Perioperative Management of Buprenorphine at an Urban Academic Medical Center.

INTRODUCTION: Buprenorphine is a partial mu opioid receptor agonist with high affinity to its receptor, which raises concerns of blocking or displacing full opioid agonists when used during the perioperative period of surgical patients. However, buprenorphine itself has high analgesic potency and discontinuing buprenorphine may lead to suboptimal pain control and risk for opioid use disorder relapse. There is limited data for the continuation of buprenorphine perioperatively. METHODS: This study is a retrospective cohort study of adult surgical patients taking buprenorphine for opioid use disorder at an urban, teaching, level 1 trauma center. Patients were split into two groups based on whether buprenorphine was continued (n = 46) or held (n = 28) within the first 48 h after surgery. RESULTS: Those who had buprenorphine continued in the first 48 h postoperatively required half the dose of nonbuprenorphine opioids compared to those who had buprenorphine held (113.25 versus 255.75 oral morphine equivalents, P = 0.0040). Both groups had a similar level of analgesia and incidence of adverse events. Nearly all patients who continued buprenorphine in the first 48 h postoperatively were discharged on this agent, while only half of patients who had buprenorphine held were restarted on it at discharge (92.68% versus 56.52%, P = 0.0013). CONCLUSIONS: This present study found lower nonbuprenorphine opioid requirements in patients with continued versus held perioperative buprenorphine use with no difference in degree of analgesia.

Heeding Pain's Prescription.

Newer definitions of pain remain suggestive of categorization by mainly neurological or psychological bases. All pain recruits cortical interpretation for any sort of directive effects in awareness, attention, and action. That unity of purpose in pain's multi-pathway manifestations can inspire neurophilosophical reflections on the existentiality, subjectivity, and sociality of pain. Pain is neither so subjective as to be relieved of meaning, nor so objective that multi-modal approaches can take turns at targeting its relief. The problem of objectifying the subjective is essential for addressing issues of assessing and treating pain. Integrative plans for pain care make sense if and when all aspects of pain's character are deemed to be integral, and are actually integrated in both theory in practice. A standpoint on the "entity-identity" of pain afflicting the whole person implies that pain is expressed behaviorally and as articulately as circumstances permit. Pain speaks, even for those not able to speak, as their patterns of brain activity may be representative of pain. Heeding pain's prescriptive voice requires collective interpretations before attempting coordinated treatments. Pain's prescription will remain unfilled until its full reality is recognized at a personal level, where comprehensive care is mobilized for the whole patient. Heeding pain looks to the central figure that is never absent from any painful situation, namely the individual person-in-pain. That holistic and humanistic value to mobilizing resources against pain should be reflected in the practice of pain medicine, and the craft of the pain physician.

Acute Pain Transfusion Reaction: A Case Report.

Transfusion-related adverse events involving packed red blood cells (PRBCs) and fresh frozen plasma (FFP) are not unusual. Reactions can happen at any time during the transfusion, as well as hours or days later. An acute pain transfusion reaction (APTR) is defined as sudden, intense joint pain, usually in the back and trunk, that appears right after transfusion after all other potential causes of transfusion reactions have been eliminated. The present article discusses two similar cases. A 38-year-old female presented with complaints of right-sided headache and photophobia for four days, associated with nausea, vomiting, and vertigo. She was evaluated for a migraine headache. Due to anemia, a one-unit PRBC was requested. After pre-transfusion testing, a one-unit non-leuko-reduced, coombs cross-match compatible B-positive packed red blood cell (PRBC) was issued and transfused. During the transfusion, the patient complained of chest pain. The transfusion was stopped. Her vitals did not vary much from the baseline. No other symptoms were present at that time. A 69-year-old female presented with complaints of vomiting, abdominal pain, and black tarry stool for a one-month duration. On evaluation, she was diagnosed with adenocarcinoma of the stomach. Given the increased prothrombin time/international normalized ratio (PT/INR) of 1.8, four-units of fresh frozen plasma (FFP) was requested, which was issued after performing minor cross-match compatibility. After five minutes of transfusion, she complained of severe pain at the transfusion site with chills and rigors. The transfusion was stopped. There was no change in the vitals of the patient from baseline. A complete workup was done to rule out other transfusion reactions in both cases. Thus, these patients experienced what is known as an acute pain transfusion reaction. APTR is typically self-limited and requires treatment of symptoms with pain control, supplemental oxygen, and emotional support. In both cases, supportive treatments were enough to control the pain symptoms of the patients.

Optimizing Pain Management in Cardiac Surgery: A Review of Analgesic Adjuvants.

PURPOSE OF REVIEW: Pain management following cardiac surgery is a critical component in optimizing both short- and long-term patient outcomes, with poor pain management associated with significant acute and chronic opioid use, opioid dependence and a significant rate of opioid related adverse drug events. The significant burden of both acute and chronic pain following cardiac surgery has given rise to the need for multimodel analgesic strategies, to optimize outcomes and minimize side effects. RECENT FINDINGS: While significant research has focused recently on the additive value of peripheral nerve blocks, less emphasis has been given to the value of non-opioid based analgesics in preference to traditional opioid based anesthetic and analgesic strategies. In this review, we examine the evidence for several common analgesics, highlighting the evidence supporting efficacy following cardiac surgery, as well as the safety concerns with each agent. We demonstrate the value of a multimodal analgesic strategy to reduce pain scores and improve patient-centered outcomes, and highlight the need for further studies of combination analgesic strategies.

Efficacy of ozone therapy for oral mucosa wound healing: a systematic review and meta-analysis.

OBJECTIVES: To conduct a systematic review and meta-analysis to assess the effectiveness of ozone therapy in oral ulcers healing when compared to placebo or active treatments. MATERIALS AND METHODS: The search was carried out using PubMed, EMBASE, Scopus, and Lilacs databases. Clinical trials involving human participants were included. The Risk Ratio (RR) and the standardized mean difference (SMD) with 95%CI (confidence interval) were calculated. The ROBINS-I (risk of bias in non-randomized studies of interventions) and RoB2 (risk of bias tool for randomized trials) assessment tool was used to detect bias. RESULTS: After the selection process, 12 studies were included. The meta-analysis showed that ozone therapy helps to reduce the size of the traumatic and autoimmune ulcers (RR=-0.44; 95% CI -0.71,-0.17; I2=0%) in comparison to placebo. Regarding pain reduction, ozone was superior to placebo (RR = 1.29, 95% CI -1.6 to -0.95); I2=0%), and equivalent to topical corticosteroid and laser photobiomodulation (RR = 0.26, 95% CI -0.27,0.78, p = 0.34). CONCLUSION: Ozone therapy is an alternative for accelerating healing and reducing pain for both traumatic and autoimmune ulcers. However, the quality of evidence is limited. CLINICAL RELEVANCE: Oral ulcerations are usually painful and impact quality of life requiring different approaches to boost wound healing and reduce symptoms. For this purpose, ozone therapy is a promising strategy.

Advanced statistical approaches for predicting pain after pediatric thoracotomy: a cross-sectional study using zero-inflated and Poisson models.

BACKGROUND: Thoracotomy is one of the surgical procedures most burdened by chronic post-operative pain. There is poor evidence regarding the possibility that even in pediatric patients, thoracotomy can be followed by post-operative pain. The primary objective of this analysis is to identify associations with home pain therapy, pain intensity, and possible protective factors acting on chronic pain in this population. METHODS: A retrospective cross-sectional study was conducted at Ospedale Pediatrico Bambino Gesù IRCCS. The study included pediatric patients undergoing thoracotomy. For statistical analyses, a logistic model and a zero-inflated strategy were implemented to explore associations and predict factors related to home-based analgesic therapy and pain intensity. RESULTS: Gender and age were identified as significant factors in the assignment of home therapy, with males having over seven times the risk compared to females (OR = 7.06, 95% CI = [2.11, 29.7]). At the last measurement, pain intensity was positively associated with age and the number of pain events during the week. CONCLUSIONS: The study highlights significant factors influencing post-thoracotomy pain management in pediatric patients. These findings underscore the importance of tailored pain management strategies that consider gender and age to improve post-operative care and outcomes in pediatric thoracotomy patients.

Hidden Agony: Foot Pain Linked to Pet Hair Splinter.

Cutaneous pili migrans is a rare and interesting dermatological condition characterized by embedding a hair or its fragment in the epidermis or superficial dermis, sometimes leading to pain and a serpiginous rash. We present a 28-year-old male who came to the clinic concerned about the sudden onset of pain in his foot over 10 hours. Upon meticulous physical examination, we found a white hair embedded in the skin of the fifth toe of his left foot, which the patient immediately recognized as hair from his dog. Upon removal of the hair, the pain immediately resolved. We believe our case represents the first reported case in Panama, the second in Latin America, and the second associated with dog hair. We anticipate that more cases related to animal hairs will be reported in the coming years due to the increasing popularity of pets in this century.

Continuous Ultrasound-Guided Lumbar Erector Spinae Plane Block for Thigh Cellulitis Analgesia: A Case Report.

The management of refractory acute medical pain can be challenging, especially if severe and decompensated systemic pathologies contraindicate neuraxial techniques and deep peripheral blocks. In this case report, we propose a continuous ultrasound-guided lumbar erector spinae plane block (ESPB) for multimodal analgesia of thigh cellulitis. The patient was an 80-year-old male, admitted to the intensive care unit due to septic shock originating from cellulitis of the right lower limb, associated with multiorgan dysfunction. To address refractory pain in the thigh, an ultrasound-guided lumbar ESPB at L3 was performed, with the placement of a perineural catheter and administration of 30 mL of 0.5% ropivacaine, followed by 30 mL boluses of 0.375% ropivacaine every six hours with progressive weaning. The patient maintained controlled pain without the need for rescue analgesia. Continuous ultrasound-guided lumbar ESPB is an effective and safe alternative for thigh analgesia in patients with refractory acute medical pain and systemic pathologies that contraindicate other regional techniques.

The analgesic effects of combined bilateral parasternal block and serratus anterior plane block for coronary artery bypass grafting surgery.

BACKGROUND: Severe pain occurs after cardiac surgery in the sternum and chest tubes sites. Although analgesia targeting the sternum is often prioritized, the analgesia of the drain site is sometimes overlooked. This study of patients undergoing coronary artery bypass grafting (CABG) aimed to provide optimized analgesia for both the sternum and the chest tubes area by combining parasternal block (PSB) and serratus anterior plane block (SAPB). METHODS: Ethics committee approval (E.Kurul-E2-24-6176, 07/02/2024) was received for the study. Then, the trial was registered on www. CLINICALTRIALS: gov ( https://clinicaltrials.gov/ ) under the identifier NCT05427955 on 17/03/2024. Twenty patients between the ages of 18-80, with ASA physical status classification II-III, undergoing coronary artery bypass grafting CABG with sternotomy, were included. While the patients were under general anesthesia, PSB was performed through the second and fourth intercostal spaces, and SAPB was performed over the sixth rib. The primary outcome was VAS (Visual Analog Scale) during the first 12 h after extubation. The secondary outcomes were intraoperative remifentanil consumption and block-related side effects. RESULTS: The average age of the patients was 64 years. Five patients were female, and 15 were male. For the sternum area, only one patient had resting VAS scores of 4, while the VAS scores for resting for the other patients were below 4. For chest tubes area, only two patients had resting VAS scores of 4 or above, while the resting VAS scores for the other patients were below 4. The patients' intraoperative remifentanil consumption averaged 2.05 mg. No side effects related to analgesic protocol were observed in any of the patients. CONCLUSIONS: In this preliminary study where PSB and SAPB were combined in patients undergoing CABG, effective analgesia was achieved for the sternum and chest tubes area.

Headache management in traumatic brain injury.

Traumatic brain injury (TBI) is estimated to rank as the third most important disease burden worldwide. About 60% of the survivors develop chronic headaches and visual symptoms, and the long-term management of headaches in these patients is controversial. Importantly, the care pathway of most patients is fragmented, complicating conclusive headache management. Here we review the epidemiology and aetiology of post traumatic headaches (PTH), discuss the diagnostic work up and summarise the acute and long-term management.

Acute Pain Management in a Multi-site Trauma Patient.

Pain management is often difficult in the setting of multi-site trauma such as that caused by motor vehicle accidents (MVA), which is especially compounded in the setting of polysubstance abuse. This often results in patients with poor pain tolerance requiring escalating doses of opioid therapy, which creates a vicious cycle. The use of peripheral nerve blocks (PNB) has been shown to decrease overall opioid consumption and can be used effectively to manage postoperative pain in this patient population. Our case report aims to highlight the importance of PNBs as part of a multimodal approach to pain management in patients with polytrauma in the setting of polysubstance abuse.

Celecoxib-tramadol co-crystal in patients with moderate-to-severe pain following bunionectomy with osteotomy: Secondary analyses by baseline pain intensity and use of rescue medication of a phase 3, randomized, double-blind, factorial, active- and placebo-controlled trial.

BACKGROUND: In the randomized, phase 3, SUSA-301 trial, celecoxib-tramadol co-crystal (CTC) provided significantly greater analgesia compared with celecoxib, tramadol, or placebo in adults with acute, moderate-to-severe, postoperative pain. This post hoc, secondary analysis further evaluated the use of rescue medication and the incidence of treatment-emergent adverse events (TEAEs). METHODS: Patients (N = 637) were randomized 2:2:2:1 to receive oral CTC 200 mg twice daily (BID; n = 184), tramadol 50 mg four times daily (QID; n = 183), celecoxib 100 mg BID (n = 181), or placebo QID (n = 89). Post hoc analyses were conducted on the use of rescue medications up to 4 and 48 h post-study drug dose, stratified by baseline pain intensity (moderate/severe), and on the incidence of TEAEs, stratified by rescue medication use. RESULTS: A significantly lower proportion of patients received any rescue medication within 4 h post-study dose with CTC (49.5%) versus tramadol (61.7%, p = 0.0178), celecoxib (65.2%, p = 0.0024), and placebo (75.3%, p = 0.0001); this was also seen for oxycodone use. Fewer patients in the CTC group received ≥3 doses of rescue medication compared with the other groups, irrespective of baseline pain intensity. In patients who did not receive opioid rescue medication, CTC was associated with a lower incidence of nausea and vomiting TEAEs versus tramadol alone. In patients who received rescue oxycodone, the incidence of nausea was similar in the CTC and tramadol groups, and higher versus celecoxib and placebo. CONCLUSION: Celecoxib-tramadol co-crystal was associated with reduced rescue medication use and an acceptable tolerability profile compared with tramadol or celecoxib alone in adults with acute, moderate-to-severe, postoperative pain.

A Narrative Review of Ultrasound-Guided and Landmark-based Percutaneous Cryoneurolysis for the Management of Acute and Chronic Pain.

PURPOSE OF REVIEW: Cryoneurolysis refers to the process of reversibly ablating peripheral nerves with extremely cold temperatures to provide analgesia for weeks to months. With ultrasound-guidance or landmark-based techniques, it is an effective modality for managing both acute and chronic pain. In this review, we summarize the reported literature behind its potential applications and efficacy. RECENT FINDINGS: Here, we summarize several studies (from case reports to clinical trials) describing the use of ultrasound-guided and landmark-based cryoneurolysis for acute and chronic pain. Acute pain indications included pain related to knee arthroplasty, limb amputations, mastectomies, shoulder surgery, rib fractures, and burn. Chronic pain indications included chronic knee pain (due to osteoarthritis), shoulder pain, painful neuropathies, postmastectomy pain syndrome, phantom limb pain, facial pain/headaches, foot/ankle pain, inguinal pain, and sacroiliac joint pain. For both acute and chronic pain indications, more high quality randomized controlled clinical trials are needed to definitively assess the efficacy of cryoneurolysis versus other standard therapies for a multitude of pain conditions.

Efficacy of parasternal peripheral nerve catheters versus no block for median sternotomy: a single-centre retrospective study.

Background: Sternal pain after cardiac surgery results in considerable discomfort. Single-injection parasternal fascial plane blocks have been shown to reduce pain scores and opioid consumption during the first 24 h after surgery, but the efficacy of continuous infusion has not been evaluated. This retrospective cohort study examined the effect of a continuous infusion of local anaesthetic through parasternal catheters on the integrated Pain Intensity and Opioid Consumption (PIOC) score up to 72 h. Methods: We performed a retrospective analysis of patients undergoing cardiac surgery with median sternotomy at a single academic centre before and after the addition of parasternal nerve catheters to a standard multimodal analgesic protocol. Outcomes included PIOC score, total opioid consumption in oral morphine equivalents, and time-weighted area under the curve pain scores up to 72 h after surgery. Results: Continuous infusion of ropivacaine 0.1% through parasternal catheters resulted in a significant reduction in PIOC scores at 24 h (-62, 95% confidence interval -108 to -16; P<0.01) and 48 h (-50, 95% CI -97 to -2.2; P=0.04) compared with no block. A significant reduction in opioid consumption up to 72 h was the primary factor in reduction of PIOC. Conclusions: This study suggests that continuous infusion of local anaesthetic through parasternal catheters may be a useful addition to a multimodal analgesic protocol in patients undergoing cardiac surgery with sternotomy. Further prospective study is warranted to determine the full benefits of continuous infusion compared with single injection or no block.

Comparison of Butorphanol, Methadone, and Pethidine in Combination with Alfaxalone for Premedication in Isoflurane-Anesthetized Cats Undergoing Ovariectomy.

The aim of this study was to compare three different anesthetic protocols administered intramuscularly (IM) in cats undergoing elective ovariectomy, while evaluating the quality of sedation, antinociceptive, isoflurane-sparing effect, and analgesia in the intra-operative and post-operative phases. A total of 71 female cats were sedated IM with alfaxalone (3 mg/kg) combined with either butorphanol (0.3 mg/kg), methadone (0.3 mg/kg), or pethidine (5 mg/kg). During surgery, vital parameters were constantly monitored; at the end of the procedure, the quality of recovery was assessed through a specific form and each cat was scored for perceived pain using the UNESP-Botucatu scale for 5 days, and rescue analgesia was provided with buprenorphine IM when indicated. Moreover, differences between two different post-operative resting regimens (hospital kennels vs. home) were also assessed. A significant difference emerged for the amount of IM dexmedetomidine required to achieve an adequate level of sedation for intravenous catheterization, highlighting a greater need in the pethidine group (p = 0.021). There was no significant difference between opioid groups for the requirement of intra-operative rescue analgesia, and the clinical parameters were kept within physiological ranges regardless of the opioid used in premedication. Lastly, differences between the UNESP-Botucatu scores were detected from day 3 to day 5 post-operatively, with lower scores in cats with home resting regimens compared to the hospitalized animals, likely due to the presence of an unfamiliar condition and the absence of a cat-friendly environment.

How to undertake a pain assessment for -patients with acute post-operative pain.

RATIONALE AND KEY POINTS: Acute post-operative pain is common among patients in secondary care settings, and the alleviation of this pain is a principal responsibility for all healthcare professionals, including nurses. To achieve this, it is essential to regularly undertake comprehensive pain assessments, using validated pain assessment tools, for all patients who have undergone a surgical procedure. Inadequate pain assessment may lead to ineffective or inappropriate pain management, which can adversely affect the patient's recovery and increase their risk of developing chronic pain. •  Pain is a subjective experience and therefore requires individualised, comprehensive assessment and management interventions. •  The assessment process for patients with acute pain is fundamental to understanding the patient's current status, informing differential diagnoses regarding the underlying cause of the pain, providing appropriate treatment and monitoring, and evaluating the effectiveness of treatment. •  Pain assessment should not be undertaken as a one-off care activity; it should be completed whenever a patient reports pain and repeated following pharmacological and/or non-pharmacological interventions. REFLECTIVE ACTIVITY: 'How to' articles can help you to update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of: •  How this article might improve your practice when undertaking a comprehensive pain assessment with patients experiencing acute post-operative pain. •  How you could use this information to educate nursing students or colleagues on the appropriate actions to take when undertaking a comprehensive pain assessment with patients experiencing acute post-operative pain.