Significant reduction of postoperative pain and opioid analgesics requirement with an Enhanced Recovery After Thoracic Surgery protocol

ObjectiveTo evaluate differences in postoperative pain control and opioids requirement in thoracic surgical patients following implementation of an Enhanced Recovery after Thoracic Surgery protocol with a comprehensive postoperative pain management strategy.Material and MethodsA retrospective analysis of a prospectively maintained database of patients undergoing pulmonary resections by robotic thoracoscopy or thoracotomy from January 1, 2017, to January 31, 2019, was conducted. Multimodal pain management strategy (opioid-sparing analgesics, infiltration of liposomal bupivacaine to intercostal spaces and surgical sites, and elimination of thoracic epidural analgesia use in thoracotomy patients) was implemented as part of Enhanced Recovery after Thoracic Surgery on February 1, 2018. Outcome metrics including patient-reported pain levels, in-hospital and postdischarge opioids use, postoperative complications, and length of stay were compared before and after protocol implementation.ResultsIn total, 310 robotic thoracoscopy and 62 thoracotomy patients met the inclusion criteria. This pain management strategy was associated with significant reduction of postoperative pain in both groups with an overall reduction of postoperative opioids requirement. Median in-hospital opioids use (morphine milligram equivalent per day) was reduced from 30 to 18.36 (P = .009) for the robotic thoracoscopy group and slightly increased from 15.48 to 21.0 (P = .27) in the thoracotomy group. More importantly, median postdischarge opioids prescribed (total morphine milligram equivalent) was significantly reduced from 480.0 to 150.0 (P < .001) and 887.5 to 150.0 (P < .001) for the thoracoscopy and thoracotomy groups, respectively. Similar short-term perioperative outcomes were observed in both groups before and following protocol implementation.ConclusionsImplementation of Enhanced Recovery after Thoracic Surgery allows safe elimination of epidural use, better pain control, and less postoperative opioids use, especially a drastic reduction of postdischarge opioid need, without adversely affecting outcomes.     

Patients' expectations,experience and acceptability of postoperative analgesia: a nested qualitative study within a randomised controlled trial comparing rectus sheath catheter and thoracic epidural analgesia

Adequate postoperative analgesia is a key element of enhanced recovery programmes. Thoracic epidural analgesia is associated with superior postoperative analgesia but can lead to complications. Rectus sheath catheter analgesia may provide an alternative. In a nested qualitative study (within a two-year randomised controlled trial) focussing on the acceptability, expectations and experiences of receiving the interventions, participants (n = 20) were interviewed 4 weeks post-intervention using a grounded theory approach. Constant comparative analysis, with patient and public involvement, enabled emerging findings to be pursued through subsequent data collection. We found no notable differences regarding postoperative acceptability or the experience of pain management. Pre-operatively, however, thoracic epidural analgesia was a source of anticipatory fear and anxiety. Both interventions resulted in some experienced adverse events (proportionately more with thoracic epidural analgesia). Participants had negative experiences of the insertion of thoracic epidural analgesia; others receiving the rectus sheath catheter lacked confidence in staff members' ability to manage the local anaesthetic infusion pump. The anticipation of the technique of thoracic epidural analgesia, and concerns about its impact on mobility, represented an additional, unpleasant experience for patients already managing an illness experience, anticipating a life-changing operation and dealing with concerns about the future. The anticipation of rectus sheath catheter analgesia was not associated with such anxieties. Patients' experiences start far earlier than the experience of the intervention itself through anticipatory anxieties and fears about receiving a technique and its potential implications. Complex pain packages can take on greater meaning than their actual efficacy in relieving postoperative pain. Future research into patient acceptability and experience should not focus solely on efficacy of pain relief but should include anticipatory fears, anxieties and experiences.     

经颈椎间孔类固醇激素注射治疗神经根性颈椎病的临床疗效观察

目的 探讨X线引导下经颈椎间孔类固醇激素注射（cervical transforaminal epidural steroids injection, CTFESI）治疗由神经根性颈椎病所致慢性颈部疼痛的临床疗效。方法 回顾性分析2016年5月至2018年3月于我院门诊骨科治疗室经X线引导下行CTFESI治疗的47例慢性颈部疼痛病人的临床资料，将其纳入研究组；将同期采用牵引、按摩等保守治疗的56例慢性颈部疼痛病人纳入对照组。收集并比较两组病人治疗前后的疼痛视觉模拟量表（visual analogue score, VAS）评分、颈椎功能障碍指数（neck disability index, NDI），并利用Odom''s评分计算两组病人的治疗有效率。结果 研究组病人均顺利完成注射，其中1例病人于术后出现瞳孔缩小、眼睑下垂等Honor综合征表现，2例病人出现疑似局部血肿症状，经按压、冰敷后症状好转，上述病人均经急诊室留观确认病情稳定后出院。治疗后6个月，研究组和对照组VAS评分分别为（1.96±1.23）分、（3.27±1.52）分，NDI分别为20.18%±1.83%、29.73%±3.57%，均较治疗前水平显著改善，且研究组优于对照组，两组间比较，差异具有统计学意义（P＜0.05）。研究组的治疗总有效率为72.34%（34/47），对照组为51.79%（29/56），两组间比较，差异具有统计学意义（χ²=4.550，P=0.043）。结论 CTFESI治疗由神经根性颈椎病所致慢性颈部疼痛临床疗效好，是介于保守治疗与手术治疗之间的一种有效方法。     

Accidental external rotation of distal interlock jig in retrograde femoral nailing can lead to more prominent screws

Objective

Symptomatic distal interlocking screws in retrograde femoral nailing are common due the difficulties of imaging the trapezoidal femur. Screws appearing to have appropriate length on imaging may possibly be prominent, creating symptoms. Screw trajectory may influence the degree of this radiographic error. We hypothesize that external rotation of screw trajectory will increase measurement error of screw length.

高血压性脑出血血肿清除术后癫痫发作的影响因素分析

目的 探讨高血压性脑出血颅内血肿清除术后并发癫痫发作的影响因素。方法 回顾性分析2011年3月至2018年7月开颅血肿清除术治疗的485例高血压性脑出血的临床资料。采用多因素logistic回归分析检验术后并发癫痫的危险因素。结果 485例中，术后发生癫痫62例（12.9%）。多因素logistic回归分析结果显示，血肿体积≥60 ml、血肿位于小脑、术后再出血、术后电解质紊乱、脑电图异常、术前C反应蛋白（CRP）水平升高、术前肿瘤坏死因子-α（TNF-α）水平升高、术前白细胞介素-6（IL-6）水平升高是术后并发癫痫发作的独立危险因素（P<0.05）。结论 高血压性脑出血开颅血肿清除术后癫痫发作发生率较高，对于血肿较大、血肿位于小脑、术后再出血、术后电解质紊乱、脑电图异常、术前CRP、TNF-α、IL-6水平升高的病人，应采取针对性措施预防术后癫痫发作。