A randomized controlled study on acupuncture for peri-operative pain after open radical prostatectomy.

OBJECTIVES: To evaluate the advantages of adding acupuncture to standard postoperative pain management for open radical prostatectomy (RP). MATERIALS AND METHODS: A randomized controlled trial (1:1:1) comparing routine postoperative analgesic care (control [CON]) vs the addition of press tack needle acupuncture (ACU) or press tack placebo acupressure (SHAM) for pain management after open RP was performed. A total of 126 patients were enrolled between February 2020 and April 2021. After open RP, the CON group received standard postoperative analgesia, the ACU group received long-term acupuncture with press tacks at specific points (P-6, Shenmen and SP-6) along with standard analgesia, and the SHAM group received placebo press tacks at the same acupuncture points alongside standard analgesia. The primary endpoint was postoperative pain measured on a numeric rating scale, the NRS-11, calculated as the area under the curve. The cumulative use of routine postoperative analgesics, time to first defaecation, and quality of life were analysed using the Kruskal-Wallis rank sum test, Fisher's exact test, and Pearson's chi-squared test. RESULTS: The ACU group reported significantly less postoperative pain compared to the SHAM (P = 0.007) and CON groups (P = 0.02). There were no significant difference in median (interquartile range) cumulative pain medication usage, time to first defaecation (CON: 37 [33, 44] h; SHAM: 37 [33, 42] h; ACU: 37 [33, 41] h; P > 0.9), or health status at discharge (EuroQol five-dimension, five-level general health assessment questionnaire: CON: 70 [65-83]; SHAM: 70 [60-80]; ACU: 70 [50-80]). CONCLUSION: Incorporating acupuncture into postoperative pain management can improve patient postoperative outcomes.

Association of peri-operative prescription of non-steroidal anti-inflammatory drugs with continued prescription of opioids after total knee arthroplasty: a retrospective claims-based cohort study.

Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the mainstays of multimodal pain management. While effective for acute pain control, recent pre-clinical evidence has raised concerns regarding an association between NSAIDs and chronic pain and potential opioid use. Our objective was to explore the association between peri-operative use of prescription NSAIDs and the need for continued opioid prescriptions lasting 90-180 days in previously opioid-naïve patients undergoing total knee arthroplasty. A database of health claims in the USA was used to identify all opioid-naïve adult patients who underwent primary knee arthroplasty between January 2010 and October 2021. We evaluated the magnitude of association between peri-operative prescription NSAID claims and claims for opioids at 90 days postoperatively using multivariable logistic regression models. Secondary outcomes included: the magnitude of association between peri-operative NSAID prescription and claims for opioids at 180 days postoperatively; and identifying other potential factors associated with opioid claims at 90 days postoperatively. After risk adjustment using multivariable logistic regression models in the 789,736-patient cohort, the adjusted odds ratio (95%CI) for a continuous claim of opioids at 90 and 180 days postoperatively among patients with a peri-operative NSAID prescription within 30 days was 1.32 (1.30-1.35), p < 0.001; and 1.12 (1.10-1.15), p < 0.001, respectively. This estimate of effect remained robust at 90 days after accounting for known potential confounders, including pre-existing knee pain and acute postoperative pain severity. Similar analysis of other pain medications (e.g. paracetamol) did not detect such an association. This population-based cohort study suggests that peri-operative prescription NSAID use may be associated with continued opioid prescription claims at 90 and 180 days after knee arthroplasty, even after adjusting for other observed covariates for continuous opioid claims. These novel findings can inform clinical decision-making for post-surgical pain management, risk-benefit discussions with patients and future research.

Comparison of transversus abdominis plane catheters with thoracic epidurals for cost and length of stay in open colorectal surgeries: a cohort study.

BACKGROUND: Thoracic epidural analgesia has long been a common method of postoperative analgesia for major open abdominal surgeries and is frequently used within enhanced recovery after surgery programs. An alternative postoperative analgesia method is the single shot transversus abdominis plane block, which has shown promising outcomes with respect to total length of stay, cost, pain scores, and decreased opioid usage. However, far less is known regarding continuous transversus abdominis plane analgesia using catheters. We evaluated the total cost-effectiveness of transversus abdominis plane catheter analgesia compared to thoracic epidural analgesia for patients undergoing open colorectal surgeries within the enhanced recovery after surgery program at our institution. METHODS: This cohort study included patients booked under the colorectal surgery enhanced recovery after surgery program from November 2016 through March 2018 who received either bilateral transversus abdominis plane catheters (n = 52) or thoracic epidural analgesia (n = 24). RESULTS: There was no difference in total direct cost (p = 0.660) and indirect cost (p = 0.220), and median length of stay (p = 0.664) in the transversus abdominis plane catheter group compared to the thoracic epidural group. Additionally, the transversus abdominis plane catheter group received significantly less morphine equivalents compared to the thoracic epidural group (p = 0.008) and had a lower mean body mass index (p = 0.019). There was no significant difference between the two groups for age (p = 0.820), or sex (p = 0.330). CONCLUSIONS: Transversus abdominis plane catheter analgesia is not associated with increased cost or longer hospital stays when compared to thoracic epidural analgesia in patients undergoing open colorectal surgery within an enhanced recovery after surgery program. Furthermore, transversus abdominis plane catheter analgesia led to decreased opioid consumption while maintaining similar pain scores, suggesting similar pain control between the two modalities.

Prospective pilot study to identify psychological factors influencing peri-operative pain in total knee arthroplasty (TKA).

PURPOSE: Up to 20% of total knee arthroplasty (TKA) patients remain dissatisfied, with chronic pain as the most frequently named cause. A pilot study was conducted to assess the progression of peri-operative pain intensity and the parallel development of different psychological factors and coping strategies, as well as correlations indicating potential inter-relationships. METHODS: Pain, psychological impairment [FESV BE], and coping strategies [FESV BW] were assessed before and after TKA [days - 5 to 31]. Patients were stratified according to the presence or absence of peri-operative pain improvement [decreasing pain: Group 1 [69%; n = 36]; persisting pain: group 2 [31%; n = 16]]. Group 2 was additionally tested with the Toronto Alexithymia Scale [TAS] and Screening for Somatoform Disorders [SOMS]. RESULTS: Pain intensity in group 1 decreased from significantly higher pre-operative levels to significantly lower values at 31 days post-operatively, whereas group 2 did not show significant changes. Concurrently, the psychological impairment parameter anxiety (AN) significantly decreased and the pain coping parameter relaxation significantly increased in group 1, but not in group 2. Whereas pre-operative pain was positively and significantly correlated with AN throughout time in group 2, it was negatively correlated with relaxation at day 29 in group 1. Concerning TAS and SOMS, considerable percentages of the participants in group 2 (37.5% and 68.75%, respectively) showed values > 50% of those in normal controls. CONCLUSIONS: Parallel (or anti-parallel) and partially correlated developments of pain improvement and parameters of psychological impairment or coping strategies after TKA suggest a pre-operative screening with tools like the FESV BE and BW or TAS and SOMS questionnaires in order to classify individuals for peri-operative mental training.

Use of Nanotechnology as an Alternative to Opioids for Post-operative Pain Management Following TKA.

Introduction: In response to the current opioid crisis, there is a great interest to develop non-pharmacologic approaches to post-operative pain management for patients undergoing total knee arthroplasty (TKA). Case Report: We report a case of a patient whose post-operative pain following TKA was managed using the newly designed NeuroCuple™ device, a patch based on the use of nanotechnology. The NeuroCuple™ device was placed above the knee by the patient at home. The use of the NeuroCuple™ device allowed the patient completely avoid the use of any opioids at home. Conclusion: Our report suggests that the use of the NeuroCuple™ device may represent an interesting alternative to opioids for the peri-operative management of pain following a primary, unilateral TKA.

Comparing paracetamol/codeine and meloxicam for postoperative analgesia in dogs: a non-inferiority trial.

BACKGROUND: There are limited published data on the analgesic efficacy of paracetamol/codeine in dogs. METHODS: Prospective, randomised, blinded, positive-controlled clinical trial with 70 dogs (paracetamol/codeine, n=46; meloxicam, n=24) undergoing surgery. Drugs were administered orally 2 hours before and for 48 hours after surgery at the licensed dose. Anaesthesia was standardised. Dogs received buprenorphine 6 hourly for the first 24 hours after surgery. Outcome assessments were made pretrial and at regular intervals up to 48 hours after extubation and comprised the Glasgow Composite Measure Pain Score-Short Form, visual analogue scale for sedation and inflammation and mechanical nociceptive threshold (MNT). Non-inferiority of paracetamol/codeine compared with meloxicam was defined using a non-inferiority margin (Δ) against the 95 per cent confidence interval of the difference between the treatment means. RESULTS: Pain scores were low in both treatment groups. With the exception of MNT all upper 95 per cent confidence intervals for the differences between outcome variable treatment means were within +Δ for each variable, establishing non-inferiority for each outcome variable. CONCLUSIONS: Paracetamol/codeine is a useful perioperative analgesic that within the context of the perioperative analgesia regimen studied (methadone premedication, buprenorphine for the first 24 hours after surgery) shows non-inferiority to the NSAID meloxicam.

Study of Peri-Articular Anaesthetic for Replacement of the Knee (SPAARK): study protocol for a patient-blinded, randomised controlled superiority trial of liposomal bupivacaine.

BACKGROUND: Optimising the management of peri-operative pain and recovery following knee replacement has been identified as a patient priority. Current pain relief strategies use opiate-based analgesia; however, up to 50% of patients experience significant side effects. Local anaesthetic incisional infiltration is one alternative. The length of the duration of action is a major limiting factor of current local anaesthetic techniques. Liposomal bupivacaine has been reported to be effective for up to 72 h. This randomised controlled trial will evaluate the clinical and cost effectiveness of liposomal bupivacaine. METHODS: SPAARK is a patient-blinded, multi-centre, active comparator, superiority, two-arm, parallel-group randomised controlled trial. Five hundred patients undergoing knee replacement will be recruited and randomised to liposomal bupivacaine plus bupivacaine hydrochloride or bupivacaine hydrochloride alone. The co-primary outcomes are the Quality of Recovery 40 measured at 72 h post-surgery and also cumulative pain measured daily using a 0-10 visual analogue scale for the first 3 days following surgery. Secondary outcomes include cumulative opioid consumption, fitness for discharge, functional outcomes assessed using the Oxford Knee Score and American Knee Society Score, the EuroQol five dimensions instrument and complications. A cost utility analysis is also planned. DISCUSSION: The clinical effectiveness and cost effectiveness of liposomal bupivacaine have yet to be evaluated in the National Health Service, making this trial appropriate and timely. TRIAL REGISTRATION: ISRCTN registry, ISRCTN54191675. Registered on 14 November 2017.

Peri-operative pain and its consequences.

Recent advances in the management of peri-operative pain principally concern the recognition of the risk of developing pain chronicity. The best identified risk factors for pain chronicity are the presence of pain pre-operatively, pre-operative opioid use, and the intensity of post-operative pain. Ideal management of peri-operative pain in 2015 aims to optimize post-operative pain management, to detect the risk of pain chronicity begins pre-operatively with early detection of risk factors for chronicity. In terms of treatment, the systematic and generous use of morphine has shown its limitations, particularly due to reduced efficacy for movement-related pain. Meanwhile, opioid side effects can be very debilitating for the patient, leading to delay in post-operative rehabilitation, a dose-dependent hyperalgesic effect resulting in both acute and chronic pain, immune modulation that may have a deleterious impact on infectious complications or cancer [1], and, finally, some question of possible neurotoxicity. Therefore, modern analgesia depends on both intra-operative and post-operative morphine sparing. The goal at the present time is to obtain optimal analgesia that allows rapid rehabilitation without sequelae or chronicity through the use of drugs and/or techniques to avoid the need for opioid medications.

Best evidence in multimodal pain management in spine surgery and means of assessing postoperative pain and functional outcomes.

Multimodal approaches to pain management have arisen with the goal of improving postoperative pain and reducing opioid analgesic use. We performed a comprehensive literature review to determine grades of recommendation for commonly used agents in multimodal pain management and provide a best practice guideline. To evaluate common drugs used in multimodal treatment of pain, a search was performed on English language publications on Medline (PubMed; National Library of Medicine, Bethesda, MD, USA). Manuscripts were rated as Level I-V according to the North American Spine Society's (NASS) standardized levels of evidence tables. Grades of recommendation were assigned for each drug based on the NASS Clinical Guidelines for Multidisciplinary Spine Care. There is good (Grade A) evidence gabapentinoids, acetaminophen, neuraxial blockade and extended-release local anesthetics reduce postoperative pain and narcotic requirements. There is fair (Grade B) evidence that preemptive analgesia and nonsteroidal anti-inflammatory drugs (NSAID) result in reduced postoperative pain. There is insufficient and/or conflicting (Grade I) evidence that muscle relaxants and ketamine provide a significant reduction in postoperative pain or narcotic usage. There is fair (Grade B) evidence that short-term use of NSAID result in no long-term reduction in bone healing or fusion rates. Comprehensive assessment of the effectiveness of perioperative pain control can be accomplished through the use of validated measures. Multimodal pain management protocols have consistently been demonstrated to allow for improved pain control with less reliance on opioids. There is good quality evidence that supports many of the common agents utilized in multimodal therapy, however, there is a lack of evidence regarding optimal postoperative protocols or pathways.