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Post-operative knee pain management has become a challenge to provide early relief and pain-free postoperative care to the patient. The major objectives of post-operative analgesic treatment are to reduce opioid requirements, post-operative pain, and adverse events related to opioid intake. This narrative review aimed to document post-operative analgesia techniques after total knee arthroplasty (TKA). The traditional approach involved high-dose opioid-based regimen, though opioid is considered strong analgesic, but are associated with a number of unwanted side effects to seek for alternative techniques. The role of sciatic nerve block in TKA pain is doubtful. Femoral Nerve Block (FNB) is still considered as the gold standard; however, FNB is associated with quadriceps weakness and risk of fall and sciatic block with foot drop. To overcome these drawback more distal nerve block techniques has evolved, namely saphenous nerve block in adductor canal, selective tibial which are claimed to provide comparable analgesia to that of femoral and sciatic nerve block. The combination of pre-emptive and multi-modal analgesia and technically well-delivered regional nerve blocks and postoperative physical therapy are an essential component which not only minimize the side effects of traditional opioid-based analgesia but also speed up functional recovery, increases patient satisfaction, and reduces the overall length of hospitalization and cost.

Background: Percutaneous nephrolithotomy (PCNL) a minimally invasive method for the removal of renal calculi and is associated with significant pain in postoperative period. Conventionally, intravenous opioids, local anesthetic infiltration, and regional blocks (intercostal/paravertebral blocks) have been tried with less efficacy to control postoperative pain. The present study is conducted to assess the effectiveness of erector spinae plane block (ESPB) performed under fluoroscopy guidance for postoperative analgesia during PCNL. Subjects and Methods: After obtaining ethical clearance, the study was conducted on 61 American Society of Anaesthesiologists (ASA) I and II patients aged between 18-65 years admitted for PCNL. Group I (n = 30) did not receive ESPB while Group II (n = 31) received ESPB under fluoroscopy guidance and 20 ml of 0.375% ropivacaine was administered after PCNL. Patient-reported pain intensity using visual analogue scale (VAS) was considered as a primary outcome. The hemodynamic variables (heart rate, systolic, diastolic, and mean blood pressure) was considered as a secondary outcome. Statistical analysis was performed using Student's t-test and Mann-Whitney U test. Data analysis was performed using the Statistical Package for the Social Sciences version 23.0. Results: Postoperatively VAS score was significantly lower in Group II at 0, 1, 2, 3, 4, 6, 12, 18, and 24 hours after PCNL (P < 0.001). Dose of rescue analgesia significantly decreased in Group II compared to Group I. Conclusion: ESPB performed under fluoroscopic guidance is a simple and effective technique and it provides significantly better postoperative pain relief.

Inguinal hernia repair (IHR) is one of the most common pediatric surgeries, particularly in early childhood. Postoperative pain from IHR can cause significant psychological and physiological distress in children. This study investigates the efficacy and safety of ultrasound-guided rectus sheath block (RSB) in managing postoperative pain and emergence agitation (EA) in children undergoing single-incision laparoscopic inguinal hernia repair, aiming to improve strategies for postoperative care. This single-blind, prospectively, randomized controlled trial enrolled 90 pediatric patients who were randomly assigned to three groups, they were respectively the bilateral rectus abdominis sheath block group under ultrasound guidance (Group R), Local anesthesia infiltration group (Group L) and blank control group (Group C). Primary outcomes included the incidence of EA. Secondary outcomes comprised pain scores, opioid consumption, and adverse events, and Pediatric Anesthesia Emergence Delirium (PAED) scales at various postoperative time points. EA incidence was significantly reduced in Groups R compared to Group C (RR [95% confidence interval] of 0.083 [0.007,0.019], < 0.05). Extubation time in Group R (RSB) was significantly shorter compared to Group C ( < 0.05). During skin incision, mean arterial pressure (MAP) and heart rate (HR) were lower in Group R than in Groups L and C, with significant differences noted only between Groups R and C ( < 0.05). Postoperative pain scores were significantly reduced in Groups R and L compared to Group C ( < 0.05). Additionally, Group R demonstrated prolonged analgesia and reduced opioid consumption. Ultrasound-guided RSB is a safe and effective technique for postoperative analgesia in pediatric single-incision laparoscopic inguinal hernia repair. It provides superior pain relief, reduces EA incidence, and minimizes opioid use. These findings suggest that RSB may be a valuable adjunct to general anesthesia for this specific procedure.

Preoperative oral pregabalin could improve postoperative analgesia and prevent chronic pain development. The aim of this study is to evaluate the effect of oral pregabalin on the duration and quality of postoperative analgesia in spinal anesthesia. Sixty adult patients presented for internal fixation of femoral fracture under spinal anesthesia were included in the study. They were randomly distributed to a placebo group and a pregabalin group receiving 150 mg pregabalin capsules 1 hr before surgery. The onset, duration, and regression of sensory and motor block were recorded. Rescue analgesia consumption, postoperative pain score, and quality of sleep were also assessed. Oral pregabalin significantly prolonged the time to two-segment regression of sensory block, reaching 86.67±17.88 mins, the time required to regression of spinal block to L2, reaching 155.33± 34.71 mins, and the duration of motor block, reaching 138 ± 23.5 mins, with no effect on the onset of sensory or motor block ( = 0.60 and 0.62). It significantly decreased the VAS score 4 hrs, 6 hrs, and 12 hrs postoperatively, prolonged the duration of postoperative analgesia, reaching 392.00±47.23 mins, and decreased morphine consumption to 7.67±3.65 mg. It also improved the quality of sleep in the first night after surgery. Preemptive oral pregabalin prolonged the time to the first request for postoperative analgesics and improved sleep in the first night after surgery.

Obstructive sleep apnea (OSA) is prevalent and presents perioperative challenges. There are guidelines regarding perioperative care of OSA, but analgesia management of OSA patients is inconsistent or inadequate. This is a study of the United Kingdom anesthesiologists' postoperative analgesia preferences for OSA patients. Overall, the 1st choice of main analgesia was continuous epidural local anesthetic (LA) without opioid, at 30% rate; P = 0.001. The 2nd choice was continuous epidural LA plus fentanyl, at 21% rate; P = 0.001. The 3rd choice was intrathecal diamorphine, at 19% rate; P = 0.001. The 4th choice was nerve block catheter LA infusion, at 13% rate; P = 0.001. The 5th choice was wound infiltration with LA ± epinephrine, at 8% rate; P = 0.001. The 6th choice was systemic opioid, at 7% rate; P = 0.007. The 7th choice was systemic nonsteroidal anti-inflammatory drugs, at 2% rate; P = 0.001. The hospital setting or anesthesiologists' experience did not significantly impact analgesia choice: P =0.411. This study shows that current practice by anesthesiologists has a preference for regional or opioid-sparing analgesia for OSA patients. This safe approach conforms to guidelines and should be encouraged.

To evaluate the analgesic effect of ultrasound-guided erector spinae plane (ESP) block in breast cancer surgery. Randomized controlled, single-blinded trial. Operating room. Fifty ASA I–II patients aged 25–65 and scheduled for elective breast cancer surgery were included in the study. Patients were randomized into two groups, ESP and control. Single-shot ultrasound (US)-guided ESP block with 20 ml 0.25% bupivacaine at the T4 vertebral level was performed preoperatively to all patients in the ESP group. The control group received no intervention. Patients in both groups were provided with intravenous patient-controlled analgesia device containing morphine for postoperative analgesia. Morphine consumption and numeric rating scale (NRS) pain scores were recorded at 1, 6, 12 and 24 h postoperatively. Morphine consumption at postoperative hours 1, 6, 12 and 24 decreased significantly in the ESP group (p < 0.05 for each time interval). Total morphine consumption decreased by 65% at 24 h compared to the control group (5.76 ± 3.8 mg vs 16.6 ± 6.92 mg). There was no statistically significant difference between the groups in terms of NRS scores. Our study findings show that US-guided ESP block exhibits a significant analgesic effect in patients undergoing breast cancer surgery. Further studies comparing different regional anesthesia techniques are needed to identify the optimal analgesia technique for this group of patients. •Erector spinae plane block is a new and promising technique for many indications.•Ultrasound guided erector spinae plane block is an effective modality of analgesia for breast surgeries.•Postoperative total morphine consumption in block group reduced by 65% in postoperative 24 h.•Ultrasound guided erector spinae plane block is a relatively easy and safe method for providing analgesia.

Background and objectivesTo investigate the possible effect of postoperatively applied analgesics—epidurally applied levobupivacaine or intravenously applied morphine—on systemic inflammatory response and plasma concentration of interleukin (IL)-6 and to determine whether the intensity of inflammatory response is related to postoperative cognitive dysfunction (POCD).MethodsThis is a randomized, prospective, controlled study in an academic hospital. Patients were 65 years and older scheduled for femoral fracture fixation from July 2016 to September 2017. Inflammatory response was assessed by leukocytes, neutrophils, C reactive protein (CRP) and fibrinogen levels in four blood samples (before anesthesia, 24 hours, 72 hours and 120 hours postoperatively) and IL-6 concentration from three blood samples (before anesthesia, 24 hours and 72 hours postoperatively). Cognitive function was assessed using the Mini-Mental State Examination preoperatively, from the first to the fifth postoperative day and on the day of discharge.ResultsThe study population included 70 patients, 35 in each group. The incidence of POCD was significantly lower in the levobupivacaine group (9%) than in the morphine group (31%) (p=0.03). CRP was significantly lower in the levobupivacaine group 72 hours (p=0.03) and 120 hours (p=0.04) after surgery. IL-6 values were significantly lower in the levobupivacaine group 72 hours after surgery (p=0.02). The only predictor of POCD in all patients was the level of IL-6 72 hours after surgery (p=0.03).ConclusionsThere is a statistically significant association between use of epidural levobupivacaine and a reduction in some inflammatory markers. Postoperative patient-controlled epidural analgesia reduces the incidence of POCD compared with intravenous morphine analgesia in the studied population.Trial registration numberNCT02848599.

To test the hypothesis that thoracic epidural anesthesia and analgesia (TEA) reduces the incidence of chronic postoperative pain (CPSP) after video-assisted thoracoscopic surgery (VATS). A single-center, single-blind, randomized controlled trial was conducted. The study was conducted in the operating room, with follow-up assessments performed in the ward. Telephone was used to follow the long-term outcomes. 231 patients ≥18 years of age and scheduled for VATS. Patients were randomized into two groups, including an epidural block (EPI) group (general anesthesia with patient-controlled epidural analgesia) and a general anesthesia with patient-controlled intravenous analgesia (PCIA) group. The primary endpoint was the incidence of CPSP at 3 months postoperatively. CPSP data, including acute pain, neuropathic pain, depression, and side effects, were collected at 3 and 6 months postoperatively through telephone follow-up. A total of 231 patients were analyzed, including 114 in the PCIA group and 117 in the EPI group. Sixty-six patients (56.4 %) in the PCIA group and 33 patients (28.9 %) in the EPI group experienced chronic pain at 3 months postoperatively. The odds ratio (OR) was 0.31 (95 % confidence interval [CI], 0.18 to 0.54; P < 0.0001). After adjusting for confounding factors, the adjusted OR was 0.28 (95 % CI, 0.16 to 0.50, P < 0.001). Six months postoperatively, 50 (42.7 %) and 17 (14.9 %) patients in the PCIA and EPI groups, respectively, were diagnosed with CPSP (P < 0.0001). •Thoracic epidural analgesia can reduce the incidence of chronic pain after VATS.•Thoracic epidural analgesia can reduce the severity of acute pain after 24 h of VATS.•Thoracic epidural analgesia should be superior considered for patients with high risks of CPSP.

Background: Intravenous patient-controlled analgesia (IVPCA) and patient-controlled epidural analgesia (PCEA) were studied in terms of analgesic efficacy, respiratory function and side effects after thoracic surgery for 24h. PCEA using fentanyl and bupivacaine as compared to IVPCA using morphine provides better pain relief both at rest and during coughing and is associated with fewer side effects. Aims: To compare IVPCA and PCEA in terms of analgesic efficacy, respiratory function and side effects after thoracic surgery. Settings and Design: Tertiary care teaching hospital. Prospective, randomized and open study. Materials and Methods: Thirty ASA-I or II patients undergoing thoracotomy were assigned randomly to receive either IVPCA using morphine or PCEA using fentanyl and bupivacaine combination postoperatively. No background infusion was administered in either group. Postoperative evaluation included pain intensity both at rest and during coughing, degree of sedation, arterial blood gas, forced vital capacity (FVC), peak expiratory flow rate (PEFR), presence of side effects such as nausea/vomiting and pruritis at 0, 2, 8, 12 and 24h. The primary outcome of the study was the percentage of patients with analgesia failure defined as VAS>30 despite three consecutive PCA boluses requiring rescue analgesia with intravenous fentanyl. Statistical Analysis: Data were analyzed using t -test, χ2 test and Mann-Whitney test. Results: Significantly less number of patients required rescue analgesia in PCEA group ( P< 0.05). Pain relief was better both at rest and during coughing ( P< 0.05) in PCEA group as compared to IVPCA. Patients in the PCEA group were less sedated and had fewer incidences of side effects, i.e. nausea/vomiting and pruritis. Postoperative FVC and PEFR were reduced significantly compared to baseline only in IVPCA group ( P< 0.05). Conclusion: After thoracic surgery, PCEA using fentanyl and bupivacaine as compared to IVPCA using morphine provides better pain relief both at rest and during coughing and associated with fewer side effects.

Background: Levobupivacaine is an effective local anesthetic agent with less systemic toxicity than racemic bupivacaine, but it has short postoperative analgesic duration. Dexmedetomidine and fentanyl are promising adjuncts to provide excellent and prolonged postoperative caudal analgesia. This study compared the effects of caudal levobupivacaine plus dexmedetomidine and levobupivacaine plus fentanyl for postoperative analgesia and sedation in children undergoing lower limb orthopedic surgery. Patients and Methods: Ninety children, whose age ranged from 1 to 7 years, American Society of Anesthesiologists I-II, undergoing orthopedic lower limb surgery under general anesthesia received caudal block for postoperative analgesia. The children were randomly allocated into three groups: Group L (control) received 0.75 ml/kg levobupivacaine 0.25% diluted in saline; Group LD received 0.75 ml/kg levobupivacaine 0.25% with dexmedetomidine 1 μg/kg; and Group LF received 0.75 ml/kg levobupivacaine 0.25% with fentanyl 1 μg/kg. Following the administration of the drugs; hemodynamic variables, the total anesthesia time, sedation score, Face, Legs, Activity, Cry, Consolability score, duration of analgesia, and side effects were recorded. Results: Demographically, all the groups were comparable, both the baseline and the intraoperative hemodynamic profile were similar in all groups. The mean duration of analgesia and the mean sedation score in the Group LD were significantly greater as compared to both the other groups. Conclusion: Dexmedetomidine may be a better additive to levobupivacaine than fentanyl for caudal postoperative analgesia, arousable sedation with comparable hemodynamic and side effect profile in children.