Continuous Infraclavicular Brachial Plexus Block for Postoperative Pain Control at Home: A Randomized, Double-blinded, Placebo-controlled Study

Background: This randomized, double-blinded, placebo-controlled study investigated the efficacy of patient-controlled regional analgesia using an infraclavicular brachial plexus perineural catheter and a portable infusion pump for outpatients undergoing moderately painful, upper extremity orthopedic surgery.

Methods: Preoperatively, patients (n = 30) received an infraclavicular nerve block and perineural catheter. Postoperatively, patients were discharged home with oral narcotics and a portable infusion pump delivering study solution (0.2% ropivacaine or 0.9% saline) via the catheter for 3 days. Investigators and patients were blinded to random group assignment. Daily end points included pain scores at rest and with limb movement, narcotic use and side effects, sleep quality, patient satisfaction, and symptoms of catheter- or local anesthetic-related complications.

Results: Ropivacaine (n = 15) infusion significantly reduced pain compared with saline (n = 15) infusion (P < 0.001). For example, the average pain with movement (scale, 0-10) on postoperative day 1 was 6.1 +/- 2.3 for the saline group versus 2.5 +/- 1.6 for the ropivacaine group (P < 0.001). Oral narcotic use and related side effects were significantly decreased in the ropivacaine group. For example, on postoperative day 1, mean tablet consumption was 5.5 +/- 2.4 and 1.7 +/- 1.6 for the saline and ropivacaine groups, respectively (P < 0.001). Sleep disturbance scores were 10-fold greater for saline administration than for ropivacaine infusion (P < 0.001). Overall satisfaction was significantly greater in the ropivacaine group. No catheter- or local anesthetic-related complications occurred.     

Intraoperative Nefopam Reduces Acute Postoperative Pain after Laparoscopic Gastrectomy: a Prospective,Randomized Study

Background

We assessed whether intraoperative nefopam would reduce opioid consumption and relieve postoperative pain in patients undergoing laparoscopic gastrectomy.

Methods

The 60 enrolled patients were randomly assigned to the control (n?=?32) or nefopam (n?=?28) group. All patients were blinded to their group assignment. We administered 100 ml of normal saline only (control group) or 20 mg of nefopam mixed in 100 ml normal saline (nefopam group) after anesthesia induction and at the end of surgery. The cumulative amount of fentanyl via intravenous patient-controlled analgesia (PCA), incidence of rescue analgesic medication, and numerical rating scale (NRS) for postoperative pain were evaluated along with the total remifentanil consumption.

Results

The mean infusion rate of remifentanil was significantly lower in the nefopam group (0.08?±?0.05 μg/kg/min) than in the control group (0.13?±?0.06 μg/kg/min) (P?<?0.001). Patients in the nefopam group required less fentanyl via intravenous PCA than those in the control group during the first 6 h after surgery (323.8?±?119.3 μg vs. 421.2?±?151.6 μg, P?=?0.009). Additionally, fewer patients in the nefopam group than in the control group received a rescue analgesic during the initial 6 h postoperatively (78.6 vs. 96.9%, P?=?0.028). The NRS measured while patients were in the post-anesthetic care unit was significantly lower in the nefopam group than in the control group (3.8?±?1.1 vs. 4.8?±?1.4, P?=?0.012). The subsequent NRS obtained after patients had been transferred to the general ward was comparable between the two groups during the following postoperative period.

Conclusions

Intraoperative nefopam decreased postoperative pain and opioid consumption in the acute postoperative period after laparoscopic gastrectomy. Hence, nefopam may be considered as a component of multimodal analgesia after laparoscopic gastrectomy.

     

Micronized Flavonoids in Pain Control After Hemorrhoidectomy: A Prospective Randomized Controlled Study

Purpose. We conducted a prospective randomized controlled study to evaluate the effect of micronized flavonoid fractions (MFF) on pain after hemorrhoidectomy. Methods. The subjects were 112 consecutive patients randomly assigned either to receive MFF (group 1) for 1 week or not to receive MFF, as a control (group 2), after hemorrhoidectomy, The severity of pain and the number of intramuscular analgesic injections required were recorded for the first 3 days, then 1 week after hemorrhoidectomy. The number of days that intramuscular analgesic injections were required, hospital stay, and patient satisfaction were also assessed. Results. On postoperative day (POD) 1, there were no significant differences between the parameters of the two groups, but on PODs 2 and 3, both the pain score (P = 0.033 and P = 0.011, respectively) and the number of patients who required intramuscular analgesic injections were significantly less in group 1 (P = 0.022 and P = 0.007, respectively). Moreover, the hospital stay was shorter and patient satisfaction was superior in group 1 (P = 0.001 and P = 0.001, respectively). After 1 week, the pain score and number of intramuscular analgesic injections given were significantly less in group 1 (P = 0.001 and P = 0.021). Conclusion. Using MFF after hemorrhoidectomy reduced the severity of pain and intramuscular analgesic requirement.     

The Frank Stinchfield Award: The Impact of Socioeconomic Factors on Outcome After THA: A Prospective, Randomized Study

Background  

Most studies of total hip arthroplasty (THA) focus on the effect of the type of implant on the clinical result. Relatively little data are available on the impact of the patient’s preoperative status and socioeconomic factors on the clinical results following THA.     

Pain Amelioration after Thoracotomy: A Prospective,Randomized Study

Twenty patients undergoing a posterolateral thoracotomy for lung resection or a nonpulmonary procedure were divided into four groups. Group 1 was the control group. Patients in Group 2 had an intercostal nerve block at the time of closure. Those in Group 3 underwent a continuous intercostal nerve block for five days. Electronic pain control was used in Group 4. An additional group of patients underwent operation through an anterolateral thoracotomy (Group 5) and was compared with the control group. Breathing performance was evaluated daily for five days with bedside spirometry, and intergroup comparison was done utilizing the unpaired t test and analysis of variance. Forced expiratory volume in one second, expressed as percent of preoperative values, was significantly better in Group 3 (continuous intercostal nerve block) at 52.4 ± 9.2% (standard deviation; p < 0.05) and in Group 5 (anterolateral thoracotomy) at 52.0 ± 7.5% (p < 0.05) than in the control group (38.4 ± 8.8%) five days postoperatively. It is concluded that bedside spirometry is a simple and reliable technique to assess postoperative changes in ventilatory mechanics due to pain. The pain that follows posterolateral thoracotomy can be substantially decreased with a continuous intercostal nerve block. Anterolateral thoracotomy is notably less painful than posterolateral thoracotomy and should be considered the approach of choice for patients with decreased pulmonary reserve who undergo uncomplicated pulmonary resection.     

Prospective, Randomized, Placebo-controlled Study of the Effect of TENS on Postthoracotomy Pain and Pulmonary Function

We investigated the efficacy of transcutaneous electrical nerve stimulation (TENS) for postthoracotomy pain control in a prospective, randomized, double-blind, placebo-controlled study. We studied two groups of patients undergoing posterolateral thoracotomy. In group 1, TENS was used postoperatively on 60 patients for 5 days. Group 2 contained 56 patients without TENS. In both groups a visual analog scale (VAS) was used to indicate if analgesia was needed. When the VAS was higher than 4, an analgesic was administered. We observed the forced expiratory volume in 1 second (FEV₁), the forced vital capacity (FVC), partial arterial oxygen pressure (PaO₂), partial arterial carbon dioxide pressure (PaCO₂), and how many doses of analgesia were given at postoperative 0 (extubation time), 2, 6, 12, 24, 48, 72, and 120 hours. TENS was not employed in patients with cardiac or neurologic disease. In group 1, TENS reduced the need to administer opioids during the 5-day postoperative period. This result is statistically significant (P = 0.013). Additionally, following the sixth postoperative hour, TENS increased the spirometric breath function. The FEV₁, FVC, and PaO₂ were high and PaCO₂ was low when the first group is compared to the second. All these results are statistically significant (P = 0.012, P = 0.01, P = 0.024, and P = 0.02 respectively). We observed that TENS produced no evidence of side effects or intolerance in the patients of group 1. TENS is thus beneficial for pain relief following thoracotomy and has no side effects. Consequently, the routine use of TENS following thoracic surgery is recommended.     

Preemptive Analgesia: Intraperitoneal Local Anesthetic in Laparoscopic Cholecystectomy: A Randomized, Double-blind, Placebo-controlled Study

Background: A controversy exists over the effectiveness and clinical value of preemptive analgesia. Additional studies are needed to define the optimum intensity, duration, and timing of analgesia relative to incision and surgery.

Methods: One hundred twenty patients undergoing laparoscopic cholecystectomy under general anesthesia plus topical peritoneal local anesthetic or saline were studied. Local anesthetic (0.5% bupivacaine with epinephrine) or placebo solutions were given as follows: immediately after the creation of a pneumoperitoneum (blocking before surgery), and at the end of the operation (blocking after surgery). Patients were randomly assigned to one of four groups of 30 patients each. Group A (placebo) received 20 ml 0.9% saline both before and after surgery, group B received 20 ml 0.9% saline before surgery and 20 ml local anesthetic after surgery, group C received 20 ml local anesthetic both before and after surgery, group P received 20 ml local anesthetic before and 20 ml 0.9% saline after surgery. Pain was assessed using a visual analog scale and a verbal rating scale at 0, 4, 8, 12, and 24 h after surgery. Metabolic endocrine responses (blood glucose and cortisol concentrations) and analgesic requirements also were investigated.

Results: Pain intensity (visual analog and verbal rating scales) and analgesic requirements were significantly less in the group receiving bupivacaine after surgery compared to placebo. However, in the groups receiving bupivacaine before surgery, both pain intensity and analgesic consumption were less than in the group receiving bupivacaine only after surgery. Blood glucose and cortisol concentrations 3 h after surgery were significantly less in groups receiving bupivacaine before surgery.     

Intra-Articular Bupivacaine Reduces Postoperative Pain and Meperidine Use After Total Hip Arthroplasty: A Randomized,Double-Blind Study

One hundred patients receiving unilateral total hip arthroplasty (THA) were randomized to receive an intra-articular injection of 300 mg bupivacaine or normal saline after completion of surgery. Pain scores of the bupivacaine group were significantly lower than those of the control group the first 12 hours postoperatively (all, P < 0.001). A significantly lower dose of meperidine was used in the study group than in the control group the first 24 hours postoperatively (median, 25 vs. 45 mg, P < 0.001). Nineteen patients in the study group required meperidine the first day after surgery, as compared to 45 patients in the control group. We conclude that intra-articular injection of bupivacaine after THA reduces pain and meperidine use in the first 12 hours after surgery.     

Tranexamic Acid Administration after Cardiac Surgery: A Prospective, Randomized, Double-blind, Placebo-controlled Study

Background: Many different doses and administration schemes have been proposed for the use of the antifibrinolytic drug tranexamic acid during cardiac surgery. This study evaluated the effects of the treatment using tranexamic acid during the intraoperative period only and compared the results with the effects of the treatment continued into the postoperative period.

Methods: Patients undergoing elective cardiac surgery with use of cardiopulmonary bypass (N = 510) were treated intraoperatively with tranexamic acid and then were randomized in a double-blind fashion to one of three postoperative treatment groups: group A: 169 patients, infusion of saline for 12 h; group B: 171 patients, infusion of tranexamic acid, 1 mg [middle dot] kg-1 [middle dot] h-1 for 12 h; group C: 170 patients, infusion of tranexamic acid, 2 mg [middle dot] kg-1 [middle dot] h-1 for 12 h. Bleeding was considered to be a primary outcome variable. Hematologic data, allogeneic transfusions, thrombotic complications, intubation time, and intensive care unit and hospital stay duration also were evaluated.

Results: No differences were found among groups regarding postoperative bleeding and outcomes; however, the group treated with 1 mg[middle dot]kg-1[middle dot]h-1 tranexamic acid required more units of packed red blood cells because of a significantly lower basal value of hematocrit, as shown by multivariate analysis.     

Effect of Postoperative Epidural Analgesia on Rehabilitation and Pain after Hip Fracture Surgery: A Randomized, Double-blind, Placebo-controlled Trial

Background: Hip fracture surgery usually carries a high demand for rehabilitation and a significant risk of perioperative morbidity and mortality. Postoperative epidural analgesia may reduce morbidity and has been shown to facilitate rehabilitation in elective orthopedic procedures. No studies exist on the effect of postoperative epidural analgesia on pain and rehabilitation after hip fracture surgery.

Methods: Sixty elderly patients were included in a randomized, double-blind study comparing 4 days of continuous postoperative epidural infusion of 4 ml/h bupivacaine, 0.125%, and 50 [mu]g/ml morphine versus placebo. Both patient groups received balanced analgesia and intravenous nurse-controlled analgesia with morphine. All patients followed a well-defined multimodal rehabilitation program. Pain, ability to participate in four basic physical functions, and any factors restricting participation were assessed on the first 4 postoperative days during physiotherapy.

Results: Epidural analgesia provided superior dynamic analgesia during all basic physical functions, and patients were significantly less restricted by pain, which was the dominating restricting factor in the placebo group. Motor blockade was not a restricting factor during epidural analgesia. Despite improved pain relief, scores for recovery of physical independence were not different between groups.     

Intravenous Lidocaine for Effective Pain Relief After a Laparoscopic Colectomy: A Prospective,Randomized, Double-Blind,Placebo-Controlled Study

A perioperative intravenous lidocaine infusion has been reported to decrease postoperative pain. The goal of this study was to evaluate the effectiveness of intravenous lidocaine in reducing postoperative pain for laparoscopic colectomy patients. Fifty-five patients scheduled for an elective laparoscopic colectomy were randomly assigned to 2 groups. Group L received an intravenous bolus injection of lidocaine 1.5 mg/kg before intubation, followed by 2 mg/kg/h continuous infusion during the operation. Group C received the same dosage of saline at the same time. Postoperative pain was assessed at 2, 4, 8, 12, 24, and 48 hours after surgery by using the visual analog scale (VAS). Fentanyl consumption by patient-controlled plus investigator-controlled rescue administration and the total number of button pushes were measured at 2, 4, 8, 12, 24, and 48 hours after surgery. In addition, C-reactive protein (CRP) levels were checked on the operation day and postoperative days 1, 2, 3, and 5. VAS scores were significantly lower in group L than group C until 24 hours after surgery. Fentanyl consumption was lower in group L than group C until 12 hours after surgery. Moreover, additional fentanyl injections and the total number of button pushes appeared to be lower in group L than group C (P < 0.05). The CRP level tended to be lower in group L than group C, especially on postoperative day1 and 2 and appeared to be statistically significant. The satisfaction score was higher in group L than group C (P = 0.024). Intravenous lidocaine infusion during an operation reduces pain after a laparoscopic colectomy.Key words: Analgesics, Colectomy, Pain, LidocaineBecause of a substantial increase in the incidence of benign and malignant tumors of the colon, the number of laparoscopic colorectal surgeries has increased.¹ Laparoscopic colectomy appears to be less painful, involves less bleeding, and has a faster recovery than an open colectomy.² Further, laparoscopic colorectal surgery has been proven to be beneficial in comparison with robot-assisted laparoscopic colorectal surgery in many aspects.³ However, postoperative pain because of surgical incision is still an issue that requires resolution. Therefore, various clinical applications such as intrathecal morphine, epidural analgesia, patient-controlled analgesia (PCA), and nonsteroidal anti-inflammatory drugs (NSAIDs) are used to control pain after a laparoscopic colectomy.^4,5 However, optimal management has not yet been established. A regional block can have technical difficulties and complications. The epidural failure rate has been reported up to 40%, and other drugs, such as opioids or NSAIDs, have side effects or drug allergies.^5,6Intravenous lidocaine is inexpensive, easy to inject, and a relatively safe drug.⁷ A number of studies showed that intravenous lidocaine has analgesic, anti-hyperalgesic, and anti-inflammatory properties, as well as a fast recovery, reducing the hospital stay and the time for bowel function recovery.^8–10 In addition, lidocaine in a nontoxic concentration has been reported to decrease the variant volatile anesthesia requirement in an animal study.¹⁰ Therefore, the authors aimed to determine whether a continuous infusion of intravenous lidocaine would have an adequate postoperative analgesic effect for a laparoscopic colectomy. The hypothesis of this study was that an intravenous lidocaine infusion during an operation could decrease postoperative pain.     

The Addition of Dexmedetomidine to Analgesia for Patients After Abdominal Operations: A Prospective Randomized Clinical Trial

Background

Postoperative pain and anxiety are two common factors influencing patient’s recovery. Benefits and safety in the use of sedative agents after abdominal operations to improve recovery are not well known. The present study is to evaluate the efficacy and safety of dexmedetomidine use in this population.

Methods

A prospective randomized controlled trial of 145 patients undergoing abdominal operations was conducted in the Surgical Intensive Care Unit of Jinling Hospital between October and December 2015. Thirty-two patients were excluded, and 113 were included and divided into the experimental group (59 patients) receiving dexmedetomidine and analgesics for 72 h after abdominal operations, and the control group (54 patients) receiving only analgesics. Postoperative pain, inflammatory response, recovery of gastrointestinal function, adverse events, and sedation level were analyzed.

Results

Pain scores, assessed by Prince Henry Pain Scale (PHPS), in the experimental group were significantly lower than in the control group on the first (1.53 vs. 2.07, p ≤ 0.01), second (1.07 vs. 1.63, p ≤ 0.01), and third day (1.08 vs. 1.82, p = 0.01). Time to defecation was 0.60 days shorter in the experimental group than the control group (2.51 vs. 3.11, p = 0.01). There was no significant difference between inflammatory responses in the two groups (p > 0.05). Both groups had similar blood pressure, heart rate, prevalence of bradycardia, and hypotension requiring interventions (p > 0.05).

Conclusions

The addition of dexmedetomidine to analgesia after abdominal operations is safe and could enhance gastrointestinal function recovery and pain control when monitored carefully. The capacity of dexmedetomidine to attenuate inflammatory responses requires further investigation.