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Objectives: The objective of this study was to evaluate the impact of liposomal bupivacaine (LB) as part of an opioid-sparing multimodal analgesic protocol on postoperative pain control in cats undergoing limb amputation surgery compared with traditional pain management protocols more heavily reliant on injectable opioid and non-opioid analgesics., Methods: Medical records of 29 cats that underwent forelimb or hindlimb amputation were reviewed to evaluate postoperative systemic pain medications utilized, appetite and time to discharge as presumptive gauges of postoperative pain. Statistical analysis of the data included Wilcoxon's rank-sum test and Fisher's exact test., Results: Of the 29 cats, seven (24%) did not receive LB and 22 (76%) did. No statistically significant differences were found between the two groups in the outcome variables evaluated. The median time to eating was similar (6.0 h in the LB group vs 5.0 h in the non-LB group), the median time to discharge was shorter in the LB group (25.0 h vs 42.0 h in the non-LB group) and the median time to discontinuation of opioids in the LB treatment group was shorter than the non-LB group (18.0 h in LB group vs 22.0 h non-LB). A lower proportion of the LB group needed adjuvant systemic analgesics compared with the non-LB group (5% LB vs 29% non-LB)., Conclusions and Relevance: The addition of liposomal bupivacaine to an analgesic protocol after limb amputation in cats is associated with reduced opioid dosing, earlier return to eating and earlier hospital discharge. The use of LB may minimize the negative side effects associated with systemic opioid administration and therefore decrease patient morbidity. Future studies are needed to definitively compare LB efficacy and safety for postoperative pain control and traditional systemic analgesic medications., Competing Interests: Conflict of interestThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To evaluate the impact of adding epidural dexmedetomidine to low-concentration patient-controlled epidural analgesia (PCEA) on pain control and side effects in total knee arthroplasty (TKA)., Methods: In this double-blind study, American Society of Anesthesiologists I to II patients undergoing TKA were assigned to receive 0.125% bupivacaine + fentanyl 4 µg/mL (group R) or 0.1% bupivacaine + fentanyl 2 µg/mL with an epidural injection of dexmedetomidine 1 µg/kg (group D). The primary outcomes were the effectiveness of postoperative pain control as assessed by the numeric pain rating scale (NRS) and the incidence of side effects. Secondary outcomes included hemodynamic parameters (systolic and diastolic blood pressure, heart rate), motor block assessment, sensory block duration, analgesia duration, and the need for additional analgesia., Results: Both groups achieved similar pain control as indicated by NRS scores. However, group D experienced lower rates of urinary retention and pruritus, whereas sedation in the recovery room was greater in group D. Group R had significantly higher systolic pressure in the recovery room. group D exhibited significantly lower heart rates at 5 and 10 minutes., Conclusions: Low-concentration PCEA with epidural dexmedetomidine provides similar analgesia after TKA as high-concentration PCEA with fewer side effects., Competing Interests: Declaration of conflicting interestThe authors declare no conflict of interest in preparing this article.

Background and Objectives: Multimodal analgesia has been shown to be effective in facilitating early postoperative gastrointestinal function and rehabilitation in patients undergoing open gastrectomy. We conducted a clinical trial to investigate the effectiveness of bilateral rectus sheath block (RSB) with continuous bupivacaine infusion in comparison with placebo following elective open gastrectomy. Materials and Methods: Patients indicated for elective open gastrectomy were screened, enrolled, and randomised between October 2021 and September 2023. The patients were randomised to either Group A (intervention-continuous bupivacaine) or Group B (control-NaCl saline). The primary outcome measures were the quantity of an opioid analgesic administered during the initial 72 h post-surgery and the level of postoperative pain as indicated by the visual analogue scale (VAS). Mann-Whitney U test was used for quantitative analysis while Pearson Chi-square was used for categorical variables. Results: A total of 60 patients completed the trial, with 30 patients in each of the two groups. Patients in Group A reported lower median VAS pain scores at all observed time points following surgery ( p < 0.001). No patient in Group A required rescue opioid analgesia, although non-steroidal anti-inflammatory drugs were necessary during the initial 12 h postoperatively. Clinically, Group A patients had a significantly shorter time to first gas ( p = 0.001), a shorter time to first bowel movement ( p < 0.001), a shorter time to first out-of-bed activity ( p < 0.001), and a shorter overall hospitalisation duration ( p < 0.001) compared to Group B patients. Conclusions: Bilateral RSB with continuous bupivacaine infusion is effective in managing pain and can reduce the use of opioid analgesics in the postoperative period. Furthermore, it promotes early recovery, and a shorter hospital stay.

Study Objective: Vaginal packing is traditionally placed after pelvic floor reconstructive surgery (PFRS) to prevent hematoma formation. We seek to determine if there is a difference in postoperative pain scores after PFRS if vaginal packing is soaked with estrogen cream, bupivacaine, or saline. The primary outcome was pain as measured by a visual analog scale at 2 hours, 6 hours, and 1 day postoperatively. Secondary outcomes include changes in hemoglobin, urinary retention and length of stay (LOS) in hospital., Design: Prospective cohort study., Setting: Tertiary care academic teaching hospital. All PFRS is performed by fellowship-trained urogynecologists., Participants: Consenting patients undergoing PFRS., Interventions: At the completion of surgery, gauze packing soaked with either estrogen cream, 0.25% bupivacaine with 1% epinephrine, or normal saline was placed inside the vagina and removed on postoperative day 1., Measurements and Main Results: We included 210 patients (74 estrogen, 66 bupivacaine, 70 saline). There was no significant difference in mean postoperative pain scores between the groups (estrogen, bupivacaine, saline-soaked vaginal packs respectively) at 2 hours (2.66 ± 2.25, 2.30 ± 2.17, 2.24 ± 2.07; p = .4656), 6 hours (2.99 ± 2.38, 2.52 ± 2.30, 2.36 ± 2.01; p = .2181) or on postoperative day 1 (1.89 ± 2.01 vs 2.08 ± 2.15 vs 2.44 ± 2.19; p = .2832) as measured by visual analog scale scores (0-10). There was no difference in the secondary outcomes of change in pre/postoperative hemoglobin (21.8 ± 10.73g/L, 20.09 ± 11.55 g/L, 21.7 ± 9.62g/L, p = .68), urinary retention (37%, 45% and 48%, p = .45), LOS (1.05 ± 0.46 days, 1.02 ± 0.12, 1.03 ± 0.24, p = .97) or in-hospital opioid usage during admission (represented in morphine milligram equivalents [median (IQR1, IQR3)], Kruskal-Wallis test): 11.25 mg (0, 33), 7.5 mg (0, 22.5) and 15 mg (0, 33.88) p = .41., Conclusion: There was no difference found between soaking vaginal packing with estrogen cream, bupivacaine, or saline after PFRS with respect to postoperative pain scores, LOS, in-hospital opioid usage, or urinary retention. Saline-soaked packing is an equivalent alternative to estrogen or bupivacaine vaginal packing., (Copyright © 2024 AAGL. Published by Elsevier Inc. All rights reserved.)

Postoperative pain control in adolescent patients following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) requires a multimodal pain regimen involving a combination of opioids and adjuvant analgesic medications. The purpose of this study was to identify whether the use of the local anesthetic liposomal bupivacaine (LB) at time of closure following PSF reduced postoperative narcotic use in patients when compared with an alternative local anesthetic. Twenty-five patients who received LB at time of wound closure were matched with 25 AIS patients from the year prior to minimize changes in protocol and instrumentation. Charts were retrospectively reviewed, and significant difference was found in age, gender, body mass index, length of stay, visual analog scores for pain, or number of levels fused. However, the LB group had significantly less morphine equivalent totals. Based on the results, the authors would recommend the use of LB during closure of PSF for AIS. (Journal of Surgical Orthopaedic Advances 33(4):219-221, 2024).

Background Context: Postoperative pain management in spine surgery remains a challenge. Liposomal bupivacaine (LB) has emerged as an alternative or adjunct to opioid-based analgesia. However, existing studies evaluating LB efficacy in spine surgery yield conflicting results and a meta-analysis compiling the literature is lacking., Purpose: The purpose of this meta-analysis was to evaluate pain outcomes, opioid use, and LOS following LB administration after spine surgery., Study Design: Meta-analysis., Methods: Following the PRISMA guidelines, PubMed, Cochrane, and Google Scholar (pages 1-20) were accessed and explored up to May 2024. Data on medical complications, postoperative pain, postoperative opioid consumption, and length of stay were extracted. Mean differences (MD) with 95% CI were used for continuous data, and odds ratios (OR) were calculated for dichotomous data., Results: This meta-analysis comprised eleven studies consisting of 1,269 patients (677 in the LB group, 592 in the control group). No statistically significant difference was observed in complication rates. The LB group exhibited significantly lower pain scores at postoperative day 2 (MD=-0.31; 95% CI: -0.52 to -0.09, p=.006), lower postoperative opioid consumption (MD=-0.42; 95% CI: -0.79 to -0.06, p=.02), and shorter length of stay (MD=-0.57; 95% CI: -0.94 to -0.20, p=.002)., Conclusion: In the immediate postoperative period after spine surgery, the utilization of liposomal bupivacaine was associated with improved pain outcomes, decreased opioid consumption, and shortened length of stay. Although further research is warranted, these findings suggest that LB may offer a valuable adjunct to pain management strategies in patients undergoing spine surgery., Competing Interests: Declaration of competing interest One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Transversus abdominis plane block is becoming more common as part of multimodal analgesia for post-abdominal operation pain relief. This study compared the analgesic effects of adding dexmedetomidine to levobupivacaine (transversus abdominis plane) block in elderly patients undergoing inguinal hernia surgery to adding fentanyl., Methods: Overall, 90 elderly patients with a simple inguinal hernia repair were randomly assigned to one of three groups. After spinal anaesthesia, an ultrasound-guided transversus abdominis plane block was performed. Transversus abdominis plane block was accomplished with 0.25% levobupivacaine + 0.9% normal saline in Group L (n = 30) (20mL). Transversus abdominis plane block was accomplished with 0.25% levobupivacaine + 1 µg/kg dexmedetomidine in Group D (n = 30) (20mL). Transversus abdominis plane block was obtained with 0.25% levobupivacaine + 1 µg/kg fentanyl in Group F (n = 30) (20mL). The primary outcome was the first analgesic request, and the secondary outcomes were the visual analog scale, postoperative analgesic requirements, sedation, hemodynamic stability, and related complications 24 hours postoperatively. 1gm paracetamol intravenously was provided as rescue analgesia., Results: The time to first analgesic request in the dexmedetomidine group was substantially more prolonged than in the fentanyl and control groups (516.5±27.8, 451.2±11.1, and 403.9±10.5min, respectively; p < 0.05). Postoperative analgesic requirements were significantly decreased in dexmedetomidine 1(1-2) than control 2(1-3) and fentanyl 1.5(1-2) respectively (P<0.01). VAS was significantly lower in Group D and Group F than in Group L postoperatively. No significant difference in side effects was noted between the groups., Conclusion: The transversus abdominis plane block is the best multimodal analgesia choice for inguinal hernia repair in older patients. Combining dexmedetomidine with levobupivacaine in the transversus abdominis plane block can improve the quality of postoperative analgesia while avoiding significant side effects.

Background Context: Perioperative pain management affects cost and outcomes in elective spine surgery., Purpose: This study investigated the association between liposomal bupivacaine (LB) and outpatient spine surgery outcomes, including perioperative, postoperative, and postdischarge opioid use and healthcare resource utilization., Study Design: This was a retrospective comparative study., Patient Sample: Eligibility criteria included adults with ≥6 months of continuous data before and after outpatient spine procedures including discectomy, laminectomy, or lumbar fusion. Patients receiving LB were matched 1:3 to patients receiving non-LB analgesia by propensity scores., Outcome Measures: Outcomes included (1) opioid use in morphine milligram equivalents (MMEs) during the perioperative and postdischarge periods and (2) postdischarge readmission and emergency department (ED) visits up to 3 months after surgery. Generalized linear mixed-effects modeling with appropriate distributions was used for analysis., Methods: Deidentified data from the IQVIA linkage claims databases (2016-2019) were used for the analysis. This study was funded by Pacira BioSciences, Inc., Results: In total, 381 patients received LB and 1143 patients received non-LB analgesia. Baseline characteristics were well balanced after propensity score matching. The LB cohort used fewer MMEs versus the non-LB cohort before discharge (80 vs 132 MMEs [mean difference, -52 MMEs; p=.0041]). Following discharge, there was a nonsignificant reduction in opioid use in the LB cohort versus the non-LB cohort within 90 days (429 vs 480 MMEs [mean difference, -50 MMEs; p=.289]) and from >90 days to 180 days (349 vs 381 MMEs [mean difference, -31 MMEs; p=.507]). The LB cohort had significantly lower rates of ED visits at 2 months after discharge versus the non-LB cohort (3.9% vs 7.6% [odds ratio, 0.50; p=.015]). Postdischarge readmission rates did not differ between cohorts., Conclusions: Use of LB for outpatient spine surgery was associated with reduced opioid use at the hospital and nonsignificant reduction in opioid use at all postoperative timepoints examined through 90 days after surgery versus non-LB analgesia. ED visit rates were significantly lower at 60 days after discharge. These findings support reduced cost and improved quality metrics in patients treated with LB versus non-LB analgesia for outpatient spine surgery., Competing Interests: Declaration of competing interest One or more of the authors declare financial or professional relationships on ICMJE-TSJ disclosure forms., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

This study retrospectively evaluated the use of intraoperative locally infiltrated peri-incisional liposomal bupivacaine in kidney transplant recipients with the primary outcome of oral morphine equivalent reduction during the transplant admission. Secondary outcomes included pain scores, time to first bowel movement and length of stay. Postoperative morphine equivalents were significantly lower in the liposomal bupivacaine group <24 hours (50% reduction, p < 0.05) and 24-48 hours (56.5% reduction, p < 0.05). When accounting for analgesic medication choices, liposomal bupivacaine did not result in a significant reduction in opioid use within 48 hours postoperatively with the exception of a 51% (p = 0.02) median reduction in fentanyl patient-controlled analgesia morphine equivalents <24 hours postoperatively. Morphine equivalence reductions >48 hours, differences in pain scores, time to first bowel movement or length of stay did not reach significance. Intraoperative liposomal bupivacaine reduced kidney transplant recipient's postoperative opioid requirements, but this benefit did not reliably extend past 24 hours postoperatively., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Background: The incidence of acute poststernotomy pain after cardiac surgery is 80%1. Pecto-intercostal fascial plane block (PIFB) adjacent to the sternum anesthetizes the anterior cutaneous branches of the intercostal nerves and may provide effective analgesia after sternotomy., Methodology: A randomized controlled, double-blinded, prospective comparative trial was conducted at a tertiary care center on patients of midline sternotomy between 18 and 65 years and NYHA Class 2 and 3 for open cardiac surgery with the primary aim to evaluate analgesia on deep breathing after 3 hours of PIFB block bilaterally. A total of 60 patients were enrolled and randomly divided into three groups. PIFB was administered bilaterally before extubation, with 15 ml 0.125% bupivacaine plain (Group B), and bupivacaine+ clonidine 0.25 mcg/kg (Group B+C). Group C did not receive any intervention. All patients received acetaminophen 1 gram three times a day and injectable tramadol 1 mg/kg as a rescue analgesic., Results: Baseline characteristics were similar among all the groups. The Numeric Rating Scale (NRS) for pain was statistically lower (P < 0.05) in Groups B and B+C compared to Group C at rest, deep breathing, and coughing at 3, 6, and 12 hours after extubation. NRS on deep breathing in Groups B, B+C, and C was {(2.3, 1.5, 4.4) at 3 hours, (2.3, 1.6, 4.3) at 6 hours, (2.8, 2.1, 3.9) at 12 hrs, and {(4.3, 3.5, 3.6)} at 24 hours after extubation. The peak expiratory flow rate was the highest in Group B. Rescue analgesia was not required in Group B., Conclusion: PIFB reduces sternotomy pain compared to the control group on deep breathing at 3 hours after block, with delayed requirement of rescue analgesia and improved respiratory mechanics in terms of peak expiratory flow rate at all time points. There is no benefit from adding clonidine., (Copyright © 2024 Copyright: © 2024 Annals of Cardiac Anaesthesia.)

Endometriosis is a debilitating chronic condition often accompanied by severe pelvic pain and infertility issues. When outpatient medical management is not adequate, controlling pain can be challenging for providers in the acute setting. We report the case of a 23-year-old female with a past medical history of endometriosis who presented to a freestanding emergency department with a chief complaint of 10/10 pelvic pain on a numeric rating scale. She had tried non-steroidal inflammatory medications and heat with no success. The patient had medication intolerances to opioid analgesics and was given ketorolac intramuscularly with no relief of her pain. The emergency physician discussed and offered to perform an erector spinae plane nerve block (ESPB) for pain relief. Ultrasonography was utilized for visualization of landmarks with a curvilinear transducer; a 20-gauge Pajunk® Sonoplex needle was used to inject a total of 100 mg bupivacaine 0.25% without epinephrine along with dexamethasone 10 mg under the bilateral erector spinae fascial planes at the T9 level. Post-procedure, the patient had significant improvement in pain and rated it a 2/10. Utilizing nerve blocks for endometriosis and other chronic pelvic pain in the acute care setting can serve as an effective alternative to opioids. In patients with multiple medication intolerances and for providers navigating pain control in the setting of a nationwide opioid crisis, ESPB blocks can help alleviate acute pain or exacerbations of chronic pain. This case demonstrates the first known use of an ESPB to relieve endometriosis pain in the emergency department., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To determine (1) the dose of liposomal bupivacaine (LB) to eliminate grade 2 of 5 lameness, the (2) duration of analgesia of LB versus bupivacaine hydrochloride (BH), and (3) LB pharmacokinetics versus BH., Methods: A reversible lameness model was validated in conditioned Thoroughbred horses (n = 12), aged 3 to 10 years. A dose-response trial compared subjective and objective lameness following abaxial sesamoid block with 25 mg BH/nerve or 30, 60, or 133 mg LB/nerve (n = 3/group). The LB dose that eliminated lameness and reduced lameness for the longest was used for blinded, randomized, crossover pharmacokinetic/pharmacodynamic trials (n = 12/group). Data were analyzed using a paired t test or Wilcoxon signed-rank test, P < .05., Results: The 133-mg/nerve dose of LB eliminated lameness in 3 of 3 horses in the dose-response trial, and lameness returned at 6, 36, and 72 hours. In the pharmacokinetic/pharmacodynamic trials, time to return of lameness greater than or equal to starting lameness was longer for LB compared to BH on subjective (LB, 12 hours, 4 to 24 hours; BH, 4 hours, 4 to 12 hours) and objective (LB, 12 hours, 4 to 24 hours; BH, 4 hours, 2 to 6 hours) evaluations. The terminal half-life was not different between formulations (LB, 17.8 hours ± 10.1; BH, 12.4 hours ± 6.3); however, LB had increased area under the concentration-versus-time curve from time 0 to infinity (LB, 388 ng·h/mL ± 117; BH, 63 ng·h/mL ± 18) and mean residence time (LB, 17.6 hours ± 2.4; BH, 3.9 hours ± 1.6)., Conclusions: Liposomal bupivacaine analgesia duration was greater than BH, but the median time until lameness returned was only 12 hours. Bupivacaine is quantifiable in serum and urine beyond loss of clinical effect., Clinical Relevance: A single, high-dose injection of LB is not effective for providing perineural analgesia over several days. Bupivacaine is detectable after the effect of the drug has worn off.

Objective: The objectives of the study were to compare the clinical efficacy and adverse effects of two analgesic protocols consisting of bupivacaine liposome injectable solution (BLIS) and 0.5% bupivacaine and fentanyl for postsurgical analgesia in dogs undergoing limb amputation., Study Design: Randomized, double-blind, prospective, controlled, intent-to-treat, clinical noninferiority trial., Animals: Forty client-owned dogs., Methods: Dogs undergoing amputation were randomly assigned to either the BLIS or control group. Postoperative pain, sedation, nausea, and amount eaten were assessed using appropriate scales at 6, 12, 18, and 24 h by trained individuals blinded to the treatment protocol. Rescue analgesia was provided for Glasgow composite measure pain scale (short form) (CMPS-SF) scores of 5 or above. Clients were requested to pain score their dogs at home using a visual analogue scale (VAS) for 48 h following discharge., Results: Forty dogs completed this study (20 control dogs and 20 BLIS dogs). The BLIS and control groups were equivalent for sedation, nausea, amount eaten, and pain, at all time periods except at 6 h (p < .01), when the BLIS group pain score was lower., Conclusion: The BLIS provided equivalent analgesia with fewer adverse effects than fentanyl constant rate infusion (CRI) following limb amputation. Rescue analgesia was provided to five dogs in the BLIS group and four in the control group, and there was no statistical difference. Nausea scores did not differ statistically., Clinical Significance: As BLIS provides equivalent analgesia, this may allow for decreased reliance on opioids in the immediate postoperative period., (© 2024 The Authors. Veterinary Surgery published by Wiley Periodicals LLC on behalf of American College of Veterinary Surgeons.)

Importance: The utility of pudendal nerve blocks (PNBs) at the time of transvaginal surgery is mixed in the literature. No published study has evaluated the efficacy of PNB since the widespread adoption of Enhanced Recovery After Surgery (ERAS) pathways., Objective: This study aimed to determine if PNB, in addition to ERAS measures, at the time of vaginal reconstructive surgery reduces opioid use in the immediate postoperative period., Study Design: In this randomized, blinded, controlled trial, women scheduled for transvaginal multicompartment prolapse repair were randomized to bilateral PNB before incision with 20 mL of 0.5% bupivacaine versus usual care. Primary outcome was opioid use in morphine milligram equivalents (MME) for the first 24 hours. The study was powered to detect a 5.57-MME difference in opioid use in the first 24 hours between groups., Results: Forty-four patients were randomized from January 2020 to April 2022. The PNB and control groups were well matched in demographic and surgical data. There was no difference in opioid use in first 24 hours between the control and PNB groups (8 [0-20] vs 6.7 [0-15]; P = 0.8). Median pain scores at 24 and 48 hours did not differ between groups (4 ± 2 vs 3 ± 3; P = 0.44) and 90% of participants were satisfied with pain control across both groups. Time to return to normal activities (median, 10 days) was also not different between the groups., Conclusions: Because pain satisfaction after transvaginal surgery in the era of ERAS is high, with overall low opioid requirements, PNB provides no additional benefit., Competing Interests: M.T. is a consultant for Iota Biosciences and Willow Innovations. A.L.A. is a consultant for Watershed Medical and an investigator for MicroGenDx. The other authors report no conflict of interest., (Copyright © 2024 American Urogynecologic Society. All rights reserved.)

Introduction: Opioids are commonly added to local anaesthetic for subarachnoid block for caesarean section due to their synergistic effects. The physiochemical characteristics of opioids suggest premixing with hyperbaric bupivacaine may limit their distribution within the CSF. We studied the effect of a separate injection with a combination of bupivacaine, morphine and fentanyl on block characteristics, haemodynamic changes, postoperative pain and patient satisfaction., Method: Following ethical approval and informed consent, a prospective double-blinded randomised controlled trial was performed in a university hospital. A total of 126 patients undergoing caesarean section were randomised to two groups. In group M, the premixed group, patients received 12 mg of hyperbaric bupivacaine, 20 mcg of fentanyl and 100 mcg of morphine injected as a single mixture. In group S, the separate injection group, patients received the same drugs in separate injections. Measurements included haemodynamics, block distribution, intra- and postoperative pain, as well as patient satisfaction., Results: Patients in both groups had similar block height, time to maximum sensory block, time to block regression and motor block. However, haemodynamics were different between the groups. The proportion of systolic hypotension episodes was greater in group S [159/1320 (12.05%)] than group M [113/1452 (7.78%)], with P = 0.0002. Moreover, a greater amount of ephedrine was administered in group S than group M, with values 12.09 (8.1) and 9.09 (8.5) mg respectively (P = 0.001). Additionally, postoperative pain, as measured by the Visual Analogue Scale (VAS), was greater in group M, with a VAS of 4.6 (1.7), vs. group S, which recorded a VAS of 3.8 (2.0) (P = 0.017)., Conclusion: Sequential injection of intrathecal opioids and hyperbaric bupivacaine resulted in greater early haemodynamic instability and slightly better postoperative analgesia without any difference in block height or patient satisfaction., Clinical Trial Registration: NCT04403724., (© 2024. The Author(s), under exclusive licence to Royal Academy of Medicine in Ireland.)

Background: Gynaecological laparoscopic surgery is a minimally invasive surgical technique that can cause pain and discomfort in the postoperative period. To manage this pain, various analgesic techniques have been employed, including rectus sheath block (RSB). Bupivacaine is a long-acting local anaesthetic that has been used in bilateral rectus sheath block (BRSB) for postoperative pain relief after laparoscopic surgery. The objective of this study was to assess the impact of bupivacaine's bilateral rectus sheath block (BRSB) on post-laparoscopic pain relief with its intraperitoneal (IP) administration., Methods: This prospective randomized, double-blind, clinical trial was done at the department of obstetrics and gynaecology Patel hospital Karachi, from September 2022 to February 2023. All the adult female patients aged 18 years or older undergoing elective gynecological laparoscopic surgery and willing to receive RSB as a postoperative analgesic technique were included. After taking informed consent, the patients were randomly allocated into two groups. In group I, BRSB was performed with 25 mg of bupivacaine and in group II was given 25 mg of bupivacaine intraperitoneal. Visual analogue pain score (VAS) was used to evaluate the postoperative pain at 1st, 6th, 10the and 24the hours postoperatively. Data was collected via study proformas., Results: The study comprises 60 patients who underwent gynaecological laparoscopic surgeries, with group I having an average age of 38.10±11.19 years and an average was BMI of 27.07±5.15 kg/m2, and group II having a mean age of 41.36±11.18 years and an average BMI of 27.51±4.22 kg/m2. Average (VAS) was significantly lower in group I compared to group II at 1st, 6th, 10th, and 24th hour, with a statistically significant p-value of 0.001. The average duration of surgery was statistically insignificant in both groups, as an average duration in group I was 32.14±12.20 minutes and in group II was 31.0±19.21 minutes., Conclusions: The use of bupivacaine in a bilateral rectus sheath block (BRSB) with was observed to be more effective for post-laparoscopic pain relief compared to 25 mg of bupivacaine intraperitoneal administration.

Study Objectives: The study aimed to compare the analgesic effect of USG-guided PENG (Peri capsular nerve group) block with Intravenous Nalbuphine hydrochloride (IVN) in patients with hip fracture coming to the emergency department (ED). The purpose was also to monitor the adverse effects and rescue analgesic requirements in both treatment modalities., Methods: The study was an open-label randomised controlled trial (RCT) comparing PENG block versus IVN in treating patients with femoral head and neck fractures, as well as pubic rami fracture of the hip (HF). The participants in the PENG group received a USG-guided PENG block by injection of 25 ml of 0.25% bupivacaine, whereas the IVN group received 0.15 mg/kg of nalbuphine. An emergency physician with expertise in ultrasound-guided nerve blocks performed the PENG blocks. The primary outcome was to measure the improvement of the NRS (Numerical rating scale) score at 30 min in both static position (Patient-chosen position for the best comfort) and dynamic position (15-degree passive affected lower limb elevation). Secondary outcomes were to measure static and dynamic NRS pain scores at 2 h, 4 h, and 6 h after intervention in both groups. The requirement for rescue analgesia, adverse events and any block-related complications were also recorded., Results: A total of 60 patients with HF were included in the final analysis. The static and dynamic NRS score was significantly lower in the PENG group compared to the IVN group at 30 min, 2 h, 4 h, and 6 h post-intervention. In the PENG group, the static NRS score was improved by 5.73 ± 1.17, while In the IVN group, the static NRS score was just improved by 2.13 ± 0.97 at 30 min. In the same duration, the Dynamic NRS score in the PENG group was improved by 6.13 ± 1.38, while In the IVN group, it improved just by 2.43 ± 1.28. Rescue analgesia was required in 50.0% of patients in the IVN group but none in the PENG group. Further, no block-related complications or adverse events were observed in the patients of the PENG group., Conclusion: The study provides evidence that the ultrasound-guided PENG block has a better analgesic effect and has fewer adverse events than IV opioids in patients with HF., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: This study examines an Enhanced Recovery After Surgery (ERAS) protocol for patients with cleft palate and hypothesizes that patients who followed the protocol would have decreased hospital length of stay and decreased narcotic usage than those who did not., Design: Retrospective cohort study., Setting: The study takes place at a single tertiary children's hospital., Patients: All patients who underwent cleft palate repair during a 10-year period (n = 242)., Interventions: All patients underwent cleft palate repair with the most recent cohort following a new ERAS protocol., Main Outcome Measures: Primary outcomes included hospital length of stay and narcotic usage in the first 24 hours after surgery., Results: Use of local bupivacaine during surgery was associated with decreased initial 24-hour morphine equivalent usage: 2.25 vs 3.38 mg morphine equivalent (MME) (P < 0.01), and a decreased hospital length of stay: 1.71 days vs 2.27 days (P < 0.01). The highest 24-hour morphine equivalent a patient consumed prior to the ERAS protocol implementation was 24.53 MME, compared with 6.3 MME after implementation. Utilization of the ERAS protocol was found to be associated with a decreased hospital length of stay: 1.67 vs 2.18 days (P < 0.01)., Conclusions: Use of the proposed ERAS protocol may lead to lower narcotic usage and decreased length of stay., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To describe the percutaneous image-guided treatment of mucoid degeneration of the ACL causing deep knee pain on flexion in patients with advanced knee osteoarthritis., Methods: Five patients with mucoid degeneration of the ACL complicating knee osteoarthritis underwent percutaneous image-guided steroid bupivacaine ACL sleeve injections over a 3-year period., Results: There were four males and one female of mean age 54 (range 48-59 years). Each patient had Kellgren and Lawrence grade 4 medial compartment knee osteoarthritis with coexistent mucoid degeneration of the ACL sleeve. Each patient complained of deep knee pain on flexion as a dominant symptom. Each patient underwent image-guided (CT or ultrasound) steroid bupivacaine injection of the ACL sleeve resulting in symptom resolution and improved mobility for a mean duration of 8 months, (range 6-15 months.) CONCLUSION: Mucoid degeneration of the ACL should be sought in patients with osteoarthritis presenting with deep knee pain on flexion. Image-guided ACL sleeve injection in affected patients may result in symptom resolution and potential deferral of planned knee replacement surgery., Advances in Knowledge: Emphasises Image guided percutaneous treatment of Mucoid degeneration of ACL in patients with knee osteoarthritis., (© 2024. The Author(s), under exclusive licence to Royal Academy of Medicine in Ireland.)

Objective: To compare the perioperative opioid requirements among dogs receiving an erector spinae plane (ESP) block with bupivacaine, with or without dexmedetomidine, and a control group., Animals and Procedure: Thirty client-owned, healthy adult dogs undergoing hemilaminectomy were included in this randomized, prospective, blinded clinical study. Dogs were randomly assigned to 1 of 3 treatment groups: Group B, ESP block with bupivacaine; Group BD, ESP block with bupivacaine and dexmedetomidine; and Group C, control. Rescue intra- and postoperative analgesia consisted of fentanyl and methadone, respectively. Postoperative pain was evaluated using the short form of the Glasgow Composite Measure Pain Scale (CMPS-SF)., Results: In Group BD, 0/10 dogs required intraoperative fentanyl, compared to 9/10 in Group C ( P < 0.001), whereas 1/10 required postoperative methadone, compared to 9/10 in Group B ( P = 0.003) and 10/10 in Group C ( P < 0.001). The total amount of intraoperative fentanyl (μg/kg) was 0 (0 to 4) in Group B and 0 (0 to 0) in BD, compared to 6 (0 to 8) in C ( P = 0.004 and P < 0.001, respectively). Postoperative methadone (mg/kg) required during the first 12 h was 0.5 (0 to 1.4) in Group B ( P = 0.003) and 0 (0 to 0) in BD ( P < 0.001), compared to C ( P = 0.003 and P < 0.001, respectively)., Conclusion: An ESP block with bupivacaine, with or without dexmedetomidine, was associated with a reduction in perioperative opioid consumption and provided effective acute pain control., (Copyright and/or publishing rights held by the Canadian Veterinary Medical Association.)

Training and expertise in regional anaesthesia have increased significantly in tandem with increased interest over the past two decades. This review outlines the most recent advances in regional anaesthesia and focuses on novel areas of interest including fascial plane blocks. Pharmacological advances in the form of the prolongation of drug duration with liposomal bupivacaine are considered. Neuromodulation in the context of regional anaesthesia is outlined as a potential future direction. The growing use of regional anaesthesia outside of the theatre environment and current thinking on managing the rebound plane after regional block regression are also discussed. Recent relevant evidence is summarised, unanswered questions are outlined, and priorities for ongoing investigation are suggested.

Study Design: Prospective, double-blind randomized controlled trial., Objective: If an intraoperative single bolus of epidural bupivacaine can result in less postoperative pain following lumbar spinal decompression surgery., Summary of Background Data: Adequate postoperative pain management following lumbar spinal decompression surgery is important, as it will lead to early mobilization, less complications, and a shorter hospital stay. Opioid consumption should be limited due to their frequently accompanied side effects and their addictive nature. During the final phase of lumbar decompression surgery, the epidural space becomes easily accessible. This might be an ideal moment for surgeons to administer an epidural bolus of analgesia as a safe and effective method for postoperative pain relief., Materials and Methods: In this trial, we compared a single intraoperative bolus of epidural analgesia using bupivacaine 0.25% to placebo (NaCl 0.9%) and its effect on postoperative pain following lumbar spinal decompression surgery. The primary outcome was the difference in Numeric (Pain) Rating Scale between the intervention and placebo groups during the first 48 hours after surgery., Results: Both the intervention group and the placebo group consisted of 20 randomized patients (N=40). Statistically significant lower mean Numeric (Pain) Rating Scale pain scores were observed in the intervention group in comparison with the control group (main effect group: -2.35±0.77, P =0.004). The average pain score was lower in the intervention group at all postoperative time points. No study-related complications occurred., Conclusion: This randomized controlled trial shows that administrating a bolus of intraoperative epidural bupivacaine is a safe and effective method for reducing early postoperative pain following lumbar decompression surgery., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: In this study, we investigated the effect of local injection of ropivacaine and bupivacaine with magnesium sulfate on postoperative pain in vertebral laminectomy surgery., Design: This randomized double-blind prospective study was conducted among 60 patients aged 18-65 years old with ASA class I and II., Methods: Group RM: (30 people) received 70 mg ropivacaine (14 ml) plus 1 ml magnesium sulfate (500 mg) volume up to 20 ml with normal saline. Group BM: (30 people) received 70 mg bupivacaine (14 ml) plus 1 ml magnesium sulfate (500 mg) volume up to 20 ml with normal saline. The results were analyzed by SPSS 23 software, and statistical analysis consisted of χ 2 test and t -test, and a p value less than .05 was considered significant., Findings: Mean pain score based on VAS in 6 and 12 h after surgery in the RM group was lower in the BM group ( p  < 0.05). The analgesic request frequency in the RM group was lower than the BM group ( p = 0.01). The mean morphine consumption in the RM group was 185 mg and in the BM group was 220 mg. According to the T -test, there was a significant difference between the two groups ( p = 0.03). there was no significant difference between the mean arterial blood pressure and mean heart rate between the two groups at 6, 12, 24 and 24 h after surgery ( p > 0.05)., Conclusion: This study showed that wound infiltration with ropivacaine and magnesium sulfate compared to bupivacaine and magnesium sulfate provided better postoperative analgesia and significantly reduced postoperative opioid consumption in patients undergoing lumbar laminectomy.

Background and Purpose:

Discontinua&shy;tion of medication still remains a key element in the treatment of medication overuse headache (MOH), but there is no consensus on the withdrawal procedure. We aimed to share the promising results of anesthetic blockade of greater occipital nerve (GON), which can be an alternative to existing treatments during the early withdrawal period of MOH treatment.

This study was conducted using regular electronic medical records and headache diaries of patients diagnosed with MOH and treated with anesthetic GON blockade with 0.5% bupivacaine solution in a specia&shy;lized headache outpatient clinic. A total of 86 patients who developed MOH while being followed up for chronic migraine were included in the study.

The treatment schemes for MOH are based on expert consensus and withdrawal strategies are the most challenging part of treatment. In our study, numerical rating scale for headache intensity, overused medication consumption per month, headache frequency (day/month) and the duration of each attack (hour/day) decreased significantly in the first month compared to pre-treatment (p &lt; 0.01).&nbsp;

Conclusion &ndash; Our study suggests that GON blockade can be used as a good alternative therapy in the treatment of MOH.

Objective: We aimed to investigate the effect of bilateral sphenopalatine ganglion blockade (SPGB) on the main postoperative complications in septorhinoplasty operations., Methods: In this randomized, controlled, prospective study, 80 cases planned for Septorhinoplasty operations under general anesthesia were included in the study. The cases were divided into two groups; SPGB was performed with 2 mL of 0.25% bupivacaine bilaterally 15 min before the end of the operation in the SPGB group (Group S, n = 40). In the control group (Group C, n = 40), 2 mL of 0.9% NaCl solution was applied into both SPG areas. In the recovery unit after the operation; the pain and analgesic needs of the patients at 0, 2, 6 and 24 h were evaluated., Results: There was no statistically significant difference between the groups in terms of hemodynamic parameters (ASA, MBP, HR) (p > 0.05) All VAS values were statistically lower in Group S than in Group C (p < 0.05). In Group S, the need for analgesic medication was found in 5 cases between 0-2 h, whereas in Group C, this rate was found in 17 cases, and it was statistically significant (p < 0.05)., Conclusion: Bilateral SPGB application was determined to provide better analgesia in the early postoperative period compared to the control group, it was concluded that further studies are needed to say that there are significant effects on laryngospasm and nausea-vomiting., Level of Evidence: 2, degree of recommendation B., (Copyright © 2023 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier España S.L.U. All rights reserved.)

Objective: To test the hypothesis that paracervical block with 0.5 % bupivacaine decreases postoperative pain after total laparoscopic hysterectomy (TLH)., Materials and Method: This randomized double-blind placebo control trial included 152 women. We injected 10 mL 0.5 % bupivacaine (study group, n = 75) or 10 mL normal saline (control group, n = 77) at the 3 and 9 o'clock positions of the uterine cervix. The primary outcome was the visual analog scale score (VAS) determined 1 h (h) postoperatively., Results: The 152 patients did not differ in their baseline demographics or perioperative characteristics. The mean VAS 1 h postoperatively was significantly lower in the study group than in controls (5.7 ± 1.2 vs. 6.8 ± 1.1, P < 0.001). The average VAS at 30 min, 3 h, and 6 h postoperatively was also significantly lower in the study group. Patients in the study group had a significantly lower analgesic requirement than did controls during the first 24 h postoperatively (6 [7.8 %] vs. 16 [21 %], P = 0.021). Total QoR-40 questionnaire scores were higher in patients who received bupivacaine., Conclusion: Paracervical bloc with 0.5 % bupivacaine just before TLH is an effective and safe method to reduce pain and lower postoperative analgesic requirement. URL LINK THAT LEADS DIRECTLY TO THE TRIAL REGISTRATION: https://clinicaltrials.gov/ct2/show/NCT05341869?cond=NCT05341869&draw=2&rank=1., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest., (Copyright © 2024. Published by Elsevier B.V.)

Introduction: Patients with advanced cancer nearing end of life often present with complex multifactorial pain. Although epidural analgesia is routinely used in inpatient hospital settings for targeted pain control, there is scant description in the literature of the use of low-dose epidural analgesia for relief of cancer-related pain at end of life. In this study, we present a case of difficult to control cancer-related rectal and pelvic pain in a patient who responded well in her last days of life to a low-dose bupivacaine epidural. Case Description: A 66-year-old woman presented for inpatient hospital admission for pain control from home hospice with intractable cancer-related pain from metastatic colorectal adenocarcinoma marked by extensive erosive lesions extending from the anterior perineum to the posterior rectum, with rectovaginal fistula. The patient reported poor tolerance of medications and described spiritual beliefs (based in Buddhism) that caused her and her family to prioritize maintaining a lucid, clear mind above nearly all else while seeking symptom management. The patient was so debilitated by pain at the time of presentation that she was bedbound in a quadruped position. Case Management and Outcome: After 2 weeks of poor pain control in the hospital with multiple failed attempts at palliation-including bilateral pudendal block, as well as opioids and other routine, but potentially sedating or deliriogenic, medications to treat her pain-the patient permitted administration of a low-dose bupivacaine epidural that significantly reduced her pain and allowed the patient to remain clear-headed up until the time of her death. Twenty-three days after admission, and 5 days after initiation of low-dose bupivacaine epidural for pain control, the patient died peacefully in the hospital. Conclusion: Low-dose epidural analgesia for cancer-related pain at end of life from malignancy involving the pelvis-perineum, rectum, or vagina-may be a viable option for patients, particularly those who wish to avoid the risk of somnolence or confusion from systemic opioids and other analgesics.

Competing Interests: The authors declare no conflict of interest.

Opioid-sparing pain management is an integral component of enhanced recovery after colonic and rectal surgery. In our hospital, rectus sheath catheters (RSCs) are routinely placed during emergency laparotomy for colorectal procedures to allow a postoperative compartmental block of the surgical site with repeated doses of bupivacaine. However, RSCs require a significant amount of clinical nursing time to maintain and 'top-up'. We present a quality improvement project in which we administered single-shot liposomal bupivacaine (LB) intraoperatively as an alternative to bolus doses of conventional bupivacaine delivered through RSCs. Having thereby reduced the demands placed on nursing time through a reduction in the use of RSCs, we sought to establish whether there was any associated change in analgesic efficacy. Patient pain scores, use of patient-controlled analgesia (PCA) and length of stay following surgery were analysed before and after the introduction of LB. No disruption in these outcomes was identified using statistical process control analysis. A direct comparison of results for patients who received LB versus those who received bolus dosing of bupivacaine via RSCs found no significant differences, with a median total PCA dose of 270 mg oral morphine equivalents (OME) for patients who received LB versus 396 mg OME for patients who had RSCs (p=0.54). The median length of stay for patients who received LB was 15.5 days versus 16 days for those who had RSCs (p=0.87). We conclude that LB represents a viable alternative to boluses of conventional bupivacaine via RSCs in promoting enhanced recovery after emergency laparotomy and look to extend its use locally., 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: As posterior lumbosacral spine fixation surgeries are common spine procedures done nowadays due to different causes and mostly accompanied with moderate-to-severe postoperative pain, so should find effective postoperative analgesia for these patients. This study aimed to observe analgesic effect of dexmedetomidine combined with bupivacaine versus bupivacaine alone for erector spinae plane block ESPB for postoperative pain control of posterior lumbosacral spine fixation surgeries., Methods: Double-blind randomized controlled study including 90 patients who were randomly allocated into 3 groups (30 patients for each): Dexmedetomidine combined with bupivacaine (DB group), bupivacaine (B group), and saline (control) (S group). US-guided ESPB was performed preoperatively bilaterally in all patients of the 3 groups. All patients received intravenous patient-controlled postoperative analgesia with morphine and 1 gm intravenous paracetamol every 8 hours. Primary clinical outcomes were active (while mobilization) and passive (at rest) visual analog scale (VAS) pain score at first 24 hours measured every 2 hours, opioid consumption (number of PCA presses), and need for rescue analgesia. Other clinical outcomes included active and passive VAS pain score at second 24 hours, measured every 4 hours, opioid consumption, need for rescue analgesia, postoperative opioid side effects, and intraoperative dexmedetomidine side effects as bradycardia and hypotension., Results: Active and passive VAS pain scores, postoperative opioid consumption, need for rescue analgesia, and postoperative opioid side effects were significantly lower in DB group when compared to other groups (B and S groups). There were no additional intraoperative dexmedetomidine side effects as bradycardia and hypotension. The estimated effect-size r was -0.58 and Cohen's d was -1.46., Conclusion: Addition of dexmedetomidine to bupivacaine 0.25% in ESPB for postoperative pain control in patients of posterior lumbosacral spine fixation surgeries resulted in lower active and passive VAS pain scores, decreased postoperative opioid consumption, need for rescue analgesia and postoperative opioid side effects without additional intraoperative dexmedetomidine side effects., Clinicaltrialsgov Identifier: NCT05590234., Competing Interests: The authors declare no conflicts of interest in this study., (© 2024 Abu El Hassan et al.)

Objective: To evaluate the effects of liposomal bupivacaine use for interscalene blocks on postoperative analgesia in total shoulder arthroplasty patients., Methods: De-identified total or reverse total shoulder arthroplasty patients between 2018 and 2021 were analyzed. Patients were grouped into single shot interscalene block with liposomal bupivacaine (LB) with plain bupivacaine, other block (OB) with other local anesthetics (mepivacaine, ropivacaine, or plain bupivacaine), or no block (NB). The primary outcome was the proportion of patients with clinically tolerable pain scores (mean VAS ≤4) from 0 to 24 ​h in each group. Secondary outcomes included averaged visual analog pain scores (VAS) and opioid consumption measured in morphine milligram equivalents (MMEs) from 0 to 24 ​h. We also analyzed the proportion of patients with clinically tolerable pain, mean VAS, and opioid consumption from 0 to 72 ​h in those patients with at least a 3-day hospital length of stay., Results: A total of 491 de-identified total shoulder arthroplasty patients, 285 liposomal bupivacaine group (LB), 178 other block group (OB), and 28 no block group (NB), were analyzed. The primary outcome showed a statistically significant different proportion of patients with clinically tolerable pain from 0 to 24 ​h in the LB group (69 ​%) vs. OB group (39 ​%) vs. NB group (11 ​%) (<0.001). Secondary outcomes included statistically significant differences in VAS (LB median ​= ​3.35, OB median ​= ​4.38, NB median ​= ​5.25 (p ​< ​0.001, <0.001)) and total MME opioid consumption (LB median ​= ​40, OB median ​= ​60, NB median ​= ​88 (p ​< ​0.001, 0.001)) between groups from 0 to 24 ​h. For patients who had hospital stays of at least 3 days, a significant association was found with having achieved clinically tolerable pain 0-72 ​h and the LB group (51 ​%) vs. OB group (21 ​%) vs. NB group (11 ​%) (P ​= ​0.006). However, there was no statistical difference in mean VAS or opioid consumption between these groups., Conclusion: A greater proportion of total shoulder arthroplasty patients that received liposomal bupivacaine in interscalene block have clinically tolerable pain scores from 0 to 24 ​h, lower VAS, and lower MME consumption in patients following total shoulder arthroplasty., Level of Evidence: Level III - Clinical Study., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Importance: Pudendal nerve block has been frequently used as a pain management modality for vaginal prolapse surgery. However, studies investigating its efficacy and the type of anesthetic used have had conflicting results., Objective: This study aimed to evaluate the effect of intraoperative pudendal nerve block with liposomal bupivacaine on postoperative pain after sacrospinous ligament suspension surgery., Study Design: In this single-blinded randomized controlled trial, 83 women undergoing sacrospinous ligament suspension were randomized to receive either intraoperative pudendal nerve block with liposomal bupivacaine or no block. Participants recorded their pain level on postoperative days (PODs) 1-3 and 7, the number of pain medication pills consumed, and the quality of their recovery using a validated questionnaire., Results: There were no significant differences in pain scores between the groups on POD 1 and POD 3: 5 (2-6.25) versus 5.5 (4-8; P = 0.058) and 4 (1-6) versus 5 (2-7; P = 0.146), respectively. On POD 2, the overall pain score was statistically different between the groups, with the block group having lower interquartile ranges. This difference, however, was not clinically significant: 5 (1.75-5) versus 5 (3.25-7.75; P = 0.023). In the subset of participants who underwent a concomitant midurethral sling procedure, POD 2 and POD3 pain scores were significantly lower in those who received the block: 3 (1-5) versus 6 (5-8; P = 0.006) for POD 2 and 3 (1-5) versus 5 (3.250-7; P = 0.042) for POD 3. There were no significant differences in pain medication consumption or the quality of recovery scores., Conclusion: Pudendal nerve block with liposomal bupivacaine did not result in significant differences in postoperative pain after sacrospinous ligament suspension, except in those participants who underwent a concomitant midurethral sling procedure., (Copyright © 2023 American Urogynecologic Society. All rights reserved.)

Background: Liposome bupivacaine (LB) is a long-acting anesthetic to enhance postoperative analgesia. Studies evaluating the efficacy of the LB against an active comparator (bupivacaine or placebo) on acute postoperative pain control in hemorrhoidectomy procedures are few and heterogeneous. Therefore, we performed a systematic review and meta-analysis comparing LB's analgesic efficacy and side effects to conventional/placebo anesthetic in hemorrhoidectomy patients., Methods: We performed a systematic review and meta-analysis of randomised controlled trials investigating the use of LB after haemorrhoidectomy. We searched the literature published from the time of inception of the datasets to August 19, 2022. The electronic databases included English publications in Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, and Scopus., Results: A total of 338 patients who underwent a hemorrhoidectomy procedure enrolled in three randomized clinical trials were included. The overall mean age was 45.84 years (SD ± 11.43), and there was a male predominance (53.55% male). In total 194 patients (52.2%) received LB and 144 (47.8%) received either bupivacaine or placebo. Pain scores at 72 h in the LB (199, 266, and 300 mg) were significantly lower than in the bupivacaine HCl group (p = 0.002). Compared to the bupivacaine/placebo group, the time to first use of opioids in the LB group was significantly longer at LB 199 mg (11 h vs. 9 h), LB 266 mg (19 h vs. 9 h), and LB 300 mg (19 h vs. 8 h) (p < 0.05). Moreover, compared to the bupivacaine/epinephrine group, it was significantly lower in the LB 266 mg group (3.7 vs. 10.2 mg) and at LB 300 mg (13 vs. 33 mg) (p < 0.05). Finally, regarding adverse effects, the conventional anesthetic/placebo group reported more pain in bowel movement than LB groups (OR 2.60, 95% CI 1.31-5.16)., Conclusions: Comparing LB to conventional anesthetic/placebo anesthetic for hemorrhoidectomy, we found a statistically significant reduction in pain through 72 h, decreased opioid requirements, and delayed time to first opioid use. Moreover, the conventional anesthetic/placebo group reported more pain in bowel movement than LB groups., (© 2024. The Author(s).)

Study Design: Retrospective controlled cohort., Objective: To evaluate the effect of intraoperative liposomal bupivacaine (LB) infiltration on postsurgical pain management in adolescent idiopathic scoliosis (AIS) patients by analyzing postoperative opioid consumption, ambulation, and length of stay (LOS)., Summary of Background Data: Optimal postoperative pain control for AIS patients undergoing posterior spinal fusion (PSF) is challenging. Multimodal pain management protocols provide adequate analgesia while decreasing opioid consumption. LB was recently approved for pediatric patients; however, use in AIS patients is understudied., Methods: 119 consecutive patients with AIS who underwent PSF were included. Patients were divided into 2 groups: patients who received LB as erector spinae block in addition to the standard postoperative pain management protocol (Group A), and patients who received only the standard postoperative pain protocol (Group B). Oral morphine equivalents, intravenous opioid and valium consumption, pain scores (VAS), nausea/vomiting, ambulation distance and LOS were assessed., Results: Group A experienced significantly lower total opioid consumption compared to Group B (44.5 mg vs. 70.2 mg). Morphine use was lower in Group A on postoperative day (POD) 0, and oxycodone use was lower in Group A on PODs 1 and 2. There was a higher proportion of patients who used only oral opioids in Group A (81% vs. 41%). Of patients requiring any intravenous opioids, 79% did not receive LB. A significantly higher proportion of LB patients were discharged on POD 2 (55% vs. 27%); therefore, LOS was shorter for Group A. Group A ambulated further postoperatively. There were no differences in pain scores, valium requirements or nausea/vomiting., Conclusions: LB was associated with decreased total opioid use, shorter LOS, and improved ambulation in AIS patients undergoing PSF. Including LB in multimodal pain management protocols proved effective in reducing opioid use while increasing mobilization in the immediate postoperative period., Level of Evidence: 3., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Breast cancer survivors under endocrine therapy (ET) suffer from side effects such as hot flashes and sleep disturbance accompanied by poor quality of life. Many quit ET early and reduce their survival rate. Guidelines recommend gabapentin next to yoga or acupuncture. The role of side effects related to compliance with ET over years require new and effective therapies. Stellate ganglion block (SGB) has shown evidence of safety and efficacy and was found to be more effective than pregabalin without side effects. However, practical guidelines for the long-term use of SGB are still missing. We primarily used procaine instead of bupivacaine presuming effectiveness paired with lower toxic risks. Twenty-nine breast cancer survivors with severe hot flashes and sleep disturbance under ET received SGB with Procaine. Diaries recorded hot flashes and sleep quality scores up to week 24. All patients took part and none refused SGB. Each Patient received one SGB every 4 weeks without any side effects observed. Weekly scores were reduced from baseline by -33.6% (P < .01) (hot flashes) and -22.3% (P < .01) (sleep disturbances) after 4, and by -58.8% (P < .01) (hot flashes) and -50.8% (P < .01) (sleep disturbances) after twenty-for weeks. A wavelike reduction indicated a limited effect of a single SGB during continuous ET. We showed, that procaine in SGB is as effective as bupivacaine with lower risks and costs. High significant reductions in hot flashes and sleep disturbances after 1 and 6 months were found. We conclude that breast cancer survivors need individual treatment with SGB due to her personal impact. Hence, SGB should find its way to guidelines and daily routines as a valuable method for treating side effects in breast cancer survivors undergoing ET., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: Postoperative delirium (POD) is the most common acute fluctuating mental state change after hip fractures in older adults. Postoperative pain is a Grade A risk factor for POD and is closely related to the prognosis of patients undergoing hip fracture surgery. The fascia iliac block has a definite analgesic effect and few side effects, and several studies have reported that it reduces the occurrence of POD in patients undergoing general anaesthesia for hip fracture surgery. Liposomal bupivacaine is a local anaesthetic with a long half-life that significantly reduces the use of opioids and is conducive to patient prognosis and recovery. However, whether regional nerve block analgesia can decrease the occurrence of POD in elderly patients undergoing hip fracture surgery has not been reported., Methods and Analysis: This is a single-blinded, randomised, parallel-controlled prospective clinical study. Participants will be randomly assigned preoperatively to either the liposomal bupivacaine (ie, Exparel) or ropivacaine groups by block randomisation. Then, the occurrence of POD (primary outcome) and postoperative pain (secondary outcome) will be evaluated., Ethics and Dissemination: This research protocol complies with the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 guidelines and is approved by the Ethics Committee of Shanghai General Hospital (ID 2023-437). The original data are expected to be released in July 2029 on the ResMan original data-sharing platform (IPD-sharing platform) of the China Clinical Trial Registry, which can be viewed on the following website: http://www.medresman.org.cn., Prospero Registration Number: ChiCTR2300074022., 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: Perioperative care after surgery for thoracic outlet syndrome (TOS) involves multimodal pain control. Pain catheters with bupivacaine infusion are a modality to minimize perioperative narcotic use. Our study aims to compare surgically placed pain catheters (SP) with erector spinae pain catheters (ESP) placed by the anesthesia pain service., Methods: Retrospective review of a prospectively maintained surgical TOS database identified patients undergoing transaxillary first rib resection (FRR) who had either SP or ESP placed for pain control. Patients were matched for age and gender. Data collected included demographics, operative details, and perioperative pain medication use. Narcotic pain medication doses were converted to milligram morphine equivalents (MMEs) for comparison between groups. Pain medications were collected for several time points: intraoperatively, for each postoperative day (POD) and for the entire hospital stay., Results: Eighty-eight total patients were selected for comparison: 44 patients in the SP and ESP groups. Patients in each group did not differ with regards to age, body mass index, gender, diagnosis, or comorbidities. There were no differences in preoperative narcotic use, preoperative pain score, or Quick Disabilities of Arm, Shoulder, and Hand score. All patients underwent FRR. Concurrent cervical rib resection was performed in 6.8% SP and 6.8% ESP patients (P = 1.00), pectoralis minor tenotomy in 34.1% SP and 29.5% ESP patients (P = 0.65), and venogram in 31.8% SP and 31.8% ESP patients (P = 1.00). Mean operating room time was 90.0 min in SP and 105.3 min in ESP cases (P = 0.15). Mean length of stay was 1.9 days for SP and 1.8 days for ESP patients (P = 0.56). There were no significant differences in intraoperative narcotics dosing in MME (SP: 22.1 versus ESP: 25.3, P = 0.018). On POD 0, there were no differences in total narcotics dosing (MME) (SP: 112.0 versus ESP: 100.7, P = 0.59), or in the use of acetaminophen, nonsteroidal anti-inflammatory drugs, or muscle relaxants. A similar trend in narcotics dosing was observed on POD 1 (SP: 58.6 versus ESP: 69.7, P = 0.43) and POD 2 (SP: 23.5 versus ESP: 71.3, P = 0.23). On POD 1, there was a higher percentage of SP patients taking nonsteroidal anti-inflammatory drugs (63.6% vs. 40.9%, P = 0.024); however, this difference was not observed on POD 2. There were no differences in acetaminophen or muscle relaxant use on POD 1 or 2. Total hospital stay MME was similar between groups (SP: 215.9 versus ESP: 250.9, P = 0.23)., Conclusions: Pain catheters with bupivacaine infusions are helpful adjuncts in postoperative pain control after FRR for TOS. This study compares SP to ESP and demonstrates no difference in narcotics use between SP and ESP groups. SP should be used for pain control in facilities which do not have an anesthesia pain service available for ESP placement., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To investigate postoperative analgaesic efficacy of modified thoracoabdominal nerve block through perichondrial approach (M-TAPA) and its effect on opioid consumption in patients undergoing laparoscopic cholecystectomy (LC) surgery., Study Design: Randomised, controlled trial. Place and Duration of the Study: Department of Anaesthesiology and Reanimation, Sivas Cumhuriyet University, Sivas, Turkiye, from April to May 2023., Methodology: The study was conducted in two randomised groups: M-TAPA (n = 21) and control group (CG) (no block) (n = 21). All patients had standard general anaesthesia. M-TAPA patients had bilateral M-TAPA block with 0.25% bupivacaine (total volume, 40 ml) at the end of the surgery. In contrast, CG patients had only tramadol for postoperative pain. A numerical rating scale (NRS) and visual analogue scale (VAS) were used for postoperative pain assessment. Total tramadol consumption was calculated., Results: M-TAPA's NRS and VAS scores were lower in postoperative 24 hours (p<0.05). Total tramadol consumption was 116.67 ± 32.91 mg in CG and 35.71 ± 39.19 mg in M-TAPA (p<0.001)., Conclusion: Bilateral M-TAPA block for postoperative pain control after LC surgery provided effective analgaesia for up to 24 hours and reduced total opioid consumption. Although the M-TAPA block is a novel approach, it will be a part of multimodal analgaesia for routine postoperative pain management in abdominal surgeries. However, more studies with higher numbers of patients will be needed., Key Words: Analgaesia, Bupivacaine, Laparoscopic cholecystectomy, Nerve block, Pain management.

Objective: To evaluate the effectiveness of a liposomal-encapsulated bupivacaine suspension (LEBS; Nocita), at a 1:5 dilution with 0.9% NaCl, for the reduction of postoperative pain scores and a related reduction in the need for postoperative opioids in dogs undergoing ventral midline celiotomy., Hypothesis: When infused at a 1:5 dilution, LEBS results in less postoperative pain (as indicated by pain scale scores), and a reduction in postoperative opioids, in dogs undergoing ventral midline celiotomy. The use of LEBS does not affect wound healing when compared to placebo., Study Design: This was a randomized, blinded, prospective clinical trial., Animals: We studied 40 client-owned dogs undergoing abdominal surgery via a ventral midline celiotomy., Procedure: Dogs undergoing a ventral midline celiotomy were enrolled and randomly allocated to 1 of 2 groups: those receiving LEBS or a placebo injection protocol into tissue planes during closure. The Glasgow Composite Pain Scale-Short Form (GCPS-SF) was used by an observer blinded to the treatment group to assess patients at 0, 1, 2, 6, 12, 18, 24, 30, 36, 42, 48, 54, 60, 66, and 72 h after extubation. Dogs with a score of ≥ 3 in any single category or ≥ 6 total were given a rescue analgesia. Data were analyzed to compare the number of rescue therapy doses administered between the 2 treatment groups., Results: Forty dogs completed the study. Dogs that received a diluted LEBS protocol were equally likely to require a rescue therapy as those that received the placebo (0.9% NaCl). There were no significant difference in the pain scores or the total number of opioid injections required between the 2 treatment groups., Conclusion and Clinical Relevance: In dogs undergoing ventral midline celiotomy, 1:5 diluted LEBS administration alone should not be considered the sole method of pain relief. Liposomal-encapsulated bupivacaine suspension should be used in conjunction with systemic opioids as part of a multimodal analgesic regime. This multimodal approach would allow a reduction in dose or frequency of opioids, therefore lessening the undesired side effects associated with opioids while also decreasing client costs., (Copyright and/or publishing rights held by the Canadian Veterinary Medical Association.)

Purpose: We sought to determine if the addition of liposomal bupivacaine to bupivacaine hydrochloride improves opioid-free rate and postoperative pain scores among children undergoing ambulatory urologic surgery., Materials and Methods: A prospective, phase 3, single-blinded, single-center randomized trial with superiority design was conducted in children 6 to 18 years undergoing ambulatory urologic procedures between October 2021 and April 2023. Patients were randomized 1:1 to receive dorsal penile nerve block (penile procedures) or incisional infiltration with spermatic cord block (inguinal/scrotal procedures) with weight-based liposomal bupivacaine plus bupivacaine hydrochloride or bupivacaine hydrochloride alone. The primary outcome was opioid-free rate at 48 hours. Secondary outcomes included parents' postoperative pain measure scores, numerical pain scale scores, and weight-based opioid utilization at 48 hours and 10 to 14 days., Results: We randomized 104 participants, with > 98% (102/104) with complete follow-up data at 48 hours and 10 to 14 days. At interim analysis, there was no significant difference in opioid-free rate at 48 hours between arms (60% in the intervention vs 62% in the control group; estimated difference in proportion -1.9% [95% CI, -20%-16%]; P = .8). We observed no increased odds of patients being opioid-free at 48 hours with the intervention compared to the control group (OR 0.96 [95% CI 0.41-2.3]; P = .9). The trial met the predetermined futility threshold for early stopping. There was no difference in parents' postoperative pain measure scores, numerical pain scale scores, or opioid utilization at 48 hours or 10 to 14 days. No difference in adverse events was observed., Conclusions: The addition of liposomal bupivacaine to bupivacaine hydrochloride did not significantly improve opioid-sparing effect or postoperative pain compared with bupivacaine hydrochloride alone among children ≥ 6 years undergoing ambulatory urologic surgery.

Objective: The transversus abdominis plane (TAP) block and local anaesthetic infiltration (LAI) of port sites provide adequate analgesia after laparoscopic cholecystectomy (LC). Little is known if the two techniques affect the day-case (DC) rate of LC. We tested the appropriateness of the research design in view of a larger randomised controlled trial (RCT) - laparoscopic-assisted right subcostal TAP block plus local anaesthetic wound infiltration (STALA) versus LAI., Subjects and Methods: Sixty patients having DC LC were randomised into STALA and LAI. Participants received bupivacaine 0.5% 30 mL. Pain scores were evaluated with the Visual Analogue Scale (VAS) score, at 1 h post-surgery and at discharge. Need of postoperative intravenous (IV) opioids, DC rate, and Quality of Recovery-15 questionnaires were compared between groups and were considered as measures of efficacy of the interventions and follow-up in a definitive trial., Results: Twenty-nine participants were randomised to STALA, and 31 to LAI. Subjects in LAI group were all women (p = 0.0007) and younger (43.8 vs. 37.7 years, p = 0.023). Median VAS scores were 0 versus 1 at 1 h (p = 0.60), 0 versus 1.5 at discharge (p = 0.55). The need of IV opioids was 15/29 (51.7%) versus 13/31 (41.9%; p = 0.60). The DC rate was 93.1% versus 93.5% (p = 0.39). Fifty (83.3%) participants responded the questionnaires., Conclusions: The laparoscopically guided right subcostal TAP block provided no additional benefit to LAI on pain control after LC and DC rate. Despite the appropriate design, our findings do not support a larger RCT., (© 2024 The Author(s). Published by S. Karger AG, Basel.)

A 39-year-old woman with juvenile idiopathic arthritis complicated by nonuremic calciphylaxis presented for pain management of bilateral lower extremity wounds requiring frequent dressing changes. Bilateral single-shot femoral nerve blocks using liposomal bupivacaine and 0.25% bupivacaine were performed. The patient reported decreased pain scores and had reduced opioid use for 72 hours postblock. Repeat, bilateral single-shot femoral nerve blocks with liposomal bupivacaine and 0.25% bupivacaine were performed approximately every 72 hours to maintain adequate analgesia. We conclude that off-label use of liposomal bupivacaine in femoral nerve blocks results in prolonged block duration without adverse effects or tachyphylaxis., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2023 International Anesthesia Research Society.)

Background/aim: In this study, it was aimed to retrospectively compare the effect of greater occipital nerve (GON) block performed with ultrasonography using low (0.3%) and high (0.5%) concentrations of bupivacaine on pain scores and patient satisfaction in chronic migraine (CM)., Materials and Methods: The mean number of days with pain, the mean duration of pain in the attacks, and the highest numerical rating scale (NRS) scores recorded in the 1 month preblock and 1 and 3 months postblock of 80 patients (40 for Group 1, 0.3% bupivacaine; 40 for Group 2, 0.5% bupivacaine) who underwent ultrasonography-guided GON block were recorded from the patient file data. According to the protocol applied by our clinic, GON block was applied to each patient 6 times with the same procedures, in total., Results: While there was a statistically significant difference between the groups in terms of the number of days with pain and the maximum NRS score in the 1-month preblock evaluation (p = 0.01, p < 0.001), at 3 months postblock, no statistical difference was observed in terms of the number of days with pain, duration of pain, or NRS score (p = 0.961, p = 0.108, and p = 0.567). In the intragroup evaluations, at 3 months postblock, the number of days with pain decreased from 17.5 days to 7 days in Group 1 and from 24.0 days to 8.0 days in Group 2. The duration of pain and maximum NRS values were statistically significantly decreased in the intragroup evaluation in both groups pre and postblock., Conclusion: Complications arising from the procedure and the local anesthetic used are essential points to consider in applying GON block. In CM treatment using GON block application, a similar effect to the standard local anesthetic application (0.5%) can be achieved by administering local anesthetic at a lower dose (0.3%)., Competing Interests: Conflict of interest: The authors declare that they have no conflicts of interest., (© TÜBİTAK.)

Background: Postoperative pain continues to be an undermanaged part of the surgical experience. Multimodal analgesia has been adopted in response to the opioid epidemic, but opioid prescribing practices remain high after minimally invasive hysterectomy. Novel adjuvant opioid-sparing analgesia to optimize acute postoperative pain control is crucial in preventing chronic pain and minimizing opioid usage., Objective: This study aimed to determine the effect of direct laparoscopic uterosacral bupivacaine administration on opioid usage and postoperative pain in patients undergoing benign minimally invasive (laparoscopic and robotic) hysterectomy., Study Design: This was a single-blinded, triple-arm, randomized controlled trial at an academic medical center between March 15, 2021, and April 8, 2022. The inclusion criteria were patients aged >18 years undergoing benign laparoscopic or robotic hysterectomy. The exclusion criteria were non-English-speaking patients, patients with an allergy to bupivacaine or actively using opioid medications, patients undergoing transversus abdominis plane block, and patients undergoing supracervical hysterectomy or combination cases with other surgical services. Patients were randomized in a 1:1:1 fashion to the following uterosacral administration before colpotomy: no administration, 20 mL of normal saline, or 20 mL of 0.25% bupivacaine. All patients received incisional infiltration with 10 mL of 0.25% bupivacaine. The primary outcome was 24-hour oral morphine equivalent usage (postoperative day 0 and postoperative day 1). The secondary outcomes were total oral morphine equivalent usage in 7 days, last day of oral morphine equivalent usage, numeric pain scores from the universal pain assessment tool, and return of bowel function. Patients reported postoperative pain scores, total opioid consumption, and return of bowel function via Qualtrics surveys. Patient and surgical characteristics and primary and secondary outcomes were compared using chi-square analysis and 1-way analysis of variance. Multiple linear regression was used to identify predictors of opioid use in the first 24 hours after surgery and total opioid use in the 7 days after surgery., Results: Of 518 hysterectomies screened, 410 (79%) were eligible, 215 (52%) agreed to participate, and 180 were ultimately included in the final analysis after accounting for dropout. Most hysterectomies (70%) were performed laparoscopically, and the remainder were performed robotically. Most hysterectomies (94%) were outpatient. Patients randomized to bupivacaine had higher rates of former and current tobacco use, and patients randomized to the no-administration group had higher rates of previous surgery. There was no difference in first 24-hour oral morphine equivalent use among the groups (P=.10). Moreover, there was no difference in numeric pain scores (although a trend toward significance in discharge pain scores in the bupivacaine group), total 7-day oral morphine equivalent use, day of last opioid use, or return of bowel function among the groups (P>.05 for all). The predictors of increased 24-hour opioid usage among all patients included only increased postanesthesia care unit oral morphine equivalent usage. The predictors of 7-day opioid usage among all patients included concurrent tobacco use and mood disorder, history of previous laparoscopy, estimated blood loss of >200 mL, and increased oral morphine equivalent usage in the postanesthesia care unit., Conclusion: Laparoscopic uterosacral administration of bupivacaine at the time of minimally invasive hysterectomy did not result in decreased opioid usage or change in numeric pain scores., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Craniotomy tumour is brain surgery that can induce a stress response. The stress response can be measured using haemodynamic parameters and plasma cortisol concentration. The stress response that occurs can affect an increase in sympathetic response, such as blood pressure and heart rate, which can lead to an increase in intracranial pressure. Scalp block can reduce the stress response to surgery and post-operative craniotomy tumour pain. The local anaesthetic drug bupivacaine 0.25% is effective in reducing post-operative pain and stress in the form of reducing plasma cortisol levels. The adjuvant addition of clonidine 2 μg/kg or dexamethasone may be beneficial., Materials and Methods: A randomised control clinical trial was conducted at the Central Surgery Installation and Hasan Sadikin General Hospital Bandung and Dr. Mohammad Husein Hospital Palembang from December 2022 to June 2023. A total of 40 participants were divided into two groups using block randomisation. Group I receives bupivacaine 0.25% and clonidine 2 μg/kg, and group II receives bupivacaine 0.25% and dexamethasone 8 mg. The plasma cortisol levels of the patient will be assessed at (T0, T1 and T2). All the patient were intubated under general anesthaesia and received the drug for scalp block based on the group being randomised. Haemodynamic monitoring was carried out., Results: There was a significant difference in administering bupivacaine 0.25% and clonidine 2μg/kg compared to administering bupivacaine 0.25% and dexamethasone 8 mg/kg as analgesia for scalp block in tumour craniotomy patients on cortisol levels at 12 hours post-operatively (T1) (p=0.048) and 24 hours post-surgery (T2) (p=0.027), while post-intubation cortisol levels (T0) found no significant difference (p=0.756). There is a significant difference in Numeric Rating Scale (NRS) at post-intubation (T0) (p=0.003), 12 hours post-operatively (T1) (p=0.002) and 24 hours post-surgery (T2) (p=0.004), There were no postprocedure scalp block side effects in both groups., Conclusion: The study found that scalp block with 0.25% bupivacaine and 2μg/kg clonidine is more effective in reducing NRS scores and cortisol levels compared bupivacaine 0.25% and dexamethasone 8mg in tumour craniotomy patients.

Background: Liposomal bupivacaine (LB) is a long-acting local anesthetic used for postsurgical analgesia to reduce pain and the need for opioid pain medication., Purpose: The purpose of this study was to assess patient interest in the use of LB as an alternative to opioid pain medication following third molar extraction., Study Design, Setting, Sample: A cross-sectional, questionnaire-based study was performed. Study subjects included patients 17 years old or greater who presented to the Oral and Maxillofacial Surgery clinic at Thomas Jefferson University for third molar extraction from May 2019 through January 2020., Main Outcome Variables: The primary outcome variable was patient interest in LB, defined by "yes" or "no" from the survey question: "would you be interested in an alternative medication administered during the procedure that may decrease the need for opioid pain medication?". The secondary outcome variable was patient willingness to pay (WTP) for LB, defined by the out-of-pocket cost threshold patients reported they would pay., Covariates: Covariates included patient demographics, attitudes towards opioid medication, and prior opioid use., Analyses: Data were analyzed using descriptive statistics, Fisher's exact test, Kruskal-Wallis and Dunn's tests, Kendall's tau correlation, and multivariable logistic regression. Statistical significance was set at P value < .05., Results: A total of 183 subjects completed the study (68% female, 32% male). The mean age was 27.5 years ± 11.1 years. Most subjects (76%) were interested in LB, but 88% had a WTP threshold below $200. Interest in LB was associated with higher WTP thresholds (adjusted odds ratio {aOR} 2.07; 95% confidence interval {CI} [1.48, 3.13]; P < .001). There was also an association between interest and subjects concerned of the addictive potential of opioids (aOR 4.04; 95% CI [1.52, 11.49]; P = .01) and between interest and previous use of prescribed opioid medication (aOR 6.00; 95% CI [1.59, 31.23]; P = .02)., Conclusions and Relevance: Although most subjects were interested in LB, the current out-of-pocket cost of LB appears to be a barrier to patient acceptability. A lower cost option may increase the accessibility and adoption of this nonopioid analgesic for postoperative pain control in third molar extractions., (Copyright © 2023 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Open major abdominal surgery is one of the most risky surgical procedures for acute postoperative pain. Thoracic epidural analgesia (TEA) has been considered the standard analgesic approach. In different reports, lidocaine i.v. has been shown to have an analgesic efficacy comparable with TEA. We compared the analgesic efficacy of i.v. lidocaine with thoracic epidural analgesia using bupivacaine in patients undergoing major abdominal surgery., Methods: In this noninferiority clinical trial, 210 patients were randomised to thoracic epidural bupivacaine with morphine or i.v. lidocaine. Dynamic pain at 24 h after surgery was measured using a numerical pain rating scale (NPR), and morphine consumption was also measured. A difference in i.v. the lidocaine-epidural bupivacaine NPR of ≤1 for dynamic pain was considered a noninferiority margin., Results: The NPR for dynamic pain in the lidocaine group at 24 h was between 5.7 (1.8) and 5.2 (1.9) in the epidural group, with a difference of 0.53 (95% confidence interval 0.0-1.0). In the first 24 h, the average difference in morphine consumption was 1.8 mg between the i.v. lidocaine and epidural groups (95% confidence interval 1-3 mg). No differences were found in adverse events or complications associated with the procedures., Conclusions: Intravenous lidocaine is noninferior to thoracic epidural analgesia for acute postoperative pain control in major abdomial surgery at 24 h postoperatively., Clinical Trials Registration: NCT04017013., (Copyright © 2023 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Objective: To determine the dose effect of peri-neural liposomal bupivacaine (LB) in an induced forelimb lameness model., Animals: 12 clinically normal adult horses., Methods: A randomized cross-over design was performed with 1 limb receiving saline and the other LB: low dose (6), high dose (6). Lameness was induced in 1 forelimb using a frog-pressure model. In the lame limb, peri-neural injection of the palmar nerves at the proximal sesamoid bones was performed using saline, low dose LB (0.25 mg/kg) (LDLB), or high dose LB (0.5mg/kg) (HDLB) in random order with a 1-week washout period between treatments. Distal limb swelling, mechanical nociceptive thresholds (MNT), and objective lameness data were collected before and up to 72 hours after peri-neural anesthesia. Data analysis was performed with mixed model ANOVA, equality of medians test, and Kaplan Meier survival analysis., Results: Compared with baseline, horses treated with LDLB and HDLB had improvements in MNT and lameness (P < .001). In the LDLB group, the median duration of analgesia was 4.5 hours (range = 3-6 hours) and the median return to lameness was 7 hours (range = 4-24 hours). In the HDLB group, the median duration of analgesia was 12 hours (range = 4-48 hours) and the median return to lameness was 9 hours (range = 3-48 hours). Mild to moderate swelling was identified in 11/12 (92%) LB limbs., Clinical Relevance: Both LDLB and HDLB resulted in loss of skin sensation and improvement of lameness. There was high variability among horses in duration of action for both doses.

Objective: To evaluate the difference in postoperative pain scores of dogs undergoing abdominal surgery receiving surgical incision infiltration of saline or bupivacaine liposomal injectable suspension (BLIS)., Animals: 40 dogs undergoing exploratory laparotomy., Methods: Dogs were prospectively enrolled and randomized to receive either BLIS or saline surgical incision infiltration. All dogs received 5.3 mg of BLIS/kg or an equal volume of saline infiltrated in the muscle/fascia, subcutaneous tissue, and intradermal layer during closure. All dogs received a standardized postoperative pain management protocol. Pain assessment was performed at select time points postoperatively by blinded observers with an electronic algometer, short version of the Glasgow Composite Measure Pain Scale (GCMPS), and indirect measures of pain, including systolic blood pressure, heart rate, and serum cortisol levels., Results: At day 0, blood pressure was higher in the saline group (149.6 vs 125.8 mm Hg; P = .006). At day 3, GCMPS was lower in the BLIS group (BLIS = 1, saline = 2, P = .027), though both average GCMPS scores were low and only 10 dogs were available for day 3 assessments (6 BLIS and 4 saline). No other differences in algometer readings, GCMPS scores, other measured parameters, or need for rescue analgesia were present between BLIS and saline groups at any time point. There was no difference in postoperative incisional infection rate or complications., Clinical Relevance: Use of BLIS for exploratory laparotomy did not provide improved pain control over postoperative opioid administration alone. Patients that received BLIS had no increase in short-term complications.