Comparing modalities of opioid education in patients undergoing total knee arthroplasty: a randomized pilot trial.

BACKGROUND: Patients undergoing total knee arthroplasty (TKA) experience significant postoperative pain and routinely require opioids, yet they often lack knowledge regarding appropriate use and handling of these medications. Evidence suggests that educational interventions in various formats may help reinforce proper usage and improve postoperative pain control. The aim of this study is to compare the institution standard of care (webinar) with two novel educational interventions-one in-person and the other a video recording-that focus specifically on the use of opioids and pain control. METHODS: This prospective, randomized pilot study included 42 patients undergoing TKA. Patients were randomized into one of three groups: (1) webinar: 50 min virtual session standard of care at Hospital for Special Surgery (HSS), (2) in-person education, or (3) video education. The primary outcomes of this study were the number of opioid refill requests through postoperative day (POD) 30 and POD 60. The secondary outcomes evaluated Numerical Rating Scale (NRS) pain scores, opioid consumption in oral morphine equivalents (OME), surveys on medication usage and opioid knowledge, reported medication storage and disposal. We hypothesize that the novel educational interventions, presented either in-person or by video, will lead to a decrease in opioid refills within 60 days compared with current education delivered through virtual webinar. RESULTS: No significant differences were found among groups in the number of opioid refill requests, average NRS pain score, or OME consumption at any time point. Opioid refill requests ranged from 0% to 16.7% at POD 30 (Fisher's exact test, p=0.625) and from 0% to 8.3% at POD 60 (p=1.000). The median opioid refill request was zero requests per group from POD 21 to 60 (webinar 0 (0.0, 0.0), in-person 0 (0.0, 0.0), video 0 (0.0, 0.0), Kruskal-Wallis test, p=0.381). Average NRS pain scores were 5 or below for all groups on POD 1, 7 and 14. By POD 7, all groups had an average daily intake OME of 14 or below. CONCLUSIONS: Overall, patients in each group did well with postoperative pain management after TKA and had minimal opioid refill requests. There were no statistically significant differences in outcomes of NRS pain scores or opioid usage among groups suggesting that educational interventions were similarly effective. As a pilot trial, study demonstrated successful recruitment and retention of participants, and important feedback was elicited from patients regarding education, as well. Of note, this was a pilot study and was likely underpowered to detect a difference. TRIAL REGISTRATION NUMBER: NCT05593341.

Posterior quadratus lumborum block versus intrathecal morphine analgesia after scheduled cesarean section: a prospective, randomized, controlled study.

BACKGROUND: During the postoperative period of elective cesarean section, intrathecal morphine is effective in the multimodal analgesic regimen, but can cause significant adverse effects. Bilateral posterior quadratus lumborum block could be alternatively used. The aim of this study was to compare efficacy and safety of both strategies as part of a multimodal analgesic regimen. METHODS: This was a prospective, randomized, blinded, controlled study. 104 parturients were randomly selected to receive intrathecal morphine or posterior quadratus lumborum block during cesarean section under spinal anesthesia. The primary endpoint was patient-controlled 24-hour cumulative intravenous morphine use. Secondary endpoints were 48-hour cumulative morphine use, static/dynamic pain scores, functional recovery (ObsQoR-11 questionnaire) and adverse effects. RESULTS: There was no statistical difference in the mean cumulative morphine dose at 24-hour between groups (posterior quadratus lumborum block group, 13.7 (97.5% CI 10.4 to 16.9) mg; intrathecal morphine group, 11.1 (97.5% CI 8.4 to 13.8) mg, p=0.111). Pain scores did not show any difference between groups, excepted at 6 hours for the pain at cough/movement in favor of the posterior quadratus lumborum block group (p=0.013). A better recovery quality was observed at 24 hours in the posterior quadratus lumborum block group (p=0.009). Pruritus was more frequent in intrathecal morphine group parturients (35% vs 2%) CONCLUSIONS: No difference in cumulative morphine dose at 24 hours was observed in posterior quadratus lumborum block group compared with intrathecal morphine group. Posterior quadratus lumborum block can be considered an alternative to intrathecal morphine in cesarean postoperative analgesia, especially in cases of intolerance to morphine. TRIAL REGISTRATION NUMBER: NCT04755712.

Efficacy of laser adjuvant therapy in the management of post-operative endodontic pain: A systematic review and meta-analysis.

BACKGROUND: Postoperative endodontic pain (PEP) is crucial in clinical practice. Recently, the effects of various laser adjuvant therapies in endodontic treatments have been widely evaluated. However, as a virtually side-effect-free treatment, its effect on postoperative pain management during endodontic treatment remains controversial. OBJECTIVES: This review aimed to compare the efficacy of laser adjuvant therapy for pain management after endodontic treatment. METHOD: The Cochrane Library, PubMed, Embase, Scopus and Web of Science databases were systematically searched for articles published until 12 February 2023. The risk of bias in the included studies was evaluated based on the Cochrane risk-of-bias assessment tool. Data on continuous outcomes of visual analogue scale pain scores are expressed as standard mean difference (SMD) and dichotomous outcomes of pain prevalence as relative risk (RR). RESULTS: We included 22 studies, of which 15 enrolled 892 patients with visual analogue scale pain scores and 7 enrolled 422 patients with pain prevalence. Of the 22 studies, seven studies had a low risk of bias, 10 had a moderate risk of bias and 5 had a high risk of bias. For pain level, the pooled outcomes indicated reduced pain scores in all laser adjuvant therapy, including low-level laser therapy (SMD = -0.86 [95% CI: -1.16, -0.55] in 24 h and SMD = -0.64 [95% CI: -0.84, -0.43] in 48 h), diode laser therapy (SMD = -0.27 [95% CI: -0.50, -0.04] in 48 h) and photodynamic therapy (SMD = -1.12 [95% CI: -2.18, -0.05] in 24 h). For postoperative pain incidence, a significant correlation was observed with reduced pain incidence rates in the photodynamic therapy group (pooled RR = 0.47 [95% CI: 0.31, 0.72]) but not in the low-level laser therapy group (RR = 0.89 [95% CI: 0.30, 2.70] at 12 h and RR = 0.57 [95% CI: 0.09, 3.72] at 24 h). CONCLUSIONS: High-quality evidence suggests that laser adjuvant therapies such as low-level laser therapy, diode laser therapy and photodynamic therapy have a positive impact on reducing postoperative endodontic pain intensity. However, the differences in PEP management effects between laser therapies are unknown, and no significant differences were observed among the subgroups. REGISTRATION: CRD 42023402872 (PROSPERO).

Risk factors for persistent postoperative opioid use: an entity distinct from chronic postsurgical pain.

Despite a decline in opioid prescriptions over the past decade, patients commonly receive opioid analgesics as a treatment for postoperative pain in the USA. One complication that patients may experience after surgery is persistent postoperative opioid use (PPOU), or opioid use beyond the typical recovery period. Often defined as beyond 3 months postsurgery, PPOU is frequently conflated with chronic postsurgical pain (CPSP), where pain persists well after the expected healing time following surgery. This narrative review explores the distinct risk factors for each condition, their interrelation, and potential future research directions.For PPOU, major risk factors include the risky use of substances including misuse and use disorders; depression and other mental health disorders; a history of chronic pain before surgery including back pain; and certain surgical types (ie, total knee arthropathy, open cholecystectomy, total hip arthropathy). Conversely, CPSP risk factors include the type of surgery (ie, thoracic and breast surgeries), mental health conditions (particularly catastrophizing), and pain in both the preoperative and postoperative phases. Despite the overlap of some factors, studies typically employ different frameworks when examining PPOU and CPSP, with a biopsychosocial model applied for CPSP and little emphasis on an individual's social environment employed for PPOU. Additionally, existing studies predominantly rely on retrospective insurance claims data, which may not capture the full scope of risk factors.To fill gaps in understanding, investigations may prospectively assess and analyze patient-reported outcomes, implement similar frameworks, and concurrently measure both conditions to advance the scientific understanding of PPOU and CPSP.

Criteria for continuous neuraxial analgesia associated with reduced mortality in patients undergoing thoracotomy.

INTRODUCTION: Both thoracic epidural analgesia and thoracic paravertebral analgesia are effective techniques to control pain and minimize the stress response following thoracic surgery. We hypothesized that continuous neuraxial techniques may be associated with a decrease in the incidence of postoperative mortality after thoracotomy. Additionally, we aimed to identify subgroup populations that may benefit more from neuraxial anesthesia. METHOD: 1620 patients who underwent open thoracotomy were included in this retrospective study from the German Thoracic Registry database at four university hospitals. All-cause inpatient mortality was determined for patients who had and did not have neuraxial anesthesia. Logistic regression was used to adjust for and explore various covariates. RESULTS: Continuous neuraxial analgesia was associated with a lower overall mortality in the postoperative period (2.9%, 23/796 vs 5.3%, 44/824, p=0.02) only after the univariate analysis but not the multivariable analysis (OR 0.49, 95 % CI 0.237 to 1.12, p=0.15). In patients with epidural or paravertebral catheters, mortality was significantly lower in the following subgroups: age >75 (5/113 vs 18/77, OR 0.1, 95% CI 0.02 to 0.67, p=0.02), American Society of Anesthesiologists Performance Score >III (11//97 vs 33/155, OR 0.32, 95% CI 0.11 to 0.89, p=0.03), chronic kidney disease (5/83 vs 16/77, OR 0.16, 95% CI 0.03 to 0.82, p=0.03), and postoperative sepsis (9/21 vs 17/25, OR 0.13, 95% CI 0.07 to 0.44, p<0.01). CONCLUSIONS: Neuraxial analgesic techniques are associated with reductions in postoperative mortality after open thoracic surgery in selected patients.

Dexamethasone as a perineural adjuvant to a ropivacaine popliteal sciatic nerve block for pediatric foot surgery: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: This study assessed the effect of perineural dexamethasone on block duration, opioid requirement, blood glucose levels, and stress response to surgery as measured by the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR), following pediatric foot and ankle surgery. METHODS: In this parallel, double-blinded randomized controlled trial, 90 children (ages 2-5 years, >5 kg) scheduled for foot or ankle surgery under spinal anesthesia with ultrasound-guided single-shot popliteal sciatic nerve block were randomized into 3 groups: 0.5% ropivacaine with saline (control), 0.5% ropivacaine plus dexamethasone 0.1 mg/kg (DEX0.1), and 0.5% ropivacaine plus dexamethasone 0.05 mg/kg (DEX0.05). Primary outcome was the time to first rescue opioid analgesia. Secondary outcomes included motor block duration, pain scores, NLR, PLR, and blood glucose levels. RESULTS: Time to first rescue opioid analgesia was significantly longer in the DEX0.1 group compared with the DEX0.05 group (18.4 hours, SD 2.6 hours vs 16 hours, SD 2.8 hours), with a mean difference of 2.2 hours (95% CI 0.7 to 3.6), p<0.01; and the control group (8.5 hours, SD 1.5 hours), with a mean difference of -9.9 (95% CI -11.4 to -8.4), p<0.001. Motor block was significantly longer in the DEX0.1 group (17.3 hours, SD 2.5 hours) compared with the DEX0.05 (15.2 hours, SD 2.7 hours; p<0.01) and control groups (7.8±1.1, p<0.001). Total opioid consumption was significantly lower in the DEX0.1 group compared with the control group (p=0.01). NLR, PLR, and glucose levels did not differ significantly between the groups at baseline, 24 hours, and 48 hours post surgery. CONCLUSIONS: Perineural dexamethasone significantly prolonged postoperative motor block duration and did not influence blood glucose, NLR, or PLR levels. TRIAL REGISTRATION NUMBER: NCT06086418.

The effect of nalbuphine on prevention of emergence delirium in children: a systematic review with meta-analysis.

BACKGROUND: Emergence delirium remains a major postoperative concern for children undergoing surgery. Nalbuphine is a synthetic mixed agonist-antagonist opioid, which is believed to reduce the incidence of emergence delirium in children. The primary objective was to examine the effect of nalbuphine on emergence delirium in children undergoing surgery. METHODS: Databases of MEDLINE, EMBASE, and CENTRAL were searched from their starting dates until April 2023. Randomized Clinical Trials (RCT) and observational studies comparing nalbuphine and control in children undergoing surgery were included. RESULTS: Eight studies (n = 1466 patients) were eligible for inclusion of data analysis. Compared to the control, our pooled data showed that the nalbuphine group was associated with lower incidence of emergence delirium (RR = 0.38, 95% CI [0.30, 0.47], p < 0.001) and reduced postoperative pain scores (MD = -0.98, 95% CI [-1.92, -0.04], p = 0.04). CONCLUSIONS: This review showed the administration of nalbuphine is associated with significant decrease in the incidence of emergence delirium and postoperative pain scores among children undergoing surgery. However, due to limited sample size, high degree of heterogeneity and low level of evidence, future adequately powered trials are warranted to explore the efficacy of nalbuphine on emergence delirium among the pediatric population.

One-year opioid consumption trajectories among individuals receiving multidisciplinary postsurgical care: a single-center observational study from the Toronto General Hospital Transitional Pain Service.

INTRODUCTION: The Transitional Pain Service (TPS) is an innovative, personalized approach to postsurgical opioid consumption and pain management. The objectives of this study were to identify trajectories of opioid consumption and pain intensity within 12 months after initiating treatment through the TPS, identify biopsychosocial factors associated with trajectory membership, and examine the relationship between trajectory membership and other outcomes of interest over the same 12-month period. METHODS: Consecutive patients referred to the TPS were included in the present study (n=466). After providing informed consent, they completed self-report questionnaires at the initial visit at the TPS (either pre surgery or post surgery) and at every TPS visit until 12 months. Growth mixture modeling was used to derive trajectories and identify associated factors. RESULTS: Results showed three distinct opioid consumption trajectories for both presurgical opioid consumers and opioid-naïve patients. These trajectories all decreased over time and among those who were consuming opioids before surgery that returned to presurgical levels. Being man, having a substance use disorder, or reporting higher levels of pain interference were associated with higher daily opioid consumption for presurgical opioid consumers. For presurgical opioid-naïve individuals, higher opioid consumption trajectories were associated with higher levels of psychological distress. Five pain intensity trajectories were identified, and there were no significant association between opioid consumption and pain intensity trajectories. CONCLUSIONS: Results suggest that opioid consumption and pain intensity trajectories mostly decrease after surgery in a high-risk population enrolled in a TPS. Results also show heterogeneity in postsurgical recovery and highlight the importance of using personalized interventions to optimize individual trajectories.

A smart device application for acute pain service in surgical patients at a tertiary hospital in South Korea: a prospective observational feasibility study.

BACKGROUND: Pain assessment and patient education are essential for successful postoperative pain management. However, the provision of personnel for performing these tasks is often insufficient. Recently, attempts have been made to implement smartphone applications for educating and monitoring surgical patients. We developed a smartphone application (app) for postoperative pain management, and conducted a feasibility study. METHODS: This single-center prospective observational study included 60 patients aged < 70 years who underwent elective surgery. This study evaluated the SmartAPS application, which offers tools for postoperative pain assessment and educational materials for pain management. The primary outcome was the active usage rate, defined as responding at least twice daily on postoperative days (PODs) 1 and 2. Additionally, we investigated patient satisfaction with the app and educational videos as well as any challenges encountered during use. RESULTS: Sixty patients were enrolled in the study and active app use was achieved in 56.7% of them. Response rates peaked at 85.0% for pain intensity and 83.3% for opioid-related side effects at 14:00 on POD 1 but dropped to 56.7% and 58.3%, respectively, at 18:00 on POD 2. Among the patients who responded to the survey regarding the app usage, 84.0% reported satisfaction with the app and 80% found it beneficial for managing postoperative pain. Furthermore, 92.0% did not encounter difficulties using the app, indicating a generally positive user experience. CONCLUSIONS: Our findings support the utility of the SmartAPS application in acute pain services, highlighting its potential for improving postoperative pain management.

Oblique subcostal transverse abdominis plane block for postoperative pain control in patients undergoing open sublay mesh hernia repair: a prospective double-blind randomized placebo-controlled clinical trial.

BACKGROUND: A bilateral oblique subcostal transverse abdominis plane block may help provide perioperative analgesia and reduce opioid use in patients undergoing sublay mesh hernia repair, but its clinical value is unclear. METHODS: In a single-centre, prospective, placebo-controlled, double-blind study, patients scheduled for sublay mesh hernia repair were randomized to receive oblique subcostal transverse abdominis plane blocks with either 60 ml of 0.375% ropivacaine (n=19) or isotonic saline (placebo, n=17). The primary outcome was patient-controlled total morphine consumption at 8:00 p.m. on the second postoperative day (POD), while secondary outcomes included the total morphine consumption during the post-anesthesia care unit stay and the occurrence of adverse events. RESULTS: Total morphine consumption at 8:00 p.m. on the second POD was higher in patients receiving ropivacaine (39 mg, IQR 22, 62) compared with placebo (24 mg, IQR 7, 39), p value = 0.04. In contrast, the ropivacaine group received 2 mg less morphine during the post-anesthesia care unit stay (4 mg, IQR: 4, 9 mg vs 2 mg, IQR: 2,6 mg, p = 0.04). Patients receiving ropivacaine used more morphine (8:00 p.m. on the first POD until 8:00 a.m. on the second POD: 8 mg, IQR: 4, 18 mg vs 2 mg, IQR: 0, 9 mg, p = 0.01) and reported higher maximum pain scores since the last assessment (8:00 a.m. on the second POD: 5, IQR: 4, 7 vs 4, IQR: 3, 5, p = 0.03). There were no differences in adverse events between groups. CONCLUSIONS: Bilateral oblique subcostal transverse abdominis plane blocks in patients undergoing sublay mesh hernia repair were not associated with a prolonged reduction in patient-controlled total morphine consumption in the evening of the second POD in this study. Rebound pain might explain the additional excess opioid required by the ropivacaine group.

Effects of popliteal plexus block after total knee arthroplasty: a randomized clinical trial.

BACKGROUND AND OBJECTIVES: Motor-sparing peripheral nerve blocks enhance multimodal opioid-sparing strategies after total knee arthroplasty. We hypothesized that adding a popliteal plexus block to a femoral triangle block could reduce 24-hour opioid consumption after total knee arthroplasty, compared with standalone femoral triangle block or adductor canal block. METHODS: This patient- and assessor-blinded, randomized controlled trial allocated 165 patients into three equally sized parallel groups, receiving either 1) popliteal plexus block+femoral triangle block, 2) femoral triangle block, or 3) adductor canal block. Intravenous oxycodone was administered via patient-controlled analgesia pumps. The primary outcome was 24-hour postoperative opioid consumption. Secondary outcomes were preoperative maximum voluntary isometric contraction and manual muscle tests of knee and ankle movement assessed before and after the nerve block procedure together with postoperative pain scores, mobilization, and 12-hour opioid consumption. RESULTS: 24-hour postoperative intravenous oxycodone consumption varied significantly between groups (p<0.01), with medians (IQR) of 6 mg (2-12) in the popliteal plexus block+femoral triangle block group, 10 mg (8-16) in the femoral triangle block group, and 12 mg (6-18) in the adductor canal block group. Median consumption in the popliteal plexus block+femoral triangle block group was reduced by -4 mg (95% CI -7.4 to -1.0, p<0.01) and -6 mg (95% CI -8.3 to -1.3, p=0.01) compared with groups of femoral triangle block and adductor canal block, respectively. No differences were found in pain scores, mobilization, or changes in preoperative muscle strength. Post hoc analysis revealed successful 24-hour opioid-free postoperative care among 12 patients with popliteal plexus block+femoral triangle block, as compared with two with femoral triangle block and six with adductor canal block. CONCLUSION: Adding a popliteal plexus block to a femoral triangle block resulted in a statistically significant reduction of 24-hour postoperative opioid consumption after total knee arthroplasty. However, no differences were found in pain scores. Popliteal plexus block did not impair the lower leg muscles.

Cannabis use and acute postoperative pain outcomes in older adults: a propensity matched retrospective cohort study.

INTRODUCTION: Cannabis use is increasing among older adults, but its impact on postoperative pain outcomes remains unclear in this population. We examined the association between cannabis use and postoperative pain levels and opioid doses within 24 hours of surgery. METHODS: We conducted a propensity score-matched retrospective cohort study using electronic health records data of 22 476 older surgical patients with at least 24-hour hospital stays at University of Florida Health between 2018 and 2020. Of the original cohort, 2577 patients were eligible for propensity-score matching (1:3 cannabis user: non-user). Cannabis use status was determined via natural language processing of clinical notes within 60 days of surgery and structured data. The primary outcomes were average Defense and Veterans Pain Rating Scale (DVPRS) score and total oral morphine equivalents (OME) within 24 hours of surgery. RESULTS: 504 patients were included (126 cannabis users and 378 non-users). The median (IQR) age was 69 (65-72) years; 295 (58.53%) were male, and 442 (87.70%) were non-Hispanic white. Baseline characteristics were well balanced. Cannabis users had significantly higher average DVPRS scores (median (IQR): 4.68 (2.71-5.96) vs 3.88 (2.33, 5.17); difference=0.80; 95% confidence limit (CL), 0.19 to 1.36; p=0.01) and total OME (median (IQR): 42.50 (15.00-60.00) mg vs 30.00 (7.50-60.00) mg; difference=12.5 mg; 95% CL, 3.80 mg to 21.20 mg; p=0.02) than non-users within 24 hours of surgery. DISCUSSION: This study showed that cannabis use in older adults was associated with increased postoperative pain levels and opioid doses.