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Background: Dexamethasone is a potent anti-inflammatory, analgesic, and antiemetic drug. Individual randomized controlled trials found a possible benefit of epidural dexamethasone. The purpose of this meta-analysis is to estimate the benefit of epidural dexamethasone on postoperative pain and opioid consumption and to formulate a recommendation for evidence-based practice. Materials and Methods: Prospective, randomized controlled trials comparing the analgesic efficacy of epidural local anesthetic and dexamethasone combination, with local anesthetic alone for postoperative pain management after abdominal surgery, were planned to be included in this meta-analysis. PubMed, PubMed Central, Scopus, and Central Register of Clinical Trials of the Cochrane Collaboration (CENTRAL) databases were searched for eligible controlled trials using the following search words: \"Epidural\", \"dexamethasone\", and \"postoperative pain\", until February 20, 2015. Results: Data from five randomized control trials have been included in this meta-analysis. Epidural dexamethasone significantly decreased postoperative morphine consumption (mean difference −7.89 mg; 95% confidence interval [CI]: −11.66 to −3.71) and number of patients required postoperative rescue analgesic boluses (risk ratio: 0.51; 95% CI: 0.41-0.63). Conclusion: The present data shows that the addition of dexamethasone to local anesthetic in epidural is beneficial for postoperative pain management.

PurposeEnhanced recovery after surgery (ERAS) pathways are increasingly promoted in post-mastectomy reconstruction, with several articles reporting their benefits and safety. This meta-analysis appraises the evidence for ERAS pathways in breast reconstruction.MethodsA systematic search of Medline, EMBASE, and Cochrane databases was performed to identify reports of ERAS protocols in post-mastectomy breast reconstruction. Two reviewers screened studies using predetermined inclusion criteria. Studies evaluated at least one of the following end-points of interest: length of stay (LOS), opioid use, or major complications. Risk of bias was assessed for each study. Meta-analysis was performed via a mixed-effects model to compare outcomes for ERAS versus traditional standard of care. Surgical techniques were assessed through subgroup analysis.ResultsA total of 260 articles were identified; 9 (3.46%) met inclusion criteria with a total of 1191 patients. Most studies had “fair” methodological quality and incomplete implementation of ERAS society recommendations was noted. Autologous flaps comprised the majority of cases. In autologous breast reconstruction, ERAS significantly reduces opioid use [Mean difference (MD) = − 183.96, 95% CI − 340.27 to 27.64, p = 0.02) and LOS (MD) = − 1.58, 95% CI − 1.99 to 1.18, p < 0.00001] versus traditional care. There is no significant difference in the incidence of complications (major complications, readmission, hematoma, and infection).ConclusionERAS pathways significantly reduce opioid use and length of hospital stay following autologous breast reconstruction without increasing complication rates. This is salient given the current US healthcare climate of rising expenditures and an opioid crisis.

The use of remifentanil in clinical practice offers several advantages and it is used for a wide range of procedures, ranging from day-surgery anesthesia to more complex procedures. Nonetheless, remifentanil has been consistently linked with development of opioid-induced hyperalgesia (OIH), which is described as a paradoxical increase in sensitivity to painful stimuli that develops after exposure to opioid treatment. The development of OIH may cause several issues, delaying recovery after surgery and preventing timely patient's discharge. Moreover, it causes patient's discomfort with higher pain scores, greater use of analgesics, and associated side effects. Remifentanil is the opioid most convincingly associated with OIH, and hereby we provide a review of remifentanil-induced hyperalgesia, describing both the underlying mechanisms involved and the available studies investigating experimental and clinical pharmacologic approaches aiming at reducing its incidence and degree.

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

The management of acute postoperative pain remains challenging, and the search for adjuvants to reduce opioid use continues. We studied the effect of intravenous dexmedetomidine and lidocaine on postoperative pain, opioid consumption, and functional recovery. A randomized controlled trial was performed. The trial was conducted at Aretaieio University Hospital, Athens, Greece. In this double-blind study, 91 women, 30-70 years old, with an American Society of Anesthesiologists Physical Status of I or II, scheduled for abdominal hysterectomy or myomectomy, were randomized to receive either dexmedetomidine (DEX group), lidocaine (LIDO group), or placebo (CONTROL group). Before anesthesia induction, a loading intravenous dose of one of the aforementioned drugs was given to all patients (0.9mL/kg/h for 10 minutes), followed by 0.15mL/kg/h infusion until the last suture. Identical 50 mL syringes containing dexmedetomidine 4 mg/mL (bolus: 0.6 µg/kg, infusion: 0.6 µg/kg/h), or lidocaine 10 mg/mL (bolus: 1.5 mg/kg, infusion: 1.5 mg/kg/ h), or NaCl 0.9% were used. The main outcomes were cumulative morphine consumption and postoperative pain at rest and cough (Numeric Rating Scale, [NRS]: 0-10). Other measurements included anesthetic (sevoflurane) consumption, nausea/vomiting, postoperative sedation, time to first passage of flatus/stool, mobilization, sleep quality, satisfaction, discharge time, and drug side effects. Measurements were performed at Post-anesthesia Care Unit (PACU), 2 hours, 4 hours, 8 hours, 24 hours, and 48 hours. Data from 81 patients were analyzed (DEX group:26, LIDO group:29, CONTROL group:26). Cumulative morphine consumption (mg) was significantly lower in the LIDO group versus the CONTROL group in the PACU (LIDO group: 8.41 ± 1.45, CONTROL group: 10.4 ± 3.29, P = 0.017); at 24 hours (LIDO group: 16.86 ± 5.85, CONTROL group: 23.4 ± 9.54, P = 0.036); and 48 hours (LIDO group: 20.45 ± 6.58, CONTROL group: 28.87 ± 12.55, P = 0.022). The DEX group experienced significantly less nausea compared to the CONTROL group in the PACU (P = 0.041). Finally, the use of vasoconstrictors was higher in the treatment groups, especially in the DEX group compared to the CONTROL group (P = 0.012). The rest of the measurements regarding NRS scores, sevoflurane consumption, bowel function, and other recovery characteristics, satisfaction, discharge time, and drug side effects did not differ significantly among the groups. Different doses of the studied medications were not assessed, drugs were administered only pre- and intraoperatively, and pain was not managed according to the World Health Organization (WHO) pain relief ladder. However, all patients were adequately covered with patient-controlled anesthesia morphine and acetaminophen; parecoxib (not approved for use in the United States) was preserved as a rescue analgesic. Dexmedetomidine and lidocaine could be useful adjuvants for analgesia after abdominal surgery. Lidocaine significantly reduced postoperative opioid consumption, while dexmedetomidine prevented early postoperative nausea. However, hypotension and the need for vasopressors was common with both agents, especially with dexmedetomidine.

Background The adductor canal block has been proven effective in controlling postoperative pain, but it requires additional space and manpower. In contrast, intraoperative or direct adductor canal block (D-ACB) is performed during the surgical procedure, eliminating additional time and cost. The purpose of this study was to evaluate the efficacy and safety of D-ACB. The authors hypothesized that adding D-ACB to periarticular injection (PAI) would help control postoperative pain and reduce opioid use after TKA without causing major side effects. Methods Among patients scheduled to undergo primary TKA from September 2023 to February 2024, 38 patients in the PAI-alone group and 40 patients in the D-ACB + PAI group were eligible for analysis. The PAI-alone group received only PAI, while the D-ACB + PAI group received an additional ACB intraoperatively. Pain VAS scores and opioid consumption from the day of operation to postoperative day 5 were collected. Neurotoxicity and cardiotoxicity were considered major adverse events and were monitored along with postoperative motor weakness and fall-down events. Results The D-ACB + PAI group used less opioid compared to the PAI-alone group. No major adverse effects were observed in either group during the perioperative period. Conclusion Intraoperative direct ACB demonstrated an opioid-sparing effect when combined with PAI. By performing ACB intraoperatively, no additional space, cost, or manpower was required, and patients did not need an additional catheter for pain control. Direct ACB is a simple and safe procedure that can facilitate recovery after TKA. Trial registration This study was retrospectively registered at the Clinical Research Information Service on April 5, 2024 (KCT0009311).

Background Hip fractures are a source of severe pain among the elderly population and pose challenges due to limited analgesic tolerance. Perioperative methadone has shown promise in our pilot study suggesting a safe dose of 0.10 mg/kg, prompting further investigation into its benefits for elderly hip fracture patients. Methods This study employs a double-blinded randomized controlled trial to assess the analgesic effects of a single dose of methadone during hip fracture surgery. Patients aged ≥ 60 years are consecutively enrolled and randomized to receive either perioperative methadone (treatment group) or a saline solution (placebo group). A sample size of 130 patients is required for 88% statistical power. The medication is administered intravenously at anesthesia induction and monitored until discharge. A follow-up observation is conducted 3 months post-surgery. Discussion Primary outcome: Daily consumption of opioids within the first 3 days after surgery. Secondary outcomes include pain, mobility, nausea, vomiting, time to discharge, need for antidote, delirium, and constipation. The 3-month follow-up includes opioid use, pain, EQ-5D-5L scores, mobility, and persistent side effects. If statistically significant advantages are found in the treatment group, perioperative methadone could be considered as standard care for hip fracture patients, potentially enhancing their pain management. The study’s outcomes will provide insights into the feasibility and effectiveness of incorporating methadone into routine clinical practices for this patient group. Trial registration ClinicalTrials.gov ID: NCT06086171, submitted 4. October 2023. EU-CT: 2023–506252-24–00, UTN: U1111-1294–6125.

We sought to analyze postoperative discharge opioid prescription, consumption, and pain over three months following total hip arthroplasty (THA) and total knee arthroplasty (TKA). We conducted a prospective observational study in patients undergoing THA and TKA at two centres in Toronto, ON, Canada. We contacted study participants at two, six, and 12 weeks after discharge to collect data on analgesic satisfaction, pain relief, time point of stopping opioids, quantity of unconsumed opioid pills, quality of pain, and mental health. We also evaluated patient factors that may have contributed to a higher opioid consumption or dissatisfaction with the analgesic prescription at six weeks. The median [interquartile range] opioid pill count prescribed at the time of discharge for the 443 participants was 60 [50-80]. At 12 weeks after surgery, 33.9% of participants had more than one-third of their prescribed quantity remaining. Three-quarters of the cohort indicated that pain relief after arthroplasty was appropriate at all postoperative follow-ups. The incidence of neuropathic pain reduced from 24.1% before TKA or THA to 4.3% at 12 weeks after arthroplasty. Female sex (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.08 to 2.95; P = 0.03), a history of preoperative opioid use (OR, 2.46; 95% CI, 1.25 to 5.1; P = 0.01), and TKA vs THA (OR, 2.46; 95% CI, 1.47 to 4.17; P = 0.001) were associated with higher opioid consumption at six weeks after arthroplasty. A discharge prescription of 60 opioid pills may be excessive for patients undergoing THA or TKA. Identifying patients with risk factors for higher postoperative opioid consumption may result in more appropriate analgesic regimens.

Postoperative pain following thoracic surgery is often severe, and serratus anterior plane block (SAPB) is widely used for perioperative analgesia in such patients. Local anesthetics injected on the surface of the serratus anterior muscle are called superficial SAPB (SSAPB), while those injected on the deep surface are called deep SAPB (DSAPB). We observed the differences in analgesic effects of two variants of SAPB (superficial and deep) on patients receiving single-port video-assisted thoracoscopic surgery (VATS). A randomized prospective trial. Single university teaching hospital. Eighty patients who underwent single-port VATS under general anesthesia. Eighty patients who received single-port VATS were randomly assigned to Group S (patients who received SSAPB) and Group D (patients who received DSAPB). The primary outcome was opioid consumption within 24 h after surgery. Secondary outcomes were pain scores at rest and on coughing before surgery, immediately after surgery, 6, 12, and 24 h after surgery. Within 24 h after surgery, the total opioid consumption of patients in Group S was lower than that of patients in Group D (P = 0.001). The pain scores of patients in Group S were lower than those in Group D at rest or coughing 6 h after surgery (P = 0.000, P = 0.000). The pain score on coughing in Group S was lower than that in Group D at 12 h after surgery (P = 0.000), and there was no difference in postoperative pain scores between the two groups at other time points. For patients undergoing single-port VATS lobectomy, SSAPB was associated with reduced opioid consumption and lower pain scores compared to DSAPB. •SSAPB reduced pain scores at 6 and 12 h after VATS than DSAPB.•SSAPB produced a smaller consumption of opioids within 24 h after VATS than DSAPB.•SSAPB potentially reduced the incidence of pain one month after VATS.

Purpose Major spine surgery with multilevel instrumentation is followed by large amount of opioid consumption, significant pain and difficult mobilization in a population of predominantly chronic pain patients. This case–control study investigated if a standardized comprehensive pain and postoperative nausea and vomiting (PONV) treatment protocol would improve pain treatment in this population. Methods A new regimen with acetaminophen, NSAIDs, gabapentin, S-ketamine, dexamethasone, ondansetron and epidural local anesthetic infusion or patient controlled analgesia with morphine, was introduced in a post-intervention group of 41 consecutive patients undergoing multilevel (median 10) instrumented spinal fusions and compared with 44 patients in a pre-intervention group. Results Compared to patients in the pre-intervention group, patients treated according to the new protocol consumed less opioid on postoperative day (POD) 1 ( P  = 0.024) and 2 ( P  = 0.048), they were mobilized earlier from bed ( P  = 0.003) and ambulation was earlier both with and without a walking frame ( P  = 0.027 and P  = 0.027, respectively). Finally, patients following the new protocol experienced low intensities of nausea, sedation and dizziness on POD 1–6. Conclusions In this study of patients scheduled for multilevel spine surgery, it was demonstrated that compared to a historic group of patients receiving usual care, a comprehensive and standardized multimodal pain and PONV protocol significantly reduced opioid consumption, improved postoperative mobilization and presented concomitant low levels of nausea, sedation and dizziness.