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Anesthesia and Pain Management

Works Count: 132520

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This cluster of papers focuses on the management of postoperative pain, risk factors, and complications associated with various anesthesia techniques. It covers topics such as regional anesthesia, chronic pain, analgesia efficacy, surgical outcomes, and perioperative care.

Keywords

Postoperative Pain; Regional Anesthesia; Chronic Pain; Analgesia; Surgical Outcome; Epidural Analgesia; Pain Management; Neuraxial Blockade; Acute Pain; Perioperative Care

Epidural versus non-epidural or no analgesia in labour

2011-12-05

Millicent Anim-Somuah , Rebecca MD Smyth , Leanne Jones

Cardiac Arrest Following Regional Anesthesia with Etidocaine or Bupivacaine

1979-10-01

George A. Albright

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Acute Pain after Thoracic Surgery Predicts Long-Term Post-Thoracotomy Pain

1996-03-01

Joel Katz , Marla Jackson , Brian P. Kavanagh +1 more

Objective: Long-term pain is a common sequela of thoracotomy, occurring in approximately 50% of patients 2 years after thoracic surgery. Despite this alarming statistic, little is known about the factors … Objective: Long-term pain is a common sequela of thoracotomy, occurring in approximately 50% of patients 2 years after thoracic surgery. Despite this alarming statistic, little is known about the factors responsible for the transition of acute to chronic pain. The aim of the present study is to identify predictors of long-term post-thoracotomy pain. Design: Follow-up was for 1.5 years for patients who had participated in a prospective, randomized, controlled trial of preemptive, multimodal analgesia. Setting: Subjects were recruited from a tertiary care center. Patients: Thirty patients who had undergone lateral thoracotomy were followed up by telephone, administered a structured interview, and classified according to long-term pain status. Main Outcome Measures: Present pain status was measured by a verbal rating scale (VAS). Measures obtained within the first 48 h after surgery were compared between patients with and without pain 1.5 years later. These include VAS pain scores at rest and after movement, McGill Pain Questionnaire data, patient-controlled morphine consumption (mg), and pain thresholds to pressure applied to a rib contralateral to the thoracotomy incision. Results: Fifty-two percent of patients reported long-term pain. Early post-operative pain was the only factor that significantly predicted long-term pain. Pain intensity 24 h after surgery, at rest, and after movement was significantly greater among patients who developed long-term pain compared with pain-free patients. A significant predictive relationship was also found at 24 and 48 h using the McGill Pain Questionnaire. Cumulative morphine was comparable for the two groups. Pain thresholds to pressure applied to a rib contralateral to the incision did not differ significantly between the groups. Conclusion: Aggressive management of early postoperative pain may reduce the likelihood of long-term post-thoracotomy pain.

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Predictors of Postoperative Pain and Analgesic Consumption

2009-08-19

Hui Yun Vivian Ip , Amir Abrishami , Philip Peng +2 more

Pain is a subjective and multidimensional experience that is often inadequately managed in clinical practice. Effective control of postoperative pain is important after anesthesia and surgery. A systematic review was … Pain is a subjective and multidimensional experience that is often inadequately managed in clinical practice. Effective control of postoperative pain is important after anesthesia and surgery. A systematic review was conducted to identify the independent predictive factors for postoperative pain and analgesic consumption. The authors identified 48 eligible studies with 23,037 patients included in the final analysis. Preoperative pain, anxiety, age, and type of surgery were four significant predictors for postoperative pain. Type of surgery, age, and psychological distress were the significant predictors for analgesic consumption. Gender was not found to be a consistent predictor as traditionally believed. Early identification of the predictors in patients at risk of postoperative pain will allow more effective intervention and better management. The coefficient of determination of the predictive models was less than 54%. More vigorous studies with robust statistics and validated designs are needed to investigate this field of interest.

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Prevalence of and Factors Associated With Persistent Pain Following Breast Cancer Surgery

2009-11-10

Rune Gärtner , Maj‐Britt Jensen , Jeanette K.S. Nielsen +3 more

<h3>Context</h3> Persistent pain and sensory disturbances following surgical treatment for breast cancer is a significant clinical problem. The pathogenic mechanisms are complex and may be related to patient characteristics, surgical … <h3>Context</h3> Persistent pain and sensory disturbances following surgical treatment for breast cancer is a significant clinical problem. The pathogenic mechanisms are complex and may be related to patient characteristics, surgical technique, and adjuvant therapy. <h3>Objective</h3> To examine prevalence of and factors associated with persistent pain after surgical treatment for breast cancer. <h3>Design, Setting, and Patients</h3> A nationwide cross-sectional questionnaire study of 3754 women aged 18 to 70 years who received surgery and adjuvant therapy (if indicated) for primary breast cancer in Denmark between January 1, 2005, and December 31, 2006. A study questionnaire was sent to the women between January and April 2008. <h3>Main Outcome Measures</h3> Prevalence, location, and severity of persistent pain and sensory disturbances in 12 well-defined treatment groups assessed an average of 26 months after surgery, and adjusted odds ratio (OR) of reported pain and sensory disturbances with respect to age, surgical technique, chemotherapy, and radiotherapy. <h3>Results</h3> By June 2008, 3253 of 3754 eligible women (87%) returned the questionnaire. A total of 1543 patients (47%) reported pain, of whom 201 (13%) had severe pain, 595 (39%) had moderate pain, and 733 (48%) had light pain. Factors associated with chronic pain included young age (18-39 years: OR, 3.62; 95% confidence interval [CI], 2.25-5.82;<i>P</i> < .001) and adjuvant radiotherapy (OR, 1.50; 95% CI, 1.08-2.07;<i>P</i> = .03), but not chemotherapy (OR, 1.01; 95% CI, 0.85-1.21;<i>P</i> = .91). Axillary lymph node dissection (ALND) was associated with increased likelihood of pain (OR, 1.77; 95% CI, 1.43-2.19;<i>P</i> < .001) compared with sentinel lymph node dissection. Risk of sensory disturbances was associated with young age (18-39 years: OR, 5.00; 95% CI, 2.87-8.69;<i>P</i> < .001) and ALND (OR, 4.97; 95% CI, 3.92-6.30;<i>P</i> < .001). Pain complaints from other parts of the body were associated with increased risk of pain in the surgical area (<i>P</i> < .001). A total of 306 patients (20%) with pain had contacted a physician within the prior 3 months for pain complaints in the surgical area. <h3>Conclusion</h3> Two to 3 years after breast cancer treatment, persistent pain and sensory disturbances remain clinically significant problems among Danish women who received surgery in 2005 and 2006.

α2-Adrenergic Agonists for Regional Anesthesia

1996-09-01

James C. Eisenach , Marc De Kock , Walter Klimscha

(Eisenach) Professor and Chair for Anesthesia Research, Wake Forest University Medical Center, Winston-Salem, North Carolina.(De Kock) Staff Anesthesiologist, Service d'Anesthesiologie, Universite Catholique de Louvain, Brussels, Belgium.(Klimscha) Staff Anesthesiologist, University of … (Eisenach) Professor and Chair for Anesthesia Research, Wake Forest University Medical Center, Winston-Salem, North Carolina.(De Kock) Staff Anesthesiologist, Service d'Anesthesiologie, Universite Catholique de Louvain, Brussels, Belgium.(Klimscha) Staff Anesthesiologist, University of Vienna, Vienna, Austria.From the Department of Anesthesia, Wake Forest University Medical Center, Winston-Salem, North Carolina, and Universite Catholique de Louvain, Brussels, Belgium. Submitted for publication January 26, 1996. Accepted for publication May 10, 1996. Supported in part by National Institutes of Health grants GM35523 and GM48085. Dr. Eisenach is a consultant to Fujisawa, USA, which is developing clonidine for epidural use in the United States, and Abbott Laboratories, which is developing dexmedetomidine for intravenous use in the United States.Address reprint requests to Dr. Eisenach: Department of Anesthesia, Wake Forest University Medical Center, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1009. Address electronic mail to: [email protected] words: Alpha2-adrenergic agonists, clonidine. Anesthetic techniques; epidural; spinal. Pain.Alpha2-ADRENERGIC mechanisms of analgesia have been exploited for more than 100 yr. Cocaine, the first spinal anesthetic, produces analgesia primarily by its local anesthetic action, but also inhibits norepinephrine re-uptake, and spinal cocaine produces analgesia, in part, by enhancing noradrenergic stimulation of alpha2-adrenoceptors. [1]Near the turn of the century, epinephrine was shown to produce spinal analgesia in animals, [2]an effect now recognized to be secondary to alpha2-adrenoceptor stimulation. [3,4]Nearly 50 yr ago, spinal epinephrine alone was shown to produce clinically useful analgesia, [5]although it is most commonly combined with local anesthetics for this purpose.Veterinarians have used alpha2-adrenergic agonists (xylazine, detomidine, medetomidine) for many years for regional analgesia, but experience with these agents in humans dates back only slightly more than 10 yr. In 1984, Tamsen and Gordh, [7]after testing for neurotoxicity in animals, [6]injected a parenteral preparation of the alpha2-adrenergic agonist, clonidine, epidurally in two patients with chronic pain. Since then, a complete toxicologic assessment (effects on spinal cord blood flow, [8-10]behavior after lumbar and cervical intrathecal injection in sheep and monkeys, [11,12]and histopathology in sheep, rats, and dogs [11,13,14]) has suggested that clonidine is safe for intraspinal use, and the vast majority of publications examining injectable clonidine for analgesia come from Europe, using their commercially available preparation. In the United States, a preservative-free preparation of clonidine has been submitted to the Food and Drug Administration for approval under the orphan drug indication of epidural treatment for intractable cancer pain.The goal of this review is to provide a clinically useful synthesis of published experience with clonidine for regional anesthesia, focusing on efficacy when administered alone and in combination with other analgesics in specific patient populations and appropriate monitoring and treatment of side effects. A reasonably comprehensive review of publications through 1995 includes 2,116 patients treated with clonidine via epidural, intrathecal, or peripheral injection (Table 1). Neuraxial administration reports consist primarily of single or multiple boluses for < 24 h (1,437 patients, 77% of total), followed by brief (< 48 h) continuous infusion (270 patients, 15% of total). Prolonged epidural infusion for > 1 week in the treatment of chronic pain represents 148 patients, only 8% of the total.Alpha2-Adrenoceptors are located on primary afferent terminals (both at peripheral and spinal endings), on neurons in the superficial laminae of the spinal cord, and within several brainstem nuclei implicated in analgesia, [15]supporting the possibility of analgesic action at peripheral, spinal, and brainstem sites. Experimental work in animals supports analgesic actions of alpha2-adrenergic agonists at all three sites, although their relative importance is controversial. Notably lacking are alpha2-adrenoceptors on axons of peripheral nerves. Clonidine does produce a minor degree of nerve conduction blockade at high concentrations, however, with some preference for C-fibers. [16-18]This conduction blockade may underlie, in part, the enhancement of peripheral nerve block when this agent is added to local anesthetics (see below).Several lines of evidence support a spinal action of clonidine in producing analgesia in humans. First, in a study in volunteers, [19]a single lumbar epidural bolus injection of clonidine produced analgesia in the lower, but not upper, extremity against a noxious cold stimulus, as would be anticipated from a spinal action. When clonidine was infused for 4 h in the lumbar epidural space in a subsequent study in volunteers, [20]analgesia spread to the upper extremity, suggesting that more extensive dermatomal distribution of analgesia is possible with continuous infusion.Second, pharmacokinetic and dynamic analysis supports a spinal site of action of clonidine in humans. After epidural administration in volunteers and patients, clonidine is rapidly absorbed, with peak concentrations in arterial blood within 10 min and in venous blood within 30-45 min (Table 2). Elimination from blood is slow (Table 2) compared with the relatively brief duration of analgesia after epidural clonidine administration (3-5 h), arguing against an action by systemic absorption and redistribution to peripheral or central sites. As expected from these divergent time courses, the correlation between blood clonidine concentration and analgesia within individuals is relatively poor.In contrast to blood, there is a strong correlation between clonidine concentration in cerebrospinal fluid (CSF) and analgesia after epidural clonidine administration. Clonidine is rapidly and extensively absorbed into the spinal CSF compartment after epidural administration (Table 2), with concentrations peaking 30-60 min after injection. This coincides closely with attainment of near-maximal analgesia. In volunteers, [19]there is a close correlation between lumbar CSF clonidine concentration and analgesia to a noxious stimulus to the lower extremity, with a concentration producing a 95% maximal effect (EC95) of 130 ng/ml (Figure 1). This agrees with the observation in patients after surgery that rescue pain medication usage by patient-controlled analgesia (PCA) approaches zero when calculated CSF clonidine concentrations approach 130 ng/ml (Figure 1). [21]Similarly, the duration of effective analgesia from epidural bolus injection of clonidine, 100-900 micro gram, [22]is in keeping with clonidine's rapid elimination from CSF (Table 2). Duration of complete analgesia in those patients corresponds to the time for CSF clonidine concentrations to decline to 97 plus/minus 52 ng/ml (here and throughout the manuscript, variability is given as plus/minus SD). Finally, computer-controlled infusion of epidural clonidine to steady state CSF concentrations in volunteers [20]yields a concentration-response for analgesia similar to that obtained in volunteers after bolus administration or in patients after continuous infusion (Figure 1).Cerebrospinal fluid is clearly not the site of action of alpha2-adrenergic agonists for analgesia, and the drug can reach sites producing analgesia in the spinal cord and elsewhere. As with lipophilic opioids, it is possible to achieve analgesia from systemic, epidural, or intrathecal administration of clonidine. However, clonidine is more potent after neuraxial than systemic administration, indicating a spinal site of action and favoring neuraxial administration. This is typified in two types of experiments. In the first, one can compare analgesia from an equal dose of clonidine administered by each of these routes. Therefore, intrathecal injection of a small clonidine dose, 150 micro gram, after cesarean section or minor orthopedic surgery yields analgesia for 4-6 h, but injection of this same dose by intramuscular or epidural routes produces no more analgesia than a placebo (Figure 2). [23,24]Comparing epidural and intravenous administration of a larger clonidine dose, epidural administration produces better analgesia, accompanied by a 50% reduction in rescue morphine requirements. [25]These results are in accordance with a spinal site of action.In the second type of study, one can allow patients to titrate drug to similar degrees of pain relief via PCA to compare the relative potency of the drug by different routes of administration. Using this paradigm for opioids, for example, fentanyl is equipotent by intravenous or epidural administration, whereas hydromorphone is approximately twice as potent when given epidurally. [26,27]Using this method, Bernard and colleagues [28]recently demonstrated that clonidine is also approximately twice as potent given epidurally as intravenously.Clonidine produces analgesia by actions on alpha2-adrenoceptors, as shown by partial reversal in humans of epidural clonidine analgesia and sedation, by the alpha2-adrenergic antagonist, yohimbine, although clonidine's effects on blood pressure and heart rate were not reversed. [29]In animals, intraspinal alpha2-adrenergic agonists cause analgesia, in part, by spinal cholinergic activation (Figure 3), [30,31]and two observations suggest this may also occur in humans. First, epidural clonidine, either by bolus [19]or computer-controlled infusion, [20]increases acetylcholine concentrations in lumbar CSF (Figure 3). More precise experiments in animals have demonstrated that this increase is due to release of acetylcholine in the dorsal, but not the ventral, horn. [32]Second, epidural clonidine analgesia in volunteers is enhanced by intrathecal injection of the cholinesterase inhibitor, neostigmine (Figure 3). [33]Whereas this interaction is only additive in humans compared with its synergy observed in animals, it nonetheless supports a reliance on cholinergic mechanisms in spinal analgesia from clonidine.Clonidine enhances both sensory and motor blockade from epidural or peripheral nerve block injection of local anesthetics (see below). Three possible mechanisms for this interaction have been suggested. First, clonidine blocks conduction of C and A delta fibers [17]and increases potassium conductance [34]in isolated neurons in vitro and intensifies conduction block of local anesthetics. [16]Because systemic pharmacokinetics are not a factor in these in vitro experiments, these data support a direct effect of clonidine on neural transmission in high local concentrations, such as may occur after local injection. Second, clonidine may cause local vasoconstriction in the clinical setting, thereby reducing vascular removal of local anesthetic surrounding neural structures. Although clonidine and other alpha2-adrenergic agonists can vasoconstrict in high concentrations, there is little evidence for this mechanism with clinically used concentrations. For example, plasma lidocaine concentrations are similar whether or not clonidine is combined with lidocaine for epidural anesthesia. [35]In contrast, combining lidocaine with epidural epinephrine does reduce systemic absorption, as reflected in reduced lidocaine concentrations in blood. [35]Finally, it has become evident that analgesics, whether administered systemically or with local anesthetics, can enhance peripheral or spinal blockade. For example, intravenous or intrathecal fentanyl both enhance intrathecal lidocaine anesthesia, [36,37]and the same is observed with clonidine. [38,39]Alpha2-Adrenergic agonists also enhance analgesia from intraspinal opioids. In animals, this interaction occurs both pre- and postsynaptic to the primary afferent synapse in the spinal cord, and is clearly synergistic when both drugs are administered intrathecally. [12,40,41]In contrast, epidural clonidine and fentanyl interact in an additive or only mildly synergistic manner after bolus administration in humans. [42]Nonetheless, the dose of each component can be reduced by more than 60% when epidural clonidine and fentanyl are combined for postoperative analgesia. The type of interaction between clonidine and opioids after intrathecal administration has not been quantified.Mechanistic studies support a primary spinal site of action of alpha2-adrenergic agonists for analgesia and a multifactorial mechanism of action in enhancing peripheral or intraspinal blockade from local anesthetics. Pharmacokinetic studies support an EC95of 130 ng/ml clonidine in CSF for analgesia after intraspinal administration and help to clarify the dose responses observed in clinical studies (see below). Opioids and neostigmine enhance intraspinal alpha2-adrenergic agonist analgesia, and it is likely that a combination of all three classes of agents could result in dramatic reductions in the dose of each.Because systemic absorption of clonidine and other lipophilic alpha2-adrenergic agonists after spinal administration is rapid and extensive, their hemodynamic effects are due, in part, to actions in the brain and the periphery.Clonidine affects blood pressure in a complex fashion after neuraxial or systemic administration because of opposing actions at multiple sites (Figure 4). [43,44]In the nucleus tractus solitarius and locus coeruleus of the brainstem, activation of postsynaptic alpha2-adrenoceptors reduces sympathetic drive. In addition, clonidine is not a pure alpha2/alpha1adrenergic agonist; it also activates nonadrenergic imidazoline-preferring binding sites in the lateral reticular nucleus, thereby producing hypotension and an antiarrythmogenic action. [45,46]Blood pressure typically decreases more in hypertensive than in normotensive patients after systemic or epidural clonidine administration, [22]perhaps reflecting increased tonic sympathetic drive in some patients with chronic hypertension. In the periphery, activation of presynaptic alpha sub 2 -adrenoceptors at sympathetic terminals reduces their release of norepinephrine by the sympathetic nerve terminals, which could cause vasorelaxation and reduced chronotropic drive. These brainstem and peripheral effects of alpha2-adrenoceptor stimulation are counter-balanced by direct peripheral vasoconstriction from circulating concentrations of the alpha2/alpha1adrenergic agonist, clonidine. [47]As a result, the dose response for clonidine by neuraxial or systemic administration is U-shaped, with peripheral vasoconstriction from circulating drug concentrations at high doses opposing central sympatholysis (Figure 4).In addition to brainstem and peripheral sites of actions, neuraxial administration of clonidine directly inhibits sympathetic preganglionic neurons in the spinal cord. [48]As a result, the degree of clonidine-induced hypotension is related to the spinal level of injection. At low thoracic or lumbar levels of injection, epidural clonidine is not associated with an increased incidence of hemodynamic side effects when compared with intravenous injection. [25]In contrast, more profound hypotension occurs with thoracic epidural injection (Figure 4), [49,50]perhaps reflecting the rostrocaudal gradient of noradrenergic innervation of sympathetic preganglionic neurons. [51]Alternatively, direct inhibition of sympathetic preganglionic neurons in the upper thoracic dermatomes, which supply the heart, may also have a more profound impact on resting blood pressure than does the inhibition of sympathetic preganglionic neurons elsewhere.The action of alpha2-adrenergic agonists on myocardial performance is complex. Clonidine reduces heart rate partly by a presynaptically mediated inhibition of norepinephrine release at the neuroreceptor junction and partly by a vagomimetic effect. Although clonidine depresses atrioventricular nodal conduction, severe bradyarrhythmias are rare with chronic clonidine use. [52]By reducing afterload, cardiac output may increase after clonidine treatment in some patients, including those with heart failure, whereas by reducing heart rate, it may reduce cardiac output in other patients. [53]Clonidine may reduce myocardial oxygen demand and has been shown to reduce infarct size when administered to patients in the acute phase of myocardial infarction. [54]Hemodynamic effects of clonidine after neuraxial or systemic administration begin within 30 min, reach maximum within 1-2 h, and last approximately 6-8 h after a single injection. Delayed onset of hypotension has not been observed with use of clonidine for analgesia alone or in combination (see below).Combination of an alpha2-adrenergic agonist with neuraxially administered local anesthetic could increase the degree of sympatholysis and resulting hypotension. However, in clinical studies in which local anesthetic alone was compared with that anesthetic and clonidine infrequently report significant reduction in arterial blood pressure or heart rate in patients having received the combination therapy (see below). Clonidine has minor or no effects on responses to vasoconstrictors or atropine given to treat hypotension or bradycardia that may occur with neuraxial anesthesia. [55-58]Clonidine pretreatment delays the central nervous system and cardiovascular toxic manifestations of bupivacaine overdose in animals, without accentuating the subsequent hypotension. [59]Treatment with an alpha2-adrenoceptor agonist during bupivacaine overdose improves the ventricular electrophysiologic parameters in dogs. [60]This is not to imply that clonidine should be used as treatment for bupivacaine overdose, but rather to emphasize that, should such overdose occur, inclusion of clonidine is unlikely to exacerbate the problem.Spinal neostigmine counteracts the hypotension produced by clonidine, [61]likely due to a cholinergically mediated increase in preganglionic sympathetic nervous system activity. [62]Because neostigmine also enhances clonidine-induced analgesia, [33]this combination may be clinically useful.Sedation commonly accompanies the use of clonidine for regional anesthesia, consistent with the known sedative/anesthetic-sparing properties of alpha2-adrenergic agonists by actions in the locus coeruleus. [63]This brainstem nucleus is associated with a wide variety of physiologic regulatory processes, including regulation of sleep and wakefulness, and is inhibited by alpha2-adrenergic agonists via a G-protein mediated mechanism that involves inhibition of adenylate cyclase. [63]Sedation after epidural administration of clonidine likely reflects systemic absorption and vascular redistribution to higher centers. Although it is conceivable that cephalad migration of clonidine in CSF could result in delayed onset of sedation, such delayed onset sedation has not been observed, nor has delayed-onset hypotension, as described earlier. The more profound depression of electroencephalographic measure of cerebral activity during enflurane/N sub 2 O anesthesia in patients having received epidural compared with intravenous administration [64]could be construed as indicating more profound sedation. However, this more likely represents reduced noxious afferent input to the central sites from a regional spinal effect. Sedation from epidural clonidine represents an alpha2-adrenergic effect, as witnessed in its reversal by the relatively specific antagonist, yohimbine, in postoperative patients. [29]Clonidine produces dose-dependent sedation over the dose range 50-900 micro gram of rapid onset (< 20 min) regardless of route of administration. After a large epidural bolus dose (700 micro gram), sedation is intense for 4-6 h. In many cases, sedation is a desired property, and several studies have demonstrated the reduced need for other sedatives and anxiolytic medications when clonidine is administered intraoperatively. With continuous infusion, as much as 40 micro gram/h epidural clonidine produces no more sedation than epidural placebo plus PCA intravenous morphine for postoperative pain, [21,65]nor does 30 micro gram/h epidural clonidine produce more sedation than epidural placebo plus PCA epidural morphine for cancer pain. [66]Although there is some evidence that implicates a noradrenergic mechanism of opioid-induced respiratory depression, alpha sub 2 -adrenergic agonists alone do not induce profound respiratory depression, even after massive overdose, [67]nor do they potentiate respiratory depression from opioids. [68,69]A few studies indicate greater respiratory depression from epidural than from systemic clonidine, but lack of true control groups calls these results into question. [70,71]A study conducted on human volunteers failed to demonstrate any important effect of epidural clonidine on resting respiratory control. [19]However, when considering the respiratory effects of clonidine, it must be considered that drugs acting on the central nervous system to alleviate pain, relieve anxiety, and produce sedation are almost always accompanied by some reduction in alveolar ventilation. As such, it is conceivable that clonidine therapy, by causing pain relief, could unmask respiratory depression from other drugs administered concurrently. Occasional reports of intermittent upper airway obstruction during deep sedation with clonidine, accompanied by transient oxyhemoglobin desaturation, suggest that monitoring with pulse oximetry may be indicated for 30 min to 2 h after large bolus doses. Two human volunteer studies specifically addressed the question of the potentiation of the respiratory depressant effects of opiates by the alpha2-adrenoceptor agonists. Absolutely no potentiation of this effect could be demonstrated. [68,72]As will be noted later, oxyhemoglobin desaturation is less likely with an epidural clonidine-opioid combination than with opioid alone.Clonidine is a potent sympatholytic agent, as discussed earlier. In stress situations, it reduces, but does not suppress, the neurohormonal secretion (norepinephrine, epinephrine, adrenocorticotrophic hormone, cortisol) secondary to sympathoadrenal hyperactivation. [73,74]alpha2-Adrenergic agonists promote the release of growth hormone, but this effect is short lived. [75]They also inhibit the release of insulin by a direct action on the cells of the islets of Langerhans, although this effect is minor and devoid of clinical consequences. [22]By far, the largest reported experience with clonidine for regional anesthesia is with epidural administration. Following is a review of published reports of epidural clonidine treatment for chronic pain, intra- and postoperative pain, and in obstetric and pediatric patients, followed by suggested guidelines in the use of epidural clonidine.Reasons for the use of epidural clonidine in patients with chronic pain are several: avoidance of opioids because of concerns over addiction in patients with nonmalignant conditions or when opioids cause therapy-limiting side effects, efficacy in cases of reduced potency of opioids due to development of tolerance or in pain syndromes poorly responsive to opioids, and specific indications of neuropathic or sympathetically maintained pain.Cancer Pain (123 Patients Total, 94 Receiving Clonidine). [66,76-80]Epidural clonidine is indicated in the treatment of intractable pain, which is the basis for approval of clonidine in the United States. In the pivotal trial underlying this indication, [66]85 patients with severe cancer pain unresponsive to maximally tolerated doses of oral or epidural opioids were randomized to receive epidural 30 micro gram/h clonidine or a placebo, in a double-blind, multicenter study. All patients received rescue pain medication (epidural morphine) by PCA, and success was defined as a reduction in either epidural morphine use or visual analog scale (VAS) pain, with the other variable not increasing. Success was more common in patients receiving clonidine (45%) than placebo (21%), and average VAS pain scores were reduced in patients receiving clonidine (Figure 5). Clonidine was particularly effective in patients with neuropathic pain (36 patients total, 56% success with clonidine vs. 6% with placebo).After completion of the 2-week blinded study, patients were allowed to receive continuous epidural clonidine infusion in an open-label manner. Thirty-five patients received clonidine for an average of 8 weeks (1-94 weeks) before their death. An example of VAS pain in a patient with neuropathic pain who received epidural clonidine in the blinded and open-label portions of the study, separated by the obligatory 3-day washout between the study parts, demonstrates the dramatic response observed in many patients (Figure 5).Five uncontrolled studies of 38 patients with intractable pain support the results of this trial. [76-80]For example, epidural clonidine bolus produced dose-dependent analgesia in 9 patients with cancer receiving 100-900 micro gram, and continuous infusion of 12.5-70 micro gram/h for as long as 94 weeks resulted in sustained analgesia during the period of infusion. [77]In only 1 of the 38 reported patients was epidural clonidine considered ineffective. [80]Although the vast majority of patients in the double-blind trial of epidural clonidine for cancer pain experienced side effects, there was no difference in the incidence of side effects between clonidine and placebo. [66]Clonidine decreased blood pressure by 10-20%, but hypotension led to discontinuation of the drug in < 10% of cases. Although sedation was noted on initiation of clonidine therapy, this rapidly decreased, and there were no differences in sedation between clonidine and placebo treatments during the 2-week trial. Nausea was less in patients receiving clonidine plus rescue morphine than in those receiving placebo plus rescue morphine. These observations of mild hypotension and transient sedation from epidural clonidine are supported in the uncontrolled studies.Chronic Noncancer Pain (128 Patients Total, 117 Receiving Clonidine). [7,50,81-88]There are few controlled studies of epidural clonidine for chronic non-cancer pain, and all but one examined single boluses of small doses (25-150 micro gram). Glynn and colleagues [85]used a randomized, double-blind design to compare 150 micro gram epidural clonidine to 5 mg epidural morphine in patients with chronic low back pain or pain from arachnoiditis. Clonidine relieved pain in 16 of 20 patients, was as good or better than epidural morphine, and produced fewer side effects than morphine. These results were supported in their open-label studies of 25 patients with deafferentation pain after spinal injury [82,84]and 20 patients with chronic pain, primarily of the lower back. [86]These open-label trials should, however, be viewed with caution, because this group failed to demonstrate efficacy from epidural clonidine in a double-blind trial of patients with low back pain who had reported analgesia from clonidine in a previous open-label study. [87]Similarly, Taniguchi et al. [81]reported excellent pain relief from thoracic epidural injection of extremely small doses (25-75 micro gram) of clonidine in 10 patients with postherpetic neuralgia. Whether this reflects exquisite sensitivity of this pain syndrome to clonidine or is an artifact of the open-label design awaits further testing.Clearly, some patients with chronic pain obtain relief from regional sympatholysis, and the syndrome of sympathetically maintained pain is classically considered to consist of altered neural function at three sites: sensitivity to norepinephrine at peripheral primary afferent terminals, recruitment of large diameter fibers in pain perception at dorsal horn sites, and enhanced sympathetic outflow from the spinal cord. alpha2-Adrenergic agonists could reduce pain in such states by actions at all three sites: reduction in peripheral norepinephrine release by stimulation of prejunctional inhibitory alpha sub 2 -adrenoceptors, inhibition of noxious neural transmission in the dorsal horn by both pre- and postsynaptic mechanisms, and direct inhibition of spinal preganglionic sympathetic neurons.Clinical experience suggests that epidural clonidine is effective in patients with sympathetically maintained pain. Epidural clonidine, 300 and 700 micro gram, produced analgesia as assessed by VAS and McGill Pain Questionnaire measures in 26 patients with the clinical diagnosis of reflex sympathetic dystrophy in a double-blind, placebo-controlled trial. [50]Neither sedation nor hypotension from epidural clonidine was more severe with cervical, compared with lumbar, injection. Nineteen patients in this study then received continuous epidural clonidine infusion in an open-label manner for 43 plus/minus 35 days (range 7-225 days). Clonidine usage averaged 32 plus/minus 26 micro gram (range 14-50 micro gram/h), and VAS pain during this open-label phase was significantly reduced (5.1 plus/minus 2.6) compared with their VAS pain before the study (7.9 plus/minus 1.7).It has been suggested that certain chronic pain syndromes, such as phantom limb pain after amputation, are due to plastic changes that occur in the spinal cord in response to peripheral neural injury and deafferentation, and that preemptive block of afferent input by neuraxial analgesia may block development of such pain. This is supported by a small clinical study in which 24 patients scheduled to undergo lower limb amputation were randomized to receive no preoperative epidural treatment or 24 h of epidural infusion of a combination of diamorphine, bupivacaine, and clonidine, extending for 72 h after amputation. [88]The incidence of phantom limb pain 1 yr after surgery was reduced from 73% in the control group to 8% in the epidural treatment group. The relative contribution of clonidine to this dr

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The Comparative Effects of Postoperative Analgesic Therapies on Pulmonary Outcome

1998-03-01

Jane C. Ballantyne , Daniel B. Carr , Sarah deFerranti +5 more

We performed meta-analyses of randomized, control trials to assess the effects of seven analgesic therapies on postoperative pulmonary function after a variety of procedures: epidural opioid, epidural local anesthetic, epidural … We performed meta-analyses of randomized, control trials to assess the effects of seven analgesic therapies on postoperative pulmonary function after a variety of procedures: epidural opioid, epidural local anesthetic, epidural opioid with local anesthetic, thoracic versus lumbar epidural opioid, intercostal nerve block, wound infiltration with local anesthetic, and intrapleural local anesthetic. Measures of forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), vital capacity (VC), peak expiratory flow rate (PEFR), PaO2, and incidence of atelectasis, pulmonary infection, and pulmonary complications overall were analyzed. Compared with systemic opioids, epidural opioids decreased the incidence of atelectasis (risk ratio [RR] 0.53, 95% confidence interval [CI] 0.33-0.85) and had a weak tendency to reduce the incidence of pulmonary infections (RR 0.53, 95% CI 0.18-1.53) and pulmonary complications overall (RR 0.51, 95% CI 0.20-1.33). Epidural local anesthetics increased PaO2 (difference 4.56 mm Hg, 95% CI 0.058-9.075) and decreased the incidence of pulmonary infections (RR 0.36, 95% CI 0.21-0.65) and pulmonary complications overall (RR 0.58, 95% CI 0.42-0.80) compared with systemic opioids. Intercostal nerve blockade tends to improve pulmonary outcome measures (incidence of atelectasis: RR 0.65, 95% CI 0.27-1.57, incidence of pulmonary complications overall: RR 0.47, 95% CI 0.18-1.22), but these differences did not achieve statistical significance. There were no clinically or statistically significant differences in the surrogate measures of pulmonary function (FEV1, FVC, and PEFR). These analyses support the utility of epidural analgesia for reducing postoperative pulmonary morbidity but do not support the use of surrogate measures of pulmonary outcome as predictors or determinants of pulmonary morbidity in postoperative patients. Implications: When individual trials are unable to produce significant results, it is often because of insufficient patient numbers. It may be impossible for a single institution to study enough patients. Meta-analysis is a useful tool for combining the data from multiple trials to increase the patient numbers. These meta-analyses confirm that postoperative epidural pain control can significantly decrease the incidence of pulmonary morbidity. (Anesth Analg 1998;86:598-612)

Serious Complications Related to Regional Anesthesia

1997-09-01

Yves Auroy , P. Narchi , Antoine Messiah +3 more

Background Serious complications related to regional anesthesia have previously been described primarily in case reports and retrospective surveys. The authors prospectively evaluated a multicenter series of regional anesthetics, using preplanned … Background Serious complications related to regional anesthesia have previously been described primarily in case reports and retrospective surveys. The authors prospectively evaluated a multicenter series of regional anesthetics, using preplanned criteria to measure the incidence and characteristics of associated serious complications. Methods Requests were sent to 4,927 French anesthesiologists in advance of a subsequent 5-month study period. Participating anesthesiologists were asked for detailed reports of serious complications occurring during or after regional anesthetics performed by them during the study interval. Details regarding each complication then were obtained via a second questionnaire. Results The number of responding anesthesiolgists was 736. The number of regional anesthetics performed was 103,730, corresponding to 40,640 spinal anesthetics, 30,413 epidural anesthetics, 21,278 peripheral nerve blocks, and 11,229 intravenous regional anesthetics. Reports of 98 severe complications were received, with follow-up information being obtained for 97. In 89 cases, complications were attributed fully or partially to regional anesthesia. Thirty-two cardiac arrests, seven of which were fatal, occurred during the study. Of these, 26 occurred during spinal anesthesia, with 6 being fatal, 3 occurred during epidural anesthesia, and 3 more occurred during peripheral blocks. The higher incidence of cardiac arrest during spinal anesthesia (6.4 +/- 1.2 per 10,000 patients) compared with all other regional anesthesia (1.0 +/- 0.4 per 10,000 patients) was statistically significant (P &lt; 0.05). Of 34 neurologic complications (radiculopathy, cauda equina syndrome, paraplegia), 21 were associated either with paresthesia during puncture (n = 19) or with pain during injection (n = 2), suggesting nerve trauma or intraneural injection. Twelve patients who had neurologic complications after spinal anesthetics had no paresthesia during needle placement and no pain on injection. Of these 12 patients (7 with radiculopathy and 5 with cauda equina syndrome), 9 received intrathecal hyperbaric lidocaine, 5%. The incidence of neurologic injury was significantly greater after spinal anesthesia (6 +/- 1 per 10,000 cases; P &lt; 0.05) than after each of the other types of regional procedures (1.6 +/- 0.5 per 10,000 cases for the weighted average). Seizures attributed to elevated serum levels of local anesthetics occurred in 23 patients, but none suffered a cardiac arrest. Conclusions (1) The incidence of cardiac arrest and neurologic injury related to regional anesthesia were very low, but both were more than three SDs greater after spinal anesthesia than after other regional procedures. (2) Two thirds of the patients with neurologic deficits had either a paresthesia during needle placement or pain on injection. (3) Seventy-five percent of the neurologic deficits after nontraumatic spinal anesthesia occurred in patients who had received hyperbaric lidocaine, 5%.

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Major Complications of Regional Anesthesia in France

2002-11-01

Yves Auroy , Dan Benhamou , L. Bargues +5 more

Background Several previous surveys have estimated the rate of major complications that occur after regional anesthesia. However, because of the increase in the use of regional anesthesia in recent years … Background Several previous surveys have estimated the rate of major complications that occur after regional anesthesia. However, because of the increase in the use of regional anesthesia in recent years and because of the introduction of new techniques, reappraisal of the incidence and the characteristics of major complications is useful. Methods All French anesthesiologists were invited to participate in this 10-month prospective survey based on (1) voluntary reporting of major complications related to regional anesthesia occurring during the study period using a telephone hotline service available 24 h a day and managed by three experts, and (2) voluntary reporting of the number and type of regional anesthesia procedures performed using pocket booklets. The service was free of charge for participants. Results The participants (n = 487) reported 56 major complications in 158,083 regional anesthesia procedures performed (3.5/10,000). Four deaths were reported. Cardiac arrest occurred after spinal anesthesia (n = 10; 2.7/10,000) and posterior lumbar plexus block (n = 1; 80/10,000). Systemic local anesthetic toxicity consisted of seizures only, without cardiac toxicity. Lidocaine spinal anesthesia was associated with more neurologic complications than bupivacaine spinal anesthesia (14.4/10,000 vs. 2.2/10,000). Most neurologic complications were transient. Among 12 that occurred after peripheral nerve blocks, 9 occurred in patients in whom a nerve stimulator had been used. Conclusion This prospective survey based on a free hotline permanent telephone service allowed us to estimate the incidence of major complications related to regional anesthesia and to provide a detailed analysis of these complications.

Chronic catheterization of the spinal subarachnoid space

1976-12-01

Tony L. Yaksh , Thomas A. Rudy

Long-term Analgesic Use After Low-Risk Surgery

2012-03-12

Asim Alam

<h3>Background</h3>This study evaluated the risk of long-term analgesic use after low-risk surgery in older adults not previously prescribed analgesics.<h3>Methods</h3>We conducted a retrospective cohort study using linked, population-based administrative data in … <h3>Background</h3>This study evaluated the risk of long-term analgesic use after low-risk surgery in older adults not previously prescribed analgesics.<h3>Methods</h3>We conducted a retrospective cohort study using linked, population-based administrative data in Ontario, Canada, from April 1, 1997, through December 31, 2008. We identified Ontario residents 66 years and older who were dispensed an opioid within 7 days of a short-stay surgery (cataract surgery, laparoscopic cholecystectomy, transurethral resection of the prostate, or varicose vein stripping) and assessed the risk of long-term opioid use, defined as a prescription for an opioid within 60 days of the 1-year anniversary of the surgery. In a secondary analysis, we examined the risk of long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs). We used multivariate logistic regression to examine the association between postsurgical use of analgesics and long-term use.<h3>Results</h3>Among 391 139 opioid-naive patients undergoing short-stay surgery, opioids were newly prescribed to 27 636 patients (7.1%) within 7 days of being discharged from the hospital, and opioids were prescribed to 30 145 patients (7.7%) at 1 year from surgery. An increase in the use of oxycodone was found during this time (from 5.4% within 7 days to 15.9% at 1 year). In our primary analysis, patients receiving an opioid prescription within 7 days of surgery were 44% more likely to become long-term opioid users within 1 year compared with those who received no such prescription (adjusted odds ratio, 1.44; 95% CI, 1.39-1.50). In a secondary analysis, among 383 780 NSAID-naive patients undergoing short-stay surgery, NSAIDs were prescribed to 1169 patients (0.3%) within 7 days of discharge and to 30 080 patients (7.8%) at 1 year from surgery. Patients who began taking NSAIDs within 7 days of surgery were almost 4 times more likely to become long-term NSAID users compared with patients with no such prescription (adjusted odds ratio, 3.74; 95% CI, 3.27-4.28).<h3>Conclusion</h3>Prescription of analgesics immediately after ambulatory surgery occurs frequently in older adults and is associated with long-term use.

Preemptive Analgesia—Treating Postoperative Pain by Preventing the Establishment of Central Sensitization

1993-08-01

Clifford J. Woolf , Mun-Seng Chong

Woolf, Clifford J. MB, BCh PhD, MRCP; Chong, Mun-Seng BSc, MB, BS, MRCP Author Information Woolf, Clifford J. MB, BCh PhD, MRCP; Chong, Mun-Seng BSc, MB, BS, MRCP Author Information

Prediction of chronic post-operative pain: Pre-operative DNIC testing identifies patients at risk

2008-01-09

David Yarnitsky , Yonathan Crispel , Elon Eisenberg +5 more

Surgical and medical procedures, mainly those associated with nerve injuries, may lead to chronic persistent pain. Currently, one cannot predict which patients undergoing such procedures are 'at risk' to develop … Surgical and medical procedures, mainly those associated with nerve injuries, may lead to chronic persistent pain. Currently, one cannot predict which patients undergoing such procedures are 'at risk' to develop chronic pain. We hypothesized that the endogenous analgesia system is key to determining the pattern of handling noxious events, and therefore testing diffuse noxious inhibitory control (DNIC) will predict susceptibility to develop chronic post-thoracotomy pain (CPTP). Pre-operative psychophysical tests, including DNIC assessment (pain reduction during exposure to another noxious stimulus at remote body area), were conducted in 62 patients, who were followed 29.0+/-16.9 weeks after thoracotomy. Logistic regression revealed that pre-operatively assessed DNIC efficiency and acute post-operative pain intensity were two independent predictors for CPTP. Efficient DNIC predicted lower risk of CPTP, with OR 0.52 (0.33-0.77 95% CI, p=0.0024), i.e., a 10-point numerical pain scale (NPS) reduction halves the chance to develop chronic pain. Higher acute pain intensity indicated OR of 1.80 (1.28-2.77, p=0.0024) predicting nearly a double chance to develop chronic pain for each 10-point increase. The other psychophysical measures, pain thresholds and supra-threshold pain magnitudes, did not predict CPTP. For prediction of acute post-operative pain intensity, DNIC efficiency was not found significant. Effectiveness of the endogenous analgesia system obtained at a pain-free state, therefore, seems to reflect the individual's ability to tackle noxious events, identifying patients 'at risk' to develop post-intervention chronic pain. Applying this diagnostic approach before procedures that might generate pain may allow individually tailored pain prevention and management, which may substantially reduce suffering.

Serratus plane block: a novel ultrasound-guided thoracic wall nerve block

2013-08-07

Rafael Blanco , Teresa Parras , John G. McDonnell +1 more

We present a novel ultrasound-guided regional anaesthetic technique that may achieve complete paraesthesia of the hemithorax. This technique may be a viable alternative to current regional anaesthetic techniques such as … We present a novel ultrasound-guided regional anaesthetic technique that may achieve complete paraesthesia of the hemithorax. This technique may be a viable alternative to current regional anaesthetic techniques such as thoracic paravertebral and central neuraxial blockade, which can be technically more challenging and have a higher potential side-effect profile. We performed the serratus block at two different levels in the midaxillary line on four female volunteers. We recorded the degree of paraesthesia obtained and performed fat-suppression magnetic resonance imaging and three-dimensional reconstructions of the spread of local anaesthetic in the serratus plane. All volunteers reported an effective block that provided long-lasting paraesthesia (750–840 min). There were no side-effects noted in this initial descriptive study. While these are preliminary findings, and must be confirmed in a clinical trial, they highlight the potential for the serratus plane block to provide analgesia following surgery on the thoracic wall. We suggest that this novel approach appears to be safe, effective, and easy to perform, and is associated with a low risk of side-effects.

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Incidence, patient satisfaction, and perceptions of post-surgical pain: results from a US national survey

2013-11-15

Tong J. Gan , Ashraf S. Habib , Timothy E. Miller +2 more

Objective:During the past two decades, professional associations, accrediting bodies, and payors have made post-surgical pain treatment a high priority. In light of the disappointing findings in previous surveys, a survey … Objective:During the past two decades, professional associations, accrediting bodies, and payors have made post-surgical pain treatment a high priority. In light of the disappointing findings in previous surveys, a survey was conducted to assess patient perceptions and characterize patient experiences/levels of satisfaction with post-surgical pain management.Research design and methods:Survey included a random sample of US adults who had undergone surgery within 5 years from the survey date. Participants were asked about their concerns before surgery, severity of perioperative pain, pain treatments, perceptions about post-surgical pain and pain medications, and satisfaction with treatments they received.Results:Of the 300 participants, ∼86% experienced pain after surgery; of these, 75% had moderate/extreme pain during the immediate post-surgical period, with 74% still experiencing these levels of pain after discharge. Post-surgical pain was the most prominent pre-surgical patient concern, and nearly half reported they had high/very high anxiety levels about pain before surgery. Approximately 88% received analgesic medications to manage pain; of these, 80% experienced adverse effects and 39% reported moderate/severe pain even after receiving their first dose.Study limitations:Key study limitations include the relatively small population size, potential for recall bias associated with the 14-month average time delay from surgery date to survey date, and the inability to account for influences of type of surgery and intraoperative anesthetic/analgesic use on survey results.Conclusions:Despite heightened awareness and clinical advancements in pain management, there has been little improvement in post-surgical analgesia as measured by this survey of post-surgical patients.

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Central nervous system mechanisms of analgesia

1976-12-01

David J. Mayer , Donald D. Price

Department of Physiology, Medical College of Virginia, Virginia Commonwealth University, Richmond, Va. 23298 and National Institute of Dental Research, Bethesda, Md. 20014 U.S.A. Accepted June 22, 1976. Department of Physiology, Medical College of Virginia, Virginia Commonwealth University, Richmond, Va. 23298 and National Institute of Dental Research, Bethesda, Md. 20014 U.S.A. Accepted June 22, 1976.

Pain Intensity on the First Day after Surgery

2013-02-08

H. U. Gerbershagen , Sanjay Aduckathil , Albert J. M. van Wijck +3 more

Severe pain after surgery remains a major problem, occurring in 20-40% of patients. Despite numerous published studies, the degree of pain following many types of surgery in everyday clinical practice … Severe pain after surgery remains a major problem, occurring in 20-40% of patients. Despite numerous published studies, the degree of pain following many types of surgery in everyday clinical practice is unknown. To improve postoperative pain therapy and develop procedure-specific, optimized pain-treatment protocols, types of surgery that may result in severe postoperative pain in everyday practice must first be identified.This study considered 115,775 patients from 578 surgical wards in 105 German hospitals. A total of 70,764 patients met the inclusion criteria. On the first postoperative day, patients were asked to rate their worst pain intensity since surgery (numeric rating scale, 0-10). All surgical procedures were assigned to 529 well-defined groups. When a group contained fewer than 20 patients, the data were excluded from analysis. Finally, 50,523 patients from 179 surgical groups were compared.The 40 procedures with the highest pain scores (median numeric rating scale, 6-7) included 22 orthopedic/trauma procedures on the extremities. Patients reported high pain scores after many "minor" surgical procedures, including appendectomy, cholecystectomy, hemorrhoidectomy, and tonsillectomy, which ranked among the 25 procedures with highest pain intensities. A number of "major" abdominal surgeries resulted in comparatively low pain scores, often because of sufficient epidural analgesia.Several common minor- to medium-level surgical procedures, including some with laparoscopic approaches, resulted in unexpectedly high levels of postoperative pain. To reduce the number of patients suffering from severe pain, patients undergoing so-called minor surgery should be monitored more closely, and postsurgical pain treatment needs to comply with existing procedure-specific pain-treatment recommendations.

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Efficacy of Postoperative Epidural Analgesia

2003-11-11

Brian M. Block , Spencer S. Liu , Andrew J. Rowlingson +3 more

Whether epidural analgesia is a better method than parenteral opioids for postoperative pain control remains controversial.To systematically review the efficacy of postoperative epidural analgesia vs parenteral opioids, the primary alternative … Whether epidural analgesia is a better method than parenteral opioids for postoperative pain control remains controversial.To systematically review the efficacy of postoperative epidural analgesia vs parenteral opioids, the primary alternative technique.Studies were identified primarily by searching the National Library of Medicine's PubMed database (1966 to April 25, 2002) and other sources for studies related to postoperative epidural analgesia.Inclusion criteria were a comparison of epidural therapy vs parenteral opioids for postoperative analgesia, measurement of pain using a visual analog scale (VAS) or numeric rating scale, randomization of patients to either therapy, and adult patients (> or =18 years). A total of 1404 abstracts were identified, 100 of which met all inclusion criteria.Each article was reviewed and data extracted from tables, text, or extrapolated from figures as needed. Weighted mean pain scores, weighted mean differences in pain score, and weighted incidences of complications were determined by using a fixed-effect model.Epidural analgesia provided better postoperative analgesia compared with parenteral opioids (mean [SE], 19.40 mm [0.17] vs 29.40 mm [0.20] on the VAS; P<.001). When analyzed by postoperative day, epidural analgesia was better than parenteral opioids on each postoperative day (P<.001 for each day after surgery). For all types of surgery and pain assessments, all forms of epidural analgesia provided significantly better postoperative analgesia compared with parenteral opioid analgesia (P<.001 for all), with the exception of thoracic epidural analgesia vs opioids for rest pain after thoracic surgery (weighted mean difference, 0.6 mm; 95% confidence interval, -0.3 to 1.5 mm; P =.12). The complication rates were lower than expected for nausea or vomiting and pruritus but comparable with existing data for lower extremity motor block.Epidural analgesia, regardless of analgesic agent, location of catheter placement, and type and time of pain assessment, provided better postoperative analgesia compared with parenteral opioids.

Acute Opioid Tolerance

2000-08-01

B. Guignard , Anne Elisabeth Bossard , C. Coste +5 more

Background Rapid development of acute opioid tolerance is well established in animals and is more likely to occur with large doses of short-acting drugs. The authors therefore tested the hypothesis … Background Rapid development of acute opioid tolerance is well established in animals and is more likely to occur with large doses of short-acting drugs. The authors therefore tested the hypothesis that intraoperative remifentanil administration results in acute opioid tolerance that is manifested by increased postoperative pain and opioid requirement. Methods Fifty adult patients undergoing major abdominal surgery were randomly assigned to two anesthetic regimens: (1) desflurane was kept constant at 0.5 minimum alveolar concentrations and a remifentanil infusion was titrated to autonomic responses (remifentanil group); or (2) remifentanil at 0.1 microg. kg-1. min-1 and desflurane titrated to autonomic responses (desflurane group). All patients were given a bolus of 0.15 mg/kg morphine 40 min before the end of surgery. Morphine was initially titrated to need by postanesthesia care nurses blinded to group assignment. Subsequently, patients-who were also blinded to group assignment-controlled their own morphine administration. Pain scores and morphine consumption were recorded for 24 postoperative h. Results The mean remifentanil infusion rate was 0.3 +/- 0.2 microg. kg-1. min-1 in the remifentanil group, which was significantly greater than in the desflurane group. Intraoperative hemodynamic responses were similar in each group. Postoperative pain scores were significantly greater in the remifentanil group. These patients required morphine significantly earlier than those in the desflurane group and needed nearly twice as much morphine in the first 24 postoperative h: 59 mg (25-75% interquartile range, 43-71) versus 32 mg (25-75% interquartile range, 19-59; P &lt; 0.01). Conclusions Relatively large-dose intraoperative remifentanil increased postoperative pain and morphine consumption. These data suggest that remifentanil causes acute opioid tolerance and hyperalgesia.

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Neural Blockade in Clinical Anesthesia and Management of Pain

1981-10-01

Michael J. Cousins , Phillip O. Bridenbaugh , Philadelphia J. B. Lippincott

(Section Titles) Introduction Pharmacology and Physiology of Neural Blockade Techniques of Neural Blockade Neural Blockade in the Management of Pai (Section Titles) Introduction Pharmacology and Physiology of Neural Blockade Techniques of Neural Blockade Neural Blockade in the Management of Pai

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The prevention of postoperative pain

1988-06-01

Patrick D. Wall

Pain: June 1988 - Volume 33 - Issue 3 - p 289-290 doi: 10.1016/0304-3959(88)90286-2 Pain: June 1988 - Volume 33 - Issue 3 - p 289-290 doi: 10.1016/0304-3959(88)90286-2

A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy—a systematic review and meta-analysis of randomized trials

2006-02-14

Ryan Davies , Paul S. Myles , Jon M. Graham

Central nervous and cardiovascular effects of i.v. infusions of ropivacaine, bupivacaine and placebo in volunteers

1997-05-01

K Knudsen , M Suurküla , S. Blomberg +2 more

Epidural Anesthesia and Analgesia

1995-06-01

Spencer Liu , Randall L. Carpenter , Joseph M. Neal

Pain Relief by Intrathecally Applied Morphine in Man

1979-02-01

Josef K. Wang , Lee A. Nauss , Juergen E. Thomas

Pain Relief by Intrathecally Applied Morphine in Man Josef Wang;Lee Nauss;Juergen Thomas; Anesthesiology Pain Relief by Intrathecally Applied Morphine in Man Josef Wang;Lee Nauss;Juergen Thomas; Anesthesiology

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Effect of postoperative analgesia on surgical outcome

2001-07-01

Henrik Kehlet , Kathrine Holte

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Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists

2009-01-13

Tim Cook , David Counsell , J.A.W. Wildsmith

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Regional anesthesia in the anticoagulated patient: Defining the risks (the second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation)

2003-05-01

Terese T. Horlocker

Neuraxial anesthesia and analgesia provide several advantages over systemic opioids, including superior analgesia, reduced blood loss and need for transfusion, decreased incidence of graft occlusion, and improved joint mobility following … Neuraxial anesthesia and analgesia provide several advantages over systemic opioids, including superior analgesia, reduced blood loss and need for transfusion, decreased incidence of graft occlusion, and improved joint mobility following major knee surgery. 1-4 New challenges in the management of patients undergoing neuraxial block have arisen over the last 2 decades, as medical standards for the prevention of perioperative venous thromboembolism were established. 5,6 Concern for patient safety in the presence of potent antithrombotic drugs has resulted in avoidance of regional anesthesia. Indeed, perioperative anesthesia and analgesia are often determined by the antithrombotic agent. 7 Conversely, although the anesthesia community is well aware of the potential for spinal bleeding, other specialties have only recently become cognizant of the risk, as documented by case reports

Persistent postsurgical pain: risk factors and prevention

2006-05-01

Henrik Kehlet , Troels S. Jensen , Clifford J. Woolf

Acute Toxicity of Ropivacaine Compared with That of Bupivacaine

1989-11-01

D.B. Scott , Alistair Lee , D. Fagan +3 more

The acute central nervous and cardiovascular effects of the local anesthetics ropivacaine and bupivacaine were compared in 12 volunteers in a randomized double-blind manner with use of intravenous infusions at … The acute central nervous and cardiovascular effects of the local anesthetics ropivacaine and bupivacaine were compared in 12 volunteers in a randomized double-blind manner with use of intravenous infusions at a rate of 10 mg/min up to a maximal dose of 150 mg. The volunteers were all healthy men. They were familiarized with the central nervous system (CNS) toxic effects of local anesthetics by receiving a preliminary intravenous injection of lidocaine. The infusions of ropivacaine and bupivacaine were given not less than 7 days apart. CNS toxicity was identified by the CNS symptoms and the volunteers were told to request that the infusion be stopped when they felt definite but not severe symptoms of toxicity such as numbness of the mouth, lightheadedness, and tinnitus. In the absence of definite symptoms, the infusion was stopped after 150 mg had been given. Cardiovascular system (CVS) changes in conductivity and myocardial contractility were monitored using an interpretive electrocardiograph (which measured PR interval, QRS duration, and QT interval corrected for heart rate) and echocardiography (which measured left ventricular dimensions from which stroke volume and ejection fraction were calculated). Ropivacaine caused less CNS symptoms and was at least 25% less toxic than bupivacaine in regard to the dose tolerated. Both drugs increased heart rate and arterial pressure. Stroke volume and ejection fraction were reduced. There was no change in cardiac output. Although both drugs caused evidence of depression of conductivity and contractility, these appeared at lower dosage and lower plasma concentrations with bupivacaine than with ropivacaine.(ABSTRACT TRUNCATED AT 250 WORDS)

Postoperative Pain Experience: Results from a National Survey Suggest Postoperative Pain Continues to Be Undermanaged

2003-08-01

Jeffrey L. Apfelbaum , Connie Chen , S. Mehta +1 more

In Brief Postoperative pain can have a significant effect on patient recovery. An understanding of patient attitudes and concerns about postoperative pain is important for identifying ways health care professionals … In Brief Postoperative pain can have a significant effect on patient recovery. An understanding of patient attitudes and concerns about postoperative pain is important for identifying ways health care professionals can improve postoperative care. To assess patients’ postoperative pain experience and the status of acute pain management, we conducted a national study by using telephone questionnaires. A random sample of 250 adults who had undergone surgical procedures recently in the United States was obtained from National Family Opinion. Patients were asked about the severity of postsurgical pain, treatment, satisfaction with pain medication, patient education, and perceptions about postoperative pain and pain medications. Approximately 80% of patients experienced acute pain after surgery. Of these patients, 86% had moderate, severe, or extreme pain, with more patients experiencing pain after discharge than before discharge. Experiencing postoperative pain was the most common concern (59%) of patients. Almost 25% of patients who received pain medications experienced adverse effects; however, almost 90% of them were satisfied with their pain medications. Approximately two thirds of patients reported that a health care professional talked with them about their pain. Despite an increased focus on pain management programs and the development of new standards for pain management, many patients continue to experience intense pain after surgery. Additional efforts are required to improve patients’ postoperative pain experience. IMPLICATIONS: A survey of 250 US adults who had undergone a recent surgical procedure asked about their postoperative pain experience. Approximately 80% of patients experienced pain after surgery. Of these patients, 86% had moderate, severe, or extreme pain. Additional efforts are required to improve patients’ postoperative pain experience.

Acute flank pain: comparison of non-contrast-enhanced CT and intravenous urography.

1995-03-01

Robert C. Smith , Arthur T. Rosenfield , K A Choe +4 more

PURPOSE: To compare non-contrast-enhanced computed tomography (CT) and intravenous urography (IVU) in the evaluation of patients who present with acute flank pain and in whom ureteric obstruction is suspected. MATERIALS … PURPOSE: To compare non-contrast-enhanced computed tomography (CT) and intravenous urography (IVU) in the evaluation of patients who present with acute flank pain and in whom ureteric obstruction is suspected. MATERIALS AND METHODS: The findings at non-contrast-enhanced CT and IVU in 20 patients with acute flank pain were compared for the presence or absence of ureteric obstruction and delineation of ureteric stones. RESULTS: Twelve of the 20 patients had non-contrast-enhanced CT and IVU findings consistent with ureteric obstruction. Of these 12 patients, five had a ureteric stone that was demonstrated on both non-contrast-enhanced CT scans and IVU radiographs, six had a stone that was depicted on non-contrast-enhanced CT scans only, and in one patient a stone could not be delineated definitively on either non-contrast-enhanced CT scans or IVU radiographs. Eight patients had findings at non-contrast-enhanced CT and IVU consistent with the absence of obstruction. CONCLUSION: Non-contrast-enhanced CT is more effective than IVU in precisely identifying ureteric stones and is equally effective as IVU in the determination of the presence or absence of ureteric obstruction.

Effects of Perioperative Analgesic Technique on the Surgical Outcome and Duration of Rehabilitation after Major Knee Surgery

1999-07-01

Xavier Capdevila , Y Barthelet , Philippe Biboulet +3 more

Background Continuous passive motion after major knee surgery optimizes the functional prognosis but causes severe pain. The authors tested the hypothesis that postoperative analgesic techniques influence surgical outcome and the … Background Continuous passive motion after major knee surgery optimizes the functional prognosis but causes severe pain. The authors tested the hypothesis that postoperative analgesic techniques influence surgical outcome and the duration of convalescence. Methods Before standardized general anesthesia, 56 adult scheduled for major knee surgery were randomly assigned to one of three groups, each to receive a different postoperative analgesic technique for 72 h: continuous epidural infusion, continuous femoral block, or intravenous patient-controlled morphine (dose, 1 mg; lockout interval, 7 min; maximum dose, 30 mg/4 h). The first two techniques were performed using a solution of 1% lidocaine, 0.03 mg/ml morphine, and 2 microg/ml clonidine administered at 0.1 ml x kg(-1) x h(-1). Pain was assessed at rest and during continuous passive motion using a visual analog scale. The early postoperative maximal amplitude of knee flexion was measured during continuous passive motion at 24 h and 48 h and compared with the target levels prescribed by the surgeon. To evaluate functional outcome, the maximal amplitudes were measured again on postoperative day 5, at hospital discharge (day 7), and at 1- and 3-month follow-up examinations. When the patients left the surgical ward, they were admitted to a rehabilitation center, where their length of stay depended on prospectively determined discharge criteria Results The continuous epidural infusion and continuous femoral block groups showed significantly lower visual analog scale scores at rest and during continuous passive motion compared with the patient-controlled morphine group. The early postoperative knee mobilization levels in both continuous epidural infusion and continuous femoral block groups were significantly closer to the target levels prescribed by the surgeon than in the patient-controlled morphine group. On postoperative day 7, these values were 90 degrees (60-100 degrees)(median and 25th-75th percentiles) in the continuous epidural infusion group, 90 degrees (60-100 degrees) in the continuous femoral block group, and 80 degrees (60-100 degrees) in the patient-controlled morphine group (P &lt; 0.05). The durations of stay in the rehabilitation center were significantly shorter: 37 days (range, 30-45 days) in the continuous epidural infusion group, 40 days (range, 31-60 days) in the continuous femoral block group, and 50 days (range, 30-80 days) in the patient-controlled morphine group (P &lt; 0.05). Side effects were encountered more frequently in the continuous epidural infusion group. Conclusion Regional analgesic techniques improve early rehabilitation after major knee surgery by effectively controlling pain during continuous passive motion, thereby hastening convalescence.

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Chronic Pain as an Outcome of Surgery

2000-10-01

Frederick M. Perkins , Henrik Kehlet

ONE potential adverse outcome from surgery is chronic pain. Analysis of predictive and pathologic factors is important to develop rational strategies to prevent this problem. Additionally, the natural history of … ONE potential adverse outcome from surgery is chronic pain. Analysis of predictive and pathologic factors is important to develop rational strategies to prevent this problem. Additionally, the natural history of patients with and without persistent pain after surgery provides an opportunity to improve the understanding of the physiology and psychology of chronic pain.Ideally, studies of chronic postoperative pain should include (1) sufficient preoperative data (assessment of pain, physiologic and psychologic risk factors for chronic pain); (2) detailed descriptions of the operative approaches used (location and length of incisions, handling of nerves and muscles); (3) the intensity and character of acute postoperative pain and its management; and (4) follow-up at intervals to 1 yr or more. In addition, there would be information about postoperative interventions that may influence pain, such as radiation therapy or chemotherapy. At long-term follow-up visits, patient function, physical signs, and symptoms would be evaluated using a standardized algorithm, including quantitative and descriptive pain assessments. We found no studies that contain all of these data.For this review, we specifically sought population data that reflect the incidence of chronic postoperative pain or predictors (medical, physiologic, and psychologic) of chronic pain. We selected five groups of surgeries (limb amputations, breast surgery, gallbladder surgery, lung surgery, and inguinal hernia surgery). These surgeries were selected because the incidence of pain is known to be high, thus improving the probability of detecting predictive factors. They also represent a range of major surgical procedures.We performed a computerized search of the medical literature using the OVID search engine (OVID Technologies, Wolters Kluwer, Amsterdam, The Netherlands). The search was performed on the entire database in January 1999 and covered 1966 through most of 1998. Additional articles published during the review process have also been included. Terms were used in their “exploded” format. The term “pain” was combined with the other appropriate term (e.g., “cholecystectomy”); also the text words associated with the pain syndromes were searched, resulting in more than 1,700 citations. Letters to the editor were not reviewed. Additionally, articles known to the authors but not found in the search were used. If the article contained data about persistent pain (12 weeks or more after surgery), it was considered for inclusion in this review. To calculate the incidence of pain, we used the number of individuals responding at the time the chronic pain data was gathered, and only used data from articles in which the methods section indicated that there was systematic collection of long-term pain information from patients. Studies of fewer than 50 patients were excluded in the incidence data analysis for breast surgery, gallbladder surgery, and lung surgery. Studies of fewer than 100 patients were excluded from the data analysis for inguinal hernia surgery. Amputation studies of 25 subjects or more were included because of the higher incidence of chronic pain.The reported incidence of phantom limb pain varies from 30 to 81% (table 1). Finch et al . 1reported pain in 30% of 57 long-term survivors of amputation for vascular insufficiency. Fisher and Hanspal 2described 93 consecutive amputees referred to a prosthetic rehabilitation clinic; therefore, selection bias may be a factor. The remainder of the studies (table 1) report an incidence of phantom limb pain of more than 50%. Sherman et al. 3noted at least a 78% incidence of phantom limb pain, and perhaps as high as 85%; however, their questionnaire response rate was not high (55%). Stump pain was noted in 66% of patients with phantom pain and in half of those without phantom pain; therefore, the overall stump pain incidence exceeds 60%. Wartan et al . 4reported a 62% incidence of phantom limb pain and 63% for stump pain. Similar to Sherman et al., 66% of patients with phantom limb pain also have stump pain. Smith and Thompson 5reported that pain was more common after amputation for cancer than for trauma, but this study was a chart review (phantom pain noted in medical record), and there were only eight amputations for trauma. No large studies systematically evaluate the incidence of phantom limb pain after trauma, vascular disease, and cancer-related surgeries. The presence of intense preoperative pain in the extremity increases the probability of phantom limb pain (from 33 to 72% at 3 months). 6,7Some early reports 8,9indicated that the incidence of phantom limb pain decreased with prolonged (72 h) preoperative epidural pain control, followed by postoperative epidural pain control. Both studies were small (23 and 24 patients, respectively at 6 months follow-up), and neither was properly randomized. In a subsequent randomized controlled study, 10this observation was not confirmed, but preoperative pain control was limited to 18 h, and the extent and intensity of perioperative blockade was not sufficient to control pain without supplemental systemic opioids.The effect of anesthesia (epidural, spinal, or general) alone has not been studied. Surgical handling of the major nerves is rarely mentioned, so we cannot assess the effect of nerve ligation or clipping versus section alone.Administration of chemotherapy increases the incidence of phantom limb pain. 5Stump pain at 1 week is significantly associated with phantom pain at 1 week, 6and long-term stump pain predicts long-term phantom limb pain. 3There is also a correlation between nonpainful phantom sensations and phantom pain. 4Control of acute postoperative pain with nerve sheath infusion of local anesthetic decreased the incidence of phantom limb pain in one series of 11 patients, 11but a subsequent randomized controlled trial (n = 14 at long term follow-up) 12failed to confirm this finding. Both of these studies are small, and the negative study 12does not have the statistical power to conclude that there is no significant effect. There has also been a negative retrospective report of this technique (n = 21). 13As mentioned previously, data regarding epidural analgesia 8–10as a method to decrease the incidence of phantom limb pain conflict.Most authorities believe that phantom limb sensation and phantom limb pain are central phenomena and explain them using the neuromatrix theory expounded by Melzack. 14,15That is, there is a matrix in the central nervous system for the perception of a body part, and this matrix exists even when the body part does not. Sherman et al . 3emphasized that multiple etiologies may lead to phantom limb pain, based on the inconsistency of therapeutic responses.The incidence of phantom limb pain decreases during the first year after amputation, as does the frequency of painful episodes 7,16; however, about half the individuals with long-term phantom pain report no decrease in the intensity of this pain. 3Phantom limb pain is common after extremity amputation, and documented predictors of this pain include preamputation pain and persistent stump pain (acute and chronic). No conclusive studies have evaluated the effect of acute or subacute stump pain control on long-term stump pain or on long-term phantom limb pain. Also no psychologic studies have evaluated patients before amputation for predictors of chronic pain.Long-term pain after thoracotomy, the postthoracotomy pain syndrome (PTPS), may have an incidence of more than 50%. 17,18Six studies met our inclusion–exclusion criteria (table 2), assessing 878 patients, of whom 417 (47%) had PTPS. Katz et al . 2could not predict PTPS from preoperative psychologic testing (state or trait anxiety, depression inventory) or preoperative pain sensitivity as determined by pressure algometry. This study (n = 23) was the extension of a previous acute pain study; it therefore lacks statistical power and may be subject to selection bias. Perttunen et al . 19noted the presence of preoperative pain in 17% of their patients but did not analyze it as an independent risk factor.Several recent case series report that video-assisted thoracoscopic lung surgery (VATS) is associated with a low incidence of PTPS. Walker et al . 20reported only 1 case of 83 (1.2%), and Mouroux et al . 21noted a 3% incidence of PTPS, but neither group reports systematically looking for PTPS. In a large retrospective survey, Landreneau et al . 22(table 2) noted a lower incidence of pain in patients who had VATS compared with those who underwent lateral thoracotomy (30 vs. 44%); however, pain medication requirements did not differ. The difference in pain incidence was statistically significant only during the first year after surgery. In a small (n = 30), nonrandomized prospective study, Furrer et al. 23found a 36% incidence of PTPS in patients undergoing VATS wedge resection, and a 33% incidence of PTPS in a matched group of patients undergoing lobectomy by a classic posterolateral thoracotomy. However, the results are confounded because the thoracotomy group received thoracic epidural analgesia with local anesthetic and opioid, whereas the thoracoscopic group received intravenous patient-controlled opioids. Nomori et al. 24retrospectively and Benedetti et al. 25prospectively (case series) reported a decreased severity of chronic pain after anterolateral thoracotomy when compared with classic posterolateral thoracotomy (mean visual analog scale [VAS] score, 6 of 100 vs. 21 of 100). Both studies were small (24 and 42 patients), and chronic postoperative pain was not a primary outcome parameter. In descriptions of the surgical technique for posterolateral thoracotomy, details about whether a rib was resected or about how the intercostal nerves were handled were missing from most reports.A recent report by Obata et al . 26(table 2) found a significant effect of intraoperative plus postoperative epidural analgesia when compared with just postoperative epidural analgesia (decreasing the incidence of pain at 6 months from 67% to 33%). This is a prospective, randomized, single-blind study.The intensity of acute postoperative pain is a statistically significant predictor 18,27of PTPS (36 vs. 56% PTPS for minor vs. moderate to severe acute pain). As mentioned previously herein, the combination of intraoperative plus postoperative epidural analgesia with local anesthetic was associated with a decreased incidence of pain at 6 months. An attempt at preemptive analgesia 28had not improved analgesia on long-term follow-up. 18Another small study found that the type of postoperative analgesia affected the incidence of pain at 12 weeks (less pain with epidural analgesia or intercostal nerve cryoablation), but data of only 33 subjects divided among four treatment regimens were reported. 29Benedetti et al. 25,30showed that intercostal nerve dysfunction (loss of the superficial abdominal reflex) is associated with more acute, subacute, and chronic (3 months) pain. Of 23 patients with intact reflexes on postoperative day 1, none had pain at 2 to 3 months, whereas 50% of individuals with persistent loss of the reflex still had pain at this time.The etiology of PTPS may depend on nerve damage because it is more severe after chest wall resection, 31–33and the loss of superficial abdominal reflexes is associated with an increased probability of PTPS. 25,30Another contributing factor is recurrence of tumor. 31For thoracoscopic surgeries and posterolateral thoracotomy, Landreneau et al . 22noted a 30% decrease in the incidence in pain reported by patients more than 12 months after surgery compared with those 3–12 months after surgery. The prospective study by Perttunen et al . 19noted the incidence of pain at 3, 6, and 12 months to be decreasing (80, 75, and 61%, respectively). Of patients with long-term pain after thoracotomy, up to half describe their pain as moderate or severe, 18and 66% are prescribed analgesics for the pain. 27Postthoracotomy pain syndrome is common. The predictors of this syndrome (when tumor recurrence is excluded) include the extent of acute postoperative pain and intercostal nerve dysfunction (which may link more acute pain and persistent pain). One prospective, randomized controlled study 28found that the combination of intraoperative plus postoperative thoracic epidural analgesia decreases the incidence of PTPS at 6 months.Table 3summarizes various studies of pain after breast surgery. Women who undergo breast surgery experience chest wall, breast, or scar pain (range, 11–57%), phantom breast pain (13–24%), and arm and shoulder pain (12–51%). The incidence of pain in one or more of these sites is close to 50% 1 yr after breast surgery for cancer. The postmastectomy pain syndrome (PMPS) has recently been reviewed, 34with some disagreement about which pains to include in this syndrome. Husted et al . 35documented that, of 163 women who had undergone mastectomy with axillary node dissection, 45% reported cicatrix pain, 45% reported arm, neck, or shoulder pain, and only 21% were symptom free (symptoms included pain, paresthesia, lymphedema, and impaired shoulder function) 1–5 yr after surgery. Moderate to severe pain was reported by 16 patients (10%). Krøner et al . 36reported a significant relation between preoperative breast pain and postoperative phantom breast pain in a prospective study of 120 patients. In contrast, Tasmuth et al., 37,38in a prospective study of 93 patients, did not find the presence of preoperative pain to be a predictive factor, but only 9 patients had pain before surgery. Preoperative depression and anxiety were more common in patients in whom chronic pain developed when compared with those in whom chronic pain did not develop, although statistical significance was not achieved. 37The type of surgery may affect the incidence of pain. Tasmuth et al. 39found that chronic pain was more common after breast conserving surgery than after radical surgery in their large retrospective study, but did not confirm this in smaller prospective studies. 37,38Wallace et al., 40in their questionnaire survey of women who had undergone breast surgery, found that mastectomy combined with implantation of a breast prosthesis yielded a higher incidence of pain (53%) than did mastectomy alone (31%). Abdullah et al . 41reported sensory deficits in the distribution of the intercostobrachial nerve at 3 months after axillary node dissection in 61% of women in whom the nerve was preserved and in 80% of women in whom it was divided. Maunsell et al . 42found that axillary dissection increased the likelihood of arm problems and greater levels of psychologic distress. Kerampoulos et al . 43also found the extent of axillary dissection correlated with the incidence of arm pain and symptoms.Tasmuth et al . 44performed a multivariate analysis of factors that predisposed the patient to chronic pain after breast cancer surgery. The extent of acute postoperative pain and the number of doses of postoperative analgesics were the best predictors of persistent pain in both the breast area and the ipsilateral arm. Additionally, adjuvant postoperative radiation therapy was a risk factor for chronic pain in both the breast area and the arm. 44Kerampoulos et al . 43found that immediate axillary radiation therapy increased the incidence of arm pain and symptoms. Neither Staps et al . 45nor Krøner et al . 36found a relation between phantom breast sensations and radiation therapy, but their studies were smaller and only sought a particular subgroup of symptoms.Much of the pain after breast surgery has been attributed to nerve damage, whether from surgery or radiation. 39,46,47Courtiss and Goldwyn 48demonstrated that nipple and areola sensation decreased (intercostal nerve dysfunction) in the long-term in 15% of 249 women undergoing augmentation mammoplasty and 65% of 138 women undergoing reduction mammoplasty, but pain data were not reported. Sensation was altered in the distribution of the intercostobrachial nerve in 48–84% of women undergoing axillary dissection. In turn, in 25–50% of women with these sensory alterations intercostobrachial neuralgia developed. 41,49Psychologic distress was associated with a higher incidence of arm pain and arm symptoms 42; and both were more common after breast surgery with axillary node dissection. The relations among distress, pain, and preoperative psychologic characteristics have not been elucidated among women undergoing breast surgery.The natural history of pain during the first year after surgery has not been well-characterized. In one study, the incidence of pain in the breast area decreased from 35 to 23% from 3 weeks to 1 yr after surgery, whereas the incidence of hyperesthesia decreased from 38 to 13%. 50In another study, the incidence of arm pain decreased insignificantly from 3 to 15 months after surgery (55 to 51%, respectively). 42The incidence of phantom breast pain is constant from 3 weeks to 6 yr. 51,52Chronic pain is common after breast surgery, and the major predictive factors are the extent of acute postoperative pain, the presence of pain before surgery, the type of surgery, intercostobrachial nerve damage, adjuvant radiation therapy, and possibly preoperative anxiety or depression.Chronic abdominal pain after cholecystectomy is common (range, 3–56%;table 4), but less frequent than the preoperative incidence of pain (83–100%). The postcholecystectomy syndrome (PCS) has a number of components in addition to abdominal pain, and may not have a single underlying etiology. 53“Pathogenic” factors include postoperative somatic incisional pain; pain causes by postoperative sphincter of Oddi dysfunction; pain caused by a preoperatively undiagnosed disease other than gallbladder stone; pain caused by a bile duct stone; and other preoperative factors that predispose the patient to an unfavorable outcome. 54Psychologic vulnerability is a predictor of long-term pain and symptoms after cholecystectomy, 54–56whereas other risk factors include female gender 57and long-standing symptoms before surgery. 58A history of classic gallbladder attack symptoms is associated with reduced risk of chronic pain and symptoms. 59–61The surgical approach appears to make no significant difference in overall complaints. Nicholl et al., 62in a randomized controlled trial (n = 163), noted that patients randomized to lithotripsy had more complications related to biliary “colic,” whereas patients randomized to open cholecystectomy had more complaints of scar pain and diarrhea; they did not report pain incidence data. There appears to be no difference in chronic abdominal pain when laparoscopic cholecystectomy is compared with open cholecystectomy. 63Gui et al . 61reported a 30% incidence of nonspecific abdominal pain more than 1 yr after cholecystectomy, but this incidence did not include 16 patients (17.4%) with wound pain. Stiff et al . 64noted significantly more right upper quadrant pain after open cholecystectomy than after laparoscopic surgery and hypothesized that there was more intercostal nerve damage from the open procedures.Borly et al., 56in a prospective study of 100 patients who underwent cholecystectomy, noted that pain at 6 weeks was a strong predictor of persistent pain and other symptoms at 1 yr (written communication, L. Borly and H. Kehley, 1999). We found no studies that evaluated acute postoperative pain as a predictor of chronic pain.There are multiple etiologies of the PCS, including sphincter of Oddi dysfunction, bile duct stones, ulcer, colonic dysfunction, and scar pain. The relative importance of each factor has not been evaluated.Despite the frequency of persistent symptoms after cholecystectomy, patient satisfaction after the procedure is high, with authors documenting satisfaction rates that exceed 90%. 65–67This may relate to patient expectations 68because most patients with abdominal pain and gallstones believe that they will worsen without surgery and that their lives will improve after surgery.Chronic symptoms are common after cholecystectomy, as is chronic abdominal pain. Predictive factors include psychologic vulnerability, long-standing preoperative symptoms (including pain), and pain at 6 weeks after surgery. Prospective studies of the postcholecystectomy syndrome have not separated scar pain and neuropathic pain from other causes of chronic visceral pain and symptoms.A number of studies have evaluated chronic pain after groin surgery, with the reported incidence of chronic pain varying from 0 to 37% (table 5). The overall incidence from these studies is 11.5% (616 of 5,357). Chronic pain was a primary outcome parameter in only four studies, 69–72and these studies report a variable incidence. In a prospective study of 500 surgeries, surgery for a recurrent hernia had a higher incidence of moderate to severe pain at 12 months than did surgery for a primary repair. 70Patients receiving care under workers’ compensation for work-related injury have a higher pain incidence at 6 months than those who are being cared for by commercial insurance (5 of 22 vs. 1 of 22) 73; additionally, they have had pain for a longer period of time before surgery.The data are inconclusive about whether the surgical approach alters the incidence of chronic pain. Liem et al., 74in a prospective randomized controlled study that evaluated recurrence rates, found a lower incidence of chronic pain (2%) after a laparoscopic repair when compared with an open nonmesh repair (14%). The Medical Research Council study 72also found a significantly lower incidence of pain at 12 months after a laparoscopic repair (28%) compared with an open repair (37%). Dirksen et al. 75found no difference in the incidence of chronic pain in their prospective randomized controlled study that compared an open repair (14%) to a laparoscopic repair (20%). Likewise, Gillion and Fagniez 71found no difference in the incidence of pain in their case series, with both open and laparoscopic repairs having approximately a 14% incidence of chronic pain. Two of the studies 71,75noted that complications, including pain, were more common early in their experience with laparoscopic hernia repair.In a prospective multicenter study, Hay et al. 76did not find statistically significant differences in chronic pain after open repairs (Bassini, Cooper ligament, or Shouldice). Likewise, in a prospective analysis of 500 surgeries, Callesen et al., 70found no significant differences in chronic pain between mesh and nonmesh open repairs in primary hernia surgery. Whether the experience of the surgeon or the degree of specialization is a factor in chronic pain or recurrence has been debated. 77The incidence of chronic pain in case series data from hernia centers is low, 78,79whereas reports with higher incidences of chronic pain typically come from teaching institutions. 72,74,75,80There are no controlled, prospective studies of this factor.The extent of pain at 1 and 4 weeks after surgery is a predictive factor 70for pain at 1 yr. Neither length of convalescence nor type of employment affects the incidence of chronic pain. 70The demonstrated relation between postoperative sensory dysfunction and chronic pain 71supports the interpretation that nerve damage is a pathologic factor. Most authors assume the pain is usually of neuropathic origin, 81–83although Wantz 84also mentions the possibility of the repair being too tight.Callesen et al . 70noted the incidence of moderate to severe pain decreased from 11% at 4 weeks to 6% at 1 yr. Moderate to severe pain at 1 and 4 weeks was the strongest predictor of pain at 1 yr.Chronic pain after groin hernia surgery is not rare, but it appears to be less common than chronic pain after the surgeries previously cited. Because hernia surgery is common, a large number of individuals are affected by chronic pain. Nerve dysfunction has been shown to be a factor, as has the intensity of early postoperative pain. The role of acute pain therapy on the incidence of chronic pain is unknown.Although patient satisfaction with surgical results is reported to be high, 65–67the studies reported herein show that chronic pain is common after these surgeries, and this has been confirmed in a recent review. 85Chronic pain is costly to society in terms of suffering and disability. For humanitarian and economic reasons, the problem of chronic pain after surgery should be addressed. It is also clear there is significant variability in the incidence of chronic pain among these surgical procedures (11.5–47% for inguinal hernia and thoracic surgery). We believe that our review has been thorough, but despite the use of broad search criteria, our electronic search did not detect all articles known to the authors that relate to the development or incidence of chronic pain after the selected surgeries. Reasons for this include publication in journals not included in the Index Medicus at the time of publication (e.g., Kanner et al . 31and Gillion and Fagniez 71) or “pain” not being identified as a key word or used in the title or abstract (e.g., Hay et al. 76). As a result, we are not certain that we identified all articles that contain data relevant to this review.We identified a number of risk factors for prolonged pain after surgery and divide these factors into three categories: (1) preoperative factors, (2) intraoperative factors, and (3) postoperative factors (table 6). Preoperative pain is a predictor of chronic pain for postamputation pain, 16phantom breast pain, 36and noncolicky abdominal pain and symptoms after cholecystectomy. 56,58,86For each of these surgeries, the characteristic of the preoperative pain that predicted chronic pain tended to be continuous pain of 1 month or more in duration. Psychologic vulnerability is a risk factor for persistent pain after cholecystectomy 54–56but has not been evaluated in the other surgeries reviewed herein. It has also been found to predict outcome after lumbar spine surgery. 87Nerve damage is an intraoperative factor that contributes to chronic postoperative pain. Patients undergoing anterior thoracotomy are less likely to have intercostal nerve dysfunction and less likely to have PTPS. 24,25After breast surgery, intercostobrachial neuralgia is associated with damage of that nerve, and attempts to preserve the nerve are associated with a lower incidence of pain. 41However, nerve damage per se does not necessarily cause pain because the incidence of decreased sensation was 2–4 times higher than the incidence of pain in the distribution of the intercostobrachial nerve after axillary node dissection. 41,49Likewise, Benedetti et al. 25,30found chronic pain in only 50% of individuals with intercostal nerve dysfunction after thoracotomy. Nevertheless, nerve dysfunction appears to be associated with chronic pain. 30The most striking predictive postoperative factor is the severity of acute postoperative pain after breast surgery, 44thoracic surgery, 18,27and hernia repair. 70Postoperative adjuvant radiation therapy increases the risk of chronic pain after breast surgery, 44and neurotoxic chemotherapy increases the risk of phantom limb pain. 5Whether acute pain causes chronic pain has been debated. 88–92Dworkin 88proposed a model that incorporates psychosocial and pathophysiologic factors and the severity of acute pain as factors in the development of chronic pain. Using his model, we believe that ongoing nociceptive input from peripheral nerve injury increases acute pain and maintains early (3–12 months) chronic pain. Basbaum 93recently reviewed changes in the nervous system associated with acute pain, with the conclusion that “persistent pain should be considered a disease state of the nervous system, not merely a symptom of some other disease conditions.” If persistent pain after surgery results from sensitization, prevention may be possible if sensitization can be blocked. Obata et al . 26achieved this in thoracotomy patients with intraoperative plus postoperative epidural analgesia, but other clinical studies of preemptive analgesia are far from consistent. 94–96Psychosocial factors are also predictors of chronic pain. Of the surgical procedures we reviewed, the only reproducible psychologic predictor has been “psychologic vulnerability.” The questionnaire for psychologic vulnerability measures a personality disorder that correlates with neuroticism. 55Neither depression nor anxiety are preoperative predictors of chronic pain after surgery. 18,37Gatchel et al . 97noted similar findings when trying to predict chronic back pain in acute back pain patients. They concluded that psychopathology (e.g. , depression) is not associated with an increased risk of development of chronic low back pain, but personality disorders may reflect psychosocial vulnerabilities or deficits in coping skills that are antecedents to chronic pain. The hypothesis of Gatchel et al. 97is consistent with the psychologic vulnerability observations in PCS.In conclusion, chronic pain is common after amputation, inguinal hernia surgery, breast surgery, gallbladder surgery, and lung surgery, and this is also confirmed in another recent review. 85For each of these surgeries, data may be interpreted as showing chronic neuropathic pain as one etiology. Intensity of acute postoperative pain is a predictor of chronic pain. Future studies should characterize the factors of importance in the transition from acute to chronic pain. Such knowledge may result in designing more effective and more rational early interventions. We hypothesize that, in some patients, the type of nerve injury may explain both the increase in acute pain and the chronic pain, but the extent of pain will be modified by other factors, particularly psychologic and physiologic factors that heighten pain sensitivity.

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The Analgesic Efficacy of Transversus Abdominis Plane Block After Abdominal Surgery: A Prospective Randomized Controlled Trial

2006-12-13

John G. McDonnell , Brian D. O’Donnell , Gerard F. Curley +3 more

The transversus abdominis plane (TAP) block is a novel approach for blocking the abdominal wall neural afferents via the bilateral lumbar triangles of Petit. We evaluated its analgesic efficacy in … The transversus abdominis plane (TAP) block is a novel approach for blocking the abdominal wall neural afferents via the bilateral lumbar triangles of Petit. We evaluated its analgesic efficacy in patients during the first 24 postoperative hours after abdominal surgery, in a randomized, controlled, double-blind clinical trial.Thirty-two adults undergoing large bowel resection via a midline abdominal incision were randomized to receive standard care, including patient-controlled morphine analgesia and regular nonsteroidal antiinflammatory drugs and acetaminophen (n = 16), or to undergo TAP block (n = 16) in addition to standard care (n = 16). After induction of anesthesia, 20 mL of 0.375% levobupivacaine was deposited into the transversus abdominis neuro-fascial plane via the bilateral lumbar triangles of Petit. Each patient was assessed by a blinded investigator in the postanesthesia care unit and at 2, 4, 6, and 24 h postoperatively.The TAP block reduced visual analog scale pain scores (TAP versus control, mean +/- sd) on emergence (1 +/- 1.4 vs 6.6 +/- 2.8, P < 0.05), and at all postoperative time points, including at 24 h (1.7 +/- 1.7 vs 3.1 +/- 1.5, P < 0.05). Morphine requirements in the first 24 postoperative hours were also reduced (21.9 +/- 8.9 mg vs 80.4 +/- 19.2 mg, P < 0.05). There were no complications attributable to the TAP block. All TAP patients reported high levels of satisfaction with their postoperative analgesic regimen.The TAP block provided highly effective postoperative analgesia in the first 24 postoperative hours after major abdominal surgery.

Effectiveness of acute postoperative pain management: I. Evidence from published data

2002-09-01

S.J. Dolin , J. N. Cashman , John M. Bland

Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial

2002-04-01

John R. A. Rigg , Konrad Jamrozik , Paul S. Myles +4 more

Anaesthesia, surgery, and challenges in postoperative recovery

2003-12-01

Henrik Kehlet , Jørgen B. Dahl

A Qualitative and Quantitative Systematic Review of Preemptive Analgesia for Postoperative Pain Relief

2002-03-01

Steen Møiniche , Henrik Kehlet , Jørgen B. Dahl

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Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised

2000-12-16

Anthony Rodgers

<h3>Abstract</h3> <b>Objectives:</b> To obtain reliable estimates of the effects of neuraxial blockade with epidural or spinal anaesthesia on postoperative morbidity and mortality. <b>Design:</b> Systematic review of all trials with randomisation … <h3>Abstract</h3> <b>Objectives:</b> To obtain reliable estimates of the effects of neuraxial blockade with epidural or spinal anaesthesia on postoperative morbidity and mortality. <b>Design:</b> Systematic review of all trials with randomisation to intraoperative neuraxial blockade or not. <b>Studies:</b> 141 trials including 9559 patients for which data were available before 1 January 1997. Trials were eligible irrespective of their primary aims, concomitant use of general anaesthesia, publication status, or language. Trials were identified by extensive search methods, and substantial amounts of data were obtained or confirmed by correspondence with trialists. <b>Main outcome measures:</b> All cause mortality, deep vein thrombosis, pulmonary embolism, myocardial infarction, transfusion requirements, pneumonia, other infections, respiratory depression, and renal failure. <b>Results:</b> Overall mortality was reduced by about a third in patients allocated to neuraxial blockade (103 deaths/4871 patients versus 144/4688 patients, odds ratio=0.70, 95% confidence interval 0.54 to 0.90, P=0.006). Neuraxial blockade reduced the odds of deep vein thrombosis by 44%, pulmonary embolism by 55%, transfusion requirements by 50%, pneumonia by 39%, and respiratory depression by 59% (all P<0.001). There were also reductions in myocardial infarction and renal failure. Although there was limited power to assess subgroup effects, the proportional reductions in mortality did not clearly differ by surgical group, type of blockade (epidural or spinal), or in those trials in which neuraxial blockade was combined with general anaesthesia compared with trials in which neuraxial blockade was used alone. <b>Conclusions:</b> Neuraxial blockade reduces postoperative mortality and other serious complications. The size of some of these benefits remains uncertain, and further research is required to determine whether these effects are due solely to benefits of neuraxial blockade or partly to avoidance of general anaesthesia. Nevertheless, these findings support more widespread use of neuraxial blockade.

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Transition from acute to chronic postsurgical pain: risk factors and protective factors

2009-04-29

Joel Katz , Ze’ev Seltzer

Most patients who undergo surgery recover uneventfully and resume their normal daily activities within weeks. Nevertheless, chronic postsurgical pain develops in an alarming proportion of patients. The prevailing approach of … Most patients who undergo surgery recover uneventfully and resume their normal daily activities within weeks. Nevertheless, chronic postsurgical pain develops in an alarming proportion of patients. The prevailing approach of focusing on established chronic pain implicitly assumes that information generated during the acute injury phase is not important to the subsequent development of chronic pain. However, a rarely appreciated fact is that every chronic pain was once acute. Here, we argue that a focus on the transition from acute to chronic pain may reveal important cues that will help us to predict who will go on to develop chronic pain and who will not. Unlike other injuries, surgery presents a unique set of circumstances in which the precise timing of the physical insult and ensuing pain are known in advance. This provides an opportunity, before surgery, to identify the risk factors and protective factors that predict the course of recovery. In this paper, the epidemiology of chronic postsurgical pain is reviewed. The surgical, psychosocial, socio-environmental and patient-related factors that appear to confer a greater risk of developing chronic postsurgical pain are described. The genetics of chronic postsurgical pain are discussed with emphasis on known polymorphisms in human genes associated with chronic pain, genetic studies of rodent models of pain involving surgical approaches, the importance of developing accurate human chronic postsurgical pain phenotypes and the expected gains for chronic postsurgical pain medicine in the post-genomic era. Evidence is then reviewed for a preventive multimodal analgesic approach to surgery. While there is some evidence that chronic postsurgical pain can be minimized or prevented by an analgesic approach involving aggressive perioperative multimodal treatment, other studies fail to show this benefit. The transition of acute postoperative pain to chronic postsurgical pain is a complex and poorly understood developmental process, involving biological, psychological and social-environmental factors.

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Chronic post-surgical pain: 10 years on

2008-04-24

W.A. Macrae

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Epidural Anesthesia and Analgesia in High-risk Surgical Patients

1987-06-01

Mark P. Yeager , D. David Glass , Raymond K. Neff +1 more

The authors conducted a randomized controlled clinical trial to evaluate the effect of epidural anesthesia and postoperative analgesia (EAA) on postoperative morbidity in a group of high-risk surgical patients. A … The authors conducted a randomized controlled clinical trial to evaluate the effect of epidural anesthesia and postoperative analgesia (EAA) on postoperative morbidity in a group of high-risk surgical patients. A total of 53 patients were admitted to the study, 28 received EAA, and 25 received standard anesthetic and analgesic techniques without EAA. Surgical "risk" was evaluated preoperatively and found to be comparable in the two groups. When compared to control patients, patients who received EAA had a reduction in the overall postoperative complication rate (P = 0.002) and in the incidence of cardiovascular failure (P = 0.007) and major infectious complications (P = 0.007). Urinary cortisol excretion, a marker of the stress response, was significantly diminished during the first 24 postoperative hours in the group receiving EAA (P = 0.025). Finally, hospital costs were significantly reduced for patients who received EAA (P = 0.02). The authors conclude that EAA exerted a significant beneficial effect on operative outcome in a group of high risk surgical patients.

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Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council

2016-01-29

Roger Chou , Debra B. Gordon , Oscar A. de León-Casasola +7 more

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THE MANAGEMENT OF PAIN

1954-05-01

John J. Bonica

The Erector Spinae Plane Block

2016-01-01

Mauricio Forero , Sanjib Das Adhikary , Hector Lopez +2 more

<h3>Abstract</h3> Thoracic neuropathic pain is a debilitating condition that is often poorly responsive to oral and topical pharmacotherapy. The benefit of interventional nerve block procedures is unclear due to a … <h3>Abstract</h3> Thoracic neuropathic pain is a debilitating condition that is often poorly responsive to oral and topical pharmacotherapy. The benefit of interventional nerve block procedures is unclear due to a paucity of evidence and the invasiveness of the described techniques. In this report, we describe a novel interfascial plane block, the erector spinae plane (ESP) block, and its successful application in 2 cases of severe neuropathic pain (the first resulting from metastatic disease of the ribs, and the second from malunion of multiple rib fractures). In both cases, the ESP block also produced an extensive multidermatomal sensory block. Anatomical and radiological investigation in fresh cadavers indicates that its likely site of action is at the dorsal and ventral rami of the thoracic spinal nerves. The ESP block holds promise as a simple and safe technique for thoracic analgesia in both chronic neuropathic pain as well as acute postsurgical or posttraumatic pain.

Postoperative Multimodal Analgesia Pain Management With Nonopioid Analgesics and Techniques

2017-05-31

Elizabeth C. Wick , Michael C. Grant , Christopher L. Wu

Amid the current opioid epidemic in the United States, the enhanced recovery after surgery pathway (ERAS) has emerged as one of the best strategies to improve the value and quality … Amid the current opioid epidemic in the United States, the enhanced recovery after surgery pathway (ERAS) has emerged as one of the best strategies to improve the value and quality of surgical care and has been increasingly adopted for a broad range of complex surgical procedures. The goal of this article was to outline important components of opioid-sparing analgesic regimens.Regional analgesia, acetaminophen, nonsteroidal anti-inflammatory agents, gabapentinoids, tramadol, lidocaine, and/or the N-methyl-d-aspartate class of glutamate receptor antagonists have been shown to be effective adjuncts to narcotic analgesia. Nonsteroidal anti-inflammatory agents are not associated with an increase in postoperative bleeding. A meta-analysis of 27 randomized clinical trials found no difference in postoperative bleeding between the groups taking ketorolac tromethamine (33 of 1304 patients [2.5%]) and the control groups (21 of 1010 [2.1%]) (odds ratio [OR], 1.1; 95% CI, 0.61-2.06; P = .72). After adoption of the multimodal analgesia approach for a colorectal ERAS pathway, most patients used less opioids while in the hospital and many did not need opioids after hospital discharge, although approximately 50% of patients received some opioid during their stay.Multimodal analgesia is readily available and the evidence is strong to support its efficacy. Surgeons should use this effective approach for patients both using and not using the ERAS pathway to reduce opioid consumption.

Poorly controlled postoperative pain: prevalence, consequences, and prevention

2017-09-01

Tong J. Gan

Abstract: This review provides an overview of the clinical issue of poorly controlled postoperative pain and therapeutic approaches that may help to address this common unresolved health-care challenge. Postoperative pain … Abstract: This review provides an overview of the clinical issue of poorly controlled postoperative pain and therapeutic approaches that may help to address this common unresolved health-care challenge. Postoperative pain is not adequately managed in greater than 80% of patients in the US, although rates vary depending on such factors as type of surgery performed, analgesic/anesthetic intervention used, and time elapsed after surgery. Poorly controlled acute postoperative pain is associated with increased morbidity, functional and quality-of-life impairment, delayed recovery time, prolonged duration of opioid use, and higher health-care costs. In addition, the presence and intensity of acute pain during or after surgery is predictive of the development of chronic pain. More effective analgesic/anesthetic measures in the perioperative period are needed to prevent the progression to persistent pain. Although clinical findings are inconsistent, some studies of local anesthetics and nonopioid analgesics have suggested potential benefits as preventive interventions. Conventional opioids remain the standard of care for the management of acute postoperative pain; however, the risk of opioid-related adverse events can limit optimal dosing for analgesia, leading to poorly controlled acute postoperative pain. Several new opioids have been developed that modulate µ-receptor activity by selectively engaging intracellular pathways associated with analgesia and not those associated with adverse events, creating a wider therapeutic window than unselective conventional opioids. In clinical studies, oliceridine (TRV130), a novel µ-receptor G-protein pathway-selective modulator, produced rapid postoperative analgesia with reduced prevalence of adverse events versus morphine. Keywords: acute pain, chronic pain, surgical procedures, analgesics, opioid

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Transition from acute to chronic pain after surgery

2019-04-01

Paul Glare , Karin R. Aubrey , Paul S. Myles

The Comparative Effects of Postoperative Analgesic Therapies on Pulmonary Outcome

1998-03-01

Jane C. Ballantyne , Daniel B. Carr , Sarah deFerranti +5 more

Efficacy of intravenous acetaminophen as adjunct analgesia in patients undergoing cardiovascular surgery: a systematic review and meta-analysis

2025-06-25

Soowon Lee , Chang‐Hoon Koo , Yu Kyung Bae +1 more | The Korean journal of pain

Although intravenous (IV) acetaminophen (AAP) may help reduce severe postoperative pain and opioid use after cardiovascular surgery, its effectiveness must be further validated. Therefore, the authors aimed to evaluate the … Although intravenous (IV) acetaminophen (AAP) may help reduce severe postoperative pain and opioid use after cardiovascular surgery, its effectiveness must be further validated. Therefore, the authors aimed to evaluate the analgesic efficacy of perioperative IV AAP in patients undergoing cardiovascular surgery by conducting this meta-analysis. A comprehensive literature search was conducted of PubMed, Embase, CENTRAL, CINAHL, Scopus, and Web of Science databases for studies published up to March 21, 2024. Six randomized controlled trials comparing IV AAP with a placebo in cardiovascular surgery were included. The mean difference (MD) was calculated to estimate pooled effect sizes. The primary outcome was opioid consumption, measured in morphine equivalent dose, and the secondary outcome was postoperative pain score. Postoperative opioid consumption was significantly reduced with IV AAP than it was with a placebo (MD: -21.68, 95% confidence interval [CI]: -38.41 to -4.95, P = 0.011). Significant reductions in postoperative pain scores were observed at 6 hours (MD: -0.76, 95% CI: -1.43 to -0.10, P = 0.025) and 24 hours (MD: -0.63, 95% CI: -1.02 to -0.25, P = 0.001) after surgery. However, these reductions did not meet clinically meaningful thresholds. No significant differences were observed at 12, 18, and 48 hours postoperatively. IV AAP was more effective than a placebo for postoperative adjunct analgesia in patients who underwent cardiovascular surgery.

Shifting From Thoracic Epidurals to Nerve Blocks—Redefining Gold Standards

2025-06-25

Joseph D. Phillips | JAMA Surgery

Intercostal or Paravertebral Block vs Thoracic Epidural in Lung Surgery

2025-06-25

Louisa N Spaans , Marcel G.W. Dijkgraaf , Denis Susa +7 more | JAMA Surgery

Importance Effective pain control after thoracic surgery is crucial for enhanced recovery. While thoracic epidural analgesia (TEA) traditionally ensures optimal analgesia, its adverse effects conflict with the principles of enhanced … Importance Effective pain control after thoracic surgery is crucial for enhanced recovery. While thoracic epidural analgesia (TEA) traditionally ensures optimal analgesia, its adverse effects conflict with the principles of enhanced recovery after thoracic surgery. High-quality randomized data regarding less invasive alternative locoregional techniques are lacking. Objective To evaluate the efficacy of continuous paravertebral block (PVB) and a single-shot intercostal nerve block (ICNB) as alternatives to TEA. Design, Setting, and Participants This randomized clinical trial compared PVB and ICNB vs TEA (1:1:1) in patients undergoing thoracoscopic anatomical lung resection at 11 hospitals in the Netherlands and Belgium, enrolled from March 5, 2021, to September 5, 2023. The study used a noninferiority design for pain and a superiority design for quality of recovery (QoR). Interventions Continuous PVB and single-shot ICNB. Main Outcomes and Measures Primary outcomes were pain, defined as mean proportion of pain scores 4 or greater during postoperative days (POD) 0 through 2 (noninferiority margin for the upper limit [UL] 1-sided 98.65% CI, 17.5%), and QoR, assessed with the QoR-15 questionnaire at POD 1 and 2. Secondary measures included opioid consumption, mobilization, complications, and hospitalization. Results A total of 450 patients were randomized, with 389 included in the intention-to-treat (ITT) analysis (mean [SD] age, 66 [9] years; 208 female patients [54%] and 181 male [46%]). Of these 389 patients, 131 received TEA, 134 received PVB, and 124 received ICNB. The mean proportions of pain scores 4 or greater were 20.7% (95% CI, 16.5%-24.9%) for TEA, 35.5% (95% CI, 30.1%-40.8%) for PVB, and 29.5% (95% CI, 24.6%-34.4%) for ICNB. While PVB was inferior to TEA regarding pain (ITT: UL, 22.4%; analysis per-protocol [PP]: UL, 23.1%), ICNB was noninferior to TEA (ITT: UL, 16.1%; PP: UL, 17.0%). The mean (SD) QoR-15 scores were similar across groups: 104.96 (20.47) for TEA, 106.06 (17.94; P = .641) for PVB ( P = .64 for that comparison), and 106.85 (21.11) for ICNB ( P = .47 for that comparison). Both ICNB and PVB significantly reduced opioid consumption and enhanced mobility compared with TEA, with no significant differences in complications. Hospitalization was shorter in the ICNB group. Conclusions and Relevance After thoracoscopic anatomical lung resection, only ICNB provides noninferior pain relief compared with TEA. ICNB emerges as an alternative to TEA, although risks and benefits should be weighed for optimal personalized pain control. Trial Registration ClinicalTrials.gov Identifier: NCT05491239

Corrigendum to “Genicular nerve block with corticosteroid for chronic knee Pain: Patient-Reported outcomes across 9-years of practice” [Intervent Pain Med 4 (2025) 100601]

2025-06-25

Mingda Chen , Sercan Tosun , Nicolas R. Thompson +1 more | Interventional Pain Medicine

Adjuvants and rebound pain following peripheral nerve block in adult surgical patients: a systematic review and network meta-analysis of randomized controlled trials

2025-06-25

Xiaodan Yang , Bin Su , Yu‐Pei Chen +3 more | Anesthesiology and Perioperative Science

Abstract Purpose Rebound pain occurs when peripheral nerve blocks (PNBs) subside and this hampers patient recovery after surgery. This study aims to determine the most effective adjuvant to mitigate rebound … Abstract Purpose Rebound pain occurs when peripheral nerve blocks (PNBs) subside and this hampers patient recovery after surgery. This study aims to determine the most effective adjuvant to mitigate rebound pain in adult surgical patients. Methods A comprehensive search was conducted for randomized controlled trials (RCTs) that reported rebound pain and utilized perineurally (PN) or intravenously (IV) administered adjuvants. We used multiple databases, including PubMed, Web of Science, the Cochrane Library, Embase, CNKI, Wanfang Data, SinoMed and Chinese medical journals from their inception until September 30, 2024. The primary outcome measured was the incidence of rebound pain. A network meta-analysis was performed using a frequentist approach. Results The meta-analysis included three RCTs examining ketamine/esketamine, eight evaluating dexamethasone and one assessing tropisetron. Compared to no adjuvant, IV dexamethasone was found to significantly reduce the incidence of rebound pain (odds ratio [OR] = 0.13, 95% confidence interval [CI]: 0.05, 0.35) and postoperative nausea and vomiting (PONV; OR = 0.33, 95% CI: 0.12, 0.85), while also prolonging the time to onset of rebound pain (mean difference [MD] = 3.95 h, 95% CI: 1.36, 6.53). PN dexamethasone extended the time to onset of rebound pain (MD = 6.57 h, 95% CI: 3.20, 9.93) but did not significantly reduce the incidence of rebound pain or PONV. Ketamine/esketamine was associated with a reduction in the incidence of rebound pain (OR = 0.30, 95% CI: 0.10, 0.89) but did not affect PONV. According to the rank order of surface under the cumulative ranking curve analysis, IV dexamethasone exhibited the lowest incidence of rebound pain and PONV compared to PN dexamethasone, ketamine/esketamine, tropisetron and no adjuvant. PN dexamethasone was most effective in prolonging the onset of rebound pain compared to IV dexamethasone, tropisetron and no adjuvant. The overall quality of evidence was rated as low or very low. Conclusion Current evidence, albeit of low quality, indicates that IV dexamethasone is the most effective adjuvant for the prevention of rebound pain, while PN dexamethasone is optimal for delaying its onset. Therefore, a combined approach utilizing both IV and PN dexamethasone following PNB may represent an effective strategy for managing rebound pain in adult surgical patients.

Ultrasound Guided Transversalis Fascia Plane Block in Paediatric Population Undergoing Anterior Iliac Bone Harvest – A Prospective, Randomised Clinical Trial

2025-06-24

Sourav Das | International Journal of Oral and Maxillofacial Surgery

Delayed Temporary Paresthesia Following Implant Placement: A Case Report and Review of the Literature

2025-06-24

H. El-Awour | International Journal of Oral and Maxillofacial Surgery

Comparison of Flupirtine and Diclofenac for Post Operative Analgesia in Maxillofacial Trauma – A Randomized Control Trial

2025-06-24

Shital Pise , Ashish Chugh , C. KISTI +2 more | International Journal of Oral and Maxillofacial Surgery

Mastering the GON Block: A practical four-step ultrasound-Guided approach

2025-06-24

Mustafa Turgut Yıldızgören , Hatice Ozeken , Abdulkadir Bartu +1 more | Interventional Pain Medicine

An uncommon approach of Bier block for tibial surgery; A case report

2025-06-24

Liaquat Ali , Usama Ahmed Ali , Sana Nasir +2 more | Anaesthesia Pain & Intensive Care

This case report presents the first documented use of a Bier block (intravenous regional anesthesia) for lower limb surgery in Pakistan, detailing its application in a 39-year-old male undergoing the … This case report presents the first documented use of a Bier block (intravenous regional anesthesia) for lower limb surgery in Pakistan, detailing its application in a 39-year-old male undergoing the removal of a dynamic compression plate from his left tibia. The procedure utilized a total of 50 mL of lignocaine, achieving effective analgesia throughout the surgery, with the patient reporting minimal discomfort. This case underscores the efficacy and safety of the Bier block as a viable alternative to general anesthesia for orthopedic procedures, addressing a significant gap in the literature regarding its use in lower limb surgeries. The successful outcome highlights the potential for improved postoperative pain management and sets a precedent for further research and clinical practice in this area. Abbreviations: IVRA: intravenous regional anesthesia, MET score: Metabolic Equivalent of Task score, PACU: Post-Anesthesia Care Unit, VAS: Visual Analog Scale Keywords: Lower Extremity; Orthopedic Procedures; Tourniquets; Compartment Syndromes; IVRA Citation: Ali L, Ali U, Qureshi AA, Nasir S, Fatima N. An uncommon approach of Bier block for tibial surgery; A case report. Anaesth. pain intensive care 2025;29(3):695-698. DOI: 10.35975/apic.v29i3.2780 Received: October 23, 2024; Revised: February 05, 2025; Accepted: March 23, 2025

Pharmacogenetic aspects of the efficacy of nonsteroidal anti-inflammatory drugs and opioid analgesics for postoperative pain relief after total joint arthroplasty

2025-06-24

A. S. Zhiryakova , Н. П. Денисенко , С. Н. Тучкова +7 more | Modern Rheumatology Journal

Objective: to investigate possible associations between genetic, clinical, laboratory, and demographic parameters and the level of pain in the early postoperative (p/o) period, the need for opioid analgesics, and gastrointestinal … Objective: to investigate possible associations between genetic, clinical, laboratory, and demographic parameters and the level of pain in the early postoperative (p/o) period, the need for opioid analgesics, and gastrointestinal symptoms in patients who underwent primary total knee (TKR) or hip replacement (THR). Material and methods. Sixty-one patients hospitalized for THR or TKR were included in the study. P/o pain relief was achieved using nonsteroidal anti-inflammatory drugs (NSAIDs) – ketoprofen or ketorolac – with tramadol prescribed "on demand." Pain was assessed in all patients using the numeric rating scale (NRS) on postoperative days 1–5. The amount of opioid analgesics used during hospitalization was recorded. Gene polymorphisms of CYP2C9, CYP2C8, PTGS1, PTGS2, ABCB1, CYP2D6, OPRM1, COMT, and C3orf20 were analyzed using real-time polymerase chain reaction. Results and discussion. Patients with the AC genotype of CYP2C9*3 experienced less intense pain on postoperative day 1 (4.5±1.0 vs. 7.0±2.3; p=0.03) and required fewer opioids during hospitalization (20.0±11.5 vs. 28.0±7.4 morphine equivalent units; p=0.04) compared to those with the AA genotype. Carriers of the CC genotype of the rs1045642 polymorphism of the ABCB1 gene reported less pain on day 5 (1.5±0.7 vs. 3.7±1.2; p=0.04) than those with the CT genotype. Patients with the AA genotype of rs1799971 in the OPRM1 gene required more opioids in p/o period than those with AG + GG genotypes (28.4±7.1 vs. 21.6±9.8 morphine equivalent units; p=0.03). Patients with the GG genotype of rs12496846 in the C3orf20 gene experienced more intense pain on p/o day 4 (6.0±1.41) than those with the AA genotype (2.60±1.50; p=0.002). Conclusion. Following THR and TKR, pain intensity and/or opioid use were associated with patients’ pharmacogenetic profiles in CYP2C9, ABCB1, OPRM1, and C3orf20.

Temporal Trends in the Use of Regional Anesthesia for Hip Fracture Surgery: A Retrospective Single-Center Study

2025-06-24

Casey Kukielski , Brittany L Deiling , Bhiken I. Naik +3 more | Cureus

Erector Spinae Plane Block for Percutaneous Transhepatic Biliary Drainage: A Comparative Analysis

2025-06-24

Çağrı Erdim , Mehmet Hamza Türkcanoğlu , Rabia Deniz +5 more | CardioVascular and Interventional Radiology

Tale of two approaches to ultrasound-guided interscalene brachial plexus block: a pro-con

2025-06-24

Robert L. Owen , Beth VanderWielen , Adam W. Amundson +1 more | Regional Anesthesia & Pain Medicine

The interscalene brachial plexus block is a well-described and widely used peripheral nerve block effective for regional anesthesia and analgesia in orthopedic surgical procedures of the shoulder, upper arm, and … The interscalene brachial plexus block is a well-described and widely used peripheral nerve block effective for regional anesthesia and analgesia in orthopedic surgical procedures of the shoulder, upper arm, and clavicle. Conventionally, an in-plane ultrasound-guided approach has been the technique of choice, while the out-of-plane approach, though less described, has been gaining anecdotal momentum among a growing number of proceduralists. This pro-con discussion highlights the out-of-plane approach’s goal of avoiding needle injuries to nerves that course through the middle scalene muscle and the in-plane approach’s benefit of whole-shaft needle visualization and increased distance away from the plexus on entry. We aim to provide a comprehensive comparison to guide proceduralists in their clinical decision-making.

Comparison of Analgesic Efficacy of Ultrasound Guided Ilioinguinal/iliohypogastric Nerve Block and Transversus Abdominis Plane Block in Pediatric Unilateral Lower Abdominal Surgery

2025-06-23

Özlem Turhan , Hacer Şebnem Türk , Pınar Sayın +1 more | Hitit Medical Journal

Objective: Regional techniques providing effective postoperative analgesia in pediatrics are controversial. We compared analgesic efficacy of ilioinguinal/iliohypogastric nerve and transversus abdominis plane blocks in children underwent abdominal surgery. Material and … Objective: Regional techniques providing effective postoperative analgesia in pediatrics are controversial. We compared analgesic efficacy of ilioinguinal/iliohypogastric nerve and transversus abdominis plane blocks in children underwent abdominal surgery. Material and Method: In this retrospectively designed study, a total of 60 patients aged between 2 and 12 years who underwent abdominal surgery were divided into two groups: Group I (n=30), which received an ilioinguinal/iliohypogastric nerve block, and Group II (n=30), which received a transversus abdominis plane block. Demographics, intraoperative heart rate, fentanyl consumption, duration of anesthesia and surgery, postoperative pain scores and time to first additional analgesic, number of patients requiring additional analgesia, and complications were recorded. Results: The time to first postoperative analgesia requirement was similar between Group I and Group II (258 ± 135 min and 193 ± 94 min, respectively p=0.369). Demographics, intraoperative fentanyl consumption, duration of anesthesia and surgery were similar in both groups. Intraoperative heart rate and postoperative pain scores at 0th, 1st, and 2nd hours were comparable between the groups. Heart rate decreased significantly from baseline at 15 and 30 minutes within each group. Pain scores decreased significantly at 1st and 2nd hours compared to 0th hour within each group. The number of patients requiring additional analgesia in the first 24 hours postoperatively was similar between the groups. No patients experienced any complications. Conclusion: Ilioinguinal/iliohypogastric nerve and transversus abdominis plane blocks provided similar analgesic efficacy in pain management after pediatric lower abdominal surgery. Both techniques could be preferable regional analgesia methods as part of a multimodal approach in this population.

HIỆU QUẢ GIẢM ĐAU DO BỆNH NHÂN TỰ ĐIỀU KHIỂN ĐƯỜNG TĨNH MẠCH SAU PHẪU THUẬT CẮT AMIDAL VÀ CHỈNH HÌNH MÀN HẦU

2025-06-23

Dương Lê Xuân , Định Ngô Văn | Tạp chí Y học Việt Nam

Mục tiêu: Đánh giá hiệu quả giảm đau và một số tác dụng không mong muốn của phương pháp giảm đau do bệnh nhân tự điều khiển (PCA) đường tĩnh … Mục tiêu: Đánh giá hiệu quả giảm đau và một số tác dụng không mong muốn của phương pháp giảm đau do bệnh nhân tự điều khiển (PCA) đường tĩnh mạch bằng hỗn hợp fentanyl kết hợp với nefopam và granisetron sau phẫu thuật cắt amidal, chỉnh hình màn hầu. Phương pháp: Nghiên cứu tiến cứu trên 30 bệnh nhân phẫu thuật cắt amidal, chỉnh hình màn hầu được làm giảm đau đường tĩnh mạch bằng dung dịch fentanyl 5mcg/ml kết hợp với nefopam 0,5mg/ml và granisetron 0,01mg/ml. Giảm đau tự điều khiển với liều khởi đầu 2ml/h, liều bolus 1ml, thời gian khóa 60 phút. Đánh giá mức độ đau theo thang điểm VAS (Visual Analogue Scale) khi nghỉ và khi vận động; theo dõi mạch, huyết áp, tần số thở, SpO2 trong 3 ngày liên tiếp sau mổ. Bổ sung liều giảm đau Paracetamol 1g nếu sau 3 lần bấm yêu cầu liên tiếp có đáp ứng nhưng điểm VAS vẫn ≥ 4. Kết quả: 100% bệnh nhân được giảm đau ở mức đau nhẹ đến đau vừa (điểm VAS < 4) khi nghỉ; khi ho, 80% BN có điểm VAS <4. Tác dụng không mong muốn bao gồm: vã mồ hôi 6,67%, buồn nôn và nôn 13,33%, trong khi không gặp bệnh nhân hạ huyết áp, suy hô hấp. Kết luận: Giảm đau do bệnh nhân tự điều khiển đường tĩnh mạch bằng hỗn hợp fentanyl kết hợp với nefopam và granisetron sau phẫu thuật cắt amidal, chỉnh hình màn hầu có hiệu quả giảm đau tốt trong phẫu thuật cắt amidal, chỉnh hình màn hầu. Tác dụng không mong muốn bao gồm: vã mồ hôi, buồn nôn và nôn, không gặp bệnh nhân hạ huyết áp, suy hô hấp.

HIỆU QUẢ GIẢM ĐAU CỦA PHƯƠNG PHÁP GÂY TÊ CƠ NGANG BỤNG DƯỚI HƯỚNG DẪN CỦA SIÊU ÂM BẰNG BUPIVACAIN VÀ DEXAMETHASONE SAU PHẪU THUẬT MỔ LẤY THAI

2025-06-23

Dương Lê Xuân , Định Ngô Văn | Tạp chí Y học Việt Nam

Mục tiêu: Đánh giá hiệu quả giảm đau, biến chứng của kỹ thuật gây tê cơ ngang bụng (TAP block) dưới hướng dẫn của siêu âm sau phẫu thuật mổ … Mục tiêu: Đánh giá hiệu quả giảm đau, biến chứng của kỹ thuật gây tê cơ ngang bụng (TAP block) dưới hướng dẫn của siêu âm sau phẫu thuật mổ lấy thai. Phương pháp: Nghiên cứu tiến cứu trên 30 sản phụ được gây tê cơ ngang bụng dưới hướng dẫn của siêu âm sử dụng thuốc tê bupivacaine 0,25% liều 1mg/kg kết hợp dexamethasone 4mg mỗi bên. Sau khi xác định được vị trí giữa cơ ngang bụng với cơ chéo bụng trong và đầu kim trên màn hình siêu âm, tiến hành tiêm thuốc vào giữa hai lớp cơ, theo dõi thời gian khởi phát tác dụng, hiệu quả giảm đau, tỷ lệ thành công và những biến chứng. Kết quả: Các phẫu thuật gồm: 40,9% mổ lấy thai lần 1, 50% mổ lấy thai lần 2, 9,1% mổ lấy thai lần 3 trở lên; thời gian khởi phát giảm đau trung bình là 12,7±3,3 phút, thời gian giảm đau trung bình là 638,7 ± 91,9 phút, điểm VAS trung bình khi nghỉ ngơi sau 1 giờ là 1,08±0,92; sau 6 giờ là 1,92±0,95; sau 12 giờ là 3,38±1,04; sau 24 giờ là 3,92±1,21; không dùng fentanyl ở 100% bệnh nhân; tỷ lệ thành công là 100%; không có biến chứng nào của kỹ thuật được ghi nhận. Kết luận: Gây tê cơ ngang bụng dưới hướng dẫn của siêu âm cho 30 bệnh nhân sau phẫu thuật mổ lấy thai có hiệu quả giảm đau tốt, không dùng thuốc giải cứu đau cho tất cả bệnh nhân, tỷ lệ thành công là 100%, không có biến chứng nào ở tất cả các trường hợp.

Analgesic efficacy of continuous erector spinae plane block vs. opioid‐based regimen for postoperative pain management following video‐assisted thoracoscopic lung resection: a prospective, randomised, open‐label, non‐inferiority trial

2025-06-23

Junqiang Hu , Weichao Zhou , Xi Zheng +6 more | Anaesthesia

Summary Introduction Video‐assisted thoracoscopic lung resection causes significant postoperative pain. We hypothesised that continuous erector spinae plane block would provide non‐inferior analgesia compared with a conventional opioid‐based regimen for this … Summary Introduction Video‐assisted thoracoscopic lung resection causes significant postoperative pain. We hypothesised that continuous erector spinae plane block would provide non‐inferior analgesia compared with a conventional opioid‐based regimen for this procedure. Methods Patients were allocated randomly to continuous erector spinae plane block (continuous infusion of 0.25% ropivacaine via perineural catheters (5 ml.h ‐1 ) combined with programmed intermittent bolus (10 ml every 6 h for the initial 24 h)) or conventional opioid‐based regimen (continuous infusion of opioid (2 μg.kg ‐1 sufentanil and 16 mg ondansetron diluted to 100 ml with 0.9% normal saline) at 2 ml.h ‐1 for 48 h). The primary outcome was overall analgesic efficacy with cough, quantified by the cumulative area under curve for the pain numeric rating scale scores, from post‐anaesthesia care unit discharge to 48 h postoperatively. Results The cumulative area under curve for the pain numeric rating scale score in patients allocated to the continuous erector spinae plane block group was non‐inferior to those allocated to the conventional group (mean difference − 0.99, 95%CI ‐11.97–9.98, p = 0.011). Patients allocated to the continuous erector spinae plane block group showed superior quality of recovery‐15 scores at 24 h (median difference 11, 95%CI 6–16, p < 0.001) and 48 h postoperatively (median difference 10, 95%CI 7–15, p < 0.001), alongside reduced postoperative pulmonary complications (relative risk 0.45, 95%CI 0.21–0.96, p = 0.031). Safety outcomes favoured continuous erector spinae plane block, with lower incidences of postoperative nausea (relative risk 0.17, 95%CI 0.04–0.73, p = 0.005); retching (relative risk 0.11, 95%CI 0.02–0.89, p = 0.023); and dizziness (relative risk 0.22, 95%CI 0.07–0.72, p = 0.005). Discussion Following video‐assisted thoracoscopic lung resection, continuous erector spinae plane block provides non‐inferior postoperative analgesia compared with conventional opioid‐based regimen whilst enhancing recovery quality significantly and reducing complications.

Dexmedetomidine-enhanced chest wall fascial plane blocks in ultra-fast-track minimally invasive heart valve surgery: a randomized controlled trial

2025-06-23

Shenjie Jiang , Tian Jiang , Han-Wei Wei +3 more | Perioperative Medicine

Injury to the sternocostal joint during minimally invasive cardiac surgery frequently results in severe pain, yet there is no established standard for perioperative analgesia. This randomized controlled trial evaluated whether … Injury to the sternocostal joint during minimally invasive cardiac surgery frequently results in severe pain, yet there is no established standard for perioperative analgesia. This randomized controlled trial evaluated whether adding 1 μg/kg dexmedetomidine to 0.375% ropivacaine for chest wall fascial plane blocks enhances opioid sparing in ultra-fast-track (UFT) minimally invasive heart valve surgery. Seventy-six elective patients were randomized (1:1) in a double-blind manner. The control group received 60 mL of 0.375% ropivacaine, while the DEX group was administered 60 mL of 1 μg/kg dexmedetomidine plus 0.375% ropivacaine. The primary outcomes were intraoperative remifentanil use and 24-h postoperative sufentanil consumption, which served as co-primary endpoints to evaluate opioid-sparing effects. Secondary outcomes included 24-h postoperative sufentanil consumption, 24-h oxycodone use, patient-controlled analgesia (PCA) activations, episodes of Visual Analog Scale (VAS) scores ≥ 3 within 48 h, time to recovery of consciousness, time to extubation, duration of intensive care unit (ICU), and hospital stays, and complications. The DEX group exhibited significantly reduced intraoperative remifentanil consumption (2.45 ± 0.47 vs. 2.98 ± 0.53 mg, p < 0.001) and 24-h sufentanil use (median with interquartile range (IQR) 57 [54-60] vs. 63 [63-66] μg, p < 0.001). It also demonstrated lower 24-h oxycodone consumption (median [IQR] 5 [0-10] vs. 10 [10-20] mg, p < 0.001), fewer 24-h PCA activations (median [IQR] 3 [2-4] vs. 5 [5-6], p < 0.001), and less frequent VAS ≥ 3 episodes (median [IQR] 3 [2.5-4] vs. 6 [5-6], p < 0.001), alongside shorter lengths of ICU (21.34 ± 3.59 vs. 24.29 ± 4.07 h, p = 0.002) and hospital stays (6.51 ± 1.04 vs. 8.65 ± 1.80 days, p < 0.001). Postoperative complications did not differ significantly between groups, though dexmedetomidine-related hemodynamic effects were not systematically monitored. The administration of 1 μg/kg dexmedetomidine in combination with ropivacaine for chest wall fascial plane blocks reduces opioid requirements and shortens ICU/hospital stays in UFT cardiac surgery, supporting its safety and efficacy, but limitations include the single-center design, fixed dexmedetomidine dosage, and incomplete complication assessment, warranting multicenter validation with standardized safety monitoring. ChiCTR2100051182.

Update on scalp nerve block for craniotomy

2025-06-23

Anna Maria Bombardieri , Maxim Pochebyt , Mark A. Burbridge | Current Opinion in Anaesthesiology

The purpose of this review is to outline the indications, technique, and ideal local anesthetics and adjuvants that can be administered for scalp nerve block (SNB) in adult patients undergoing … The purpose of this review is to outline the indications, technique, and ideal local anesthetics and adjuvants that can be administered for scalp nerve block (SNB) in adult patients undergoing craniotomy. SNBs are an effective means to provide patients with analgesia with lower opioid requirements. Recent literature shows a wide range of neurosurgical procedures can benefit from the administration of scalp blocks. Scalp blocks remain a technically straightforward regional anesthesia technique; however, the literature is insufficient to firmly recommend any specific local anesthetic or adjuvant. SNBs should be considered a low risk, technically easy to perform, and highly effective regional anesthesia technique in a wide range of neurosurgical procedures. A long-acting local anesthetic such as ropivacaine, bupivacaine, or levobupivacaine is recommended, and the addition of an adjuvant such as dexmedetomidine, clonidine, or dexamethasone has been shown to prolong the duration of the block. Ultrasound may be useful addition to improve block success.

Comparison of different bolus delivery speeds of a programmed intermittent epidural bolus combined with dural puncture epidural block during labour analgesia

2025-06-23

Yilu Zhou , Ruijing Ma , Jian Tang +3 more | European Journal of Anaesthesiology

Dural puncture epidural block (DPE) with programmed intermittent epidural bolus (PIEB) delivery provides effective analgesia for labour pain; however, it poses a risk of a high level of block. To … Dural puncture epidural block (DPE) with programmed intermittent epidural bolus (PIEB) delivery provides effective analgesia for labour pain; however, it poses a risk of a high level of block. To investigate the effect different pump speeds for a PIEB on maternal sensory block after DPE. A prospective, double-blind, randomised controlled study. An Obstetrics and Gynaecology Hospital, China, from June 2023 to December 2023. Labour analgesia was administered to 120 nulliparous women with a singleton pregnancy during the first stage of labour. After DPE insertion, women using labour analgesia were randomly allocated into a low-speed group (120 ml h-1), a medium-speed group (240 ml h-1) or a high-speed group (360 ml h-1). Epidural catheters were placed at L3/4 or L4/5, and epidural analgesia was maintained with a PIEB; 10 ml every 60 min using 0.1% ropivacaine with 0.3 μg ml-1 sufentanil. The primary outcome was the highest level of upper sensory block from administering DPE combined with PIEB until delivery. A total of 143 parturients were approached and 120 were randomised to three groups of 40. There were no statistically significant differences between the three groups at any time in either the highest sensory block (P = 0.14) or the upper sensory block (P = 0.27). Lower sensory (P = 0.20) and sacral blocks (P = 0.84) did not differ between groups. Nevertheless, the highest visual analogue pain scores (> 3) after labour anaesthesia was statistically different between the three groups (P = 0.023). Satisfaction with labour analgesia was significantly different between groups (P = 0.006). No differences in other secondary outcomes were noted. DPE with PIEB delivery of 360 ml h-1 did not produce higher sensory block levels than either 240 ml h-1 or 120 ml h-1. However, in secondary outcomes, the high speed delivery did provide more effective labour analgesia and higher satisfaction than low speed delivery.

Ultrasound-guided combined femoral-sciatic-obturator nerve block versus sub-arachnoid block in anterior cruciate ligament (ACL) reconstruction: A randomized single-blind study

2025-06-23

Kushal Mohan Bhattrai , T Pahari , Rozeeta Hirachan +2 more | Journal of Gandaki Medical College-Nepal

Introduction: Ultrasound-guided combined femoral-sciatic-obturator nerve block (peripheral nerve block) is the preferred technique in anterior cruciate ligament reconstruction because it avoids subarachnoid block (SAB) related complications and ensure prolonged postoperative … Introduction: Ultrasound-guided combined femoral-sciatic-obturator nerve block (peripheral nerve block) is the preferred technique in anterior cruciate ligament reconstruction because it avoids subarachnoid block (SAB) related complications and ensure prolonged postoperative analgesia. The aim of the study was to compare ultrasound-guided peripheral nerve block and SAB for anterior cruciate ligament (ACL) reconstruction. Methods: A randomized, single-blind study was conducted among patients undergoing ACL reconstruction at our center from February through November 2024. Fifty patients undergoing the procedure were randomly assigned to either receive SAB- 2 ml of 0.5% hyperbaric bupivacaine (group A) or ultrasound-guided combined femoral-sciatic-obturator nerve block- 30 ml mixture of 5 ml 2.0% lidocaine, 15 ml 0.5% bupivacaine plus 10 ml distilled water (group B). Hemodynamic changes, visual analogue score (VAS), time-to-spontaneous micturition following surgery, time to return motor power and time to rescue analgesia were compared between the groups. Results: In Group A, the mean VAS was 2.32±0.69 and 5.48±0.82 after 2 and 3 hours respectively, whereas the VAS was zero in group B throughout. The time to first rescue analgesia was significantly longer in Group B (630.4±36.11 min) when compared to Group A (248.4±26.09 min). Conclusions: Ultrasound-guided combined femoral-sciatic-obturator nerve block provided better hemodynamic stability, prolonged postoperative analgesia and allowed early ambulation due to early return of motor power.

Desfechos obstétricos e neonatais associados à analgesia neuroaxial no trabalho de parto

2025-06-23

Guilherme Frederico Abdul Nour , Maíra Maria Leite de Freitas , Luana de Sousa Oliveira +5 more | Revista Enfermagem UERJ

Objetivo: analisar os desfechos obstétricos e neonatais associados ao uso de analgesia neuroaxial durante o trabalho de parto. Método: estudo descritivo, documental. com abordagem quantitativa, realizado entre os meses de … Objetivo: analisar os desfechos obstétricos e neonatais associados ao uso de analgesia neuroaxial durante o trabalho de parto. Método: estudo descritivo, documental. com abordagem quantitativa, realizado entre os meses de março e agosto de 2022, após aprovação no Comitê de Ética em Pesquisa. Dados analisados descritiva e inferencialmente. Resultados: entre 240 parturientes, a técnica peridural foi a mais utilizada (87%), 70% das parturientes evoluíram com parto vaginal, 44,2% realizaram amniotomia, 35% utilizaram ocitocina e 10,2% apresentaram perda da mobilidade. Sobre os recém-nascidos, 36,2% necessitaram de intervenções, com 99% de (aspiração de vias aéreas, 10,3% ventilação por pressão positiva e 9,1% cateterismo venoso; 3,3% foi encaminhado para unidade intensiva neonatal. Conclusão: o uso da analgesia neuroaxial mostrou-se seguro, podendo ser ofertada para controle da dor de parturientes, a fim de reduzir cesáreas eletivas, não tendo influência negativa para o desfecho materno e neonatal, porém esteve relacionada com maior tendência a intervenções obstétricas, quando comparada com gestantes que não a utilizaram.

Incidences and predictors of moderate-to-severe movement-evoked pain until postoperative day three following gastrointestinal and hepatobiliary surgery: a retrospective study

2025-06-23

Si Wei , Kumiko Ishida , Takashi Ishida +1 more | Journal of Anesthesia

Comparison of periarticular injection and low-concentration high-volume suprainguinal fascia Iliaca plane block in total knee arthroplasty: a randomized prospective study

2025-06-21

Mehmet Cenk Turğut , Elif Oral Ahıskalıoğlu , Yunus Emre Karapınar +5 more | Archives of Orthopaedic and Trauma Surgery

Abstract Background The suprainguinal fascia iliaca plane block (SFIPB) has been used effectively for postoperative analgesia in hip surgeries due to its extensive dermatomal coverage. This technique may also serve … Abstract Background The suprainguinal fascia iliaca plane block (SFIPB) has been used effectively for postoperative analgesia in hip surgeries due to its extensive dermatomal coverage. This technique may also serve as an alternative in knee surgeries. However, studies investigating the use of SFIPB in total knee arthroplasty (TKA) are limited. This study evaluates the efficacy of SFIPB compared to periarticular infiltration (PAI) in TKA, focusing on postoperative opioid consumption, pain scores, motor function, and rehabilitation outcomes. Methods This randomized controlled trial included 70 patients undergoing TKA, allocated to either the SFIPB group or the PAI group. Postoperative pain management was standardized across groups using patient-controlled fentanyl analgesia. Primary outcomes included opioid consumption over 48 h, and secondary outcomes assessed pain scores, quadriceps strength, mobilization times, range of motion (ROM), and rehabilitation test results. Results SFIPB resulted in significantly reduced opioid consumption at 24 and 48 h compared to PAI ( p < 0.001). Pain scores assessed via visual analogue scale (VAS) were lower in the SFIPB group, particularly for anterior knee pain during rest and movement ( p < 0.05). SFIPB also demonstrated superior rehabilitation outcomes, with improved quadriceps strength ( p = 0.002) and better performance on the Time Up and Go (TUG) test. Both groups reported minimal side effects, but opioid-related nausea and vomiting were less frequent in the SFIPB group. Conclusion The use of SFIPB with a dilute, high-volume local anesthetic was superior to PAI by reducing opioid consumption and opioid-related side effects without impairing motor function or patient mobilization. This highlights its potential as an effective analgesic technique in TKA.

Local anesthesia for transperineal prostate biopsy performed under sedation: effects on intraoperative and postoperative narcotic use

2025-06-21

Thomas Li , Taylor M. McCready , Sunny Nalavenkata +7 more | World Journal of Urology

Comparing Adductor Canal Blocks With Bupivacaine and Magnesium to Bupivacaine and Buprenorphine After Same-Day Discharge Total Knee Arthroplasty: A Prospective Randomized Controlled Trial

2025-06-21

Nazia Siddiqui , Kinjal Patel , Ronak Desai +7 more | Cureus

The intrathecal morphine analgesia for full endoscopic lumbar discectomy: a prospective dose-finding study

2025-06-21

Lei Yue , Feng Zhang , Ziqi Wang +7 more | European Spine Journal

Morphine/Tramadol

2025-06-21

| Reactions Weekly

Pain and Sleep Biomarkers in Participants Undergoing Orthopedic Surgeries

2025-06-21

Manish Bhomia , Nicholas A. Giordano , Krista B. Highland +6 more | International Journal of Molecular Sciences

The bidirectional relationship between chronic pain and poor sleep are well reported. Disrupted sleep and chronic pain, either alone or in conjunction, are often associated with poor post-surgical outcomes. However, … The bidirectional relationship between chronic pain and poor sleep are well reported. Disrupted sleep and chronic pain, either alone or in conjunction, are often associated with poor post-surgical outcomes. However, the relationship between peripheral blood biomarkers and chronic pain and sleep disturbances after orthopedic surgery has not been extensively studied. The goal of this observational prospective study was to conduct an analysis on the relationship of blood cytokines and chemokines with chronic pain and sleep outcomes among US service members undergoing orthopedic surgery. Active-duty service members (N = 114) who underwent orthopedic extremity or spinal surgery were recruited, of whom 69 completed pre-surgery and 64 completed 6-week post-surgery surveys and blood draws. Blood cytokine and chemokine analyses were performed using multiplex immunoassays. Non-parametric correlations with blood cytokine and chemokine showed significant associations with both pre- and post-surgical pain scores whereas no significant correlations were observed with sleep disturbance scores. Increased pain intensity 6 weeks after surgery was positively associated with increased hepatocyte growth factor (ρs = 0.11; p < 0.05) and negatively correlated with interleukin-2r (ρs= −0.42; p < 0.001). This study found that inflammatory biomarkers are associated with pre- and post-surgical pain but not sleep disturbances.

Dexmedetomidine as an Adjunct in Anesthesia for Adolescent Idiopathic Scoliosis (AIS) Surgery: A Case Series

2025-06-21

Eko Nofiyanto , Radian Ahmad Halimi , Iwan Fuadi +1 more | Jurnal Neuroanestesi Indonesia

Scoliosis is a spinal curvature deformity >10°, with Adolescent Idiopathic Scoliosis (AIS) affecting those aged 10-18 years. The global prevalence of AIS is between 1%-2%, while in Indonesia, it stands … Scoliosis is a spinal curvature deformity >10°, with Adolescent Idiopathic Scoliosis (AIS) affecting those aged 10-18 years. The global prevalence of AIS is between 1%-2%, while in Indonesia, it stands at 2,93%, with a female-to-male ratio of 4.7:1. Perioperative challenges include nerve damage, bleeding, and postoperative pain. Neuromonitoring (MEP and SSEP) helps prevent injury, while careful drug selection supports spinal protection. Three female patients scoliosis reconstructions were performed under general anesthesia. All received target- controlled infusion (TCI) propofol, dexmedetomidine, and fentanyl, with stable hemodynamics and no neurological changes post-surgery. Epidemiological data showed that AIS predominantly affects females. The study included patients with curve progression impacting activity, with no motor or sensory abnormalities observed. Anesthesia was induced with propofol TCI (4 μg/mL) and dexmedetomidine (0.3-0.7 mcg/kg/hr), reducing propofol and opioid use. Dexmedetomidine targets α2-adrenergic receptors, reducing sympathetic outflow, stabilizing hemodynamics, blocking pain transmission, and improving recovery by reducing blood loss and inflammation. Dexmedetomidine provides sedation, analgesia, and stable hemodynamics in scoliosis surgery, minimizing blood loss and transfusion needs. It supports neurophysiological monitoring, reduces postoperative pain, and enhances recovery

Opioid-Free Anesthesia Technique for Anterior Cervical Discectomy and Fusion (ACDF): Anesthesia Management

2025-06-21

Albinus Yunus Cobis , Dewi Yulianti Bisri , Iwan Abdul Rachman | Jurnal Neuroanestesi Indonesia

Anterior cervical discectomy and fusion (ACDF) is a safe and effective surgical procedure to treat cervical spine pathology. ACDF treats Cervical Spondylotic Myelopathy (CSM), where degeneration of the cervical vertebrae … Anterior cervical discectomy and fusion (ACDF) is a safe and effective surgical procedure to treat cervical spine pathology. ACDF treats Cervical Spondylotic Myelopathy (CSM), where degeneration of the cervical vertebrae compresses the spinal cord, causing sensory, motor, reflex, and bowel function impairment. The use of opioids can have unpleasant effects, hence opioid-free anaesthesia techniques were developed as a strategy to reduce this risk. A man, 62 years old, complained of weakness in the upper limbs until it was difficult to move the hands. Supportive examination revealed cervical myeloradiculopathy due to multiple hernia nucleus pulposus (HNP). Management of opioid-free anaesthesia techniques using multimodal analgesics. During the operation, haemodynamics were relatively stable. Extubation was performed in the operating room and then the patient was transferred to the intensive care unit. The choice of opioid-free anaesthesia technique in the case was to provide multimodal using specific agents that have anaesthetic or analgesic properties. Opioid-free anaesthesia methods that support the Enhanced Recovery after Surgery (ERAS) concept are considered highly beneficial in accelerating recovery time, reducing length and cost of treatment and minimizing opioid-related unpleasant risks. The opioid-free anaesthetic technique in this case report demonstrates the feasibility and benefits of opioid-free anaesthesia in effective pain management and minimizing opioid-related risks, especially in ACDF surgical procedures. This technique is in line with the ERAS protocol

Üçüncü Basamak Bir Üniversite Hastanesinde Sezaryen Vakalarının Klinik Analizi: Retrospektif Klinik Çalışma

2025-06-20

Rüstem Taş , Arzu Esen Tekeli , Nurettin Kurt +2 more | Dicle Medical Journal / Dicle Tip Dergisi

Amaç: Bu çalışma, bir üçüncü basamak üniversite hastanesinde uygulanan sezaryen operasyonlarında tercih edilen anestezi yöntemleri ile postoperatif yoğun bakım ihtiyacı, intraoperatif ve postoperatif mortalite oranları arasındaki ilişkileri değerlendirmeyi amaçlamaktadır. Yöntem: … Amaç: Bu çalışma, bir üçüncü basamak üniversite hastanesinde uygulanan sezaryen operasyonlarında tercih edilen anestezi yöntemleri ile postoperatif yoğun bakım ihtiyacı, intraoperatif ve postoperatif mortalite oranları arasındaki ilişkileri değerlendirmeyi amaçlamaktadır. Yöntem: Retrospektif tasarımlı bu kohort çalışma kapsamında, 2018 ile 2023 yılları arasında Van Yüzüncü Yıl Üniversitesi Dursun Odabaşı Tıp Merkezi Hastanesi'nde genel veya rejyonal anestezi ile gerçekleştirilen 2709 sezaryen vakası analiz edilmiştir. Katılımcılara ait veriler, hastanenin dijital veri sisteminden retrospektif olarak toplanmıştır. Bulgular: Çalışma kapsamındaki bireylerin yaş ortalaması 30,48 ± 6,76 yıldır. Sezaryen doğumların %66,3'ünde genel anestezi, %33,7'sinde ise spinal anestezi tercih edilmiştir. Postoperatif yoğun bakıma alınan hastaların oranı %0,6 olarak bulunmuştur. Genel anestezi kullanımının; artmış komorbidite sayısı, 1. ve 5. dakikalarda düşük APGAR skorları, yüksek ASA değerleri, HELLP sendromu, preeklampsi, plasenta invazyon bozuklukları, artmış eritrosit süspansiyonu ve taze donmuş plazma gereksinimi ile ilişkili olduğu tespit edilmiştir. Aynı faktörler, postoperatif yoğun bakım gereksinimi ile de anlamlı düzeyde ilişkili bulunmuştur. Sonuç: Bulgular, merkezimizde genel anestezinin sezaryen doğumlarda daha sık tercih edildiğini, ancak spinal anestezinin daha avantajlı klinik sonuçlar sunduğunu ortaya koymaktadır. Bu kapsamda, genel anestezi endikasyonlarının yeniden değerlendirilmesi gerekmektedir.

Evaluating The Efficacy of MGSO4 as an Adjuvant to 0.5% Bupivacaine in Supraclavicular-Intercostobrachial Nerve Blocks for Upper Extremity Hemodialysis Vascular Access Surgery

2025-06-20

Albert Albert , Tjokorda Gde Agung Senapathi , I Made Agus Kresna Sucandra | Eduvest - Journal Of Universal Studies

Magnesium sulfate (MgSO₄) has garnered increasing attention as an adjunct to regional anesthesia, particularly for patients with compromised kidney function requiring upper limb surgery for hemodialysis access. While peripheral nerve … Magnesium sulfate (MgSO₄) has garnered increasing attention as an adjunct to regional anesthesia, particularly for patients with compromised kidney function requiring upper limb surgery for hemodialysis access. While peripheral nerve blocks are commonly selected for their safety and efficacy in such populations, their delayed onset of action can pose a clinical drawback. To address this issue, a randomized clinical study was conducted at RSUP Prof. I.G.N.G. Ngoerah to investigate the benefits of adding 200 mg of 20% MgSO₄ to supraclavicular-intercostobrachial nerve blocks. A total of 28 participants were randomized into two groups: one receiving the magnesium additive and another as a control. The study assessed onset time for full sensory and motor block as well as analgesia duration. Results indicated that patients in the MgSO₄ group experienced faster sensory (average 10.08 minutes) and motor block onset (average 17.98 minutes), compared to the control group (17.19 and 25.19 minutes, respectively). Moreover, the duration of pain relief was substantially extended in the MgSO₄ group, exceeding 470 minutes on average. Secondary observations also revealed a lower intraoperative requirement for fentanyl and a potential regulatory effect on inflammation-related biomarkers, such as neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios. Overall, the findings suggest that MgSO₄ can serve as a valuable and safe enhancer of nerve block performance, especially in vulnerable surgical populations.

Cervical Epidural Block: Transforaminal Approach

2025-06-20

Steven D. Waldman | Elsevier eBooks

Cervical Epidural Block: Translaminar Approach

2025-06-20

Steven D. Waldman | Elsevier eBooks

Lateral Thoracolumbar Interfascial Plane Block

2025-06-20

Steven D. Waldman | Elsevier eBooks

Triple Nerve Injection for Open Reduction and Internal Fixation of Fracture Tibia and Fibula – A Feasibility Study

2025-06-20

Sandeep Diwan , Rasika Timane , Abhijit Nair +1 more | Journal of Medical Ultrasound

Abstract Background: Targeting femoral, obturator, and sciatic nerves with an anterior approach is a daunting task. Surface landmarks have been described but with limited success. This feasibility study describes a … Abstract Background: Targeting femoral, obturator, and sciatic nerves with an anterior approach is a daunting task. Surface landmarks have been described but with limited success. This feasibility study describes a single-puncture approach to the three nerves in real time under the guidance of a curvilinear probe and investigates the feasibility in the proximal thigh for patients undergoing bicondylar fixation with fractures of the proximal tibia. Methods: Forty patients with fractures of the proximal tibia planned for a bicolumnar open reduction and fixation with a plate were recruited in this feasibility study. We named this unique approach the “triple nerve injection” (TNI) block. These blocks were injected with 40 mL of 0.2% ropivacaine injected in the vicinity of the branches of the femoral nerve (10 mL), the sciatic nerve (20 mL), and between the adductors targeting the anterior and posterior division of the obturator nerves (5 mL each). Results: The pain was perceived at a mean of the 12 th h on the medial side as against a mean of the 13 th h on the lateral aspect. The time to rescue analgesia was 12 h. An optimal spread was visualized in 90% of blocks, while the diffusion in 10% of sciatic blocks was inadequate. Conclusion: A TNI block facilitates a single-puncture and a single-probe placement technique enables a satisfactory visualization of three fascial planes, together with a single needle redirection.

Lumbar Subarachnoid Block: Midline Approach

2025-06-20

Steven D. Waldman | Elsevier eBooks

Transversus Abdominis Plane Block

2025-06-20

Steven D. Waldman | Elsevier eBooks

Hypogastric Plexus Block: Single-Needle Anterior Technique

2025-06-20

Steven D. Waldman | Elsevier eBooks

Ganglion of Walther (Impar) Block: Transcoccygeal Technique

2025-06-20

Steven D. Waldman | Elsevier eBooks

The effect of intravenous dexamethasone on rebound pain after wrist and hand surgery under supraclavicular brachial plexus blockade: a randomized placebo-controlled trial

2025-06-20

RyungA Kang , Yu Jeong Bang , Jae Woo Shim +6 more | Canadian Journal of Anesthesia/Journal canadien d anesthésie

Trajectories of Pain in Low-Opioid and Opioid-Based Postoperative Analgesia in Older Patients—Perioperative Clinical Study

2025-06-20

Urszula Kościuczuk , Marek Tałałaj , Ewa Rynkiewicz-Szczepańska | Journal of Clinical Medicine

Background/Objectives: The use of opioid drugs in the elderly population is characterized by an increased risk of sedation and respiratory depression, and in the immediate postoperative period, it is associated … Background/Objectives: The use of opioid drugs in the elderly population is characterized by an increased risk of sedation and respiratory depression, and in the immediate postoperative period, it is associated with a higher incidence of postoperative delirium. The dilemma of opioid use as an element of acute postoperative pain therapy is crucial in elderly patients. Methods: This study was conducted in 80 patients qualified for laparoscopic cholecystectomy under general combined anesthesia. Two methods of analgesia were performed—Low-Opioid Analgesia (LOA) and Opioid-Based Analgesia (OBA)—and pain intensity based on the Numerical Rating Scale (NRS) was assessed at 0–2, 2–6, 6–12, and 12–24 h after surgery. The mean NRS in LOA and OBA was compared in age categories. Pain trajectory in patients over 60 years old was compared between LOA and OBA. Results: The trajectory of analgesia presented a negative slope in LOA for patients over 60 years of age, with reductions in pain intensity of 33%, 25%, and 66%. In OBA, a positive slope trajectory was noted, and pain intensity was higher within 12–24 h after surgery than within 0–2 and 2–6 h. Conclusions: Opioid analgesia in patients over 60 years of age presented a better effect in the immediate postoperative period. Non-opioid analgesia is indicated for patients over 60 years old in the later postoperative period. The model of combined minimal opioid anesthesia and non-opioid postoperative analgesia presents a favorable therapeutic effect for patients over 60 years old.

Is there still a need for cadaveric studies on the superficial parasternal intercostal plane block?

2025-06-20

Burhan Dost , Alessandro De Cassai | Journal of Clinical Anesthesia

Systemic Lidocaine Infusion for Acute Pain Management in a Surgical Intensive Care Unit: A Single-Arm Pilot Trial

2025-06-20

Hina Faisal , Faisal Masud , Mahmoud Sabawi +3 more | Journal of Clinical Medicine

Objectives: Currently, there are a lack of data on the use of systemic lidocaine infusion in critically ill surgical patients, particularly regarding optimal dosing and monitoring. This study aimed to … Objectives: Currently, there are a lack of data on the use of systemic lidocaine infusion in critically ill surgical patients, particularly regarding optimal dosing and monitoring. This study aimed to assess the feasibility of conducting a subsequent full-scale, randomized controlled trial (RCT) on the use of systemic lidocaine infusion in surgical intensive care units (ICUs). Methods: A single-center, prospective, single-arm pilot trial was conducted at the surgical intensive care unit (ICU) at Houston Methodist Hospital. The study population included 12 subjects over 18 years old who were admitted to the surgical ICU after open abdominal surgery. A low-dose lidocaine infusion of 10–30 mcg/kg/min within 1 h of ICU admission. Results: The feasibility outcomes encompassed recruitment, retention, and withdrawal rates. The study initially screened 18 participants, all of whom were successfully enrolled, resulting in a recruitment rate of 100%. However, 6 participants (33.3%) from the enrolled group were subsequently withdrawn for various reasons, resulting in a retention rate of 12 participants (66.7%). All 12 remaining participants were included in the analysis at the baseline stage. The safety outcomes included adverse events and serum lidocaine levels, with no serious adverse events reported. Dizziness and hypertension were the most frequently reported adverse events in their respective categories, affecting 16.7% of patients each. Four patients (33%) exhibited elevated lidocaine levels exceeding 5 mcg/mL; however, no clinical features of lidocaine toxicity were observed. This study adhered to the CONSORT 2010 extension for pilot and feasibility trials. In accordance with these guidelines, no formal hypothesis testing for efficacy was performed. The exploratory outcomes included a reduction in opioid requirements, as measured by morphine milligram equivalents (MMEs), and pain scores. The median MMEs decreased from 22.6 on postoperative day 0 to 2.5 on day 3. The pain scores decreased by 1.09 units per day (β = −1.09; 95% CI: −1.82 to −0.36; p = 0.003); however, the absence of a control group limits the robustness of this observation. Conclusions: A large-scale, randomized controlled trial to evaluate the safety and efficacy of systemic lidocaine infusion in the surgical intensive care unit (ICU) seems feasible, with minor adjustments to the eligibility criteria and improved collaboration among nurses, anesthesiologists, and surgeons.

Saphenous nerve neuralgia: A potentially devastating complication of perioperative adductor canal block used for total knee arthroplasty analgesia

2025-06-20

Raja Dhalla , Preena Loomba , Jasmine Dhalla +1 more | Journal of Musculoskeletal Surgery and Research

Objectives: Adductor canal blocks are commonly employed for post-operative pain control in total knee arthroplasty (TKA), offering advantages such as reduced opioid use, faster quadriceps recovery, and earlier discharge. However, … Objectives: Adductor canal blocks are commonly employed for post-operative pain control in total knee arthroplasty (TKA), offering advantages such as reduced opioid use, faster quadriceps recovery, and earlier discharge. However, the incidence of sartorial branch saphenous neuralgia – a potentially debilitating complication – remains poorly characterized. This study aims to evaluate its occurrence following perioperative adductor canal block in a community-based setting. Methods: A total of 206 TKA patients were observed, and anesthesia types were documented alongside the incidence of persistent sartorial branch saphenous neuralgia and paresthesia at a two-month follow-up. Sixty-nine patients received adductor canal blocks, 15 received femoral nerve blocks, and 14 had popliteal blocks in combination with femoral or adductor blocks. The remaining 123 underwent general or spinal anesthesia without peripheral nerve blocks. All nerve blocks were ultrasound-guided. Results: Of the 69 patients who received adductor canal blocks, 5 (7.2%) developed persistent saphenous neuralgia. Three patients (4.3%) experienced severe symptoms requiring referral to pain management and further intervention. Two (2.9%) had milder cases managed conservatively. No neuralgia was reported in patients who received femoral or popliteal blocks, or those who had spinal or general anesthesia alone. Conclusion: Saphenous neuralgia occurred in 7.2% of patients following adductor canal block, with some cases severe enough to require further treatment. Given the potential to impede recovery, this risk should be discussed during informed consent, and clinicians should monitor for symptoms. Although adductor canal blocks are effective, their use should be considered on a case-by-case basis rather than assumed universally appropriate.

Anesthetics as an Alternative to Opioids in Laparoscopic Surgeries: An Observational Study

2025-06-20

Niki Pandya , Neal Patel , Charmi Bhimbha +3 more | Cureus