Preoperative Acute Sleep Deprivation Causes Postoperative Pain Hypersensitivity and Abnormal Cerebral Function.

Preoperative sleep loss can amplify post-operative mechanical hyperalgesia. However, the underlying mechanisms are still largely unknown. In the current study, rats were randomly allocated to a control group and an acute sleep deprivation (ASD) group which experienced 6 h ASD before surgery. Then the variations in cerebral function and activity were investigated with multi-modal techniques, such as nuclear magnetic resonance, functional magnetic resonance imaging, c-Fos immunofluorescence, and electrophysiology. The results indicated that ASD induced hyperalgesia, and the metabolic kinetics were remarkably decreased in the striatum and midbrain. The functional connectivity (FC) between the nucleus accumbens (NAc, a subregion of the ventral striatum) and the ventrolateral periaqueductal gray (vLPAG) was significantly reduced, and the c-Fos expression in the NAc and the vLPAG was suppressed. Furthermore, the electrophysiological recordings demonstrated that both the neuronal activity in the NAc and the vLPAG, and the coherence of the NAc-vLPAG were suppressed in both resting and task states. This study showed that neuronal activity in the NAc and the vLPAG were weakened and the FC between the NAc and the vLPAG was also suppressed in rats with ASD-induced hyperalgesia. This study highlights the importance of preoperative sleep management for surgical patients.

Clinical Application of Artificial Intelligence: Auto-Discerning the Effectiveness of Lidocaine Concentration Levels in Osteosarcoma Femoral Tumor Segment Resection.

Adolescents and children worldwide are threatened by osteosarcoma, a tumor that predominantly affects the long bone epiphysis. Osteosarcoma is the most common and highly malignant bone tumor in youngsters. Early tumor detection is the key to effective treatment of this disease. The discovery of biomarkers and the growing understanding of molecules and their complex interactions have improved the outcome of clinical trials in osteosarcoma. This article describes biomarkers of osteosarcoma with the aim of positively influencing the progress of clinical treatment of osteosarcoma. Femoral bone tumor is a typical condition of osteosarcoma. Due to the wide range of femoral stem types, complexities in the distal femur, and tumors in the rotor part of femur, physicians following the traditional clinical approach face difficulties in removing the lesion and fixing the femur with resection of the tumor segment. In this paper, the effect of small doses of different concentrations of lidocaine anesthesia in patients undergoing lumpectomy for osteosarcoma femoral tumor segments is investigated. A computer-based artificial intelligence method for automated determination of different concentration levels of lidocaine anesthesia and amputation of osteosarcoma femoral tumor segment is proposed. Statistical analysis is carried on the empirical data including intraoperative bleeding, intraoperative and postoperative pain scores, surgical operation time, postoperative complications, patient satisfaction, and local anesthetic dose. The results showed that the patients in the study group had low intraoperative bleeding, short operation time, low postoperative hematoma formation rate, high patient satisfaction, higher dosage of anesthetic solution, and low dosage of lidocaine. Results revealed that mean arterial pressure and heart rate in extubating and intubating were significantly lower in the observation group than in the control group, and a significant difference (P < 0.05) was observed between the two groups. This proves that the proposed algorithm can adequately reduce bleeding, alleviate postoperative pain, shorten operation time, reduce complications, accelerate recovery, and ensure better treatment results.

Utilization and evolving prescribing practice of opioid and non-opioid analgesics in patients undergoing lymphadenectomy for cutaneous malignancy.

BACKGROUND AND OBJECTIVES: Opioids are commonly prescribed following surgery and can lead to persistent opioid use. We assessed changes in prescribing practices following an opioid education initiative for patients undergoing lymphadenectomy for cutaneous malignancy. METHODS: A single-institution retrospective study of all eligible patients (3/2016-3/2020) was performed. RESULTS: Indications for lymphadenectomy in 328 patients were metastatic melanoma (84%), squamous cell carcinoma (10%), and Merkel cell carcinoma (5%). At discharge, non-opioid analgesics were increasingly utilized over the 4-year study period, with dramatic increases after education initiatives (32%, 42%, 59%, and 79% of pts, respectively each year; p < 0.001). Median oral morphine equivalents (OMEs) prescribed also decreased dramatically starting in year 3 (250, 238, 150, and 100 mg, respectively; p < 0.001). Patients discharged with 200 mg OMEs were less likely to also be discharged with non-opioid analgesics (40% vs. 64%. respectively, p < 0.001). CONCLUSIONS: Analgesic prescribing practices following lymphadenectomy for cutaneous malignancy improved significantly over a 4-year period, with use of non-opioids more than doubling and a 60% reduction in median OME. Opportunities exist to further increase non-opioid use and decrease opioid dissemination after lymphadenectomy for cutaneous malignancy.

Macrophage Activation in the Dorsal Root Ganglion in Rats Developing Autotomy after Peripheral Nerve Injury.

Autotomy, self-mutilation of a denervated limb, is common in animals after peripheral nerve injury (PNI) and is a reliable proxy for neuropathic pain in humans. Understanding the occurrence and treatment of autotomy remains challenging. The objective of this study was to investigate the occurrence of autotomy in nude and Wistar rats and evaluate the differences in macrophage activation and fiber sensitization contributing to the understanding of autotomy behavior. Autotomy in nude and Wistar rats was observed and evaluated 6 and 12 weeks after sciatic nerve repair surgery. The numbers of macrophages and the types of neurons in the dorsal root ganglion (DRG) between the two groups were compared by immunofluorescence studies. Immunostaining of T cells in the DRG was also assessed. Nude rats engaged in autotomy with less frequency than Wistar rats. Autotomy symptoms were also relatively less severe in nude rats. Immunofluorescence studies revealed increased macrophage accumulation and activation in the DRG of Wistar rats. The percentage of NF200+ neurons was higher at 6 and 12 weeks in Wistar rats compared to nude rats, but the percentage of CGRP+ neurons did not differ between two groups. Additionally, macrophages were concentrated around NF200-labeled A fibers. At 6 and 12 weeks following PNI, CD4+ T cells were not found in the DRG of the two groups. The accumulation and activation of macrophages in the DRG may account for the increased frequency and severity of autotomy in Wistar rats. Our results also suggest that A fiber neurons in the DRG play an important role in autotomy.

An observational cohort study comparing ibuprofen and oxycodone in children with fractures.

OBJECTIVE: To compare the effectiveness and safety of prescribing ibuprofen and oxycodone for at-home management of children's fracture pain. METHODS: A prospective observational cohort was conducted at the Stollery Children's Hospital pediatric emergency department (June 2010-July 2014). Children aged 4-16 years with an isolated fracture discharged home with advice to use either ibuprofen or oxycodone were recruited. RESULTS: A cohort of 329 children (n = 217 ibuprofen, n = 112 oxycodone) were included. Mean age was 11.1 years (SD 3.5); 68% (223/329) were male. Fracture distribution included 80.5% (264/329) upper limb with 34.3% (113/329) requiring fracture reduction. The mean reduction in Faces Pain Score-Revised score (maximum pain-post-treatment pain) for Day 1 was 3.6 (SD 1.9) (ibuprofen) and 3.8 (SD 2.1) (oxycodone) (p = 0.50); Day 2 was 3.6 (SD 1.8) (ibuprofen) and 3.7 (SD 1.6) (oxycodone) (p = 0.56); Day 3 was 3.7 (SD 1.7) (ibuprofen) and 3.3 (SD 1.7) (oxycodone) (p = 0.24). Children prescribed ibuprofen (51.2%, 109/213) experienced less adverse events compared to those prescribed oxycodone (70.5% 79/112) on Day 1 (p = 0.001). Children prescribed ibuprofen (71.8%, 150/209) had their function (eat, play, school, sleep) affected less than those prescribed oxycodone (83.0%, 93/112) (p = 0.03) on Day 1. CONCLUSION: Children prescribed ibuprofen or oxycodone experienced similar analgesic effectiveness for at-home fracture pain. Oxycodone prescribing was associated with more adverse events and negatively impacted function. Oxycodone use does not appear to confer any benefit over ibuprofen for pain relief and has a negative adverse effect profile. Ibuprofen appears to be a safe option for fracture-related pain.

Longitudinal peripheral tissue RNA-Seq transcriptomic profiling, hyperalgesia, and wound healing in the rat plantar surgical incision model.

Postoperative pain and delayed healing in surgical wounds, which require complex management strategies have understudied complicated mechanisms. Here we investigated temporal changes in behavior, tissue structure, and transcriptomic profiles in a rat model of a surgical incision, using hyperalgesic behavioral tests, histological analyses, and next-generation RNA sequencing, respectively. The most rapidly (1 hour) expressed genes were the chemokines, Cxcl1 and Cxcl2. Consequently, infiltrating leukocytes were abundantly observed starting at 6 and peaking at 24 hours after incising which was supported by histological analysis and appearance of the neutrophil markers, S100a8 and S100a9. At this time, hyperalgesia was at a peak and overall transcriptional activity was most highly activated. At the 1-day timepoint, Nppb, coding for natriuretic peptide precursor B, was the most strongly upregulated gene and was localized by in situ hybridization to the epidermal keratinocytes at the margins of the incision. Nppb was basically unaffected in a peripheral inflammation model transcriptomic dataset. At the late phase of wound healing, five secreted, incision-specific peptidases, Mmp2, Aebp1, Mmp23, Adamts7, and Adamtsl1, showed increased expression, supporting the idea of a sustained tissue remodeling process. Transcripts that are specifically upregulated at each timepoint in the incision model may be potential candidates for either biomarkers or therapeutic targets for wound pain and wound healing. This study incorporates the examination of longitudinal temporal molecular responses, corresponding anatomical localization, and hyperalgesic behavioral alterations in the surgical incision model that together provide important and novel foundational knowledge to understand mechanisms of wound pain and wound healing.

Cortical representation of experimental periodontal pain: a functional magnetic resonance imaging study.

The aim of this study was to investigate central pain representations during loading of the periodontium induced by orthodontic and occlusal stress. Nineteen healthy male volunteers (25.7 ± 2.8 years) were tested on two consecutive days: after phenotyping (questionnaires) and determination of warmth (WPT) and heat (HPT) pain thresholds, functional magnetic resonance imaging was performed as event-related paradigm including 36 tooth clenchings of 3 s duration, alternating with rest periods varying between 20-30 s. The task was performed in absence (T1) and 24 h after placement of an elastic separator between the second bicuspid and the first molar on the right side of the lower jaw (T2). No significant changes in WPT and HPT were observed but pain ratings were significantly elevated at T2. Significantly elevated activation at T2, as compared to T1, was found in bilateral sensorimotor cortex, bilateral secondary sensory cortex, supplementary motor area, right rolandic operculum, and bilateral insula. Our data show for the first time in humans that periodontal stimulation, as tested by tooth clenching in the presence of an elastic separator, goes along with specific expressions of pain at behavioral and neuronal network levels. Findings supplement the existing neuroimaging literature on odontogenic pain.

The potential for diversion of prescribed opioids among orthopaedic patients: Results of an anonymous patient survey.

INTRODUCTION: Diversion of prescription opioid medication is a contributor to the opioid epidemic. Safe handling practices can reduce the risk of diversion. We aimed to understand: 1) if orthopaedic patients received instructions on how to safely handle opioids, 2) their typical storage/disposal practices, and 3) their willingness to participate in an opioid disposal program (ODP). METHODS: Cross-sectional study of adult orthopaedic patients who completed an anonymous survey on current or past prescription opioid use, instruction on handling, storage and disposal practices, presence of children in the household, and willingness to participate in an ODP. Frequencies and percentages of responses were computed, both overall and stratified by possession of unused opioids. RESULTS: 569 respondents who reported either current or past prescription opioid use were analyzed. 44% reported receiving storage instructions and 56% reported receiving disposal instructions from a health care provider. Many respondents indicated unsafe handling practices: possessing unused opioids (34%), using unsafe storage methods (90%), and using unsafe disposal methods (34%). Respondents with unused opioids were less likely to report receiving handling instructions or using safe handling methods, and 47% of this group reported having minors or young adults in the household. Respondents who received storage and disposal instructions were more likely to report safe storage and disposal methods. Seventy-four percent of respondents reported that they would participate in an ODP. CONCLUSION: While many orthopaedic patients report inadequate education on safe opioid handling and using unsafe handling practices, findings suggest targeted education is associated with better behaviours. However, patients are willing to safely dispose of unused medication if provided a convenient option. These findings suggest a need to address patient knowledge and behavior regarding opioid handling to reduce the risk of opioid diversion.

Temporomandibular joint dysfunction following the use of a supraglottic airway device during general anaesthesia: a prospective observational study.

Supraglottic airway devices are commonly used to manage the airway during general anaesthesia. There are sporadic case reports of temporomandibular joint dysfunction and dislocation following supraglottic airway device use. We conducted a prospective observational study of adult patients undergoing elective surgery where a supraglottic airway device was used as the primary airway device. Pre-operatively, all participants were asked to complete a questionnaire involving 12 points adapted from the Temporomandibular Joint Scale and the Liverpool Oral Rehabilitation Questionnaire. Objective measurements included inter-incisor distance as well as forward and lateral jaw movements. The primary outcome was the inter-incisor distance, an accepted measure of temporomandibular joint mobility. Both the questionnaire and measurements were repeated in the postoperative period and we analysed data from 130 participants. Mean (SD) inter-incisor distance in the pre- and postoperative period was 46.5 (7.2) mm and 46.3 (7.5) mm, respectively (p = 0.521) with a difference (95%CI) of 0.2 (-0.5 to 0.9) mm. Mean (SD) forward jaw movement in the pre- and postoperative period was 3.6 (2.4) mm and 3.9 (2.4) mm, respectively (p = 0.018). Mean (SD) lateral jaw movement to the right in the pre- and postoperative period was 8.9 (4.1) mm and 9.1 (4.0) mm, respectively (p = 0.314). Mean (SD) lateral jaw movement to the left in the pre- and postoperative period was 8.8 (4.0) mm and 9.3 (3.6) mm, respectively (p = 0.008). The number of patients who reported jaw clicks or pops before opening their mouth as wide as possible was 28 (21.5%) vs. 12 (9.2%) in the pre- and postoperative period, respectively (p < 0.001) with a difference (95%CI) of 12.3% (6.7-17.9%). There was no significant difference in the responses to the other 11 questions or in the number of patients who reported pain in the temporomandibular joint area postoperatively. No clinically significant dysfunction of the temporomandibular joint following the use of supraglottic airway devices in the postoperative period was identified by either patient questionnaires or objective measurements.

Impact of the pericapsular nerve group (PENG) block on postoperative analgesia and functional recovery following total hip arthroplasty: a randomised, observer-masked, controlled trial.

The pericapsular nerve group (PENG) block is a novel regional anaesthesia technique that aims to provide hip analgesia with preservation of motor function, although evidence is currently lacking. In this single-centre, observer-masked, randomised controlled trial, patients undergoing total hip arthroplasty received pericapsular nerve group block or no block (control group). Primary outcome measure was maximum pain scores (0-10 numeric rating scale) measured in the first 48 h after surgery. Secondary outcomes included postoperative opioid consumption; patient mobilisation assessments; and length of hospital stay. Sixty patients were randomly allocated equally between groups. The maximum pain score of patients receiving the pericapsular nerve group block was significantly lower than in the control group at all time-points, with a median (IQR [range]) of 2.5 (2.0-3.7 [0-7]) vs. 5.5 (5.0-7.0 [2-8]) at 12 h; 3 (2.0-4.0 [0-7]) vs. 6 (5.0-6.0 [2-8]) at 24 h; and 2.0 (2.0-4.0 [0-5]) vs. 3.0 (2.0-4.7 [0-6]) at 48 h; all p < 0.001. Moreover, the pericapsular nerve group showed a significant reduction in opioid consumption, better range of hip motion and shorter time to ambulation. Although no significant difference in hospital length of stay was detected, our results suggest improved postoperative functional recovery following total hip arthroplasty in patients who received pericapsular nerve group block.

Diclofenac Versus Dexamethasone Following Strabismus Surgery: A Systematic Review and Meta-Analysis.

Purpose: To compare outcomes of diclofenac versus dexamethasone in patients after strabismus surgery. Methods: A systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search was conducted on MEDLINE, EMBASE, EMCARE, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL). All randomized controlled trials (RCTs) comparing the outcomes of diclofenac versus dexamethasone poststrabismus surgery were included. An extraction spreadsheet for data collection and Review Manager 5.3 were used for data analysis based on the fixed and random effects models. Discomfort, inflammation, chemosis, conjunctival gap, and intraocular pressure (IOP) were primary outcome measures. Secondary outcomes included conjunctival congestion and injection, discharge, and drop intolerance. Fixed and random effects models were used for the analysis. Results: Five RCTs enrolling 248 subjects were enrolled. At week 2 postoperatively, there was a significant difference favoring diclofenac over dexamethasone in terms of discomfort (mean difference [MD] = -0.37, P = 0.02), conjunctival inflammation (MD = -0.16, P = 0.02), conjunctival chemosis (MD = -0.16, P = 0.04), and postoperative conjunctival gap (MD = -0.17, P = 0.002). In terms of IOP, there were no significant differences. However, no statistically significant differences were noted at weeks 1 and 4 postoperatively. For secondary outcomes, dexamethasone had significantly improved conjunctival congestion; however, diclofenac had significantly less injection at the site of muscle attachments at week 2. No significant difference was noted in terms of discharge and drop intolerance. Conclusion: Diclofenac is comparable to dexamethasone when used following strabismus surgery. However, a significant difference favoring diclofenac in terms of discomfort, inflammation, conjunctival chemosis, and conjunctival gap was only noted at 2 weeks postoperatively. The authors suggest conducting further studies to support the effectiveness of diclofenac as an alternative to corticosteroids following strabismus surgery.

Continuous erector spinae plane block for postoperative analgesia in robotic lung lobectomy: a case report.

BACKGROUND: Erector spinae plane block (ESPB) has been described as an effective regional anesthesia technique in thoracic parenchymal surgery. Evidence highlighting the use of this technique continuously via perifascial catheter is lacking. CASE PRESENTATION: In this case report, we present the case of a patient scheduled for robotic-assisted thoracic surgery for a pulmonary neoformation in the lower right lobe. We decided to manage this patient with a multimodal approach in order to have an opioid-sparing effect. This is the first reported case of continuous ESPB in robot-assisted thoracic surgery. CONCLUSIONS: Anesthesiologists should consider this method in surgery that is slower than conventional surgery, such as robot-assisted, and less invasive than thoracotomy, which does not warrant the use of neuroaxial or paravertebral techniques that increase the risk of iatrogenic complications.

A randomised trial of bilateral erector spinae plane block vs. no block for thoracolumbar decompressive spinal surgery.

Major spinal surgery causes significant postoperative pain. We tested the efficacy and safety of bilateral erector spinae block on quality of recovery and pain after thoracolumbar decompression. We randomly allocated 60 adults to standard care or erector spinae block. Erector spinae block improved the mean (SD) quality of recovery-15 score at 24 postoperative hours, from 119 (20) to 132 (14), an increase (95%CI) of 13 (4-22), p = 0.0044. Median (IQR [range]) comprehensive complication index was 1 (0-3 [0-5]) in the control group vs. 1 (0-1 [0-4]) after block, p = 0.4. Erector spinae block reduced mean (SD) area under the curve pain during the first 24 postoperative hours: at rest, from 78 (49) to 50 (39), p = 0.018; and on sitting, from 125 (51) to 91 (50), p = 0.009. The cumulative mean (SD) oxycodone consumption to 24 h was 27 (18) mg in the control group and 19 (26) mg after block, p = 0.20. In conclusion, erector spinae block improved recovery and reduced pain for 24 h after thoracolumbar decompression surgery.

A prospective cohort register-based study of chronic postsurgical pain and long-term use of pain medication after otorhinolaryngological surgery.

Data on chronic postsurgical pain (CPSP) after otorhinolaryngological surgery are sparse. Adult in-patients treated in 2017 were included into the prospective PAIN OUT registry. Patients' pain on the first postoperative day (D1), after six months (M6) and 12 months (M12) were evaluated. Determining factor for CPSP was an average pain intensity ≥ 3 (numeric rating scale 0-10) at M6. Risk factors associated with CPSP were evaluated by univariate and multivariate analyses. 10% of 191 included patients (60% male, median age: 52 years; maximal pain at D1: 3.5 ± 2.7), had CPSP. Average pain at M6 was 0.1 ± 0.5 for patients without CPSP and 4.2 ± 1.2 with CPSP. Average pain with CPSP still was 3.7 ± 1.1 at M12. Higher ASA status (Odds ratio [OR] = 4.052; 95% confidence interval [CI] = 1.453-11.189; p = 0.007), and higher minimal pain at D1 (OR = 1.721; CI = 1.189-2.492; p = 0.004) were independent predictors of CPSP at M6. Minimal pain at D1 (OR = 1.443; CI = 1.008-2.064; p = 0.045) and maximal pain at M6 (OR = 1.665; CI = 1.340-2.069; p < 0.001) were independent predictors for CPSP at M12. CPSP is an important issue after otorhinolaryngological surgery. Better instrument for perioperative assessment should be defined to identify patients at risk for CPSP.

Iliopsoas pathology after total hip arthroplasty: a young person's complication.

AIMS: Iliopsoas pathology is a relatively uncommon cause of pain following total hip arthroplasty (THA), typically presenting with symptoms of groin pain on active flexion and/or extension of the hip. A variety of conservative and surgical treatment options have been reported. In this retrospective cohort study, we report the incidence of iliopsoas pathology and treatment outcomes. METHODS: A retrospective review of 1,000 patients who underwent THA over a five-year period was conducted, to determine the incidence of patients diagnosed with iliopsoas pathology. Outcome following non-surgical and surgical management was assessed. RESULTS: In all, 24 patients were diagnosed as having developed symptomatic iliopsoas pathology giving an incidence of 2.4%. While the mean age for receiving a THA was 65 years, the mean age for developing iliopsoas pathology was 54 years (28 to 67). Younger patients and those receiving THA for conditions other than primary osteoarthritis were at a higher risk of developing this complication. Ultrasound-guided steroid injection/physiotherapy resulted in complete resolution of symptoms in 61% of cases, partial resolution in 13%, and no benefit in 26%. Eight out of 24 patients (who initially responded to injection) subsequently underwent surgical intervention including tenotomy (n = 7) and revision of the acetabular component (n = 1). CONCLUSION: This is the largest case series to estimate the incidence of iliopsoas pathology to date. There is a higher incidence of this condition in younger patients, possibly due to the differing surgical indications. Arthoplasty for Perthes' disease or developmental dysplasia of the hip (DDH) often results in leg length and horizontal offset being increased. This, in turn, may increase tension on the iliopsoas tendon, possibly resulting in a higher risk of psoas irritation. Image-guided steroid injection is a low-risk, relatively effective treatment. In refractory cases, tendon release may be considered. Patients should be counselled of the risk of persisting groin pain when undergoing THA. Cite this article: Bone Joint J 2021;103-B(2):305-308.

NGF-Induced Nav1.7 Upregulation Contributes to Chronic Post-surgical Pain by Activating SGK1-Dependent Nedd4-2 Phosphorylation.

At present, chronic post-surgical pain (CPSP) is difficult to prevent and cure clinically because of our lack of understanding of its mechanisms. Surgical injury induces the upregulation of voltage-gated sodium channel Nav1.7 in dorsal root ganglion (DRG) neurons, suggesting that Nav1.7 is involved in the development of CPSP. However, the mechanism leading to persistent dysregulation of Nav1.7 is largely unknown. Given that nerve growth factor (NGF) induces a long-term increase in the neuronal hyperexcitability after injury, we hypothesized that NGF might cause the long-term dysregulation of Nav1.7. In this study, we aimed to investigate whether Nav1.7 regulation by NGF is involved in CPSP and thus contributes to the specific mechanisms involved in the development of CPSP. Using conditional nociceptor-specific Nav1.7 knockout mice, we confirmed the involvement of Nav1.7 in NGF-induced pain and identified its role in the maintenance of pain behavior during long-term observations (up to 14 days). Using western blot analyses and immunostaining, we showed that NGF could trigger the upregulation of Nav1.7 expression and thus support the development of CPSP in rats. Using pharmacological approaches, we showed that the increase of Nav1.7 might be partly regulated by an NGF/TrkA-SGK1-Nedd4-2-mediated pathway. Furthermore, reversing the upregulation of Nav1.7 in DRG could alleviate spinal sensitization. Our results suggest that the maintained upregulation of Nav1.7 triggered by NGF contributes to the development of CPSP. Attenuating the dysregulation of Nav1.7 in peripheral nociceptors may be a strategy to prevent the transition from acute post-surgical pain to CPSP.

Intra-articular infiltration analgesia for arthroscopic shoulder surgery: a systematic review and meta-analysis.

Phrenic-sparing analgesic techniques for shoulder surgery are desirable. Intra-articular infiltration analgesia is one promising phrenic-sparing modality, but its role remains unclear because of conflicting evidence of analgesic efficacy and theoretical concerns regarding chondrotoxicity. This systematic review and meta-analysis evaluated the benefits and risks of intra-articular infiltration in arthroscopic shoulder surgery compared with systemic analgesia or interscalene brachial plexus block. We sought randomised controlled trials comparing intra-articular infiltration with interscalene brachial plexus block or systemic analgesia (control). Cumulative 24-h postoperative oral morphine equivalent consumption was designated as the primary outcome. Secondary outcomes included visual analogue scale pain scores during the first 24 h postoperatively; time-to-first analgesic request; patient satisfaction; opioid-related side-effects; block-related adverse events; and any indicators of chondrotoxicity. Fifteen trials (863 patients) were included. Compared with control, intra-articular infiltration reduced 24-h postoperative analgesic consumption by a weighted mean difference (95%CI) of -30.9 ([-38.9 to -22.9]; p < 0.001). Intra-articular infiltration also reduced the weighted mean difference (95%CI) pain scores up to 12 h postoperatively, with the greatest reduction at 4 h (-2.2 cm [(-4.4 to -0.04]); p < 0.05). Compared with interscalene brachial plexus block, there was no difference in opioid consumption, but patients receiving interscalene brachial plexus block had better pain scores at 2, 4 and 24 h postoperatively. There was no difference in opioid- or block-related adverse events, and none of the trials reported chondrotoxic effects. Compared with systemic analgesia, intra-articular infiltration provides superior pain control, reduces opioid consumption and enhances patient satisfaction, but it may be inferior to interscalene brachial plexus block patients having arthroscopic shoulder surgery.

Ultrasound guided lateral quadratus lumborum block enhanced recovery in patients undergoing laparoscopic colorectal surgery.

PURPOSE: This study aimed to evaluate the effects of lateral quadratus lumborum block (QLB) on postoperative pain and recovery in patients undergoing laparoscopic colorectal surgery. MATERIALS AND METHODS: Patients between 18 and 70 years old, diagnosed with colon or rectal cancer, with American Society of Anesthesiologists (ASA) physical status I or II, and scheduled for laparoscopic colorectal surgery were recruited. Patients were excluded if they were allergic to local anesthetics and unable to complete the procedure of puncture or follow-up evaluation. All included patients were randomly allocated to either QLB or Sham group. The primary outcome was perioperative cumulative sufentanil consumption. RESULTS: There were no significant differences between the groups in anesthetic time, operation time, dosage of propofol, and remifentanil (P â€‹> â€‹0.05). Patients in the QLB group had significantly less sufentanil consumption both intraoperatively and postoperatively, compared with the Sham group (P â€‹< â€‹0.05). Postoperative VAS pain scores on coughing in the QLB group at 2 â€‹h, 6 â€‹h, 12 â€‹h, 24 â€‹h time points and VAS pain score at rest 2 â€‹h, 6 â€‹h after surgery were significantly lower than in the Sham group (P â€‹< â€‹0.05). Compared with the Sham group, time to first ambulation and anal flatus after surgery in the QLB group were significantly shorter (P â€‹< â€‹0.05). Significant differences of postoperative rescue analgesic usage and QoR-15 score at 48 â€‹h were found between the two groups (P â€‹< â€‹0.05). CONCLUSIONS: Ultrasound-guided lateral QLB significantly reduced perioperative opioid consumption, alleviated postoperative pain, shortened the time to first ambulation and anal flatus, and enhanced postoperative recovery of the patients undergoing laparoscopic colorectal surgery.

Opioid prescribing exceeds consumption following common surgical oncology procedures.

BACKGROUND AND OBJECTIVES: Surgical oncology patients are vulnerable to persistent opioid use. As such, we aim to compare opioid prescribing to opioid consumption for common surgical oncology procedures. METHODS: We prospectively identified patients undergoing common surgical oncology procedures at a single academic institution (August 2017-March 2018). Patients were contacted by telephone within 6 months of surgery and asked to report their opioid consumption and describe their discharge instructions and opioid handling practices. RESULTS: Of the 439 patients who were approached via telephone, 270 completed at least one survey portion. The median quantity of opioid prescribed was significantly larger than consumed following breast biopsy (5 vs. 2 tablets of 5 mg oxycodone, p < .001), lumpectomy (10 vs. 2 tablets of 5 mg oxycodone, p < .001), and mastectomy or wide local excision (20 tablets vs. 2 tablets of 5 mg oxycodone, p < .001). The majority of patients reported receiving education on taking opioids, but only 27% received instructions on proper disposal; 82% of prescriptions filled resulted in unused opioids, and only 11% of these patients safely disposed of them. CONCLUSIONS: This study demonstrates that opioid prescribing exceeds consumption following common surgical oncology procedures, indicating the potential for reductions in prescribing.