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Background: Periarticular local infiltration analgesia (LIA) has become a widely used method for postoperative pain management after unicompartmental knee arthroplasty (UKA). However, the efficacy of using magnesium sulphate or sodium bicarbonate in LIA cocktails during UKA is not yet clear. The present study aimed to evaluate whether the modified LIA has advantages in pain control and joint function recovery after UKA surgery., Methods: Sixty-one patients who underwent UKA were enrolled and randomly assigned to receive periarticular infiltration of a modified cocktail (comprising ropivacaine, epinephrine, dexamethasone, magnesium sulphate, and sodium bicarbonate) or a conventional cocktail (comprising ropivacaine, epinephrine, dexamethasone, ketorolac, and morphine). The outcomes included the consumption of patient-controlled intravenous analgesia (PCIA) medication used for postoperative analgesia, pain score, early joint functional recovery, discharge time, and complication rates., Results: In the first 12 h after surgery, the conventional cocktail was not superior to the modified cocktail in terms of visual analogue scale (VAS) scores. However, beginning on the second postoperative day, the analgesic effect was significantly prolonged in the modified group, leading to lower VAS scores and better knee functional recovery. Additionally, patients in the modified group required less pain medication via PCIA, both within the first 24 h and cumulatively up to 48 h after surgery. Both groups had similar rates of complications., Conclusions: The present modification of a conventional cocktail significantly prolonged the analgesic effect and reduced pain medication consumption after UKA surgery, which was associated with better functional recovery in the early postoperative days., Trial Registration: Chinese Clinical Trial Registry, ChiCTR2200060500. 21 March 2023., Competing Interests: Declarations Ethics approval and consent to participate Ethics approval was obtained from the ethics committee of our hospital and informed consent was provided by all participants. Approval number: 008-IH01. The study was registered in the Chinese Clinical Trials Registry with the registration number: ChiCTR2200060500. 21 March 2023. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Background: Open liver surgery remains a primary surgical approach for complex liver resections and liver transplantation. However, the postoperative pain management is still a major challenge. Ultrasound-guided external oblique intercostal (EOI) plane block is a novel approach of regional anaesthesia and has a great potential to relieve postoperative pain after upper abdominal surgeries. This study aims to investigate the efficacy and safety of ultrasound-guided EOI plane block in managing postoperative pain after open liver surgery., Methods: Seventy-four participants scheduled for open liver surgery will be randomly assigned to either the intervention group, receiving an ultrasound-guided EOI plane block with a single dose of 30 ml 0.375% ropivacaine, or the control group, which will not receive this block. All participants will be provided with opioid-based patient-controlled intravenous analgesia (PCIA) postoperatively. The primary outcome is resting pain score at 3 h postoperatively, assessed using numerical rating scale. Secondary outcomes include pain score at 6, 24, 48, and 72 h postoperatively, perioperative opioid consumption, remedial analgesics within 72 h postoperatively, PCIA usage within postoperative 72 h, postoperative recovery, length of hospital stay, postoperative side effects, block-related complications, and ropivacaine plasma concentration of participants receiving the block., Discussion: This study is a randomised controlled trial to evaluate the efficacy and safety of ultrasound-guided EOI plane block for postoperative analgesia after open liver surgery. As regional anaesthesia plays an important role in the multimodal pain management, EOI plane block may prove to be an effective regional technique for enhancing postoperative pain relief and contributing to enhanced recovery after open liver surgery., Trial Registration: Chinese Clinical Trial Registry ChiCTR2200065745. Registered on November 14, 2022., Competing Interests: Declarations Ethics approval and consent to participate {24} This study has been approved by IRB of Peking Union Medical College Hospital (approval No. I-23PJ1983). Written informed consent to participate will be obtained from all participants. Consent for publication {32} Not applicable.Competing interests {28}The authors declare that they have no competing interests., (© 2024. The Author(s).)

Objectives: Optimising postoperative pain following knee replacement is important for patients, healthcare professionals and healthcare funders. Adductor canal blocks (ACB) are widely used but there is uncertainty about their efficacy when combined with local infiltration analgesia (LIA) compared with either LIA or ACB alone., Design: A systematic review and meta-analyses of randomised controlled. The primary outcome was pain over the first 72 hours. Secondary outcomes included morphine use, range of movement, distance walked, length of hospital stay, health economic outcomes and reported adverse events., Data Sources: MEDLINE, Embase, EB Health - KSR Evidence, Cochrane Central Register of Controlled Trials, CINAHL, International HTA database, ClinicalTrials.gov and the International Clinical Trials Registry Platform (WHO) were searched up to June 2023., Eligibility Criteria: Randomised controlled trials involving patients undergoing primary total knee replacement comparing LIA combined with ACB to either LIA or ACB alone., Data Extraction and Synthesis: All eligible studies were data extracted independently by two reviewers. Studies were pooled for each outcome at each timepoint in a random effects meta-analysis., Results: We identified 13 completed studies including 1154 participants. 12 studies compared LIA vs combination and 5 compared ACB vs combination. We identified that participants receiving the combination had lower pain scores at rest at 24 hours compared with LIA alone (SMD 0.42, 95% CI 0.20 to 0.64) or ACB alone (SMD 0.63, 95% CI 0.42 to 0.83). Pain on movement at 24 hours was also lower for patients with combination vs LIA alone (SMD 0.37, 95% CI 0.01 to 0.73) or ACB alone (SMD 0.81, 95% CI 0.35 to 1.26). We also identified that patients on combination used less morphine than on LIA alone (MD 1.06, 95% CI -0.09 to 2.20) or ACB alone (MD 5.94, 95% CI -2.41 to 14.29). The same was seen with range of motion at 24 hours with combination having a larger improvement than LIA alone (MD -5.19, 95% CI -5.55 to -4.83) or ACB alone (MD -3.80, 95% CI -4.37 to -3.23). These findings were consistent across all time points; however, there were no studies deemed to be at a low risk of bias., Conclusions: Further well-designed and conducted randomised controlled trials are needed to confirm if a combination of LIA and ACB is superior to either option alone for patients undergoing primary total knee arthroplasty., Prospero Registration Number: CRD42023436895., Competing Interests: Competing interests: HP has received grants from the NIHR(HTA), NIHR (BRC), Allay Therapeutics, Paradigm Pharma, Depuy Synthes, & Zimmer Biomet. He has received consulting fees from Medacta International, Zimmer Biomet, Invibio, MAT Ortho, Allay Therapeutics, Paradigm Pharma, Microport, & Teleflex. He has also received support to attend meetings from Medacta International, Zimmer Biomet, & Invibio and has received equipment, materials, drugs gifts, or other services from Pacira Pharmaceuticals, Medacta International, & Zimmer Biomet. TH is currently in receipt of a grant from the NIHR., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The current gold standard for postoperative analgesia following a pancreaticoduodenectomy (PD) is a thoracic epidural analgesia (TEA). Spinal analgesia with continuous wound infusion (CWI) of local anaesthetic is an emerging alternative modality. This non-inferiority study aimed to compare CWI with spinal analgesia to TEA and assess its impact on clinical outcomes., Methods: A retrospective observational analysis of patients undergoing open pancreatoduodenectomy through a midline laparotomy. A total of 74 patients were included in the study forming two groups: CWI (n = 33) and TEA (n = 41)., Results: TEA resulted in lower median pain scores at rest (p = 0.002) and with coughing (p = 0.005) on postoperative day 2. CWI was non-inferior to TEA for all other pain outcomes measures from days 0-5. Patients in the CWI group had a shorter time to first bowel motion (p = 0.001), commencement of a liquid diet (p = 0.04), earlier removal of nasogastric tube (p = 0.005), abdominal drain (p = 0.003) and indwelling catheter (p < 0.001). Analgesic failure and postoperative nausea and vomiting were also less frequent (p = 0.001 and p < 0.001 respectively)., Conclusion: Local CWI with spinal analgesia was non-inferior to TEA for pain management in open pancreaticoduodenectomy. CWI demonstrated advantages in measures associated with enhanced recovery after surgery programs without disadvantages in terms of analgesia requirements., Competing Interests: Declarations Competing interests The authors declare no competing interests. Conflict of interest None., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Pericapsular nerve group (PENG) block has emerged as a reliable analgesia technique for hip arthroplasty (HA). However, the effects of PENG block on perioperative neurocognitive disorder (PND) after HA has not yet been assessed. The present study aimed to investigate the effects of PENG block on early postoperative cognitive function in older people undergoing hip arthroplasty., Methods: Sixty older patients undergoing HA under spinal anesthesia were randomly assigned to group P (n = 30) receiving PENG block with ropivacaine and patient-controlled intravenous analgesia (PCIA) pump with sufentanil after surgery or group C (n = 30) only receiving PCIA pump with sufentanil after surgery. The primary outcome was the Mini-Mental State Examination (MMSE) score at 7 days postoperatively. Secondary outcomes consisted of the incidence of PND 7 days postoperatively, the static VAS pain scores at 6, 12, 24, and 48 h postoperatively; cumulative sufentanil consumption and the requirement of rescue analgesia during the 0-24 h period after surgery; quality of recovery-15 (QoR-15) scale scores at 24 h postoperatively; and the plasma levels of high mobility group box protein 1 (HMGB1) preoperatively and 1 day after surgery, and adverse events., Results: After surgery, the PENG block group had higher MMSE score than the control group at 7 days postoperatively (27.0 ± 1.8 vs. 26.1 ± 1.7, P = 0.048), with a mean difference of 0.9 (95%CI, 0.1-0.9). The incidence of PND at 7 days postoperatively was 6.7% in group P, lower than that of 30% in group C (P = 0.044). In group P, the static VAS scores at 6, 12, and 24 h postoperatively were significantly lower than those in group C (all P < 0.05). Compared with group C, the cumulative sufentanil consumption and the number of patients required rescue analgesia during the 0-24 h period after surgery were significantly lower in group P (all P < 0.05). The scores of QoR-15 scale were higher in group P at 24 h postoperatively than those in group C (P < 0.05). Patients in group P showed lower plasma levels of HMGB1 than group C at 1 day after surgery (P < 0.05), and the rate of complications didn't differ between both groups., Conclusions: Older people undergoing HA receiving a PENG block for perioperative analgesia experience improved early postoperative cognitive function, reduced postoperative pain, higher quality of recovery, and less postoperative inflammatory response., Trial Registration: Chictr.org.cn identifier ChiCTR2200061055 (Date of registry: 15/06/2022, prospectively registered)., Competing Interests: Declarations Ethics approval and consent to participate This study was approved by the Medical Ethics Committee of the Affiliated LiHuiLi Hospital of Ningbo University, China (KY2022PJ126), and the protocol was registered at the Chinese Clinical Trial Registry (ChiCTR2200061055) (prospectively registered). The initial registration date was 15/06/2022. All procedures performed in this study involving human participants were in accordance with the Ethical Standards of the Institutional Ethics Committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. All patients signed written informed consent before surgery. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Objective: The aim of the study was to compare the postoperative effects of endotracheal tube cuff inflation with alkalized lidocaine in patients undergoing thyroidectomy surgery., Methods: This is a randomized, double-blind clinical trial between August 2020 and August 2022 at the Hospital São Domingos, São Luís, Maranhão, Brazil. Patients over 18 years who underwent thyroidectomy of both sexes, American Society of Anesthesiologists (ASA) I or ASA II, were included. Patients with difficult orotracheal intubation, smoking, cuff rupture during orotracheal intubation, heart, lung, or neuropathies, previous surgery of the larynx or trachea, with risk of aspiration of gastric contents, or with the need to use a nasogastric tube were excluded. Patients were randomly selected and divided into the control group, whose cuff was filled with 0.9% saline solution, and the alkalinized lidocaine group, where the cuff was filled with 2% lidocaine and 8.4% sodium bicarbonate., Results: The control group had higher systolic blood pressure [137 (94-183) mmHg] medians after extubation than the alkalinized lidocaine group [127 (82-189) mmHg] (p=0.03). The same was observed in heart rate values [control group: 86 (62-120); alkalinized lidocaine group: 80 (53-120)] (p=0.034). The alkalinized lidocaine group showed a significant increase in the ability to sustain phonation in the 24 h postoperatively, from 82.0 to 98.0% (p=0.031)., Conclusion: There was no protective effect of the use of alkalinized lidocaine on the sensation of swallowing and complaints after thyroidectomy surgery. There was a significant improvement in hemodynamic response in the intervention group after extubation.

Background: Catheter-related bladder discomfort (CRBD) and pain commonly arises postoperatively in patients who undergo intra-operative urinary catheterization. The study aims to demonstrate the effectiveness of intravenous lidocaine to prevent CRBD and postoperative pain in complex lumbar spinal surgery., Methods: Eighty male patients, aged 20-79 years, scheduled for elective fusion spine surgery at least two levels were randomly assigned to receive either intravenous lidocaine (1.5 mg/kg followed by 2 mg/kg/h) (Group L) or a parallel volume of normal saline (Group C). The primary outcome was incidence of moderate to severe CRBD in a postanesthetic care unit (PACU) between the two groups. Secondary outcomes included postoperative pain, 24-hour post operative opioid requirement, mild and moderate to severe CRBD at 1, 2, 6 and 24 h postoperatively, patient satisfaction on Global Perceived Effect Scale (GPES), and the adverse effects of lidocaine and surgical complications., Results: Group L showed a significantly lower incidence of moderate-to-severe CRBD compared to Group C in the PACU (P = 0.002) and at 1 h postoperatively (P = 0.039). Additionally, Group L experienced a significantly lower average pain scores compared to Group C at all time points (P < 0.001, P < 0.001, P = 0.001, P < 0.001 and P < 0.001 at 0, 1, 2, 6 and 24 h, respectively) and demonstrated a significantly reduced postoperative morphine requirement across all time intervals (P < 0.05). Group L also reported significantly higher satisfaction on GPES compared to group C (P < 0.001). No adverse outcome was observed in either group., Conclusion: Intravenous lidocaine administration significantly reduced the incidence of moderate-to-severe CRBD at PACU and at 1 h postoperatively. Additionally, its use in complex spine surgery led to reductions in postoperative pain, opioid requirement, and improved patient satisfaction, without any observed side effects., Competing Interests: Declarations Ethics approval and consent to participate The study was approved by the Institutional Review Board of the Royal Thai Army Medical Department (Code: S058h/64), with the approval granted on 24 January 2022. Consent to participate is provided in the attached file. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Background: High spinal block is a serious complication of spinal anesthesia. However, findings regarding its associated risk factors are inconsistent, and no studies have reported a relevant risk prediction score. We aimed to determine the risk prediction score for high spinal block in patients who were induced spinal anesthesia for cesarean delivery., Methods: This retrospective cohort study was conducted at a hospital in Southern Thailand between 2019 and 2020. We recorded demographic characteristics, gestational age (GA), hyperbaric bupivacaine dose, sensory block level, pre- and post-procedure blood pressure, and birth weight. High spinal block was defined as a decrease in pinprick sensation > T4. Risk scores, adjusted odds ratios (OR), and 95% confidence intervals (CI) were determined. Risk scores were derived from the coefficients of the final multivariate logistic regression model., Results: The incidence of high spinal block was 22.4% among the 1003 parturients. Our risk prediction tool for high spinal block had a sensitivity and specificity of 76% and 49%, respectively, and was classified into high (> 21), intermediate (15-21), and low (≤ 14) risk groups. The patient-related predictors were a GA < 35 weeks (OR [95% CI]: 2.31 [1.13, 4.71], score of 8), height < 150 cm (2.21 [1.11, 4.38], score of 8), and post-pregnancy body mass index > 27.5 kg/m 2 (2.68 [1.33, 5.41], score of 10). The anesthesia-related predictors were a hyperbaric bupivacaine dose > 11 mg (2.56 [1.34, 4.87], score of 9) and induction by a first-year resident (1.48 [1.05, 2.09], score of 4). The surgery-related predictors were previous cesarean delivery in labor (1.83 [1.2, 2.78], score of 6) and elective cesarean delivery (2.53 [1.57, 4.07], score of 9) compared to indication by cephalopelvic disproportion. The incidence of intraoperative hypotension was significantly higher in the high-block group than in the control group (46% vs. 25%, p < 0.001)., Conclusion: The combination of patient- and anesthesia-related predictors played an important role in the intermediate- and high-risk groups for high sensory spinal block. Addressing the modifiable risk factors-a GA < 35 weeks, an optimal dose of bupivacaine, and the experience level of the spinal block performer-could minimize the risk of high spinal block during cesarean delivery., Competing Interests: Declarations Ethics approval and consent to participate The study was approved by the Human Research Ethics Committee of the Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand, Chairperson Assoc. Prof. Boonsin Tangtrakulwanich, REC 64–080-8–4 on April 23, 2021. The requirement for informed consent to participate was waived. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Background: Elderly hip fracture patients experience severe pain. Surgical stress and pain during position changes for spinal anesthesia puncture can adversely affect hemodynamics. The objective of this study was to compare the perioperative analgesic efficacy of anterior iliopsoas muscle space block with supra-inguinal fascia iliaca compartment block (S-FICB) in elderly patients undergoing hip surgery., Method: In this randomized control trial, 66 patients were randomly assigned to either the iliopsoas space or the S-FICB group. Each patient received 30 mL of ropivacaine 0.375%. Perioperative pain scores were assessed and compared in both groups. The primary outcome was pain scores during changes in position for neuraxial anesthesia. Secondary outcomes included postoperative pain intensity, inflammatory markers for 12 to 24 hours, and perioperative adverse reactions., Results: The iliopsoas space group demonstrated a faster median block onset of 7 [6-8] minutes compared to S-FICB 14.50 [13-16] minutes (P < .001). Neuraxial anesthesia position changes resulted in lower pain scores for iliopsoas 2 [1-2] versus S-FICB 3 [3-4] (P < .001). Resting pain scores were similar at 12 hours post-surgery, but during exercise, the iliopsoas group had significantly lower scores [1-2] compared to S-FICB 4 [2-4] (P < .001). After 24 hours, C-RP levels were lower in the iliopsoas group (14.86 ± 1.23 mg/L) than S-FICB (17.90 ± 1.25 mg/L) (P < .001). The 2 groups differed from one another (P < .001). These findings suggest that iliopsoas space block may offer faster, superior dynamic pain control, and potentially reduced inflammation compared to FICB block for postoperative pain management., Conclusion: In elderly hip fracture patients, the anterior iliopsoas space block works slightly better than S-FICB at providing effective perioperative analgesia., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Postoperative sore throat (POST) is a common complaint after general anaesthesia. The prevalence of POST caused by a neural integrity monitor electromyography endotracheal tube (NIM-EMG-ETT) is high. This study aimed to determine whether ultrasound-guided internal branch of superior laryngeal nerve block (iSLNB) could alleviate POST associated with a NIM-EMG-ETT., Methods: This randomized controlled trial plans to enroll 182 patients scheduled to undergo general anaesthesia with a NIM-EMG-ETT. Patients will be randomly allocated into the iSLNB group or the control group according to randomized numbers generated by Excel. After induction, patients in the iSLNB group will undergo ultrasound-guided iSLNB with ropivacaine, and patients in the control group will undergo the same procedure with normal saline. The prevalence, severity, visual analogue scale score of POST, and postoperative acoustic analysis will be recorded., Discussion: To the best of our knowledge, this is the first study to evaluate the effect of ultrasound-guided iSLNB with ropivacaine on the mitigation of POST induced by NIM-EMG-ETT. Our study will provide clinical answers to alleviate POST induced by NIM-EMG-ETT. The results of this study may provide a safe method to prevent POST caused by NIM-EMG-ETT., Trial Registration: Chinese Clinical Trial Registry, ChiCTR2300076393. Registered on October 24, 2023, http://www.chictr.org.cn/index.aspx ., (© 2024. The Author(s).)

Background: Labor analgesia can be achieved by different approaches. The efficacy and safety of combined dural puncture epidural (DPE) with program intermittent epidural bolus (PIEB) are not well characterized. This study aimed to compare the efficacy and safety of DPE combined with PIEB vs epidural (EP) combined with PIEB for labor analgesia., Methods: We performed a prospective, randomized, double-blind, parallel-group, controlled clinical trial. Eligible pregnant nulliparous women received either DPE combined with PIEB (group D) or epidural combined with PIEB (group E) for labor analgesia. Analgesia was initiated with 0.1% ropivacaine + 0.3 µg/mL sufentanil and maintained with PIEB at 12 mL/h. Primary outcome was the proportion of women with adequate analgesia within 10 minutes after the initiation of analgesics. Secondary outcomes (time to achieve analgesia, time to first request for additional analgesic, proportion of women required additional analgesic or epidural catheter adjustment and resetting, total labor duration, total analgesic consumption, level of anesthesia, and motor block), side effects, and patient satisfaction were also documented., Results: Out of 174 enrolled women, 160 were included in the analysis. Baseline characteristics were comparable. The proportion of women who achieved adequate analgesia in group D was significantly greater than that in group E (38.8% vs 20.0%, P < .05). Compared with group E, group D also showed advantages in faster adequate analgesic achievement, more likely to reach adequate analgesia, a longer time to maintain analgesia, lesser requirements for additional analgesic, and better sensory blocks. There were no significant inter-group differences in other outcome measures., Conclusions: Compared with epidural and PIEB mode, DPE and PIEB mode achieved better analgesia without increasing maternal or neonatal side-effects during labor., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: Typically, labor analgesia is initiated with a manual loading dose. The programmed intermittent epidural bolus (PIEB) effectively maintains labor analgesia. However, no PIEB method has been studied for the initial loading dose. This study aimed to compare the effectiveness of loading doses administered via a PIEB versus a manual bolus., Patients and Methods: In total, 164 full-term singleton parturients were randomly assigned to receive a 12 mL loading dose (0.1% ropivacaine and 0.3 μg·mL -1 sufentanil) via manual or pump-driven injection. A standardized maintenance protocol was employed. The primary outcome was the percentage of parturients with adequate analgesia 20 min after the initial epidural injection. Adequate analgesia was defined as a numeric rating score (NRS) of ≤3 during two consecutive uterine contractions, without an additional analgesia request. Kaplan-Meier survival curves were constructed for the time interval needed to achieve adequate analgesia. A non-inferiority analysis was conducted by comparing the 90% confidence interval of the pain score difference with the non-inferiority margin., Results: The percentage of parturients achieving adequate analgesia was comparable (75.61% manual injection vs 76.83% pump injection, P =0.05 for non-inferiority). The median NRS was similar, except at 2 min (7 [5-8] manual injection vs 8 [6-9] pump injection, P =0.04). Median time to adequate analgesia, median ropivacaine consumption, median duration of epidural analgesia, incidence of requests for patient-controlled epidural analgesia (PCEA), median number of PCEA boluses, percentage of bilateral S 2 blocks at 20 min, incidence of breakthrough pain, percentage of highest block level ≥T6 at 20 min, adverse effects, and obstetric and neonatal outcomes were similar between the groups., Conclusion: Within 20 min of administering a loading dose through a PIEB pump, non-inferior analgesia comparable to that achieved with manual injection was observed. This hands-free approach could help mitigate the impact of individual operational differences on analgesic efficacy., Registration: This trial was registered at chictr.org.cn (ChiCTR2300074063)., Competing Interests: The authors report no conflicts of interest in this work., (© 2024 Lu et al.)

Introduction: This study aims to determine whether paravertebral block (PVB) provides better postoperative analgesia, lower incidence of complications and faster recovery compared with local anaesthetic wound infiltration for school-aged children undergoing cardiac surgery with cardiopulmonary bypass via thoracotomy., Method and Analysis: This is a single-centre, randomised controlled trial. We will enrol 100 children aged 6-14 years with atrial or ventricular septal defects scheduled for thoracotomy cardiac surgery with cardiopulmonary bypass. The patients will be randomly assigned to the PVB group and the control group in a ratio of 1:1. After the surgery, we will conduct unilateral PVB with ropivacaine for patients in the PVB group, and local anaesthetic wound infiltration for patients in the control group. We will use the double-dummy design to ensure blinding. The patients will not be administered analgesics after returning to the PICU(paediatric intensive care unit). Their bedside nurse will monitor their pain condition. When the Faces Pain Scale-Revised (FPS-R) Pain Score is ≥4, sufentanil infusion will be started. The primary outcome will be total opioid consumption within 24 hours after surgery. Secondary outcomes will be (1) FPS-R Scores at 6 hours, 12 hours, 18 hours and 24 hours after surgery; (2) The rate of opioid treatment for remedial analgesia; (3) The first time of FPS-R Score is ≥4 postoperatively. Exploratory outcomes will be: (1) Length of postoperative mechanical ventilation, ICU stay and hospital stay; (2) The rate of postoperative nausea and vomiting and respiratory depression 24 hours after surgery., Ethics and Dissemination: This study was approved by the Ethics Committee of the Chinese Academy of Medical Sciences, Fuwai Hospital (No 2023-2135) and PUMC. Written informed consent will be obtained from each patient or their legal representatives before enrolment. The results of this trial will be published in an international peer-reviewed scientific journal., Trial Registration Number: Chinese Clinical Trial Registry (ChiCTR2400081773) Clinical Trial（NCT06312904）., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

BACKGROUND Intravenous ciprofol is a short-acting sedative with minimal respiratory and circulatory suppression and limited analgesia. Intravenous lidocaine provides analgesia during surgical procedures. This study included 70 patients who underwent gastroscopy with analgesia and aimed to evaluate the effects of intravenous lidocaine on the dose of ciprofol required to produce 50% of the maximal effect (ED50). MATERIAL AND METHODS Seventy patients scheduled for elective painless gastroscopy were randomly assigned into 2 groups: group L (n=35, received ciprofol and 1.5 mg/kg lidocaine) and group S (n=35, received ciprofol and normal saline). The primary outcomes measured were the ED50 and the 95% effective dose (ED95) of ciprofol, determined using the modified up-down sequential method and Probit analysis. Secondary outcomes included induction, operation, and recovery times; monitoring of vital signs such as mean arterial pressure, heart rate, and oxygen saturation; and evaluation of postoperative adverse reactions, including sore throat, nausea, vomiting, abdominal pain, and satisfaction scores from endoscopists and anesthesiologists. RESULTS The ED50 of ciprofol in group L was 0.315 mg/kg (95% CI, 0.291-0.342 mg/kg), which was significantly lower than that in group S, 0.42 mg/kg (95% CI, 0.371-0.491 mg/kg). Additionally, group L exhibited shorter induction and recovery times, a lower incidence of postoperative sore throat, and a temporary drop in blood pressure following induction. CONCLUSIONS Intravenous lidocaine during painless gastroscopy reduces the required ciprofol dose, shortens induction and recovery times, and lowers the incidence of postoperative complications, such as sore throat. These findings support its effective role in improving sedation quality and patient outcomes during gastroscopy.

Background: The drug volume to be used in caudal in pediatric patients has remained an unmet issue since long. We determined the minimum drug volume required to reach T10 level in pediatric patients using ultrasonography and compared it with the already established volume by Armitage formula., Aim: To determine the minimum effective caudal local anesthetic dose using ultrasound guidance., Methods: Study was performed at two centres and at each centre, 50 pediatric patients (Total 100 patients), aged 1 to 3 years, undergoing below umbilical surgeries were included and randomised into two groups of 25 each (Total 50) to receive ultrasound guided drug volume vs. Armitage formula based volume. The volume required to reach T10 level was assessed with ultrasound in one group. Also, maximum height achieved, cutaneous level achieved after 15 min, FLACC scores 30 min post extubation and parental satisfaction scores were noted., Results: The mean drug volume required to reach T10 level in Group U was 0.755 ± 0.053 ml/kg with a P value < 0.001. (Compared to the drug volume of 1 ml/kg using one sample t test). The highest level achieved in both groups were calculated as the mode value of T8 and T7 in Group U and Group A respectively. The highest cutaneous level achieved after 15 min was also calculated as the mode value of T4 in both groups. FLACC scores at 30 min were also comparable. Satisfaction scores were comparable in both groups., Conclusion: A volume of 0.7 ml/kg of local anaesthetic in pediatric caudal block is sufficient to achieve a target of T10 level for infraumblical surgeries., (© 2024. The Author(s).)

Background: Liposomal bupivacaine (LB) is a long-lasting local anesthetic agent that was developed for use in the surgical setting to help manage postoperative pain. The objective of this study was to evaluate the effect of LB on postoperative pain, function, and overall hospital course in patients with intracapsular hip fractures who were treated with hip hemiarthroplasty., Methods: This was a single-center, randomized prospective double-blinded study of 50 patients with an isolated intracapsular femoral neck fracture who were treated with hip hemiarthroplasty from 2018 to 2022. The study group consisted of 25 patients who were treated with intraoperative LB and bupivacaine hydrochloride injections, while the control group consisted of 25 patients who were treated with intraoperative bupivacaine hydrochloride injections only. Primary outcomes were a visual analog scale (VAS) score for pain, total morphine milligram equivalents (MME), delirium, and time to ambulation with physical therapy., Results: No significant differences between the study and control groups were found in any of the outcomes measured. Most notably, there were no differences in the average postoperative pain score (VAS, 2.26 versus 2.7; p = 0.34), total MME used postoperatively (11.73 versus 9.98 MME; p = 0.71), and postoperative day of discharge (4.00 versus 3.88 days; p = 0.82)., Conclusions: The results of our study suggest that use of LB is not associated with substantially improved postoperative pain or function or with a shorter hospital course following hip hemiarthroplasty for a femoral neck fracture. Given the higher cost of LB compared with standard postoperative pain modalities, it is worth questioning its use in the setting of geriatric hip fractures., Level of Evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/I173 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Botulinum injection is a well-known non-surgical intervention utilized in the management of myofascial pain syndrome (MPS). However, sparse evidence exists regarding the utility of ultrasound guidance of injectate or lidocaine as a predictive marker of patient response to botulinum toxin A (BTX-A). A 39-year-old male active duty service member demonstrated typical signs and symptoms of MPS. He reported a 10-year history of neck and back spasms that were triggered by exertion but also could occur spontaneously. Based on the characteristic regional motor-sensory defects, treatment options were discussed. With shared decision-making, the patient opted to try ultrasound-guided injection of lidocaine followed by xenomin brand BotoxA. Immediately following lidocaine injection, the patient reported complete relief of symptoms. Both injections were uncomplicated, and the patient reported great reduction in symptoms during the subsequent visit 2 months later. Relief of pain following ultrasound-guided injection of lidocaine may serve as an indicator of successful patient response to BTX-A in patients with MPS., (© The Association of Military Surgeons of the United States 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site–for further information please contact journals.permissions@oup.com.)

Background: Surgery induces a temporal change in the immune system, which might be modified by regional anesthesia. Applying a bilateral preoperative anterior quadratus lumborum block has proven to be a safe and effective technique in pain management after abdominal and retroperitoneal surgery, but the effect on the immune response is not thoroughly investigated., Methods: This study is a substudy of a randomized, controlled, double-blinded trial of patients undergoing laparoscopic hemicolectomy due to colon cancer. Twenty-two patients were randomized to undergo either a bilateral anterior quadratus lumborum nerve block with a total of 60 mL ropivacaine 0.375% or placebo with corresponding isotonic saline injections. The main objective of this exploratory substudy was to investigate the systemic immune response in the first postoperative day by examining changes in blood transcript levels (n=750) and stimulated secretion of cytokines (n=17) on ex vivo activation with microbial ligands and anti-CD3/CD28., Results: Using unsupervised data analysis tools, we observed no effect of the bilateral anterior quadratus lumborum nerve block on gene expression in immune cells (permutational multivariate analysis of variance using distance matrices: F=0.52, p=0.96), abundances of major immune cell populations (Wilcoxon rank-sum test: p>0.05), and stimulated cytokine secretion (Wilcoxon rank-sum test: p>0.05)., Conclusions: Our study provides evidence that administration of bilateral anterior quadratus lumborum nerve block as a part of a multimodal analgesic regimen in an enhanced recovery after surgery for laparoscopic hemicolectomy in this cohort does not alter the systemic immune response. Trial registration number NCT03570541., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To investigate the efficacy of esketamine as an adjuvant to epidural ropivacaine for labour analgesia by determining its effect on the median effective concentration (EC 50 ) in a 20 ml volume of ropivacaine., Design: A prospective, double-blind dose-response study., Setting: This study was conducted in Women's Hospital, School of Medicine, Zhejiang University, China., Participants: One hundred and fifty parturients who requested epidural analgesia were recruited in this study to randomly receive epidural ropivacaine alone or with esketamine of 0.2 mg ml -1 , 0.3 mg ml -1 , 0.4 mg ml -1 or 0.5 mg ml -1 , respectively., Primary and Secondary Outcome Measures: The primary outcome, EC 50 of ropivacaine, was determined using an up-down sequential allocation technique. The secondary outcomes were analgesia characteristics, Ramsay Sedation Scale score, labour duration, caesarean section rate and adverse effects., Results: The EC 50 of ropivacaine with the addition of esketamine at concentrations of 0.3 mg ml -1 , 0.4 mg ml -1 and 0.5 mg ml -1 resulted in significant reductions in the EC 50 of ropivacaine to 0.050%, 0.044% and 0.043%, respectively, from baseline (esketamine 0 mg ml -1 ) (p<0.0001). However, reductions of the EC 50 of ropivacaine were similar among the groups with esketamine of 0.3 mg ml -1 , 0.4 mg ml -1 and 0.5 mg ml -1 (p>0.05). The Ramsay Sedation Scale score was higher and more dizziness was observed in the Group of esketamine 0.5 mg ml -1 compared with all other groups (p<0.0001). During the peripartum period, no differences in sensory blockade level, Bromage score, labour duration and percentage of caesarean delivery were found among the groups., Conclusions: Under the conditions of this study, the addition of epidural esketamine of 0.3 mg⋅mL -1 , 0.4 mg⋅mL -1 and 0.5 mg⋅mL -1 offered a similar ropivacaine dose-sparing effect; 0.5 mg⋅mL -1 of esketamine produced more adverse effects., Trial Registration Number: ChiCTR2100054348., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To compare postoperative pain scores at rest and on movement in patients undergoing open inguinal hernia repair between those receiving illioinguinal/illiohypogastric nerve block with ropivacaine or wound infiltration with ropivacaine., Methods: The randomised clinical trial was conducted at the Department of Anaesthesiology, Aga Khan University Hospital a tertiary care centre from March to August 2019 and comprised patients of either gender scheduled for elective unilateral open inguinal hernia repair under general anaesthesia. They were randomised into illioinguinal/illiohypogastric nerve block group A, and wound infiltration group B. In group A, 20 ml of 0.25% ropivacaine was infiltrated in the vicinity of the nerves under ultrasound guidance, while group B received wound infiltration with ropivacaine 10ml 0.25% at the end of surgery. Postoperative static and dynamic pain was assessed at 0, 2, 6, 12 and 24 hours using visual analogue scale. Total usage of opioids in 24 hours postoperatively in both groups, patient satisfaction and complications were recorded. Data was analysed using SPSS 19., Results: Of the 60 patients, 30(50%) were in each of the 2 groups. There were 29(96.7%) males and 1(3.3%) female in group A with mean age 45.63±17.43 years, and 28(93.3%) males and 2(6.7%) females in group B with mean age 49.33±15.39. The mean pain score at rest was not significantly different between the groups (p>0.05). On movement, the mean pain score between the groups was different only at 6 hours (p=0.02). There were no significant intergroup difference in total usage of opioids in 24 hours postoperatively and patient satisfaction (p>0.05)., Conclusions: Illioinguinal/illiohypogastric nerve block and wound infiltration with ropivacaine were found to be equally effective methods in controlling postoperative pain., Clinicaltrials.gov Id: NCT04462510.

The sensation of pain can elevate anxiety levels, establishing a cyclical pattern that may result in the avoidance or premature termination of dental procedures. Previous endeavors employing various methods and products have produced varied outcomes. Jet injection systems, employing high pressure and velocity to deliver anesthesia without needles, offer a non-invasive option for local anesthesia administration. To assess and measure pain perception levels in a pediatric population during the restoration of young permanent teeth, comparing a needle-free injection system with the traditional dental needle method. Sixty participants with young permanent first molars requiring indirect pulp capping were enrolled, all under the care of a single operator. A simple randomization method was employed, utilizing sequentially numbered, opaque, sealed envelopes to allocate participants into two intervention groups: Group 1 and Group 2. Group 1 received traditional needle syringe anesthesia, while Group 2 received the needle-less injection system, Injex (INJEX Pharma AG, Germany). Following topical anesthesia application, local anesthesia was administered, and indirect pulp capping was performed. The Face, Legs, Activity, Cry, Consolability Scale (FLACC), Wong-Baker Scale, Time of local anesthesia (LA) Administration, Frankl Behavior Rating Scale (FBRS), and Pulse rate were evaluated and recorded at various intervals. The needle-less injection system required approximately 26.2 seconds for anesthesia administration, significantly less time than the traditional syringe ( p < 0.001). FBRS score analysis revealed no significant differences between groups at all intervals. FLACC score analysis during anesthesia administration indicated lower scores in the needle-free injection group ( p < 0.001). Evaluation of Wong Baker Scale (WBS) scores showed higher values in the traditional syringe needle group ( p < 0.05). Using the Injex system presents a promising alternative for dental anesthesia administration, enhancing patient comfort and alleviating fear associated with traditional injections., Competing Interests: The authors declare no conflict of interest., (©2024 The Author(s). Published by MRE Press.)

This observational study analyzed data from 502 participants undergoing cesarean section (CS) procedures at an obstetrics and gynecology department, aiming to explore anesthesia practices, neonatal outcomes, and demographic characteristics within the cohort. Participants, aged 17 to 59 years with a mean age of 32.23 years, were enrolled based on the clinical necessity for cesarean delivery during the study period. Informed consent was obtained from each participant or their guardians before data collection, which included detailed demographic information, medical histories, specifics of the cesarean section procedure, and APGAR scores of neonates immediately postbirth (at 0 and 5 minutes). Primary outcomes focused on APGAR scores, critical indicators of neonatal health, while secondary outcomes included the distribution of patient ages, reasons for cesarean sections, and the administration of Bupivacaine during anesthesia. Data were rigorously analyzed using descriptive and inferential statistics to summarize participant demographics, anesthesia practices, and neonatal outcomes. Statistical methods included measures of central tendency and dispersion, correlation analyzes to explore associations between variables, and regression models to identify predictors of neonatal APGAR scores. The study identified a range of indications for cesarean sections, with common reasons including fetal distress and maternal health complications. Findings indicated an average APGAR score of 7.02 at 0 minutes and 7.84 at 5 minutes, reflecting generally favorable immediate neonatal outcomes. Anesthesia protocols predominantly involved Bupivacaine, with doses ranging from 1.8 to 2.2 mL, administered based on clinical requirements. In conclusion, this study underscores the importance of comprehensive data collection and rigorous statistical analysis in evaluating cesarean section procedures. Future research could further explore long-term neonatal outcomes and refine anesthesia protocols to optimize maternal and neonatal health during cesarean deliveries., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: A retrospective data analysis was performed on 17 eyes from 13 horses which underwent a sub-Tenon's injection to facilitate phacoemulsification or pars plana vitrectomy under general anesthesia between 2018 and 2022. All procedures were performed by the same veterinary ophthalmologist. Seven eyes received a sub-Tenon's dose of 7 ml lidocaine (XylocainÒ, 2 % lidocaine hydrochloride, Germany, Aspen Germany GmbH), and 10 eyes received 7 ml mepivacaine (MepinaestÒ purum 2 %, mepivacaine hydrochloride, Switzerland, Gebro Pharma GmbH). Statistical analysis compared onset and duration of globe centralization and pupil mydriasis between the two groups. Intraoperative and postoperative complications were also assessed. Mepivacaine had a significantly later onset of action regarding globe centration and mydriasis (8,9 minutes vs. 6 minutes), but also a significantly longer duration of globe centration than lidocaine (31,5 minutes vs. 15,6 minutes). There were no statistically relevant differences between solutions regarding duration of pupil dilation (40,4 minutes for 2 % lidocaine vs. 69,2 minutes for 2 % mepivacaine). Chemosis occurred in all 17 eyes. Surgical complications included corneal epithelial defects (5), retinal detachment (5), lens opacification (5), temporary blindness during recovery (3) and glaucoma (2). Sub-Tenon's anesthesia is a feasible alternative to systemic neuromuscular blockade and retrobulbar block anesthesia for surgical procedures on the equine globe. A controlled prospective in vivo study is needed to further evaluate effects and risks.

This study aimed to compare the analgesic and cardiopulmonary effects of levobupivacaine with or without dexmedetomidine, in cats undergoing ovariohysterectomy. In this prospective, randomized, and blinded clinical trial, 24 healthy cats were recruited. Animals received either saline (S group; 2 mL NaCl), levobupivacaine alone (Lev; 0.35 mg/kg), or levobupivacaine with dexmedetomidine (LevDex group; 0.004 mg/kg), which was infiltrated intraoperatively into the subcutaneous tissue at various incision sites, including the right and left ovarian pedicles and the caudal aspect of the uterine body. Intraoperative analgesia was evaluated using a cumulative pain scale, while postoperative analgesia was assessed at various time points: before surgery (T b ), and at 0 (T 0 ), 1 (T 1h ), 2 (T 2h ), 4 (T 4h ), 8 (T 8h ), 12 (T 12h ), and 24 (T 24h ) hours after the procedure, using the UNESP-Botucatu multidimensional composite pain scale (MCPS). Significant decreases in heart rate, respiratory rate, and mean arterial pressure were observed in LevDex group as compared to S and Lev groups (p < 0.05). The S group required significantly more rescue morphine doses than the LevDex group (p = 0.029), but the difference was not significant when compared to the Lev group (p = 0.123). At T 1h and T 2h , the S group had significantly higher MCPS scores than both the Lev and LevDex groups (p = 0.029). However, at T 8h , no significant difference was found between the S and LevDex groups (p = 0.741). While adding dexmedetomidine to levobupivacaine may slightly prolong postoperative analgesia, this combination does not provide significant additional benefit over levobupivacaine alone in terms of response to surgical stimulation., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objective: To determine if preoperative intraperitoneal bupivacaine can minimize intra- and postoperative nociception/pain in cats undergoing ovariohysterectomy., Study Design: Prospective, randomized, investigator-blinded, placebo-controlled clinical trial., Animals: Forty-seven, intact female cats., Methods: Cats were anesthetized using a standard protocol and randomized to receive ultrasound-guided intraperitoneal 0.9 % saline (US-S) or 0.25 % bupivacaine (US-IPLA) before ovariohysterectomy. On recovery, US-S cats received 2 mg/kg robenacoxib subcutaneously and US-IPLA cats received equivalent volume of 0.9 % saline subcutaneously. Intraoperative outcome variables included heart rate (HR), respiratory rate (fR), systolic arterial pressure (SAP), and vaporizer setting associated with relevant surgical events characterized by manipulation of each ovarian pedicle (OP1, OP2) and the uterine body (UB). The postoperative outcome variable was need for rescue analgesia, determined using the Glasgow Composite Measure Pain Scale during 6 h after tracheal extubation. Intraoperative data were analyzed using two-way ANOVA and Šidák's multiple comparisons test. The probability of postoperative rescue analgesia was analyzed using the Gehan-Breslow-Wilcoxon test. Significance was p < 0.05., Results: Compared to baseline, all surgical events caused significant increases in HR and SAP in both groups, fR increased in US-IPLA but not in US-S, vaporizer settings remained unchanged during OP1, OP2 and UB in group US-IPLA, and were significantly higher only during OP1 in group US-S. There were no significant between-group differences in intraoperative variables and postoperative need for rescue analgesia., Conclusions and Clinical Relevance: Preoperative intraperitoneal bupivacaine had minimal effects on intraoperative indicators of nociception. The need for rescue analgesia was not significantly different between groups., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: To compare the perioperative analgesic effect of lateral versus latero-ventral quadratus lumborum block (QLB) in dogs undergoing laparoscopic ovariectomy., Study Design: Randomized, blinded clinical study., Animals: A total of 15 client-owned female dogs undergoing laparoscopic ovariectomy., Methods: Animals were randomly assigned to receive a bilateral QLB, performed with 0.3 mL kg -1 ropivacaine 0.5%, either with lateral (group L QLB , n = 7) or latero-ventral approach (group LV QLB , n = 7). Dogs were premedicated intramuscularly with methadone 0.2 mg kg -1 and dexmedetomidine 3 μg kg -1 . General anaesthesia was induced intravenously (IV) with propofol and maintained with isoflurane. Cardiovascular and respiratory variables were continuously monitored and recorded every 5 minutes during surgery. Fentanyl 3 μg kg -1 was administered IV if there was a 20% increase in heart rate and/or mean arterial pressure from previous values recorded 5 minutes before. Meloxicam 0.2 mg kg -1 was administered IV to all dogs during recovery. The short-form of the Glasgow Composite Pain Scale was used hourly for 8 hours post-QLB. Methadone 0.2 mg kg -1 was administered IV when pain score was ≥ 6/24. A chi-square test compared the number of dogs requiring intraoperative rescue fentanyl. A Friedman test with a Dunn's post hoc was used to evaluate the trend in postoperative pain scores within each group, and a Mann-Whitney U test compared scores between the groups at each time point; p < 0.05., Results: Significantly fewer dogs required intraoperative rescue fentanyl in group L QLB than in group LV QLB . No dog required postoperative rescue methadone, and there were no significant differences in pain scores., Conclusions and Clinical Relevance: Bilateral QLB performed with lateral approach reduced the number of dogs requiring intraoperative rescue analgesia in comparison with the latero-ventral approach. No differences were detected postoperatively, possibly owing to the confounding effects of methadone, dexmedetomidine and meloxicam., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Ultrasound-guided nerve blocks serve as a valuable component of multimodal pain management for acutely injured patients in the emergency department and offer a potentially more efficient alternative to time-consuming procedural sedation., Competing Interests: Disclosure Dr A. Nagdev is senior director of education at Exo, Inc., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Anterior Iliac crest bone harvesting (AICBH) is a common surgical procedure with applications in various medical specialties, but it is often accompanied by significant postoperative pain. Effective pain management is therefore essential for optimising patient outcomes. This systematic literature review aimed to evaluate the effectiveness of local donor site pain management interventions in AICBH procedures. It followed the Cochrane Handbook for Systematic Reviews of Interventions version 6.4 guidelines and adhered to the PRISMA 2020 statement for comprehensive and high-quality reporting. A comprehensive search was conducted across PubMed, Cochrane, and Embase to identify relevant studies. Inclusion criteria encompassed randomised controlled trials assessing pain management strategies in AICBH patients. The methodological quality of the included studies was assessed using the Jadad scale. Data extraction focused on medication types, administration modes, pain scores, and use of narcotics. Fourteen eligible studies were included. Methodological quality varied, with most studies demonstrating a low risk of bias. Medication types included amide and opioid groups, administered via single-shot injections or infusion systems. Results indicated that indwelling iliac crest catheters with bupivacaine showed significant postoperative reductions in pain scores and narcotics use compared with other techniques. The findings suggest that use of an indwelling catheter with bupivacaine is an effective pain management strategy for AICBH patients. However, heterogeneity among the studies and a lack of standardised methodologies pose limitations. Further homogeneous and standardised studies are therefore needed to strengthen the evidence base and inform clinical practice., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: Local anesthetic infiltration at the surgical site has been studied in various surgical disciplines; however, its impact on deep inferior epigastric artery perforator (DIEP) flap breast reconstruction has not been previously assessed. This study aimed to evaluate the effects of multiple intramuscular ropivacaine injections on donor site pain during DIEP flap breast reconstruction., Methods: The study included 65 patients who received local ropivacaine injections during DIEP reconstructions between March 2022 and February 2023, compared to 55 patients who underwent surgeries without ropivacaine from October 2018 to July 2020. A total of 20 cc of 0.75% ropivacaine solution was evenly administered at 20 sites along the abdominal wall muscles. The effect of intramuscular ropivacaine injection on postoperative visual analog scale (VAS) was evaluated using linear mixed-effect model. Opioid consumption and hospital days were also compared., Results: The daily median VAS score was lower in the ropivacaine group (all p-values < 0.001). When analyzed using a linear mixed-effects model, those who received ropivacaine had significantly lower VAS scores over the first 5 days postoperatively (p-value < 0.001). The rate of VAS score decline was also faster in the ropivacaine group over the first 24 h postoperative (p-value = 0.045). Although opioid consumption was comparable between the groups, those receiving ropivacaine had significantly shorter hospital stay (p-value = 0.001) and no complications related to the injections were observed., Conclusion: Multiple intramuscular injections of ropivacaine to the donor site may reduce postoperative pain and shorten hospital stays, without increasing opioid consumption., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Dexmedetomidine (Dex) as a local anesthesia adjuvant for nerve block procedures can improve the quality of patient recovery. However, the impact of using Dex as a local anesthetic adjuvant for serratus anterior plane block (SAPB) procedures on recovery quality for children undergoing ear reconstruction remains unclear., Methods: Eighty-four patients who underwent ear reconstruction with autogenous costal cartilage (ACC) were randomized into two groups (n = 42/group) in which SAPB was performed with ropivacaine alone (R group) and with Dex and ropivacaine (DR group). Primary outcomes were patient 15-item quality of recovery (QoR-15) scale scores on days 1 and 2 post-surgery. Secondary outcomes included postoperative rest and coughing numerical rating scale (NRS) chest pain scores, duration of analgesia, oral rescue analgesic usage, and opioid-related side effects., Results: Forty patients per group completed the study. QoR-15 scores on days 1 and 2 post-surgery in the DR group were significantly increased relative to the R group (126.35 ± 9.81 vs. 115.53 ± 8.58 and 131.78 ± 8.67 vs. 122.80 ± 8.59, all P < 0.001). Rest and coughing NRS chest pain scores at 2, 4, 8, 12, and 24 h postoperatively in the DR group were all significantly lower relative to the R group (all P < 0.05). The DR group also exhibited significantly longer analgesic duration (P < 0.001) and significantly reduced incidences of oral rescue analgesic usage and opioid-related side effect (all P < 0.05)., Conclusion: Combining Dex and ropivacaine for SAPB in children undergoing ear reconstruction with ACC can significantly improve the quality of recovery, quality of analgesia, and analgesic duration., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objective: Phase 1: to determine the feasibility of desensitizing ventral branches of spinal nerves within the rectus sheath using an ultrasound-guided rectus sheath block (USRSB). Phase 2: to determine the effect of preoperative USRSB on intraoperative responses to surgical stimulation and postoperative pain., Study Design: Cadaveric study and prospective, randomized, blinded, parallel-arm clinical trial., Animals: A group of five cat cadavers and 37 shelter-owned cats undergoing ovariohysterectomy., Methods: Phase 1: anatomical dissection was performed on one uninjected cadaver. Abdominal walls were dissected in four cadavers (eight hemiabdomens) following bilateral USRSB using 1:1 new methylene blue and 0.5% bupivacaine (0.8 mL kg -1 total). Phase 2: preoperative bilateral USRSB was performed with 0.8 mL kg -1 of 0.25% bupivacaine (RSB) or equivalent volume of 0.9% saline (CONTROL). Intraoperative systolic arterial blood pressure (SAP), heart rate (HR), respiratory rate (f R ) and vaporizer setting (vap%) were recorded before skin incision, during celiotomy and abdominal wall closure. In recovery, cats were administered robenacoxib (2 mg kg -1 ; CONTROL) or 0.9% saline (0.1 mL kg -1 ; RSB) subcutaneously. Postoperative pain was evaluated for 6 hours using the Glasgow Composite Measure Pain Scale., Results: Phase 1: spinal nerves T9-L3 were identified within the rectus sheath, and stained in 0%, 40%, 63%, 75%, 100%, 88%, 50% and 13% of hemiabdomens, respectively. Phase 2: 37 cats were included (RSB, n = 17; CONTROL, n = 20). Intraoperatively, SAP, HR and f R were not significantly different between groups. Vap% was significantly lower in RSB during celiotomy (p = 0.036) and closure (p = 0.044). Postoperatively, RSB cats were 5.3 times (95% CI 1.8-8.3) more likely to require rescue analgesia than CONTROL cats., Conclusions and Clinical Relevance: During surgery, USRSB with bupivacaine offered minor benefits and provided markedly less postoperative analgesia than robenacoxib, indicating that relying on USRSB provides insufficient postoperative analgesia for ovariohysterectomy in cats., (Copyright © 2024 Association of Veterinary Anaesthetists and American College of Veterinary Anesthesia and Analgesia. Published by Elsevier Ltd. All rights reserved.)

Objective: Neuropathy of the lateral cutaneous branch of the iliohypogastric nerve (LCBIN) may represent a differential diagnosis for greater trochanteric pain syndrome (GTPS). Ultrasound-guided neural blockade of the LCBIN may lead to diagnosis of this neuropathy. The aim of this study was to evaluate the accuracy of ultrasound-guided nerve block in cadavers and to present a first clinical case series of patients with neuropathy of the LCBIN where the workup for GTPS remained unremarkable. Ultrasound-guided nerve block led to pain relief in these patients, indicating LCBIN neuropathy., Methods: First, ultrasound-guided injections at the LCBIN were performed bilaterally in 24 fresh, non-frozen, non-embalmed body donors. Accuracy and nerve localization were validated by anatomic dissection. Second, a clinical case series of nine patients with suspected GTPS who underwent ultrasound-guided diagnostic LCBIN blockade was retrospectively analyzed., Results: Ultrasound-guided injections at the LCBIN yielded 91.7% accuracy (95% confidence interval: 0.80-0.98). On the right side the nerve was found within a range of 3-14 cm from the anterior superior iliac spine, and within a range of 7-15 cm on the left side. This clinical case series indicates that ultrasound-guided blockade at the LCBIN provides temporary pain relief and indicates the presence of LCBIN neuropathy., Conclusion: Ultrasound has demonstrated high accuracy for localization and injection guidance in the examination of LCBIN. Ultrasound-guided injection of local anesthetics may help to identify LCBIN neuropathy as a differential diagnosis in patients with suspected GTPS., Competing Interests: Conflict of interest The authors declare no competing interests., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Abstract: Chronic pain in inflammatory arthritis (IA) reflects a complex interplay between active disease in a peripheral joint and central pronociceptive mechanisms. Because intra-articular lidocaine may be used to abolish joint-specific peripheral input to the central nervous system, we aimed to validate its use as a clinical tool to identify those patients with IA whose pain likely incorporates centrally mediated mechanisms. We began by investigating whether there was a placebo response of intra-articular injection in patients with IA 1:1 randomised to receive intra-articular lidocaine or control (0.9% saline). After, in a larger patient cohort not randomized to placebo vs lidocaine groups, we tested whether patients with IA could be stratified into 2 cohorts based on their response to intra-articular lidocaine according to markers of centrally mediated pain. To this end, we evaluated postlidocaine pain numerical rating scale (NRS) scores alongside baseline painDETECT, fibromyalgia criteria fulfillment, and quantitative sensory testing outcomes. Numerical rating scale scores were collected at baseline and 3-, 5-, and 10-minutes postinjection. Firstly, the placebo effect of intra-articular injection was low: compared to baseline, the mean pain NRS score 5-minutes postinjection was reduced by 3.5 points in the lidocaine group vs 1.2 points in the control group. Secondly, postlidocaine NRS scores were significantly higher in those with a high (>18) baseline painDETECT score, fibromyalgia, and low-pressure pain threshold at the trapezius ( P = 0.002, P = 0.001, P = 0.005, respectively). Persistent high pain after intra-articular lidocaine injection could be used as an indicator of pronociceptive mechanisms that are centrally mediated, informing centrally targeted analgesic strategies., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Association for the Study of Pain.)

Of the strategies considered to limit the discomfort of corticosteroid injection, one is to inject without lidocaine to reduce the total volume and avoid acidity. In a Bayesian trial, adults receiving corticosteroid injections were randomized to receive 0.5 mL of triamcinolone with or without 0.5 mL of lidocaine. Serial analysis was performed until a 95% probability of presence or absence of a 1.0-point difference in pain intensity on the 0-10 Numerical Rating Scale was reached. Injections with lidocaine were associated with a median of 2.4-point lower pain intensity during injection with a 95% probability of at least a 1-point reduction. The 95% probability was confirmed in 90% of the repeated analysis (36/40). Lidocaine is associated with lower immediate pain intensity during corticosteroid injection for hand and wrist conditions. Level of evidence: I., Competing Interests: Declaration of conflicting interestsThe authors disclosed the following potential conflicts of interests with respect to the research, authorship, and/or publication of this article: DR, or a member of their immediate family, has or may receive payments or benefits, in any one year, from Skeletal Dynamics for an internal joint stabilizer elbow in the amount of between US$10,000 and US$100,000 per year, from Wolter-Klewer between US$100 and US$1000 per year, that he is a Deputy Editor for Clinical Orthopaedics and Related Research and has received or may receive payments or benefits in the amount of US$5000 per year. One of the authors certifies that he (DR) received honoraria from various universities, professional associations and continuing medical education vendors. All other authors report no conflict of interest.

Background: The dural puncture epidural (DPE) technique has been associated with better sacral analgesia compared with a traditional epidural (EPL) technique in laboring parturients. The aim of this study was to investigate whether DPE with a 27-gauge pencil-point needle compared with a traditional EPL technique produces more rapid bilateral sacral blockade in nulliparous parturients., Methods: Patients were randomized to a DPE or EPL technique. Epidural analgesia in both groups was initiated with ropivacaine 0.1% and sufentanil 0.5 μg/mL (15 mL) and maintained via programmed intermittent epidural boluses. Analgesic blockade was tested bilaterally beginning 10 min after initiation, and then at predefined intervals until delivery. The presence of an S2 blockade at 20 min was the primary outcome., Results: Among 108 (54 per group) patients enrolled, bilateral sacral (S2) blockade at 20 min was significantly more common in the DPE than in the EPL group [47 (87%) vs. 23 (43%), absolute risk reduction (ARR) 44%, 95% CI 28 to 60; P < 0.001]. Time to a numeric pain rating scale score (0-10 scale) ≤ 3 (20 [20,30] min in both groups, HR 1.15, 95% CI 0.77 to 1.15; P = 0.50), number of rescue doses [0 (0, 1) vs 0 (0, 1); P 0.08], and presence of bilateral S2 blockade at delivery were not significantly different between groups., Conclusions: The DPE technique with a 27-gauge pencil-point spinal needle more often provides bilateral sacral blockade at 20 min following block initiation compared with the EPL technique. The time to adequate analgesia and need for supplemental analgesia did not appear to differ between techniques., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objective: The administration of local anesthesia in intraperitoneal space as part of the multi-modal analgesic regimen has shown to be effective in reducing postoperative pain. Recent studies demonstrated that intraperitoneal lidocaine may provide analgesic effects. Primary objective was to determine the impact of intraperitoneal lidocaine on postoperative pain scores at rest., Design: We carried out a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)., Methods: Databases of MEDLINE, EMBASE, and CENTRAL were searched from their inception date until May 2023. Randomized clinical trials (RCT) comparing intraperitoneal lidocaine and placebo in adults undergoing surgery were included., Results: Our systematic review included 24 RCTs (n = 1824). The intraperitoneal lidocaine group was significantly associated with lower postoperative pain scores at rest (MD, -0.87, 95% CI, -1.04 to -0.69) and at movement (MD, -0.50, 95% CI, -0.93 to -0.08) among adult patients after surgery. Its administration also significantly decreased morphine consumption (MD, -6.42 mg, 95% CI, -11.56 to -1.27) and lowered the incidence of needing analgesia (OR, 0.22, 95% CI, 0.14 to 0.35). Intraperitoneal lidocaine statistically reduced time to resume regular diet (MD, 0.16 days; 95% CI, -0.31 to -0.01) and lowered postoperative incidence of nausea and vomiting (OR, 0.54, 95% CI, 0.39 to 0.75)., Conclusions: In this review, our findings should be interpreted with caution. Future studies are warranted to determine the optimal dose of administering intraperitoneal lidocaine among adult patients undergoing surgery., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Fentanyl combined with bupivacaine in subarachnoid anesthesia exerts a strong synergistic analgesic effect, extending the duration of analgesia. However, the mechanism of enhanced analgesic effect of fentanyl remains elusive. The present study investigated the potential mechanism of the analgesic effect of fentanyl when combined with bupivacaine. The subarachnoid injection (SI) rat model was employed, and SI of fentanyl or/and bupivacaine was used to investigate their analgesic effect. Dorsal root ganglion (DRG)' RNA sequencing (RNA-Seq) and bioinformatics analysis were performed to evaluate the downstream mechanisms of MicroRNAs (miRNAs). Further validation tests included RT-PCR, Western blot, and immunofluorescence. A single SI of fentanyl or bupivacaine decreased the positive responses to stimulation when used alone or in combination. RNA-seq results revealed that miR-381-3p played a role in the fentanyl-driven promotion of analgesia. Bioinformatics analysis and dual-luciferase reporter identified TRPM7 as a direct downstream target gene of miR-381-3p. In vitro, overexpression of miR-381-3p could further block fentanyl-induced expression of TRPM7, p-ERK1/2, CGRP, and SP. In addition, antagomir-381-3p reversed the inhibitory effect of fentanyl on the expression of TRPM7, p-ERK1/2, CGRP, and SP, in vivo; however, TRPM7 siRNA rescued the effect of antagomir-381-3p. In conclusion, fentanyl inhibits p-ERK by targeting TRPM7 via miR-381-3p, lowering the production of CGRP and SP, and ultimately inducing analgesic effects., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objectives: To compare the out-of-plane (OP) and in-plane (IP) approaches for carpal tunnel syndrome (CTS) in terms of pain during injection and postinjection adverse effects, and to investigate whether these approaches led to any difference in terms of pain/numbness, symptom severity, functionality, and median nerve cross-sectional area and to examine the relationship of these parameters with the pain during injection., Design: Patient/assessor-blinded randomized study., Setting: Hospital outpatient clinic., Participants: Fifty patients with mild-to-moderate CTS., Interventions: The participants were randomized into OP and IP (both n=25) ultrasound-guided injection groups., Main Outcome Measures: Each patient reported the pain felt during the injection at 1 hour thereafter, and also any adverse effects at 4 weeks after injection. Before and 4 weeks after injection, patients used a visual analog scale to indicate pain/numbness; symptom severity and functionality were assessed using the Boston Carpal Tunnel Syndrome Questionnaire. The cross-sectional area of the median nerve was also obtained., Results: The average pain during injection was 2.64±0.82 in the IP group and 1.96±0.86 in the OP group (P=.017). Postinjection adverse effects were similar between the 2 groups (P<.05). After injection, the percentage change in symptom severity was 49.8±11.8 in the IP group and 40.6±11.5 in the OP group (P=.008). In the IP group, day preinjection pain/numbness, night pain/numbness percentage change scores, and symptom severity percentage change scores were moderately correlated with the pain during injection (r=.439, .469, and .429, respectively)., Conclusions: IP injection caused greater pain during injection than OP injection and led to greater reduction in symptom severity at 1 month after injection. In that group, injection pain was associated with the baseline day pain score, change in night pain score, and change in symptom severity score., (Copyright © 2024 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Peripheral nerve blocks effectively alleviate postoperative pain. Animal studies and human research suggest that opioid tolerance may reduce the effectiveness of local analgesics. The reduced effectiveness has been observed in opioid-tolerant humans and animals undergoing spinal and infiltration anaesthesia with both lidocaine and bupivacaine. However, the impact on peripheral nerve blocks in humans has not been evaluated. This study aims to assess the onset time and duration of a radial nerve block in opioid-tolerant individuals compared to opioid-naive individuals. We hypothesise that peripheral nerve blocks may be less effective in producing sensory and motor blockades in opioid-tolerant individuals compared to their opioid-naive counterparts., Methods: Twenty opioid-tolerant individuals will be matched by sex and age with opioid-naïve counterparts. Participants will receive an ultrasound-guided radial nerve block. The primary outcome is the difference in the duration of sensory nerve blockade between the two groups. The secondary outcomes include the onset time of sensory blockade, onset time of motor blockade, and difference in duration of motor nerve blockade., Conclusion: This study will compare the effectiveness of a peripheral nerve block between opioid-tolerant and opioid-naïve individuals. Any found differences could support a specific postoperative protocol for opioid-tolerant individuals regarding the use of peripheral nerve blocks., (© 2024 The Author(s). Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.)

Background: Fear of pain associated with intrauterine device (IUD) placement has been identified as a significant barrier to the adoption of long-acting reversible contraception, contributing to lower utilization of the most effective reversible contraceptive methods., Objective: To assess whether instillation of intrauterine mepivacaine before IUD placement alleviates pain more effectively than a placebo., Study Design: We conducted a multicenter, double-blind, randomized, placebo-controlled trial involving nulliparous women undergoing IUD placement. An intrauterine instillation of 10 mL of 20 mg/mL mepivacaine or 0.9 mg/mL sodium chloride was administrated through a hydrosonography catheter 2 minutes prior to IUD placement. Pain scores were assessed using a 100 mm visual analog scale (VAS) at prespecified time points. Primary outcome measured the difference in VAS pain scores between the intervention group and the placebo group during IUD placement. Secondary outcomes included VAS pain scores at instillation and 10 minutes after placement, tolerability of the placement pain, as well as acceptability of the analgesia method., Results: We enrolled 151 participants, with 76 assigned to the mepivacaine group and 75 to the placebo group. The mean VAS pain score during IUD placement showed a difference of 13.3 mm (95% confidence interval (CI) 5.75-20.87; P<.001): the mepivacaine group had a mean of 53.9 mm (standard deviation [SD] 22.8), while the placebo group had a mean of 67.2 mm (SD 22.4). After adjusting for each individual provider's impact, the difference in mean pain scores remained statistically significant (12.2 mm 95% CI 4.85-19.62; P<.001). A greater proportion of women in the intervention group reported tolerable pain during placement with 70/75 participants (93.3%) compared to 53/66 participants (80.3%) in the placebo group (P=.021)., Conclusion: The intrauterine instillation of mepivacaine results in statistically significant reduction in pain score among nulliparous women during IUD placement. Although the precise clinical impact of this pain reduction method remains uncertain, the observed reduction in pain score result in a higher proportion of women reporting tolerable pain. This finding and the high acceptance as a pain reduction method thereby suggests clinical relevance. Intrauterine instillation of mepivacaine is a possible strategy to increase IUD utilization, particularly among nulliparous women who are at high risk of unintended pregnancy., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Because of controversial results from clinical studies comparing different dental local anesthesia methods in children, the primary objective of this randomized, split-mouth, crossover, controlled trial was to compare pain intensity during local anaesthesia (LA) performed with a computer-controlled LA delivery system (C-CLADS) versus a conventional syringe (CONV). Secondary objectives included comparisons during dental treatment., Methods: Participants (4-8 years) with tooth pair requiring similar treatment were recruited from five French hospitals. The right primary molar, which was treated at the first visit, was randomly allocated to one of the anaesthesia groups (either intraosseous with C-CLADS or infiltration with CONV), whereas the contralateral molar (treated at the second visit) was assigned to the other group. Pain intensity and behaviour outcomes, assessed with the Faces Pain and Venham revised scales, respectively, were compared between groups using Proc mixed. Stratified analyses were performed on dentition and location., Results: Among 107 participants, the analysis revealed reduced pain perception during LA in the C-CLADS group compared with the CONV group (-0.72, 95% CI: -1.43, -0.006), but not during dental treatment. Stratified analyses showed that this effect was observed only in primary dentition (p = .006) and mandibular molars (p = .005). Behavioural issues were fewer in the C-CLADS group than in the CONV group (p = .05) only during injection., Conclusion: C-CLADS emerged as the preferable system in primary dentition., (© 2024 BSPD, IAPD and John Wiley & Sons Ltd.)

Background: Prolonging effects of adjuncts to local anaesthetics in peripheral nerve blocks have been demonstrated in randomised clinical trials. The chosen primary outcome and anticipated effect size have major impact on the clinical relevance of results in these trials. This scoping review aims to provide an overview of frequently used outcomes and anticipated effect sizes in randomised trials on peripheral nerve block adjuncts., Methods: For our scoping review, we searched MEDLINE, Embase and CENTRAL for trials assessing effects of adjuncts for peripheral nerve blocks published in 10 major anaesthesia journals. We included randomised clinical trials assessing adjuncts for single-shot ultrasound-guided peripheral nerve blocks, regardless of the type of interventional adjunct and control group, local anaesthetic used and anatomical localization. Our primary outcome was the choice of primary outcomes and corresponding anticipated effect size used for sample size estimation. Secondary outcomes were assessor of primary outcomes, the reporting of sample size calculations and statistically significant and non-significant results related to the anticipated effect sizes., Results: Of 11,854 screened trials, we included 59. The most frequent primary outcome was duration of analgesia (35/59 trials, 59%) with absolute and relative median (interquartile range) anticipated effect sizes for adjunct versus placebo/no adjunct: 240 min (180-318) and 30% (25-40) and for adjunct versus active comparator: 210 min (180-308) and 17% (15-28). Adequate sample size calculations were reported in 78% of trials. Statistically significant results were reported for primary outcomes in 45/59 trials (76%), of which 22% did not reach the anticipated effect size., Conclusion: The reported outcomes and associated anticipated effect sizes can be used in future trials on adjuncts for peripheral nerve blocks to increase methodological homogeneity., (© 2024 The Author(s). Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.)

Background: The administration of intravenous lidocaine during the peri-operative period may improve pain management after paediatric surgery., Objective: To explore the decrease in postoperative pain intensity and opioid consumption associated with peri-operative lidocaine administration in the paediatric population., Design: A systematic review with meta-analysis of randomised controlled trials and a Grading of Recommendations Assessment, Development and Evaluation (GRADE) analysis., Data Sources: Extensive literature review., Eligibility Criteria: This study includes clinical trials conducted during surgery that examined the effect of intravenous lidocaine compared with placebo on postoperative pain management., Results: Lidocaine administration decreased pain intensity in PACU (standardised mean difference (SMD) = -1.89 [-3.75, -0.03], I2  = 97%, P of I2  < 0.001) and on postoperative day 1 (SMD = -2.02 [-3.37, -0.66], I2  = 96%, P of I2  < 0.001, number of studies = 5). Lidocaine was associated with a decrease in opioid consumption on postoperative day 1 (SMD = -1.2 [-2.19, -0.2], I2  = 93%, P of I2  < 0.001) but not on postoperative day 2 (SMD = -1.73 [-3.9, 0.44], I2  = 96%, P of I2  < 0.001). GRADE analyses resulted in low-quality results. Subgroup analyses revealed that pain intensity in PACU and opioid consumption on postoperative day 1 decreased when lidocaine was administered during both the intra-operative and postoperative periods., Conclusions: The use of lidocaine is associated with improved pain management. However, further studies are needed to increase the level of evidence and determine the optimal administration regimen for pain management., (Copyright © 2024 European Society of Anaesthesiology and Intensive Care. Unauthorized reproduction of this article is prohibited.)

Objective: To explore the efficacy and safety of 5% lidocaine-medicated plaster (LMP) in patients with trigeminal neuralgia (TN)., Background: TN is an excruciatingly painful type of neuropathic facial pain. Anti-epileptics are the first-line treatment for TN; however, these oral drugs alone sometimes fail to achieve satisfactory analgesic effects. Two retrospective studies have shown that LMP can be an effective and safe treatment option for some patients with TN. No other high-quality clinical studies have explored the effect and safety of LMP in patients with TN., Methods: The PATCH trial is an enriched enrollment with randomized withdrawal, double-blind, vehicle-controlled, parallel-group trial performed at five study centers. Eligible patients with TN received LMP during a 3-week initial open-label phase. Patients who met the response criteria entered the double-blind treatment phase and were randomly assigned for treatment with either LMP (LMP group) or vehicle patches (control group) at a 1:1 ratio. Patients who met the criteria for treatment failure were withdrawn from the double-blind treatment phase, and treatment was continued in the remaining patients for up to 28 days. The primary outcome was the number of treatment failures. The secondary endpoints were the time to loss of therapeutic response (LTR) in the double-blind phase and the weekly mean pain severity in both the open-label phase and the double-blind phase of the study., Results: The first patient was enrolled in this study on May 1, 2021, and the enrollment of the last patient was completed on August 26, 2022. A total of 307 patients were initially screened, 226 (74.0%) of whom entered the open-label phase. Of the 226 respondents, 124 (55.0%) were randomized to the double-blind phase. In the double-blind phase, 62 patients were assigned to the LMP group, and 62 were assigned to the control group. For the primary endpoint, 16 (26.0%) patients with LMP and 36 (58.0%) patients with vehicle patches met the treatment failure criteria during the double-blind phase (relative risk, 0.48; 95% confidence interval [CI], 0.31 to 0.75; p < 0.001). The survival curve of the LTR showed that the LTR of LMP was significantly longer than that of the vehicle patches (hazard ratio, 0.275; 95% CI, 0.15 to 0.50; log-rank p < 0.001). LMP also significantly reduced the weekly mean pain severity in the double-blind phase of the study (p = 0.007)., Conclusions: LMP produced partial relief of pain symptoms in some patients with TN. For responders, LMP may be used as an add-on therapy in a multidrug treatment protocol., (© 2024 American Headache Society.)

Background: One in 4 children with cerebral palsy (CP) will undergo orthopaedic surgery during their childhood. Despite its ubiquity, postoperative pain control has been poorly studied in this patient population. Moreover, poor pain management has been associated with adverse surgical outcomes. Multimodal analgesic injections have been well studied in the adult population, demonstrating safety and efficacy in reducing postoperative pain and narcotic consumption, but this modality has not been studied in pediatric patients undergoing similarly complex procedures. The objective of this study was to evaluate the efficacy of a multimodal surgical site injection for postoperative pain control following operative management of hip dysplasia in patients with CP., Methods: After obtaining IRB approval, a multicenter, randomized double-blind placebo control trial was completed. Patients below 18 years old with a diagnosis of CP who were scheduled for varus derotation osteotomy (VDRO) of the proximal femur were randomized to receive a surgical-site injection with either a combination of ropivacaine (3 mg/kg), epinephrine (0.5 mg), and ketorolac (0.5 mg/kg) (experimental group) or normal saline (control). All included patients had identical postoperative care, including immobilization, physical therapy, and standardized, multimodal postoperative pain control. Pain scores and narcotic consumption were recorded at regular intervals and compared between groups utilizing two-tailed t test or a nonparametric Mann-Whitney test for quantitative variables and a Fischer exact test for categorical variables., Results: Thirty-four patients were included, evenly divided between study arms. There were no significant differences in demographic variables, gross motor function classification system (GMFCS), comorbidities, preoperative radiographic parameters, or concomitant surgeries between groups. Patients in the experimental group required significantly lower narcotic medications at all postoperative time points from PACU until hospital discharge compared with controls (0.41 ± 0.42 vs. 1.87 ± 2.05 total morphine mEQ/kg, P =0.01). Similarly, patients in the experimental group were found to have significantly lower pain scores throughout their hospital stays compared with controls (1.0 ± 0.6 vs. 2.4 ± 1.1 mean pain score, P <0.001). There were no significant differences in operative time, OR time, blood transfusion requirements or hospital length of stay between groups. There were no adverse medication reactions or injection site complications in either group., Conclusions: In patients with CP undergoing hip reconstruction, surgical-site injection with a multimodal analgesic combination improves pain control and reduces narcotic consumption in the early postoperative period with no observed adverse effects., Significance: Local multimodal analgesic injections should be adopted as part of standard multimodal pain control in this patient population for all osseous surgeries., Level of Evidence: Level I-therapeutic., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To evaluate systemic levels of bupivacaine after bilateral ultrasound-guided deep parasternal intercostal plan (PIP) block in cardiac surgical patients undergoing median sternotomy., Design: Prospective, observational study SETTING: Single institution; academic university hospital PARTICIPANTS: Twenty-eight adult patients undergoing cardiac surgery with median sternotomy received a PIP block with 2.5 mg/kg bupivacaine with or without dexamethasone and dexmedetomidine., Measurements: Arterial blood samples were analyzed for total serum bupivacaine concentration at 5, 15, 30, 45, 60, 90, 120, and 150 minutes after placement of PIP. Local anesthetic volume, local anesthetic adjuncts, time to extubation, postoperative pain scores, and opioid consumption were recorded., Main Results: The mean peak bupivacaine concentration was 0.60 ± 0.62 µg/mL, and the mean time to maximum concentration (Tmax) was 16.92 ± 12.97 minutes. Two patients (7.1%) had a concentration >2.0 µg/mL within 15 minutes of block placement. The mean Tmax of bupivacaine was significantly greater in patients who did not receive additives compared to those patients who did (22.86 ± 14.77 minutes v 10.0 ± 5.22 minutes; p = .004). The times to extubation and postoperative pain were not improved with additives., Conclusions: Bilateral PIP placed at the end of cardiac surgery resulted in low systemic bupivacaine levels. The inclusion of additives shortened Tmax without improving outcome., Competing Interests: Declaration of competing interest The authors declare no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Fascial plane blocks (FPBs) are widely used for abdominal surgery with the assumption that liposomal bupivacaine (LB) is more effective than standard bupivacaine (SB)., Methods: This was a single-institution retrospective cohort study of patients administered FPBs with LB or SB ​+ ​admixtures (dexamethasone/dexmedetomidine) for open abdominal cancer surgery. Propensity score matching generated a 2:1 (LB:SB) matched cohort. Opioid use (mg oral morphine equivalents, OME) and severe pain (≥3 pain scores ≥7 in a 24-h period) were compared., Results: Opioid use was >150 ​mg OME in 19.9 ​% (29/146) LB and 16.4 ​% (12/73) SB patients (p ​= ​0.586). Severe pain was experienced by 44 ​% (64/146) LB and 53 ​% (39/73) SB patients (p ​= ​0.198). On multivariable analysis, SB vs LB choice was not associated with high opioid volume >150 ​mg or severe pain., Conclusions: FPBs with standard bupivacaine were not associated with higher 72-h opioid use or more severe pain compared to liposomal bupivacaine., (Copyright © 2024 Elsevier Inc. All rights reserved.)