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Background: Ultrasound-guided supra-inguinal fascia iliaca block (FIB) provides effective analgesia after total hip arthroplasty (THA) but is complicated by high rates of motor block. The erector spinae plane block (ESPB) is a promising motor-sparing technique. In this study, we tested the analgesic superiority of the FIB over ESPB and associated motor impairment. Methods: In this randomized, observer-blinded clinical trial, patients scheduled for THA under spinal anesthesia were randomly assigned to preoperatively receive either the ultrasound-guided FIB or ESPB. The primary outcome was morphine consumption 24 h after surgery. The secondary outcomes were pain scores, assessment of sensory and motor block, incidence of postoperative nausea and vomiting and other complications, and development of chronic post-surgical pain. Results: A total of 60 patients completed the study. No statistically significant differences in morphine consumption at 24 h (P = 0.676) or pain scores were seen at any time point. The FIB produced more reliable sensory block in the femoral nerve (P = 0.001) and lateral femoral cutaneous nerve (P = 0.018) distributions. However, quadriceps motor strength was better preserved in the ESPB group than in the FIB group (P = 0.002). No differences in hip adduction motor strength (P = 0.253), side effects, or incidence of chronic pain were seen between the groups. Conclusions: ESPBs may be a promising alternative to FIBs for postoperative analgesia after THA. The ESPB and FIB offer similar opioid-sparing benefits in the first 24 h after surgery; however, ESPBs result in less quadriceps motor impairment. [ABSTRACT FROM AUTHOR]

Simple Summary: As a significant knowledge gap exists on the effect of opioid-free anesthesia on outcomes of cancer patients receiving surgery, we conducted a systematic review to assess any differences between opioid-free and opioid-based anesthesia. Few studies were included, as the main body of the existing literature in the specific population of oncologic surgery does not reflect high quality standards and displays strong heterogeneity in methodology. Despite encouraging suggestions from the few studies regarding the benefits of opioid-free approaches on the immediate perioperative outcome, more trials are required to accept or reject the superiority of opioid-free anesthesia in patients receiving surgery for cancers. Background: Surgery is an essential component of the treatment of solid tumors, but the perioperative course can be complicated by different factors (including anesthesia). Opioid-free anesthesia (OFA) may mitigate adverse outcomes of opioid-based anesthesia (OBA), but major questions remain on the actual impact in terms of analgesia and the improvement of surgical outcomes. To address this issue, we present a systematic review to evaluate the efficacy of OFA compared to OBA in the specific subset of cancer patients undergoing surgery. Methods: following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA), we searched MEDLINE, Embase and the Cochrane CENTRAL Library to include randomized controlled trials (RCTs) on adults undergoing oncological surgery, comparing OFA and OBA up to March 2022. Additional papers were added from the reference lists of identified sources. Papers were manually reviewed by two independent authors to ascertain eligibility and subsequent inclusion in qualitative analysis. Results: only two studies were eligible according to inclusion criteria. It was not possible to perform any meta-analysis. The two studies included patients undergoing prostate and gynecologic surgery on 177 patients, with significant heterogeneity in the outcomes. Conclusions: randomized controlled trial specifically addressed to cancer patients are lacking. A knowledge gap exists, neither confirming nor rejecting the capacity of OFA to improve early postoperative outcomes in cancer surgery. Long-term consequences on specific oncological outcomes are far from being elucidated. We expect a growing body of literature in the coming years. Further studies are required with homogeneous methodology and endpoints. [ABSTRACT FROM AUTHOR]

Background: The pharmacokinetic properties and clinical advantages of the local anesthetic chloroprocaine are well known. Here, we studied the pharmacokinetic profile of a new hydrogel device loaded with chloroprocaine to investigate the potential advantages of this new strategy for postoperative pain (POP) relief. Materials and methods: We performed both in vitro and in vivo analyses by considering plasma samples of four piglets receiving slow-release chloroprocaine. To quantify chloroprocaine and its inactive metabolite 4-amino-2-chlorobenzoic acid (ACBA), a HPLC–tandem mass spectrometry (HPLC-MS/MS) analytical method was used. Serial blood samples were collected over 108 hours, according to the exposure time to the device. Results: Chloroprocaine was consistently found to be below the lower limit of quantification, even though a well-defined peak was observed in every chromatogram at an unexpected retention time. Concerning ACBA, we found detectable plasma concentrations between T0 and T12h, with a maximum plasma concentration (Cmax) observed 3 hours after the device application. In the in vitro analyses, the nanogel remained in contact with plasma at 37°C for 90 minutes, 3 hours, 1 day, and 7 days. Chloroprocaine Cmax was identified 1 day following exposure and Cmin after 7 days, respectively. Additionally, ACBA reached the Cmax following 7 days of exposure. Conclusion: A thorough review of the literature indicates that this is the first study analyzing both in vivo and in vitro pharmacokinetic profiles of a chloroprocaine hydrogel device and is considered as a pilot study on the feasibility of including this approach to the management of POP. [ABSTRACT FROM AUTHOR]

Continuous wound infusion (CWI) may protect from inflammation, hyperalgesia and persistent pain. Current local anesthetics display suboptimal pharmacokinetic profile during CWI; chloroprocaine (CP) has ideal characteristics, but has never been tested for CWI. We performed an animal study to investigate the pharmacokinetic profile and anti-inflammatory effect of CP during CWI. A total of 14 piglets received an infusion catheter after pararectal laparotomy and were randomly allocated to one of three groups: 5 mL/h infusion of saline (group A), CP 1.5% (group B) and CP 0.5% (group C). Blood sampling was performed to assess absorption and systemic inflammation at 0, 3, 6, 12, 24, 48, 72, 96, 102 and 108 hours. The wound and contralateral healthy abdominal wall were sampled for histological analyses. Absorption of CP from the site of infusion, evaluated as the plasmatic concentrations of CP and its metabolite, 4-amino-2-chlorobenzoic acid (CABA), showed a peak during the first 6 hours, but both CP and its metabolite rapidly disappeared after stopping CP infusion. Local inflammation was reduced in groups B and C (CP-treated p < 0.001), in a CP dose-dependent fashion. While CP inhibited in a dose-dependent manner pig mononuclear cells (MNCs) in vitro proliferation to a polyclonal activator, no effect on systemic cytokines' concentrations or on ex vivo monocytes' responsiveness was observed, suggesting the lack of systemic effects, in line with the very short half-life of CP in plasma. CP showed a very good profile for use in CWI, with dose-dependent local anti-inflammatory effects, limited absorption and rapid clearance from the bloodstream upon discontinuation. No cytotoxicity or side effects were observed. CP, therefore, may represent an optimal choice for clinical CWI, adaptable to each patient's need, and protective on wound inflammatory response (and hyperalgesia) after surgery. [ABSTRACT FROM AUTHOR]

Poor acute pain control and inflammation are important risk factors for Persistent Postsurgical Pain (PPSP). The aim of the study is to investigate, in the context of a prospective cohort of patients undergoing hernia repair, potential risk factors for PPSP. Data about BMI, anxious-depressive disorders, neutrophil-tolymphocyte ratio (NLR), proinflammatory medical comorbidities were collected. An analysis for correlation between comorbidities and PPSP was performed in those patients experiencing chronic pain at 3 months after surgery. Tramadol resulted less effective in pain at movement in patients with a proinflammatory status. Preoperative hypertension and NLR > 4 were correlated with PPSP intensity. Regional anesthesia was significantly protective on PPSP when associated with ketorolac. Patients with pain at 1 month were significantly more prone to develop PPSP at 3 months. NSAIDs or weak opioids are equally effective on acute pain and on PPSP development after IHR, but Ketorolac has better profile in patients with inflammatory background or undergoing regional anesthesia. Drug choice should be based on their potential side effects, patient’s profile (comorbidities, preoperative inflammation, and hypertension), and type of anesthesia. Close monitoring is necessary to early detect pain conditions more prone to progress to a chronic syndrome. [ABSTRACT FROM AUTHOR]

Study Objective: The study objective is to identify differences in postoperative pain management according to different analgesic treatments, targeting 2 main pathways involved in pain perception.Design: The design is a randomized, parallel groups, open-label study.Setting: The setting is in an operating room, postoperative recovery area, and surgical ward.Patients: There are 200 patients undergoing open inguinal hernia repair (IHR) with tension-free technique (mesh repair).Interventions: The intervention is a randomization to receive ketorolac (group K) or tramadol (group T) for 3 days after surgery.Measurements: The measurements are differences in analgesic efficacy (numeric rating scale [NRS]) in the postoperative (up to 5 days) period, chronic pain incidence (1 and 3 months), side effects, and complications.Main Results: We found no differences in analgesic efficacy (NRS value ≥4 in the first 96 hours: 26% in group K vs 32% in group T, P = .43); the proportion of patients with NRS ≥4 was similar in both groups, and the time trajectories were not significantly different (P for interaction = .24). Side effects were higher (12% vs 6%) in the tramadol group, although not significantly (P = .14), with a case of bleeding in the ketorolac group and higher incidence of constipation in tramadol group. One patient in each group developed chronic pain.Conclusions: Ketorolac or weak opioids are equally effective on acute pain and on persistent postsurgical pain development after IHR, and drug choice should be based on their potential side effects and patient's comorbidities. Further studies are needed to standardize the most rational approach to prevent persistent postsurgical pain after IHR. [ABSTRACT FROM AUTHOR]

Purpose: To investigate interindividual variability in response to pain treatment, we characterized postoperative patients for morphine metabolism and for COMT, OPRM1 and UGT2B7 polymorphisms. Methods: A total of 109 patients treated with morphine were genotyped by DNA sequencing for 12 DNA polymorphisms of the COMT, OPRM1 and UGT2B7 genes. The plasma concentration of morphine and of M3G/M6G metabolites were evaluated by means of reversed phase high-performance liquid chromatography coupled with mass spectrometry. Results: An association between average morphine consumption during the first 24 postoperative hours by patient-controlled analgesia (PCA) and COMT haplotypes was found. Specifically, patients with the diplotype for average pain intensity (APS/APS) required the lowest morphine doses compared to the other subjects ( p = 0.011). The APS haplotype contains an adenine corresponding to methionine, instead of valine, at position 158 of the COMT protein. Met/Met homozygous patients consumed significantly lower morphine doses than other subjects ( p = 0.014); accordingly, Val158Met genotyping alone might be used in the clinical setting to predict PCA morphine need. Considering both COMT Val158Met and OPRM1 A118G polymorphisms, carriers of both the Met/Met and AA genotypes required less morphine than other subjects, although the difference was not significant. The analysis of UGT2B7 revealed the occurrence of two common haplotypes (G_C_C_A_C and A_T_T_G_T) that did not prove to be related with plasma morphine and M3G/M6G concentration. Conclusions: By considering COMT, OPRM1, and UGT2B7 genotypes, as well as pharmacokinetic results, only COMT polymorphisms appear to be predictive of morphine need in postoperative pain therapy. [ABSTRACT FROM AUTHOR]

Abstract: Laparoscopic procedures have been associated to moderate or severe pain that may require opioids and almost all patients referred shoulder pain. Intraperitoneal instillation of local anaesthetics, as part of a multimodal approach analgesia program, reduces pain intensity and morphine consumption after laparoscopic cholecystectomy. However, direct local anesthetic instillation is not enough to eliminate visceral and shoulder pain. Heated and humidified gas may produce positive effects such as reduction of postoperative pain. Intraperitoneal nebulization, a new technique of drug administration, provides homogeneous spread of drugs allowing a better distribution of local anaesthetics throughout the peritoneum. This technique combines the effects of gas conditioning and the analgesic benefits of local anaesthetic instillation. Nebulization of local anaesthetics during different laparoscopic procedures reduced postoperative pain, morphine consumption and allowed earlier mobilization. Future studies should determine, the optimal dose of local anaesthetics, the effect of local anaesthetic nebulization in different clinical settings and its importance on long term clinical outcomes. [ABSTRACT FROM AUTHOR]

Abstract: Two decades of attention have focused on regional anesthesia, both central neuraxial blockades as well as peripheral blocks. Though there are a considerable number of recent publications on the topic, the complex issues around the effect of regional anesthesia on outcome have not been completely resolved, possibly because the data are often not procedure-specific. In this survey, we tried to focus on current Italian practice and therapeutical criteria in the management of postoperative pain. We also evaluated how the clinical practice of the respondents follows the international and national guidelines for postoperative pain. A questionnaire was mailed to 64 anesthesiologists who had been identified from a database kept by the RICALOR Group (Registro Italiano Complicanze Anestesia LOcoRegionale – Italian Registry of Complications during Locoregional Anesthesia). The survey requested information regarding demographic data and general management, postoperative pain management and guidelines, and specific questions on epidural analgesia and on peripheral blocks. Only 35 of the 64 anesthesiologists answered the questionnaire and sended it back for analysis. Basing on these 35 returns, data from 51 surgical units (some respondent referred data of more surgical units) leading to 135 departments (surgical units may be constituted by more departments) were analyzed. A total of 245,382 surgical procedures were analyzed. Regional analgesia was used in 46.71% of the procedures. In university and teaching-hospitals, protocols concerning regional anesthesia were attended and shared with the whole staff more often than in non-teaching hospitals (P =0.0001). For postoperative pain management 31.48% of responders used <10% of regional analgesia, 20.37% used 10–30%, 25.93% used 30–50%, 14.81% used 50–75% and 7.41% used >75% of regional analgesia. We identified a huge variety of responses regarding therapeutical protocols but the majority of responders used the drugs with the best safety/efficacy profile. In conclusion, we demonstrated an improvement in the management of postoperative pain compared to previous studies, but still efforts should be made to standardize daily practice in order to avoid complications and improve safety. [Copyright &y& Elsevier]

Highlights • Continuous Erector Spinae Plane Block (cESPB) is a valuable strategy for postoperative pain relief after hip replacement. • A catheter can be easily placed under ultrasound guidance at L4 to provide prolonged analgesia. • Opioid free anesthesia can be achieved even during invasive procedures. • cESPB may configure as safer and effective alternative to epidural, but rigorous studies are required. [ABSTRACT FROM AUTHOR]