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Blunt trauma patients commonly present with multiple rib fractures, which increases overall morbidity and mortality due to pulmonary complications. Effective chest wall analgesia may be challenging due to positioning difficulty, body habitus, anticoagulation issues with neuraxial interventions, etc. Serratus anterior plane block has been shown to be beneficial in anterior and lateral rib fractures in recent studies. We propose the efficacy of this block in posterior rib fractures as well, through this small case series of blunt trauma patients with posterior rib fractures, reporting significant pain relief after the block.

Background: Patients commonly visit the emergency department for pain after musculoskeletal injury, but the problem of oligoanalgesia is prevalent. Methoxyflurane (Penthrox®) is an inhalational analgesic for moderate to severe trauma-associated pain in stable and conscious patients. It is a fast-acting, effective analgesic that can be readily administered via a non-invasive route, making it an attractive agent for managing acute pain in the emergency departments. Objectives: The aim was to assess the analgesic efficacy of methoxyflurane in patients with acute traumatic pain by comparing it to ketorolac, a standard analgesic treatment for moderate pain in emergency departments in Hong Kong. Methods: This was a single-center, open-label, randomized controlled, parallel-group, non-inferiority pilot study that enrolled adult patients with moderate trauma-associated pain in an emergency department in Hong Kong. Patients were randomized 1:1 to the methoxyflurane group or the ketorolac group. The primary outcome was the change in pain intensity measured by visual analogue scale from baseline to 5, 15, 30, and 60 min after drug administration. Results: Twenty patients received methoxyflurane, and twenty patients received ketorolac. There were significant reductions in pain score over 60 min in both groups. The pain reduction at 5 min was significantly greater for the methoxyflurane group (−13.912 mm; 95% confidence interval = −20.008 to −7.817) than for the ketorolac group (−4.888 mm; 95% confidence interval = −10.983 to 1.208), with the treatment effect (−9.025 mm; 95% confidence interval = −17.656 to −0.393; p = 0.041) demonstrating superiority of methoxyflurane. The treatment effect at 15 and 30 min demonstrated non-inferiority of methoxyflurane versus ketorolac. Conclusion: Methoxyflurane provided non-inferior analgesia in the first 30 min with a faster onset of action when compared with ketorolac in moderate traumatic pain. It can be considered a non-invasive, rapid-acting, and effective first-line alternative to currently available analgesics for traumatic pain in emergency settings.

Study Design: Retrospective review. Objective: To determine the effectiveness of erector spinae plane (ESP) blocks at improving perioperative pain control and function following lumbar spine fusions. Methods: A retrospective analysis was performed on patients undergoing < 3 level posterolateral lumbar fusions. Data was stratified into a control group and a block group. We collected postop MED (morphine equivalent dosages), physical therapy ambulation, and length of stay. PROMIS pain interference (PI) and physical function (PF) scores, ODI, and VAS were collected preop and at the first postop visit. Chi-square and student’s t-test ( P = .05) were used for analysis. We also validated a novel fluoroscopic technique for ESP block delivery. Results: There were 37 in the block group and 39 in the control group. There was no difference in preoperative opioid use ( P = .22). On postop day 1, MED was reduced in the block group (32 vs 51, P < .05), and more patients in the block group did not utilize any opioids (22% vs 5%, P < .05). The block group ambulated further on postop day 1 (312 ft vs 204 ft, P < .05), and had reduced length of stay (2.4 vs 3.2 days, P < .05). The block group showed better PROMIS PI scores postoperatively (58 vs 63, P < .05). The novel delivery technique was validated and successful in targeting the correct level and plane. Conclusions: ESP blocks significantly reduced postop opioid use following lumbar fusion. Block patients ambulated further with PT, had reduced length of stay, and had improved PROMIS PI postoperatively. Validation of the block demonstrated the effectiveness of a novel fluoroscopic delivery technique. ESP blocks represent an underutilized method of reducing opioid consumption, improving postoperative mobilization and reducing length of stay following lumbar spine fusion.

Background Acetaminophen is a non-opioid analgesic commonly utilized for pain control after several types of surgical procedures. Methods This scoping primary literature review provides recommendations for intravenous (IV) acetaminophen use based on type of surgery. Results Intravenous acetaminophen has been widely studied for postoperative pain control and has been compared to other agents such as NSAIDs, opioids, oral/rectal acetaminophen, and placebo. Some of the procedures studied include abdominal, gynecologic, orthopedic, neurosurgical, cardiac, renal, and genitourinary surgeries. Results of these studies have been conflicting and largely have not shown consistent clinical benefit. Conclusion Overall, findings from this review did not support the notion that IV acetaminophen has significant efficacy for postoperative analgesia. Given the limited clinical benefit of IV acetaminophen, especially when compared to the oral or rectal formulations, use is generally not justifiable.

Background: Shoulder arthroscopy is one of the most commonly performed orthopaedic procedures used to treat a variety of conditions, with >500,000 procedures performed each year. Purpose: To systematically review the randomized controlled trials (RCTs) on pain control after shoulder arthroscopy in the acute postoperative setting and to ascertain the best available evidence in managing pain after shoulder arthroscopy to optimize patient outcomes. Study Design: Systematic review and meta-analysis. Methods: A systematic review of the literature was performed based on the PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. Studies were included if they were RCTs evaluating interventions to reduce postoperative pain after shoulder arthroscopy: nerve blocks, nerve block adjuncts, subacromial injections, patient-controlled analgesia, oral medications, or other modalities. Meta-analyses and network meta-analyses were performed where appropriate. Results: Our study included 83 RCTs. Across 40 studies, peripheral nerve blocks were found to significantly reduce postoperative pain and opioid use, but there was no significant difference among the variable nerve blocks in the network meta-analysis. However, continuous interscalene block did have the highest P-score at most time points. Nerve block adjuncts were consistently shown across 18 studies to prolong the nerve block time and reduce pain. Preoperative administration was shown to significantly reduce postoperative pain scores ( P < .05). No benefit was found in any of the studies evaluating subacromial infusions. Conclusion: Continuous interscalene block resulted in the lowest pain levels at most time points, although this was not significantly different when compared with the other nerve blocks. Additionally, nerve block adjuncts may prolong the postoperative block time and improve pain control. There is promising evidence for some oral medications and newer modalities to control pain and reduce opioid use. However, we found no evidence to support the use of subacromial infusions or patient-controlled analgesia.

Background: The goal of adequate pain control becomes increasingly salient for children with cancer and their families as the patients approach the end of life. Methadone is one option that is particularly desirable in end-of-life care given its long duration of action and NMDA antagonism that may help in controlling pain refractory to conventional opioids. The purpose of this study was to describe a single institution’s experience with methadone for the treatment of cancer pain in pediatric end-of-life care. Methods: This retrospective, observational, single-center study included all patients during a 9-year period who died in the inpatient setting and were receiving methadone in their last 30 days of life. Results: Twenty patients were identified, 18 (90%) of whom received methadone for nociceptive pain. The median duration of methadone use was 32 days (range 2-323 days). Methadone doses ranged from 0.09 to 7.76 mg/kg per day. There were no instances of discontinuing methadone due to an increased QTc interval. No episodes of torsades de pointes were observed. Conclusion: In patients with pediatric cancer who are nearing the end of life, methadone is a valuable adjunctive therapy to treat nociceptive and neuropathic pain and to prevent opioid-induced hyperalgesia and opioid tolerance. An individualized approach to dosage and route should be considered based on specific clinical circumstances.

Introduction: Literature addressing postoperative pain management after hip arthroscopy is relatively scarce. This study aimed to assess if there was added analgesic benefit associated with postoperative intra-articular bupivacaine blockade for patients who received preoperative peri-acetabular blockade for hip arthroscopy procedures. Methods: 52 patients were included in this comparative cohort study. Group 1 consisted of 20 patients who received preoperative peri-acetabular blockade and postoperative intra-articular blockade. The control group (Group 2), consisted of 32 patients who received only preoperative peri-acetabular blockade. Postoperative pain was recorded via visual analogue scale (VAS) pain scores, analgesic consumption, and pain diaries for 2 weeks postoperatively. Results: Postoperative VAS pain scores were significantly lower in the experimental group at the 30-minute recovery room assessment (VAS scores Group 1: 1.1; Group 2: 3.00, p = 0.034). Other than the 30-minute recovery room assessment, VAS pain scores, narcotic medication consumption, and non-narcotic analgesic consumption did not differ between the 2 groups at any time point in the study period. Conclusions: This study did not demonstrate significant clinical benefit for patients who receive postoperative intra-articular blockade in addition to preoperative peri-acetabular blockade with bupivacaine 0.5%. We recommend the use of preoperative peri-acetabular bupivacaine blockade without intra-articular blockade postoperatively for pain control in the setting of hip arthroscopy surgery.

Transversus abdominis plane (TAP) block is a relatively new technique used to provide analgesia to the anterolateral abdominal wall following abdominal procedures. Transversus abdominis plane blocks can be performed using a blind/landmark technique or with ultrasound guidance. We report a 49-year-old woman who received a successful wireless ultrasound-guided TAP block during an abdominoplasty. Our case illustrates the potential advantages of a wireless ultrasound-guided TAP block versus a landmark-guided TAP block during an abdominoplasty. It also serves to promote the use of wireless ultrasound imaging when performing a TAP block to minimize risks of the procedure and achieve better pain control postoperatively. Further studies are needed to confirm the added value that ultrasound provides.

Objectives: The purpose of this quality improvement (QI) project was to improve the overall process of implementing continuous subcutaneous infusion of opioids (CSCIOs) at the West Palm Beach Veterans Affairs Medical Center and characterize their use in the hospice unit. Methods: A retrospective chart review from July 2014 to August 2017 was conducted to identify patients who had received CSCIO. Results were analyzed with descriptive statistics.The business philosphy, LEAN methodology “The 5 Whys” was utilized to identify the root causes for delayed infusion timeliness and corrections were implemented by August 2018. Follow-up retrospective time study completed from September 2018 to February 2019. Results: Of the 107 patients identified, 7 were excluded and 100 were reviewed. The mean age was 73 years, 94% male, and 86% Caucasian. A total of 55 veterans received morphine with an average final infusion rate of 2.5 mg/h. A total of 45 Veterans received hydromorphone with a final infusion rate of 1.3 mg/h. The average infusion duration until death was 5 days. Pharmacy verified 94 (94%) orders and nursing verified 55 (55%) orders within 1 hour (gold standard). Sixteen (16%) patients received CSCIO within 1 hour. The 5 Whys identified nursing order verification and pharmacy lack of visual STAT order notification for priority as the potential sources for infusion timeliness improvement. The follow-up time study confirmed improvement in pharmacy delivery time from 29% to 75% on time. Conclusion: Pharmacist-led intervention directed to improve CSCIO processes in an inpatient hospice unit utilizing LEAN QI methodology increased timeliness of pharmacy CSCIO delivery.

The transversus abdominis plane (TAP) block provides analgesia to the parietal peritoneum as well as the skin and muscles of the anterior abdominal wall. These same muscles and skin are operated on during an abdominoplasty. The purpose of this study was to determine whether the use of the TAP block will lead to reduced use of narcotics during the acute postoperative (PO) period (PO day 1 and PO 1 week). The study used a prospective, comparative design. Twenty women between 25 and 65 years of age who underwent abdominoplasty with core liposuction were recruited to participate in this study. All women were given the same PO pain medication Percocet 7.5/325 mg (1-2 tabs by mouth Q4-6 hours PRN pain #20) and Valium 2 mg (1-3 tabs by mouth Q4-6 hours PRN pain #40) at the time of surgery. The women were randomly divided into 2 groups: 10 women received local anesthetic infiltrated along the rectus plication and along the edges of the incision and 10 women received a TAP block (15 cc of 0.25% Bupivacaine with 8 mg of Decadron per side) placed under ultrasound guidance prior to the start of the procedure in conjunction with the local anesthetic along the rectus plication. Each woman was asked to record the number of narcotic pills consumed during the first 24 hours and during the first week. Data from the 2 groups were compared to determine the number of narcotics consumed during the acute PO period. The mean age of participants was 43.8 years (range: 31-63 years) in the treatment group and 38.8 years (range: 26-56 years) in the control group. The mean number of narcotics used during the first 24 hours in the treatment group was 1.95 (1.5) pills, with several women requiring no narcotics within the first 24 hours. The mean number of narcotics used during the first 24 hours in the control group was 4.6 (2.3) pills. The mean number of narcotics used during the first PO week in the treatment group was 7.15 (7.26) pills, with several women requiring no narcotics during the first PO week. The mean number of narcotics used during the first PO week in the control group was 18.7 (7.7), with 1 woman requiring 38 narcotic pills during that first PO week. Statistically significant differences were found between groups ( P = .006) at 24 hours PO and ( P = .01) at 1 week. Our results suggested that receiving a TAP block prior to the start of the procedure significantly reduced the number of narcotics used during the acute PO period.

Background: Femoral nerve block (FNB) and adductor canal block (ACB) have been used increasingly for pain control during anterior cruciate ligament (ACL) reconstruction in adolescent patients. However, recent evidence suggests that the use of FNB may affect quadriceps strength recovery 6 months after surgery. Purpose/Hypothesis: To compare postoperative isokinetic strength in adolescents who received FNB, ACB, or no block for perioperative analgesia during ACL reconstruction. We anticipated lower postoperative quadriceps and hamstring isokinetic deficits in adolescents who received FNB as compared with ACB. Study Design: Cohort study; Level of evidence, 3. Methods: Patients were included in the study if they had undergone hamstring tendon autograft ACL reconstruction by a single surgeon from July 2008 to January 2018 and if they underwent isokinetic muscle testing at 4 to 8 months postoperatively. The participants were divided into 3 groups (no block, FNB, and ACB), and we compared the deficit in percentages between the affected and unaffected limbs as calculated from the isokinetic quadriceps and hamstring strength testing at 60 and 180 deg/s. Between-group analysis was performed using analysis of variance, with an alpha of .05. Results: A total of 98 participants were included in the analysis (31 no block, 36 FNB, and 31 ACB). The mean ± SD age of the patients was 15.26 ± 1.15, 15.50 ± 1.42, and 15.71 ± 1.44, for no block, FNB, and ACB, respectively. At 5.61 months postoperatively, there was no significant difference across the 3 groups in isokinetic quadriceps deficits ( P ≥ .99), and the only significant difference in isokinetic hamstring deficit was observed for peak flexion at 180 deg/s, in which the ACB group had lower peak torque than the FNB group (–9.80% ± 3.48% vs 2.37% ± 3.23%; P = .035). The ratio of participants with a deficit exceeding 15% did not differ significantly among the 3 groups. Conclusion: Contrary to previous research, our findings indicate only minimal difference in quadriceps strength among the 3 types of perioperative analgesia in adolescents approximately 6 months after ACL reconstruction. The only significant strength deficit was seen in the hamstrings of patients receiving ACB at peak flexion as compared with those receiving FNB.

Objective Minimally invasive cardiac surgery via a right minithoracotomy (RMT) is a common approach to different valve pathologies, tumor resection, and atrial septal defect (ASD) closure. We studied intraoperative field block using liposomal bupivacaine (LB) in these operations. Methods Consecutive 171 minimally invasive RMTs (fourth intercostal space) were studied, and patients in cardiogenic or septic shock, intravenous drug abuse, and those re-explored were excluded ( n = 12). An early cohort was treated with standard postoperative analgesia while another underwent intraoperative field block with LB immediately after incision. We compared postoperative pain level, narcotic utilization (morphine milligram equivalent), and intensive care unit (ICU) and hospital length of stay. Results The procedures included 48 isolated mitral valve replacements (MVR); 2 MVR with other procedures; 93 mitral valve repairs (MVRr); 9 MVRr with other procedures; 4 isolated tricuspid valve repairs; 2 myxoma resections; 1 ASD closure. There were 13 patients in the non-LB group and 146 patients in the LB group. Use of LB decreased mean postoperative narcotic utilization by 50% ( P = 0.003). The LB group had lower pain levels on postoperative day 1 ( P = 0.039), which continued through postoperative day 5 ( P = 0.030). We found no difference in ICU or hospital length of stay between groups. There were no complications from LB field block. Conclusions LB field block decreases postoperative pain and narcotic utilization after cardiac surgery via a RMT, but it does not reduce length of stay. The technique is safe and should be considered in all patients undergoing RMT cardiac surgery.

Introduction: Scant research exists on pain control for interstitial cystitis patients undergoing pelvic reconstructive surgery. Our aim was to compare the perioperative courses in patients with and without interstitial cystitis undergoing pelvic reconstructive surgery performed using primarily monitored anesthesia care with local anesthesia. Methods: A retrospective chart review of surgical cases performed at a single site from November 2015 to July 2018 was performed. Joint non-gynecologic cases were excluded. Data including demographics, intraoperative variables, medication requirements, and postoperative courses were abstracted. Chi-square, independent t, and Mann–Whitney U tests were used to compare interstitial cystitis with non-interstitial cystitis patients. Results: In total, 65 separate cases met inclusion criteria and were analyzed, with 57 individual subjects. Out of the 65 cases, 33 cases were performed on interstitial cystitis patients. Only 2 of the 33 interstitial cystitis patient cases required general anesthesia. Interstitial cystitis patients did not require higher concentrations of 1% lidocaine with epinephrine (average of 3.8 mg/kg) compared to patients without (2.8 mg/kg). There was no difference between groups in perioperative complications, length of recovery, or postoperative narcotic consumption. Conclusion: Perioperative outcomes and pain control do not differ in those with and without interstitial cystitis undergoing pelvic reconstructive surgery. Prolapse surgery can be safely performed on a patient population with a high proportion of chronic pelvic pain using monitored anesthesia care with local anesthesia, without increased morbidity or difficultly with perioperative pain control.

Background: Opioid use is classified as an epidemic by many due to the impact of these medications on society. Federal and state laws for prescribing and dispensing opioids have changed rapidly in a short period of time to hopefully balance proper pain control with their use. Pharmacy directors must be informed of these rapid changes to effectively work as part of any opioid stewardship team. Objective: The objective of this study was to provide foundational leadership guidance to pharmacy directors on current opioid legislation, literature, and best practices to assist in improving opioid use. Methods: A review of the literature from 2003 to the present was conducted along with collating important up to date resources and other publications that provide foundational information to help support a comprehensive management of opioid use. A summary of these data has been collated into an easy to use table and summarized throughout this article. Conclusion: The information provided in this article helps to properly inform pharmacy leaders to the resources available to improve the prescribing, dispensing, and monitoring of opioids and alternatives.

Repeated invasive and painful procedures are often necessary components of pediatric cancer treatment. Adequate pain control during procedures is essential; however, procedure-related pain may be underestimated and undertreated. Currently, there is not a standard approach for the appropriate level of sedation to manage procedure-related pain in children with cancer. A team was assembled to review the evidence and develop recommendations to determine the appropriate level of sedation necessary for pain control in patients undergoing pediatric oncology procedures. After a systematic search of the literature, 15 research-based articles were synthesized and critically appraised. A recommendation was made related to the level of sedation utilized for bone marrow aspirates and bone marrow biopsies. There is a need for further research related to the necessary level of sedation for patients undergoing pediatric oncology procedures.

Background: Femoral nerve block (FNB) is a commonly performed technique that has been proven to provide effective regional analgesia after anterior cruciate ligament (ACL) reconstruction. The adductor canal block (ACB) uses a similar sensory block around the knee while avoiding motor blockade of the quadriceps muscles. Purpose/Hypothesis: The purpose of our study was to compare the efficacy of FNB versus ACB for pain control after ACL reconstruction. It was hypothesized that there would be no difference in pain levels or opioid requirements between the 2 groups. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: We performed a prospective, double-blinded, randomized controlled trial. Sixty patients undergoing primary ACL reconstruction with bone-patellar tendon-bone autograft were randomized to receive either an ACB or an FNB preoperatively. The primary outcomes assessed were pain levels (visual analog scale) and narcotic requirements for 4 days after surgery. Secondary outcomes included ability to perform a straight leg raise in the recovery room and difference in thigh circumference between the operative and nonoperative leg measured at 7 days postoperatively. Results: Morphine requirements were less in the ACB group in the first 4 hours postoperatively ( P = .02). Aside from this time interval, no differences were found between the 2 groups with regard to opioid requirements and pain scores at any other time. Similarly, no differences were noted in patients’ ability to perform a straight leg raise in the recovery room ( P = .13) or in thigh circumference at the first postoperative visit ( P = .09). Conclusion: The results of our study suggest similar efficacy in perioperative pain control with the use of an ACB for ACL reconstruction when compared with FNB. The potential long-term benefit of quadriceps preservation with the ACB is worthy of future study. Registration: NCT03033589 (ClinicalTrials.gov identifier).

Background: Purpose of this study was to compare the effects of direct, continuous adductor canal block (ACB) and ultrasonography guided, continuous femoral nerve block (FNB) on postoperative pain control, strength of the knee extensor, walking ability, and related complications after primary total knee arthroplasty. Methods: Between November 2018 and February 2019, 107 patients underwent primary total knee arthroplasty under spinal anesthesia. Forty eight patients received ACB and the other 59 received FNB for postoperative pain control. After the surgery, the patients received adductor canal or femoral nerve block via a catheter. 10 mL of 0.75% ropivacaine was administered initially, followed by continuous injection of 4 mL per hour. ACB was done before capsule repair by orthopedic surgeon and FNB was performed after the surgery. Data were prospectively collected out from these 107 patients. To evaluate postoperative pain control, the numerical rating scale scores at rest and during range of motion were recorded. To evaluate quadriceps strength, motor grade by manual muscle testing was measured. Walking ability was assessed by first weight bearing day and walking distance (steps). We also evaluated analgesic consumption using morphine equivalent and recorded related complications of peripheral nerve block. Results: No significant intergroup difference was observed in the numerical rating scale scores at rest and during range of motion on postoperative days 1, 2, 3, 4, and 5. ACB group had significantly greater quadriceps strength than did the FNB group, as evaluated by manual muscle testing on postoperative days 1. However, there was no significant difference onpostoperative days 2, 3, 4, and 5. These two groups showed no differences in walking ability in terms of first weight bearing day and walking distance. No significant intergroup difference was observed in analgesic consumption. Conclusions: The groups showed no difference in postoperative pain control. ACB showed better motor grade on postoperative day one compared with femoral nerve block, but which was similar in days after postoperative day one.

The aim of this study was to assess postoperative opioid prescribing patterns, usage, and pain control after common vascular surgery procedures in order to develop patient centered best-practice guidelines. We performed a prospective review of opioid prescribing after seven common vascular surgeries at a rural, academic medical center from December 2016 to July 2017. A standardized telephone questionnaire was prospectively administered to patients ( n = 110) about opioid use and pain management perceptions. For comparison we retrospectively assessed opioid prescribing patterns ( n = 939) from July 2014 to June 2016 normalized into morphine milligram equivalents (MME). Prescribers were surveyed regarding opioid prescription attitudes, perceptions, and practices. Opioids were prescribed for 78% of procedures, and 70% of patients reported using opioid analgesia. In the prospective group, the median MMEs prescribed were: VEIN (31, n = 16), CEA (40, n = 14), DIAL (60, n = 17), EVAR (108, n = 8), INFRA (160, n = 16), FEM TEA (200, n = 11), and OA (273, n = 4). The median proportion of opioids used by patients across all procedures was only 30% of the amount prescribed across all procedures (range 14–64%). Patients rated the opioid prescribed as appropriate (59%), insufficient (16%), and overprescribed (25%), and pain as very well controlled (47%), well controlled (47%), poorly controlled (4%), and very poorly controlled (2%). In conclusion, we observed significant variability in opioid prescribing after vascular procedures. The overall opioid use was substantially lower than the amount prescribed. These data enabled us to develop guidelines for opioid prescribing practice for our patients.

Background: The arthroscopic Latarjet-Bristow procedure is emerging as a reliable alternative to the open procedure. The reduced soft tissue damage with potential advantages of early pain control and functional recovery is attractive. However, the operation is technically more demanding, and there are concerns regarding the potential for increased recurrence and complication rates. Purpose: To evaluate the available literature focusing on the reported functional outcomes and complications of the arthroscopic Latarjet procedure and compare them with the open procedure. Study Design: Systematic review and meta-analysis. Methods: A comprehensive systematic review was performed with the keywords “arthroscopy,” “arthroscopic,” “Latarjet,” and “Bristow,” with no limit regarding the year of publication. The review was limited to the English-language articles, and each article was evaluated with a modified MINORS (methodological index for nonrandomized studies) scoring system. Results: Fourteen studies met the inclusion criteria and were included in the review. Overall, 813 patients met inclusion criteria, with a mean follow-up of 24.5 months. The mean Walch-Duplay and Rowe scores were 89.6 and 90.2, respectively. The overall complication rate was 16.5%; intraoperative conversion to open surgery, 2%; recurrence, 2.5%; and revision surgery, 5.6%. When only comparative studies were considered, the overall complication rates were 23.7% (arthroscopically) and 15.3% (open). The recurrence and revision surgery rates were 6.5% and 5.7% in the study group, while the corresponding values in the control group were 4% and 2.9%. The mean MINORS score was 14.5 (11.6 for noncomparative studies and 19 for comparative studies). Conclusion: The arthroscopic Latarjet-Bristow procedure is reliable. Outcomes are satisfactory, with less pain and faster recovery in the first postoperative week. However, the procedure is technically demanding, and higher rates of complications and reoperations should be expected. Finally, the arthroscopic operation is much more expensive in terms of implanted materials than the open procedure.

Prescription opioid medications continue to be abused on an epidemic level and have been shown to be a “gateway” drug to heroin abuse. Individuals experimenting with opioids commonly fall in the 10- to 19-year age range in which dentists are the highest prescribers. To reduce the number of excess opioids, the Department of Oral and Maxillofacial Surgery, University of Minnesota, developed and implemented an evidence-based opioid prescribing policy. Data were collected via electronic health record for the previous year and compared with the year following the protocol implementation. The results showed a drastic decrease (>46%) in the number of prescriptions given over a 1-year period. All departments reported a decrease in opioid prescriptions and the average number of tablets per prescription. The concern of undertreating pain was not found to be significant, as there was no increase in after-hours calls, recall appointments, or documentable emergency room visits. The results support the efficacy of an opioid prescribing policy's ability to lower the frequency and number of opioids given to patients, while still adequately treating patients’ pain. Continued evaluation and modifications of the protocol and close monitoring of prescriber habits will enhance patients’ pain control while also limiting the number of opioids available for abuse.

Despite the advances in pain management, achieving optimal pain control in hospice and palliative care is challenging. Patient/caregiver’s lack of pain management knowledge, poor pain reporting, and poor adherence to pain management regimens are all associated with inadequate pain control. The purpose of this integrated review is to examine behavioral interventions designed for patients and caregivers to improve pain control in hospice and palliative care settings. Ten studies were identified through a database search. Seven of the 10 studies found significant improvement in at least 1 pain marker. Of the 7 studies that looked at changes in pain knowledge, 5 had significant improvements in at least 1 knowledge subscale. The 2 studies that looked at adherence to pain management found significant improvements. One limitation of the reviewed studies was that the delivery of them would not be efficient across all health-care settings, and, as a consequence, more technologically sophisticated delivery methods are needed. Therefore, while it is clear from the review that effective pain management interventions have been developed for hospice and palliative care patients, it is also clear that future research needs to focus on providing these same interventions through a more technologically sophisticated delivery method.

The purpose of this study was to compare the level of pain control achieved with 8 versus 10 minute lockout intervals in adult patients who received patient controlled analgesia (PCA) within 24 hours of surgery. There was no difference in pain in the first 72 hours between the 8 minute and 10 minutes group. Additionally, there was no difference in time to first PCA regimen change or a composite outcome of adverse events.

Introduction Musculoskeletal pain caused by trauma is one of the common complaints of patients referred to the emergency department. Due to the lack of a proper pain control protocol, doctors and nurses do not pay attention to pain, and physicians may tend to request too many radiographs, many of which will be unnecessary. We aimed to study the effect of pain management by fentanyl in reducing the number of radiographs, reducing hospital costs and increasing satisfaction in the patients on patients with isolated trauma in limbs and spine causing musculoskeletal pain. Patients and methods A cohort of patients who were referred to the fast-track emergency department with isolated trauma of the upper and lower limbs or spine and triage levels 3, 4 and 5, were visited twice by an emergency medicine resident – before and after application of a pain management protocol using intravenous fentanyl as the principle analgesic. The primary outcome measure was the reduction in the number of radiographs requested; secondary outcomes included alterations in pain levels and patient satisfaction. Results A total of 158 patients were included in the study. The median age was 27.5 years, three quarters were male and 20.88% had a positive history of opium addiction. The number and costs of diagnostic radiography significantly decreased after the administration of fentanyl (P Conclusions The administration of fentanyl as a strong analgesic as part of an emergency department pain management protocol for trauma patients can be performed with limited minor complications; it can reduce the number of unnecessary X-rays performed, exposure to ionizing radiation and hospital costs as well as improving patient satisfaction without missing fractures.

Objective To evaluate the effectiveness of the collaboration between oncology pharmacists and anaesthesiologists for improving pain control management in cancer patients. Methods This retrospective case–control pilot study enrolled inpatients with active cancer and a pain score of >3 at least once per day for 3 consecutive days. The study group was selected from June 2018 to January 2019. Patients with the same inclusion criteria were selected between November 2017 and May 2018 to serve as the comparison group. The primary outcome was the percentage of patients that experienced pain relief within 7 days from initial pain attack. Results A total of 71 and 77 patients were enrolled in the study and comparison groups. More patients in the study group experienced pain relief within 7 days from the index date (78.9% [56 of 71 patients] versus 72.7% [56 of 77 patients], respectively). The service increased the rate of intervention from attending physicians within 4 days from index date and quality of opioid management. Conclusion The collaboration between oncology pharmacists and anaesthesiologists for cancer pain management may be associated with an increase in the rate of pain relief in cancer patients with poor pain control.

Objectives: Tranexamic acid (TXA) is a commonly used medication in orthopaedic procedures, reducing perioperative bleeding and need for transfusion. The purpose of this double-blind randomized controlled study was to evaluate if IV TXA for primary anterior cruciate ligament (ACL) reconstruction with bone-patella tendon-bone (BTB) could reduce perioperative blood loss or postoperative intra-articular hemarthrosis without postoperative drains. Methods: A controlled, randomized, double-blinded trial was conducted in 110 patients who underwent ACLR with BTB autograft. Patients were equally randomized to the control and experimental groups. The experimental group received two 1-gram boluses of IV TXA, one prior to tourniquet inflation and one prior to wound closure; the control group did not receive TXA. If a clinically significant hemarthrosis was evident, the knee was aspirated, and the volume of blood (ml) was recorded. Additionally, perioperative blood loss (ml); Visual Analog Scale (VAS) on postoperative days (POD) 1-7 and post-operative weeks (POW) 1, 6 and 12; postoperative opioid consumption POD 1-7; range of motion (ROM) and ability to straight leg raise (SLR) at POW 1, 6, 12; and pre and postoperative thigh circumference ratio (TCR). Results: There was no significant difference in perioperative blood loss between the experimental and control groups (32.5ml v. 35.6ml, p=0.47). The experimental group had 23 knees aspirated; control group had 26 knees aspirated (p=0.56). No significant difference seen in postoperative hemarthrosis volume with IV TXA (26.7ml v. 37.3ml, p=0.12). There was no significant difference in VAS score between the two groups (p=0.15), additionally, there was no difference in postoperative opioid consumption (p=0.33). There was no significant difference in ROM or ability to SLR, or pre- nor post-operative TCR (p > 0.05 for all). Conclusions: IV TXA in patients who undergo ACLR with BTB autograft does not significantly impact perioperative blood loss, postoperative hemarthrosis, or postoperative pain levels. Additionally, no significant differences were seen in early post-operative recovery regarding ROM or quadriceps reactivation.

Objectives: To compare a multimodal nonopioid pain protocol to traditional opioid medication in controlling postoperative pain following meniscal surgery. We hypothesized that our nonopioid protocol would show no significant difference in pain and reduced side effects when compared to the standard opioid regimen. Methods: Ninety-nine patients undergoing primary meniscectomy or meniscal repair were assessed for participation. A prospective randomized control trial was performed in accordance with the CONSORT (Consolidated Standards of Reporting Trials) 2010 statement. The two arms of the study included a multimodal non-opioid analgesic protocol and a standard opioid regimen with a primary outcome of postoperative pain level (visual analog scale) for 10 days. Secondary outcomes included patient reported outcomes, complications and patient satisfaction. Randomization was achieve using a random number generator. Patients were not blinded. Data collection was done by a blinded observer. Results: Eleven patients did not meet the inclusion criteria, and 27 declined participation. A total of 61 patients were analyzed with 30 randomized to the opioid regimen, and 31 randomized to the non-opioid regimen. Patients receiving the nonopioid regimen demonstrated non-inferior VAS scores compared to patients who received opioid pain medication (p>0.05) No significant differences were found in preoperative (opioid: 58.9 ± 7.0; nonopioid: 58.2 ± 5.5, p = 0.724) nor postoperative (opioid: 59.8 ± 6.5; nonopioid: 54.9 ± 7.1, p = 0.064) PROMIS-PI SF scores. No difference was found in recorded side effects between both groups: constipation (p = 0.124), nausea (p = 0.979), diarrhea (p = 0.464), upset stomach (p = 0.174), and drowsiness (p = 0.572). Conclusions: This study found that multimodal nonopioid pain protocol provided equivalent pain control and patient outcomes following primary meniscus surgery while having an equivalent side effect profile. All patients reported satisfaction with their pain management without requiring emergency opioid analgesia.

Background: Pain control following ACL Reconstruction (ACLR) presents a unique challenge due to age and early rehabilitation needs. Significant efforts have been made to reduce unnecessary opioid prescribing in this vulnerable population, but few have sought to define current practices. Purpose: The purpose of this study is to describe trends in postoperative pain management and assess factors that may mitigate overutilization of opioid medications. Methods: This is a retrospective review of a series of pediatric patients (Results: This study included 687 patients with a mean age of 15.1±1.9 years. The majority underwent ACL reconstruction using hamstring autograft (92.0%) at our main hospital (54.9%). Postoperatively, discharge medication prescribing was performed most frequently (38.1%) by advanced practitioners (NP/PA). While there was no change in the proportion of patients prescribed opioids (>95% of patients) over the 5 year period, the mean number of doses dispensed decreased annually (Fig. 1). This was accompanied by an increase in the annual percentage of patients prescribed oral NSAIDs and acetaminophen during that period. Preoperative opioid consent was obtained in 31.9% of the cohort and these patients received significantly fewer doses of prescribed opioids (25.0 vs. 34.6 doses, pConclusion: Total doses of postoperative opioids prescribed for pain management in pediatric ACLR have declined in recent years, which appears related to preoperative counseling through mandated opioid consenting and paralleled by greater utilization of non-opioid medications. Continued efforts should be made to identify measures to limit overreliance on these medications and to mitigate issues related to misuse, overdose and addiction. [Figure: see text] Annual proportion of patients prescribed ibuprofen, acetaminophen and opioid medication postoperatively and the annual mean number of opioid doses prescribed. [Table: see text] Univariate and multivariate negative binomial regression analysis of factors associated with prescription of a greater number of postoperative doses of opioid medication. CI = Confidence Interval.

Background: A universal consensus regarding standardized pain outcomes does not exist. The personalized pain goal has been suggested as a clinically relevant outcome measure. Aim: To assess the feasibility of obtaining a personalized pain goal and to compare a clinically based personalized pain goal definition versus a research-based study definition for stable pain. Design: Prospective longitudinal descriptive study. Measures: The attending physician completed routine assessments, including a personalized pain goal and the Edmonton Classification System for Cancer Pain, and followed patients daily until stable pain control, death, or discharge. Stable pain for cognitively intact patients was defined as pain intensity less than or equal to desired pain intensity goal (personalized pain goal definition) or pain intensity ⩽3 (Edmonton Classification System for Cancer Pain study definition) for three consecutive days with Setting/participants: A total of 300 consecutive advanced cancer patients were recruited from two acute care hospitals and a tertiary palliative care unit. Results: In all, 231/300 patients (77%) had a pain syndrome; 169/231 (73%) provided a personalized pain goal, with 113/169 (67%) reporting a personalized pain goal ⩽3 (median = 3, range = 0–10). Using the personalized pain goal definition as the gold standard, sensitivity and specificity of the Edmonton Classification System for Cancer Pain definition were 71.3% and 98.5%, respectively. For mild (0–3), moderate (4–6), and severe (7–10) pain, the highest sensitivity was for moderate pain (90.5%), with high specificity across all three categories (95%–100%). Conclusion: The personalized pain goal is a feasible outcome measure for cognitively intact patients. The Edmonton Classification System for Cancer Pain definition closely resembles patient-reported personalized pain goals for stable pain and would be appropriate for research purposes. For clinical pain management, it would be important to include the personalized pain goal as standard practice.

Purpose:To examine the difference in pain control and systemic pain medication usage with sub-Tenon’s bupivacaine versus bupivacaine liposome injectable suspension (BLIS) following radioactive plaq...

Objective: To determine the safety of ibuprofen used for postoperative pain control following palatoplasty in pediatric patients. Design: Retrospective chart review. Setting: Tertiary care, pediatric hospital. Participants: Patients who received ibuprofen for postoperative pain control after palatoplasty. Main Outcome Measures: Number of doses of ibuprofen given during hospitalization and the presence of postoperative primary or secondary bleeding following palatoplasty. Detection of postoperative hemorrhage was obtained from (1) chart review from inpatient hospitalization after palatoplasty, (2) chart review of each patient’s 3-week postoperative clinic visit, and (3) phone call to caretakers from primary author. Results: Thirty-two patients underwent palatoplasty who received ibuprofen for control of postoperative pain. Mean number of inpatient doses given was 4.8 (range: 1-17). None (0%) experienced hemorrhage in the hospital before discharge. Thirty-two (100%) patients were seen at a 3-week follow-up and no (0%) episodes of postoperative hemorrhage were noted. Seventeen (53%) caretakers of patients responded to contact by phone and confirmed no subsequent bleeding. Conclusions: Ibuprofen may not increase postoperative hemorrhage after palatoplasty. Further studies will be needed to evaluate safety on a larger scale.

Background: Following availability in the United States in 2011, intravenous acetaminophen (IV APAP) was added to many hospital formularies for multimodal pain control. In 2014, the price of IV APAP increased from $12/g to $33/g and became a top 10 medication expenditure at our institution. Objective: To promote appropriate IV APAP prescribing and reduce costs. Design, Setting, Participants: Quality improvement project at a 562-bed academic medical center involving all inpatient admissions from 2010 to 2017. Interventions: Using Plan-Do-Study-Act (PDSA) methodology, our Pharmacy & Therapeutics (P&T) committee aimed to reduce inappropriate use of IV APAP by refinement of restriction criteria, development of clinical decision support in the electronic medical record, education of clinical staff on appropriate use, and empowerment of hospital pharmacists to enforce restrictions. Measurements: Monthly IV APAP utilization and spending were assessed using statistical process control charts. Balancing measures included monthly usage of IV opioid, IV ketorolac, and oral ibuprofen. Results: Five PDSA cycles were conducted during the study period. Monthly spending on IV APAP decreased from the highest average of $56 038 per month to $5822 per month at study conclusion. Interventions resulted in an 80% annual cost savings, or an approximate savings of $600 000 per year. Usage of IV opioids, IV ketorolac, and oral ibuprofen showed no major changes during the study period. Conclusions: IV APAP can be restricted in a safe and cost effective manner without concomitant increase in IV opioid use.

Background: Assessment and management of postoperative pain in the pediatric population after ACL surgery can be challenging, and the optimal approach to pain control remains controversial. Recent studies have shown that the use of intraoperative nerve blocks may reduce the need for opioids to control pain in the immediate postoperative period. However, it is not clear which block type is the most beneficial for the pediatric outpatient setting. The objective of our study was to compare effectiveness of pain control between three different pain management strategies in the pediatric ACL population. Methods: A retrospective chart review from 2013-2017 of patients ages 12-17 receiving an elective ACL reconstruction. Three types of analgesia were included: femoral nerve block, combined femoral + sciatic block, and intraarticular injection of bupivacaine with cold therapy in the Post Anesthesia Care Unit (PACU) (each used by three different surgeons as their standard preference in three different hospitals), n = 50 per group. The primary variable was postoperative pain scores (visual analog scale 1-10) in the PACU. Secondary variables collected were demographic data, graft type, time in PACU and intraoperative/postoperative opioid use. Results: The mean (+ SD) age of the cohort was 15.3 + 1.4 years; there were no differences in age, BMI or ratio of boys and girls between the 3 groups (n=50 per group). However, the femoral nerve block group had a significantly lower percentage of Caucasians (28%, P = 0.002) compared to the group with combined blocks (58%) and intraarticular injection (56%). Less than 50% of patients in the combined nerve block group had opioids intraoperatively or in the PACU compared to nearly 100% of patients in the other two groups (P < 0.0001). Also, for patients receiving opioids, the total intraoperative morphine equivalents and PACU pain scores (all patients) were significantly less in the combined block group (P < 0.001). For patients receiving opioids in the PACU, the total morphine equivalents was significantly higher in the intraarticular injection group compared to the nerve block groups (P < 0.0001). Total time in the PACU was 25% longer for patients in the combined block group (P < 0.0001). Conclusion: Patients in the combined femoral and sciatic nerve block group had significantly better pain scores in the PACU with less cumulative morphine equivalent consumption compared to the femoral nerve block group and the intraarticular injection group.

Acupuncture is a traditional treatment method that has been extensively used for centuries in a number of Asian countries for pain control as well as for treatment of various diseases. Acupuncture has been known to be a safe procedure with little side effects, but at times serious complications such as infection, pneumothorax, central or peripheral nerve injury and cardiac injury may occur. Cases of cerebral hemorrhage by acupuncture are rare with few being reported. A 32-year-old woman presented with a headache that occurred after acupuncture at posterior neck. We diagnosed her symptoms initially as peripheral nerve irritation by acupuncture and administered analgesic only. However, the final diagnosis was turned up to be intraventricular hemorrhage. The authors emphasize that acupuncturists and emergency physicians should know that acupuncture can lead to intracranial hemorrhage as a serious complication and this should be considered in all causes of headache for diagnosis without prejudice.

We compared outcomes for two gastric electrical stimulation placement strategies, mini-laparotomy with adjunctive care (MLAC) versus laparoscopy without adjunctive care (LAPA). For electrode placement, the peritoneal cavity was accessed with either a single 2.5 to 3.0 cm midline incision (MLAC) or three trocar incisions (LAPA). For both groups, generator was placed subcutaneously over the anterior rectus sheath. For MLAC, adjunctive pain control measures were used for placement of both electrode and generator (transversus abdominus plane block). For LAPA, those that could not be completed by laparoscopy were converted to traditional open approach and kept in the analysis. MLAC (n = 128) resulted in shorter operative times than LAPA (n = 37) (median operative time: 87.5 vs 137.0 minutes, P ≤ 0.01). Hospital length of stay was also shorter for MLAC than for LAPA (median: 2.0 vs 3.0 days, P ≤ 0.01) without any increase in readmission rates to the hospital within 30 days of discharge (11.0 vs 16.2%, P = 0.39). After equalizing learning curves, these differences were even greater (median operative time: 84.5 vs 137.0 minutes, P < 0.01; median length of stay: 1.0 vs 3.0 days; P < 0.01) without increasing 30-day read-mission rates (9.1 vs 16.2%, P = 0.25). For implantation of gastric electrical stimulators, mini-laparotomy can result in improved outcomes when coupled with adjunctive pain control measures.

Opioid administration delivered intravenously (IV) by patient-controlled analgesia (PCA) devices has been an important development in addressing insufficient management of acute pain in the postsurgical setting. However, IV PCA has several disadvantages, including operator error, risk of patient exposure to analgesic gaps, IV line patency issues, and risk of catheter-related infection, all of which contribute to the total cost of care. Morphine, the most commonly used opioid in IV PCA, has a relatively slow onset of analgesia, which may leave patients with inadequate initial pain control and at risk of opioid dose-stacking. Sufentanil is an opioid with no major active metabolites and a rapid onset of analgesia. The sufentanil sublingual tablet system (SSTS) with a 20-minute lockout and other safety features is a novel noninvasive PCA system in development for on-demand relief of moderate to severe acute pain in the hospital setting. Data from phase 3 trials of the use of SSTS after elective major open abdominal and orthopedic surgery show that analgesia is rapidly achieved, with a longer mean interdosing interval compared with IV PCA morphine (81 vs 47 minutes) and a high level of patient and nurse satisfaction. These data suggest that SSTS may also aid in the avoidance of some of the pitfalls inherent with IV PCA, which may help reduce hospital costs associated with IV PCA–related issues. This article describes the evolution, benefits, issues, and costs associated with IV PCA and reviews data from preclinical studies of sufentanil through SSTS phase 3 trials.

ObjectiveTo evaluate the efficacy and safety of the addition of local infiltration analgesia (LIA) to adductor canal block (ACB) for pain control after primary total knee arthroplasty (TKA).MethodsTwo reviewers independently searched for potentially relevant published studies using electronic databases, including PubMed® (1966 to June 2019), Embase® (1974 to June 2019) and Web of Science (1990 to June 2019). The results were pooled using the random-effects model to produce standard mean differences for continuous outcome data and odds ratio for categorical outcome data.ResultsA total of three randomized controlled trials (RCTs) and three non-RCTs were included for data extraction and meta-analysis. There were significant differences between the two groups regarding the postoperative pain score on postoperative day (POD) 0 and POD 1. The cumulative opioid consumption in the ACB plus LIA groups was significantly lower than that in the ACB groups on POD 0 and POD 1. No significant differences were found in terms of postoperative range of motion or length of hospitalization.ConclusionACB plus LIA significantly reduced the postoperative pain score on POD 0 and POD 1 compared with isolated ACB. In addition, ACB plus LIA was associated with a significant reduction in opioid consumption during the early postoperative period.

Objectives: To perform a single-blinded, randomized controlled trial comparing pericapsular injection versus lumbar plexus blockade for post-operative pain control following arthroscopic surgery on the hip. Methods: 70 consecutive patients undergoing hip arthroscopy were prospectively assessed over a six-month period from 2017 to 2018. Patients were randomly allocated to 1 of 2 groups. 35 patients received a lumbar plexus blockade by a single anesthesiologist, while 35 patients received a pericapsular injection of 30cc of ropivacaine and 12mg of morphine. Post-operative pain in the post-anesthesia care unit (PACU) as measured by the numeric rating scale (NRS), time to discharge, PACU morphine equivalents and adverse effects were collected by PACU staff. Post-operative day (POD) 1 and POD 2 narcotic use was obtained through a phone call with the patient on post-operative day 2. Results: We found no statistically significant difference in PACU pain scores at all time-points, although there was a trend towards lower pain for patients receiving a pericapsular injection. PACU and short-term narcotic demand did not differ significantly between the two arms. Time to discharge from the PACU did not differ. There were no major adverse events reported for either intervention. Conclusion: Pericapsular injection provides equivalent analgesia when compared to lumbar plexus injection. It is a safe, time-saving intervention that allows for efficient post-operative analgesia for patients undergoing hip arthroscopy.

Introduction: The efficacy of intra-articular fentanyl supplementation for pain control after knee arthroscopy remains controversial. We conduct a systematic review and meta-analysis to explore the influence of intra-articular fentanyl supplementation for pain intensity after arthroscopic knee surgery. Methods: We searched PubMed, EMbase, Web of Science, EBSCO, and Cochrane Library databases through May 2019 for randomized controlled trials (RCTs) assessing the efficacy and safety of intra-articular fentanyl supplementation for arthroscopic knee surgery. This meta-analysis is performed using the random-effects model. Results: Four RCTs are included in the meta-analysis. Overall, compared with control group after knee arthroscopy, intra-articular fentanyl supplementation is associated with reduced pain scores at 1 h (standard mean difference (Std MD) = −3.50; 95% confidence interval (CI) = −5.68 to −1.32; p = 0.002), 2 h (Std MD = −4.73; 95% CI = −8.75 to −0.71; p = 0.02), and 8 h (Std MD = −5.02; 95% CI = −9.73 to −0.30; p = 0.04) but shows no substantial impact on pain scores at 4 h (Std MD = −3.94; 95% CI = −7.93 to 0.05; p = 0.05) or the supplementary analgesia (risk ratio = 0.56; 95% CI = 0.09–3.59; p = 0.54). Conclusions: Intra-articular fentanyl supplementation does benefit in pain control after knee arthroscopy.

Palliative care aims to improve the quality of life of patients and their families in those experiencing life-threatening illness. One of the most significant aspects of palliation is the alleviation of pain and distressing symptoms. This article aims to improve confidence in pain assessment and management by presenting a review on pain in palliative care.

Purpose Concerns about pain control in patients with cerebral palsy (CP) are especially anxiety provoking for parents, given the fact that spasticity, communication issues, and postoperative muscle spasms are significant problems that make pain control difficult in these patients. A better understanding of the magnitude and quality of the pain these patients experience after our surgical procedures would better prepare the patients and their families. The purpose of this study is to quantify the amount of postoperative pain in children with CP undergoing hip reconstruction and spinal fusion. Specifically, the study will compare pain scores and the amount of narcotics used between the two groups. Materials and methods This is a retrospective chart review of a consecutive series of children with CP (GMFCS levels IV and V) over a 5-year period undergoing hip reconstruction (femoral osteotomy, pelvic osteotomy, or both) and posterior spinal fusion (PSF) at a tertiary-care pediatric hospital. The primary end point was the total opioid used by the patient during the hospitalization, by converting all forms of narcotics to morphine equivalents. The secondary end point was the documentation of pain with standard pain scores at standard time points postoperatively. Adverse effects related to pain management were documented for both groups. Student's t-tests were utilized to statistically compare differences between the groups, with significance determined at p < 0.05. Results Forty-two patients with CP who underwent hip reconstruction (mean age 8.8 years) were compared to 26 patients who underwent PSF (mean age 15.4 years). The total opioid used, normalized by body weight and by days length of stay (DLOS), in the hip group was 0.49 mg morphine/kg/DLOS, compared to 0.24 for the spine group ( p = 0.014). The mean pain score for the hip group was 1.52, compared to 0.72 for the spine group ( p = 0.013). There were no significant differences in the occurrence of adverse effects related to pain management between the two groups. Conclusion Patients with CP undergoing hip reconstruction surgery had significantly more pain, as exhibited by requiring more narcotics and having higher pain scores, than those patients undergoing PSF. The knowledge that hip reconstruction is more painful than PSF for patients with CP will better prepare families about what to expect in the postoperative period and will alert providers to supply better postoperative pain control in these patients. Level of evidence III (case control series).

BackgroundThe use of acetaminophen as a drug for pain control is expected to increase in the neonatal field. The displacement factor of acetaminophen in the reaction in the glucose oxidase peroxidase method is very high, but is also considered to be inaccurate based on physicochemical properties.MethodUnbound bilirubin was measured using the erythrocyte-bound bilirubin measurement method and glucose oxidase peroxidase method by the addition of acetaminophen or sulfisoxazole. The displacement factor was measured using glucose oxidase peroxidase method with the addition of tert-butyl-p-hydroxyanisole.ResultsAcetaminophen did not increase erythrocyte-bound bilirubin, and the addition of tert-butyl-p-hydroxyanisole lowered its displacement factor. On the other hand, sulfisoxazole increased erythrocyte-bound bilirubin, while tert-butyl-p-hydroxyanisole did not change its displacement factor.ConclusionAcetaminophen is an accelerator of the reaction in the glucose oxidase peroxidase method and does not displace bilirubin from human serum albumin.