Search

Background: Effective analgesia for invasive office-based rhinology procedures can be challenging. While local anesthetics provide the basis for periprocedural analgesia, systemic opioids are often necessary for adequate pain control. Case report: We describe two patients successfully undergoing multiple painful rhinology procedures with the addition of a novel sufentanil 30 mcg sublingual tablet to our standard oral benzodiazepine and local anesthetic protocol. Conclusion: A sufentanil sublingual tablet administered preoperatively provided excellent analgesia throughout the duration of the procedure and was well tolerated. This new analgesic provides a rapid-acting alternative to standard oral opioid analgesics.

Background: Various regional anaesthesia approaches to branches of the anterior lumbar plexus have been proved effective in providing analgesia in hip surgery. However, some patients still experience significant residual posterior hip pain attributed to the posterior nerve supply of the hip. This not only suggests that anterior approaches may not always provide sufficient pain relief, but also that the blocking of major nerves supplying the posterior pericapsular region is needed. Methods: We present an ultrasound-guided technique to block all major nerves supplying the posterior capsule of the hip joint. The optimal target area was determined by ultrasound imaging, cross-sectional digitised anatomy, and cadaver research, and was found in the deep gluteal compartment. Furthermore, this posterior pericapsular deep-gluteal block was evaluated in two patients. Results: The spread of dye in the cadaver was observed deep to the gluteus maximus and in between the quadratus femoris and piriformis muscles, and conformed to the presumed location during the ultrasound procedure. It included all major supplying nerves to the posterior hip capsule, that is the superior gluteal nerve, nerve to quadratus femoris and sciatic nerve. In both patients where this posterior pericapsular deep-gluteal block was applied the pain was substantially reduced (numeric rating scale: 4 to 1 and 7 to 1). Conclusion: We present a successful ultrasound-guided technique targeting the deep gluteal compartment to block all major nerves supplying the hip joint's posterior capsule. This posterior pericapsular deep-gluteal block can be applied as an additional block in hip surgery, with also a possible role in chronic hip pathology.

Study Objective: Acetaminophen (APAP) and intravenous acetaminophen (IVAPAP) has been proposed as a part of many opioid-sparing multimodal analgesic pathways. The aim of this analysis was to compare the effectiveness of IVAPAP with oral APAP on opioid utilization and opioid-related adverse effects., Design: Retrospective study of population-based database., Patients: The Premier Healthcare database was queried patients undergoing surgery for a primary diagnosis of hip fracture from 2011 to 2019 yielding 245,976 patients. Primary exposure was use of IVAPAP or oral APAP on the day of surgery., Interventions: None., Measurements: The primary outcome of interest was opioid utilization over the hospital stay, secondary outcomes included opioid-related adverse effects, length, and costs of hospital stay. Mixed effect models measured the association of IVPAP and APAP and outcomes., Main Results: In the study population 30.67% (75,445) received at least 1 dose of IVAPAP on the day of surgery. Upon adjusting for relevant covariates, patients who received IVPAP on the day of surgery had slightly higher opioid use standardized by length of hospital stay (2.8% CI: 2%, 3.6%; p < .001), higher hospital cost (2.7% CI: 2.1%, 3.4%), and higher odds of naloxone use (1.18, CI: 1.1, 1.27; p < .001) when compared with patients who received oral APAP., Conclusions: In this population, IVAPAP use on the day of surgery failed to reduce opioid use or associated opioid related adverse effects when compared with oral APAP. IVAPAP was associated with increased overall costs, opioid requirements, and naloxone use. These results do not support the use of IV over oral APAP routinely for hip fracture surgery patients., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: SGM has a US patent application for a Multicatheter Infusion System (US-2017-0361063) and is the owner of SGM Consulting, LLC. He is a partner in Parvizi Surgical Innovations, LLC and investor in HATH. None of the aforementioned relations influenced the conduct of the present study. JW has received grants from the Ontario Ministry of Health and Long-Term Care, and Merck Inc. outside of the submitted work. She is supported by a Merit Research award from the University of Toronto, Department of Anesthesiology and Pain Medicine., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Effective therapies for acute pain management in trigeminal neuralgia (TN) are limited. We aimed to investigate the role of steroids in TN patients experiencing acute pain flares., Methods: We retrospectively reviewed patients presenting to the emergency department of a tertiary care institution between 2014 and 2020 for acute TN pain flares. Patients were divided into those who received steroids versus those who did not. Presenting characteristics, admission and surgical intervention rates, Barrow Neurological Institute pain scores, pain recurrence rates, and surgical intervention within 6 months of discharge were obtained for each patient., Results: Our cohort comprised 151 patients, of whom 40 (26.5%) received steroids before admission and/or discharge. These patients were less likely to undergo surgical intervention to treat acute pain (P = 0.023). Specifically, patients receiving steroids were less likely to undergo combined glycerin and radiofrequency rhizotomy compared with patients not receiving steroids (P = 0.012). Frequency and dosage of opioid administration did not differ between groups. The steroids group demonstrated a lower average Barrow Neurological Institute pain score on discharge compared with the no steroids group (P = 0.013). Patients receiving steroids for acute pain management were less likely to undergo surgical intervention within 6 months of discharge than patients who did not receive steroids (P = 0.033)., Conclusions: Steroid administration in patients with acute TN pain flares may reduce the likelihood of surgical intervention both during admission and within 6 months of discharge. Future prospective studies should examine the efficacy of steroids as an adjunctive medication in acute TN pain management., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Study Objective: This study was conducted to evaluate the effect of Dexmedetomidine as an adjuvant in quadratus lumborum block (QLB) for postoperative pain relief at rest in patients undergoing caesarean section (CS). The primary objective was to compare the time to the first request of rescue analgesia. Secondary objectives were to compare the amount of rescue analgesia, patient satisfaction, Numeric rating scale (NRS), and Ramsay sedation score (RSS) during the first 24 h., Design: A randomised, double-blinded study., Setting: The study was conducted at AIIMS Bhubaneswar from December 2019 to February 2021in the Operating Theatre complex (for the immediate postoperative follow-up) and in the Obstetric Ward (for follow-up at the later time points)., Patients: A total of 70 patients were enrolled with singleton term pregnancies scheduled for CS under spinal anaesthesia after written informed consent., Intervention: Bilateral QLB was given in the recovery area. Group A received 30 ml of 0.25% Bupivacaine and group B received 30 ml 0.25% bupivacaine with Dexmedetomidine 1 μg/kg. They received inj. Paracetamol 15 mg/kg intravenously TDS and Inj. Tramadol 1 mg/kg as rescue analgesia (if Numeric rating scale (NRS) Score ≥ 4). We also compared the rescue analgesia in the first 24 h, patient satisfaction scores, Ramsay sedation score (RSS), and NRS scores at 2, 4, 6, 8, 12, 18, and 24 h., Main Results: The time to request the first rescue analgesia was significantly prolonged in group B [Mean ± SD (95% CI)] 880 ± 351 (720-1040) min. vs group A 439 ± 208 (368-510) min., p < 0.001). There was a significant decrease in the amount of rescue analgesia [(Inj. Tramadol (1 mg/ kg)] used in the group with dexmedetomidine [group B Mean ± SD (95% CI) (57 ± 18 (49-65) mg. vs group A - 81 ± 25 (73-90)] mg., p < 0.001]. A significant difference was seen in patient satisfaction scores and pain scores between the groups up to 18 h. (p < 0.05) but not in RSS., Conclusion: Dexmedetomidine can be considered an effective adjuvant for QLB in CS in the absence of intrathecal morphine., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Fascia iliaca compartment block (FICB) has become a keystone technique for acute pain management in patients with hip and proximal femur fractures., Objectives: To demonstrate that administering FICB preoperatively to patients with hip or proximal femur fractures in the emergency department (ED) is likely to reduce opioid use and related complications, and to decrease hospital length of stay (LOS)., Methods: An unblinded study of adult patients with hip and proximal femur fractures who consented to receive an FICB with 30 cc of bupivacaine with epinephrine administered in the ED. We compared this group with a contemporaneous group of controls who only received systemic opioids. Over the course of approximately 6 months, main outcome measured between the two groups was amount of morphine equivalents given from block administration until 8 h after. We also compared complications such as delirium, constipation, and bleeding rates (oozing from injection site or hematoma formation)., Results: A total of 166 patients with hip and proximal femur fractures from August 12, 2018 to April 25, 2021; 81 received FICB plus systemic opioids, and 85 received only systemic opioids. Among the FICB group, morphine equivalents were reduced by 0.6 mg/h with no significant difference in LOS. A statistically significant difference in opioid-related adverse outcomes was found between the anticoagulated group vs. the no anticoagulation group., Conclusions: FICB is a safe and effective preoperative technique for initial pain management in patients with hip and proximal femur fractures, as it can also be used with additional systemic opioids. FICB administration may reduce systemic opioid use preoperatively, thus reducing opioid-related adverse effects with no significant impact on hospital LOS., (Copyright © 2022. Published by Elsevier Inc.)

Study Objectives: To evaluate if using regional anesthesia for post-operative pain control for patients who underwent ankle ORIF is associated with a decrease in length of stay., Design: Multicenter retrospective cohort study., Setting: Inpatient perioperative., Patients: 12,468 inpatients (2007 to 2016) who received ankle ORIF with and without regional anesthesia for pain control., Interventions: Regional Anesthesia for postoperative pain control., Measurements: Hospital length of stay along with multiple covariates., Main Results: The median [quartiles] hospital length of stay of the non-regional anesthesia and regional anesthesia cohorts were 1 day [0, 2 days] and 0 days [0, 1 day], respectively (p < 0.0001). On multivariable Cox regression analysis, the use of regional anesthesia was associated with decreased time to hospital discharge (HR 1.09, 95% CI 1.03-1.14, p = 0.002). Using 1:2 propensity score matching, the median [quartiles] hospital length of stay between the non-regional anesthesia and regional anesthesia matched cohorts were 0 days [0, 1 day] (range = 0-56 days) and 0 day [0, 1 day] (range = 0-33 days), respectively (p = 0.013)., Conclusion: The use of regional anesthesia for post-operative pain control was associated with a decreased length of stay for patients undergoing ankle ORIF., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Study Objective: We aimed to determine the magnitude of peri-operative opioid sparing effect when general anesthesia is combined with spinal analgesia for laparoscopic gynecological surgery., Design: A prospective randomized controlled study; a three-group trial with two comparisons (each intervention group to control)., Setting: Operating room and postoperative recovery area., Patients: Patients aged between 18 and 65 years with American Society of Anesthesiologists physical status 1 or 2 who were scheduled for inpatient elective laparoscopic gynecological surgery with expected pneumoperitoneum duration of at least 20 min. Of 102 randomized patients, 99 completed the study., Interventions: Patients were randomized to general anesthesia alone (control group) or combined with very-low-dose (levobupivacaine 3.75 mg; sufentanil 2.5 μg) or low-dose (levobupivacaine 7.5 mg; sufentanil 2.5 μg) spinal analgesia., Measurements: Primary endpoints were perioperative opioid consumption and pain scores (11-point numeric rating scale) at 30 min, 1 h, 2 h, 4 h and 24 h post-surgery. Secondary endpoints were patient satisfaction with anesthetic care and participation in research, sevoflurane consumption and adverse effects., Main Results: Intra-operative sufentanil (median [95% CI]) consumption was 16.1 (10.5-22.6) μg/h in the control group versus 4.7 (3.2-9.2) μg/h in the very-low-dose and versus 2.9 (0.0-4.0) μg/h in the low-dose spinal analgesia groups (p < 0.001, for both comparisons). Median (95% CI) piritramide consumption at 24 h post-surgery was 7.5 (3-8) mg in the control group versus 5 (0-7.5) mg in the very-low dose spinal analgesia group (p = 0.182) and versus 2 (0-2.5) mg in the low-dose spinal analgesia group (p = 0.001). Postoperative pain scores were consistently <3 only in the low dose spinal analgesia group. Patient satisfaction with anesthetic care and participation in research was very high in all groups., Conclusions: Low-dose spinal analgesia in combination with general anesthesia reduces peri-operative opioid consumption in laparoscopic gynecological surgery in immediate postoperative period., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: Substance use and abuse may have the significant, but unanticipated, consequence of lessening the efficacy of opioid analgesics for acute pain management. We hypothesized that pre-injury substance use increases opioid analgesic consumption following traumatic injury., Methods: This retrospective multi-institutional pilot study included admitted patients to four level 1 trauma centers with vehicular trauma over four months (n = 176). We examined the effect of positive urine drug screen (UDS; 7-drug panel, examined individually and combined, yes/no) and positive blood alcohol content (BAC, ≥80 mg/dL) on pain management with opioid analgesics over the hospital stay. Average daily opioid consumption was examined using a repeated measures mixed model, by positive UDS and BAC findings, adjusting for age, injury severity score, and non-opioid analgesia. Opioid analgesics were converted to milligram morphine equivalents (MME) and analyzed with a square-root transformation due to non-normality., Results: A positive drug or alcohol test was reported in 33.5% (59/176), including 12.5% (n = 22) with positive UDS and 26% (n = 45) with a positive BAC. There were no differences in gender, injury severity scores, Glasgow coma scores, or cause of vehicular trauma between substance users and non-users; only age was significantly different. Patients with a positive UDS consumed significantly more opioids compared to those with a negative UDS (34.7 MME vs. 24.7 MME, p = 0.04), after adjustment. Individually, detection of opiates, THC, cocaine, and amphetamines were associated with increased opioid consumption compared to their UDS negative counterparts; on the other hand, benzodiazepines and alcohol intoxication were associated with reduced opioid consumption during the course of hospitalization. However, none of the individual UDS results reached statistical significance. The largest effect of all the individual drugs was with opiates, which was associated with a borderline significant increase in opioid analgesic consumption (p = 0.06)., Conclusions: Our preliminary data suggest drug use may significantly alter acute pain management following traumatic injury, corresponding to 40% increase in opioid analgesia for substance users than non-users. These results may have broad reaching implications because of the high prevalence of substance use in the trauma population., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. The rising costs of pain care and managing adverse effects of that care have prompted action from state and federal agencies including the DOD, VHA, NIH, FDA and CDC. There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components and self-care/self-efficacy strategies. Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability. The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short- and long-term therapeutic and economic impact of comprehensive care practices., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Increasing numbers of patients with morbid obesity are presenting for surgery and their acute pain management requires an evidence-based clinical update. The objective of this study was to complete a literature review for acute pain management in morbid obesity and provide an evidence-based clinical update with recommendations. Using standardized search terms, in March 2015, we completed a literature search to determine evidence for different acute pain pharmacological modalities in morbid obesity. For each modality the highest level of evidence was ascertained and recommendations for each pharmacological modality are presented. Though overall evidence is limited to few well conducted clinical trials, mostly related to weight loss surgery, multimodal analgesia with step-wise, severity-based, opioid-sparing approach appears to improve acute pain management in morbid obesity. The perioperative use of non-opioid adjuvants appears to offer further improvements in patient safety and outcomes. Further research into standardization of pain assessments and implementation of acute pain management protocols is required., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: While previous studies have shown that elderly patients require lower dosages of opioids, the literature suggests that pain is undertreated in the geriatric population, which may lead to postoperative pain and high rescue analgesia requirements. The purpose of this study is to determine whether elderly patients undergoing hip and knee arthroplasty require higher levels of postoperative rescue opioids than their younger counterparts early after emergence from anesthesia., Methods: Using a nonconcurrent retrospective cohort study design, patients who underwent hip or knee arthroplasty under general anesthesia at a tertiary academic hospital from 2007 to 2012 were identified. Demographic information and data regarding patients' anesthetic care were obtained from the institution's anesthesia information management system. To assess the presence of pain after the emergence of anesthesia, we used, as a proxy, opioid administration by the anesthesia provider after leaving the operating room and before the end of anesthesia care., Results: A total of 2731 patients met inclusion criteria, of which 487 (17.8%) received rescue opioids. Patients older than 80 years were less likely to receive opioids after leaving the operating room (odds ratio, 0.57; 95% confidence interval, 0.37-0.88; P = .01) and received 1.37 mg less of hydromorphone equivalent opioid compared to patients younger than the age of 50 years (95% confidence interval, 1.18-1.55; P < .001). The proportion of patients who received rescue opioids varied significantly between anesthesia providers from 0% to 38% (P < .001)., Conclusions: While elderly patients received lower doses of opioids intraoperatively, they were less likely to require rescue analgesia. The variability among providers in rescue opioid administration after emergence presents an opportunity for further research., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Study Objective: To determine the ability of an ultrasound-guided single-shot adductor canal block to provide adequate analgesia and improve performance during physical therapy., Design: A retrospective chart review., Setting: All procedures were performed at Ochsner Medical Center., Measurements: Patient demographics as well as the type of peripheral nerve block performed. Pain scores and opioid consumption were recorded at postanesthesia care unit discharge and again at 8 ± 3, 16 ± 3, and 24 ± 3 hours. In addition, physical therapy performance was analyzed., Main Results: There were no significant differences in pain scores or cumulative hydromorphone requirements between the adductor canal block group and the femoral nerve block group at any of the time points analyzed. Gait distance measured during physical therapy sessions in the adductor canal block group was superior compared with the femoral nerve block group., Conclusion: Within the first 24 hours, a single-shot adductor canal block provides equally effective analgesia when compared with a femoral nerve block and improves postoperative physical therapy performance., (Copyright © 2014 Elsevier Inc. All rights reserved.)