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Abstract Background Opioid-sparing multimodal analgesic approach has been shown to provide effective postoperative pain relief and reduce postoperative opioid consumption and opioid-associated adverse effects. While many studies have evaluated analgesic strategies for elective cesarean delivery, few studies have investigated analgesic approaches in emergent cesarean deliveries under general anesthesia. The primary aim of this quality improvement project is to evaluate opioid consumption with the use of a multimodal opioid-sparing pain management pathway in patients undergoing emergent cesarean delivery under general anesthesia. Methods Seventy-two women (age > 16 years) undergoing emergent cesarean delivery under general anesthesia before (n = 36) and after (n = 36) implementation of a multimodal opioid-sparing pain management pathway were included. All patients received a standardized general anesthetic. Prior to implementation of the pathway, postoperative pain management was primarily limited to intravenous patient-controlled opioid administration. The new multimodal pathway included scheduled acetaminophen and non-steroidal anti-inflammatory medications and ultrasound-guided classic lateral transversus abdominis plane blocks with postoperative opioids reserved only for rescue analgesia. Data obtained from electronic records included demographics, intraoperative opioid use, and pain scores and opioid consumption upon arrival to the recovery room, at 2, 6, 12, 24, 48, and 72 h postoperatively. Results Patients receiving multimodal opioid sparing analgesia (AFTER group) had lower opioid use for 72 h, postoperatively. Only 2 of the 36 patients (5.6%) in the AFTER group required intravenous opioids through patient-controlled analgesia while 30 out of 36 patients (83.3%) in the BEFORE group required intravenous opioids. Conclusions Multimodal opioid-sparing analgesia is associated with reduced postoperative opioid consumption after emergent cesarean delivery.

Introduction: To meet the demand of pediatric endodontists, exclusive pediatric rotary file systems have been recently introduced by the manufactures. However, no study has been conducted to compare the clinical efficiency between pediatric rotary file systems. Aim: To determine the clinical efficiency (instrumentation time, obturation time, quality of obturation and postoperative pain) of two pediatric rotary file systems following the root canal preparation of primary molars. Materials and Methods: A total of 75 primary molars requiring pulpectomy were selected from children aged 4 to 7 years. These teeth were divided into three groups of 25 teeth each. In the first, second, and third groups, the cleaning and shaping of the root canals were carried out with Pedo-Flex pediatric rotary files (Group PF), Kedo-S pediatric rotary files (Group KS), and, manual nickel-titanium K-files (Group MF), respectively. Obturation was carried out with zinc oxide eugenol cement with an engine-driven Lentulo spiral. The instrumentation and obturation times were recorded. The quality of the root filling was radiographically assessed immediately after obturation. The postoperative pain was evaluated at time intervals of 6, 12, 24, 48, 72 h, and 1 week. Results and Discussion: The instrumentation and obturation times were significantly less with the use of pediatric rotary file systems compared to the manual file system. The quality of obturation was superior in the root canals instrumented with pediatric rotary file systems compared to manual files. There was decreased postoperative pain with the use of pediatric rotary file systems as compared to manual files. In all three groups, postoperative pain decreased over time. The optimally filled root canals showed a significant correlation with the absence of postoperative pain. Conclusions: The use of pediatric rotary file systems for root canal instrumentation of primary molars resulted in the superior quality of obturation in decreased instrumentation and obturating times with the least postoperative pain. The overfilled root canals were not associated with significant postoperative pain.

To assess the impact of intraoperative dexmedetomidine and ketamine on postoperative pain and opioid consumption within an ERAS program in thoracic pulmonary oncologic surgery. Retrospective, propensity-score matched analysis Enhanced Recovery After Surgery (ERAS) program. Patients undergoing thoracic pulmonary oncologic surgery between March 2016 and April 2020. Continuous infusion of dexmedetomidine and ketamine. The authors initially analyzed data of 1,630 patients undergoing thoracic pulmonary oncologic surgery within their ERAS program. In total, 117 matched pairs were included in this analysis. Patients in the intraoperative dexmedetomidine + ketamine group were more likely to be opioid-free (76.6% vs 60.9%, P<0.01). Raw analysis showed lower pain scores at PACU admission (2.8±2.0 vs 3.4±2.0, P=0.03) and less opioid consumption at PACU admission (5 MED [0-10] vs 7.5 MED [0-15], P=0.03) in the dexmedetomidine + ketamine group; however, these differences were not present after adjusting for multiplicity. There were no significant differences in the length of PACU stay (1.9 hours [1.5-2.8] vs 2.0 hours [1.4-2.9], P=0.48) or hospital stay (three days [two-five] vs three days [two-five], P=0.08). Both groups had similar rates of pulmonary complications (5.9% vs 9.4%, P=0.326), ileus (0.9% vs 0.9%, P=1.00), and 30-day readmission (2.6% vs 4.3%, P=0.722). There were no differences in postoperative pain scores and opioid consumption throughout their hospital stay between patients receiving concomitant dexmedetomidine and ketamine infusions versus patients who did not receive these infusions during thoracic surgery. [Display omitted] [ABSTRACT FROM AUTHOR]

This prospectively designed, clinical quality improvement project compared pain scores and opioid consumption between ultrasound-guided, erector spinae plane blocks (ESPB) and thoracic paravertebral blocks (PVB) in patients undergoing total bilateral mastectomies without reconstruction. Twenty-five patients were included in an enhanced recovery pathway and received an ESPB on one side and a PVB on the contralateral side. Numeric rating scores at rest and with movement for each side were recorded in the recovery room at 2, 6, 12, 24, and 48 hours and on days 3 to 7. There were no significant differences in the resting or movement-evoked pain scores between sides receiving ESPB or PVB at any time point up to day 7 after surgery. Both ESPB and PVB confer equal analgesic effects in patients undergoing mastectomies. ESPB provides an alternative to PVB in reducing postoperative pain in patients undergoing mastectomy as part of an enhanced recovery pathway. [ABSTRACT FROM AUTHOR]

Guidelines are increasingly being used for clinical decision-making. Such guidelines are usually based on meta-analyses, which are generally derived from RCTs. However, their interpretations are often hindered as they do not always consider current clinical relevance. Analyses of RCTs assessing analgesic efficacy of advanced regional analgesic techniques in knee arthroplasty show that the majority of trials do not include a package of basic analgesics such as paracetamol, NSAIDs or cyclooxygenase-2 specific inhibitors, dexamethasone, and local infiltration analgesia in the comparator group. Consequently, the current approach to analyse meta-analyses of pain interventions is not optimal, and may lead to inadequate or inappropriate conclusions and clinical guidance. [ABSTRACT FROM AUTHOR]

Purpose: With lumbar laminectomy increasingly being performed on an outpatient basis, optimal pain management is critical to avoid post-operative delay in discharge and readmission. The aim of this review was to evaluate the available literature and develop recommendations for optimal pain management after one- or two-level lumbar laminectomy. Methods: A systematic review utilizing the PROcedure-SPECific Post-operative Pain ManagemenT (PROSPECT) methodology was undertaken. Randomised controlled trials (RCTs) published in the English language from 1 January 2008 until 31 March 2020—assessing post-operative pain using analgesic, anaesthetic and surgical interventions—were identified from MEDLINE, EMBASE and Cochrane Databases. Results: Out of 65 eligible studies identified, 39 RCTs met the inclusion criteria. The analgesic regimen for lumbar laminectomy should include paracetamol and a non-steroidal anti-inflammatory drug (NSAID) or cyclooxygenase (COX)—2 selective inhibitor administered preoperatively or intraoperatively and continued post-operatively, with post-operative opioids for rescue analgesia. In addition, surgical wound instillation or infiltration with local anaesthetics prior to wound closure is recommended. Some interventions—gabapentinoids and intrathecal opioid administration—although effective, carry significant risks and consequently were omitted from the recommendations. Other interventions were also not recommended because there was insufficient, inconsistent or lack of evidence. Conclusion: Perioperative pain management for lumbar laminectomy should include paracetamol and NSAID- or COX-2-specific inhibitor, continued into the post-operative period, as well as intraoperative surgical wound instillation or infiltration. Opioids should be used as rescue medication post-operatively. Future studies are necessary to evaluate the efficacy of our recommendations. [ABSTRACT FROM AUTHOR]

Regional analgesia is a core component of an optimal multimodal analgesia technique. Several advanced regional analgesic techniques have been evaluated for mastectomy; however, the optimal choice remains unclear. Many randomised clinical trials (RCTs) evaluating various local/regional analgesic techniques do not include basic analgesics (i.e. paracetamol, non-steroidal anti-inflammatory drugs, cyclooxygenase-2 specific inhibitors, and dexamethasone) which precludes objective evaluation of their efficacy. The aim of this scoping review was to assess the use of basic analgesics in RCTs evaluating efficacy of local and regional analgesic techniques in patients undergoing mastectomy. PubMed was searched to identify relevant articles from January 1, 2010 to May 31, 2023. The key finding of this study is that almost 90% (n =82/92) of the RCTs evaluating local/regional analgesic techniques in patients undergoing mastectomy did not administer well accepted basic analgesics in the comparator groups. Consequently, the conclusions of the RCTs assessing local/regional analgesic techniques for mastectomy should be interpreted with caution. Also, clinical guidelines based on meta-analyses of these RCTs could be inadequate or inappropriate. [ABSTRACT FROM AUTHOR]

Purpose: Postoperative epidural analgesia for major upper abdominal and thoracic surgery can provide significant benefits, including superior analgesia and reduced pulmonary dysfunction. Nevertheless, epidural analgesia may also be associated with decreased muscle strength, sympathetic tone, and proprioception that could possibly contribute to falls. The purpose of this retrospective case-control study was to search a large national database in order to investigate the possible relationship between postoperative epidural analgesia and the rate of inpatient falls.Methods: Data from the nationwide inpatient sample for 2007-2011 were queried for adult patients who underwent elective major upper abdominal and thoracic surgery. Multiple International Classification of Diseases, Ninth Revision, Clinical Modification codes for inpatient falls and accidents were combined into one binary variable. Univariate analyses were used for initial statistical analysis. Logistic regression analyses and McNemar's tests were subsequently used to investigate the association of epidural analgesia with inpatient falls in a 1:1 case-control propensity-matched sample after adjustment of patients' demographics, comorbidities, and hospital characteristics.Results: Forty-two thousand six hundred fifty-eight thoracic and 54,974 upper abdominal surgical procedures were identified. The overall incidence of inpatient falls in the thoracic surgery group was 6.54% with an increasing trend over the study period from 4.95% in 2007 to 8.11% in 2011 (P < 0.001). Similarly, the overall incidence of inpatient falls in the upper abdominal surgery group was 5.30% with an increasing trend from 4.55% in 2007 to 6.07% in 2011 (P < 0.001). Postoperative epidural analgesia was not associated with an increased risk for postoperative inpatient falls in the thoracic surgery group (relative risk [RR], 1.18; 95% confidence interval [CI], 0.95 to 1.47; P = 0.144) and in the upper abdominal surgery group (RR, 0.84; 95% CI 0.64 to 1.09; P = 0.220). Inpatient falls compared with non-falls were associated with a longer median (interquartile range) length of hospital stay in both the thoracic surgery group (11 [7-17] days vs 9 [6-16] days, respectively; P < 0.001) and the upper abdominal surgery group (12 [7-20] days vs 10 [6-17] days, respectively; P < 0.001).Conclusion: Our study suggests that postoperative epidural analgesia for patients undergoing major upper abdominal and thoracic surgery is not associated with an increased risk of inpatient falls. [ABSTRACT FROM AUTHOR]

Pain after foot and ankle surgery can significantly affect the postoperative outcomes. We performed a systematic review of randomized controlled trials assessing postoperative pain after foot and ankle surgery, because the surgery will lead to moderate-to-severe postoperative pain, but the optimal pain therapy has been controversial. A systematic review of randomized controlled trials in English reporting on pain after foot and ankle surgery in adults published from January 1946 to February 2013 was performed. The primary outcome measure was the postoperative pain scores. The secondary outcome measures included supplemental analgesic requirements and other recovery outcomes. With 953 studies identified, 45 met the inclusion criteria. The approaches improving pain relief (reduced pain scores or opioid requirements) included peripheral nerve blocks, wound infiltration, intravenous dexamethasone, acetaminophen, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 selective inhibitors, and opioids. Wound instillation, intra-articular injection, and intravenous regional analgesia had variable analgesia. The lack of homogeneous study design precluded quantitative analyses. Optimal pain management strategies included locoregional analgesic techniques plus acetaminophen and nonsteroidal anti-inflammatory drugs or cyclooxygenase-2 selective inhibitors, with opioids used for “rescue,” and 1 intraoperative dose of parenteral dexamethasone. Popliteal sciatic nerve blocks would be appropriate when expecting severe postoperative pain (extensive surgical procedure), and ankle blocks and surgical incision infiltration would be appropriate when expecting moderate postoperative pain (less extensive and minimally invasive surgical procedures). Additional studies are needed to assess multimodal analgesia techniques. [ABSTRACT FROM AUTHOR]

Despite advances in pharmacologic options for the management of surgical pain, there appears to have been little or no overall improvement over the last two decades in the level of pain experienced by patients. The importance of adequate and effective surgical pain management, however, is clear, because inadequate pain control 1) has a wide range of undesirable physiologic and immunologic effects; 2) is associated with poor surgical outcomes; 3) has increased probability of readmission; and 4) adversely affects the overall cost of care as well as patient satisfaction. There is a clear unmet need for a national surgical pain management consensus task force to raise awareness and develop best practice guidelines for improving surgical pain management, patient safety, patient satisfaction, rapid postsurgical recovery, and health economic outcomes. To comprehensively address this need, the multidisciplinary Surgical Pain Congress™ has been established. The inaugural meeting of this Congress (March 8 to 10, 2013, Celebration, Florida) evaluated the current surgical pain management paradigm and identified key components of best practices. [ABSTRACT FROM AUTHOR]

Pain after thoracic surgery can be intense and prolonged. Inadequate pain management can have several detrimental effects, including increased postoperative morbidity and delayed recovery as well as occurrence of postthoracotomy syndrome. Therefore, establishing an adequate analgesic regimen for thoracic surgery is critical. Thoracic paravertebral block or thoracic epidural analgesia is recommended as the first-choice therapies for postthoracotomy analgesia. When these techniques are either contraindicated or not possible, intercostal analgesia or intrathecal opioids are recommended. These techniques should be combined with nonopioid analgesics, such as acetaminophen, nonsteroidal anti-inflammatory drugs, or cyclooxygenase-2-specific inhibitors, administered on a regular “round-the-clock” basis, with opioids used as “rescue” analgesics. Finally, the integration of multimodal analgesia techniques with multidisciplinary rehabilitation program can enhance recovery, reduce hospital stay, and facilitate early convalescence. [Copyright &y& Elsevier]

1 Vermeylen K, Leunen I. Ultrasound-Guided suprainguinal fascia iliaca compartment block versus periarticular infiltration for pain management after total hip arthroplasty: a randomized controlled trial. A longitudinal Supra-Inguinal fascia Iliaca compartment block reduces morphine consumption after total hip arthroplasty. [Extracted from the article]

Background: For most procedures, there is insufficient evidence to guide clinicians in the optimal timing of advanced analgesic methods, which should be based on the expected time course of acute postoperative pain severity and aimed at time points where basic analgesia has proven insufficient.Methods: We conducted a systematic search of the literature of analgesic trials for total hip arthroplasty (THA), extracting and pooling pain scores across studies, weighted for study size. Patients were grouped according to basic anaesthetic method used (general, spinal), and adjuvant analgesic interventions such as nerve blocks, local infiltration analgesia, and multimodal analgesia. Special consideration was given to high-risk populations such as chronic pain or opioid-dependent patients.Results: We identified and analysed 71 trials with 5973 patients and constructed pain trajectories from the available pain scores. In most patients undergoing THA under general anaesthesia on a basic analgesic regimen, postoperative acute pain recedes to a mild level (<4/10) by 4 h after surgery. We note substantial variability in pain intensity even in patients subjected to similar analgesic regimens. Chronic pain or opioid-dependent patients were most often actively excluded from studies, and never analysed separately.Conclusions: We have demonstrated that it is feasible to construct procedure-specific pain curves to guide clinicians on the timing of advanced analgesic measures. Acute intense postoperative pain after THA should have resolved by 4-6 h after surgery in most patients. However, there is a substantial gap in knowledge on the management of patients with chronic pain and opioid-dependent patients. [ABSTRACT FROM AUTHOR]

Background: Many regional anaesthetic techniques have been proposed to manage pain after total knee arthroplasty, but the best approach is unclear. We compared opioid consumption in the first 48 h between two different regional anaesthesia strategies in patients undergoing total knee arthroplasty.Methods: In this single-centre, prospective study, we randomly allocated 90 patients to a combination of IPACK (interspace between popliteal artery and capsule of the posterior knee), triangle femoral and obturator nerve blocks (distal group), or a combination of sciatic, femoral, obturator, and lateral femoral cutaneous nerve blocks (proximal group). All patients received an opioid-sparing general anaesthesia regimen. The primary outcome was opioid consumption in the first 48 h. Secondary outcomes included opioid consumption in the first 24 h and verbal rating pain scores in the first 48 h.Results: There was no difference in median cumulative oral morphine equivalent consumption at 48 h between the distal and the proximal block groups (33 [18-78] mg vs 30 [22-51] mg, respectively; P=0.29). Median oral morphine equivalent consumption at 24 h was higher in the distal group compared with the proximal group (30 [13-59] vs 15 [0-18], respectively; P<0.001). Verbal rating pain scores were lower in the proximal group compared with the distal group on arrival to the postanaesthesia care unit and at 6 and 12 h.Conclusions: In patients undergoing total knee arthroplasty under total intravenous general anaesthesia with a multimodal analgesia regimen, proximal nerve blocks resulted in improved pain scores in the first 12 h and reduced opioid consumption in the first 24 h when compared with distal nerve blocks. No difference in pain scores or opioid consumption was seen at 48 h.Clinical Trial Registration: NCT04499716. [ABSTRACT FROM AUTHOR]

Opioids form an important component of general anesthesia and perioperative analgesia. Discharge opioid prescriptions are identified as a contributor for persistent opioid use and diversion. In parallel, there is increased enthusiasm to advocate opioid-free strategies, which include a combination of known analgesics and adjuvants, many of which are in the form of continuous infusions. This article critically reviews perioperative opioid use, especially in view of opioid-sparing versus opioid-free strategies. The data indicate that opioid-free strategies, however noble in their cause, do not fully acknowledge the limitations and gaps within the existing evidence and clinical practice considerations. Moreover, they do not allow analgesic titration based on patient needs; are unclear about optimal components and their role in different surgical settings and perioperative phases; and do not serve to decrease the risk of persistent opioid use, thereby distracting us from optimizing pain and minimizing realistic long-term harms. [ABSTRACT FROM AUTHOR]