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Background Use of popliteal nerve blocks (PNBs) as an alternative or adjunctive therapy to traditional methods of pain control (e.g., systemic or spinal anesthesia and opioids) is increasingly popular in foot and ankle surgery. Methods We reviewed online databases for literature on PNBs in foot and ankle surgery to analyze the various techniques and positioning used, the influence of drugs on their efficacy, and possible complications associated with their use. Thirty articles were identified with a predefined search criteria, followed by a review process for relevance. Results Patient demographics, procedure specifics, and block techniques, such as anesthetic used, can impact the duration and success of a PNB. Administration with ultrasound guidance proved superior to nerve stimulation, and preoperative administration was superior to postoperative administration. Conclusions PNBs are an effective method to control postoperative pain with minimal complications, leading to decreased analgesic use, earlier discharge, and higher patient satisfaction. Level of evidence Level III, retrospective comparative study

Summary Background Pediatric thoracoscopic lobectomy is a technically challenging procedure that may result in better pain control, better cosmetic results, and shorter hospital stay. However, data describing the learning curve of total thoracoscopic lobectomy (TTL) have yet to be obtained. To evaluate our learning curve for TTL in children, we reviewed the safety and efficiency of our initial experiences with TTL in pediatric patients with congenital lung malformation. Methods This was a retrospective study of all pediatric patients undergoing TTL between March 2011 and January 2017. Cumulative summation (CUSUM) analysis of operative time (OT) was used. Results One hundred patients were retrospectively analyzed and chronologically divided into three phases: the ascending (A), plateau (B), and descending (C) phases of CUSUM of OT. Phases A, B, and C comprised 35, 22, and 43 cases, respectively. OT decreased significantly from phases A to B (P = 0.035) and B to C (P = 0.019). Age and weight of patients both reduced significantly from phase A to B (p = 0.017 and p = 0.012, respectively), while the two measures did not vary from phase B to C (p = 0.987 and p = 0.874, respectively). Chest tube duration and length of hospital stay had similar trend. All complications occurred in five cases in phase A (5/35). Six cases were converted to open surgery (6%). Four conversions occurred within phase A and two in phase C (4/35 vs 2/43, p = 0.490). There were no mortalities. Conclusions Repeated standardized training plays a role in overcoming the learning curve for thoracoscopic lobectomy in children, and CUSUMOT indicates that a learning curve of approximately 57 cases is required in our institute.

Background Given the national opioid crisis, postoperative analgesia at discharge must be thoughtfully prescribed. Data specifically related to thoracic procedures remain scarce. This study assessed adequacy of pain control with standardized and limited opioids after thoracic procedures. Methods A standardized prescription comprised 15 hydromorphone tabs, 7 days of acetaminophen, and 3 days of ibuprofen was provided on discharge to elective thoracic surgery patients. On the first postoperative visit, patients completed a questionnaire regarding the number of hydromorphones used, use of additional opioids, pain-related limitation to function, and adequacy of pain control. Results A total of 122 patients undergoing thoracic surgery procedures were surveyed. Twelve underwent open procedures and were excluded. An additional 6 patients who used opioids chronically preoperatively were also excluded. The remaining 104 patients were included in the study. Median age was 66 years (age range, 17-90 years) and median length of stay was 2 days (range, 1-15 days). Seventeen (16%) patients used all prescribed hydromorphone and 56 (54%) used none, 18 (17%) asked for additional or other opioid, and 14 (13%) felt that their pain significantly limited their function. Nine (9%) felt that that their pain was inadequately controlled. Conclusions Pain after thoracic procedures, especially video-assisted thoracoscopic surgery, is adequately controlled with minimal opioid doses (combined with adjuncts), with less than 1 in 5 patients requiring additional prescriptions and very few patients complaining of pain that significantly limited their function. This study shows that a standardized limited opioid prescription is safe, is adequate, and can easily be implemented for the majority of thoracic surgery patients.

A quality assurance study was completed following the implementation of a standardized opioid prescribing and education protocol post cesarean delivery. The primary goal was to determine the need for a policy on postpartum opioid prescribing practices and whether the protocol worked. There was a decrease in the number of tablets provided post intervention and no statistically significant maternal or neonatal readmissions for suspected opioid toxicity or pain control. Combination prescribing of Tylenol 3 and/or tramadol and another opioid occurred in both groups. Our results show a need for concise guidelines regarding opioid prescribing following cesarean delivery.

Background: Mindfulness meditation has been shown to alleviate pain and may be an appealing adjunctive pain management option. Objective: To compare measures of pain, mindfulness, and opioid usage, and collect evaluative feedback among patients undergoing septorhinoplasty with and without guided meditation. Methods: Patients undergoing septorhinoplasty were randomized to online-guided meditation postoperative days 0-3 versus standard care; all received the same pain medications. Primary outcome measures included pain intensity, opioid consumption, mindfulness scores, and evaluative feedback. Results: Twenty-one patients received guided meditation and 24 received standard care. No significant difference in opioid consumption or pain scores was seen with the exception of higher opioid use in patients with intranasal splints in the standard care group. Twenty out of 21 patients provided evaluative feedback; all recommended mindfulness meditation to friends undergoing nasal surgery, 90% reported it was beneficial, 85% believed it eased pain/discomfort, and 80% believed it aided with sleep. Conclusion: Although no objective difference was found in opioid consumption or pain scores, most patients reported that guided mindfulness meditation was beneficial to their recovery following septorhinoplasty.

OBJECTIVE To convene a multi-disciplinary panel to develop a pathway for Emergency Department (ED) patients with suspected nephrolithiasis and then prospectively evaluate its effect on patient care. MATERIALS AND METHODS The STONE Pathway was developed and linked to order sets within our Electronic Health Record in April 2019. Records were prospectively reviewed for ED patients who underwent ultrasound or Computerized Tomography (CT) to evaluate suspected nephrolithiasis between January 2019 and August 2019 within our institution. The primary outcome measure was the proportion of patients whose ED CT was low dose (

Background Acute aortic syndromes comprise a spectrum of diseases including aortic dissection, intramural hematoma, and penetrating atherosclerotic ulcers. Early diagnosis, rapid intervention, and multidisciplinary team care are vital to efficiently manage time-sensitive aortic emergencies, mobilize appropriate resources, and optimize clinical outcomes. Objective This comprehensive review outlines the multidisciplinary team approach from initial presentation to definitive interventional treatment and post-operative care. Discussion Acute aortic syndromes can be life-threatening and require prompt diagnosis and aggressive initiation of blood pressure and pain control to prevent subsequent complications. Early time to diagnosis and intervention are associated with improved outcomes. Conclusions A multidisciplinary team can help promptly diagnose and manage aortic syndromes.

Systemic sclerosis is a complex disease characterized by extensive fibrosis, microvascular alterations, and additional sequelae. Microvascular alterations can cause painful ulcers and necrosis; however, conservative or surgical treatment is often challenging in terms of healing. The study aimed to describe a toe ulcer with systemic sclerosis and its' successful treatment with spinal cord stimulation. An 83-year-old woman, who was diagnosed with systemic sclerosis over the past decade, was distressed by a non-healing toe ulcer for an extended period of time. The patient underwent spinal cord stimulation treatment with the expectation of pain relief and an improvement in microcirculatory insufficiency. Her pain scales and microcirculation improved, and the toe ulcer healed. Furthermore, the frequency of Raynaud's symptoms was reduced, and the patient's pain decreased. There was no recurrence of the ulcer and she no longer needed a cane for walking.

Analgesic options for surgical abortion (also called procedural abortion) beyond local anesthesia and minimal sedation include moderate sedation, deep sedation and general anesthesia. These clinical recommendations review the effectiveness of various moderate sedation, deep sedation, and general anesthesia regimens for pain control during abortion; medication regimens used to induce analgesia and anesthesia; patient factors affecting anesthesia safety; preoperative and intraoperative protocols to reduce anesthesia risks; personnel qualifications for administration; recommended patient monitoring protocols; and general risks of anesthesia in the context of abortion care. The scope of these recommendations is based on limited available evidence and considerably relies on existing professional society guidelines and recommendations developed by content experts and reviewers. Further research to compare the efficacy and safety of different regimens is needed.

Bilateral erector spinae fascial plane blocks (ESPB) offers a novel, alternative method of regional post-operative pain control to thoracic epidural analgesia (TEA). The aim of this study was to compare rates of postoperative hypotension, and other standard enhanced recovery after surgery (ERAS) endpoints, in patients receiving ESPB versus TEA for open hepatopancreaticobiliary (HPB) surgery.This retrospective analysis compared historical controls of ERAS patients undergoing open HPB surgery with TEA versus ESPB. The incidence of postoperative hypotension and clinical outcomes, including opioid requirements, were compared.Forty patients receiving TEA were compared to 27 ESPB patients. Return of bowel function and length of stay (mean 7.2 versus7.4 days; P = 0.83) were similar. ESPB patients received less intraoperative colloid (142cc versus 340cc; P = 0.01) and had less postoperative hypotension versus TEA (22% versus 55%; P = 0.03). No ESPB patient required patient-controlled analgesia (versus 32.5% TEA; P0.001). ESPB MME requirements decreased over time, while TEA MME requirements increased over 72 hours (P = 0.019).ESPB is a novel method that shows promising outcomes in improving enhanced recovery parameters and minimizing opioid administration in open HPB surgery.

Transcutaneous electrical nerve stimulation (TENS) is one of the non-pharmacological methods of pain relief that has been able to reduce pain by 70 to 90% in postoperative pain control. This study aimed to determine the effect of TENS on pain control after cesarean section and its effect on PNMT gene expression. For this purpose, a double-blind randomized clinical trial was performed on 70 Chinese patients with elective cesarean section. Patients were divided into case and control groups. In the case group, TENS and analgesic drugs were used to relieve pain, and in the control group, the only analgesic drug was used. Then the severity of pain, recurrence of pain attacks, the number of analgesic drugs used and the amount of analgesic drug used in the first 24 hours after surgery were evaluated and compared. Blood samples were also taken from patients to evaluate PNMT gene expression. The semi-quantitative RT-PCR was used to study changes in gene expression. The results showed that the group treated with TENS had less pain intensity and less recurrence of pain attacks than the group that received only analgesic medication. Also, the frequency of analgesic drug use and its dose in the TENS group were significantly lower than in the control group. TENS, on the other hand, has been able to greatly reduce the expression of the PNMT gene, which is produced during times of stress. Therefore, it is recommended that TENS be used as a non-invasive and non-pharmacological adjuvant effective in reducing pain after cesarean section.

Intra-articular injections with hyaluronic acid are recommended in the treatment of knee osteoarthritis; however, hypertonic dextrose prolotherapy has been reported as effective and safe. The aim was to evaluate the effectiveness of hypertonic dextrose prolotherapy for pain reduction and improvement of function in individuals with knee osteoarthritis in comparison with hyaluronic acid by meta-analysis. The search was performed in electronic databases. Six studies were included (395 participants). No statistically significant differences were found between prolotherapy and hyaluronic acid in pain control in the short-term; however, in the subanalysis that included only the studies that used intra-articular injection within the prolotherapy scheme, an effect was found in favor of the prolotherapy groups ( d = -1.33; 95% confidence interval, -2.50 to -0.16; P ( z ) = 0.03). Also, an effect was found in favor of the prolotherapy group in the improvement in function ( d = -1.05; 95% confidence interval, -2.03 to -0.08; P ( z ) = 0.03). No major adverse reactions or side effects were reported in any of the studies. Hypertonic dextrose prolotherapy seems to be an effective intervention to decrease pain and improve function in knee osteoarthritis, with efficacy similar to intra-articular injections with hyaluronic acid in the short-term follow-up. Nonetheless, better-quality clinical trials are necessary.

Virtual reality therapy has been shown to be an excellent alternative to non-pharmacological treatment for the control of burn pain. The objective was to evaluate the effects of virtual reality therapy on pain control in people who have suffered burns published in the scientific literature. Systematic review carried out as recommended by Cochrane. The search was carried out in the Embase, PubMed, Lilacs, and Cochrane Library databases, in the period from March 2021. Randomized clinical trials were included without language restriction and year of publication. The risk of bias was assessed using the Cochrane tool. Of the 3755 articles found, only 17 articles were selected for reading in full. Of these, only four articles met the inclusion criteria. The results of the studies showed that the use of virtual reality therapy reduced the intensity of pain in children and adolescents with burns, despite the fact that most results are not statistically significant. No selected study had a high risk of bias. Virtual reality therapy has been shown to be effective in controlling pain, reducing the time spent thinking about it and greater distraction during the procedures. However, most randomized clinical trials results were not statistically significant in at least one of the moments when pain was assessed. It is noteworthy that randomized clinical trials are still necessary to administer virtual reality therapy, especially in adults.

OBJECTIVE To prospectively analyze pain and pain medication use following otologic surgery. STUDY DESIGN Prospective cohort study with patient reported pain logs and medication use logs. SETTING Tertiary academic hospital.Patients: Sixty adults who underwent outpatient otologic surgeries. INTERVENTIONS Surveys detailing postoperative pain levels, nonopioid analgesic (NOA) use, and opioid analgesic use. MAIN OUTCOME MEASURES Self-reported pain scores, use of NOA, and use of opioid medications normalized as milligrams morphine equivalents (MME). RESULTS Thirty-two patients had surgery via a transcanal (TC) approach, and 28 patients had surgery via a postauricular (PA) approach. TC surgery had significantly lower reported pain scores than PA surgery on both postoperative day (POD) 1 (median pain score 2.2, IQR 0-5 vs. median pain score 4.8, IQR 3.4-6.3, respectively; p = 0.0013) and at POD5 (median pain score 0, IQR 0-0 vs. median pain score 2.0, IQR 0-3, respectively; p = 0.0002). Patients also used significantly fewer opioid medications with TC approach than patients who underwent PA approach at POD1 (median total MME 0, IQR 0-5 vs. median total MME 5.0, IQR 0-15, respectively; p = 0.03) and at POD5 (median total MME 0, IQR 0-0 vs. median total MME 0, IQR 0-5, respectively; p = 0.0012). CONCLUSIONS Surgery with a postauricular approach is associated with higher pain and opioid use following otologic surgery. Patient- and approach-specific opioid prescribing is feasible following otologic surgery.

INTRODUCTION We describe the effect of a state mandated opioid consent on opioid utilization and multimodal pain use for major pediatric genitourinary surgeries. METHODS All patients who underwent an inpatient pediatric genitourinary surgery at the Children's Hospital of Pittsburgh between August 2015 and February 2020 were identified. Inpatient and outpatient multimodal pain control utilization were assessed. Delayed prescriptions or emergency department visits within 30 days were identified and when applicable referenced against National Surgical Quality Improvement Program data. RESULTS After accounting for a 6-month transition period following policy implementation, 462 major pediatric genitourinary procedures were identified. The frequency of discharge opiate prescriptions decreased from 68.4% prior to the transition period to 10.7% afterward(p

Background Clavicle fractures are common. An emergency physician needs to understand the diagnostic classifications of clavicle fractures, have a plan for immobilization, identify associated injuries, understand the difference between treating pediatric and adult patients, and have an approach to multimodal pain control. It is also important to understand when expert orthopedic consultation or referral is indicated. Objective of the Review To provide an evidence-based review of clavicle fracture management in the emergency department. Discussion Clavicle fractures account for up to 4% of all fractures evaluated in the emergency department. They can be separated into midshaft, distal, and proximal fractures. They are also classified in terms of their degree of displacement, comminution and shortening. Emergent referral is indicated for open fractures, posteriorly displaced proximal fractures, and those with emergent associated injuries. Urgent referral is warranted for fractures with greater than 100% displacement, fractures with >2 cm of shortening, comminuted fractures, unstable distal fractures, and floating shoulder. Nondisplaced or minimally displaced fractures with no instability or associated neurovascular injury are managed non-operatively with a sling. Pediatric fractures are generally managed conservatively, with adolescents older than 9 years-old for girls and 12 years-old for boys being treated using algorithms that are similar to adults. Conclusions When encountering a patient with a clavicle fracture in the emergency department the fracture pattern will help determine whether emergent consultation or urgent referral is indicated. Most patients can be discharged safely with sling immobilization and appropriate outpatient follow-up.

Many dairy farmers in North America disbud or dehorn their cattle to improve human and animal safety. The Farmers Assuring Responsible Management (FARM v. 4.0) program requires that disbudding be performed before 8 wk of age with pain-control medication. The objective of this observational cross-sectional study was to quantify disbudding and dehorning practices of Wisconsin dairy producers to target future extension programming. Responses from 217 Wisconsin dairy producers and calf raisers were collected via digital surveys distributed at extension events and through industry contacts. Of the 217 respondents, 188 performed on-farm disbudding themselves. Most respondents (61%) used caustic paste as their primary method, which was most commonly applied on the day the calf was born (53%). Hot iron was used by 32% of respondents, and surgical methods (gouge, scoop, or wire saw) were used by 6% of respondents. Hot-iron disbudding was most commonly performed at 4 to 8 wk of age (41%) and 1 to 4 wk of age (33%), whereas surgical methods were most commonly performed at 8 wk or older (73%). Pain-control medication was used by 43% of respondents. Specifically, 35% used an anti-inflammatory, and 21% used a local nerve block. Veterinary involvement in creating the disbudding protocol was associated with increased odds of using pain control. Respondents with a target weaning age of ≥10 wk had greater odds of complying with FARM disbudding requirements and were also more likely to use polled genetics. Respondents aged 18 to 34 and respondents with >60 calves were more likely to have made changes to their disbudding or dehorning protocol in the last decade. Although use of pain control was higher than in previous US studies, full adoption of pain management requires further extension efforts. Veterinarians appeared influential on adoption of pain control, and their involvement may encourage adoption of pain management. Further research should investigate how the implementation of new FARM v. 4.0 standards will change the disbudding and dehorning practices of American dairy producers.

Rib fractures represent a significant cause of morbidity and mortality in trauma patients. The erector spinae plane block has come to the forefront as a potential safe and effective option for analgesia in painful conditions of the thorax over multiple dermatomal levels. Given the high morbidity associated with rib fractures, the inadequacy of opioid analgesia and the strong safety profile of the erector spinae plane block, this pilot study sought to address whether this block can be used to safely and effectively provide analgesia in emergency department (ED) patients with acute rib fractures.A total of nine patients underwent the procedure successfully. Patients were found to have a significant reduction in their pain score pre- and post-block. The reduction in mean pre- and post-block pain scores was 9.89 vs 3.56 which was statistically significant (p 0.0001).In a pilot sampling of emergency department patients with acute fractures who failed traditional analgesic therapy, the erector spinae plane block performed by emergency physicians provided safe and effective pain control. Further research is needed to fully establish the clinical benefit and safety of this procedure.RéSUMé: OBJECTIFS: Les fractures des côtes représentent une cause importante de morbidité et de mortalité chez les patients traumatisés. Le bloc du plan des muscles érecteurs du rachis est apparu comme une option potentiellement sûre et efficace pour l’analgésie dans les états douloureux du thorax sur plusieurs niveaux dermatomiques. Compte tenu de la morbidité élevée associée aux fractures des côtes, de l’insuffisance de l’analgésie opiacée et du profil d’innocuité solide d'un bloc du plan des muscles érecteurs du rachis, cette étude pilote visait à déterminer si ce bloc peut être utilisé pour fournir une analgésie sûre et efficace aux patients des urgences présentant des fractures aiguës des côtes. MéTHODES: Au total, neuf patients ont subi l’intervention avec succès. On a constaté que les patients avaient une réduction significative de leur score de douleur avant et après le blocage. La réduction des scores moyens de la douleur avant et après le blocage était de 9.89 contre 3.56, ce qui était statistiquement significatif (p 0.0001). CONCLUSION: Dans le cadre d’un projet pilote d’échantillonnage de patients des services d’urgence ayant subi des fractures aiguës et ayant échoué à la thérapie analgésique traditionnelle, le bloc du plan des muscles érecteurs du rachis effectué par les médecins urgentistes a permis de contrôler efficacement et en toute sécurité la douleur. Des recherches supplémentaires sont nécessaires pour établir pleinement les avantages cliniques et la sécurité de cette procédure.

Hypnotisability is a multidimensional trait predicting the proneness to enter hypnosis and/or accept suggestions and is associated with several psychophysiological correlates. This scoping review reports the differences between individuals with high (highs) and low hypnotizability (lows) in the left cerebellar lobules IV–VI grey matter volume, in the excitability of the right motor cortex and in motor and non-motor functions in which the cerebellum may be involved. A reduced cerebellar inhibition may explain the greater excitability of the highs’ right motor cortex. The latter may be involved in their greater proneness to ideomotor behaviour following sensorimotor suggestions. The associated experience of involuntariness and effortlessness could be due to the motor cortex greater excitability as well as to activation of a specific cerebellar-parietal circuit. Looser postural and visuomotor control with no learning across trials and greater attentional stability can be accounted for by a less accurate cerebellar predictive model of information processing. The highs’ stronger functional equivalence between imagery and perception/action and greater motor excitability may be involved in the highs’ greater proneness to respond to emotional stimuli. Paradoxical pain control may depend on reduced cortical inhibition of the pain matrix by the cerebellum. Cerebellar hypotheses are not alternative to other physiological mechanisms and should be tested in future research.

The use of stereotactic body radiation therapy (SBRT) to treat non-spine bone metastases (NSBM) is becoming increasingly common in clinical practice. The clinical advantages of SBRT include good pain control and high local control rates, although only limited data are available. The Spanish Society of Radiation Oncology (SEOR) SBRT group recently convened a task force of experts in the field to address key questions related to SBRT for NSBM, including treatment indications, planning, techniques, and dose fractionation. The task force reviewed the available literature to develop evidence-based recommendations for the safe application of NSBM SBRT and to standardize and optimize SBRT processes. The present document provides a comprehensive analysis of the available data, including ongoing clinical trials and controversies, providing clinically applicable recommendations.

Background Alveolar Osteitis (AO) is one of the most common complications of tooth extraction. Several therapeutic interventions have been described for the treatment of AO, however, there are no treatment standardized protocols. The aim of this study was to conduct a systematic review on the efficacy in pain control of the different treatments for AO. The feasibility of the application of these interventions is also discussed. Material and Methods A structured electronic and hand search strategy was applied to PubMed, Scopus, Cochrane Library, OpenGrey, and Google Scholar between January 2010 and July 2020 to identify studies according to PRISMA guidelines. The inclusion criteria were original English and Spanish clinical trials that analyzed pain-control parameters according to visual analog scale (VAS, 0-10 scale), or pain relief patients’ percentages. Those treatments that reach VAS ≤ 4 on day 2 or before; or ≥ 85% of patients with absence of pain symptoms at day 7 or before were considered accepTable for their recommendation. Results The final review included 17 clinical trials. Among them, there were analyzed a total of 39 different AO treatments. 53,8% of the treatments fulfill the proposed parameters for pain control. Conclusions Treatment alternatives are multiple, heterogeneous, and difficult to compare. The management of AO is summarized in basic (intra-alveolar irrigation) and specific procedures (Alveogyl®, Neocones®, SaliCept Patch®, Low-Level Laser, Platelet-Rich Fibrin) that reach pain control success. They could be selected according to their availability and advantages or disadvantages. Key words:Dry socket, alveolar osteitis, treatment, management, pain control, pain relief.

Minimally invasive repair of pectus excavatum (Nuss procedure) is associated with significant pain, and efforts to control pain impact resource utilization. Bilateral thoracic intercostal nerve cryoablation has been proposed as a novel technique to improve post-operative pain control, though the impact on hospital cost is unknown.We conducted a retrospective study of patients undergoing a Nuss procedure from 2016 to 2019. Patients who received cryoablation were compared to those that received traditional pain control (patient-controlled analgesia or epidural). Outcome variables included postoperative opioid usage (milligram morphine equivalents, MME), length of stay (LOS), and hospital cost.Thirty-five of 73 patients studied (48%) received intercostal nerve cryoablation. LOS (1.0 vs 4.0 days, p 0.01) and total hospital cost ($21,924 versus $23,694, p = 0.04) were decreased in the cryoablation cohort, despite longer operative time (152 vs 74 min, p 0.01). Cryoablation was associated with decreased opioid usage (15.0 versus 148.6 MME, p 0.01) during the 24 h following surgery and this persisted over the entire postoperative period, including discharge opioid prescription (112.5 vs 300.0 MME, p 0.01).Bilateral intercostal nerve cryoablation is associated with decreased postoperative opioid usage and decreased resource utilization in pediatric patients undergoing a minimally invasive Nuss procedure for pectus excavatum.Retrospective comparative study, level III.

Introduction Bone metastases are frequent in patients with cancer. Electrochemotherapy (ECT) is a minimally invasive treatment. Preclinical and clinical studies supported the use of ECT in patients with metastatic bone disease (MBD). The purposes of this multicentre study are to confirm the safety and efficacy of ECT, and to identify appropriate operating procedures in different MBD conditions. Materials and methods 102 patients were treated in 11 Centres and recorded in the REINBONE registry (a shared database protected by security passwords): clinical and radiological information, ECT session, adverse events, response, quality of life indicators and duration of follow-up were registered. Results 105 ECT sessions were performed (one ECT session in 99 patients, two ECT sessions in 3 patients). 24 patients (23.5%) received a programmed intramedullary nail after ECT, during the same surgical procedure. Mean follow-up was 5.9 ± 5.1 months (range 1.5–52). The response to treatment by RECIST criteria was 40.4% objective responses, 50.6% stable disease and 9% progressive disease. According to PERCIST criteria the response was: 31.4% OR; 51.7% SD, 16.9% PD with no significant differences between the 2 criteria. Diagnosis of breast cancer and ECOG values 0–1 were significantly associated to objective response. A significant decrease in pain intensity and significant better quality of life was observed after ECT session at follow-up. Conclusion The results are encouraging on pain and tumour local control. ECT proved to be an effective and safe treatment for MBD and it should be considered as an alternative treatment as well as in combination with radiation therapy.

An abuse-deterrent, microsphere-in-capsule extended-release formulation of oxycodone myristate (Xtampza® ER, Collegium Pharmaceutical Inc, Canton, Massachusetts), was approved by the FDA in 2016 for the management of pain. The advantage of this formulation of oxycodone is that the microspheres can be administered via enteral tubes without compromising the long-acting formulation. This case series characterizes the experiences of five head and neck cancer patients initiated on oxycodone myristate through enteral tube administration for control of cancer-related pain. The primary outcome of patient reported subjective improvement in pain within one week occurred in all five patients. The median time to pain control was 4 days. The safety profile of oxycodone myristate was consistent with the package insert with no new findings reported. Oxycodone myristate can be an appropriate long-acting opioid analgesic option for patients requiring enteral tube administration of medications to achieve adequate cancer-related pain control.

Objective: To evaluate the healing of open upper lip vermillion wounds irradiated with CO2 laser immediately after injury. Background: There are reports of using CO2 laser therapy on healed wounds for scar tissue reduction. However, limited data exist regarding its use immediately after an injury. Thus, the role of CO2 laser in wound healing remains unclear. Methods: Two patients with open upper lip vermillion wounds were treated using CO2 laser irradiation to the area postsuturing. Results: Good functional and aesthetic results were obtained from the therapy, with no postoperative pain complaints or infection. Conclusions: CO2 laser irradiation, performed immediately after an injury, could be an effective treatment option for open vermillion wounds.

Background: Tumor Necrosis Factor -a (TNF-a) and Interleukin-113 (IL-113) are among the cytokines released secondary to the surgical stress response. The objective of this study was to investigate the effect of a Transversus Abdominis Plane (TAP) block on postoperative pain and its immunomodulatory activity through proinflammatory cytokines. Methods: TAP (study group; n = 40) or p-TAP (placebo group; n = 40). Patients in the TAP group underwent an Ultrasound (US) guided unilateral TAP block using 20-cc 0.5% bupivacaine solution. Patients in the p-TAP group underwent a sham block using 20-cc isotonic solution. The TNF-a and IL-113 levels were measured three times at preoperative hour-0 and postoperative hours 4 and 24. Visual Analog Scale (VAS) scores were recorded at 0-hours, 30-minutes, 4-hours, and 24-hours. Analgesic use within the first 24-hours following surgery was monitored. Results: The postoperative VAS score was decreased in the TAP group at all time points (0, 4, and 24 hours), and the differences between groups were statistically significant (p < 0.001 for all comparisons). In the TAP group, the TNF-a and IL-113 levels at 4 and 24 hours post operation were significantly lower than the preoperative levels (p < 0.001 for all comparisons). Conclusion: The TAP block for pre-emptive analgesia enabled effective hemodynamic control during the intraoperative period, provided effective pain control in the postoperative period, and decreased inflammation and surgical stress due to the decreased levels of the proinflamma-tory cytokines TNF-ec and IL-1 beta in the first postoperative 24 hours, indicating immunomodulatory effect. (c) 2021 Published by Elsevier Editora Ltda. on behalf of Sociedade Brasileira de Anestesiologia. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).

BACKGROUND Improving pain control and decreasing opioid prescription and usage continue to be emphasized across both pediatric and adult populations. The purpose of this review is to provide a comprehensive assessment of recent literature and highlight new advancements pertaining to pain control in pediatric orthopaedic surgery. METHODS An electronic search of the PubMed database was performed for keywords relating to perioperative pain management of pediatric orthopaedic surgery. Search results were filtered by publication date for articles published between January 1, 2015 and December 1, 2020 and yielded 404 papers. RESULTS A total of 32 papers were selected for review based upon new findings and significant contributions in the following categories: risk factors for increased opioid usage, opioid overprescribing and disposal, nonpharmacologic interventions, nonsteroidal anti-inflammatory drugs, peripheral nerve blocks, spine surgery specific considerations, surgical pathway modifications, and future directions. CONCLUSIONS There have been many advances in pain management for pediatric patients following orthopaedic surgery. Rapid recovery surgical care pathways are associated with shorter length of stay and improved pain control in pediatric spine surgery. Opioid overprescribing continues to be common and information regarding safe opioid disposal practices should be routinely provided for pediatric patients undergoing surgery. LEVEL OF EVIDENCE Level IV-literature review.

Optimal post-cesarean pain control is important. With the rising opioid epidemic it is imperative to maximize non-opioid based primary approaches to post-cesarean pain control. In 2018, we implemented a standardized post-cesarean analgesia regimen.To determine if implementation of a standardized postoperative analgesic regimen decreases opioid use following cesarean birth.A standardized postoperative analgesia protocol was implemented in June 2018, which included scheduled oral acetaminophen (975 mg every 6 h) and nonsteroidal anti-inflammatory drugs (NSAIDs) (ketorolac 15 mg IV every 6 h for 5 doses followed by ibuprofen 600 mg oral every 6 h) with opioids available for breakthrough pain. There was no prior standardized protocol. A before-and-after study design was used to compare oral morphine milligram equivalents (MME) for nine months prior to and nine months after this protocol was implemented, excluding the two month period of protocol rollout. Women with opioid use disorder or postoperative intubation were excluded. The primary outcome was the cumulative MME used in the first 72 h postoperatively. Total dose at 12, 24, and 48 h were also compared.Of 2340 women who underwent cesarean birth during the study period (1 July 2017 - 30 April 2019), 2001 women met inclusion criteria (914 before 10 April 2018 (pre-protocol) and 1087 after 17 June 2018 (post-protocol)). Baseline characteristics of the two groups were similar, including gestational age at delivery, maternal body mass index (BMI), planned versus unplanned cesarean birth, and type of intraoperative anesthesia used. The cumulative opioid dose in the first 72 h postoperatively was 216.3 ± 84.3 MME prior to implementation compared to 171.5 ± 91.5 MME following implementation (Scheduled administration of acetaminophen and NSAIDs following cesarean birth significantly decreased the cumulative dose of opioids used in the first 72 h postoperatively.

BACKGROUND Rib fractures are uncommon in children and are markers of extreme traumatic force from high-energy or nonaccidental etiology. Traditional care includes nonoperative management, with analgesia, ventilator support, and pulmonary physiotherapy. Surgical stabilization of rib fractures (SSRFs) has been associated with improved outcomes in adults. In children, SSRF is performed and its role remains unclear, with data only available from case reports. We created a collected case series of published pediatric SSRF cases, with the aim to provide a descriptive summary of the existing data. METHODS Published cases of SSRF following thoracic trauma in patients younger than 18 years were identified. Collected data included demographics, injury mechanism, associated injuries, surgical indication(s), surgical technique, time to extubation, postoperative hospital stay, and postoperative follow-up. RESULTS Six cases were identified. All were boys, with age range 6 to 16 years. Injury mechanism was high-energy blunt force in all cases, and all patients suffered multiple associated injuries. Five of six cases were related to motor vehicles, and one was horse-related. Indication(s) for surgery included ventilator dependence in five, significant chest deformity in two, and poor pain control in one case. Plating systems were used for rib stabilization in five of six cases, while intramedullary splint was used in one. All patients were extubated within 7 days following SSRF, and all were discharged by postoperative Day 20. On postoperative follow-up, no SSRF-related major issues were reported. One patient underwent hardware removal at 2 months. CONCLUSION Surgical stabilization of rib fractures in children is safe and feasible, and should be considered as an alternative to nonoperative therapy in select pediatric thoracic trauma cases. Potential indications for SSRF in pediatric patients include poor pain control, chest wall deformity, or ventilator dependence. Further studies are needed to establish the role and possible benefits of SSRF in pediatric thoracic trauma. LEVEL OF EVIDENCE Collected case series, level V.

BACKGROUND Removal of a chest tube is a painful procedure for infants. Medications, including narcotics, are used to control pain, but nonpharmacologic interventions are also effective in reducing pain during this procedure and are not associated with adverse effects. PURPOSE To evaluate the additive effect of facilitated tucking to the use of morphine on infant pain associated at the time of chest tube removal. METHODS This was a prospective, randomized control study. Sixty infants were randomized into 2 equal groups utilizing a coin flip. All infants received 0.05-mg/kg morphine 20 minutes before chest tube removal. The intervention group received facilitated tucking and the control group received standard care. Infant pain was measured using the Neonatal Infant Pain Scale. Pain was assessed at 3 time points by 2 independent evaluators: 5 minutes before, during, and 5 minutes after removal of the chest tube. Mann-Whitney and Fisher's exact (Chi-square) tests were used to compare the intervention and control groups. RESULTS Pain scores were increased during chest tube removal for both the intervention and the control groups. Compared with the control group, pain scores for infants in the intervention group were less before, during, and after chest tube removal. IMPLICATIONS FOR PRACTICE Facilitated tucking combined with morphine administration can be an effective additive intervention for pain control in infants during chest tube removal. IMPLICATIONS FOR RESEARCH Evaluate the effect of the facilitated tucking on pain induced by chest tube removal in preterm infants. Preterm infants may respond differently to pain.

To determine whether a postoperative prescription for opioids affects parental assessment of pain control following pediatric circumcision.This postoperative survey assessed the parental assessment of pain control in 199 patients, ages18 years undergoing circumcision. This study was conducted at a quaternary care children's hospital in Houston, Texas from December 2018 to January 2020. Postoperative pain regimens included acetaminophen and ibuprofen or combination hydrocodone/acetaminophen in addition to ibuprofen for postoperative analgesia based on the surgical preference. The primary study outcome was identification of the proportion of parents rating their child's analgesia following pediatric circumcision as poor or inadequate based on the postoperative analgesic regimen.Of the 502 surveys sent, the response rate was 40% (199/502) of those who received the survey email, and 64% (199/308) for those who opened the email. Between the opioid and nonopioid groups, there was no difference in, race/ethnicity (Caucasian; 28% vs 37%; P = .43) or insurance status (insured; 51% vs 45%; P = .44). The proportion of parents who rated their child's pain as poor or inadequately controlled following circumcision was relatively rare:5.5% and 1.1% in the nonopioid and opioid groups, respectively. Parents rating their child's pain as excellent with regards to pain control following circumcision were 61% and 53% in the nonopioids and opioid groups, respectively.The results of this study indicate that nonopioid analgesic regimens following pediatric circumcision were not associated with decreased parental satisfaction or an increasing assessment of poor or inadequately controlled pain. Limiting opioid exposure following pediatric circumcision is feasible and does not result in worse parental satisfaction with the analgesic plan.

Burn injury and reconstructive operations often result in severe pain, particularly at skin graft donor sites. Traditional local anesthetics administered intraoperatively control pain at donor sites, but the duration of action is short. Liposomal bupivacaine, a novel local anesthetic, can provide sustained-release analgesia for 72h. The primary aim of this study was to describe the efficacy of liposomal bupivacaine for postoperative donor site pain control for patients undergoing skin graft procedures.A retrospective cohort study was performed on patients who received a donor site liposomal bupivacaine field block and was compared to a matched control. Patients rated donor site pain on post-operative day 0 and 1, and stated whether the donor or graft site was more painful.Fifty-eight patients were included. Twenty-nine patients received liposomal bupivacaine. Eighty-six percent of patients in the treatment group rated donor site pain as three or less on postoperative day 0 and 1, compared to 3.4% in the control (p0.0001). Also, 76% of patients in the treatment group stated donor site pain was less than graft site pain, compared to 3.4% in the control (p0.0001).Patients who received liposomal bupivacaine reported less postoperative donor site pain and found the donor site to be less bothersome without major complications. Liposomal bupivacaine may be a safe and promising agent for prolonging postoperative analgesia and minimizing donor site pain.

This case report demonstrates using buprenorphine 32 mg to achieve adequate pain control after a total knee replacement. The patient stopped buprenorphine 48 hours before surgery. He was prescribed 150 tablets of oxycodone 5 mg. After finishing oxycodone, he experienced significant pain that was relieved by 32 mg of buprenorphine daily. Urine drug screens were negative perioperatively. Patients with opioid use disorder require careful discharge planning to avoid opioid relapses or misuses of pain medications. Buprenorphine offers many unique advantages in acute pain control, including lower risk of respiratory depression, abuse potential, and lower risk of nephrotoxicity.

We report a case in which sublingual buprenorphine was used to help transition a patient off intravenous (IV) opioid analgesics medications post-multiple abdominal procedures. Intravenous opioids are commonly used in inpatient surgical pain management for patients with severe pain who are unable to take oral medications. Typically, a short course of IV analgesics is used, followed by transition to oral analgesic regimen. However, in patients with poor gastrointestinal absorption, pain control can be challenging. We present this case to highlight how sublingual buprenorphine can be a useful agent for acute pain management, especially when conventional strategies provide suboptimal responses.

International audience; Introduction: Since the development of the last generation of implants total ankle replacements (TAR) is becoming more and more popular in patients and in specialized surgeon teams, the trend for outpatient surgery is growing, and protocols now are well established for hip or knee replacement. We adapted a protocol for outpatient TAR and hypothesized that it could be performed safely as standard procedure. Patients and methods: Twenty-five consecutive patients among 141 TAR were treated with our outpatient protocol relying on three fundamentals: bleed control, pain control, and autonomy. They received 1 g of tranexamic acid before surgery, and after discard from post-operative care unit, they were operated under long-lasting nerve block precociously relayed by oral NSAIDs and had an immediate full weight-bearing authorization at discharge. Results: No patients we readmitted for an acute care following TAR, especially for haematoma or uncontrolled pain. Mean VAS was < 1 before discharge from post-operative care unit and < 2 until day 90. One patient had a delayed wound healing treated surgically at day 30 without implant revision. Conclusion: Outpatient TAR is possible and safe if a risk management process is used, and the three basic principles for outpatient procedures are respected: bleed control, pain control, and patient autonomy. We consider now this modality as a routine.

OBJECTIVES Pediatric trauma patients are injured during crucial developmental years and require subsequent absence from school and activities. The impact of these changes on pediatric trauma patients is not well studied. We sought to assess the functional and emotional impact of pediatric trauma. In addition, the inpatient experience was evaluated for performance improvement purposes. METHODS A prospective survey was conducted at our trauma center (February 2019 to May 2019) of admitted trauma patients (

Transversus abdominis plane (TAP) blocks are used in an attempt to decrease narcotic use and its subsequent consequences. The primary goal of this study was to see if TAP blocks decreased narcotic use in patients undergoing minimally invasive colorectal surgery.A randomized pilot study was conducted. The amount of narcotic used examined in morphine milligram equivalents (MME) was collected for the first 4 post-operative days (PODs). Demographic data, length of stay (LOS), readmission rate, and 90-day mortality was also examined. Statistical analysis of the data was performed with a p 0.05 determined to be significant.Eighty-eight patients were included. Forty-seven were randomized to the TAP group and 41 to the no TAP group. There was no difference in age, race, gender, indication for operation, or Charlson Comorbidity Index (p 0.05). The median MME for each POD was similar for POD 1 (22.5 vs 37.5; p = 0.054), POD 3 (15 vs 22.5; p = 0.48), and POD 4 (22.5 vs 10.5; p = 0.42) on bivariate analysis. On POD 2, the TAP group had significantly less narcotic intake than the no TAP group (17.5 vs 30; p = 0.047). However, on multivariate analysis when controlling for other variables, there was no statistical difference between the groups. Median LOS was 3 days for both groups. Readmissions, post-operative complications, and mortality were also similar between the two groups (p 0.05).Our findings indicate that continuous TAP blocks do not decrease the amount of MME used during the first 4 post-operative days compared to patient receiving traditional pain control measures.

Split-thickness skin grafts (STSG) are commonly required in reconstructive surgery but may cause significant pain. The goal of this investigator-initiated trial is to evaluate the effect of liposomal bupivacaine on donor site pain and opioid consumption. A parallel, randomized, controlled trial of adult acute burn patients with

Breath-holding spells (BHS) are commonly observed in children as a result of an autonomic nervous system disorder triggered by crying, emotional distress, or pain. There are several types of BHS and cyanotic type is one of them. We encountered a case of 3-year-old girl who presented with a delayed adaptation period and BHS 2 weeks after an endoscopic third ventriculostomy (ETV). She experienced severe headache due to increased intracranial pressure (ICP) during the delayed adaptation period, which may have contributed to the onset of BHS. Management of BHS warrants treatment of the symptoms and removal of the causative factors; in our case, intensive pain control and resolution of the increased ICP after the adaptation period were effective. While BHS are usually described as a benign condition that improves spontaneously, we highlighted the importance of recognizing and monitoring atypical symptoms such as BHS in pediatric cases.

Pain control is challenging after minimally invasive repair of pectus excavatum (MIRPE). Cryoanalgesia, which temporarily ablates peripheral nerves, improves pain control and may accelerate post-operative recovery. We hypothesized that cryoanalgesia would be associated with shorter length of stay (LOS) in children undergoing MIRPE.A matched cohort study was conducted of children (18 years) who underwent MIRPE 2016-2018, using the National Surgical Quality Improvement Program-Pediatric database. Each patient who received cryoanalgesia during MIRPE was matched to four controls (no cryoanalgesia). Univariate and multilevel regression analyses were performed.Thirty-five patients who received cryoanalgesia during MIRPE were matched to 140 controls. Patients who received cryoanalgesia had a LOS reduction with similar secondary outcomes (operative time, rates of complication, reoperation, and readmission). On multilevel regression adjusted for matched groups, cryoanalgesia was associated with a 1.3-day reduction in LOS (95% CI -1.8 to -0.8, p 0.001). On sensitivity analysis excluding patients with complications, cryoanalgesia remained associated with a LOS reduction.Cryoanalgesia is a promising adjunct in the care of pediatric patients undergoing MIRPE. Utilization is associated with a shorter LOS without an increase in operative time or complications. Cryoanalgesia should be considered for inclusion in enhanced recovery strategies for patients undergoing MIRPE.

Outpatient orthopedic surgery is gradually becoming the standard across the country, as it has been found to significantly lower costs without compromising patient care. Peripheral nerve blocks (PNBs) are largely what have made this transition possible by providing patients excellent pain control in the immediate postoperative period. However, with the increasing use of PNBs, it is important to recognize that they are not without complications. Although rare, these complications can cause patients a significant amount of morbidity. It is important for surgeons to know the risks of peripheral nerve blocks and to inform their patients.

Objective: In this study, we compared postoperative outcomes of patients submitted to varicocele correction under general or local anesthesia at a single center. Methods: All patients underwent varicocele surgical treatment with the Colpi-modified Marmar subinguinal technique. They were managed with either general (Group A) or local with ileo-inguinal and ileo-hypogastric nerves block (Group B) anesthesia. The two groups were compared in terms of timing of discharge and post-operative pain as assessed with the numeric rating scale (NRS) at both rest and movement (NRSm). §Results: Overall, 63 patients were included with a mean (SD) age of 25 years ± 5 yrs. The NRS mean score was significantly lower for Group B during the first 4 days after surgery at both rest and movement (all p < 0.05). Patients receiving local anesthesia showed a faster time to first urination (210 vs. 240 min; p = 0.02), although the time to discharge was comparable between the two groups (250 vs. 250 min). Conclusions: These results suggest that local anetshesia for varicocele surgical treatment is feasible and provide better pain control and faster recovery after surgery.