Gastrointestinal adverse effects associated with the use of intravenous oliceridine compared with intravenous hydromorphone or fentanyl in acute pain management utilizing adjusted indirect treatment comparison methods.

Background: In the absence of head-to-head comparative data from randomized controlled trials, indirect treatment comparisons (ITCs) may be used to compare the relative effects of treatments versus a common comparator (either placebo or active treatment). For acute pain management, the effects of oliceridine have been compared in clinical trials to morphine but not to fentanyl or hydromorphone. Aim: To assess the comparative safety (specifically differences in the incidence of nausea, vomiting and opioid-induced respiratory depression [OIRD]) between oliceridine and relevant comparators (fentanyl and hydromorphone) through ITC analysis. Methods: A systematic literature review identified randomized clinical trials with oliceridine versus morphine and morphine versus fentanyl or hydromorphone. The ITC utilized the common active comparator, morphine, for the analysis. Results: A total of six randomized controlled trials (oliceridine - 2; hydromorphone - 3; fentanyl - 1) were identified for data to be used in the ITC analyses. The oliceridine data were reported in two studies (plastic surgery and orthopedic surgery) and were also reported in a pooled analysis. The ITC focused on nausea and vomiting due to limited data for OIRD. When oliceridine was compared with hydromorphone in the ITC analysis, oliceridine significantly reduced the incidence of nausea and/or vomiting requiring antiemetics compared with hydromorphone (both orthopedic surgery and pooled data), while results in plastic surgery were not statistically significant. When oliceridine was compared with hydromorphone utilizing data from Hong, the ITC only showed a trend toward reduced risk of nausea and vomiting with oliceridine that was not statistically significant across all three comparisons (orthopedic surgery, plastic surgery and combined). An ITC comparing oliceridine with a study of fentanyl utilizing the oliceridine orthopedic surgery data and combined orthopedic and plastic surgery data showed a trend toward reduced risk that was not statistically significant. Conclusion: In ITC analyses, oliceridine significantly reduced the incidence of nausea and/or vomiting or the need for antiemetics in orthopedic surgery compared with hydromorphone and a non-significant trend toward reduced risk versus fentanyl.

Lower extremity peripheral nerve block for total knee arthroplasty in a patient with chronic inflammatory demyelinating polyneuropathy: A case report.

RATIONALE: Chronic inflammatory demyelinating polyneuropathy (CIDP) is an autoimmune disorder that affects the peripheral nerves, leading to weakness and sensory symptoms. CIDP is a rare disease, and few studies have reported on anesthetic management in patients with this condition, especially the peripheral nerve block (PNB). Therefore, a safe and standardized anesthetic approach remains to be established. This case report aims to address this gap in evidence by documenting our experience with PNB in a patient with CIDP undergoing surgery. It contributes significantly to expanding the range of anesthetic options and enhancing perioperative outcomes for patients with CIDP. PATIENT CONCERNS: A 58-year-old woman diagnosed with CIDP was scheduled to undergo left total knee arthroplasty due to osteonecrosis. We anticipated postoperative pain and aggravation of neurological symptoms. DIAGNOSIS: CIDP. INTERVENTIONS: To manage the postoperative pain, we planned a combination of general anesthesia (GA) and lower extremity PNBs, viz. the tibial and femoral nerve blocks, supplemented with intravenous patient-controlled analgesia. An initial dose of fentanyl 50 µg was administered as analgesia. The tibial and femoral nerves were identified using a peripheral nerve stimulator in conjunction with an ultrasonic echo device while the patient was conscious, to minimize the risk of nerve injury. The tibial and femoral nerve blocks were performed with 20 mL of ropivacaine (0.25%) and dexamethasone 2.2 mg, respectively. Subsequently, we administered fentanyl and ketamine and initiated continuous infusion of remifentanil. Thereafter, propofol 120 mg was administered intravenously over a span of 1 minute, followed by continuous infusion at 4 mg/kg/h. Upon confirming loss of consciousness, we induced GA using a supraglottic airway device without using muscle relaxants. For postoperative analgesia, we administered acetaminophen 1000 mg. OUTCOMES: The patient experienced no pain immediately after surgery, and good analgesia was achieved subsequently without worsening of sensory symptoms during rehabilitation. LESSONS: We achieved effective anesthetic management in a patient with CIDP by combining GA with nerve stimulation and ultrasound-guided PNB. It is crucial to devise a personalized anesthesia plan that focuses on the patients' safety and comfort while minimizing risk in patients with CIDP.

Effectiveness of opioid switching for dyspnea and its predictors in cancer patients: a single-center retrospective observational study.

BACKGROUND: Morphine is the most used opioid for dyspnea, but other opioids such as oxycodone and fentanyl are increasingly used, and opioid switching to these is sometimes undertaken. No studies have verified the effectiveness of opioid switching for relief of dyspnea. We retrospectively investigated the effectiveness of opioid switching for dyspnea and its predictors. METHODS: All patients with opioid switching for dyspnea during hospitalization at Komaki City Hospital from January 2019 to August 2022 were included. Opioid switching was defined as a change to another opioid, and the assessment period for evaluating the effectiveness and adverse events of opioid switching was set as 1 week. Patients with Numeric Rating Scale or Japanese version of the Support Team Assessment Schedule reduction for dyspnea of at least 1, or with clear improvement based on medical records, were considered valid. Mitigating factors for dyspnea were identified using logistic regression analysis. RESULTS: Of the 976 patients with opioid switching, 57 patients had opioid switching for relief of dyspnea. Of these, opioid switching was effective in 21 patients (36.8%). In a multivariate analysis, older patients (odds ratio: 5.52, 95% CI: 1.50-20.20, P < 0.01), short prognosis for post-opioid switching (odds ratio: 0.20, 95% CI: 0.04-0.87, P = 0.03) and cachexia (odds ratio: 0.12, 95% CI: 0.02-0.64, P < 0.01) were significantly associated with opioid switching effects for dyspnea. There were no serious adverse events after opioid switching. CONCLUSION: This study indicates that opioid switching for dyspnea may have some effect. Furthermore, opioid switching for dyspnea may be more effective in older patients and less effective in terminally ill patients or in those with cachexia.

Analgesic Efficacy of Epidural Patient-Controlled Analgesia on Cancer Pain: A Retrospective Observational Study.

BACKGROUND: In patients with severe cancer pain, systemic analgesics are often refractory or have limited application due to the side effects of opioids. In these cases, epidural analgesia may be effective. However, data on the effects of epidural patient-controlled analgesia (PCA) on cancer pain are limited. OBJECTIVES: To evaluate the analgesic efficacy of epidural PCA in patients with cancer pain through a retrospective chart review. STUDY DESIGN: Retrospective analysis. SETTING: A single academic center in Daegu, South Korea. METHODS: The analgesic efficacy of epidural PCA on cancer pain was analyzed in patients who underwent epidural PCA using a disposable balloon pump with a flow regulator between 2012 and 2021. The pump was filled with a 600-mL mixture of 6 ampoules of 0.2% ropivacaine, 1 mg fentanyl, and normal saline. For the first use of epidural PCA, the basal rate, bolus dose, and lockout time were set as 4 mL/h, 2 mL, and 15 min, respectively. The basal rate was increased and decreased depending on the degree of pain relief effect and occurrence of side effects, respectively. To increase the usage time of epidural PCA and reduce the patient's cost burden, the fentanyl dose was increased by 1 mg when the disposable balloon pump was replaced with a new one after exhaustion of the drug if no side effects from the previous dose were observed. Analgesic efficacy was confirmed by comparing the number of types and the total amount of opioids used in patients before and after epidural PCA application in terms of the equivalent dose of oral morphine. RESULTS: Epidural catheterization was performed 105 times, and PCA was refilled 257 times in 88 patients. On average, epidural catheterization was performed 1.2 ± 0.4 (1-3) times, and epidural PCA was refilled 3.2 ± 2.3 (1-11) times per patient. The mean duration of PCA use was 15.6 ± 13.4 (1-82) days. The mean number of opioid types used the day before the procedure and the mean smallest number of opioids used per day up to 5 days after the procedure were 3.4 ± 1.2 and 2.4 ± 1.4, respectively (P < 0.05). The total amount of opioids used the day before the procedure and the smallest total amount of opioids used per day up to 5 days after the procedure were converted into oral morphine equivalent doses, respectively, and the mean doses were 449.5 ± 555.9 and 331.9 ± 462.8 mg, respectively (P < 0.05). LIMITATIONS: The study results are the author's observations from a single center. Epidural PCA was performed only on hospitalized patients. Individual differences were not considered in the composition of drugs for PCA. Transmucosal immediate-release fentanyl was not accurately converted to oral morphine; thus, it was excluded from the analysis of the total amount used, and the effect of adjuvant analgesics could not be considered. CONCLUSION: Epidural PCA using subcutaneous tunneling is a useful cancer pain control method. Furthermore, it can be safely used for a longer duration owing to its low infection risk.

A randomized controlled trial of propofol-remifentanil total intravenous anesthesia and sevoflurane-fentanyl anesthesia on early postoperative fatigue in patients undergoing laparoscopic colorectal surgery.

PURPOSE: Even after uncomplicated surgery, postoperative fatigue prevalence has been reported to be 30-80% for various surgeries. We evaluated postoperative fatigue according to anesthetic technique in patients who underwent colorectal surgery. METHODS: One hundred thirty patients who underwent colorectal surgery were randomly assigned to either propofol-remifentanil total intravenous anesthesia (propofol-remifentanil group, n = 65) or sevoflurane-fentanyl anesthesia (sevoflurane-fentanyl group, n = 65). The primary outcome was the prevalence of postoperative fatigue, as defined by the Chalder Fatigue Questionnaire (total score ≥ 16), at 24 h postoperatively. Secondary outcomes were early postoperative complications during hospitalization and laboratory examination. RESULTS: The final analyses included 127 patients. The prevalence of postoperative fatigue on the 1st postoperative day was lower in the propofol-remifentanil group than the sevoflurane-fentanyl group: 56.3% (36/64) in the propofol-remifentanil group and 73.0% (46/63) in the sevoflurane-fentanyl group (relative risk [RR] = 0.77, 95% confidence interval [CI] 0.59-1.00; P = 0.048). However, there was no difference between the two groups in postoperative fatigue at postoperative day 3. Other postoperative outcomes including the severity of pain and the incidence of nausea/vomiting were not different between the two groups, but postoperative atelectasis on chest X-ray was higher in the sevoflurane-fentanyl group (2/64 [3.1%] vs. 9/63 [14.3%], P = 0.025). C-reactive protein change from preoperative to postoperative day 1 and 5 was significantly lower in the propofol-remifentanil group (P = 0.044). CONCLUSION: Propofol-remifentanil total intravenous anesthesia was associated with reduced postoperative fatigue at the 1st postoperative day compared with sevoflurane-fentanyl anesthesia. Clinical trial The Korean Clinical Research Registry (study identifier: KCT0006917, principal investigator's name: MiHye Park, date of registration: January 12, 2022).

Comparison of the Effects of OPRM1 A118G Polymorphism Using Different Opioids: A Prospective Study.

CONTEXT: µ-opioid receptor gene (OPRM1) A118G polymorphism (rs1799971) causes loss of N-glycosylation sites at the extracellular domain of µ-opioid receptors. G-allele carriers show a limited response to morphine; however, studies investigating the impact of A118G polymorphism on the efficacy of opioids other than morphine are limited. OBJECTIVE: To compare the impact of A118G polymorphism on the efficacy of various opioids. METHODS: This prospective cohort study enrolled 222 in-patients administered one of the following opioid therapies for cancer pain as part of an opioid introduction or rotation strategy: tapentadol extended-release tablets, methadone tablets, hydromorphone controlled-release tablets, oxycodone controlled-release tablets, or transdermal fentanyl patches. The impact of A118G polymorphism on the difference in the Brief Pain Inventory-Short Form score on days three, seven, and 14 from baseline was compared among the groups. RESULTS: Overall, 81, 74, and 67 patients had the AA, AG, and GG genotypes, respectively, with an OPRM1 A118G G-allele variant frequency of 0.47. The reduction in the Brief Pain Inventory-Short Form score after opioid therapy initiation did not differ significantly among the patients with the three A118G genotypes treated with tapentadol (p = 0.84) or methadone (p = 0.97), whereas it was significantly smaller in G-allele carriers than that in AA homozygous patients treated with hydromorphone (p < 0.001), oxycodone (p = 0.031), or fentanyl (p < 0.001). CONCLUSION: Tapentadol and methadone may be more suitable than hydromorphone, oxycodone, and fentanyl for G-allele carriers due to their dual mechanism of action and low susceptibility to OPRM1 A118G polymorphism.

Cancer-related breathlessness: opioids other than morphine - comprehensive literature review.

INTRODUCTION: Although there is low-quality evidence, there has been an increase in publications on the experience of evaluating and managing cancer-related breathlessness using opioids other than morphine. METHODS: The author conducted a non-systematic literature review in the PubMed/Medline and Embase until 4 October 2022. Eligible studies have evaluated the efficacy of opioids other than morphine for cancer-related breathlessness. Studies focused on sedation, anaesthesia, paediatric patients, opioid toxicity or basic research were excluded. Reviews/meta-analyses and non-English language publications were also excluded. RESULTS: A total of 1556 records were identified, of which 23 studies including 469 patients who were treated with fentanyl (n=223), oxycodone (n=171) and hydromorphone (n=75) were considered eligible. Six phase II randomised clinical trials (RCTs), four observational studies and four case reports of fentanyl were found. For breathlessness on exertion, fentanyl yielded promising results, but no RCT showed significant superiority of fentanyl to placebo or morphine. For terminal breathlessness, three RCTs, five non-randomised or observational studies and one case report on oxycodone or hydromorphone were found. Although the results of the observational studies suggested that oxycodone and hydromorphone might be effective alternatives to morphine, the superiority over placebo or non-inferiority to morphine had not been demonstrated in the RCTs. CONCLUSION: As an alternative to morphine, the author recommends fentanyl for breathless crisis or breathlessness on exertion, and oxycodone or hydromorphone for terminal breathlessness in advanced cancer. Larger and well-designed studies based on firm research policies are needed to confirm this current knowledge.

Finding predictors for successful opioid response in cancer patients: An analysis of data from four randomized controlled trials.

CONTEXT: There is no consensus on which "strong" (or step 3 WHO analgesic ladder) opioid to prescribe to a particular patient with cancer-related pain. A better understanding of opioid and patient characteristics on treatment response will contribute to a more personalized opioid treatment. OBJECTIVES: Assessment of potential predictors for successful opioid treatment response in patients with cancer pain. METHODS: An international partnership between four cancer pain research groups resulted in a combined individual-level database from four relevant randomized controlled trials (RCTs; n = 881). Together, these RCTs investigated the short-term (1 week) and medium-term (4 or 5 weeks) treatment responses for morphine, buprenorphine, methadone, oxycodone, and fentanyl. Candidate predictors for treatment response were sex, age, pain type, pain duration, depression, anxiety, Karnofsky performance score, opioid type, and use of anti-neuropathic drug. RESULTS: Opioid type and pain type were found statistically significant predictors of short-term treatment success. Sex, age, pain type, anxiety, and opioid type were statistically, significantly associated with medium-term treatment success. However, these models showed low discriminative power. CONCLUSION: Fentanyl and methadone, and mixed pain were found to be statistically significant predictors of treatment success in patients with cancer-related pain. With the predictors currently assessed our data did not allow for the creation of a clinical prediction model with good discriminative power. Additional - unrevealed - predictors are necessary to develop a future prediction model.

Safety and efficacy of remimazolam tosilate combined with low-dose fentanyl for procedural sedation in obese patients undergoing gastroscopy: study protocol for a single-centre, double-blind, randomised controlled trial.

INTRODUCTION: Obese patients are susceptible to hypoxaemia during procedural sedation. Propofol combined with low-dose opioids is commonly used as a sedation strategy, but it can exacerbate hypoxaemia by causing cardiopulmonary depression and airway obstruction, especially in obese patients. Remimazolam, a novel ultra-short-acting benzodiazepine, has minimal accumulative effects and less cardiorespiratory depression. This study aims to evaluate the safety and efficacy of combining remimazolam tosilate with low-dose fentanyl as an alternative option for procedural sedation in obese patients undergoing gastroscopy. METHODS AND ANALYSIS: This randomised controlled trial (RCT) will be conducted in the Endoscopy Centre of the First Affiliated Hospital of Xiamen University, recruiting 174 participants scheduled for painless gastroscopy with a body mass index of 30-39.9 kg×m-2. All patients will be randomly divided into two groups in a 1:1 ratio. The sedation strategy of the intervention group is remimazolam tosilate combined with fentanyl, while the control group is propofol combined with fentanyl. The primary outcome is the incidence of hypoxaemia and the secondary outcomes include the time to ambulation, need for airway manoeuvres and rescue sedation, sleep quality, the incidence of sedation failure, adverse events and the cost of sedatives. All statistical tests will be performed using IBM SPSS V.20.0 statistical software. A p value<0.05 is considered statistically significant. ETHICS AND DISSEMINATION: This RCT was reviewed and approved by the Ethics Committee of the First Affiliated Hospital of Xiamen University (Scientific Research Ethics Review 2022, No.093). The results will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ChiCTR2200067076.

Intravenous acetaminophen for postoperative pain in the neonatal intensive care unit: A protocol for a pilot randomized controlled trial (IVA POP).

BACKGROUND: In neonates, uncontrolled pain and opioid exposure are both correlated with short- and long-term adverse events. Therefore, managing pain using opioid-sparing approaches is critical in neonatal populations. Multimodal pain control offers the opportunity to manage pain while reducing short- and long-term opioid-related adverse events. Intravenous (IV) acetaminophen may represent an appropriate adjunct to opioid-based postoperative pain control regimes. However, no trials assess this drug in patients less than 36 weeks post-conceptual age or weighing less than 1500 g. OBJECTIVE: The proposed study aims to determine the feasibility of conducting a randomized control trial to compare IV acetaminophen and fentanyl to a saline placebo and fentanyl for patients admitted to the neonatal intensive care unit (NICU) undergoing major abdominal or thoracic surgery. METHODS AND DESIGN: This protocol is for a single-centre, external pilot randomized controlled trial (RCT). Infants in the NICU who have undergone major thoracic or abdominal surgery will be enrolled. Sixty participants will undergo 1:1 randomization to receive intravenous acetaminophen and fentanyl or saline placebo and fentanyl. After surgery, IV acetaminophen or placebo will be given routinely for eight days (192 hours). Appropriate dosing will be determined based on the participant's gestational age. Patients will be followed for eight days after surgery and will undergo a chart review at 90 days. Primarily feasibility outcomes include recruitment rate, follow-up rate, compliance, and blinding index. Secondary clinical outcomes will be collected as well. CONCLUSION: This external pilot RCT will assess the feasibility of performing a multicenter RCT comparing IV acetaminophen and fentanyl to a saline placebo and fentanyl in NICU patients following major abdominal and thoracic surgery. The results will inform the design of a multicenter RCT, which will have the appropriate power to determine the efficacy of this treatment. TRIAL REGISTRATION: ClinicalTrials.gov NCT05678244, Registered December 6, 2022.

[Electrophysiological appropriateness technique based on TCM meridian theory for postoperative pain after urethral reconstruction: A real-world study].

OBJECTIVE: To investigate the clinical efficacy of electrophysiological appropriateness technique (EAT) therapy based on the traditional Chinese medicine (TCM) meridian theory in managing postoperative pain after urethral reconstruction surgery. METHODS: Using the real-world study approach, we enrolled 61 male patients undergoing urethral reconstruction and divided them into a control group (n = 30) and an observation group (n = 31), the former receiving patient-controlled intravenous analgesia (PCIA), while the latter PCIA plus EAT at 4 pairs of acupoints (Hegu, Neiguan, Zusanli and Sanyinjiao bilaterally) and the Ashi point, with 100 mg tramadol hydrochloride given orally as remedial analgesia in both groups in case of postoperative Visual Analogue Scale (VAS) score ≥4. We compared the VAS scores at 4, 12, 24 and 48 hours postoperatively, the dose of cumulative fentanyl used at 48 hours, the number of cases needing remedial analgesia, the time to first flatus and the incidence of adverse reactions between the two groups of patients. RESULTS: The VAS scores were markedly lower in the observation than in the control group at 4, 12, 24 and 48 hours after surgery (P < 0.05), with statistically significant differences in time-dependent effect and interactive effect (P < 0.05). Significant reduction was observed in the doses of cumulative fentanyl (P < 0.05) and remedial tramadol analgesia (P < 0.05), time to first flatus (P < 0.05), and incidence of adverse reactions (P < 0.05) in the observation group in comparison with the controls. CONCLUSION: Electrophysiological therapy based on the TCM meridian theory can safely and effectively alleviate postoperative pain after urethral reconstruction, reduce opioid consumption, and decrease adverse events.

Pericapsular nerve group block in hip arthroplasty: A prospective randomized trial.

OBJECTIVES: This study aimed to evaluate the analgesic effect of the ultrasound-guided pericapsular nerve group (PENG) block in hip arthroplasty (HA) surgery. DESIGN: A prospective double-blinded, randomized study. SETTING: Tertiary institutional clinical care. PARTICIPANTS: Fifty patients, more than 50 years old of both genders, were chosen according to the American Society of Anesthesiologists classification, with physical status I-III, and scheduled for unilateral HA surgeries. INTERVENTIONS: Patients were randomized to receive either a sham PENG block with 20 mL of normal saline (control group) or a PENG block with 20 mL of bupivacaine 0.25 percent (PENG group). MAIN OUTCOME MEASURES: From the onset of the first request for rescue opioid analgesia, preoperative pain scores before and after block (at rest and with a raised straight leg), the incidence of quadriceps weakness after the block, intraoperative fentanyl consumption, post-operative pain scores, and morphine consumption, besides the presence and frequency of adverse events, were recorded. RESULTS: The patients undergoing PENG block with bupivacaine had prolonged durations before the first analgesic request, lower perioperative pain scores, less intraoperative rescue fentanyl, and less post-operative morphine consumption than the control group, with nonsignificant motor weakness after the block and similar adverse events. CONCLUSIONS: The PENG block provided effective perioperative analgesia for HA with prolonged duration of analgesia, nonsignificant motor effects, reduced perioperative opioids consumption, and no major side effects.

Comparative efficacy of serratus anterior plane block (SAPB) and fentanyl for postoperative pain management and stress response in patients undergoing minimally invasive cardiac surgery (MICS).

Background: Fast-tracking plays a significant role in reducing perioperative morbidity and postoperative hospital stay by facilitating early extubation and optimal pain control. Attenuating the stress response to surgery also has a crucial function in enhancing recovery. Serratus anterior plane block (SAPB) is a recently described technique for chest wall analgesia. More data is required to find out the effectiveness of analgesia by SAPB for minimally invasive cardiac surgery (MICS). Aim: The study aimed to assess the efficacy and safety of ultrasound-guided SAPB compared to fentanyl for controlling post-thoracotomy pain and stress response in patients undergoing MICS. Setting and Design: Time framed comparative, prospective, and observational study. Materials and Methods: Patients undergoing MICS for coronary artery bypass grafting under general anesthesia were randomly assigned into two groups. SAPB group (Group A) patients were given 0.2% of 20 ml ropivacaine followed by catheter insertion for continuous infiltration at the end of the procedure. Fentanyl group (Group B) patients were given fentanyl infusion for postoperative analgesia. The primary outcome measured changes in visual analog scale (VAS) score (pain) and cortisol levels (for stress response) in both groups. Results: VAS score was significantly low in Group A when compared to Group B (P < 0.0001). Cortisol levels were also lower in the SAPB group. Hemodynamic parameters (systolic blood pressure, diastolic blood pressure, pulse rate, and oxygen saturation) were more stable in Group A with a lesser requirement of top-up analgesics. Conclusion: SAPB was more effective than fentanyl in managing post-thoracotomy pain after MICS. Cortisol level was lower in the group that received SAPB.

Association of Intraoperative Opioid Administration With Postoperative Pain and Opioid Use.

Importance: Opioids administered to treat postsurgical pain are a major contributor to the opioid crisis, leading to chronic use in a considerable proportion of patients. Initiatives promoting opioid-free or opioid-sparing modalities of perioperative pain management have led to reduced opioid administration in the operating room, but this reduction could have unforeseen detrimental effects in terms of postoperative pain outcomes, as the relationship between intraoperative opioid usage and later opioid requirements is not well understood. Objective: To characterize the association between intraoperative opioid usage and postoperative pain and opioid requirements. Design, Setting, and Participants: This retrospective cohort study evaluated electronic health record data from a quaternary care academic medical center (Massachusetts General Hospital) for adult patients who underwent noncardiac surgery with general anesthesia from April 2016 to March 2020. Patients who underwent cesarean surgery, received regional anesthesia, received opioids other than fentanyl or hydromorphone, were admitted to the intensive care unit, or who died intraoperatively were excluded. Statistical models were fitted on the propensity weighted data set to characterize the effect of intraoperative opioid exposures on primary and secondary outcomes. Data were analyzed from December 2021 to October 2022. Exposures: Intraoperative fentanyl and intraoperative hydromorphone average effect site concentration estimated using pharmacokinetic/pharmacodynamic models. Main Outcomes and Measures: The primary study outcomes were the maximal pain score during the postanesthesia care unit (PACU) stay and the cumulative opioid dose, quantified in morphine milligram equivalents (MME), administered during the PACU stay. Medium- and long-term outcomes associated with pain and opioid dependence were also evaluated. Results: The study cohort included a total of 61 249 individuals undergoing surgery (mean [SD] age, 55.44 [17.08] years; 32 778 [53.5%] female). Increased intraoperative fentanyl and intraoperative hydromorphone were both associated with reduced maximum pain scores in the PACU. Both exposures were also associated with a reduced probability and reduced total dosage of opioid administration in the PACU. In particular, increased fentanyl administration was associated with lower frequency of uncontrolled pain; a decrease in new chronic pain diagnoses reported at 3 months; fewer opioid prescriptions at 30, 90, and 180 days; and decreased new persistent opioid use, without significant increases in adverse effects. Conclusions and Relevance: Contrary to prevailing trends, reduced opioid administration during surgery may have the unintended outcome of increasing postoperative pain and opioid consumption. Conversely, improvements in long-term outcomes might be achieved by optimizing opioid administration during surgery.

Popliteal sciatic nerve block for high-risk patients undergoing lower limb angioplasty: A prospective double-blinded randomized controlled trial.

BACKGROUND: To assess the rate of conversion to general anesthesia, sedative and analgesic drug-sparing effects, and complications of popliteal sciatic nerve block (PSNB) compared with a sham block during lower limb angioplasty. METHODS: A randomized, controlled, double-blinded trial of patients with chronic limb-threatening ischemia (CLTI) who receive PSNB with 0.25% levobupivacaine 20 mL compared with a sham block (control) during lower limb angioplasty. Pain scores, conversion rate to general anesthesia, amount of sedoanalgesia drug usage, complications, and satisfaction with the anesthesia technique by surgeons and patients were assessed. RESULTS: Forty patients were enrolled in this study. Two of 20 (10%) control group patients were converted to general anesthesia, while none of the patients in the intervention group required general anesthesia (P = .487). Pain scores before PSNB did not differ between the groups (P = .771). After the block, pain scores in the block group were lower than those in the control group: 0 (0, 1.5) (median, interquartile range) and 2.5 (0.5, 3.5), respectively (P = .024). The analgesic effect persisted until immediately after the surgery (P = .035). There was no difference in pain scores at the 24-hours follow-up visit (P = .270). The total propofol and fentanyl dosage requirements, a number of patients who required propofol and fentanyl, side effects, and satisfaction were not different between the groups. No major complications were noted. CONCLUSIONS: PSNB provided effective pain relief during and immediately after lower limb angioplasty, but did not statistically affect the rate of conversion to general anesthesia, sedoanalgesia drug usage, or complications.

How Does the Addition of Dexamethasone to a Brachial Plexus Block Change Pain Patterns After Surgery for Distal Radius Fractures? A Randomized, Double-blind Study.

BACKGROUND: Although brachial plexus block in volar plating surgery for distal radius fractures is reportedly associated with lower postoperative pain scores, rebound pain has been reported to occur after the initial block wears off. Dexamethasone can be used in multimodal strategies for antiemesis and to control pain postoperatively. Although prior studies have suggested that anesthesia can be prolonged by adding dexamethasone to regional blocks, no randomized trials we are aware of have ascertained whether doing so will make a clinically important difference in pain after surgery for distal radius fractures. QUESTIONS/PURPOSES: Do patients who receive supplemental dexamethasone in a brachial plexus block for volar plating of unstable distal radius fractures have (1) better pain scores at 4, 8, 24, and 48 hours postoperatively than patients who have not received dexamethasone, and (2) lower fentanyl consumption and administration of antiemetic drugs without change in serum blood glucose, as well as a longer analgesic duration from the block after surgery than patients who have not received dexamethasone? METHODS: This randomized, double-blind trial included 69 patients undergoing surgery for distal radius fractures under ultrasound-guided supraclavicular brachial plexus blocks who were randomly allocated into two groups: a nondexamethasone group receiving a brachial plexus block with 0.5% ropivacaine and a dexamethasone group receiving 0.5% ropivacaine and 5 mg of dexamethasone. Thirty-four patients were allocated to the dexamethasone group and 35 were allocated to the nondexamethasone group. Nine patients (four in the dexamethasone group and five in the nondexamethasone group) were excluded after randomization because local anesthetics were used during their surgical procedures owing to an incomplete block or they requested patient-controlled analgesia after surgery. The treatment groups did not differ in any important ways, including age, gender, BMI, hand dominance, and AO/Orthopaedic Trauma Association classification. All patients received the same surgical procedure and perioperative care protocol, except for the injected agents during their brachial plexus block. The primary outcome was postoperative pain, evaluated using a 10-mm VAS at 4, 8, 12, 24, and 48 hours after surgery. The minimum clinically important difference for the VAS score was 2 of 10 points. Secondary outcome variables included fentanyl administration as a rescue analgesic, the number of patients receiving antiemetic medications because of fentanyl administration, and the duration of brachial plexus block. Serum blood glucose was measured 1 day before, immediately after, and 24 hours after surgery. Patients, surgeons, and outcome assessors were blinded to treatment allocation. RESULTS: The only clinically important between-group difference in VAS pain scores was at 8 hours, favoring the group that received dexamethasone over the group that did not (1.9 ± 1.6 versus 4.7 ± 2.7; mean difference -2.8 [95% CI -3.9 to -1.6]; p < 0.001). After brachial plexus block, the most severe pain score in both groups was reported at 12 hours postoperatively and gradually diminished over time. There was no between-group difference in fentanyl use between those who received dexamethasone and those who did not (21 ± 38 mcg versus 31 ± 29 mcg; mean difference -10 [95% CI -27.4 to 7.4]; p = 0.26). Furthermore, the use of antiemetics did not differ between the groups (27% [eight of 30] versus 37% [11 of 30]; odds ratio 1.6 [95% CI 0.5 to 4.8]; p = 0.41). Baseline and 24-hour postoperative serum blood glucose level did not differ between the groups. However, the immediately postoperative serum blood glucose level was higher in the dexamethasone group than in the nondexamethasone group (121 ± 29 versus 104 ± 20; mean difference 16 [95% CI 3.3 to 28.8]; p = 0.02). The brachial plexus block duration was 3 hours longer (95% CI 0.8 to 5.2 hours) in the dexamethasone group than that in the nondexamethasone group (11 ± 5 hours versus 8 ± 3 hours; p = 0.01). CONCLUSION: The postoperative pain level in patients who received supplemental dexamethasone in a regional block was not clinically different from that of patients who received conventional brachial plexus block anesthesia when undergoing volar plating for distal radius fractures. However, patients who received a brachial plexus block with dexamethasone experienced slight prolongation of their block and decrease in pain 8 hours after surgery. LEVEL OF EVIDENCE: Level I, therapeutic study.

Comparison between ketorolac- and fentanyl-based patient-controlled analgesia for acute kidney injury after robot-assisted radical prostatectomy: a retrospective propensity score-matched analysis.

PURPOSE: It is unclear whether ketorolac-based patient-controlled analgesia (PCA) leads to acute kidney injury (AKI) after robot-assisted radical prostatectomy (RARP) in patients susceptible to AKI. We compared the postoperative AKI incidence with ketorolac- and fentanyl-based PCA after RARP. METHODS: After medical record review, eligible patients were divided in ketorolac and fentanyl groups. We conducted propensity score matching of 3239 patients and assigned 641 matched patients to each group, and compared the AKI incidence. We investigated potential risk factors for postoperative AKI, defined according to the Kidney Disease Improving Global Outcomes criteria. We collected preoperative data (age, height, weight, body mass index, American Society of Anesthesiologists physical status, medical history, creatinine level, estimated glomerular filtration rate, and hemoglobin level) and intraoperative data (maintenance anesthetics, surgery duration, anesthesia duration, crystalloid amount, colloid use, total amount of fluid administered, estimated blood loss, norepinephrine use, phenylephrine use, and PCA type). RESULTS: The postoperative AKI incidence was significantly higher in the ketorolac than in the fentanyl group, both before (31.1% vs. 20.4%; p < 0.001) and after (31.5% vs. 22.6%; p < 0.001) matching. In the univariate analysis, ketorolac was significantly associated with postoperative AKI, both before (odds ratio [OR], 1.762; 95% confidence interval [CI], 1.475-2.105; p < 0.001) and after (OR, 1.574; 95% CI, 1.227-2.019; p < 0.001) matching. In the multivariate analysis, ketorolac-based PCA was independently associated with development of postoperative AKI in the matched groups (OR, 1.659; 95% CI, 1.283-2.147; p < 0.001). CONCLUSION: Ketorolac-based PCA may increase postoperative AKI incidence after RARP; thus, renal function should be monitored in these patients.

Efficacy appraisal of four regimens (granisetron, ketamine, dexmedetomidine, and lidocaine combined with fentanyl) for cystoscopy-associated sedation and analgesia and catheter-related bladder tolerance: a randomized clinical trial.

The authors sought to quantify the clinical impacts of granisetron, ketamine, dexmedetomidine, and lidocaine combined with fentanyl, for procedural sedation and analgesia in cystoscopy and for bladder catheter tolerance. This double-blind trial recruited four stratified blocked randomized eligible groups of patients (n = 120) formerly identified as needing cystoscopy, each receiving one of the above four anesthetic agents. Dexmedetomidine-sedated subjects experienced less pain from 5 to 120 minutes after the beginning of procedure, and next the ketamine manifested a better pain relief experienced. Sedation score was found to be rather more satisfactory in the early-mentioned from 15 to 55 minutes and at 90 and 105 minutes after procedure. The mean opioid use was observed lower in the dexmedetomidine treated patients and next in the ketamine administered patients. Considering the findings emanating from the study and the lack of complications that need to be treated, dexmedetomidine and ketamine afforded superior pain relief, greater sedation, and less postoperative opioid use in patients undergoing cystoscopy, and thus, they could be suggested to be combined with fentanyl during outpatient cystoscopy.

Effect of Fentanyl for Preterm Infants on Mechanical Ventilation: A Systematic Review and Meta-Analysis.

INTRODUCTION: Because excessive physical stress is harmful, reducing pain and discomfort in premature neonates during mechanical ventilation is a major challenge for physicians. There are no consensus and systematic review on the use of fentanyl, the most commonly used pain reliever in preterm neonates during mechanical ventilation. We aim to compare the benefits and harms of fentanyl versus placebo or no drug for preterm neonates receiving mechanical ventilation. METHODS: A systematic review of randomized controlled trials (RCTs) was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions. The systematic review was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Scientific databases such as MEDLINE, Embase, CENTRAL, and CINAHL were searched. All preterm infants on mechanical ventilation and enrolled in an RCT of fentanyl versus control were included. RESULTS: Of 256 reports initially retrieved, 4 reports met the eligibility criteria. Fentanyl was not associated with mortality risk compared to the control (risk ratio: 0.72, 95% confidence intervals [CIs]: 0.36-1.44). No increase in ventilation duration (mean difference [MD]: 0.04, 95% CIs: -0.63-0.71) and no effect on hospital stay length (MD: 4.00, 95% CIs: -7.12-15.12) were found. Fentanyl intervention does not affect any other morbidities, including bronchopulmonary dysplasia, periventricular leukomalacia, patent ductus arteriosus, intraventricular hemorrhage (IVH), severe IVH, sepsis, and necrotizing enterocolitis. CONCLUSION: The present systematic review and meta-analysis failed to demonstrate the benefit of administering fentanyl to preterm infants on mechanical ventilation in mortality and morbidities. Follow-up studies are required to investigate the long-term neurodevelopment of the children.