Postoperative Pain Management and the Incidence of Ipsilateral Shoulder Pain After Thoracic Surgery at an Australian Tertiary-Care Hospital: A Prospective Audit.

OBJECTIVES: Ipsilateral shoulder pain (ISP) is a common but variably occurring (42%-85%) complication after thoracic surgery. Multiple potential treatments, including upper limb blocks, intrapleural local anaesthetic infiltration, and systemic opioids, have undergone trials, with limited efficacy. Phrenic nerve infiltration is a potential intervention that may prevent ISP. The aim of this study was to assess the incidence and severity of ISP after thoracic surgery at the authors' institution, where phrenic nerve infiltration is commonly used. DESIGN: Observational cohort study. SETTING: A single- center study in a tertiary referral center in Brisbane, Australia. PARTICIPANTS: This study comprised all adult patients undergoing thoracic surgery at a tertiary- care referral center from May to July 2018. MEASUREMENTS AND MAIN RESULTS: Surgical procedures were divided into open thoracotomy, video-assisted thoracic surgery (VATS) and VATS-guided mini-thoracotomy. The primary outcome was a comparison of incidence of ISP among the 3 types of surgical procedures. Data were analyzed using Stata (StataCorp), with significance testing by Kruskal-Wallis equality of populations rank test. A p value of < 0.05 was deemed significant. Sixty thoracic surgeries were performed during the audit period. Nineteen patients had thoracotomies performed for lobectomy or pneumonectomy, all of whom received phrenic nerve infiltration. The incidence of moderate-to-severe ipsilateral shoulder pain among the thoracoctomy cohort was 15.8% (3/19). Of the 36 VATS procedures audited, 7 patients (19.4%) received infiltration of their phrenic nerve, none of whom reported postoperative ISP. Of the remaining twenty-nine patients who did not receive phrenic nerve infiltration, there were 4 cases of moderate-to-severe ipsilateral shoulder pain (11.1%). Four of the 5 patients (80%) who underwent VATS-guided mini-thoracotomies received phrenic nerve infiltration intraoperatively. Three patients reported moderate-to-severe ISP and of these 3 patients, 2 patients had phrenic nerve infiltration, and 1 patient did not receive infiltration. Overall, there were no statistically significant differences in rest or dynamic pain scores across the surgical groups at any time point. Mann-Whitney test revealed that the participants with ISP were significantly older than those without ISP (p = 0.006). However, there were no significant differences in sex or body mass index between those with and without ISP. CONCLUSION: The authors observed a lower (15.8%) incidence of moderate-to-severe ISP among their thoracotomy patients than reported in prior literature. Injection of local anesthetic into the phrenic nerve fat pad at the level of the diaphragm appeared to be an effective and safe surgical intervention that may eliminate a significant cause of ISP. None of the VATS patients who received phrenic nerve infiltration experienced ISP. Postoperative pain in VATS is expected to be reduced by avoiding the use of a rib spreader, severing of the intercostal nerves, and division of muscle tissue, which may account for the lower observed rates of ISP in the VATS cohort who did not receive phrenic nerve infiltration. Further randomized controlled trials are warranted to establish if patients undergoing various VATS procedures benefit from this intervention.

Intra-articular Alpha-2 Agonists as an Adjunct to Local Anesthetic in Knee Arthroscopy: A Systematic Review and Meta-Analysis.

The infiltration of local anesthetic has been shown to reduce postoperative pain in knee arthroscopy. Several studies have shown that the addition of agents such as magnesium and nonsteroidal antiinflammatory drugs (NSAIDs) result in an increased time to first analgesia and overall reduction in pain. The aim of this systematic review and meta-analysis was to determine whether the addition of an α-2 agonist (A2A) to intra-articular local anesthetic, results in a reduction in postoperative pain. Four major databases were systematically searched for relevant randomized controlled trials (RCTs) up to July 2017. RCTs containing a control group receiving a local anesthetic and an intervention group receiving the same with the addition of an A2A were included in the review. The included studies were assessed for level of evidence and risk of bias. The data were then analyzed both qualitatively and where appropriate by meta-analysis. We reviewed 12 RCTs including 603 patients. We found that the addition of an A2A resulted in a significant reduction in postoperative pain up to 24 hours. The addition of the A2A increased time to first analgesia request by 258.85 minutes (p < 0.00001). Total 24-hour analgesia consumption was analyzed qualitatively with all included studies showing a significant reduction in total analgesia requirement. Interestingly, none of the studies found an increase in side effects associated with the A2A. This study provides strong evidence for the use of A2As as a means to reduce postoperative pain post arthroscopic knee surgery, without a corresponding increase in side effects.

Tramadol as an adjunct to intra-articular local anaesthetic infiltration in knee arthroscopy: a systematic review and meta-analysis.

BACKGROUND: Arthroscopic knee surgery is a common technique used in Australia. Post-operative pain is common and can lead to delayed discharge and impair early mobilization. Use of local anaesthesia can reduce pain while avoiding systemic side effects. This systematic review and meta-analysis aimed to establish the use of tramadol as an adjunct to intra-articular local anaesthetic infiltration in knee arthroscopy in the current literature. METHODS: Two independent reviewers performed a systematic search of four databases, where 24 articles were identified with six studies (four high-quality and two low-quality randomized controlled trials), with a total of 334 patients were included for analysis. RevMan 5.3 software (The Nordic Cochrane Centre, Copenhagen, Denmark) was used to perform the data analysis. The studies included focused on outcomes such as pain scores, breakthrough analgesia, total analgesia, time to discharge and adverse events related to the use of tramadol as an adjunctive therapy. RESULTS: This study found that using tramadol as an adjunct to intra-articular local anaesthetic infiltration in arthroscopic knee surgery reduced post-operative pain and increased time to breakthrough analgesia without an increase in side effects. CONCLUSION: This meta-analysis suggests that tramadol is an efficacious adjunct for use in intra-articular local anaesthetic infiltration following arthroscopic knee surgery.

Apnoeic oxygenation during intubation in the intensive care unit: A systematic review and meta-analysis.

Hypoxaemia increases the risk of cardiac arrest and mortality during intubation. The reduced physiological reserve and reduced efficacy of pre-oxygenation in intensive care patients makes their intubation particularly dangerous. Apnoeic oxygenation is a promising means of preventing hypoxaemia in this setting. We sought to ascertain whether apnoeic oxygenation reduces the incidence of hypoxaemia when used during endotracheal intubation in the intensive care unit (ICU). A systematic review of five databases for all relevant studies published up to November 2016 was performed. Eligible studies investigated apnoeic oxygenation during intubation in the ICU, irrespective of design. All studies were assessed for risk of bias and level of evidence. A meta-analysis was performed on all data using Revman 5.3. Six studies including 518 patients were retrieved. The study found level 1 evidence of a significant reduction in the incidence of critical desaturation (RR = 0.69, CI = 0.48-1.00, p = 0.05) and a significant increase in the lowest SpO2 value by 2.83% (CI = 2.28-3.38, p < 0.00001). There was a significant reduction in ICU stay (WMD = -2.89, 95%CI = -3.25 to -2.51, p < 0.00001). There was no significant difference between groups regarding mortality (RR = 0.77, 95%CI = 0.59-1.03, p = 0.08), first pass intubation success (RR = 1.17, 95%CI = 0.67 to 2.03, p = 0.58), arrhythmia during intubation (RR = 0.58, 95%CI = 0.08 to 4.29, p = 0.60), cardiac arrest during intubation (RR = 0.33, 95%CI = 0.01 to 7.84, p = 0.49) and duration of ventilation (WMD = -1.97, 95%CI = -5.89 to 1.95, p = 0.32). Apnoeic oxygenation reduces patient hypoxaemia during intubation performed in the ICU. This meta-analysis found evidence that apnoeic oxygenation may significantly reduce the incidence of critical desaturation and significantly raises the minimum recorded SpO2 in this setting. We recommend apnoeic oxygenation be incorporated into ICU intubation protocol.

Antiviral Chemistry & Chemotherapy's current antiviral agents FactFile 2006 (1st edition).

The number of useful antiviral compounds is rapidly expanding. The current antiviral agents FactFile is a convenient key to the vital statistics of antiviral compounds to be used as an aide mémoire when reading or writing antiviral literature. A mini-portrait is provided for each of the antiviral compounds. The minimum criteria for inclusion of new compounds in the FactFile is the granting of an investigational new drug application with the realistic potential for medical or veterinary application. Several compounds that were subsequently withdrawn from further development are also included because of their historical importance or particular interest. The compounds are listed alphabetically according to their generic names together with systematic chemical names, common names and chemical structures. The compounds are grouped by virus targets; thus, the list is sub-divided into inhibitors of DNA viruses, RNA viruses, and retroviruses. The authors welcome comments and suggestions to be incorporated in future editions of the FactFile.

Scientific report: highlights of 25th ICAR, 16-19 April 2012, Sapporo, Japan.

Each year, the International Society for Antiviral Research (ISAR) organises a conference covering many differing aspects of antiviral research. The 25th International Conference on Antiviral Research (ICAR) was held in Japan. This special anniversary meeting was co-sponsored by the Japanese Association for Antiviral Therapy.This Workshop Report contains summaries of the four major lectures and each of the invited presentations in the Clinical symposium and in the three mini-symposia. Of the many interesting contributor presentations, there are brief summaries of a small selection of these. This report concludes with a few personal comments and observations.A brief summary of this report is included within the ISAR News published in this issue of AVCC.

Scientific report: highlights of 24th ICAR, 8-11 May 2011, Sofia, Bulgaria.

The 24th ICAR meeting was held in Sofia, Bulgaria, 8-11 May 2011. This report summarizes the presentations by the ICAR award winners, Earl Kern and Brian Gowen; the keynote address by Albert (ADME) Osterhaus; the Plenary lectures by Raina Fichorova, Ralf Bartenschlager and Esteban Domingo; the invited speakers for the symposia; and a few of those by contributors. This report aims to reflect the diversity of topics across different disciplines (chemistry to biology) discussed at ICAR: old viruses (smallpox), emerging viruses (SARS, new strains of influenza and flaviviruses), problematic viruses (HIV and HCV), sporadic viruses (arenaviruses), neglected viruses (enteroviruses), new research targets (for HCV) and new approaches (lethal mutagenesis). There were timely reports on promising compounds against adenoviruses, cytomegalovirus, HCV and HIV in clinical trials.This conference illuminated the constantly evolving field of antiviral chemotherapy by providing a forum to present and discuss new antiviral compounds, new uses for old compounds and exciting clinical results. This ICAR was a fitting testament to the 'father of antiviral chemotherapy', Bill Prusoff, who died aged 90 in April 2011.