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This document is a letter to the editor of the Journal of Anesthesia discussing the analgesia mode after cesarean section. The authors express their interest in a previous paper that suggested patient-controlled epidural analgesia (PCEA) may provide better analgesia than epidural morphine alone. They raise a few points and reservations, including the need for further analysis of preoperative and intraoperative factors that may influence postoperative pain, clarification on the use of BMI in the study, and the importance of considering the adverse effect of motor block when using local anesthetics. The authors appreciate the innovative work and emphasize the importance of optimizing doses of local anesthetics and opioids for PCEA. [Extracted from the article]

Perioperative pain management related to hip surgical procedures is challenging. Pericapsular nerve group (PENG) block is a novel technique that is assumed to provide better analgesia in addition to its post-operative motor-sparing effect. In this review, we aim to assess the safety and efficacy of PENG block on pain management in patients undergoing hip surgeries. Fifteen clinical trials with a total of 837 patients were included. Pain scores favored PENG group when compared to FICB group (fascia iliaca compartment block) or analgesics-only group, but the difference could only be detected in the early post-operative period. Afterward, it seems to lose its superiority, and no difference could be detected. In addition, cumulative opioid consumption favored PENG group at 24 h but not at 48 h. Regarding patients' satisfaction, our analysis showed results favoring PENG group, but there was no difference in time to first opioid or length of hospital stay. The incidence of vomiting was lower in PENG, but there was no difference in the incidence of nausea, pruritis, and dizziness. PENG provides better analgesia and lower opioid consumption in the initial post-operative period. Current evidence is not enough, and further high-quality randomized controlled trials with larger sample sizes are required. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to elucidate the effects of neuraxial analgesia on labor in women classified based on the Robson classification system. Methods: We retrospectively reviewed the clinical data of singleton cephalic nulliparous deliveries in labor at term between January 2018 and December 2021 and compared obstetrical outcomes between deliveries with and without neuraxial analgesia in women of Robson group 1 (spontaneous labor) and group 2a (induced labor). Statistical analyses were performed using the Wilcoxon ranked-sum test, Fisher's exact test, and logistic regression model. Statistical significance was set at p < 0.05. Results: We identified 2726 deliveries during the period, of which 387 deliveries (215 with analgesia and 172 without analgesia) were in Robson group 1 and 502 deliveries (258 with analgesia and 244 without analgesia) in Robson 2a. In Robson group 1 pregnancies, the cesarean section (CS) rate was higher in those who received analgesia (15%) than in those who did not (3%) (p = 0.0001). Multivariate analysis revealed that labor with analgesia was a significant risk factor for CS (p < 0.0001). Similarly, in Robson group 2a pregnancies, we observed a higher CS rate in those with analgesia than in those without analgesia (18 vs. 11%, p = 0.042). Conclusion: A higher CS rate was observed in deliveries with analgesia than in those without analgesia both in the Robson group 1 and group 2a pregnancies. [ABSTRACT FROM AUTHOR]

Purpose: This meta-analysis of all relevant clinical trials investigated surgical plethysmographic index (SPI)-guided analgesia's efficacy under general anesthesia for perioperative opioid requirement and emergence time after anesthesia. Methods: PubMed, Embase, Web of Science, and Cochrane Library were searched up to January 2022 to identify clinical trials comparing SPI-guided and conventional clinical practice for patients who underwent general anesthesia. With the random-effects model, we compared intraoperative opioid consumption, emergence time, postoperative pain, analgesia requirement, and incidence of postoperative nausea and vomiting (PONV). Results: Thirteen randomized controlled trials (RCTs) (n = 1314) met our selection criteria. The overall pooled effect sizes of all RCTs indicated that SPI-guided analgesia could not significantly reduce opioid consumption during general anesthesia. SPI-guided analgesia accompanied with hypnosis monitoring could decrease intraoperative opioid consumption (standardized mean difference [SMD] − 0.31, 95% confidence interval [CI] − 0.63 to 0.00) more effectively than SPI without hypnosis monitoring (SMD 1.03, 95% CI 0.53–1.53), showing a significant difference (p < 0.001). SPI-guided analgesia could significantly shorten the emergence time, whether assessed by extubation time (SMD − 0.36, 95% CI − 0.70 to − 0.03, p < 0.05, I2 = 67%) or eye-opening time (SMD − 0.40, 95% CI − 0.63 to − 0.18, p < 0.001, I2 = 54%). SPI-guided analgesia did not affect the incidence of PONV, postoperative pain, and analgesia management. Conclusion: SPI-guided analgesia under general anesthesia could enhance recovery after surgery without increasing the postoperative complication risk. However, it did not affect intraoperative opioid requirement. Notably, SPI-guided analgesia with hypnosis monitoring could effectively reduce intraoperative opioid requirement. [ABSTRACT FROM AUTHOR]

Genetic factors have been the leading risk factor for ASD based on the evidence of Folstein's twin study in 1977, which reported that the concordance ratio of ASD is higher in monozygotic twins than in dizygotic twins [[6]]. Keywords: Autism spectrum disorder; Risk factor; Labor neuraxial analgesia; Systematic literature search EN Autism spectrum disorder Risk factor Labor neuraxial analgesia Systematic literature search 327 329 3 03/29/23 20230401 NES 230401 Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/s00540-023-03162-y. Hanley et al. conducted a within-sibling and discordance in ASD status analysis, which restricted the population to women who were discordant for the ASD status of at least 2 of their children (i.e., at least 1 child was diagnosed with ASD and at least 1 other child was not diagnosed with ASD). However, LNA may be a risk factor for autism spectrum disorders (ASD) in offspring as the placental transfer of local anesthetics may produce neurotoxic effects and alter subsequent normal behavioral development [[3]]. [Extracted from the article]

The present study compared the effects of pectoral nerve block II (PECS II) and erector spinae plane (ESP) block for postoperative analgesia in patients who underwent modified radical mastectomy by performing a network meta-analysis (NMA) using indirect comparison with systemic analgesia. Studies comparing the analgesic effects of PECS II and ESP block were searched on MEDLINE, PubMed, EMBASE and the Cochrane Library. The primary outcome of this study was cumulative opioid consumption for 24 h postoperatively. Pain score during this period was also assessed. NMA was performed to compare the postoperative analgesic effects of plane blocks and systemic analgesia. A search of databases identified 17 studies, with a total of 1069 patients, comparing the analgesic efficacies of PECS II block, ESP block, and systemic analgesia. Compared with systemic analgesia, mean difference of opioid consumption was − 10 mg (95% credible interval [CrI] − 15.0 to − 5.6 mg) with PECS II block and − 5.7 mg (95% CrI − 11.0 to − 0.7 mg) with ESP block. Relative to systemic analgesia, PECS II block showed lower pain scores over the first postoperative 24 h, whereas ESP block did not. PECS II block showed the highest surface under the cumulative ranking curves for both opioid consumption and pain score. Both PECS II and ESP blocks were shown to be more effective than systemic analgesia regarding postoperative analgesia following modified radical mastectomy, and between the two blocks, PECS II appeared to have favorable analgesic effects compared to ESP block. [ABSTRACT FROM AUTHOR]

Third, in this study, intravenous tramadol (1 mg/kg) was administered as rescue analgesia, if the NRS pain score was 4 or more and the proportion of patients needing rescue analgesia was significantly reduced in the M-TAPA group. As opioid sparing is one of the main objectives of postoperative multimodal analgesia protocols including a nerve or fascial plane block [[3]], the authors should provide whether morphine milligram equivalent of tramadol for rescue analgesia was significantly different between groups. Keywords: Laparoscopic cholecystectomy; Postoperative analgesia; Thoracoabdominal nerves block through perichondrial approach; Local infiltration EN Laparoscopic cholecystectomy Postoperative analgesia Thoracoabdominal nerves block through perichondrial approach Local infiltration 495 496 2 06/01/23 20230601 NES 230601 This comment refers to the article available online at https://doi.org/10.1007/s00540-022-03158-0. [Extracted from the article]

Purpose: Procedural sedation and analgesia (PSA) is widely performed outside of the operating theater, often in emergency departments (EDs). The practice and safety of PSA in the ED in an aging society such as in Japan have not been well described. We aimed to characterize the practice pattern of PSA including indications, pharmacology and incidence of adverse events (AEs) in Japan. Methods: We formed the Japanese Procedural Sedation and Analgesia Registry, a multicenter prospective observation registry of ED patients undergoing PSA. We included all patients who received PSA in the ED. PSA was defined as any systemic pharmacological intervention intended to facilitate a painful or uncomfortable procedure. The main variables in this study were patients' demographics, American Society of Anesthesiologists (ASA) physical status, indication of PSA, medication choices, and AEs. The primary outcome measure was overall AEs from PSA. Results: We enrolled 332 patients in four EDs during the 12-month period. The median age was 67 years (IQR, 46–78). In terms of ASA physical status, 79 (23.8%), 172 (51.8%), and 81 (24.4%) patients were class 1, 2, 3 or higher, respectively. The most common indication was cardioversion (44.0%). The most common sedative used was thiopental (38.9%), followed by midazolam (34.0%) and propofol (19.6%). Among all patients, 72 (21.7%, 95% confidence interval, 17–26) patients experienced one or more AEs. The most common AE was hypoxia (9.9%), followed by apnea (7.2%) and hypotension (3.5%). All of the AEs were transient and no patient had a serious AE. Conclusion: In a multicenter prospective registry in Japan, PSA in the ED appears safe particularly since the patients who underwent PSA were older and had a higher risk profile compared to patients in previous studies in different countries. [ABSTRACT FROM AUTHOR]

Purpose: Prolonged postoperative analgesia with early motor recovery for early rehabilitation is a challenge in regional block. The purpose of this study is to evaluate the effect of adding 20 mg nalbuphine to 25 ml of 0.25% levobupivacaine in supraclavicular brachial plexus block.Methods: One hundred thirty-five (135) patients scheduled for hand and forearm surgeries with supraclavicular block were randomly allocated into three equal groups. Group L received 25 ml of 0.5% levobupivacaine + 1 ml normal saline; group H received 25 ml of 0.25% levobupivacaine + 1 ml normal saline; and group N received 25 ml of 0.25% levobupivacaine + 1 ml (20 mg) nalbuphine. Onset time and duration of sensory and motor block, and time to first analgesic dose were recorded.Results: Sensory block onset was comparable between the three groups. Motor block onset in group L and group N was comparable (13.16 ± 3.07 and 13.84 ± 3.05 min, respectively) and was shorter than that in group H (15.71 ± 2 0.91 min). Sensory block duration in group L and group N was comparable (522.22 ± 69.57 and 533.78 ± 66.03 min, respectively) and was longer than that in group H (342.67 ± 92.80 min). Motor block duration in group N and group H was comparable (272.00 ± 59.45 and 249.78 ± 66.01 min, respectively) and was shorter than that in group L (334.67 ± 57.90 min). Time to first analgesic dose was significantly longer in group N (649.78 ± 114.76 min) than that of group L and group H (575.56 ± 96.85 and 375.56 ± 84.49 min, respectively) and longer in group L when compared to group H.Conclusions: Adding 20 mg nalbuphine to 25 ml of 0.25% levobupivacaine in supraclavicular block provided prolonged duration of sensory block with similar duration of motor block. [ABSTRACT FROM AUTHOR]

Purpose: Nerve stimulation may be combined with ultrasound imaging for a block of deeply located nerves such as the sciatic nerve in the subgluteal region. At present, it is unknown how the use of nerve stimulation affects blockade after this nerve block. We retrospectively compared the effects of the two types of motor response and those of minimal evoked current above and below 0.5 mA on ultrasound-guided subgluteal sciatic nerve block using mepivacaine or ropivacaine, two local anesthetics with different onset time and duration. Methods: We reviewed records and video images of patients who, from April 2008 until October 2011, received ultrasound-guided subgluteal sciatic nerve block combined with nerve stimulation using 20 ml of either 1.5 % mepivacaine with 1:400,000 epinephrine or 0.5 % ropivacaine. Sensory and motor blockade data for 30 min after the block and for the duration of the blockade were gathered. Patients for whom any data were missing, the video image was poor, and/or intraneural injection was observed during the block were excluded from the study. The same data were compared in two ways: regarding the motor response pattern between the response of the tibial nerve and the common peroneal nerve, and regarding the minimal current between low current (< 0.5 mA) and high current (≥0.5 mA). The primary endpoints were the onset and duration of blockade of the sciatic nerve block. Results: We analyzed the data of 170 and 99 patients who received mepivacaine and ropivacaine, respectively. The progress of sensory and motor blockade as well as block duration was similar between different motor response patterns after both anesthetics. The proportion of patients who developed sensory block of the tibial nerve and motor block at 30 min was higher in the low minimal current group than in the other group receiving mepivacaine. Patients in the former group also had longer block duration. With ropivacaine, complete motor blockade was present at 30 min in a higher proportion of patients after lower minimal evoked current than after higher minimal evoked current. Conclusion: When ultrasound-guided subgluteal sciatic nerve block was conducted with nerve stimulation, the motor response pattern did not markedly affect the progress of sensory or motor blockade or block duration. Lower minimal evoked current was associated with faster onset in sensory and motor block and longer block duration after mepivacaine and faster onset in motor block after ropivacaine. The clinical significance of this, however, has yet to be determined. [ABSTRACT FROM AUTHOR]

Second, the main outcome is the clinical diagnosis of ASD, but the basis for the diagnosis is unclear and no other comorbidities (such as ADHD) have been identified, it cannot be determined whether the outcome ASD diagnosis is reliable. Keywords: Labor epidural analgesia; Autism spectrum disorders; Hazard ratio EN Labor epidural analgesia Autism spectrum disorders Hazard ratio 319 320 2 03/19/21 20210401 NES 210401 To the Editor: We read with great interest the Association between Epidural Analgesia during Labor and Risk of Autism Spectrum Disorders in Offspring by Chunyuan Qiu et al. published in JAMA Pediatrics on October 12, 2020 [[1]]. The findings were that in this multiethnic population-based clinical birth cohort that included 147,895 children, Autism spectrum disorders (ASD) were diagnosed in 1.9% of the children delivered vaginally with labor epidural analgesia (LEA) vs. 1.3% without the exposure, 37% relative increase in risk that was significant after adjusting for potential confounders. [Extracted from the article]

Purpose Methods. Male Sprague-Dawley rats with lumbar intrathecal catheters received YM 872 at 1 µg · 10 µl-1 (eight rats; YM group) or normal saline 10 µl (eight rats; C group) intrathecally once a day for 30 days. We evaluated the analgesic effects every 3 days, by tail-flick test and behavioral side effects. On the 31st day, the lumbar spinal cord was removed from four randomly selected rats in each group for histological examination. Results. The YM group showed significantly longer tail-flick latency when subjected to a high-intensity light beam than the C group at each measurement time point, although no significant changes in the latency according to the time course of the study were observed for the entire study period of 30 days in either group. No rats showed any side effects. Histologically, only slight lymphocytic cell infiltration and degeneration of myelinated fibers occurred, similarly in both groups. No changes were observed in the spinal cord in either group. Conclusion. Administration of YM 872 (1 µg) once a day for 30 days did not induce any tolerance and caused no histological changes in the spinal cord. Although the Α-amino-3-hydroxy-5-methylisoxazole-4-propionic acid (AMPA) receptor antagonist, YM 872, has been considered to be useful in analgesia for both acute and chronic pain, there are no studies of its neurotoxicity and tolerance. We examined the spinal neurotoxicity and tolerance of YM 872 analgesia by repeated intrathecal administration in rats. [ABSTRACT FROM AUTHOR]

Opioid derivatives with mixed agonist-antagonist activities are becoming increasingly more popular in analgesia. We tested the mydriatic and analgesic activity of morphine in mice in comparison with similar effects of three agonist-antagonist agents: buprenorphine, butorphanol and nalbuphine. We also examined the antagonistic action of these three drugs by evaluating the analgesia and mydriasis in animals pretreated with morphine. The analgesic effect was assayed using the hot plate method while the pupillary responses were measured with a binocular operating microscope. Morphine produced dose-dependent mydriasis and analgesia in mice. The morphine-type agent buprenorphine and two nalorphine-type agonistantagonists, butorphanol and nalbuphine, caused agonistic mydriatic and analgesic effects, usually less effective then morphine. Buprenorphine proved to have higher agonist activity than butorphanol and nalbuphine. The difference between butorphanol and nalbuphine was not statistically significant. A correlation between the mydriatic and the analgesic activity, known to exist among oploid derivatives with agonist activity only, was also demonstrated in the three investigated agonist-antagonist agents. Morphine-induced mydriasis and analgesia were reversed by all three agonist-antagonist drugs, but buprenorphine is a significantly weak antagonist in comparison with butorphanol and nalbuphine. An antagonistic property (antimydriatic and antianalgesic effects after pretreatment with morphine) of both nalorphine-type investigated drugs was not statistically significant, except for the antianalgesic effect of nalbuphine in doses 1 and 3 mg·kg which was higher in comparison with butorphanol. [ABSTRACT FROM AUTHOR]

Author(s): Yusuke Mazda [sup.1] Author Affiliations: (1) grid.410802.f, 0000 0001 2216 2631, Department of Obstetric Anesthesiology, Center for Maternal-Fetal and Neonatal Medicine, Saitama Medical Center, Saitama Medical University, , 1981 [...]

Achieving analgesia not only at rest but also during movement, with the minimization of unpleasant symptoms related to analgesics, is one of the goals of postoperative analgesia (POA). 'Multimodal analgesia' [...]