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Background: As a fascial plane block technique, further exploration is needed to determine the safety and efficacy of a peri-capsular nerve group (PENG) block in elderly patients with intertrochanteric femur fractures. We aimed to evaluate whether opioid consumption during a PENG block is better than a conventional opioid-based program for postoperative pain management after proximal femoral nail anti-rotation (PFNA)., Methods: We conducted a prospective, randomized, controlled trial comparing the efficacy of the PENG block with the control group for elderly patients undergoing primary PFNA under general anesthesia. The primary outcome was the cumulative administration of sufentanil during the first 48 h after surgery., Results: 110 participants (55 in each group) were included in the analysis. Cumulative Sufentanil consumption between the PENG group and the control group at 48 h was 132.6 ± 12.3 vs. 141.0 ± 15.3, with a difference of -8.4; 95% CI, -13.6 to -3.1, P = 0.002. Sufentanil consumption at 24 h was 78.3 ± 6.1 vs. 94.0 ± 10.2, with a difference of -15.7; 95% CI, -18.9 to -12.5, P < 0.001. There were statistical differences in the visual analogue scale score trajectories between the two groups at 48 h postoperatively (P < 0.001). The median time to first remedial analgesia was lower in the PENG block group than in the control group (P < 0.001). However, there was no difference in the time to first standing., Conclusion: Incorporating the PENG block into a multimodal analgesia regimen can decrease opioid consumption among elderly patients undergoing PFNA under general anesthesia., Trial Registration: The study was registered in the Chinese Clinical Trial Registry (ChiCTR2100054290, principal investigator: Xiao-dan, Wu, 13/12/2021)., Competing Interests: Declarations. Ethics approval and consent to participate: The study was approved by the institutional review board of Fujian Provincial Hospital (April 30, 2021; K2021-04–080) and was registered in the Chinese Clinical Trial Registry (ChiCTR2100054290) on December 13, 2021. This study followed the CONSORT guidelines and Declarations of Helsinki. Written informed consent was obtained from all participants in this study. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Background: Erector spinae plane block (ESPB) is a promising technique for effective analgesia. It is still uncertain if ESPB offers the same opioid-sparing effect as thoracic paravertebral block (PVB) in midline incision for upper abdominal surgery., Methods: The study is a prospective, bi-center, randomized, controlled, non-inferior trial. One hundred fifty-eight patients scheduled for upper abdominal surgery will be randomly assigned to receive bilateral ESPB or PVB before surgery. The primary outcome will be the equivalent cumulative analgesia dosage of sufentanil during the surgery, which is defined as the total dosage of sufentanil from anesthesia induction to tracheal extubation. The main secondary outcomes include postoperative complications and the quality of recovery-15 score at 24 h, 48 h, and 30 days after surgery., Discussion: This study will assess the opioid-sparing efficacy of ESPB and PVB, complications, and the quality of recovery of two blocks., Trial Registration: ChiCTR2300073030 ( https://www.chictr.org.cn/ ). Registered on 30 June 2023., Competing Interests: Declarations Ethics approval and consent to participate {24} This manuscript reported a study protocol involving human participants and human data. The institutional Ethics Committee of Changhai Hospital of Shanghai (CHEC2023-135) and Public Health Clinical Center of Shanghai(2023-S079-02) approved this registered trial. This trial was registered on the Clinical Trial Registry of China (Registration No: ChiCTR2300073030, June 30, 2023.). Written informed consent will be obtained from all the participants. Results will be disseminated via an international peer-reviewed publication. Consent for publication {32} Not applicable. Competing interests {28} The authors declare that they have no competing interests., (© 2024. The Author(s).)

Background: Catheter-related bladder discomfort (CRBD) and pain commonly arises postoperatively in patients who undergo intra-operative urinary catheterization. The study aims to demonstrate the effectiveness of intravenous lidocaine to prevent CRBD and postoperative pain in complex lumbar spinal surgery., Methods: Eighty male patients, aged 20-79 years, scheduled for elective fusion spine surgery at least two levels were randomly assigned to receive either intravenous lidocaine (1.5 mg/kg followed by 2 mg/kg/h) (Group L) or a parallel volume of normal saline (Group C). The primary outcome was incidence of moderate to severe CRBD in a postanesthetic care unit (PACU) between the two groups. Secondary outcomes included postoperative pain, 24-hour post operative opioid requirement, mild and moderate to severe CRBD at 1, 2, 6 and 24 h postoperatively, patient satisfaction on Global Perceived Effect Scale (GPES), and the adverse effects of lidocaine and surgical complications., Results: Group L showed a significantly lower incidence of moderate-to-severe CRBD compared to Group C in the PACU (P = 0.002) and at 1 h postoperatively (P = 0.039). Additionally, Group L experienced a significantly lower average pain scores compared to Group C at all time points (P < 0.001, P < 0.001, P = 0.001, P < 0.001 and P < 0.001 at 0, 1, 2, 6 and 24 h, respectively) and demonstrated a significantly reduced postoperative morphine requirement across all time intervals (P < 0.05). Group L also reported significantly higher satisfaction on GPES compared to group C (P < 0.001). No adverse outcome was observed in either group., Conclusion: Intravenous lidocaine administration significantly reduced the incidence of moderate-to-severe CRBD at PACU and at 1 h postoperatively. Additionally, its use in complex spine surgery led to reductions in postoperative pain, opioid requirement, and improved patient satisfaction, without any observed side effects., Competing Interests: Declarations Ethics approval and consent to participate The study was approved by the Institutional Review Board of the Royal Thai Army Medical Department (Code: S058h/64), with the approval granted on 24 January 2022. Consent to participate is provided in the attached file. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Background: While the pericapsular nerve group (PENG) block has become increasingly popular for managing pain after hip surgery, its efficacy remains controversial., Methods: We systematically searched Pubmed, Web of Science, Embase, and the Cochrane Library for randomized controlled trials to assess current evidence about the efficacy of the PENG block. Patients who received PENG block were compared to those who received sham/no block in terms of opioid consumption and pain within 24h after surgery, time to first opioid requirement, functional recovery, risk of nausea and vomiting, and patient dissatisfaction. The quality of evidence was assessed using the "Grading of Recommendations Assessment, Development and Evaluation" (GRADE) system., Results: We meta-analyzed six trials involving 416 patients who received preoperative PENG block and 415 who received sham/no block. Patients did not receive any other type of multimodal analgesia. Within 24 h after hip surgery, PENG block significantly reduced postoperative opioid consumption (MD = -12.03, 95% CI: -21.47 to -2.59, P < 0.01, I2 = 97%), particularly in subpopulations undergoing hip replacement, hip fracture, or who had spinal anesthesia, and it significantly decreased dynamic pain scores, but not static scores, without increasing risk of nausea or vomiting or patient dissatisfaction. Individual studies suggested that the PENG block can prolong the time to the first opioid requirement and can improve functional recovery. Most meta-analyses provided evidence of moderate quality according to the GRADE system., Conclusions: The available evidence indicates that preoperative PENG block can significantly decrease opioid consumption and pain early after hip surgery, and it may also promote early functional rehabilitation. However, the limited number of included studies and sample size make it difficult to draw firm conclusions. The decision on whether to apply the PENG block should take into account the patient's age and the type of surgery and anesthesia., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Hu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Effective postoperative pain management is essential to the patient's recovery. The use of opioids as the primary line of pain treatment has been known to increase rates of length of stay, pulmonary complications, paralytic ileus, and nausea and vomiting. Therefore, guidelines strongly recommend alternative paths to reduce opioid consumption through multimodal analgesia, and the transversus abdominis plane block(USG-TAP) has been considered to be one of these optimistic alternatives. A comprehensive systematic search was conducted in four databases until April 2024. We only considered for this analysis randomized controlled trials that assessed the USG-TAP as part of multimodal anesthesia in patients undergoing laparoscopic bariatric surgery. Eleven studies comprising 789 patients were included in the meta-analysis. Our results showed a significant decrease in opioid consumption after the first 24 h of surgery (MD - 32.02 mg; 95% IC - 51.33, - 12.71; p < 0.01) and fewer patients required extra-dose of opioid (OR 0.20; 95% IC 0.07, 0.62; p < 0.01). The pain score showed to be also improved with the TAP block (MD - 0.69; 95% IC - 1.32, - 0.07; p = 0.03). No difference concerning time to deambulate, nausea and vomiting, and time of surgery was observed among the studies. This study reinforces the benefits of the use of USG-TAP block as part of multimodal analgesia in patients undergoing laparoscopic bariatric surgery., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Metabolic bariatric surgery (MBS) advocates multimodal analgesia, discouraging opioid use to minimize side effects, such as nausea and vomiting, during postoperative pain management for quicker recovery. Combining erector spinae plane block (ESPB) with multimodal analgesia aims to reduce opioid consumption, improving postoperative recovery. This study aimed to compare morphine consumption between patients with severe obesity undergoing laparoscopic MBS with and without ESPB., Methods: This study enrolled 91 patients with severe obesity who underwent laparoscopic MBS involving either sleeve gastrectomy or Roux-en-Y gastric bypass. Of these, 63 patients were included in this study. The participants were randomly allocated to either the intervention group, which received an ESPB before the standard anesthesia protocol, or the control group, which did not receive pre-anesthesia block. The primary outcome measured was 24-h morphine consumption via a patient-controlled analgesia machine. Secondary outcomes included patients' satisfaction, postoperative numerical rating score, changes over time, and quality of recovery (QoR) using the Thai QoR-35 score., Results: We found no statistically significant difference in morphine consumption between the intervention group and the control group. Furthermore, our analysis revealed no significant between-group differences in patient satisfaction, postoperative numeric rating score, or QoR across all five aspects evaluated using the Thai QoR-35 score., Conclusions: ESPB did not reduce morphine consumption or QoR following laparoscopic MBS. Further studies are required to confirm and identify the reasons for the ineffectiveness of ESPB., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The relationship between perioperative temperatures and postoperative pain is unknown. The present study investigated the relationship of intraoperative hypothermia and perioperative opioid requirements after immediate implant-based breast reconstruction., Methods: A retrospective chart review was conducted on patients undergoing immediate implant-based breast reconstruction from 2019-2023. Patients were classified into the hypothermic group (majority of procedure <36.0 °C) or normothermic group (majority of procedure ≥36.0 °C). Cumulative inpatient opioid requirements (morphine milli-equivalents [MMEs]) and frequency of patients requiring "high-dose opioids" (≥100 MMEs) were collected and compared between the groups., Results: In total, 536 patients (835 breasts) were included, among whom 135 (25.1%) were hypothermic. The hypothermic group had lower mean intraoperative (88.4 vs. 99.1 MMEs, P = 0.007) and postoperative (45.6 vs. 56.8 MMEs, P = 0.006) than the normothermic group. Mean (B = 14.6, P = 0.004) and nadir (B = 10.4, P = 0.038) intraoperative temperatures directly predicted higher opioid requirements while higher percentages of the procedure time spent under 36 °C (B = -27.6, P = 0.004) predicted lower opioid requirements. The hypothermic group was associated with 66% decreased odds of requiring high-dose opioids after adjusting for differences in patient and operative characteristics (P = 0.007)., Conclusion: Hypothermia is associated with decreased perioperative opioid requirements. Future studies should further investigate ideal temperature thresholds for warming protocols to minimize postoperative pain., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: The nociception level (NOL) index is a quantitative parameter derived from physiological signals to measure intraoperative nociception. The aim of this systematic review and meta-analysis was to evaluate if NOL monitoring reduces intraoperative opioid use compared to conventional therapy (opioid administered at clinician discretion)., Methods: This meta-analysis comprises randomized clinical trials comparing NOL-guided opioid administration to conventional therapy in adult patients undergoing any type of surgery. A systematic search of PubMed, Scopus, and CENTRAL databases was conducted. The primary outcome was intraoperative opioid consumption and the effect estimate of the NOL index was measured using the standardized mean difference (SMD) where 0.20 is considered a small and 0.80 a large effect size. A random-effects model with Hartung-Knapp-Sidik-Jonkman adjustment was applied to estimate the treatment effect. Heterogeneity was explored clinically and statistically (using the inconsistency I ² statistic, prediction intervals, and influence analysis). The quality (certainty) of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) guidelines methodology., Results: This review comprised 9 trials (519 patients). The intraoperative opioid SMD (NOL monitoring versus conventional therapy) was -0.26 (95% confidence interval [CI], -0.82 to 0.30; P = .31; low certainty of evidence). We observed substantial clinical (intraoperative opioid regimens) and statistical heterogeneity with the I ² statistic being 86% (95% CI, 75%-92%). The prediction interval was between -1.95 and 1.42 indicating where the SMD between NOL and conventional therapy would lie if a similar study were conducted in the future., Conclusions: This meta-analysis does not provide evidence supporting the role of NOL monitoring in reducing intraoperative opioid consumption., Competing Interests: Conflicts of Interest, Funding: Please see DISCLOSURES at the end of this article., (Copyright © 2024 International Anesthesia Research Society.)

Background: Opioid analgesic use before total hip or knee arthroplasty has been associated with worse postoperative outcomes. This pilot study aimed to examine the feasibility of a telehealth-based pharmacist-partnered opioid tapering intervention before elective primary hip or knee arthroplasty and its potential effectiveness compared with usual care., Methods: This study was conducted at seven hospitals in New South Wales, Australia. Eligible patients were those aged ≥ 18 years, scheduled to undergo primary hip or knee arthroplasty for osteoarthritis and taking opioid analgesics pre-operatively. The intervention group participated in an opioid tapering telehealth service, a partnership between a pharmacist and general practitioner, for 3 months pre-operatively up to the day of surgery, while the control group received usual care. The primary outcomes of the study were to investigate the feasibility of the intervention (i.e. adherence to treatment) and potential effectiveness in decreasing baseline daily opioid dose by > 50% before surgery., Results: Between December 2021 and June 2023, 70 patients were recruited and assigned randomly to the intervention group (n = 35) or control group (n = 35). Baseline characteristics were similar between groups. Thirty patients in each group completed their allocated treatment. All patients allocated to the intervention group completed at least one appointment with a pharmacist, with the median (IQR [range]) being 2 (1-4 [1-6]) appointments. The number of patients who successfully decreased their baseline daily opioid dose by ≥ 50% before surgery was 27/30 in the intervention group compared with 5/30 in the usual care group (p < 0.001)., Conclusions: The findings of this pilot study support the feasibility of a telehealth-delivered, pharmacist-partnered opioid tapering service for patients scheduled for primary hip or knee arthroplasty. A broader multicentre study to examine the effectiveness of this intervention on clinical outcomes is warranted., (© 2024 The Author(s). Anaesthesia published by John Wiley & Sons Ltd on behalf of Association of Anaesthetists.)

Background: Fascial plane blocks (FPBs) are widely used for abdominal surgery with the assumption that liposomal bupivacaine (LB) is more effective than standard bupivacaine (SB)., Methods: This was a single-institution retrospective cohort study of patients administered FPBs with LB or SB ​+ ​admixtures (dexamethasone/dexmedetomidine) for open abdominal cancer surgery. Propensity score matching generated a 2:1 (LB:SB) matched cohort. Opioid use (mg oral morphine equivalents, OME) and severe pain (≥3 pain scores ≥7 in a 24-h period) were compared., Results: Opioid use was >150 ​mg OME in 19.9 ​% (29/146) LB and 16.4 ​% (12/73) SB patients (p ​= ​0.586). Severe pain was experienced by 44 ​% (64/146) LB and 53 ​% (39/73) SB patients (p ​= ​0.198). On multivariable analysis, SB vs LB choice was not associated with high opioid volume >150 ​mg or severe pain., Conclusions: FPBs with standard bupivacaine were not associated with higher 72-h opioid use or more severe pain compared to liposomal bupivacaine., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Breast cancer is the most frequent type of cancer and the second leading cause of cancer-related mortality in women. Mastectomies remain a key component of the treatment of non-metastatic breast cancer, and strategies to treat acute postoperative pain, a complication affecting nearly all patients undergoing surgery, continues to be an important clinical challenge. This study aimed to determine the impact of intraoperative methadone administration compared to conventional short-acting opioids on pain-related perioperative outcomes in women undergoing a mastectomy., Methods: This single-center retrospective study included adult women undergoing total mastectomy. The primary outcome of this study was postoperative pain intensity on day 1 after surgery. Secondary outcomes included perioperative opioid consumption, perioperative non-opioid analgesics use, duration of surgery and anesthesia, time to extubation, pain intensity in the postanesthesia care unit (PACU), anti-emetic use in PACU, and length of stay in hospital. We used the propensity score-based nearest matching with a 1:3 ratio to balance the patient baseline characteristics., Results: 133 patients received methadone, and 2192 patients were treated with short-acting opioids. The analysis demonstrated that methadone was associated with significantly lower intraoperative and postoperative opioid consumption as measured by oral morphine equivalents and lower average pain intensity scores in the postanesthesia care unit. Moreover, methadone was also shown to reduce the use of non-opioid analgesia during surgery., Conclusion: Our study suggests that the unique pharmacological properties of methadone, including a short onset of action when given intravenously, long-acting pharmacokinetics, and multimodal effects, are associated with better acute pain management after a total mastectomy., Competing Interests: Declaration of competing interest Evan D. Kharasch reports financial support was provided by National Institutes of Health. Peter F. Thall and Ruitao Lin report financial support to NIH/NCI under award number P30CA016672. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: Urologic surgery involving placement of an indwelling ureteral and/or urethral drain can be associated with significant catheter-related bladder discomfort causing increased postoperative morbidity and opioid medication use. We sought to assess if a single dose of oxybutynin given preoperatively reduces immediate postoperative opioid use in common pediatric urology surgeries., Materials and Methods: This single-institution retrospective study identified pediatric patients who underwent surgery on the urinary tract with concomitant placement of a urethral and/or ureteral drain. Patients were given a single weight-based dose of oral oxybutynin in the preoperative area prior to surgery. The primary outcome was receipt of postoperative opioid medication. Multivariable regression analyses were used to assess variables associated with postoperative opioid use., Results: A total of 134 patients were included in our final study population with 42 receiving oxybutynin and 92 who did not. There was no statistical difference between the groups in terms of age, procedure type, anesthesia block, postoperative drain, or intraoperative morphine milligram equivalents per kilogram. Patients who received oxybutynin preoperatively had a decrease in postoperative opioid use (19%) compared to those who did not receive oxybutynin (47%). On multivariable logistic regression analysis, preoperative oxybutynin was associated with a 77% reduced risk of receiving postoperative opioid (odds ratio 0.23, [95% CI 0.09-0.56], P < .001)., Conclusions: For pediatric patients with an indwelling urinary drain after urologic surgery, a single preoperative dose of oxybutynin was significantly associated with lower postoperative utilization of opioids. This relatively low-risk intervention can be easily implemented.

Objective: The impact of a transversus abdominis plane (TAP) block in patients undergoing cesarean section requires further evaluation. The aim of this study was to compare postoperative pain scores and opioid use in cesarean surgery patients undergoing either a TAP block and scheduled multimodal pain management (SMPM) or SMPM alone., Methods: In this retrospective, dual cohort study, cesarean surgery patients underwent neuraxial anesthesia and a TAP block (SMPM/TAP) or SMPM; the TAP block incorporated ropivacaine (20-30 mL) administered bilaterally. The group analyses involved a comparison of postoperative pain scores using the visual analog scale and opioid consumption at 24 and 24-48 h., Results: There were 94 (52.8%) patients in the SMPM/TAP group and 84 (47.2%) subjects in the SMPM alone group. At 24 h postoperatively, the SMPM/TAP group exhibited significantly lower pain scores (4.07 vs 4.54) than the SMPM group (P < 0.001) and reduced opioid consumption (2.29 vs 3.28 mg; P < 0.001). However, at 24-48 h, the SMPM group demonstrated lower pain scores (5.46 vs 5.98) compared to the SMPM/TAP group (P < 0.001) and reduced opioid consumption (8.75 vs 10.21 mg; P < 0.001); overall opioid consumption was higher (12.50 vs 12.02 mg) in the SMPM/TAP group (P < 0.001)., Conclusion: The TAP block improved cesarean surgery patients' pain scores and reduced opioid consumption at 24 h postoperatively but the effect of the TAP block was ephemeral as the SMPM/TAP group exhibited inferior pain scores and greater opioid consumption compared to the SMPM group at 24-48 h postoperatively., (© 2024 International Federation of Gynecology and Obstetrics.)

Objectives: The opioid crisis has prompted consideration of analgesic prescriptions. This study explored the value of preoperative acetaminophen for pain control following microsuspension laryngoscopy (MSL) and compared the results with a previous study of pain and opioid use following MSL (Tsang et al.)., Methods: A prospective open-label clinical trial was conducted in patients undergoing MSL. All patients were administered preoperative acetaminophen. Short-form McGill Pain Questionnaire (SF-MPQ), pain visual analogue scale (VAS), and present pain intensity (PPI) scores were collected preoperatively and on postoperative days (PODs) 1, 3, 7, and 14. Statistical analysis identified variables associated with opioid use or increased pain scores, and compared outcomes with Tsang et al. RESULTS: Eighty-nine patients were included (mean age 52.8 ± 17.3 years, 40 males). All patients received preoperative 1 g acetaminophen (77 (86.5%) orally) with no adverse effects. On POD1, opioid usage was 10%. Median [IQR] pain scores were 5 [2-11], 21 [12.3-56.8], and 3 [2-3.3] on SF-MPQ, VAS, and PPI, respectively. Post-Anesthesia Care Unit (PACU) opioid requirements significantly correlated with POD1 opioid consumption (τb = 0.214; p ≤ 0.05), and significant associations with PACU opioid administration were found for total anesthesia time (OR (95%CI) = 1.271 (1.043-1.548), p = 0.017) and total laryngoscope suspension time (OR (95%CI) = 0.791 (0.651-0.962, p = 0.019)). This cohort demonstrated reduced opioid usage on POD1 compared with Tsang et al (23%)., Conclusions: Preoperative acetaminophen is a safe intervention, resulting in decreased postoperative opioid use following MSL. Anesthesia time correlated with need for postoperative opioids., Level of Evidence: 4 Laryngoscope, 134:4625-4635, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Enhanced recovery after surgery (ERAS) pathways utilize multimodal analgesia. In pathways already utilizing incisional injection of liposomal bupivacaine (ILB), we assessed the benefit of adding intrathecal opioid analgesia (ITA)., Methods: In this randomized controlled non-inferiority trial in patients undergoing laparotomy for gynecologic malignancy, we allocated patients 1:1 to ILB alone versus ITA + ILB with 150 μg intrathecal hydromorphone. The primary endpoint was the Overall Benefit of Analgesia Score (OBAS) at 24 h following surgery. Secondary endpoints included pain scores, intravenous opioid use, and cost of care., Results: Demographic and surgical factors were balanced for 105 patients. For the primary endpoint, ILB alone was non-inferior to ITA + ILB (median OBAS at 24 h of 4 vs 4; p = 0.70). We observed a significant reduction in the need for intravenous opioids (26% vs 71%; p < 0.001) and total opioid requirements (median 7.5 vs 39.3 mg morphine equivalents, p < 0.001) in the first 24 h. Clinically relevant improvements in pain scores were identified in the first 16 h after surgery favoring ITA + ILB. Total cost of the index episode, pharmacy costs, and costs at 30 days were not statistically different., Conclusions: Using OBAS as the primary endpoint, ILB alone was non-inferior to ITA + ILB. However, important cost-neutral benefits for ITA + ILB in the first 24 h post-operatively included lower pain scores and reduced need for intravenous opioids. These early, incremental benefits of adding ITA to ERAS bundles already utilizing ILB should be considered to optimize immediate post-operative pain., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To compare perioperative opioid consumption in dogs undergoing pelvic limb surgeries and receiving a lumbosacral plexus block by combining a lumbar [lateral pre-iliac (LPI)] block with a lumbosacral trunk [i.e. parasacral (PS group) or greater ischiatic notch plane (GIN group)] block. Study design Retrospective, descriptive, exploratory, noninferiority cohort study., Methods: Medical records of 37 client-owned dogs were analyzed. Intraoperative (primary outcome) and postoperative (24 hours) opioid use, 24 hour cumulative pain scores and prevalence of complications were compared between the two groups. Opioid use was quantified in morphine equivalents (ME, mg kg -1 ). The noninferiority limit for intraoperative opioid consumption was set at 0.05 ME kg -1 hour -1 . Demographic data, procedure duration, surgery type and perioperative dexmedetomidine and ketamine use were also collected. A t-test or Wilcoxon rank-sum test, a Fisher's exact test and multivariable linear regression were used. Significance was set at p < 0.05., Results: The GIN and PS groups comprised 17 and 20 dogs, respectively. Total intraoperative ME consumption was 0.17 (0.11-0.21) and 0.22 (0.16-0.30) mg kg -1 hour -1 for the GIN and PS groups, respectively (p = 0.077). The noninferiority analysis adjusted by surgery type and body mass revealed that the mean difference between the groups (GIN - PS) was -0.039 (95% CI -0.11-0.03, p = 0.247) ME mg kg -1 hour -1 , indicating that the GIN group was not inferior to the PS group regarding intraoperative ME consumption. Dexmedetomidine and ketamine use, postoperative ME consumption and pain scores were similar between groups., Conclusions and Clinical Relevance: This retrospective study and preliminary observations support the clinical use of the GIN plane block, demonstrating its noninferiority to the PS block when combined with the LPI block for multimodal perioperative analgesia in dogs undergoing pelvic limb surgeries., (Copyright © 2024 Association of Veterinary Anaesthetists and American College of Veterinary Anesthesia and Analgesia. Published by Elsevier Ltd. All rights reserved.)

Background: Erector spinae plane block (ESPB) is a novel analgesic technique that can reduce post-operative pain and postoperative opioid consumption in laparoscopic surgeries., Methods: We searched PubMed, Scopus, and Web of Science on November 17th, 2023 for clinical trials comparing ESPB with other analgesic techniques or placebo for laparoscopic surgeries. We meta-analyzed post-operative pain at rest, postoperative opioid consumption, time to first rescue analgesic request, and postoperative nausea and vomiting using a random effects model., Results: ESPB significantly reduced opioid consumption compared to placebo (SMD, (95CI), p-value; -1.837, (-2.331, -1.343), < 0.001) and also compared to transversus abdominis plane block (TAPB) (SMD, (95CI), p-value; -1.351, (-1.815, -0.887), < 0.001) but not quadratus lumborum plane block (QLB) (SMD, (95CI), p-value; 0.022, (-0.241, 0.286), 0.869). ESPB also significantly reduced participant-reported pain scores at rest at 24h post-operation compared to placebo (SMD, (95CI), p-value; -0.612, (-0.797, -0.428), < 0.001) and TAPB (SMD, (95CI), p-value; -0.465, (-0.767, -0.162), < 0.001), however, there was a significant increase in pain score compared to QLB (SMD, (95CI), p-value; 1.025, 0.156, 1.894), 0.021). A statistically significant increase in time to first rescue analgesic in ESPB groups compared to placebo and TAPB groups was observed in our meta-analysis. There was a lower post-operative nausea and vomiting rate in the ESPB groups compared to placebo groups, yet a comparable rate with QLB and TAPB groups was observed in the meta-analysis., Conclusion: ESPB is an effective and safe analgesic technique for managing post-operative pain and opioid consumption in laparoscopic surgeries compared to placebo, reducing postoperative nausea or vomiting as well. Compared to other techniques, ESPB has a similar efficacy to QLB, except for the pain score at 24 h post-operation, but appears to be superior to TAPB as an analgesic technique in laparoscopic surgeries, with a similar safety profile., Trial Registration: Prospero registration ID: CRD42024508363. Link: https://www.crd.york.ac.uk/PROSPERO/#recordDetails., (© 2024. The Author(s).)

With the growing adoption of robotic techniques in gynecologic surgery, the advantages of minimally invasive procedures over traditional open surgery, such as reduced postoperative pain and quicker recovery, are clear. Yet, establishing an effective multimodal analgesic regimen remains a challenge. This retrospective study from a tertiary care center aimed to assess the analgesic efficacy of the rectus sheath block (RSB) on postoperative pain and opioid consumption after robotic gynecologic surgery. Between June 2022 and March 2023, 20 patients who underwent robotic gynecologic surgery were evaluated. Key parameters included postoperative visual analog scale scores, opioid consumption, and postoperative nausea/vomiting instances. Anesthesia protocols were standardized, with postsurgical pain management involving RSB and a patient-controlled analgesia device filled with morphine. Patients showed an average morphine intake of 8.2 ± 5.09 mg over the initial 24 hours postsurgery. During mobilization, average pain scores were consistently low, with no correlation identified between opioid consumption and age or body mass index. 40% of patients reported postoperative nausea on the first day, and no complications linked to the RSB were observed. The study underlines the potential of integrating RSB in a multimodal analgesic regimen after robotic gynecologic surgery. Its application may lead to reduced opioid consumption and more efficient postoperative pain management. Further randomized controlled trials are recommended to validate these findings., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Effective postoperative pain management after total abdominal hysterectomy is crucial for patient recovery and satisfaction. This study compared the efficacy of the erector spinae plane block (ESPB) and quadratus lumborum block (QLB) in reducing postoperative opioid consumption and pain in patients with total abdominal hysterectomy., Methods: In this prospective, randomized controlled trial, 90 patients undergoing total abdominal hysterectomy were divided into 3 groups: ESPB, QLB, and control. The primary outcome was postoperative opioid consumption. Secondary outcomes included pain scores assessed by the visual analog scale at predetermined times and the incidence of postoperative nausea and vomiting. Statistical significance was determined using analysis of variance, the Mann-Whitney U test, and the Kruskal-Wallis test., Results: The ESPB and QLB groups showed a significant reduction in postoperative opioid consumption compared with the control group (P < .001 for both comparisons). Pain scores were significantly lower in the ESPB and QLB groups than in the control group at 2, 6, and 24 hours postoperatively (P < .001 at each time point). The incidence of postoperative nausea and vomiting was lower in the ESPB and QLB groups than that in the control group; however, this difference was not statistically significant (P = .029). No significant differences were observed in opioid consumption or pain scores between the 2 groups., Conclusion: Both the erector spinae plane and quadratus lumborum blocks effectively reduced postoperative opioid consumption and pain in patients with total abdominal hysterectomy. These techniques offer a promising approach for postoperative pain management, potentially reducing the need for opioids., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: This study compared the efficacy of ultrasound-guided erector spinae plane block (ESPB) and wound infiltration (WI) for postoperative analgesia in patients who underwent lumbar spinal surgery with instrumentation., Methods: In this randomized controlled trial, 80 patients were divided into two groups: ESPB (n = 40) and WI (n = 40). Postoperative pain intensity was assessed via the visual analog scale (VAS) at multiple time points within 24 h. Additionally, opioid consumption, time to first rescue analgesia, incidence of postoperative nausea and vomiting (PONV), and patient satisfaction were evaluated., Results: Both ESPB and WI provided effective postoperative pain management, with no significant differences in VAS scores. However, the ESPB group demonstrated a significantly longer duration of analgesia, a shorter time to first rescue analgesia, and lower total tramadol consumption (50 ± 60 mg vs. 100 ± 75 mg; p = 0.010) than did the WI group. Furthermore, a trend toward reduced PONV incidence was observed in the ESPB group, likely due to its opioid-sparing effect., Conclusion: While both ESPB and WI provided effective postoperative pain management, ESPB demonstrated a distinct advantage by offering a longer duration of analgesia and significantly reducing opioid consumption. These findings suggest that ESPB is more effective than WI for postoperative analgesia in lumbar spinal surgeries, providing prolonged pain relief and improving patient outcomes. Further studies are warranted to explore its long-term benefits and cost-effectiveness., Trial Registration: ClinicalTrials.govPRS: NCT06567964 Date: 08/21/2024 Retrospectively registered., (© 2024. The Author(s).)

Background: Finding the balance of good postoperative analgesia while facilitiating mobility is important for a safe and satisfactory patient experience during Total Knee Arthroplasty (TKA). This study aimed to compare the efficacy of intrathecal morphine, adductor canal block, and their combination in optimizing pain management and postoperative recovery in TKA patients. This retrospective analysis of prospectively collected data evaluated postoperative pain scores, time to mobilisation, and length of hospital stay., Methods: 1006 consecutive patients undergoing elective TKA across two large tertiary centres were included over six years. They were divided into one of four groups according to the type of analgesia received: Group N patients received no neuraxial morphine or regional block. Group B patients received adductor canal block (ACB) only. Group M patients received intrathecal morphine (ITM) but no regional block. Group BM patients received both ACB and ITM., Results: Patients who received an ACB had faster postoperative mobilization compared to those without (p < 0.001). Patients in Group BM had the lowest pain scores at rest (Visual Analogue Scale (VAS) 2.9) and with movement (VAS 5.3), while Group B patients experienced the highest pain scores at rest (VAS 3.7) and on movement (VAS 6.5) (p = 0.005). Patients who received ITM had the lowest opioid requirements (p < 0.001). There was no significant differences between groups in requirement for rescue pain management strategies (p = 0.06)., Conclusions: The combination of ITM and ACB in patients undergoing TKA provides improved postoperative analgesia with lower postoperative opioid requirement and earlier mobilization compared with ACB or ITM alone., (© 2024. Crown.)

Background: Assessing pain in infants and neonates is challenging due to their inability to communicate verbally. While validated subjective tools exist, they rely on interpreting the child's behavior, leading to potential inconsistencies and underestimation of pain. Based on heart rate variability, the newborn infant parasympathetic evaluation (NIPE) index offers a more objective approach to pain assessment in children under 2 years. Although promising, research on its effectiveness during surgery under general anesthesia remains limited and inconclusive., Objective: This study compared the effectiveness of NIPE-guided fentanyl administration to traditional vital signs (heart rate and mean arterial pressure) in managing pain during surgery in children under 2 years., Methods: Seventy children undergoing head, neck, or upper extremity surgery were randomized into group N (NIPE) or group C (Control) with 35 participants in each group. Both groups received standardized anesthesia and monitoring, including NIPE. Group N received fentanyl when NIPE scores fell below 50, while group C received fentanyl upon a 20% increase in heart rate or mean arterial pressure (MAP). Postoperative pain was assessed using the Face, Legs, Activity, Cry, and Consolability (FLACC) scores, alongside fentanyl consumption, sedation levels, and potential side effects., Results: Both groups exhibited similar outcomes in terms of postoperative pain scores, fentanyl consumption, sedation levels, and absence of side effects (postoperative respiratory depression or nausea and vomiting). Additionally, intraoperative NIPE scores, heart rate, and MAP were comparable between the groups. There are strong correlations between both groups in terms of NIPE scores ( r = 0.735, p < 0.0001), heart rate ( r = 0.630, p < 0.0001), and MAP ( r = 0.846, p < 0.0001). In both group C and group N, the NIPE scores reveal strong negative correlations with heart rate ( r = -0.610, p < 0.0001, and r = -0.674, p < 0.0001) and MAP ( r = -0.860, p < 0.0001, and r = -0.756, p < 0.0001)., Conclusion: NIPE-guided intraoperative fentanyl administration was not superior to heart rate/MAP-guided administration, as both achieved similar pain management outcomes in this study. However, NIPE may offer a more practical and precise approach, as it is an objective tool with a defined threshold. These findings suggest NIPE's promise as a valuable tool for managing pain in children under 2 years undergoing surgery. However, confirmation of its widespread effectiveness requires further research with larger, multicenter studies encompassing procedures with a broader spectrum of pain severity., Competing Interests: The authors declare that they have no competing interests., (© 2024 Sripadungkul et al.)

Significant knowledge gaps exist in the perioperative pain management of patients with a history of chronic pain, substance use disorder, and/or opioid tolerance as highlighted in the US Health and Human Services Pain Management Best Practices Inter-Agency Task Force 2019 report. The report emphasized the challenges of caring for these populations and the need for multidisciplinary care and a comprehensive approach. Such care requires stakeholder alignment across multiple specialties and care settings. With the intention of codifying this alignment into a reliable and efficient processes, a consortium of 15 professional healthcare societies was convened in a year-long modified Delphi consensus process and summit. This process produced seven guiding principles for the perioperative care of patients with chronic pain, substance use disorder, and/or preoperative opioid tolerance. These principles provide a framework and direction for future improvement in the optimization and care of 'complex' patients as they undergo surgical procedures., Competing Interests: Competing interests: DMD receives research support from Abbott and SPR therapeutics; speaker and/or consulting fees from Abbott, SPR Therapeutics, Vertos, Pfizer, Myovant, Nalu, and Biotronik; NME receives consulting fees for legal case review and from Pacira; SS receives consulting fees from SPR Therapeutics, Masimo Corp, and Allergan. GS receives consulting fees from Pacira and holds minor stake equity (stock options) in Dorsal Health; MS receives consulting fees and research support from Saluda Medical, consulting fees from Patch technologies, Witness, etc and iVitalie, and holds stock and/or receives consulting fees from Cellarian, Spark Biomedical, Nanomedical Systems, Full Spectrum Healthcare Management, MedAnswers, Reveliance solutions, and Assurance Med Management, (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Introduction: Opioid tapering after surgery is recommended among patients with chronic opioid use, but it is unclear how this process affects their quality of life. The objective of this study was to evaluate how opioid tapering following surgery was associated with patient-reported outcome measures related to pain control and behavioral changes that affect quality of life., Methods: We conducted an explanatory sequential mixed-methods study at a VA Medical Center among patients with chronic opioid use who underwent a spectrum of orthopedic, vascular, thoracic, urology, otolaryngology, and general surgery procedures between 2018 and 2020. Patients were stratified based on the extent that opioid tapering was successful (complete, partial, and no-taper) by 90 days after surgery, followed by qualitative interviews of 10 patients in each taper group. Longitudinal patient-reported outcome measures related to pain intensity, interference, and catastrophizing were compared using Kruskal Wallis tests over the 90-day period after surgery. Qualitative interviews were conducted among patients in each taper group to identify themes associated with the impact of opioid tapering after surgery on quality of life., Results: We identified 211 patients with chronic opioid use (92% male, median age 66 years) who underwent surgery during the time period, including 42 (20%) individuals with complete tapering, 48 (23%) patients with partial tapering, and 121 (57%) patients with no taper of opioids following surgery. Patients who did not taper were more likely to have a history of opioid use disorder (10%-partial, 2%-complete vs 17%-no taper, p<0.05) and be discharged on a higher median morphine equivalent daily dose (52-partial, 30-complete vs 60-no taper; p<0.05) than patients in the partial and complete taper groups. Pain interference (-7.2-partial taper and -9.8-complete taper vs -3.5-no taper) and pain catastrophizing (-21.4-partial taper and -16.5-complete taper vs -1.7-no taper) scores for partial and complete taper groups were significantly improved at 90 days relative to baseline when compared with patients in the no-taper group (p<0.05 for both comparisons), while pain intensity was similar between groups. Finally, patients achieving complete and partial opioid tapering were more likely to report improvements in activity, mood, thinking, and sleep following surgery as compared with patients who failed to taper., Conclusions: Partial and complete opioid tapering within 90 days after surgery among patients with chronic opioid use was associated with improved patient-reported measures of pain control as well as behaviors that impact a patient's quality of life., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: The authors declare no conflicts of interest.

Competing Interests: The authors declare no conflicts of interest.

Background: Whether regional anesthesia impacts the development of chronic postsurgical pain is currently debateable, and few studies have evaluated an effect on prolonged opioid use. We sought to systematically review the effect of regional anesthesia for adults undergoing noncardiac elective surgery on these outcomes., Methods: A systematic search was conducted in MEDLINE, EMBASE, CENTRAL, and CINHAL for randomized controlled trials (from inception to April 2022) of adult patients undergoing elective noncardiac surgeries that evaluated any regional technique and included one of our primary outcomes: (1) prolonged opioid use after surgery (continued opioid use ≥2 months postsurgery) and (2) chronic postsurgical pain (pain ≥3 months postsurgery). We conducted a random-effects meta-analysis on the specified outcomes and used the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach to rate the quality of evidence., Results: Thirty-seven studies were included in the review. Pooled estimates indicated that regional anesthesia had a significant effect on reducing prolonged opioid use (relative risk [RR] 0.48, 95% CI, 0.24-0.96, P = .04, I 2 0%, 5 trials, n = 348 patients, GRADE low quality). Pooled estimates for chronic pain also indicated a significant effect favoring regional anesthesia at 3 (RR, 0.74, 95% CI, 0.59-0.93, P = .01, I 2 77%, 15 trials, n = 1489 patients, GRADE moderate quality) and 6 months (RR, 0.72, 95% CI, 0.61-0.85, P < .001, I 2 54%, 19 trials, n = 3457 patients, GRADE moderate quality) after surgery. No effect was found in the pooled analysis at 12 months postsurgery (RR, 0.44, 95% CI, 0.16-1.17, P = .10)., Conclusions: The results of this study suggest that regional anesthesia potentially reduces chronic postsurgical pain up to 6 months after surgery. Our findings also suggest a potential decrease in the development of persistent opioid use., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 International Anesthesia Research Society.)

Background: Few studies report outcomes for enhanced recovery pathways in ambulatory anorectal surgery. We hypothesize that an ambulatory anorectal enhanced recovery pathway with multimodal analgesia can reduce postoperative opioid use., Objective: To compare postoperative opioid use in patients undergoing ambulatory anorectal surgery who receive multimodal analgesia versus standard of care without multimodal analgesia., Design: A prospective randomized trial of patients undergoing elective anal fistula or hemorrhoid surgery from September 2018 to May 2022., Setting: Urban teaching hospital., Patients: Adults aged 18 to 70 years undergoing elective anal fistula or hemorrhoid surgery from September 2018 to May 2022., Intervention: Multimodal enhanced recovery pathway including preoperative and postoperative nonopioid analgesia with oral acetaminophen, gabapentin, and ketolorac., Main Outcome Measures: Primary end point was oral opioid use during the first postoperative week. Secondary end points included maximum pain and nausea scores, adverse events, and emergency room or hospital admissions during the first 30 days postoperatively., Results: Of the 109 enrolled patients, 20 were lost to follow-up. The remaining 89 patients had a median age of 38 years (range, 20-67) and included 41 women (46%). There were no significant differences between the enhanced recovery protocol arm and non-enhanced recovery protocol arm in terms of preoperative and surgical characteristics. The primary end point of this study, that is, oral morphine milligram equivalents use during the first week, was significantly higher among patients in the non-enhanced recovery protocol arm (79 mg; range, 0-600) than patients in the enhanced recovery protocol arm (8 mg; range, 0-390; p = 0.002). On subgroup analysis, both fistula and hemorrhoid surgery patients assigned to the non-enhanced recovery protocol arm took significantly higher oral morphine milligram equivalents in the first week than patients in the enhanced recovery protocol arm. There was no significant difference in secondary end points., Limitations: Patients and providers were not blinded. Our findings are limited to hemorrhoid and fistula surgery and may not be applicable to other anorectal procedures., Conclusions: Enhanced recovery protocols including multimodal analgesia should be used in elective anal fistula and hemorrhoid surgery to decrease postoperative opioid use. See the Video Abstract ., Clinical Trial Registration: ClinicalTrials.gov ID NCT03738904., Implementacin De Protocolo De Recuperacin Acelerada Multimodal En Ciruga Anorrectal Ambulatoria Un Estudio Aleatorizado: ANTECEDENTES:Pocos estudios reportan resultados de programas de recuperación acelerada en la cirugía anorrectal ambulatoria. Presumimos que un programa anorrectal ambulatorio de recuperación acelerada con analgesia multimodal puede reducir el uso posoperatorio de opioides.OBJETIVO:Comparar el uso posoperatorio de opioides en pacientes sometidos a cirugía anorrectal ambulatoria que reciben analgesia multimodal versus atención estándar sin analgesia multimodal.DISEÑO:Un estudio prospectivo aleatorizado de pacientes sometidos a cirugía electiva de fístula anal o hemorroides desde septiembre de 2018 hasta mayo de 2022.LUGAR: Hospital universitario urbano.PACIENTES:Adultos de 18 a 70 años sometidos a cirugía electiva de fístula anal o hemorroides desde septiembre de 2018 hasta mayo de 2022.INTERVENCIÓN:Programa de recuperación acelerada multimodal que incluye analgesia no opioide pre y posoperatoria con paracetamol oral, gabapentina y ketoloraco.PRINCIPALES MEDIDAS DE RESULTADO:El resultado principal fue el uso de opioides orales durante la primera semana postoperatoria. Los resultados secundarios incluyeron puntuaciones máximas de dolor y náuseas, eventos adversos e ingresos a la sala de emergencias o al hospital durante los primeros 30 días después de la operación.RESULTADOS:De los 109 pacientes incluidos, 20 se perdieron durante el seguimiento. Los 89 pacientes restantes tenían una mediana de edad de 38 (rango, 20-67) años e incluían 41 (46%) mujeres. No hubo diferencias significativas entre los grupos del protocolo de recuperación acelerada (Grupo E) y del protocolo de recuperación no acelerada (Grupo NE) en términos de características preoperatorias y quirúrgicas. El resultado principal del estudio, el uso de MME oral durante la primera semana, fue significativamente mayor entre los pacientes del grupo NE (79 mg; rango: 0-600) que los pacientes del grupo E (8 mg; rango: 0-390) ( p = 0,002). En el análisis de subgrupos, los pacientes de cirugía de fístula y hemorroides asignados al grupo NE tomaron MME oral significativamente más alto en la primera semana que los pacientes del grupo E. No hubo diferencias significativas en los resultados secundarios.LIMITACIONES:Los pacientes y proveedores no fueron cegados. Nuestros hallazgos se limitan a la cirugía de hemorroides y fístulas y pueden no ser aplicables a otros procedimientos anorrectales.CONCLUSIONES:Se deben utilizar protocolos de recuperación acelerada que incluyan analgesia multimodal en la cirugía electiva de fístula anal y hemorroides para disminuir el uso posoperatorio de opioides. (Traducción- Dr. Francisco M. Abarca-Rendon )CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov ID NCT03738904., (Copyright © The ASCRS 2024.)

Objectives: Evaluate the effect of intravenous (IV) methadone versus intrathecal morphine (ITM) within an Enhanced Recovery After Cardiac Surgery (ERACS) pathway on postoperative pain and outcomes (length of hospital stay and postoperative complications) after cardiac surgery., Design: Retrospective cohort study., Setting: Two tertiary academic medical institutions within the same health system., Participants: Eligible 289 adult patients undergoing elective cardiac surgery with an enhanced recovery pathway from January 2020 through July 2021., Interventions: Patients were administered ITM (0.25 mg) or IV methadone (0.1 mg/kg) if ITM was contraindicated. All patients were enrolled in an ERACS pathway using current Enhanced Recovery After Surgery society guidelines., Measurements and Main Results: Primary outcome measures included postoperative pain scores and opioid consumption measured as oral morphine equivalents. We analyzed patient demographics, procedural factors, intraoperative medications, and outcomes. Adjusted linear mixed models were fit to analyze associations between intervention and pain outcomes. ITM was associated with decrease in pain scores on postoperative day 0 after adjusting for clinical variables (average marginal effect, 0.49; 95% confidence interval, 0.002-0.977; p = 0.049). No difference in opioid consumption could be demonstrated between groups after adjusting for postoperative day and other variables of interest., Conclusions: ITM when compared with IV methadone was associated with a decrease in pain scores without any difference in opioid consumption after elective cardiac surgery. Methadone can be considered as a safe and effective alternative to ITM for ERACS protocols. Future large prospective studies are needed to validate this finding and further improve analgesia and safety., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Post-operative pain control improves patient's satisfaction and affects the period of admission. Local wound infiltration following hernia surgery using xylocaine or bupivacaine has been a common practice. The use of tramadol for such infiltration is relatively new and has not been studied in our environment. This study compared the efficacy of post-operative pain control between Bupivacaine and Tramadol wound infiltration in children who underwent herniotomy and orchidopexy., Materials and Methods: This was a prospective randomised study involving 104 patients. A simple random method was used to allocate the study group into two equal groups (A, n = 52 and B, n = 52) using sealed envelopes with contents labelled A or B. Pre- and post-operative respiratory rate, heart rate, and C-reactive protein (CRP) were all recorded. Time to first and subsequent analgesia was determined using face, legs, activity, cry, consolability (FLACC) pain score., Results: Fifteen patients in Group A and 18 patients in Group B received each two doses of supplemental analgesia within the first 24 h, ( P = 0.527). Time to first analgesia was significantly different between the two groups, (6.93 ± 0.80 h and 6.11 ± 1.08 h, P = 0.020). The mean FLACC pain score at the time of first analgesia in hours was 4.93 ± 0.59 and 4.72 ± 0.67 for Group A and B, respectively, P = 0.350. The changes in CRP were not different in the two groups, ( P = 0.665). Four patients in Group A, but none in Group B had an episode each of post-operative vomiting., Conclusion: Tramadol showed comparable efficacy with bupivacaine in post-operative pain control by wound infiltration in children who had unilateral herniotomy or orchidopexy. Tramadol, however, achieves a longer duration of action before rescue analgesic is required. Caution is necessary to avoid post-operative vomiting., (Copyright © 2024 Copyright: © 2024 African Journal of Paediatric Surgery.)

Objective: This study was designed to evaluate the effect of low-dose ketamine infusion on the perioperative consumption of opioids in pediatric open cardiac surgery., Design: A randomized, controlled, double-blinded single-center study was conducted., Setting: The study took place in a tertiary care children's hospital., Participants: Patients of both sexes aged 2-12 years who underwent cardiac surgery were included., Interventions: Patients in the ketamine group received a bolus of 0.3 mg/kg of ketamine before skin incision followed by continuous intraoperative infusion of 0.25 mg/kg/h and postoperative infusion of 0.1 mg/kg/h for 24 h. Patients in the control groups received volumes of normal saline either bolus or continuous infusion like that of the ketamine group., Measurements and Main Results: The primary outcome was the total dose of fentanyl consumed over the first 24 hours postoperatively. Secondary outcomes were intraoperative fentanyl consumption, time to extubation, modified objective pain score, and incidence of vomiting, pruritus, diplopia, or hallucinations. A total of 80 patients were recruited but the final analysis was done on 35 patients in the ketamine group and 34 in the control group. Fentanyl consumption during surgery and in the first 24 hours postoperatively was significantly lower in the ketamine than the control group. Patients in both the ketamine and control groups had similar times to extubation. Modified objective pain scores were significantly lower in the ketamine group than the control group. None of the patients in either group had diplopia or hallucinations., Conclusions: Low-dose ketamine infusion in children undergoing open cardiac surgery reduced intra- and postoperative opioid consumption and postoperative pain scores. Moreover, ketamine did not cause diplopia or hallucinations., Competing Interests: Declaration of competing interest The authors report no conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose of Review: Heart and lung transplantation evolution marked significant milestones. Pioneering efforts of Dr Christiaan Barnard with the first successful heart transplant in 1967, followed by advancements in heart-lung and single-lung transplants by Drs Bruce Reitz, Norman Shumway, and Joel Cooper laid the groundwork for contemporary organ transplantation, offering hope for patients with end-stage heart and pulmonary diseases., Recent Findings: Pretransplant opioid use in heart transplant recipients is linked to higher mortality and opioid dependence posttransplant. Effective pain control is crucial to reduce opioid-related adverse effects and enhance recovery. However, research on specific pain management protocols for heart transplant recipients is limited. In lung transplantation effective pain management is crucial. Studies emphasize the benefits of multimodal strategies, including thoracic epidural analgesia and thoracic paravertebral blocks, to enhance recovery and reduce opioid use. Perioperative pain control challenges in lung transplantation are unique and necessitate careful consideration to prevent complications and improve outcomes., Summary: This review emphasizes the importance of tailored pain management in heart and lung transplant recipients. It advocates for extended follow-up and alternative analgesics to minimize opioid dependency and enhance quality of life. Further high-quality research is needed to optimize postoperative analgesia and improve patient outcomes., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Minimally invasive thoracic surgery is associated with substantial pain that can impair pulmonary function. Fascial plane blocks may offer a favorable alternative to opioids, but conventional local anesthetics provide a limited duration of analgesia. We therefore tested the primary hypothesis that a mixture of liposomal bupivacaine and plain bupivacaine improves the overall benefit of analgesia score (OBAS) during the first three postoperative days compared to bupivacaine alone. Secondarily, we tested the hypotheses that liposomal bupivacaine improves respiratory mechanics, and decreases opioid consumption., Methods: Adults scheduled for robotically or video-assisted thoracic surgery with combined ultrasound-guided pectoralis II and serratus anterior plane block were randomized to bupivacaine or bupivacaine combined with liposomal bupivacaine. OBAS was measured on postoperative days 1-3 and was analyzed with a linear mixed regression model. Postoperative respiratory mechanics were estimated using a linear mixed model. Total opioid consumption was estimated with a simple linear regression model., Results: We analyzed 189 patients, of whom 95 were randomized to the treatment group and 94 to the control group. There was no significant treatment effect on total OBAS during the initial three postoperative days, with an estimated geometric mean ratio of 0.93 (95% CI: 0.76, 1.14; p = 0.485). There was no observed treatment effect on respiratory mechanics, total opioid consumption, or pain scores. Average pain scores were low in both groups., Conclusions: Liposomal bupivacaine did not improve OBAS during the initial postoperative three days following minimally invasive thoracic procedures. Furthermore, there was no improvement in respiratory mechanics, no reduction in opioid consumption, and no decrease in pain scores. Thus, the data presented here does not support the use of liposomal bupivacaine over standard bupivacaine to enhance analgesia after minimally invasive thoracic surgery., Summary Statement: For minimally invasive thoracic procedures, addition of liposomal bupivacaine to plain bupivacaine for thoracic fascial plane blocks does not improve OBAS, reduce opioid requirements, improve postoperative respiratory mechanics, or decrease pain scores., Competing Interests: Declaration of competing interest Sudish Murthy is a consultant for Advanced Medical Solutions, LLC, an advisor for Lazzaro Medical, and received honoraria from Intuitive Surgical and Medtronic; Alparslan Turan is a consultant for Civco medical and received a research grant from Pacira Pharmaceuticals. Daniel I Sessler - is a consultant for Pacira Pharmaceuticals. Other authors have no conflicts of interest to declare. Sudish Murthy is a consultant for Advanced Medical Solutions, LLC, an advisor for Lazzaro Medical, and received honoraria from Intuitive Surgical and Medtronic; Alparslan Turan is a consultant for Civco medical and received a research grant from Pacira Pharmaceuticals. All other authors declare no conflicts of interest. Pacira Pharmaceuticals was not involved in the data collection, data analysis, preparation of paper, or the decision to submit. The manuscript was not shared with the sponsor., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Study Objective: To determine if single-injection bilateral posterior quadratus lumborum block (QLB) with ropivacaine would improve postoperative analgesia in the first 24 h after laparoscopic hepatectomy, compared with 0.9% saline., Design: Prospective, double blinded, randomized controlled trial., Setting: A single tertiary care center from November 2021 and January 2023., Patients: A total of 94 patients scheduled to undergo laparoscopic hepatectomy due to hepatocellular carcinoma., Interventions: Ninety-four patients were randomized into a QLB group (receiving 20 mL of 0.375% ropivacaine on each side, 150 mg in total) or a control group (receiving 20 mL of 0.9% saline on each side)., Measurements: The primary outcome was the cumulative opioid consumption during the initial 24-h post-surgery. Secondary outcomes included pain scores and intraoperative and recovery parameters., Main Results: The mean cumulative opioid consumption during the initial 24-h post-surgery was 30.8 ± 22.4 mg in the QLB group (n = 46) and 34.0 ± 19.4 mg in the control group (n = 46, mean differences: -3.3 mg, 95% confidence interval, -11.9 to 5.4, p = 0.457). The mean resting pain score at 1 h post-surgery was significantly lower in the QLB group than in the control group (5 [4-6.25] vs. 7 [4.75-8], p = 0.035). No significant intergroup differences were observed in the resting or coughing pain scores at other time points or in other secondary outcomes., Conclusions: Preoperative bilateral posterior QLB did not reduce cumulative opioid consumption during the first 24 h after laparoscopic hepatectomy., Competing Interests: Declaration of competing interest None declared., (Copyright © 2024. Published by Elsevier Inc.)

Background: Opioids are the main analgesic drugs used in the perioperative period, but they often have various adverse effects. Recent studies have shown that quadratus lumborum block (QLB) has an opioid sparing effect. The aim of this study was to further evaluate the effect of opioid-free anesthesia (OFA) combined with regional block on the quality of recovery in patients undergoing retroperitoneoscopic renal surgery., Methods: Sixty patients undergoing elective retroperitoneoscopic renal surgery were divided into the opioid-free anesthesia with quadratus lumborum block group (OFA group, N.=30) and opioid anesthesia with quadratus lumborum block group (OA group, N.=30) using the random number table method. The main outcome measures were the quality of recovery assessed by Quality of Recover-40 (QoR-40) at the 24 th postoperative hour. Secondary outcomes were postoperative pain score, postoperative opioid consumption, postoperative nausea and vomiting, time to ambulate, and time to readiness for discharge., Results: The QoR-40 score on the first postoperative day was significantly higher in the OFA group than that in the OA group (175.41±6.74 vs. 165.07±4.55; P<0.05). OFA also significantly reduced postoperative pain (P<0.05) and morphine consumption at both the 24th and 48th postoperative hour (P<0.05), as well as time to ambulate, and time to readiness for discharge (P<0.05)., Conclusions: OFA with regional block is superior to opioid anesthesia with regional block in the quality of recovery after retroperitoneiscopic renal surgery.

Background: We evaluated the individual contributions of rigid-plate fixation (RPF) and an enhanced recovery protocol (ERP) on postoperative pain, opioid use, and other outcomes after median sternotomy as they were sequentially adopted into practice., Methods: This single-center, retrospective, case-cohort study compared outcomes between median sternotomy patients (all comers) who underwent operation before implementation of RPF or ERP ("controls"), patients closed with RPF before ERP implementation ("RPF-only"), and patients managed with RPF and ERP during early "RPF+ERP-2020" and late "RPF+ERP-2022" implementation., Results: The analysis included 608 median sternotomy patients (mean age, 65.7 ± 10.8 years; 29.6% women). Of those, 59.2% were isolated coronary artery bypass grafting, 7.7% were isolated valve procedures, and the rest were mixed/concomitant procedures. Median in-hospital, postoperative opioid administration was 172.5 morphine milligram equivalents (MMEs) in the control cohort vs 0 MMEs for RPF+ERP-2022 (P < .0001), despite similar or slightly reduced patient-reported pain scores. The proportion of patients discharged directly to home was 66.2% for controls, 79.6% for RPF-only (P = .010), and 93.5% for RPF+ERP-2022 (P < .0001). Median opioids prescribed at discharge were 600 MMEs for controls and 0 for RPF+ERP-2020 and RPF+ERP-2022 (P < .0001). At discharge, 86.7% of RPF-only patients received prescription opioids vs 5% in RPF+ERP-2020 and 4.3% RPF+ERP-2022 (P < .0001). These outcomes occurred without increased readmissions., Conclusions: Systematic implementation of RPF and ERP was associated with a significant and clinically meaningful decrease in opioid use in this large, real-world patient population., Competing Interests: Disclosures Marc Gerdisch reports financial support was provided by Zimmer Biomet and Arthrex Inc and reports a relationship with Arthrex Inc that includes: consulting or advisory; with Artivion, Inc. that includes: consulting or advisory; with AtriCure Inc that includes: consulting or advisory; with Corcym SRL that includes: consulting or advisory; with ClearFlow Inc that includes: consulting or advisory; with CorVivo that includes: consulting or advisory; with DASI that includes: consulting or advisory; with Edwards Lifesciences Corporation that includes: consulting or advisory; and with Zimmer Biomet that includes: consulting or advisory and funding grants. The other authors have no conflicts of interest to disclose., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: There is limited research on the impact of an ilioinguinal-iliohypogastric nerve block on intraoperative opioid consumption when conducting groin hernia repair in adults. Thus, the aim was to evaluate ilioinguinal-iliohypogastric nerve block for groin hernia patients at Shouldice Hospital., Methods: The study was a pilot retrospective chart review on patients who underwent a Shouldice Repair from November 2023 to December 2023. This study compared individuals receiving an ilioinguinal-iliohypogastric nerve block with local anesthesia and fentanyl analgesia to those who received local anesthesia and fentanyl analgesia, by manually matching 1:1 on 12 demographic and intraoperative characteristics. Comparison between groups was performed using chi-square/Fisher Exact test for categorical and t-test/Mann-Whitney test for numerical variables depending on data distribution. Multivariable regression analysis was used to examine predictors of intraoperative use of fentanyl., Results: In this study 50 matched pairs of unilateral primary inguinal hernia patients were analyzed. The ilioinguinal-iliohypogastric nerve block patients had lower recorded intraoperative fentanyl (85mcg less than control, p < .001) and dimenhydrinate (13 mg less than control, p < .001) than the control group patients. No differences were found in postoperative day 0 to 3 for acetaminophen, non-steroidal anti-inflammatory drug, and opioid consumption between the patients who did receive an ilioinguinal-iliohypogastric nerve block prior to surgery and those that did not., Conclusion: The administration of an ilioinguinal-iliohypogastric nerve block prior to primary inguinal hernia repair using a Shouldice Repair is associated with a significantly lower intraoperative fentanyl consumption compared to non-administration., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: To compare patient-controlled epidural analgesia (PCEA) and epidural morphine (EM) for post-cesarean section analgesia in real-world experience from China., Methods: Parturients receiving one dose of EM (1-2 mg), PCEA, or both EM and PCEA from Peking Union Medical College Hospital were retrospectively recruited. Logistic models were used to identify risk factors., Results: Of 1079 parturients enrolled, 919 (85.2%) parturients received only EM, 105 (9.7%) parturients received PCEA, and 55 (5.1%) parturients received both EM and PCEA. Significantly more parturients from EM group requested supplementary analgesia than those from PCEA and PCEA + EM group (583, 63.4% vs 52, 49.5% vs 25, 45.5%, P = 0.001) with more times of supplementary analgesia (1, IQR: 0-2 vs 0, IQR: 0-1 vs 0, IQR: 0-1 times, P < 0.001) and larger amounts of nonsteroidal anti-inflammatory drugs (NSAIDs) (50, IQR: 0-100 mg vs 0, IQR: 0-50 mg vs 0, IQR: 0-50 mg, P < 0.001). In multivariable Logistic regression for the supplementary analgesia risk, the application of PCEA (OR: 0.557, 95%CI 0.396-0.783, P = 0.001) and the use of NSAIDs intraoperatively (OR: 2.996, 95%CI 1.811-4.957, P < 0.001) were identified as independent predictors. A total of 1040 (96.4%) patients received prophylactic antiemetic therapy during surgery. Only 13 (1.2%) and 7 (0.6%) patients in our cohort requested antiemetic and antipruritic drugs, respectively., Conclusion: The use of PCEA was an independent protective factor for supplementary analgesia during the post-cesarean section. Prophylactic antiemetic therapy may reduce the side effects of post-cesarean analgesia., (© 2024. The Author(s) under exclusive licence to Japanese Society of Anesthesiologists.)

Purpose of Review: The escalating opioid crisis has intensified the need to explore alternative pain management strategies for patients undergoing spine surgery. This review is timely and relevant as it synthesizes recent research on opioid alternatives for perioperative management, assessing their efficacy, side effects, and postoperative outcomes., Recent Findings: A systematic search was conducted to capture articles from the past 18 months that examined opioid-sparing strategies. Findings indicate that multimodal analgesia, incorporating nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, lidocaine, gabapentinoids, N-methyl-D-aspartate (NMDA) antagonists, dexmedetomidine, and emerging regional block techniques like the erector spinae block and TLIF (thoraco lumbar interfascial block), can significantly reduce opioid consumption without compromising pain relief. Additionally, these approaches reduce opioid-related side effects such as postoperative nausea, vomiting, and prolonged hospital stays., Summary: The use of multimodal analgesia aligns with current pain management guidelines and addresses public health concerns related to opioid misuse. While effective, these alternatives are not without side effects, and the ultimate outcome depends on balancing benefits and risks. Future research should focus on the long-term outcomes of opioid alternatives, their effectiveness across diverse populations, and further validation and optimization of these strategies., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Buprenorphine is a partial mu opioid receptor agonist with high affinity to its receptor, which raises concerns of blocking or displacing full opioid agonists when used during the perioperative period of surgical patients. However, buprenorphine itself has high analgesic potency and discontinuing buprenorphine may lead to suboptimal pain control and risk for opioid use disorder relapse. There is limited data for the continuation of buprenorphine perioperatively., Methods: This study is a retrospective cohort study of adult surgical patients taking buprenorphine for opioid use disorder at an urban, teaching, level 1 trauma center. Patients were split into two groups based on whether buprenorphine was continued (n = 46) or held (n = 28) within the first 48 h after surgery., Results: Those who had buprenorphine continued in the first 48 h postoperatively required half the dose of nonbuprenorphine opioids compared to those who had buprenorphine held (113.25 versus 255.75 oral morphine equivalents, P = 0.0040). Both groups had a similar level of analgesia and incidence of adverse events. Nearly all patients who continued buprenorphine in the first 48 h postoperatively were discharged on this agent, while only half of patients who had buprenorphine held were restarted on it at discharge (92.68% versus 56.52%, P = 0.0013)., Conclusions: This present study found lower nonbuprenorphine opioid requirements in patients with continued versus held perioperative buprenorphine use with no difference in degree of analgesia., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: To assess the importance of appropriate opioid administration methods according to nociceptive monitoring., Methods: We conducted a randomized controlled trial involving 54 patients who underwent robot-assisted laparoscopic radical prostatectomy at our hospital. Patients were randomly allocated to either receive nociception level (NOL)-directed intraoperative opioid management with a minimum flow of remifentanil (NOL group) or conventional intraoperative analgesic management (control group). The primary outcome was the mean intraoperative remifentanil infusion flow rate (intraoperative remifentanil usage [μg]/ideal body weight [kg]/operation time [min]). The main secondary outcomes were plasma concentrations of three perioperative inflammatory biomarkers (interleukin-6, C-reactive protein [CRP], and cortisol levels) and postoperative pain (Numeric Rating Scale [NRS]) scores 2 h postoperatively and on postoperative days 1, 2, 3, and 7., Results: Compared with standard analgesia management, NOL-directed analgesic management reduced remifentanil consumption by 20% ( - 0.038; 95% confidence interval, - 0.059 to - 0.017; p = 0.0007). NOL-directed management did not lead to an increase in IL-6, CRP, or cortisol levels compared with conventional analgesic management. Furthermore, this protocol led to improvements in the NRS scores at rest 2 h postoperatively and upon movement up to postoperative day 3., Conclusion: NOL-directed analgesic management reduced remifentanil consumption by 20% and the NRS scores at rest 2 h postoperatively and upon movement up to postoperative day 3 without an increase in inflammatory marker levels., Registry Number: Japan Registry of Clinical Trials, JRCTs052220034., (© 2024. The Author(s) under exclusive licence to Japanese Society of Anesthesiologists.)

Background: The study aimed to compare the pain-relieving effectiveness of anterior quadratus lumborum block (QLB3) and erector spinae plane block (ESPB), both of which have been documented to provide relief during abdominal surgery., Methods: This prospective observational study, conducted between February and July 2023, included 96 patients who had undergone percutaneous nephrolithotomy (PCNL). Patients were divided into three groups: QLB3, ESPB, and control (no block) and received the corresponding nerve block in the preanesthetic room for regional block. Cumulative morphine consumption during the initial 24 h after PCNL, numerical rating scale resting/movement scores, intraoperative remifentanil usage, rescue analgesic requirements, time when the first analgesic was requested, and postoperative nausea and vomiting scores were documented and compared between the groups., Results: Total median morphine consumption in the first 24 h postoperatively was similar in the QLB3 and ESPB groups but higher in the control group (QLB3, 7 mg [(Q1-Q3) 7-8.5]; ESPB, 8 mg [6.5-9]; control, 12.5 [10-17]; P < 0.001). Similarly, median intraoperative remifentanil consumption did not differ between the block groups but was higher in the control group (QLB3, 1082 µg [IQR 805.5-1292.7]; ESPB, 1278 µg [940.2-1297.5]; control, 1561 µg [1315-2068]; P < 0.001). The number of patients receiving rescue analgesic medication was similar in the block groups but higher in the control group (QLB3, n = 9 [30%]; ESPB, n = 14 [46.7%]; control, n = 21 [70%]; P = 0.008)., Conclusions: QLB3 and ESPB were adequate and comparable in providing postoperative analgesia as part of multimodal analgesia after PCNL., Trial Registration: The study was registered on ClinicalTrials.gov (Identifier: NCT05822492)., (© 2024. The Author(s).)

Background: Open liver resection necessitates a substantial upper abdominal inverted-L incision, resulting in severe pain and compromising patient recovery. Despite the efficacy of epidural analgesia in providing adequate postoperative analgesia, the potential epidural-related adverse effects should be carefully considered. This study aims to compare the efficacy and safety of continuous epidural analgesia and intravenous analgesia in open liver resection., Methods: A retrospective study was conducted, collecting data from patients who underwent open liver resection between 2007 and 2017. Propensity score matching was implemented to mitigate confounding variables, with patients being matched in a 1:1 ratio based on propensity scores. The primary outcome was the comparison of postoperative morphine consumption at 24, 48, and 72 hours between the two groups. Secondary outcomes included pain scores, postoperative outcomes, and epidural-related adverse effects., Results: A total of 612 patients were included, and after matching, there were 204 patients in each group. Opioid consumption at 24, 48, and 72 hours postoperatively was statistically lower in the epidural analgesia group compared to the intravenous analgesia group (p < 0.001). However, there was no significant difference in pain scores (p = 0.422). Additionally, perioperative hypotension requiring treatment, as well as nausea and vomiting, were significantly higher in the epidural analgesia group compared to the intravenous analgesia group (p < 0.001)., Conclusions: Epidural analgesia is superior to intravenous morphine in terms of reducing postoperative opioid consumption within the initial 72 h after open liver resection. Nevertheless, perioperative hypotension, which necessitates management, should be approached with consideration and vigilance., Trial Registration: The study was registered in the Clinical Trials Registry at www., Clinicaltrials: gov/ , NCT number: NCT06301932., (© 2024. The Author(s).)