promising results regarding CPP have been published in patients with Lateral Inguinal Hernia (LIH) using a slowly resorbable mesh in Lichtenstein technique. For this reason the aim of the present study was to find the effect of a slowly resorbable implant on the long-term rate of hernia recurrence and chronic post-operative pain in patients with LIH repaired with TEP procedure. METHODS: Prospective pilot study of TEP repair using TIGR® Matrix Surgical Mesh in 35 primary LIH. At 3-year follow-up the Visual Analogue Scale (VAS) and the Inguinal Pain Questionnaire were employed to assess pain. Recurrence was determined by ultrasound and clinical examination. RESULTS: All patients completed the pain questionnaires but one patient did not attend the planned clinical examination for the 3-year follow-up. No patients had CPP, as defined in the World Guidelines for Groin Hernia Management. Almost all patients had lower VAS score in any activity 3 years following surgery in comparison to the preoperative period. Three patients (8.8%) suffered symptomatic recurrence during the 3-year follow-up. CONCLUSION: TEP repair in patients with LIH using a synthetic long-term resorbable mesh was found to be encouraging respecting chronic post-operative pain at 3-year follow-up but at the cost of an increased risk of recurrence.