Ultrasound Image-Guided Nerve Block Combined with General Anesthesia under an Artificial Intelligence Algorithm on Patients Undergoing Radical Gastrectomy for Gastric Cancer during and after Operation.

This study was aimed at investigating the location of gastric cancer by using a gastroscope image based on an artificial intelligence algorithm for gastric cancer and the effect of ultrasonic-guided nerve block combined with general anesthesia on patients undergoing gastric cancer surgery. A total of 160 patients who were undergoing gastric cancer surgery from March 2019 to March 2021 were collected as the research objects, and the convolutional neural network (CNN) algorithm was used to segment the gastroscope image of gastric cancer. The patients were randomly divided into a simple general anesthesia group of 80 cases and a transversus abdominis plane block combined with rectus abdominis sheath block combined with the general anesthesia group of 80 cases. Then, compare the systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) at the four time points T0, T1, T2, and T3. The times of analgesic drug use within 48 hours after operation and postoperative adverse reactions were recorded. The visual analog scale (VAS) scores were also recorded at 4 h, 12 h, 24 h, and 48 h. The results show that the image quality after segmentation is good: the accuracy of tumor location is 75.67%, which is similar to that of professional endoscopists. Compared with the general anesthesia group, the transversus abdominis plane block combined with the rectus sheath block combined with the general anesthesia group had fewer anesthetics, and the difference was statistically significant (P < 0.05). Compared with the general anesthesia group, SBP, DBP, and HR were significantly reduced at T1, T2, and T3 in the transverse abdominis plane block combined with rectus sheath block and general anesthesia group (P < 0.05). Compared with the simple general anesthesia group, the VAS scores of the transversus abdominis plane block combined with rectus sheath block combined with the general anesthesia group decreased at 4 h, 12 h, and 24 h after surgery, and the difference was statistically significant (P < 0.05). The number of analgesics used in transversus abdominis plane block combined with the rectus sheath block combined with the general anesthesia group within 48 hours after operation was significantly less than that in the general anesthesia group, and the difference was statistically significant (P < 0.05). The average incidence of adverse reactions in the nerve block combined with the general anesthesia group was 2.5%, which was lower than the average incidence of 3.75% in the general anesthesia group. In summary, the CNN algorithm can accurately segment the lesions in the ultrasonic images of gastric cancer, which was convenient for doctors to make a more accurate judgment on the lesions, and provided a basis for the preoperative examination of radical gastrectomy for gastric cancer. Ultrasonic-guided nerve block combined with general anesthesia can effectively improve the analgesic effect of radical gastrectomy for gastric cancer, reduced intraoperative and postoperative adverse reactions and analgesic drug dosage, and had a good effect on postoperative recovery of patients. The combined application of these two methods can further improve the precision treatment of gastric cancer patients and accelerate postoperative recovery.

Perioperative Multimodal Anesthetic Care Incorporating Transversus Abdominis Plane Block Is Associated With Reduced Narcotic Use in Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric surgery performed in North America. As our knowledge of the importance in limiting narcotic use in postoperative patients increases, we sought to evaluate the effect of transversus abdominis plane (TAP) blocks on inpatient narcotic use in patients undergoing LSG. METHODS: A retrospective review of LSG performed at a single institution by 3 bariatric surgeons was performed. All cases over a 15-month period were included, and anesthesia records were reviewed to stratify patients that received a TAP block and those that did not. Demographic, as well as surgical, outcomes were collected for all patients. Narcotic utilization, as reported in morphine equivalents (ME), was evaluated between the 2 groups. RESULTS: 384 LSG patients were identified, of which 37 (9.6%) received a TAP block. There was no statistically significant difference in postoperative morbidity, length of stay, or readmission between groups. Median narcotic utilization in hospital days 1 and 2 in patients with TAP blocks was 49 ME (Interquartile Range (IQR) 14.5-84.5) to 82.5 ME (IQR 57.4-106) in the no-TAP group (P < .001). After controlling for multiple demographic- and patient-related cofactors, multiple linear regression analysis demonstrated TAP block patients utilized 22.48 ME less than the no-TAP group (P < .001) in the first 2 days of their hospitalization. DISCUSSION: Patients that received a TAP block as a part of their perioperative anesthetic care utilized less in-hospital narcotics than those patients that did not receive a TAP block. TAP blocks should be considered as part of a multimodal pain control strategy for patients undergoing LSG.

Efficacy of fascia iliaca nerve block in daily routine for children with femoral fractures in a pediatric emergency department.

OBJECTIVES: We aimed to evaluate the efficacy of fascia iliaca nerve block (FINB), routinely used for children with femoral fractures, in a pediatric emergency department (PED). METHODS: This retrospective, single-center, observational study examined FINB using ropivacaine and a 1% lidocaine hydrochloride solution, in all patients under 18 years of age admitted with a femoral fracture from January 2012 to December 2016. Pain was assessed using two validated pediatric pain scales: EVENDOL or a visual analog scale. A level of ≥ 4 on either scale indicates the need for an analgesic. The primary outcome was the percentage of patients who were pain free after the FINB procedure defined by a pain score of < 4. Secondary outcomes were the time spent between PED admission and FINB, the need of additional analgesics, side effects, and the success rate of FINB. RESULTS: Of 161 patients screened, 144 were included. The median age was 3.2 years (range 2 months to 16 years) and 74% were boys. The number of children determined to be pain free (pain score < 4) increased from 36 (25%) before the FINB to 123 (85%) after the FINB (absolute risk difference 60%, 95% CI: 51%-70%). Overall, 21 children (15%) required a second analgesic after the FINB. CONCLUSION: The routine use of FINB with ropivacaine and lidocaine by pediatric ED physicians provided effective pain relief for children admitted for a femoral fracture in the emergency department. Our data support the efficiency and feasibility of FINB for the antalgic management of children with femoral fracture.

Persistent Postoperative Opioid Prescription Fulfillment and Peripheral Nerve Blocks for Ambulatory Shoulder Surgery: A Retrospective Cohort Study.

BACKGROUND: There is need to identify perioperative interventions that decrease chronic opioid use. The authors hypothesized that receipt of a peripheral nerve block would be associated with a lower incidence of persistent postoperative opioid prescription fulfillment. METHODS: This was a retrospective population-based cohort study examining ambulatory shoulder surgery patients in Ontario, Canada. The main outcome measure was persistent postoperative opioid prescription fulfillment. In opioid-naive patients (no opioid prescription fulfillment in 90 days preoperatively), this was present if an individual fulfilled an opioid prescription of at least a 60-day supply during postoperative days 90 to 365. In opioid-exposed (less than 60 mg oral morphine equivalent dose per day within 90 days preoperatively) or opioid-tolerant (60 mg oral morphine equivalent dose per day or above within 90 days preoperatively) patients, this was classified as present if an individual experienced any increase in opioid prescription fulfillment from postoperative day 90 to 365 relative to their baseline use before surgery. The authors' exposure was the receipt of a peripheral nerve block. RESULTS: The authors identified 48,523 people who underwent elective shoulder surgery from July 1, 2012, to December 31, 2017, at one of 118 Ontario hospitals. There were 8,229 (17%) patients who had persistent postoperative opioid prescription fulfillment. Of those who received a peripheral nerve block, 5,008 (16%) went on to persistent postoperative opioid prescription fulfillment compared to 3,221 (18%) patients who did not (adjusted odds ratio, 0.90; 95% CI, 0.83 to 0.97; P = 0.007). This statistically significant observation was not reproduced in a coarsened exact matching sensitivity analysis (adjusted odds ratio, 0.85; 95% CI, 0.71 to 1.02; P = 0.087) or several other subgroup and sensitivity analyses. CONCLUSIONS: This retrospective analysis found no association between receipt of a peripheral nerve block and a lower incidence of persistent postoperative opioid prescription fulfillment in ambulatory shoulder surgery patients.

Postoperative pain after clitoral reconstruction in women with female genital mutilation: An evaluation of practices.

INTRODUCTION: More than 200 million women and girls have undergone genital mutilation. Clitoral reconstruction (CR) can improve the quality of life of some of them, but is accompanied by significant postoperative pain. OBJECTIVE: Assess and describe the management of postoperative pain after CR, and the practices amongst specialists in different countries. METHODS: Between March and June 2020, 32 surgeons in 14 countries (Germany, Austria, Belgium, Burkina Faso, Canada, Ivory Coast, Egypt, Spain, United States of America, France, the Netherlands, Senegal, Switzerland, Sweden) responded to an online questionnaire on care and analgesic protocols for CR surgery. RESULTS: At day 7 post CR, 97% of the surgeons observed pain amongst their patients, which persisted up to 1 month for half of them. 22% of the participants reported feeling powerless in the management of such pain. The analgesic treatments offered are mainly step II and anti-inflammatory drugs (61%). Screening for neuropathic pain is rare (3%), as is the use of pudendal nerve block, used by 8% of the care providers and only for a small percentage of women. CONCLUSION: Pain after CR is frequent, long-lasting, and potentially an obstacle for the women who are willing to undergo clitoral surgery and also their surgeons. Most surgeons from different countries follow analgesic protocols that do not use the full available therapeutic possibilities. Early treatment of neuropathic pain, optimisation of dosing of standard analgesics, addition of opioids, use of acupuncture, and routine intraoperative use of pudendal nerve block might improve the management of pain after CR.

Factors associated with Successful Responses to Ganglion Impar Block: A Retrospective Study.

Background: The ganglion impar (ganglion of Walther) block has been used to manage coccygeal and perineal (perianal and genital) pain due to both benign and malignant causes. However, the factors associated with successful responses to ganglion impar block are unknown. Therefore, in the present study, we aimed to identify the independent factors associated with successful responses to ganglion impar block in patients with chronic pain in coccygeal and perineal regions. Methods: From January 2008 to December 2017, we performed a retrospective review of 106 patients who underwent ganglion impar block. Patients were considered successful responders if they reported a decrease of more than 50% or 4 points on the 11-point (0 = no pain and 10 = worst possible pain) numerical rating scale 1 month after the procedure, while others were considered non-responders. Logistic regression analysis was performed to identify factors independently associated with successful responses at 1 month after the procedure. Results: Multivariable logistic regression analysis showed that cancer-related causes were significantly associated with successful responses at 1 month after ganglion impar block (odds ratio = 2.60, 95% confidence interval = 1.05 to 6.43, P = 0.038). Conclusion: Ganglion impar block may be more effective in cancer-related pain than pain due to benign causes.

Occipital Nerve Blockade for the Treatment of Occipital Neuralgia-Like Acute Postcraniotomy Headache: A Retrospective Study.

Objective: The therapeutic effectiveness and safety of occipital nerve blockade (ONB) on occipital neuralgia- (ON-) like acute postcraniotomy headache (ON-APCH) was evaluated. Background: Persistent occipital neuralgia is a subclassification of chronic postcraniotomy headache and has been investigated sporadically in previous publications. The long-lasting neuralgic pain significantly impairs postoperative recovery and quality of life. However, little is known regarding ON-APCH and its management. Methods: All data were retrospectively acquired from consultation records and electronic institutional medical documents. Forty-one patients, who developed drug-resistant ON-APCH after elective craniotomy and received ONB with lidocaine for diagnoses, were included in this study, all of whom were treated using dexamethasone and lidocaine. Pain intensity and ONB correlated complications and side effects were collected and analyzed at three different time points: before ONB, at 1 day after ONB, and at discharge. Results: Nineteen males and twenty-two females aged 49.6 ± 15.2 years were diagnosed with drug-resistant ON-APCH. The mean NRS was 8.0 ± 0.9 before ONB, which later significantly decreased to 2.1 ± 1.4 and 1.6 ± 0.6 at 1 day after ONB and on discharge, respectively. At 1 month after ONB, thirty patients (73%) obtained complete pain relief without medication. At 3 months after ONB, only two (5%) patients had to continue oral medications to maintain pain relief. No adverse effects or complications were observed immediately after, or within 3 months, of the nerve blockade. Conclusions: For drug-resistant ON-APCH, early occipital nerve blockade with dexamethasone and lidocaine is an effective and safe technique, which provides adequate pain relief and may prevent further development of persistent presentation of refractory ON.

Comparison of Peripheral Nerve Block and Spinal Anesthesia in Terms of Postoperative Mortality and Walking Ability in Elderly Hip Fracture Patients - A Retrospective, Propensity-Score Matched Study.

PURPOSE: To compare the effects of peripheral nerve block (PNB) and spinal anesthesia (SA) on one-year mortality and walking ability of elderly hip fracture patients after hip arthroplasty. METHODS: Patients ≥65 years who underwent unilateral hip arthroplasty due to femoral neck fracture, using either PNB or SA from 2014 to 2019, were included. Demographic data, comorbidities, and results of preoperative screening were retrospectively collected. Propensity score matching (PSM) was performed in a ratio of 1:1 for PNB and SA groups. The primary outcomes were 30-day, 90-day, and one-year mortality. Secondary outcomes included walking ability in the first postoperative year, major complications, length of stay, and the cost of hospitalization. Survival analysis was performed using Kaplan-Meier method. RESULTS: Three hundred and sixteen patients were included, of whom 200 received SA and 116 received PNB. Eighty-nine patients in each group were matched after PSM. Patients in the PNB group showed significantly lower risks of death in 30 days (2.2% vs 10.1%, P=0.029) and 90 days (3.4% vs 12.4%, P=0.026) after hip arthroplasty, when compared to the SA group. There was no significant difference in one-year mortality, walking ability, major complications, and length of stay. Higher hospitalization cost was found in the PNB group (53,828.21 CNY vs 59,278.83 CNY, P=0.024). One-year accumulated survival rate was higher in the PNB group without reaching a significant level. CONCLUSION: PNB was related to lower 30- and 90-day mortality but higher hospitalization cost in elderly hip fracture patients after hip arthroplasty. However, the anesthesia types were not associated with one-year mortality, one-year walking ability, major complications, and length of stay.

Association between Paravertebral Block and Pain Score at the Time of Hospital Discharge in Oncoplastic Breast Surgery: A Retrospective Cohort Study.

BACKGROUND: Using nonopioid analgesics may decrease the risk of patients chronically using opioids postoperatively. The authors evaluated the relationship between paravertebral block and pain score at the time of hospital discharge. METHODS: The authors performed a retrospective cohort study of 89 women with American Society of Anesthesiologists Physical Status I to III undergoing oncoplastic breast surgery with 20 to 50 percent breast tissue removal and immediate contralateral reconstruction between August of 2015 and August of 2018. The primary outcome was pain score at hospital discharge with or without paravertebral block. The secondary outcome was postoperative length of stay. Data were analyzed using the Wilcoxon rank sum test, t test, Fisher's exact test, univariable and multivariable regression, Kaplan-Meier analyses, and Cox regression. RESULTS: Median pain score at hospital discharge was lower with paravertebral block [2 (interquartile range, 0 to 2) compared to 4 (interquartile range, 3 to 5); p < 0.001]. Multivariable regression revealed that pain score at the time of hospital discharge was inversely associated with paravertebral block after adjusting for age, body mass index, American Society of Anesthesiologists class, extent of lymph node surgery, and duration of surgery (p < 0.001). Pain score at hospital discharge was also associated with total opioid consumption during the first 24 hours after surgery (p = 0.001). Patients who received paravertebral blocks had median total 24-hour postoperative opioid consumption in morphine equivalents of 7 mg (interquartile range, 3 to 10 mg) compared with 13 mg (interquartile range, 7 to 18 mg) (p < 0.001), and median length of stay of 18 hours (interquartile range, 16 to 20 hours) compared with 22 hours (interquartile range, 21 to 27 hours) (p < 0.001). CONCLUSION: Paravertebral blocks are associated with decreased pain score at the time of hospital discharge. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Role of paracervical block in reducing postoperative pain after laparoscopic hysterectomy: A systematic reivew and meta-analysis of randomized controlled trials.

OBJECTIVE: We aimed to perform a systematic review and meta-analysis in order to evaluate the effect of paracervical anesthetic block among women undergoing laparoscopic hysterectomy. METHODS: A systematic search was done in Cochrane Library, PubMed, ISI web of science, and Scopus during January 2021. We selected randomized clinical trials (RCTs) compared paracervical anesthetic block versus normal saline (control group) among women undergoing laparoscopic hysterectomy. We pooled the continuous data as mean difference (MD) and dichotomous data as risk ratio (RR) with the corresponding 95% confidence intervals using Revman software. Our primary outcome was pain scores evaluated by visual analog scale (VAS) at 30 min and 1 hour. Our secondary outcomes were postoperative additional opioids requirement and length of hospital stay. RESULTS: Three RCTs met our inclusion criteria with a total number of 233 patients. We found that paracervical anesthetic block was linked to a significant reduction in VAS pain score at 30 min and 1 hour post-hysterectomy (MD= -2.13, 95% CI [-3.09, -1.16], p>0.001 & MD= -1.87, 95% CI [-3.22, -0.52], p = 0.006). There was a significant decrease in additional opioids requirement postoperatively among paracervical anesthetic block group in comparison with control group (p = 0.002). No significant difference was found between both groups regarding the length of hospital stay. CONCLUSION: Paracervical anesthetic block is effective in reducing postoperative pain after laparoscopic hysterectomy with decrease in opioids administration postoperatively.

Was femoral nerve block effective for pain control of medial opening-wedge high tibial osteotomy?: A single blinded randomized controlled study.

BACKGROUND AND PURPOSE: Medial compartment femoro-tibial osteoarthritis (OA) is a common disease and opening-wedge high tibial osteotomy (OWHTO) is the common surgical procedure carried out for these patients. While most researchers are focusing on the surgical techniques during operation, the aim of this study is to evaluate the pain control effect of femoral nerve block (FNB) for OWHTO patients. METHODS: In this prospective, single-center, randomized controlled trial (RCT) study, 41 patients were operated on by OWHTO for OA during 2017 to 2018. Twenty of them (group A) accepted epidural anesthesia with FNB and 21 patients (group B) only had their single epidural anesthesia. All blocks were successful and all the 41 patients recruited were included in the analysis and there was no loss to follow-up or withdrawal. Systematic records of visual analog scores (VAS), quadriceps strength, mean number of times of patient-controlled intravenous analgesia (PCIA), using of additional opioids or nonsteroidal anti-inflammatory drugs (NSAIDs), and complications were done after hospitalization. The Student t test and Chi-Squared test was used and all P values ≤.05 were considered statistically significant. RESULTS: VAS scores at rest (3.48 ±â€Š1.0 vs 4.68 ±â€Š1.1) and on movemment (4.51 ±â€Š0.6 vs 4.97 ±â€Š0.8) decreased more in group A than group B with significance at follow-up of 12 hours. The quadriceps strength, consumption of additional opioids or NSAID injections and mean number of times that the patients pushed the PCIA button didnot differ significantly within each group. CONCLUSION: This RCT study shows that FNB in patients undergoing OWHTO for unicompartmental osteoarthritis of the knee could result in significant reduction in VAS scores at 12 hours postoperatively.Research registry, Researchregistry4792. Registered April 7, 2019 - Retrospectively registered, http://www.researchregistry.com.

National Trends in Neuromodulation for Urinary Incontinence Among Insured Adult Women and Men, 2004-2013: The Urologic Diseases in America Project.

OBJECTIVE: To examine US trends in neuromodulation for urinary incontinence (UI) treatment from 2004 to 2013. METHODS: This study utilized 2 data sources: the Optum© de-identified Clinformatics® Data Mart Database for privately insured adults aged 18-64 years with a UI diagnosis (N≈40,000 women and men annually) and the Medicare 5% Sample for beneficiaries aged ≥65 years with a UI diagnosis (N≈65,000 women and men annually). We created annual cross-sectional cohorts and assessed prevalence of UI-related neuromodulation procedures among men and women separately from 2004 to 2013. Analyses were conducted overall and stratified by age, race/ethnicity, and geographic region. RESULTS: Nearly all neuromodulation procedures occurred in outpatient settings. Sacral neuromodulation (SNM) procedures for UI in both women and men grew steadily from 2004 to 2013, with more procedures performed in women than men. Among women with UI, SNM prevalence grew from 0.1%-0.2% in 2004 to 0.5%-0.6% in 2013. Posterior tibial nerve stimulation (PTNS) experienced growth from 2011 to 2013. Chemodenervation of the bladder with onabotulinumtoxinA (BTX) combined with other injectable procedures (including urethral bulking) remained stable over time. CONCLUSIONS: From 2004 to 2013, SNM procedures remained relatively uncommon but increased consistently. PTNS experienced growth starting in 2011 when PTNS-specific insurance claims became available. BTX trends remain unclear; future studies should assess it separately from other injectable procedures. Neuromodulation has a growing role in UI treatment, and ongoing trends will be important to examine.

Characterizing the providers of and reimbursement for chronic migraine chemodenervation among the Medicare population.

OBJECTIVE: To characterize reimbursement trends and providers for chronic migraine (CM) chemodenervation treatment within the Medicare population since the introduction of the migraine-specific CPT code in 2013. METHODS: We describe trends in procedure volume and total allowed charge on cross-sectional data obtained from 2013 to 2018 Medicare Part B National Summary files. We also utilized the 2017 Medicare Provider Utilization and Payment Data to analyze higher volume providers (>10 procedures) of this treatment modality. RESULTS: The total number of CM chemodenervation treatments rose from 37,863 in 2013 to 135,023 in 2018 in a near-linear pattern (r = 0.999) and total allowed charges rose from ~$5,217,712 to $19,166,160 (r = 0.999). The majority of high-volume providers were neurologists (78.4%; 1060 of 1352), but a substantial proportion were advanced practice providers (APPs) (10.2%; 138 of 1352). Of the physicians, neurologists performed a higher mean number of procedures per physician compared to non-neurologists (59.6 [95% CI: 56.6-62.6] vs. 45.4 [95% CI: 41.0-50.0], p < 0.001). When comparing physicians and APPs, APPs were paid significantly less ($146.5 [95% CI: $145.6-$147.5] vs. $119.7 [95% CI: $117.6-$121.8], p < 0.001). As a percent of the number of total beneficiaries in each state, the percent of Medicare patients receiving ≥1 CM chemodenervation treatment from a high-volume provider in 2017 ranged from 0.024% (24 patients of 98,033 beneficiaries) in Wyoming to 0.135% (997 of 736,521) in Arizona, with six states falling outside of this range. CONCLUSION: Chemodenervation is an increasingly popular treatment for CM among neurologists and other providers, but the reason for this increase is unclear. There is substantial geographic variation in its use.

A Survey-Based Study Into the Use of Peripheral Nerve Blocks for Pelvic Limb Surgery Among Veterinary Professionals With an Interest in Anesthesia.

Peripheral nerve blocks are commonly recommended as perioperative analgesia for orthopedic procedures. We aimed to determine the prevalence of use of techniques and drugs among veterinary professionals with an interest in anesthesia. Veterinary professionals were contacted via an email (ACVA-list) and newsletter (Association of Veterinary Anesthetists) containing a link to an online survey. Surveys completed in full were used for analysis. Analysis found that peripheral nerve blocks (PNBs) and epidural analgesia techniques were the preferred techniques of 46% and 38% of individuals, respectively. Of those using PNBs, nerve stimulator techniques were most common, used by 72% of individuals. Bupivacaine was used by 71% of individuals. Adjuvants were used by 37% of respondents; most commonly an alpha-2 agonist. Severe adverse effects were reported by 11 respondents, while 49% of individuals had not witnessed any adverse effects. More experienced veterinary anesthetists (>100 blocks performed) were more likely to have seen adverse effects. In conclusion, PNBs are utilized by anesthetists for pelvic limb orthopedic surgery, with nerve stimulation being the most commonly used PNB technique. Bupivacaine was the most commonly used local anesthetic however, diversity in both the techniques and drugs used was evident among respondents.

A Randomized, Double-Dummy, Emergency Department-Based Study of Greater Occipital Nerve Block With Bupivacaine vs Intravenous Metoclopramide for Treatment of Migraine.

BACKGROUND: Greater occipital nerve blocks (GONB) are used increasingly to treat acute migraine. OBJECTIVE: We conducted a randomized controlled trial to determine whether GONB was as effective as intravenous metoclopramide for migraine. METHODS: This was a double-dummy, double-blind, parallel-arm, non-inferiority study conducted in 2 emergency departments (EDs). Patients with migraine of moderate or severe intensity were randomized to receive bilateral GONB with each side administered 3 mL of bupivacaine 0.5% or metoclopramide 10 mg IV, the putative standard of care. The primary outcome was improvement in pain on a 0-10 scale between time 0 and 1 hour later. To reject the null hypothesis that metoclopramide would be more efficacious in relieving pain, we required that the lower limit of the 95% CI for the difference in pain improvement between those randomized to GONB vs those randomized to metoclopramide be >-1.3, a validated minimum clinically important difference. Secondary outcomes included sustained headache relief, defined as achieving and maintaining for 48 hours a headache level of mild or none without the use of additional analgesic medication, and the use of rescue medication in the ED. RESULTS: Over a 2.5-year study period, 1358 patients were screened for participation and 99 were randomized, 51 to GONB and 48 to metoclopramide. All of these patients were included in the primary analysis. Patients who received the GONB reported mean improvement of 5.0 (95% CI: 4.1, 5.8) while those who received metoclopramide reported a larger mean improvement of 6.1 (95% CI: 5.2, 6.9). The 95% CI for the between group difference of -1.1 was -2.3, 0.1. Sustained headache relief was reported by 11/51 (22%) GONB and 18/47 (38%) metoclopramide patients (95% CI for rounded difference of 17%: -1, 35%). Of the 51 GONB patients, 17 (33%) required rescue medication in the ED vs 8/48 (17%) metoclopramide patients (95% CI for rounded difference of 17%: 0, 33%). An adverse event was reported by 16/51 (31%) GONB patients and 18/48 (38%) metoclopramide patients (95% CI for (rounded) difference of 6%: -13, 25%). CONCLUSION: GONB with bupivacaine was not as efficacious as IV metoclopramide for the first-line treatment of migraine in the ED.

Prospective Evaluation of a Standardized Opioid Reduction Protocol after Anorectal Surgery.

BACKGROUND: Surgery for anorectal disease is thought to cause significant postoperative pain. Our previous work demonstrated that most opioids prescribed after anorectal surgery are not used. We aimed to evaluate a standardized protocol for pain control after anorectal surgery. METHODS: We prospectively evaluated a standardized opioid reduction protocol over a 13-mo period for all patients undergoing elective anorectal surgery at our institution. Protocol components include preoperative query, procedural local-anesthetic blocks, first-line nonopioid analgesic use ± opioid prescription of five pills, and standardized postoperative instructions. Patients completed questionnaires at postoperative follow-up. Patients with history of opioid abuse or use within 30 d of operation, loss to follow-up, or surgical complications were excluded. Primary outcome was quality of pain control on a five-point scale. Secondary outcomes included use of nonopioid analgesics, opioids used, and need for refill. RESULTS: A total of 55 patients were included. Mean age was 47 ± 17 y with 23 women (42%). Anorectal abscess/fistula procedures were the most common (69%) followed by pilonidal procedures (11%) and hemorrhoidectomy (7%). Most had general anesthesia (60%) with the remainder local anesthesia ± sedation. Fifty-four (98%) had procedural local-anesthetic blocks. Twenty-six patients (47%) were prescribed opioids with a median of five pills. Forty-seven patients (85%) reported the use of nonopioid analgesics. Forty-six patients (84%) reported excellent to very good pain control. About 220 opioid pills were prescribed, and 122 were reported to be used. One patient (2%) received an opioid refill. CONCLUSIONS: Satisfactory pain control after anorectal surgery can be achieved with multimodality therapy with little to no opioid use for most patients.

Adductor canal block with periarticular infiltration versus periarticular infiltration alone after total knee arthroplasty: A randomized controlled trial protocol.

BACKGROUND: Effective postoperative analgesia may enhance early rehabilitation after total knee arthroplasty (TKA). The purpose of this study is to perform a randomized controlled trial to compare the efficiency of adductor canal block (ACB) with periarticular infiltration (PAI) versus PAI alone for early postoperative pain treatment after TKA. METHODS: After institutional review board approval, written informed consent was obtained from patients undergoing elective TKA. Subjects were randomized into 2 groups as follows: adductor canal blockade with 30 mL of 0.5% ropivacaine and 100 mcg of clonidine. All patients received a periarticular infiltration mixture intraoperatively with scheduled and patient requested oral and IV analgesics postoperatively for breakthrough pain. The primary outcome was morphine consumption in the first 24 hours. Secondary outcomes included pain scores, morphine consumption at 48 hours, opioid-related side effects (post-operative nausea/vomiting, sedation scores), functional outcomes, quadriceps strength, and length of hospital stay. CONCLUSIONS: For the present trial, we hypothesized that patients receiving adductor canal block + PAI would have significantly lower morphine consumption and pain scores after surgery. TRIAL REGISTRATION NUMBER: researchregistry5490.

Impact of preoperative pectoralis plane nerve blocks for mastectomy on perioperative opioid consumption: a retrospective study.

Aim: To compare perioperative opioid consumption for patients undergoing mastectomy surgery with or without pectoralis nerve (PECS) plane blocks. Patients & methods: Retrospective study evaluating 152 adult females with mastectomies. Demographics, postanesthesia care unit stay duration and opioid consumption data at three time points were collected and analyzed for statistical significance. Results: 98 patients were included in the PECS block group, 54 patients were in the general anesthesia only group. Age and BMI were comparable. Total perioperative intravenous opioid consumption was less in the PECS block group (50.88 mg) compared with the general anesthesia only group (67.83 mg), p < 0.001. Conclusion: Acute pain after mastectomy is often severe. PECS plane block may decrease perioperative opioid consumption after mastectomy surgery compared with general anesthesia alone.