Search

Purpose: Total knee arthroplasty (TKA) is associated with severe postoperative pain. Continuous adductor canal blockade provides analgesia while preserving quadriceps muscle strength. Nevertheless, uncertainty still exists as to the optimal adductor canal catheter placement approach. We sought to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the analgesic effects of proximal vs distal adductor canal catheters in patients undergoing TKA., Source: We systematically searched PubMed, EMBASE, and Cochrane for RCTs comparing distal and proximal adductor canal catheters for TKA regarding critical clinical outcomes in adult patients. Statistical analysis was performed using R version 4.1.2 (R Foundation for Statistical Computing, Vienna, Austria). Heterogeneity was assessed using the Cochran Q test and I 2 statistics. Trial sequential analysis (TSA) was performed to evaluate the risk of random errors and the uncertainty of our results. The risk of bias was appraised according to the RoB-2 tool., Principal Findings: Six RCTs and 352 patients were included, of whom 151 (42.9%) were male, and 175 (49.7%) were randomized to undergo proximal adductor canal catheter placement. Due to the randomized nature of the studies, baseline characteristics were similar between groups. There were no statistical differences between proximal and distal adductor canal catheters regarding cumulative opioid consumption in the first 24 hr (mean difference [MD], -4.86; 95% confidence interval [CI], -15.19 to 5.47; P = 0.36; four RCTs; 240 patients); pain scores at rest (MD, 0.41; 95% CI, -1.23 to 0.40; P = 0.32; six RCTs; 350 patients); and pain scores with movement for the first 24 hr (MD, -0.25; 95% CI, -0.85 to 0.35; P = 0.42; four RCTs; 246 patients). In the TSA, the required information size was not reached, and the Z-curve did not cross the monitoring boundaries in any of the endpoints., Conclusion: These findings suggest that proximal vs distal adductor canal catheter placement in patients undergoing TKA may be equally effective for the outcomes of opioid consumption in the first 24 hr, pain scores at rest, and pain scores with movement in the first 24 hr. Nevertheless, TSA findings suggest insufficient power to definitively conclude no differences between the two techniques., Study Registration: PROSPERO (CRD42022353576); registered 25 August 2022., (© 2023. Canadian Anesthesiologists' Society.)

Purpose: Minimally invasive direct coronary artery bypass (MIDCAB) surgery is associated with significant postoperative pain. We aimed to investigate the efficacy of ultrasound-guided erector spinae plane block (ESPB) for analgesia after MIDCAB., Methods: We conducted randomized controlled trial in 60 patients undergoing MIDCAB who received either a single-shot ESPB with 30 mL of ropivacaine 0.5% (ESPB group, n = 30) or normal saline 0.9% (control group, n = 30). The primary outcome was numerical rating scale (NRS) pain scores at rest within 48 hr postoperatively. The secondary outcomes included postoperative NRS pain scores on deep inspiration within 48 hr, hydromorphone consumption, and quality of recovery-15 (QoR-15) score at 24 and 48 hr., Results: Compared with the control group, the ESPB group had lower NRS pain scores at rest at 6 hr (estimated mean difference, -2.1; 99% confidence interval [CI], -2.7 to -1.5; P < 0.001), 12 hr (-1.9; 99% CI, -2.6 to -1.2; P < 0.001), and 18 hr (-1.2; 99% CI, -1.8 to -0.6; P < 0.001) after surgery. The ESPB group also showed lower pain scores on deep inspiration at 6 hr (-2.9; 99% CI, -3.6 to -2.1; P < 0.001), 12 hr (-2.3; 99% CI, -3.1 to -1.5; P < 0.001), and 18 hr (-1.0; 99% CI, -1.8 to -0.2; P = 0.01) postoperatively. Patients in the ESPB group had lower total intraoperative fentanyl use, lower 24-hr hydromorphone consumption, a shorter time to extubation, and a shorter time to intensive care unit (ICU) discharge., Conclusion: Erector spinae plane block provided early effective postoperative analgesia and reduced opioid consumption, time to extubation, and ICU discharge in patients undergoing MIDCAB., Trial Registration: www.chictr.org.cn (ChiCTR2100052810); registered 5 November 2021., (© 2023. The Author(s).)

Purpose: Although a single-injection interscalene block provides effective early postoperative analgesia following shoulder surgery, patients may experience "rebound pain" when the block resolves. Our objective was to determine if oral hydromorphone (2 mg) given six hours after a single-injection interscalene block for arthroscopic shoulder surgery leads to a clinically significant reduction in the severity of rebound pain., Methods: After approval from research ethics boards, we conducted a two-centre, parallel-group, double-blind, randomized, placebo-controlled superiority trial. Patients received preoperative interscalene block, general anesthesia, and either hydromorphone or placebo six hours after the block. The primary outcome was the worst pain score in the first 24 hr postoperatively, measured on an 11-point (0-10) numerical rating scale., Results: A total of 73 participants were randomly assigned to either the hydromorphone or placebo group. There was no statistically significant difference in the mean (standard deviation) worst pain score within 24 hr between the hydromorphone and placebo groups (6.5 [2.4] vs 5.9 [2.3]; mean difference, 0.6; 95% confidence interval, -0.5 to 1.8). Similarly, we did not find any significant difference in the pain trajectory, opioid use, or incidence of nausea and vomiting between the groups. The mean time to worst pain was 14.6 hr, and the mean time to first rescue analgesia was 11.3 hr after interscalene block., Conclusion: Hydromorphone 2 mg given six hours after interscalene block did not reduce the severity of rebound pain postoperatively compared with placebo in patients undergoing arthroscopic shoulder surgery., Study Registration: ClinicalTrials.gov (NCT02939209); registered 19 October 2016., (© 2023. Canadian Anesthesiologists' Society.)

Purpose: Traditional multimodal analgesic strategies have several contraindications in cardiac surgery patients, forcing clinicians to use alternative options. Superficial parasternal intercostal plane blocks, anesthetizing the anterior cutaneous branches of the thoracic intercostal nerves, are being explored as a straightforward method to treat pain after sternotomy. We sought to evaluate the literature on the effects of superficial parasternal blocks on pain control after cardiac surgery., Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs). We searched MEDLINE, Embase, CENTRAL, and Web of Science databases for RCTs evaluating superficial parasternal intercostal plane blocks in adult patients undergoing cardiac surgery via midline sternotomy published from inception to 11 March 2022. The prespecified primary outcome was opioid consumption at 12 hr. The risk of bias was assessed with the Cochrane Collaboration Risk of Bias Tool, and the quality of evidence was evaluated using the grading of recommendations, assessments, development, and evaluations. Outcomes were analyzed with a random-effects model. All subgroups were prespecified., Results: We reviewed 1,275 citations. Eleven RCTs, comprising 756 patients, fulfilled the inclusion criteria. Only one study reported the prespecified primary outcome, precluding the possibility of meta-analysis. This study reported a reduction in opioid consumption (-11.2 mg iv morphine equivalents; 95% confidence interval [CI], -8.2 to -14.1) There was a reduction in opioid consumption at 24 hr (-7.2 mg iv morphine equivalents; 95% CI,  -5.6 to -8.7; five trials; 436 participants; moderate certainty evidence). All five studies measuring complications reported that none were detected, which included a sample of 196 blocks., Conclusion: The literature suggests a potential benefit of using superficial parasternal blocks to improve acute postoperative pain control after cardiac surgery via midline sternotomy. Future studies specifying dosing regimens and adjuncts are required., Study Registration: PROSPERO (CRD42022306914); first submitted 22 March 2022., (© 2024. Canadian Anesthesiologists' Society.)

Purpose: Thoracic epidural analgesia (TEA) is a well stablished technique for pain management in major thoracic and abdominal surgeries; however, it has considerable failure rates. Local anesthetic (LA) administration and subsequent assessment of sensory block through physical examination (e.g., decreased temperature perception determined via an LA temperature dissociation test [LATDT]) has been the historical standard for evaluation of thoracic epidural placement. Nevertheless, newer methods to objectively evaluate successful placement have recently been developed, e.g., the epidural electrical stimulation test (EEST) and epidural pressure waveform analysis (EWA). The purpose of this study was to evaluate the effectiveness of preoperative TEA catheter testing (LATDT, EEST, and EWA) on reducing TEA failure., Methods: After obtaining an institutional research ethics board approval for a retrospective study, we conducted a single-institution retrospective review on all TEAs performed between January 2016 and December 2021. Patients were assigned to one of four groups based on the performed test method to verify the placement of the TEA catheter: no test, LATDT, EEST, and EWA. A TEA was deemed successful if it provided bilateral dermatomal sensory block to ice test in the postoperative period, and was used for patient analgesia for at least 24 hr., Results: One thousand two hundred and forty-one patients submitted to preoperative TEA were included. Twenty-eight patients were excluded. Tested and untested epidurals had failure rates of 3.8% (95% confidence interval [CI], 1.8 to 6.2) and 11.5% (95% CI, 5.2 to 17.1), respectively (P < 0.001)., Conclusion: Objective preoperative testing after placement of thoracic epidurals was associated with a reduction in failure rates., (© 2023. Canadian Anesthesiologists' Society.)

Purpose: This systematic review and meta-analysis investigated the impact of peripheral nerve blocks (PNBs) on patient-reported quality of recovery (QoR) following breast cancer surgery., Source: Medline, EMBASE, Cochrane Library, and Google scholar databases were searched for randomized controlled trials (RCTs) comparing the QoR with or without PNBs in patients receiving breast cancer surgery from inception to September 2021. Using a random effects model, the primary outcome was total scores of postoperative QoR scales (i.e., QoR-15 and QoR-40)., Principal Findings: Eight RCTs (QoR-15, n = 4; QoR-40, n = 4) involving 653 patients published from 2018 to 2021 were included. For the QoR-40 scale, pooled results revealed a significantly higher total score (mean difference [MD], 12.8 [8.2%]; 95% confidence interval [CI], 10.6 to 14.9; I 2 = 59%; five RCTs; n = 251) and scores on all subscales, except psychological support, in the PNB group than in controls at 24 hr after surgery. For the QoR-15 scale, pooled results also showed favorable QoR (MD, 7.7 [5.2%]; 95% CI, 4.9 to 10.5; I 2 = 75%; four RCTs; n = 402) in the PNB group at 24 hr after surgery. Sensitivity analysis showed no effect on the QoR-40 score and the difference in total QoR-15 score was no longer significant when a single trial was omitted. The use of PNBs was associated with a significantly lower opioid consumption and risk of postoperative nausea and vomiting without significant differences in the pain score between the two groups., Conclusion: Our results verified the efficacy of PNBs for enhancing postoperative QoR using two validated patient-reported tools in female patients receiving breast cancer surgery under general anesthesia., Study Registration: PROSPERO (CRD42021272575); first submitted 9 August 2021., (© 2022. Canadian Anesthesiologists' Society.)

Purpose: To evaluate whether opioid prescriptions at discharge after Cesarean delivery decreased following implementation of a quality improvement bundle., Methods: A quality improvement bundle was instituted at Mount Sinai Hospital in Toronto. Interventions included opioid prescribing instructions in resident orientation, nursing and patient education, and standard electronic prescriptions. We used an interrupted time series study design and included patients who had a Cesarean delivery six months pre intervention and six months post intervention. Primary outcome data (opioids prescribed at discharge in morphine milliequivalents [MME]), were aggregated (averaged) by calendar week and analyzed using interrupted time series. Secondary outcomes were assessed using bivariate methods and included opioid use for breakthrough pain in hospital, and amount of opioids prescribed by prescriber specialty and training level., Results: We included 2,578 women in our analysis. Based on the segmented regression analysis, prescribed opioids decreased from 97.6 MME in 2018 to 35.8 MME in 2019 (difference in means, - 61.7; 95% confidence interval [CI], - 72.2 to - 51.3; P < 0.001), and this decrease was sustained over the study period. Post intervention, there were no visits to our postnatal assessment clinic for inadequate pain control., Conclusion: A quality improvement bundle was associated with a marked and sustained decrease in discharge prescriptions of opioids post Cesarean delivery at a large Canadian tertiary academic hospital., (© 2021. The Author(s).)

Background: Home pain remains the most common complication in outpatient surgery. Optimal management requires good information and early availability of analgesics. The main objective of this randomized controlled trial was to compare the effects of pre- vs postoperative analgesic instruction and prescription on postoperative home pain., Methods: Patients were randomized into an anesthesia consultation group (AC group) and a standard postoperative group (POP group). The AC group and the POP group received analgesic prescription and instruction during the anesthesia consultation and after surgery, respectively. The primary outcome was the incidence of home pain on postopertive day one (D1). Home pain was defined by at least one episode with a numeric rating scale score > 3/10 at rest. Treatment compliance and postoperative nausea and vomiting (PONV) were also assessed on D1 and postoperative day 7 (D7)., Results: One hundred and eighty-six patients were included between May 2017 and May 2018 at Rouen University Hospital, France. Ninety-four patients were randomized to the AC group and 92 to the POP group. On D1, the incidence of pain was 23/94 (24%) in the AC group and 44/92 (48%) in the POP group (P < 0.001). On D1, the rate of treatment compliance was significantly higher in the AC group than in the POP group (85% vs 69%; P = 0.02). There was no statistically significant difference in the incidence of pain or treatment compliance between groups on D7 or in PONV on D1 and on D7., Conclusions: Preoperative analgesic instruction and prescription during anesthesia consultation reduces the incidence of early postoperative home pain in outpatient surgery., Trial Registration: www.clinicaltrialsgov (NCT03205189); registered 2 July 2017., (© 2021. Canadian Anesthesiologists' Society.)

Purpose: Hip fractures are debilitating in older adults because of their impact on quality of life. Opioids are associated with adverse effects in this population, so oral acetaminophen is commonly prescribed to minimize opioid use. Intravenous (iv) acetaminophen has been reported to have superior efficacy and bioavailability than oral acetaminophen. Nevertheless, its effect on postoperative outcomes in emergency hip fractures is unclear. This systematic review assessed the effect of iv acetaminophen on postoperative outcomes in older hip fracture patients., Source: We searched multiple databases from inception to June 2021 for studies on adults > 50 yr of age undergoing emergency hip fracture surgery who received iv acetaminophen (or paracetamol) and that reported postoperative outcomes. Relevant titles, abstracts, and full texts were screened based on the eligibility criteria. The Newcastle-Ottawa scale was used to assess the quality of the selected papers., Principal Findings: Of 3,510 initial studies, four met the inclusion criteria. One was a prospective cohort study and three were retrospective cohort studies. All four studies used historical control groups. Three studies reported a significantly lower mean opioid dose with iv acetaminophen than with oral acetaminophen. Three studies also reported a significantly shorter hospital stay. One study each reported a significant decrease in the number of missed physical therapy sessions, the need for one-to-one supervision, and episodes of delirium., Conclusion: There is very limited low-level evidence that iv acetaminophen improves preoperative and postoperative analgesia and shortens hospital stay in older hip fracture patients. Nevertheless, our results should be interpreted with caution since there are no prospective randomized trials investigating whether iv acetaminophen improves postoperative outcomes in this patient population., Study Registration: PROSPERO (CRD42021198174); registered 15 August 2021., (© 2022. Canadian Anesthesiologists' Society.)

Purpose: The high-thoracic erector spinae plane block (HT-ESPB) has been reported as an effective analgesic modality for the shoulder region without phrenic nerve palsy. The goal of this study was to compare the HT-ESPB as a phrenic nerve-sparing alternative to an interscalene block for total shoulder arthroplasty., Methods: Thirty patients undergoing total shoulder arthroplasty at Stanford Health Care (Palo Alto, CA, USA) were enrolled in a double-blind randomized controlled trial. We randomized 28 patients to receive either an interscalene or HT-ESPB perineural catheter preoperatively; 26 patients were included in the final analysis. The study was powered for the primary outcome of incidence of hemidiaphragmatic paralysis in the postanesthesia care unit (PACU). Other outcome measures included incentive spirometry volume, brachial plexus motor and sensory exams, adverse events, pain scores, and opioid consumption., Results: The incidence of hemidiaphragmatic paralysis in the HT-ESPB catheter group was significantly lower than in the interscalene catheter group (0/12, 0% vs 14/14, 100%; P < 0.001). No statistically significant differences were found in pain scores and opioid consumption (in oral morphine equivalents) between the interscalene and HT-ESPB groups through postoperative day (POD) 2. Nevertheless, the mean (standard deviation) point estimates for opioid consumption for the HT-ESPB group were higher than for the interscalene group in the PACU (HT-ESPB: 24.8 [26.7] mg; interscalene: 10.7 [21.7] mg) and for POD 0 (HT-ESPB: 20.5 [25.0] mg; interscalene: 6.7 [12.0] mg). In addition, cumulative postoperative opioid consumption was significantly higher at POD 0 (PACU through POD 0) in the HT-ESPB group (45.3 [39.9] mg) than in the interscalene group (16.6 [21.9] mg; P = 0.04)., Conclusions: This study suggests that continuous HT-ESPB can be a phrenic nerve-sparing alternative to continuous interscalene brachial plexus blockade, although the latter provided superior opioid-sparing in the immediate postoperative period. This was a small sample size study, and further investigations powered to detect differences in analgesic and quality of recovery score endpoints are needed., Study Registration: www., Clinicaltrials: gov (NCT03807505); registered 17 January 2019., (© 2022. Canadian Anesthesiologists' Society.)

Background: The optimal regional technique to control pain after breast cancer surgery remains unclear. We sought to synthesize available data from randomized controlled trials comparing pain-related outcomes following various regional techniques for major oncologic breast surgery., Methods: In a systematic review and network meta-analysis, we searched trials in PubMed, Embase Scopus, Medline, Cochrane Central and Google Scholar, from inception to 31 July 2020, for commonly used regional techniques. The primary outcome was the 24-hr resting pain score measured on a numerical rating score of 0-10. We used surface under the cumulative ranking curve (SUCRA) to establish the probability of an intervention ranking highest. The analysis was performed using the Bayesian random effects model, and effect sizes are reported as 95% credible interval (Crl). We conducted cluster-rank analysis by combining 24-hr pain ranking with 24-hr opioid use or incidence of postoperative nausea and vomiting., Results: Seventy-nine randomized controlled trials containing 11 different interventions in 5,686 patients were included. The SUCRA values of the interventions for 24-hr resting pain score were continuous paravertebral block (0.83), serratus anterior plane block (0.76), continuous wound infusion (0.76), single-level paravertebral block (0.68), erector spinae plane block (0.59), modified pectoral block (0.49), intercostal block (0.45), multilevel paravertebral block (0.41), wound infiltration (0.33), no intervention (0.12), and placebo (0.08). When compared with placebo, the continuous paravertebral block (mean difference, 1.26; 95% Crl, 0.43 to 2.12) and serratus anterior plane block (mean difference, 1.12; 95% Crl, 0.32 to 1.9) had the highest estimated probability of decreasing 24-hr resting pain scores. Cluster ranking analysis combining 24-hr resting pain scores and opioid use showed that most regional analgesia techniques were more effective than no intervention or placebo. Nevertheless, wound infiltration and continuous wound infusion may be the least effective active interventions for reducing postoperative nausea and vomiting., Conclusion: Continuous paravertebral block and serratus anterior plane block had a high probability of reducing pain at 24 hr after major oncologic breast surgery. The certainty of evidence was moderate to very low. Future studies should compare different regional anesthesia techniques, including surgeon-administered techniques such as wound infiltration or catheters. Trials comparing active intervention with placebo are unlikely to change clinical practice., Study Registration: PROSPERO (CRD42020198244); registered 19 October 2020., (© 2022. Canadian Anesthesiologists' Society.)

Purpose: Postoperative analgesia following total knee arthroplasty (TKA) often includes intrathecal opioids, periarticular injection (PAI) of local anesthetic, systemic multimodal analgesia, and/or peripheral nerve blockade. The adductor canal block (ACB) provides analgesia without muscle weakness and magnesium sulphate (MgSO 4 ) may extend its duration. The purpose of this trial was to compare the duration and quality of early post-TKA analgesia in patients receiving postoperative ACB (± MgSO 4 ) in addition to standard care., Methods: Elective TKA patients were randomized to: 1) sham ACB, 2) ropivacaine ACB, or 3) ropivacaine ACB with added MgSO 4 . All received spinal anesthesia with intrathecal morphine, intraoperative PAI, and multimodal systemic analgesia. Patients and assessors remained blinded to allocation. Anesthesiologists knew whether patients had received sham or ACB but were blinded to MgSO 4. The primary outcome was time to first analgesic (via patient-controlled analgesia [PCA] with iv morphine) following ACB. Secondary outcomes were morphine consumption, side effects, visual analogue scale pain scores, satisfaction until 24 hr postoperatively, and length of stay., Results: Of 130 patients, 121 were included. Nine were excluded post randomization: four were protocol violations, three did not meet inclusion criteria, and two had severe pain requiring open label blockade. There were no differences in the median [interquartile range] time to first PCA request: sham, 310 min [165-550]; ropivacaine ACB, 298 min [120-776]; and ropivacaine ACB with MgSO 4 , 270 min [113-780] (P = 0.96). Similarly, we detected no differences in resting pain, opioid consumption, length of stay, or associated side effects until 24 hr postoperatively., Conclusion: We found no analgesic benefit of a postoperative ACB, with or without added MgSO 4 , in TKA patients undergoing spinal anesthesia and receiving intrathecal morphine, an intraoperative PAI, and multimodal systemic analgesia., Trial Registration: www.clinicaltrials.gov (NCT02581683); registered 21 October 2015.

Purpose: Transversus abdominus plane (TAP) blocks are widely used for postoperative analgesia for abdominal surgical procedures. The purpose of this study was to compare the analgesic efficacy of plain bupivacaine, liposomal bupivacaine, and the mixture of plain bupivacaine with liposomal bupivacaine when used in a TAP block., Methods: This study was a single centre, prospective, patient-, observer-, and surgeon-blinded, randomized-controlled trial in which 90 patients undergoing an open abdominal hysterectomy with a midline incision were randomized to receive a TAP block with plain bupivacaine (group bupivacaine), liposomal bupivacaine (group liposomal), or a mixture of liposomal bupivacaine and plain bupivacaine (group mixture). Primary outcomes included time to the first rescue opioid analgesic and total opioid consumption during the first 72 postoperative hours. Secondary outcomes included pain scores, patient satisfaction, incidence of hemodynamic instability, presence of local anesthetic systemic toxicity, and length of hospital stay., Results: The median [interquartile range] time to first opioid was 51 [28-66] min in group bupivacaine, 63 [44-102] min in group liposomal, and 51 [24-84] min in group mixture (P = 0.20). The median [interquartile range] total opioid consumption in the first 72 postoperative hours was 208 [155-270] mg in group bupivacaine, 203 [153-283] mg in group liposomal, and 202 [116-325] mg in group mixture (P = 0.92). There were no significant differences in secondary outcomes between groups., Conclusions: In this small study at risk of being under-powered, the mixture of liposomal bupivacaine with plain bupivacaine for TAP block did not improve analgesia compared with either liposomal bupivacaine or plain bupivacaine on their own., Trial Registration: www.clinicaltrials.gov (NCT03250507); registered 5 April 2017.

Purpose: Both intravenous dexamethasone and dexmedetomidine prolong the analgesic duration of interscalene blocks (ISB) after arthroscopic shoulder surgery. This study compared their relative effectiveness and the benefit of their use in combination., Methods: This single-centre, double-blinded, parallel three-group superiority trial randomized 198 adult patients undergoing ambulatory arthroscopic shoulder surgery. Patients received preoperative ISB with 30 mL 0.5% bupivacaine and 50 µg dexmedetomidine or 4 mg dexamethasone or both of these agents as intravenous adjuncts. The primary outcome was analgesic block duration. Secondary outcomes included the quality of recovery 15 score (range: 0-150) on day 1 and postoperative neurologic symptoms in the surgical arm., Results: Block durations (n = 195) with dexamethasone (median [range], 24.5 [2.0-339.5] hr) and both adjuncts (24.0 [1.5-157.0] hr) were prolonged compared with dexmedetomidine (16.0 [1.5-154.0] hr). When analyzed by linear regression after an unplanned log transformation because of right-skewed data, the corresponding prolongations of block duration were 59% (95% confidence interval [CI], 28 to 97) and 46% (95% CI, 18 to 80), respectively (both P < 0.001). The combined adjuncts were not superior to dexamethasone alone (-8%; 95% CI, -26 to 14; P = 0.42). Median [IQR] quality of recovery 15 scores (n = 197) were significantly different only between dexamethasone (126 [79-149]) and dexmedetomidine (118.5 [41-150], P = 0.004), but by an amount less than the 8-point minimum clinically important difference., Conclusion: Dexamethasone is superior to dexmedetomidine as an intravenous adjunct for prolongation of bupivacaine-based ISB analgesic duration. There was no additional benefit to using both adjuncts in combination., Trial Registration: www.clinicaltrials.gov (NCT03270033); registered 1 September 2017.

Purpose: This systematic review and network meta-analysis (NMA) compared postoperative analgesic efficacy of transversus abdominis plane (TAP) blocks with that of wound infiltration for Cesarean delivery (CD) without long-acting neuraxial opioid administration., Methods: We sought randomized-controlled trials comparing TAP vs wound infiltration, and inactive control vs either TAP or wound infiltration. Wound infiltration included single-dose infiltration (WI), or continuous infusion via a catheter (WC). The primary outcome was 24 hr opioid consumption. Secondary outcomes included 12 and 24 hr pain scores (resting and movement), time to first analgesia request, incidence of postoperative nausea and vomiting (PONV), maternal sedation, and pruritus. We performed a NMA incorporating both direct and indirect comparisons and reported standardized mean differences and odds ratios with 95% confidence intervals for continuous and dichotomous outcomes., Results: Forty-two studies were included, comprising 2,906 participants. Transversus abdominis plane blocks and WC were associated with significantly lower 24 hr opioid consumption than inactive controls, but there were no significant differences between WI and inactive controls. There was no statistically significant difference in 24 hr opioid consumption between TAP blocks and WC or WI techniques. The network ranking of treatments was TAP block, followed by WC or WI. No significant differences were shown between TAP, WC, and WI groups for 24 hr pain scores, time to first analgesia, PONV, sedation, and pruritus. Quality of evidence was moderate for most of the outcomes assessed., Conclusion: In the absence of long-acting neuraxial opioid after CD, single-dose TAP blocks and WC are effective opioid-sparing strategies.

Purpose: The goal of the present systematic review is to determine the efficacy of the quadratus lumborum block (QLB) in providing postoperative analgesia for abdominal wall and hip surgeries when compared with placebo or other analgesic techniques., Methods: Electronic databases (Medline, Embase, Cochrane Central, and Scopus) were searched for keywords and controlled vocabulary terms related to QLB from their inception to November 2019. The included studies compared ultrasound-guided single-injection QLB to placebo and other analgesic techniques in adult patients., Results: Forty-two randomized-controlled trials provided the data for this systematic review. Eight studies were assessed as high risk of bias in at least one domain. The included studies had significant heterogeneity with regard to the type of surgery, comparator groups, and outcomes measured; therefore, a limited quantitative analysis was undertaken for the comparison of QLB vs no block or placebo in patients undergoing Cesarean delivery only. For Cesarean delivery, the QLB reduced the opioid use by 24.1 (95% confidence interval, 17.3 to 30.9) mg oral morphine equivalents in the first postoperative 24 hr compared with no block or placebo with no difference in pain scores at rest. For other surgical procedures, the pain scores and opioid use were lower in the QLB group when compared with placebo or no regional anesthesia technique. When compared with other regional anesthetic techniques, the analgesic benefit of QLB was marginal., Conclusion: Quadratus lumborum block provided analgesic benefits compared with placebo for use in the abdominal wall and hip surgery, with only marginal benefits compared with other regional analgesic techniques. The identified studies used different variants of QLB in many different surgery types. These findings and conclusions, therefore, should be considered preliminary., Trial Registration: PROSPERO (CRD42018095965); registered 6 June 2018.

Purpose: This pilot study evaluated the feasibility of investigating the effect of the erector spinae plane (ESP) block on the patient-centred outcomes of quality of recovery-15 (QoR-15), and brief pain inventory (BPI) in thoracic and breast surgery patients., Methods: In this randomized-controlled pilot trial, 82 patients undergoing video-assisted thoracoscopic surgery (n = 77) and mastectomy (n = 5) received either continuous ESP block with ropivacaine (ropivacaine group) or the same procedure with 0.9% saline (saline group). All patients received surgical intercostal block (thoracic surgery) or local anesthetic infiltration (breast surgery). Feasibility as the primary outcome was evaluated on recruitment (three patients per week), catheter retention (above 90% at 24 hr), and patient attrition (less than 10%). Secondary outcomes comprised of QoR-15, BPI, and opioid consumption., Results: Recruitment rate was 1.8 patients per week. Catheters were retained in 77 patients (94%) at 24 hr. At three months, five patients were lost to follow-up (6%). At 24 hr compared with baseline, the ropivacaine group had a smaller decline in QoR-15 score (median difference, 14; 95% confidence interval [CI], 2 to 26; P = 0.02) and a smaller increase in BPI global score (median difference, 14; 95% CI, 0 to 24; P = 0.048). There was no difference in opioid consumption (P = 0.08)., Conclusions: In this pilot study, the target recruitment rate was not met, but catheter retention and patient attrition rates were both satisfactory. A definitive trial with QoR-15 as the primary outcome would require 300 study participants., Trial Registration: Australian New Zealand Clinical Trials Registry (ID12618000701224); registered 30 April 2018.

Purpose: Peripheral nerve blocks (PNBs) provide excellent perioperative analgesia but can increase the risk of severe postoperative pain once the block wears off. Poor adherence to discharge instructions may increase this risk. Panda-Nerve Block (Panda) is an app that alerts the patient to assess their PNB, score their pain, and take scheduled pain medication. We assessed the usability and feasibility of Panda for assisting patients after receiving a PNB., Methods: Twenty-nine patients tested Panda in three rounds, for two to seven days, postoperatively to assess and manage their pain and PNB. Feedback was provided via phone interview and the Computer System Usability Questionnaire (CSUQ). Additionally, each user's usage log was analyzed for parameters such as alert response times. Feasibility was determined by alert responses that occurred before the next alert, with a goal of greater than 50%. User adherence was measured as percentage compliance with alerts within one hour; usability and user satisfaction were determined from the CSUQ and interviews., Results: A median [interquartile range (IQR)] of 68 [34-93]% responded before the next alert during the first 48 hr of app use, and 83 [54-92]% responded before the next alert with 87 [75-96]% of these within one hour. There were no significant differences in usage between rounds. Ninety-three percent of patients reported Panda to be easy to use and helpful, and 79% of patients would use Panda again. Critical themes included changes to the layout and appearance, clarification of the language of the PNB check, and requests for dynamic adjustments to the medication schedule based on user responses., Conclusion: Panda-Nerve Block is a feasible method for PNB patients to manage postoperative pain with a high response rate. Future work should include providing two-way communication for patients and clinicians and assessing its effect on pain outcomes., Trial Registration: www.clinicaltrials.gov (NCT03369392); registered 5 December 2017.

Purpose: Post-craniotomy pain is a common clinical issue and its optimal management remains incompletely studied. Utilization of a regional scalp block has the potential advantage of reducing perioperative pain and opioid consumption, thereby facilitating optimal postoperative neurologic assessment. The purpose of this study was to assess the efficacy of regional scalp block on post-craniotomy pain and opioid consumption., Methods: We performed a prospective randomized-controlled trial in adults scheduled to undergo elective supratentorial craniotomy under general anesthesia to assess the efficacy of postoperative bilateral scalp block with 0.5% bupivacaine with 1:200,000 epinephrine compared with placebo on postoperative pain and opioid consumption. The primary outcome was the visual analogue scale (VAS) for pain at 24 hr postoperatively., Results: Eighty-nine patients were enrolled (n = 44 in block group; n = 45 in control group). There was no difference in the mean (standard deviation) VAS score at 24 hr postoperatively between the treatment group and the control group [31.2 (21.4) mm vs 23.0 (19.2) mm, respectively; mean difference, 6.6; 95% confidence interval, -2.3, 15.5; P = 0.15]. There was also no significant difference in postoperative opioid consumption. Distribution of individual VAS score and opioid consumption revealed that postoperative pain was highly variable following craniotomy. Time to hospital discharge was not different between treatment and placebo groups. No adverse events associated with scalp block were identified., Conclusion: These data show that bilateral scalp blocks using bupivacaine with epinephrine did not reduce mean postoperative VAS score or overall opioid consumption at 24 hr nor the time-to-discharge from the postanesthesia care unit or from hospital., Trial Registration: www.ClinicalTrials.gov, NCT00972790; registered 9 September, 2009.

Purpose: Chronic postsurgical pain (CPSP) can occur after elective mid/hindfoot and ankle surgery. Effective treatment approaches to prevent the development of CPSP in this population have not been extensively investigated. The impact of multimodal strategies to prevent CPSP following elective mid/hindfoot surgery is unknown because of both the heterogeneity of acute pain management and the lack of a recognized definition particular to this surgery. This review aimed to identify and evaluate current pain management strategies after elective mid/hindfoot and ankle surgery., Sources: Manual and electronic searches (MEDLINE, Embase, and Cochrane Library) were conducted of literature published between 1990 and July 2017. Comparative studies of adults undergoing elective mid/hindfoot and ankle surgery were included. Two reviewers independently reviewed studies and assessed their methodological quality., Principal Findings: We found seven randomized-controlled trials meeting our inclusion criteria. Interventions focused on regional anesthesia techniques such as continuous popliteal sciatic and femoral nerve blockade. Participants were typically followed up to 48 hr postoperatively. Only one study assessed pain six months following elective mid/hindfoot and ankle surgery., Conclusion: There is an overwhelming lack of evidence regarding CPSP and its management for patients undergoing elective mid/hindfoot and ankle surgery. The lack of a recognized and standard definition of CPSP after this group of surgeries precludes accurate and consistent evaluation.

Purpose: This study examined the concordance between epidural electrical stimulation test (EEST) and local anesthetic (LA) test dose to indicate correct thoracic epidural catheter position. The relationship between the test results and epidural postoperative analgesia was also assessed., Methods: This prospective observational cohort study was done in patients receiving thoracic epidural analgesia for abdominal surgery. After insertion, the epidural catheter was tested using a nerve stimulator to elicit a motor response. The LA test dose was then administered, and sensory block to ice and pinprick was assessed. The primary outcome was the presence/absence of motor response to EEST and sensory block to test dose. Concordance of responses was assessed using kappa statistics, and their predictive power of postoperative epidural analgesia was evaluated., Results: Sixty-eight thoracic epidural catheters were inserted, of which 62 were used perioperatively. The kappa agreement between EEST and LA test dose responses was moderate at 0.42 (95% confidence interval [CI], 0.18 to 0.67). Positive responses to EEST and LA test dose were observed in 62 (100%) and 50 (81%) patients, respectively, while 52 patients (84%) showed adequate analgesia postoperatively. The sensitivity (95% CI) of EEST and LA test dose to predict adequate postoperative epidural analgesia was 1 (0.93 to 1) and 0.79 (0.65 to 0.89), respectively, and the positive predictive values (95% CI) of EEST and LA test dose were 0.84 (0.75 to 0.93) and 0.82 (0.71 to 0.92), respectively., Conclusion: Following thoracic epidural catheter insertion, the responses to the EEST and LA test dose showed "moderate" agreement. The EEST has a higher sensitivity than the LA test dose to predict adequate epidural analgesia following abdominal surgery, however, both tests have a comparable positive predictive value.

Purpose: Severe postoperative pain following spine surgery is a significant cause of morbidity, extended length of facility stay, and marked opioid usage. The erector spinae plane (ESP) block anesthetizes the dorsal rami of spinal nerves that innervate the paraspinal muscles and bony vertebra. We describe the use of low thoracic ESP blocks as part of multimodal analgesia in lumbosacral spine surgery., Clinical Features: We performed bilateral ESP blocks at the T10 or T12 level in six cases of lumbosacral spine surgery: three lumbar decompressions, two sacral laminoplasties, and one coccygectomy. Following induction of general anesthesia, single-injection ESP blocks were performed in three patients while bilateral continuous ESP block catheters were placed in the remaining three. All six patients had minimal postoperative pain and very low postoperative opioid requirements. There was no discernible motor or sensory block in any of the cases and no interference with intraoperative somatosensory evoked potential monitoring used in two of the cases., Conclusions: The ESP block can contribute significantly to a perioperative multimodal opioid-sparing analgesic regimen and enhance recovery after lumbosacral spine surgery.

Background: This randomized trial aimed to evaluate combined infraclavicular-suprascapular blocks (ICB-SSBs) as a diaphragm-sparing alternative to interscalene blocks (ISBs) for arthroscopic shoulder surgery. We hypothesized that ICB-SSB would provide equivalent postoperative analgesia to ISB 30 min after surgery without the risk of hemidiaphragmatic paralysis., Methods: Following research ethics board approval and written informed consent, participants in the ISB group received an ultrasound-guided ISB with 20 mL of levobupivacaine 0.25% and epinephrine 5 µg·mL -1 . In the ICB-SSB group, ultrasound-guided ICB (20 mL) and SSB (10 mL) were carried out using the same local anesthetic. Thirty minutes after the block was performed, a blinded investigator assessed the presence of hemidiaphragmatic paralysis. Subsequently, all patients underwent general anesthesia. Postoperatively, a blinded investigator recorded pain scores at rest at 0.5, 1, 2, 3, 6, 12 and 24 hr. Consumption of intra- and postoperative narcotics was also tabulated., Results: Compared to its ICB-SSB counterpart, the ISB group displayed non-equivalent (i.e., lower) postoperative pain scores at 30 min (difference of the medians, -4; 99% confidence interval [CI], -6 to -3), required less cumulative morphine iv at 24 hr (difference of the means, -6.1 mg; 95% CI, -10.5 to -1.6), and resulted in a higher incidence of hemidiaphragmatic paralysis (18/20 vs 0/20 patients, respectively; P < 0.001). Although postoperative pain scores at one, two, and three hours appeared lower in the ISB group, the upper bounds of the 99% CIs did not exceed the equivalence margin., Conclusion: Compared with ICB-SSB, ISB provided non-equivalent (i.e., lower) postoperative pain scores 30 min after arthroscopic shoulder surgery. Thereafter, postoperative analgesia was comparable between the two groups. Further trials are required to compare ISB with ICB-SSB using a proximal (i.e., costoclavicular) technique for ICB., Trial Registration: www.clinicaltrials.gov , NCT02993939. Registered 12 December 2016.

Purpose: Dexamethasone prolongs the duration of interscalene block, but the benefits of higher doses and perineural vs intravenous administration remain unclear., Methods: This factorial design, double-blinded trial randomized 280 adult patients undergoing ambulatory arthroscopic shoulder surgery at a single centre in a 1:1:1:1 ratio. Patients received ultrasound-guided interscalene block with 30 mL 0.5% bupivacaine and 4 mg or 8 mg dexamethasone by either the perineural or intravenous route. The primary outcome (block duration measured as the time of first pain at the surgical site) and secondary outcomes (adverse effects, postoperative neurologic symptoms) were assessed by telephone. In this superiority trial, the predetermined minimum clinically important difference for comparisons between doses and routes was 3.0 hr., Results: The perineural route significantly prolonged the mean block duration by 2.0 hr (95% confidence interval [CI], 0.4 to 3.5 hr; P = 0.01), but 8 mg of dexamethasone did not significantly prolong the mean block duration compared with 4 mg (1.3 hr; 95% CI, -0.3 to 2.9 hr, P = 0.10), and there was no significant statistical interaction (P = 0.51). The mean (95% CI) block durations, in hours, were 24.0 (22.9 to 25.1), 24.8 (23.2 to 26.3), 25.4 (23.8 to 27.0), and 27.2 (25.2 to 29.3) for intravenous doses of 4 and 8 mg and perineural doses of 4 and 8 mg, respectively. There were no marked differences in side effects between groups. At 14 postoperative days, 57 (20.4%) patients reported neurologic symptoms, including dyspnea and hoarseness. At six months postoperatively, only six (2.1%) patients had residual symptoms, with four (1.4%) patients' symptoms unlikely related to interscalene block., Conclusion: Compared with the intravenous route, perineural dexamethasone prolongs the mean interscalene block duration by a small amount that may or may not be clinically significant, regardless of dose. However, the difference in mean block durations between 8 mg and 4 mg of dexamethasone is highly unlikely to be clinically important, regardless of the administration route., Trial Registration: www.clinicaltrials.gov (NCT02426736). Registered 14 April 2015.

Purpose: Arthroscopic shoulder surgery can be performed with an interscalene brachial plexus block (ISBPB) alone, ISBPB combined with general anesthesia (GA), or GA alone. Postoperative pain is typically managed with opioids; however, both GA and opioids have adverse effects which can delay discharge. This retrospective study compares the efficacy of four methods of anesthesia management for arthroscopic shoulder surgery., Methods: Charts of all patients who underwent shoulder surgery by a single surgeon from 2012-2015 were categorized by analgesic regimen: GA only (n = 177), single-shot ISBPB only (n = 124), or pre- vs postoperative ISBPB combined with GA (ISBPB + GA [n = 72] vs GA + ISBPB [n = 52], respectively). The primary outcome measure was the time to discharge from the postanesthesia care unit (PACU)., Results: Mean (SD) time in the PACU ranged from 70.5 (39.9) min for ISBPB only to 111.2 (56.9) min for GA only. Use of ISBPB in any combination and regardless of timing resulted in significantly reduced PACU time, with a mean drop of 27.2 min (95% confidence interval [CI], 17.3 to 37.2; P < 0.001). The largest mean pairwise difference was between GA only and ISBPB only, with a mean difference of 40.7 min (95% CI, 25.5 to 55.8; P < 0.001). Use of ISBPB also reduced pain upon arrival at the PACU and, in some cases, upon discharge from the PACU (i.e., ISBPB only but not ISBPB + GA compared with GA). An ISBPB (alone or prior to GA) also reduced analgesic requirements., Conclusion: Previously reported benefits of an ISBPB for arthroscopic shoulder surgery are confirmed. Postoperative ISBPBs may also be beneficial for reducing pain and opioid requirements and could be targeted for patients in severe pain upon emergence. A sufficiently powered randomized-controlled trial could determine the relative efficacy, safety, and associated financial implications associated with each method.

Purpose: During cancer surgery, prostaglandin-mediated inflammation may promote and activate micrometastatic disease with a consequent increase in long-term cancer recurrence. Cyclooxygenase-2 inhibitors, known to have anti-proliferative properties, may offset such perioperative perturbation. We investigated the effectiveness of these agents to minimize inflammatory changes during cancer surgery., Methods: Following ethics approval, 32 patients who were to undergo major intracavity cancer surgery were enrolled in this prospective, randomized, clinical trial. The treatment group received 400 mg celecoxib preoperatively followed by five 200 mg 12-hourly doses. The control group received no anti-inflammatory agents. Inflammatory and immunomodulatory end points were measured serially. The primary end points were the measured plasma and urinary prostaglandin E metabolite (PGE M ) levels 48 hours following surgery. Secondary endpoints included interleukin levels, leucocyte profile, and clinical end points., Results: No differences in the 48-hr plasma or urinary PGE M levels were observed between the celecoxib and control groups. Linear mixed modeling, used to accommodate differences in baseline PGE M levels, showed that celecoxib (cf. control) administration lowered plasma PGE M over the entire 48-hr period following surgery (β-coefficient = -0.38 pg.ml -1 ; 95% confidence interval: -0.69 to -0.06; P = 0.021). Celecoxib administration also lowered postoperative pain scores., Discussion: Standard dosing of the cyclooxygenase-2 inhibitor celecoxib slightly reduced perioperative cyclooxygenase activity during cancer surgery. Given cyclooxygenase's role in cancer pathways, we recommend dose-finding studies be undertaken before prospective clinical trials are conducted testing the currently unsubstantiated hypothesis that perioperative anti-inflammatory administration improves long-term cancer outcomes. This trial was registered at: Australian New Zealand Clinical Trial Registry: ACTRN12615000041550; www.anzctr.org.au.

Background: Although intravenous dexamethasone prolongs the analgesic duration of interscalene brachial plexus block, it is uncertain whether this effect can be observed using lower doses of dexamethasone. This study evaluated the impact of intravenous dexamethasone (4 mg and 10 mg) on the analgesic duration of single-shot interscalene block after arthroscopic shoulder surgery. We hypothesized that both doses would prolong the analgesic duration compared with placebo., Methods: This was a prospective double-blind randomized placebo-controlled study in patients undergoing elective arthroscopic shoulder surgery under regional anesthesia with a single-shot interscalene block (0.5% ropivacaine 20 mL). Patients received dexamethasone 4 mg (D4), dexamethasone 10 mg (D10), or a placebo (normal saline [NS]) intravenously at the time of block completion. The primary outcome was the duration of analgesia, defined as the time from the onset of sensory blockade to the first analgesic request. The primary outcome was first analyzed with a Kruskal-Wallis test and then with a Mann-Whitney test for pairwise between-group comparison., Results: Sixty-nine patients completed the study. The median [interquartile range] duration of analgesia was significantly different between the three groups (D4, 19.7 [16.9-23.3] hr; D10, 19.1 [11.5-22.8] hr; and NS, 11.8 [9.3-14.0] hr; P = 0.001). This difference was statistically significant for D4 and D10 compared with placebo (median difference [MD], 7.8 hr; 95% confidence interval [CI], 4.6 to 11.1 hr; P < 0.001; and MD, 7.4 hr; 95% CI, 4.2 to 10.5 hr; P = 0.001, respectively) but not for D4 compared with D10 (MD, 0.5 hr; 95% CI, -2.8 to 3.7 hr; P = 0.38)., Conclusions: Low doses of intravenous dexamethasone (4 mg and 10 mg) significantly prolong the analgesic duration of interscalene block. This trial was registered at ClinicalTrials.gov (NCT02412657).

Background: It remains unclear whether the opioid-sparing effects of dexmedetomidine seen in patients undergoing general anesthesia are reproducible in patients undergoing spinal anesthesia. We hypothesized that the administration of intravenous dexmedetomidine for sedation during total knee arthroplasty under spinal anesthesia would decrease postoperative morphine consumption in the first 24 hr following surgery., Methods: We conducted this prospective double-blind randomized-controlled trial in 40 patients (American Society of Anesthesiologists physical status I-III) undergoing total knee arthroplasty with a standardized spinal anesthetic. Patients were randomized to receive either a dexmedetomidine loading dose of 0.5 µg·kg(-1) over ten minutes, followed by an infusion of 0.5 µg·kg·hr(-1) for the duration of the surgery, or a normal saline loading dose and an infusion of an equivalent volume. The primary outcome was the consumption of morphine delivered via patient-controlled analgesia in the first 24 hr following surgery., Results: The mean (SD) cumulative morphine at 24 hr in the dexmedetomidine group was 29.2 (11.2) mg compared with 61.2 (17.2) mg in the placebo group (mean difference, 32.0 mg; 95% confidence interval, 22.7 to 41.2; P < 0.001). In the dexmedetomidine group, there was a delay in the time to first analgesic request (P = 0.003) and a reduction in the mean morphine use at six and 12 hr following surgery (both P < 0.001)., Conclusions: Dexmedetomidine was associated with a significant decrease in morphine use in the first 24 hr following total knee arthroplasty. Our study shows that an intraoperative infusion of dexmedetomidine for sedation in patients receiving spinal anesthesia can produce postoperative analgesic effects. This offers another potential adjunct in the multimodal pain management of these patients. This trial was registered at ClinicalTrials.gov (identifier NCT02026141).