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Gynecologic surgery with minimally invasive method using robotic or laparoscopic techniques has gained popularity for reducing perioperative discomfort and length of hospital stay. However, the debate over postoperative pain superiority between traditional laparoscopy and robotic surgery persist. This study compared the postoperative pain of patients within 24 h of robotic (RM) and laparoscopic myomectomy (LM). This retrospective cohort study included 24 and 53 patients who underwent RM and LM, respectively, between January 2019 and July 2023. The primary outcomes were the postoperative pain levels of patients within 24 h and the use and dosage of postoperative analgesia. Additional perioperative analgesia, including long-acting non-steroidal anti-inflammatory drugs (Dynastat) and abdominal nerve block, was also recorded. The secondary outcomes were blood loss and hospitalization duration. The patient characteristics were similar between the groups. Factors that could potentially increase pain, such as the number of ports (p < 0.0001), additional procedures (p = 0.0195), operative time (p < 0.0001), number of myomas (p = 0.0057), and the largest myoma size (p = 0.0086), were significantly higher in the RM group than in the LM group. However, there were no significantly different in the postoperative visual analog scale pain scores, use and dosage of ketorolac and opioid, and use of Dynastat and nerve block between the groups. Hospitalization duration and intraoperative blood loss were similar between the groups. RM and LM offer comparable postoperative pain outcomes, emphasizing the importance of patient-specific factors in decision-making regarding myomectomy techniques., (© 2024. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Background: Proximal femur fracture surgeries have become increasingly prevalent, presenting unique challenges for postoperative pain management due to patient demographics and comorbidities. Erector spinae plane block (ESPB) has emerged as a relatively safe alternative to paravertebral block (PVB). Our aim was to compare ultrasound-guided continuous ESPB with continuous PVB for postoperative analgesia in patients undergoing proximal femur surgeries under spinal anesthesia., Methods: A prospective randomized interventional study was conducted on 60 patients between 18 and 60 years of age undergoing proximal femur surgeries under spinal anesthesia with American Society of Anesthesiologists physical status I and II between January 2019 and April 2020. Patients were randomly assigned to receive either ultrasound-guided continuous ESPB (Group E, n = 30) or ultrasound-guided continuous PVB (Group P, n = 30) using a computer-generated randomization table. The mean maximum visual analog scale (VAS) score, VAS score in the first 24 h, the time of rescue analgesia, and total requirement of rescue analgesia were assessed., Results: The maximum VAS score within the first 24 h was numerically higher in Group P but statistically insignificant ( p -value 0.279). VAS scores at 0, 1, 2, 6, and 18 h postoperatively were comparable in both groups. However, at the 24-h mark, the VAS score between Group E and Group P was statistically significant ( p -value 0.018) but not clinically relevant. The mean paracetamol and tramadol requirements were comparable between the two groups., Conclusion: Continuous ESPB is as effective as continuous PVB for postoperative analgesia in proximal femur surgeries. The enhanced safety profile of erector spinae block underscores its significance in postoperative pain management., (© 2024 the author(s), published by De Gruyter.)

Background: The aim of this trial was to evaluate the effect of a preoperative, single dose sublingual fast-dissolving piroxicam (20 mg) compared to placebo on postoperative pain at rest (POP), on biting (POPB) and on percussion (POPer) after single-visit endodontic treatment of asymptomatic mandibular molars with non-vital pulp., Methods: Seventy patients randomly received either piroxicam or placebo 1 h before treatment (n = 35). Patients recorded their pain (POP and POPB) level 6 h, 12 h, 24 h, 48 h, 72 h and 7 days postoperatively using an 11-point numerical rating scale; POPer was assessed after 7 days. Resuce-analgesic intake (RAI) and flare-up incidence (FUI) were recorded. Data were statistically analyzed., Results: Both groups had similar baseline characteristics (P > 0.05). Piroxicam showed less POP intensity and incidence than placebo at 6, 12 and 24 h, less POPB intensity and incidence at all timepoints, less POPer intensity and incidence and less RAI (p > 0.05), but similar FUI (P > 0.05). A significant rise in pain compared to baseline occurred with placebo from 6 to 72 h for POP and to 7 days with POPB (p > 0.05); such rise was not detected with piroxicam. POPB showed higher pain intensity than POP at all time points (p < 0.05). No swelling or adverse effects occured., Conclusions: A preoperative single dose of sublingual fast-dissolving piroxicam can be effective in reducing spontaneous pain up to 24 h, stimulated pain up to 7 days, and RAI incidence in asymptomatic mandibular molars with non-vital pulp; it can prevent rise in POP and POPB postoperatively. Stimulated postoperative pain can be more severe and longer lasting than spontaneous pain., Trial Registration: Clinicaltrials.gov ID: NCT03998826 (2019)., (© 2024. The Author(s).)

Background: Multimodal analgesia is crucial for effective postoperative pain management in minor hand surgeries, enhancing patient satisfaction. The use of local wound infiltration with Ketorolac as an adjuvant pain management strategy is proposed for open trigger finger release surgery. This study aims to compare pain scores and functional outcomes between local wound infiltration with Ketorolac and oral non-steroidal anti-inflammatory drugs., Methods: This study is a double-blind, parallel design, randomized controlled trials. Sixty-nine patients underwent trigger finger surgery between December 2021 and October 2022 were randomized into one of three groups: oral Ibuprofen alone group, local Ketorolac alone group and local Ketorolac with oral Ibuprofen group. The assessment included postoperative numeric rating scale (NRS) pain score, Disabilities of the Arm, Shoulder, and Hand (DASH) score, grip strength, mobility of proximal interphalangeal (PIP) joint. and complications., Results: NRS pain scores during movement of the operated fingers were significantly lower at 6 h in local Ketorolac alone group and local Ketorolac with oral Ibuprofen group compared to oral Ibuprofen alone group. However, there were no significant differences between the groups in postoperative DASH scores, grip strength, mobility of PIP joints, and complications., Conclusions: Local infiltration of Ketorolac as an adjunct in postoperative pain management has been shown to provide superior analgesia during finger movement within the initial 6 h following trigger finger surgery, in comparison to oral NSAIDs., Clinical Trial Registration: Thaiclinicaltrials.org identifier: TCTR20210825002. Registered 25/08/2021. https://www.thaiclinicaltrials.org/show/TCTR20210825002., (© 2024. The Author(s).)

Background: Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended for the management of acute postoperative pain as part of a multimodal strategy to reduce opioid use, relieve pain, and reduce chronic pain in non-cardiac surgery. However, significant concerns arise in cardiac surgery due to the potential adverse effects of NSAID including increased bleeding and acute kidney injury (AKI). We hypothesized that NSAIDs are effective against pain and safe in the early postoperative period following cardiac surgery, taking contraindications into account., Methods: The KETOPAIN trial is a prospective, double blind, 1:1 ratio, versus placebo multicentric trial, randomizing 238 patients scheduled for cardiac surgery. Written consent will be obtained for all participants. The inclusion criterion is patients more than 18 years old undergoing for elective cardiac surgery under cardiopulmonary bypass (CPB). Patients will be allocated to the intervention (ketoprofen) group (n = 119) or the control (placebo) group (n = 119). In the intervention group, in addition to the standard treatment, patients will receive NSAIDs (ketoprofen) at a dose of 100 mg each 12 h 48 h after. The control group, in addition to the standard treatment, will receive a placebo of NSAIDs every 12 h for 48 h after surgery. An intention-to-treat analysis will be performed. The primary endpoint will be the intensity of acute postoperative pain at rest at 24 h from the end of surgery. Pain will be assessed using the numerous rating scale. The secondary endpoints will be postoperative pain on coughing during chest physiotherapy, postoperative pain until day 7, the pain trajectory between day 3 and day 7, cumulative opioid consumption within 48 h after surgery, nausea and vomiting, the occurrence of postoperative pulmonary complications within the first 7 days after surgery, neuropathic pain at 3 months, and quality of life at 3 months., Discussion: NSAIDs function as non-selective, reversible inhibitors of the cyclooxygenase enzyme and play a role in a multimodal pain management approach. While there are recommendations supporting the use of NSAIDs in major non-cardiac surgery, recent guidelines do not favor their use in cardiac surgery. However, this is based on low-quality evidence. Major concerns regarding NSAID use in cardiac surgery patients are potential increase in postoperative bleeding or AKI. However, few studies support the possible use of NSAIDs without the risk of bleeding and/or AKI. Also, in a recent French survey, many anesthesiologists reported using NSAIDs in cardiac surgery. To date, no large randomized study has been conducted to evaluate the efficacy of NSAIDs in the management of postoperative pain in cardiac surgery. The expected outcome of this study is an improvement in the management of acute postoperative pain in cardiac surgery with a multimodal strategy including the use of NSAIDs., Trial Registration: ClinicalTrials.gov NCT06381063. Registered on April 24, 2024., (© 2024. The Author(s).)

Objective: To evaluate the effects of perioperative active warming on the core body temperature, postoperative pain, shivering and agitation in pediatric patients., Method: Children aged 2-6 years undergoing elective surgery, including orthopedic soft tissue surgeries, ear nose throat surgical procedures and general surgical interventions, all performed under general anesthesia, were randomized to receive either active warming (using the forced-air warming gowns, Bair Hugger, in the pre- and postoperative period, and a carbon fiber blanket in intraoperative period; Group A), or conventional warming using green blankets pre-and post-operatively and a carbon fiber blanket intraoperatively (Group B). Children undergoing emergency surgery, surgeries involving major body cavities (abdominal, thoracic, cranial surgery), or those with endocrinological pathologies, or baseline fever, were excluded. Core body temperature (t-core), postoperative pain, shivering and agitation scores were compared between the two groups., Results: Seventy children were included, with 35 in each group. No significant difference was observed between the groups in t-core values at 0 and 15 minutes preoperatively (P > 0.05). However, the value at 30 minutes preoperatively and all subsequent t-core values were higher in Group A (P < 0.001). Postoperative pain and shivering scores at 0 minutes, 30 minutes and 6 hours were significantly lower in Group A compared to Group B. No significant difference was observed in agitation scores in the immediate postoperative period, although, Group A showed reduced agitation at 30 minutes (P = 0.03)., Conclusion: Active warming in the pre- and post-operative period significantly maintained higher core temperatures and reduced postoperative pain and shivering in children undergoing surgery compared to those receiving conventional passive warming measures in the pre- and post-operative period.

Introduction: Total knee arthroplasty (TKA) is accompanied by severe postoperative pain, which is reported to be an important cause of chronic pain. Ultrasound-guided adductor canal block (ACB) combined with infiltration between the popliteal artery and posterior capsular of the knee (IPACK) has been proven to have a better effect on relieving acute pain after TKA. However, whether it has a significant effect on the incidence of chronic pain after TKA has not been reported. This trial was designed to investigate the effect of ultrasound-guided ACB combined with IPACK on the incidence and intensity of chronic pain after TKA., Methods: In this prospective, randomized, double-blind, placebo-controlled study, 100 subjects scheduled for TKA were randomly (1:1) divided into two groups: the ropivacaine group and the placebo group. Patients in each group received ultrasound-guided ACB + IPACK procedures with 0.25% ropivacaine or equal volume normal saline. All patients received multimodal analgesia. Pain intensity was assessed using the Numerical Rating Scale (NRS). The primary outcome was the incidence of chronic pain at 3 months after TKA by telephone follow-up. In addition, pain intensity in early resting and mobilized states, chronic pain intensity, the time to first rescue analgesia; opioid consumption; CRP and IL-6 after the operation; length of postoperative hospital stay; and cost of hospitalization and postoperative complications; as well as the function of the knee in the early stage after the operation, were recorded., Results: Ninety-one participants were included in the final analysis. At 3 months, the incidence of chronic pain was 30.4% in the ropivacaine group, significantly lower than 51.1% in the placebo group. Compared with the placebo group, the ACB + IPACK with ropivacaine group had significantly lower pain scores at 4 hours, 8 hours, 16 hours, and 24 hours after the operation; increased the knee range of motion at 8 hours and 24 hours after the operation; and a significantly decreased incidence of chronic pain at 3 months after the operation. During the follow-up period, there were no nerve block-related complications in either group., Conclusion: In the context of multimodal analgesia protocols, ACB combined with IPACK before surgery decreases the incidence and intensity of chronic pain 3 months after TKA compared with placebo injection. In addition, it reduces the NRS scores, whether at rest or during mobilization, and improves knee function within 24 hours after TKA., Trial Registration: This trial was registered in the China Clinical Trial Center (registration number ChiCTR2200065300) on November 1, 2022., (© 2024. The Author(s).)

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: There has been no consensus on what power of radiofrequency energy can be used to produce the best surgical results in patients with atrial fibrillation. In addition, patients undergoing local anesthesia and fentanyl analgesia may experience pain when radiofrequency ablation is performed. This study investigated the effect of different power radiofrequency ablations in treatment and postoperative pain in patients with atrial fibrillation., Methods: A retrospective study was performed with 60 patients who underwent radiofrequency ablation for atrial fibrillation between January and June 2023. Patients were divided into 2 groups according to the power of the radiofrequency ablation catheter used, with 30 patients in the conventional power group (35 W) and 30 patients in the high-power group (50 W). The cardiac electrophysiological indexes and postoperative pain of the 2 groups were compared., Results: Most of the procedural key parameters between the 2 groups had no significant differences. However, the total application time during radiofrequency ablation and pulmonary vein isolation time in the high-power group were significantly shorter than those in the conventional power group (p < 0.001). Patients in the high-power group reported significantly less pain than those in the conventional power group in the immediate postoperative period and the late postoperative period (p < 0.001)., Conclusions: High-power radiofrequency ablation showed a shorter treatment time, and could reduce postoperative pain compared to conventional power ablation., (© 2024. The Author(s).)

The study aimed to evaluate the effectiveness of deep subgluteal block (DSGB) for pain relief after posterolateral-approached total hip replacement. The cadaver study and observational case series assessed the spread and outcomes of ultrasound-guided DSGB. Results showed low postoperative pain scores, minimal opioid requirements, and no complications related to DSGB. Anatomical dissection revealed effective spread of the injected substance. These findings suggest that DSGB could be a promising regional analgesic technique for postoperative pain management after posterolateral-approached total hip replacement., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 International Anesthesia Research Society.)

Background: Thoracoscopic-guided thoracic paravertebral nerve block (TG-TPVB) and thoracoscopic-guided intercostal nerve block (TG-INB) are two postoperative analgesia technology for thoracic surgery. This study aims to compared the analgesic effect of TG-TPVB and TG-INB after uniportal video-asssited thoracic surgery (UniVATS)., Methods: Fifty-eight patients were randomly allocated to the TG-TPVB group and the TG-INB group. The surgical time of nerve block, the visual analog scale (VAS) scores, the consumption of sufentanil and the number of patient-controlled intravenous analgesic (PCIA) presses within 24 h after surgery, the incidence of adverse reactions were compared between the two groups., Results: The VAS scores were significantly lower during rest and coughing at 2, 6, 12, and 24 h in the TG-TPVB group than in the TG-INB group (P < 0.05). The consumption of sufentanil and the number of PCIA presses within 24 h after surgery were significantly lower in the TG-TPVB group than in the TG-INB group (P < 0.001).The surgical time of nerve block was significantly shorter in the TG-TPVB group than in the TG-INB group (P < 0.001). The incidence of bleeding at the puncture point was lower in the TG-TPVB group than that in the TG-INB group (P < 0.05)., Conclusion: TG-TPVB demonstrated superior acute pain relieve after uniVATS, shorter surgical time and non-inferior adverse effects than TG-INB., (© 2024. The Author(s).)

Objective: This randomized controlled and double-blind study aimed to investigate whether the analgesic effect of the adductor canal block (ACB) combined with the genicular nerve block (GNB) after total knee arthroplasty is noninferior to that of the adductor canal block combined with local infiltration analgesia (LIA)., Methods: A total of 102 patients undergoing total knee arthroplasty under general anesthesia were included and randomly divided into: ACB + GNB and ACB + LIA groups; the ACB + LIA group received 80 mL of 0.2% ropivacaine with adrenaline 10 µg/mL for LIA, whereas the ACB + GNB group received 4 mL of 0.2% ropivacaine for the blockade of five peri-knee nerves. The primary outcome was the median difference in the visual analog scale scores at rest at 24 h between the two groups. Secondary outcomes involved the median differences in the pain scores at other time points. Other outcomes included the cumulative dosage of opioids calculated in morphine equivalents in the first 24 h and indicators related to knee joint functional recovery., Results: In total, 36 and 38 patients were included in the ACB + GNB and ACB + LIA groups, respectively. We found that the median difference (95% confidence internal) in postoperative rest pain at 24 h (noninferiority criteria, △ = 1) was - 0.5 (- 1 to 0, p = 0.002). The median difference in cumulative opioid consumption was 1 mg (- 1 to 3, p = 0.019), meeting the noninferiority criteria, △ = 7.7 mg., Conclusions: ACB combined with GNB provides noninferior analgesia compared to ACB with LIA on the first day after total knee arthroplasty while significantly reducing local anesthetic use., Trial Registration: Name of the Registry: Chinese Clinical Trial Registry; Trial Registration Number: ChiCTR2300074274; Date of Registration. August 2, 2023., (© 2024. The Author(s).)

Background: The analgesia after lower third molar alveolectomy is based on the use of non-steroidal anti-inflammatory drugs (NSAIDs) that have significant risks, and are contraindicated in the third trimester of pregnancy. Aiming to reduce NSAIDs use after this surgery, we quantified analgesic effects of ultrasound (US)-guided extraoral mandibular nerve block., Methods: Thirty-six patients were equally allocated to the experimental or control group, based on their willingness to receive experimental US-guided extraoral mandibular nerve block for postoperative analgesia. The experimental block applied prior to lower third molar alveolectomy, was followed by standard intraoral inferior alveolar nerve block. In the control group, patients received only intraoral block of inferior alveolar nerve. All patients reported pain level (visual analogue scale, VAS) right after the application of blocks. The next day, patients reported duration of pain-free time and the use of analgesic., Results: The US-guided extraoral mandibular nerve block prolonged the pain-free time to 8 h (vs. 4 in control group, P < 0.001) and reduced NSAIDs use (12 patients needed analgesic in experimental vs. 17 patients in control group, P = 0.038). The application of experimental block was less painful (VAS = 2) than the application of intraoral inferior alveolar nerve block (VAS = 4, P = 0.011). In 8/18 patients in the experimental group US-guided extraoral mandibular nerve block solely achieved adequate surgical anesthesia., Conclusion: US-guided extraoral mandibular nerve block prolonged pain-free period and reduced the use of NSAIDs after lower third molar alveolectomy, thus proving to be successful analgesia method for this dental surgery., Clinical Trial Registration: https://classic., Clinicaltrials: gov/ct2/show/NCT06009302 , identification number: NCT06009302, date of registration: 18/08/2023., (© 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).)

Over time, the focus of evidence-based acute pain medicine has shifted, from a focus on drugs and interventions (characterized by numbers needed to treat), to an appreciation of procedure-specific factors (characterized by guidelines and meta-analyses), and now anesthesiologists face the challenge to integrate our current approach with the concept of precision medicine. Psychometric and biopsychosocial markers can potentially guide clinicians on who may need more aggressive perioperative pain management, or who would respond particularly well to a given analgesic intervention. The challenge will be to identify an easily assessable set of parameters that will guide perioperative physicians in tailoring the analgesic strategy to procedure and patient., 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.)

Background: Percutaneous auricular nerve stimulation (neuromodulation) involves implanting electrodes around the ear and administering an electric current. A device is currently available within the USA cleared to treat symptoms from opioid withdrawal, and multiple reports suggest a possible postoperative analgesic effect. The current randomized controlled pilot study was undertaken to (1) determine the feasibility and optimize the protocol for a subsequent definitive clinical trial; and (2) estimate the treatment effect of auricular neuromodulation on postoperative pain and opioid consumption following two ambulatory surgical procedures., Methods: Within the recovery room following cholecystectomy or hernia repair, an auricular neuromodulation device (NSS-2 Bridge, Masimo, Irvine, California, USA) was applied. Participants were randomized to 5 days of either electrical stimulation or sham in a double-blinded fashion., Results: In the first 5 days, the median (IQR) pain level for active stimulation (n=15) was 0.6 (0.3-2.4) vs 2.6 (1.1-3.7) for the sham group (n=15) (p=0.041). Concurrently, the median oxycodone use for the active stimulation group was 0 mg (0-1), compared with 0 mg (0-3) for the sham group (p=0.524). Regarding the highest pain level experienced over the entire 8-day study period, only one participant (7%) who received active stimulation experienced severe pain, versus seven (47%) in those given sham (p=0.031)., Conclusions: Percutaneous auricular neuromodulation reduced pain scores but not opioid requirements during the initial week after cholecystectomy and hernia repair. Given the ease of application as well as a lack of systemic side effects and reported complications, a definitive clinical trial appears warranted., Trial Registration Number: NCT05521516., Competing Interests: Competing interests: BMI, WBA, BA, JFS, ETS, BA, and JJF—the University of California San Diego has received funding and/or product from the following companies for other research studies of these authors: Epimed International (Dallas, Texas, USA), SPR Therapeutics (Cleveland, Ohio, USA), Infutronix (Natick, Massachusetts, USA), Avanos Medical (Irvine, California, USA), Masimo (Irvine, CA, USA), and Varian Medical Systems (Palo Alto, California, USA). Th remaining authors have no conflicts to disclose., (© American Society of Regional Anesthesia & Pain Medicine 2024. Re-use permitted under CC BY-NC. No commercial re-use. Published by BMJ.)

Background/importance: Cleft palate surgery is associated with significant postoperative pain. Effective pain control can decrease stress and agitation in children undergoing cleft palate surgery and improve surgical outcomes. However, limited evidence often results in inadequate pain control after cleft palate surgery., Objectives: The aim of this review was to evaluate the available evidence and to develop recommendations for optimal pain management after cleft palate surgery using procedure-specific postoperative pain management (PROSPECT) methodology., Evidence Review: MEDLINE, Embase, and Cochrane Databases were searched for randomized controlled trials and systematic reviews assessing pain in children undergoing cleft palate repair published in English language from July 2002, through August 2023., Findings: Of 1048 identified studies, 19 randomized controlled trials and 4 systematic reviews met the inclusion criteria. Interventions that improved postoperative pain, and are recommended, include suprazygomatic maxillary nerve block or palatal nerve block (if maxillary nerve block cannot be performed). Addition of dexmedetomidine to local anesthetic for suprazygomatic maxillary nerve block or, alternatively, as intravenous administration perioperatively is recommended. These interventions should be combined with a basic analgesic regimen including acetaminophen and nonsteroidal anti-inflammatory drugs. Of note, pre-incisional local anesthetic infiltration and dexamethasone were administered as a routine in several studies, however, because of limited procedure-specific evidence their contribution to pain relief after cleft palate surgery remains unknown., Conclusion: The present review identified an evidence-based analgesic regimen for cleft palate surgery in pediatric patients., Prospero Registration Number: CRD42022364788., Competing Interests: Competing interests: GJ has received honoraria for consultation from Merck., (© American Society of Regional Anesthesia & Pain Medicine 2024. Re-use permitted under CC BY-NC. No commercial re-use. Published by BMJ.)

Introduction: Genicular nerve blocks (GNBs) are an emerging technique that have been used as a part of multimodal analgesia for total knee arthroplasty. The efficacy of intraoperative landmark-based GNBs, a recently introduced technique, has been established. We hypothesized that it would provide non-inferior postoperative analgesia compared with periarticular infiltration (PAI) when combined with continuous adductor canal block., Methods: This study randomized 140 patients undergoing total knee arthroplasty to receive either intraoperative landmark-based GNB (GNB group) or PAI (PAI group), with 139 completing the study. The primary outcomes were the pain scores at rest and during movement at 12 hours postoperatively on an 11-point Numerical Rating Scale; the non-inferiority margin was 1. Pain scores at additional time points, intravenous morphine consumption, time to first rescue analgesia, functional performance and muscle strength tests, and sleep disturbance were also assessed., Results: At 12 hours postoperatively, the PAI and GNB groups had median resting pain scores of 0 (0-2) and 0 (0-2), respectively. The median difference was 0 (95% CI -0.4 to 0.4, p=1), with the 95% CI upper limit below the prespecified non-inferiority margin. The median pain score during movement was 1.5 (0-2.3) and 2 (1-3.1) in the PAI and GNB groups, respectively. The median difference was 0.9 (95% CI 0.3 to 1.6, p=0.004), failing to demonstrate non-inferiority. The GNB group had higher intravenous morphine consumption at 12 hours postoperatively and a shorter time to first rescue analgesia., Conclusions: GNB compared with PAI provides non-inferior resting pain relief. Non-inferiority was not established for pain during movement., Trial Registration Number: TCTR20220406001 (www.thaiclinicaltrials.org)., 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.)

Background: Local anesthetics are used in various sites and mechanisms to maximize perioperative analgesia and reduce opioid use and side effects. Pain management in the bariatric setting is challenging and the efficacy of local anesthetics intraoperatively is under current evaluation., Objectives: To determine the safety and efficacy of a new intra-abdominal anesthetic technique performed during laparoscopic bariatric operations: visceral block., Methods: During this prospective randomized double-blinded pilot study, 16 patients undergoing bariatric surgery were treated with the injection of ropivacaine to the anterior esophagogastric junction fat, and 15 were injected with saline as control., Results: The procedure was shown to be safe, and no adverse events nor side effects were encountered. A non-statistically significant trend toward the use of a non-opioid analgesia was documented during the first postoperative hours., Conclusions: Visceral block is a safe and feasible intraoperative procedure. A trend toward its efficacy warrants future larger scale studies.

Objective: Upper airway stimulation effectively treats patients with obstructive sleep apnea, especially among those with low long-term compliance with continuous positive airway pressure. Traditional methods to implant the hypoglossal nerve stimulator involve retraction of the digastric tendon to identify the nerve and improve exposure for stimulator implantation. Transient submental pain and discomfort are known side effects of the procedure. Placement without retraction provides an alternative approach to minimize postoperative pain. This study compares post-operative pain outcomes of patients in whom the digastric tendon was and was not retracted., Methods: Retrospective chart review of patients who received the hypoglossal nerve stimulation implant at a single institution between 2017 and 2021. A combination of descriptive and qualitative data, including age, gender, comorbidities, and postoperative symptoms are analyzed to characterize patient outcomes resulting from this intraoperative technique. The categorical and continuous variables were analyzed using chi-squared tests and independent t-tests, respectively., Results: Patients report overall satisfaction after implantation and titration. A total of 108 patients underwent HGNS implantation between September 2017 and January 2021 using the aforementioned techniques. 1.69 % of patients experienced postoperative submental pain as compared to 18.37 % prior to the change in technique (p < 0.01)., Conclusion: Avoidance of digastric tendon retraction in the implantation of the stimulating lead is a safe and effective technique that reduces postoperative pain and discomfort. Our institution has demonstrated an alternative technique for hypoglossal stimulator implantation which improves perioperative outcomes., Lay Summary: Upper airway stimulation is an effective treatment for obstructive sleep apnea. During surgery, the digastric tendon is often moved to identify the nerve and improve access. This study shows that avoiding digastric tendon movement safely reduces postoperative pain and discomfort., Level of Evidence: III., Competing Interests: Declaration of competing interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Effective postoperative pain management is essential for patient satisfaction and an uneventful postoperative course, particularly in body contouring procedures. Systemic analgesic regimens can be supported by regional procedures, such as the transverse abdominis plane (TAP) block, but these have a limited duration of action. In contrast, thoracic epidural analgesia offers the possibility of a longer-lasting, individualized regional anesthesia administered by a patient-controlled analgesia pump., Objectives: The aim of this study was to investigate the effects of a patient-controlled epidural analgesia to better classify the clinical value of this procedure in abdominoplasties., Materials and Methods: This work reviewed the digital medical charts of patients who underwent selective abdominoplasty without combined surgical procedures between September 2018 and August 2022. Evaluated data comprise the postoperative analgesia regimen, including on-demand medication, mobilization time, inpatient length of stay, and clinical outcome. The patients were grouped by the presence of a thoracic epidural catheter. This catheter was placed before anesthetic induction and a saturation dose was preoperatively applied. Postoperative PCEA patients received a basal rate and could independently administer boluses. Basal rate was individually adjusted during daily additional pain visits., Results: The study cohort included 112 patients. Significant differences in the demand for supportive nonepidural opiate medication were shown between the patient-controlled epidural analgesia (PCEA) group (n = 57) and the non-PCEA group (n = 55), depending on the time after surgery. PCEA patients demanded less medication during the early postoperative days (POD 0: PCEA 0.13 (±0.99) mg vs non-PCEA 2.59 (±4.55) mg, P = 0.001; POD 1: PCEA 0.79 mg (±3.06) vs non-PCEA 2.73 (±3.98) mg, P = 0.005), but they required more during the later postoperative phase (POD 3: PCEA 2.76 (±5.60) mg vs non-PCEA 0.61 (±2.01) mg, P = 0.008; POD 4: PCEA 1.64 (±3.82) mg vs non-PCEA 0.07 (±2.01) mg, P = 0.003). In addition, PCEA patients achieved full mobilization later (PCEA 2.67 (±0.82) days vs non-PCEA 1.78 (±1.09) days, P = 0.001) and were discharged later (PCEA 4.84 (±1.23) days vs non-PCEA 4.31 (±1.37) days, P = 0.005)., Conclusion: Because the postoperative benefits of PCEA are limited to potent analgesia immediately after abdominoplasty, less cumbersome, time-limited regional anesthesia procedures (such as TAP block) appear not only adequate but also more effective., Competing Interests: Disclosure Statement: None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. The authors declare that they have no conflict of interest. This research received no specific grant neither from National Institutes of Health (NIH), Wellcome Trust, Howard Hughes Medical Institute (HHMI), RCUK, nor from any other funding agency in the public, commercial, or not-for-profit sectors., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Ovariohysterectomy is a common surgical procedure in pet rabbits and one of its potential complications is postoperative gastrointestinal stasis, possibly exacerbated by prolonged surgery time. The objective of this prospective clinical study was to compare two techniques for surgical haemostasis with respect to procedural duration, postoperative pain, and return of gastrointestinal function, in 22 female rabbits undergoing ovariohysterectomy. Rabbits were assigned to one of two groups: conventional vessel ligation (CVL) and haemostasis with a vessel sealing device (VSD). The outcome variables for comparison between the two groups, recorded at 60-, 120-, 180-, and 360-minutes post anaesthesia, were duration of anaesthesia and surgery, postoperative Rabbit Grimace Scale scores, and measured food intake and faecal output. The vessel sealing device caused no appreciable blood loss. The duration of both surgery and anaesthesia was shorter in group VSD (20 ± 4 and 31 ± 6 minutes, respectively) than in group CVL (43 ± 9 and 54 ± 9 minutes, respectively) (p < 0.001). There were no differences between groups in time elapsed from the end of anaesthesia to both first food intake and first defecation. In both groups, the score of the Rabbit Grimace Scale decreased over time with statistically significant differences between 60 minutes and all the subsequent time points (p < 0.001). Vessel sealing devices may be recommended over conventional haemostasis for rabbit ovariohysterectomy to decrease the duration of surgery and anaesthesia, with potential beneficial effects on sustainability and practice workflow., Competing Interests: Declaration of competing interest The authors have no conflict of interest to declare., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Study Objective: To assess the effect of preoperative bilateral ultrasound-guided quadratus lumborum nerve block (QLB) on quality of recovery after minimally invasive hysterectomy, in an enhanced recovery after surgery setting., Design: Randomized, controlled, double-blinded trial (Canadian Task Force level I)., Setting: University-affiliated tertiary medical center., Patients: All women undergoing an elective robotic or laparoscopic hysterectomy. Women with chronic pain, chronic anticoagulation, and body mass index >50 kg/m 2 were excluded., Intervention: Patients were randomized with a 1:1 allocation, to one of the following 2 arms, and stratified based on robotic versus laparoscopic approach. 1. QLB: QLB (bupivacaine) + sham local trocar sites infiltration (normal saline) 2. Local infiltration: sham QLB (normal saline) + local infiltration (bupivacaine) MEASUREMENTS AND MAIN RESULTS: The primary outcome was defined as the quality of recovery score based on the validated questionnaire Quality of Recovery, completed 24 hours postoperatively. Secondary outcomes included dynamic pain scores, accumulated opioid consumption up to 24 hours, postoperative nausea and vomiting, surgical complications, length of hospital stay, time to first pain medication administration in the postanesthesia care unit, and adverse events. A total of 76 women were included in the study. Demographic characteristics were similar in both groups. Median age was 44 years (interquartile range 39-50), 47% of the participants were African American, and mean body mass index was 32.8 kg/m 2 (standard deviation [SD] 8.1). The mean Quality of Recovery score was 179.1 (SD ± 10.3) in the QLB and 175.6 (SD ± 9.7) for the local anesthesia group (p = .072). All secondary outcomes were comparable between groups., Conclusions: QLBs do not significantly improve quality of recovery after elective robotic or laparoscopic hysterectomy compared with local anesthetic port site infiltration., (Copyright © 2024. Published by Elsevier Inc.)

Background: Dexamethasone, an efficacious anti-inflammatory agent, is widely used after tooth extraction. However, its optimal injection site is yet to be investigated., Purpose: We compare the efficacy of dexamethasone injection at different sites on postoperative sequelae after extracting mandibular impacted third molars (MITMs)., Study Design, Setting, and Sample: A prospective randomized controlled trial was conducted. Healthy adults with fully MITMs scheduled for extraction were included. Exclusion criteria were 1) patients with the systemic alteration that prevented the surgical procedure; 2) pregnancy, breastfeeding, and premenstrual period; 3) hypersensitivity to the drug under test; and 4) those who did not return for postoperative follow-up at 1, 3, and 7 days., Exposure Variable: The subjects were randomized to 3 groups. An online randomization plan generator assigned each subject to a single treatment by randomly permuting blocks. Different sites for postoperative dexamethasone injections included the buccal side of the adjacent second molar and extraction sockets. Dexamethasone injection (4 mg) on the buccal side of the adjacent second molar (group 1), an injection on the buccal side of extraction sockets (group 2), and an injection of physiological saline (0.8 mL) on the buccal side of the adjacent second molar (control)., Main Outcome Variables: The outcome variables were postoperative facial swelling, limitation of the mouth opening, postoperative pain, and postoperative quality of life evaluation. The pain was assessed using a visual analog scale at 1, 3, and 7 days, postoperatively. The quality of life was recorded throughout the Posse scale at 7 days., Covariates: The covariates are age, sex, length of operation, and type of impacted teeth and surgery., Analyses: The statistical analysis was performed using analysis of variance, repeated measures analysis of variance, χ 2 test, or Fisher's exact tests with P values < .05 considered statistically significant., Results: Our study included 58 participants with a mean age of 19.48 ± 3.31 years; group 1 (n = 24), group 2 (n = 20), and control group (n = 14). On day 3 postoperative, the swelling and trismus were significantly less in group 1 than in the other 2 groups (P < .05), and group 1 had an overall postoperative quality of life compared to other groups (P < .05). Unaffected speech function was present in 73.7% of patients in group 1, while 50% of patients in group 2 had affected speech function 3 days after the operation (P < .05). The "unable to open mouth" of the "Eating subscale" and "felt tingling" had statistical significance (P < .05)., Conclusion and Relevance: Dexamethasone injections on the buccal side of the adjacent second molar can be a viable option for treating facial swelling and limitation of mouth opening after total MITMs extraction., (Copyright © 2024 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Study Objective: A Bayesian network meta-analysis was performed to compare the analgesic efficacy of the following nerve block techniques: femoral nerve block (FNB), adductor canal block (ACB), infiltration between the popliteal artery and the capsule of the posterior knee (iPACK), and genicular nerve block (GNB) following total knee arthroplasty (TKA)., Design: Systematic review and network meta-analysis (NMA)., Patients and Measurements: We searched the Web of Science, PubMed, EMBASE, and Cochrane Library databases until September 20, 2022. Patients who were treated by any of the above four nerve block techniques (alone or in combination) after TKA were included. Patients who underwent minimally invasive knee surgery were excluded. The indicators included pain scores during rest and mobilization, opioid consumption after surgery, postsurgical mobilization function (ROM [range of motion], TUG [Timed-Up-and-Go] test) at 24 h and 48 h, and length of hospital stay. The risk of bias was assessed by the Cochrane risk of bias tool., Results: Forty-two studies involving 2857 patients were eligible for this study. This NMA suggested that ACB + iPACK was the most efficacious option for improving ambulation ability and shortening the length of hospital stay. Furthermore, ACB + iPACK was the best regimen for resting-pain and movement-pain relief (78% and 87%, respectively) and for reducing opioid consumption (90%) at 48 h. However, FNB + iPACK was the most efficacious option for relief of resting pain (42%) and reducing opioid consumption (68%) at 24 h; GNB was the most efficacious option for movement pain relief at 24 h (94%)., Conclusion: Considering both pain control and knee functional recovery, ACB + iPACK may be the optimal analgesic regimen for patients after TKA. At the same time, it significantly reduces pain and opioid consumption at 48 h. However, ACB + iPACK is not the recommended technique for short-term (24 h) pain control., Clinical Trial Registration: PROSPERO (CRD42022362322)., Competing Interests: Declaration of competing interest The authors declare that they have no conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: PEMF (pulsed electromagnetic fields) founds application in several medical fields to accelerate bone wounds healing and to reduce inflammation. The aim of our study was to evaluate the effectiveness of PEMF in reducing postoperative swelling and pain in patients undergoing orthognathic surgery., Methods: A prospective observational monocentric study was conducted on a sample of 30 patients undergone to orthognathic surgery in Maxillofacial Surgery Unit of University of Naples Federico II. The patients who followed these inclusion criteria were enrolled in the study: age ≥ 18 years, Class III malocclusion, Surgical procedure of Le Fort I osteotomy + Bilateral Sagittal Split Osteotomy (BSSO), Written informed consent. Patients were divided into two groups: Group SD) postoperative standard treatment with medical therapy and cryotherapy, Group SD + PEMF) postoperative standard therapy + PEMF. Each patient underwent a 3D facial scan, at one (1d) and four (4d) days after surgery to compare the swelling reduction. The pain score was assessed through VAS score and analgesics administration amount., Results: In SD + PEMF group, the facial volume reduction between 1d and 4d scan was on average 56.2 ml (6.23%), while in SD group, it was 23.6 ml (2.63%). The difference between the two groups was 3.6% (p = 0.0168). VAS pain values were significantly higher in SD group compared to SD + PEMF group in the second day after surgery (P = 0.021) and in the total 4 days (P = 0.008)., Conclusions: Our data suggest that PEMF is valid tool to promote faster postoperative swelling and pain reduction in patients undergoing orthognathic surgery., (© 2024. The Author(s).)

Objectives: The aim of this study is to compare the use of two different opioid delivery systems (bolus PCA with/without basal infusion) to control postoperative pain and evaluate the side effect profile in pediatric patients undergoing scoliosis surgery., Patients and Methods: 38 patients who underwent posterior spinal fusion for adolescent idiopathic scoliosis were included in the study. Patients were randomly divided into 2 groups by the computer. Patients who received only bolus PCA were named Group 1, and patients who received bolus PCA with basal infusion were named Group 2.Morphine consumption, postoperative pain assessmentduring rest, movement and coughing with numeric rating scale (NRS) and the Wong -Baker pain scale, heart rate and average blood pressure, sedation levels withRamsey sedation scale and side effects such as nausea, vomiting, itching, desaturation, and urinary retention were recorded., Results: Total mean morphine consumption (mg) was 32.7 ± 9.7 in Group 1 and 43.4 ± 9.1 in Group 2. The mean morphine consumption (mg) at 12-24 hours and 0-48 hours in Group 1 was statistically lower than Group 2 (p = 0.001). There was no significant difference between the groups in terms of median NRS scores (p = 0.55). There was no statistically significant difference in the evaluation of the groups in terms of Wong-Baker pain scale. Wong-Baker pain scale is p:0.66 at the 2nd hour, p:0.951 at the 12th hour and p:0.467 at the 24th hour.There was no statistically significant difference in Ramsay Sedation Scale evaluation between groups during each follow-up time (p > 0.05). The Ramsay Sedation Scale was p: 0.94 at the 2nd hour, p:1.0 at the 12th hour, and p:1.0 at the 24th hour. The duration of vomiting between 0-2 h, 2-24 h and 0-48 h was higher in Group 2 (p = 0.001, p = 0.024, p = 0.001)., Conclusion: The two administration settings of morphine sulphate by PCA pump have shown to be equally effective in the treatment of postoperative pain following PSF. In addition, PCA with basal infusion administration causes more opioid consumption and more systemic side effects. Therefore, the use of only bolus PCA in pediatric scoliosis surgery should be encouraged., Level of Evidence: Level II, Randomized Controlled Trial., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Background: The management of pain after shoulder surgery typically includes the use of cryotherapy and the prescription of opioid analgesics. Much focus has been placed lately on the opioid epidemic, which in part is fueled by excessive prescription of opioid medication. Previous studies have found a combination of cryotherapy and compression effective at reducing analgesic consumption and increasing recovery in patients undergoing knee and spine surgery; however, efficacy in patients undergoing shoulder surgery has not been evaluated., Purpose: To evaluate the effectiveness of a cryo-pneumatic compression device on postoperative shoulder pain, narcotic use, and quality of life when compared with standard care cryotherapy., Study Design: Randomized controlled trial; Level of evidence, 2., Methods: In total, 200 patients older than 18 years scheduled for unilateral shoulder surgery were enrolled. Patients were randomized to receive either postoperative cryo-pneumatic compression or standard care. The intervention group received a cryo-pneumatic device, while the standard care group received the treating surgeon's preferred method of postoperative care, including standard cryotherapy. Narcotic use was evaluated by the number of oral morphine milligram equivalents consumed during the postoperative period, as well as the time to cessation of narcotic use. Patient-reported outcome measures consisted of a numeric rating scale pain score, 36-item Short Form Survey, patient experience assessed using the net promoter score, and adverse events. Outcomes were evaluated at 2, 6, and 12 weeks postoperatively., Results: Patients receiving cryo-pneumatic compression reported a significant decrease in opioid consumption when compared with standard care (oral morphine milligram equivalents median, 56.1 vs 112; P = .02468). A significant increase in self-reported function was seen in the cryo-pneumatic compression group at 2 weeks when compared with standard care (mean, 61.2 vs 54.2; P = .0412)., Conclusion: In patients undergoing unilateral shoulder surgery, the use of cryotherapy with pneumatic compression, when compared with standard care, resulted in significantly decreased opioid consumption as well as increased function at 2 weeks., Registration: NCT04185064 (ClinicalTrials.gov identifier)., Competing Interests: The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Objectives: Effective posttonsillectomy analgesia is crucial for patient comfort and recovery. Fentanyl, notable for its potency, rapid action, and lipophilicity, has been successfully used in various procedures through multiple administration routes. However, the use of its nebulized form for posttonsillectomy pain has not been extensively explored. This study sought to compare the analgesic efficacy, onset time, and complications between nebulized and intravenous fentanyl in posttonsillectomy patients., Methods and Methods: In this randomized controlled trial, adult patients who underwent tonsillectomy were assigned to either an intravenous fentanyl group (1 mcg/kg) or a nebulized fentanyl group (4 mcg/kg). In both groups, fentanyl was administered when pain scores exceeded three. Pain levels were monitored every 5 minutes until they fell below four. The study also recorded the duration until the next analgesia request and noted complications (such as respiratory depression, bradycardia, chest tightness, drowsiness, nausea, pruritus, sweating, and flushing) within 24 hours. Patient exclusions were based on predetermined criteria., Results: From an initial cohort of 59 patients, 22 in the intravenous group and 27 in the nebulizer group were eligible for analysis after applying the exclusion criteria. The nebulizer group exhibited a significantly prolonged period before the next analgesia request, with a median of 683.5 minutes (interquartile range 260-1440), in contrast to the 326.7 minutes (145.0-504.7) observed in the intravenous group ( P  = .009). The time to achieve a pain score less than 4 and the incidence of side effects did not differ significantly between the groups., Conclusion: Nebulized fentanyl provided a longer duration of analgesia than intravenous fentanyl in posttonsillectomy pain management, with similar onset times and side effect profiles. These findings underscore the potential of nebulized fentanyl as an effective alternative for pain control in posttonsillectomy patients., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: We evaluated the efficacy of dexmedetomidine versus magnesium sulfate as an adjuvant to intraperitoneal (IP) bupivacaine in pediatric laparoscopic inguinal herniorrhaphy., Methods: Ninety-seven male children, ASA I-II, 1-6 years old, undergoing laparoscopic inguinal herniorrhaphy, were randomized to receive before peritoneal insufflation, IP 2 mg.kg -1 bupivacaine 0.5% combined with either 1 μg.kg -1 of dexmedetomidine (Group D), 30 mg.kg -1 of magnesium sulfate (Group M), or normal saline (Group C). All tested drugs were diluted to the volume of 10 mL with normal saline. FLACC pain scores, need for rescue analgesics, time to flatus and first stool, emetic events, adverse effects, functional recovery, and parents' satisfaction were recorded for the first 48 h postoperatively., Results: FLACC scores were significantly higher in Group C than in the other two groups at 6, 8, 12, 18, 24, and 48 hours after surgery with no differences between Groups D and M. Rescue analgesia was significantly higher in Group C with none of the children in Groups D and M requiring rescue analgesia (p = 0.001). Times to first flatus and stool, emetic events, and adverse effects did not differ among groups. Times to return to normal functional activity were comparable in all groups. Parents' satisfaction was greater in Groups D and M than in Group C (p = 0.026)., Conclusion: Dexmedetomidine and magnesium sulfate added to IP bupivacaine improved the analgesia afforded by bupivacaine in the first two postoperative days in children scheduled for laparoscopic herniorrhaphy., Competing Interests: Conflicts of interest The authors declare no conflicts of interest. There were no fundings., (Copyright © 2022 Sociedade Brasileira de Anestesiologia. Published by Elsevier España S.L.U. All rights reserved.)

Background: Despite widespread efforts to combat the opioid epidemic, an ongoing contributor to opioid misuse remains post-operative opioid overprescribing by residents. The goal of this study was to evaluate the impact of a low-cost, reproducible "just in time" intervention on opioid prescribing in dialysis access operations., Methods: Standardized opioid prescribing guidelines were emailed to residents on the vascular service on the first day of the rotation. Opioid prescriptions were reviewed for four years before and one year after this intervention. Wilcoxon rank-sum test and tests of proportions were used to compare groups., Results: Overall, 299 patients underwent dialysis access procedures. There was a decrease in patients discharged with opioids following the intervention from 58% to 36% (p ​= ​0.003). For patients prescribed opioids, the median quantity decreased from 90 to 45 oral morphine equivalents (p ​= ​0.03)., Conclusions: This low-cost and timely learning intervention may be a useful adjunct to reduce post-operative opioid prescriptions., Competing Interests: Declaration of competing interest The authors have no conflicts of interest relevant to this study to report., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Competing Interests: The authors declare no conflicts of interest.

Objectives: To assess the safety and effectiveness of perioperative ibuprofen in pediatric tonsillectomy through a meta-analysis of relevant randomized controlled trials., Methods: We conducted a comprehensive review of studies available in PubMed, SCOPUS, Embase, Web of Science, and Cochrane databases up to June 2024. This analysis compared perioperative ibuprofen administration to control groups (saline, acetaminophen, or opioids). Outcomes assessed were postoperative pain management, as indicated by the frequency of analgesic use, and morbidity rates, which included the incidence of postoperative nausea and vomiting and post-tonsillectomy hemorrhage (PTH). PTH was further categorized as primary (occurring on the day of operation) or secondary (occurring after the day of operation), and classified as type 1 (observed at home or evaluated in the emergency department without further intervention), type 2 (requiring readmission for observation), or type 3 (necessitating a return to the operating room for hemorrhage control)., Results: This analysis included nine studies involving a total of 1545 patients. Incidences of primary PTH (OR = 1.0949, 95 % CI [0.4169; 2.8755], I 2  = 0.0 %), secondary PTH (OR = 1.6433 95 % CI [0.7783; 3.4695], I 2  = 0.1 %), and overall PTH (OR = 1.4296 95 % CI [0.8383; 2.4378], I 2  = 0.0 %) were not significantly higher in the ibuprofen group than the control groups. Administration of ibuprofen led to a significant decrease in postoperative nausea and vomiting (OR = 0.4228 95 % CI [0.2500; 0.7150], I 2  = 40.0 %) and frequency of postoperative analgesic uptake (OR = 0.4734 95 % CI [0.2840; 0.7893]; I 2  = 19.8 %). There was no difference in bleeding by type between the ibuprofen and control groups., Conclusions: Our meta-analysis demonstrated that administration of ibuprofen for pediatric tonsillectomy did not significantly increase the incidence of postoperative bleeding but did decrease postoperative emesis and improve pain control., 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 B.V. All rights reserved.)

Study: Propofol and sevoflurane are two anesthetic agents widely used to induce and maintain general anesthesia (GA). Their intrinsic antinociceptive properties remain unclear and are still debated., Objective: To determine whether propofol presents stronger antinociceptive properties than sevoflurane using intraoperative clinical and experimental noxious stimulations and evaluating postoperative pain outcomes., Design: A prospective randomized monocentric trial., Setting: Perioperative care., Patients: 60 adult patients with ASA status I to III who underwent elective abdominal laparoscopic surgery under GA were randomized either in propofol or sevoflurane group to induce and maintain GA., Interventions: We used clinical and experimental noxious stimulations (intubation, tetanic stimulation) to assess the antinociceptive properties of propofol and sevoflurane in patients under GA and monitored using the NOL index, BIS index, heart rate, and mean arterial blood pressure., Measurements: We measured the difference in the NOL index alterations after intubation and tetanic stimulation during either intravenous anesthesia (propofol) or inhaled anesthesia (sevoflurane). We also intraoperatively measured the NOL index and remifentanil consumption and recorded postoperative pain scores and opioid consumption in the post-anesthesia care unit. Intraoperative management was standardized by targeting similar values of depth of anesthesia (BIS index), hemodynamic (HR and MAP), NOL index values (below the threshold of 20), same multimodal analgesia and type of surgery., Main Results: We found the antinociceptive properties of propofol and sevoflurane similar. The only minor difference was after tetanic stimulation: the delta NOL was higher in the sevoflurane group (39 ± 13 for the propofol group versus 47 ± 15 for sevoflurane; P = 0.04). Intraoperative and postoperative pain outcomes and opioid consumption were similar between groups., Conclusions: Despite a precise intraoperative experimental and clinical protocol using the NOL index, propofol does not provide a higher level of antinociception during anesthesia or analgesia after surgery when compared to sevoflurane. Anesthesiologists may prefer propofol over sevoflurane to reduce PONV or anesthesia-related pollution, but not for superior antinociceptive properties., Competing Interests: Declaration of competing interest Dr. Philippe Richebé received honorariums in the past 5 years from several companies for conducting educational lectures (Medtronic Canada, Merck Canada, Medasense Ltd., Avir Pharma). Dr. Philippe Richebé received grants in the past 5 years from companies in the form of Investigator Initiated Trial grants (Medasense, Medtronic, Merck). There was no conflict with the present work. This work was sponsored and funded by the Department of Anesthesia and Pain Medicine at Maisonneuve-Rosemont Hospital. The results of this study were presented at the French Society of Anesthesia and Reanimation meeting in 2022 and received the 2nd prize at the resident competition of the Association of Anesthesiology of Quebec in 2022, and the third prize of the resident research competition of University of Montreal in 2022., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Aim: Post-operative pain may occur after non-surgical root canal treatment (NSRCT). The root filling technique and choice of sealer may be contributing factors. This randomized controlled clinical trial compared post-operative pain and analgesics intake after NSRCT using a sealer-based obturation technique (SBO) with single-cone gutta-percha and calcium silicate sealer (CSS) versus a warm-vertical compaction (WVC) technique with gutta-percha and a resin-based sealer (RBS)., Methodology: This study was designed as a parallel-two arm, double-blind, randomized superiority clinical trial registered at www., Clinicaltrials: gov (NCT04753138). Patients referred for NSRCT fulfilling the inclusion criteria participated in this study. Pre-operative periapical radiographs and CBCT scans were taken and numerical rating scale (NRS) pain scores were recorded. Upon completion of canal instrumentation, participants were randomly allocated to either Group SBO: SBO with CSS or Group WVC: Warm-vertical compaction with RBS. Post-operative pain and analgesics intake were recorded at 1, 3 and 7 days after endodontic treatment completion. Non-parametric Mann-Whitney U and Friedman tests and a generalized estimating equation were used to assess differences in pain scores between the groups, within each treatment group at different time points and for correlations, respectively., Results: The study included 195 participants (212 teeth). One participant declined to submit the NRS form. Therefore, 194 participants (211 teeth) were included in the final analysis (99.5% response rate). No statistically significant differences in post-operative pain or analgesic intake existed between the two groups at any time point (p > .05). Age, pre-operative pain, apical diagnosis and post-operative analgesic intake were significantly related to post-operative pain (p < .05)., Conclusions: Sealer-based obturation technique with CSS was associated with similar post-operative pain levels and analgesics intake as WVC with RBS. Regarding post-operative pain, SBO with CSSs may be a suitable clinical alternative., (© 2024 British Endodontic Society. Published by John Wiley & Sons Ltd.)

The study aimed to compare the quality of perioperative analgesia, the motor block duration, and the effects on main cardiovascular parameters of dexmedetomidine (1 μg/kg/nerve block) or magnesium sulphate (2 mg/kg/nerve block) as adjuvants to 0.3% ropivacaine for sciatic and saphenous nerves block in dogs undergoing tibial plateau leveling osteotomy (TPLO). Dogs randomly received perineural dexmedetomidine-ropivacaine (D group), magnesium sulphate-ropivacaine (M group), or ropivacaine (C group). Fentanyl was administered in case of intraoperative nociception. Postoperative pain was assessed using the Short Form-Glasgow Composite Measure Pain Scale (SF-GCMPS) and VAS scale. The duration of motor blockade and intra- and postoperative cardiovascular parameters were also recorded. Group M required significantly more fentanyl than D group (p = 0.04). Group M had a significantly higher SF-GCMPS score than group C at 4 (p = 0.002) and 5 h after extubation (p = 0.01), and a significantly higher VAS score than group D at 3 h after extubation (p = 0.03), and at 4 h if compared to group C (p = 0.009). No significant differences regarding the duration of motor blockade were detected between groups (p = 0.07). The heart rate was significantly lower in group D than in M and C groups intraoperatively and during the first 1.5 h post extubation. The addition of dexmedetomidine or magnesium sulphate as adjuvants to perineural ropivacaine did not improve the quality of perioperative analgesia and did not prolong the motor blockade in dogs undergoing sciatic and saphenous nerves block for TPLO surgery., 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 © 2023. Published by Elsevier Ltd.)