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Journal of Anaesthesiology, Clinical... 2024Regional anaesthesia has gained popularity in managing post-operative pain in paediatric patients. Quadratus lumborum block (QLB) is recognised as one of the...
BACKGROUND AND AIMS
Regional anaesthesia has gained popularity in managing post-operative pain in paediatric patients. Quadratus lumborum block (QLB) is recognised as one of the peri-operative pain management techniques used during abdominal surgeries. However, no consensus about the best approach has been reached.
MATERIAL AND METHODS
Sixty paediatric patients with ages ranging from 1 to 6 as well as classification I and II of the American Society of Anesthesiologists, scheduled for laparoscopic inguinal hernia, were allocated to receive either a posterior approach (Group I) or an anterior approach (Group II) QLB. Twenty four-hour morphine consumption, the face, legs, activity, cry, and consolability (FLACC) score, duration of analgesia, performance time, and block-related complications were recorded.
RESULTS
Group II showed significantly lower morphine consumption as well as a longer duration of analgesia ( = 0.039*, 0.020*, respectively), with an equivalent period for block performance being reported in the two groups ( = 0.080). At 2, 4, 6, and 12 hours post-operatively, the FLACC scores were substantially diminished in Group II compared to Group I ( = 0.001*, 0.012*, 0.002*, 0.028*, respectively). However, at twenty-four hours, comparable pain scores were observed between both groups ( = 0.626). In addition, there were no block-related complications.
CONCLUSIONS
In paediatric patients scheduled for laparoscopic inguinal hernia repair, the ultra-sound-guided anterior approach of the QLB was associated with significantly reduced post-operative morphine consumption, a lower FLACC score, and a longer analgesia duration when compared to the posterior approach.
PubMed: 38919434
DOI: 10.4103/joacp.joacp_366_22 -
Journal of Anaesthesiology, Clinical... 2024Intra-cuff pressure of Air-Q self-pressurized laryngeal airways (Air-Q SP) balances airway pressure and adapts to patient's pharyngeal and periglottic structures, thus...
BACKGROUND AND AIMS
Intra-cuff pressure of Air-Q self-pressurized laryngeal airways (Air-Q SP) balances airway pressure and adapts to patient's pharyngeal and periglottic structures, thus improves oropharyngeal leak pressure (OLP).This study was performed to compare efficacy of Air-Q SP with Proseal laryngeal mask airway (PLMA) in patients undergoing elective surgery.
MATERIAL AND METHODS
The study design was prospective, randomized and controlled. Ninety patients were randomly assigned to Air-Q SP or PLMA group. All patients were premedicated and shifted to operation theatre. Monitoring was instituted. After securing IV-line, induction with inj. Morphine + Propofol, relaxation with inj. Vecuronium was done. Supraglottic was inserted according to group allocation. Outcome measures were OLP, fibreoptic view of larynx, success rate, device insertion parameters, haemodynamic and respiratory parameters and post-operative laryngopharyngeal complications. Neostigmine + glycopyrrolate were given, device was extubated.
RESULTS
All supraglottic airway devices (SADs) were successfully placed in two attempts. The mean initial OLP, OLP at 10 minutes, and device insertion time were significantly lower in Air-Q SP group. Fiber-optic laryngeal view grading was significantly better with Air-Q SP. No significant difference was observed with respect to rate of successful insertion in first attempt, ease of insertion, and manipulations required. The hemodynamic/respiratory parameters and post-operative sore throat in the two both groups were similar.
CONCLUSIONS
Proseal LMA has a higher OLP than Air-Q SP but average insertion time was better, and fiber-optic grading of laryngeal view was shorter with Air-Q SP. However, Air-Q SP and Proseal LMA were both effective for lung ventilation.
PubMed: 38919429
DOI: 10.4103/joacp.joacp_248_22 -
Journal of Anaesthesiology, Clinical... 2024Modified radical mastectomy (MRM) is associated with significant acute post-operative pain that may progress to chronic pain syndromes in 25-60% of patients. Serratus...
BACKGROUND AND AIMS
Modified radical mastectomy (MRM) is associated with significant acute post-operative pain that may progress to chronic pain syndromes in 25-60% of patients. Serratus anterior muscle (SAM) block has proved to be an excellent analgesic option in patients undergoing MRM. Although many adjuvants have been utilized for the prolongation of analgesia, the role of tramadol in SAM has not been studied as yet. We hypothesize that the addition of tramadol to ropivacaine for SAM block may reduce morphine consumption in the post-operative period in patients undergoing elective MRM surgeries. The primary aim of the study was to compare cumulative post-operative morphine consumption over 24 h in patients receiving SAM block with or without tramadol. The secondary aims were to observe adverse events related to the procedure or medications. The other parameters recorded were non-invasive blood pressure (NIBP), pulse rate, respiratory rate, and nausea or vomiting.
MATERIAL AND METHODS
Patients scheduled to undergo MRM were randomly allocated by block randomization into two groups. The study group (Group T) received a SAM block with 0.25% ropivacaine (18 ml) with tramadol 100 mg while the control group (Group P) received a SAM block with 18 ml of 0.25% ropivacaine and 2 ml of saline. Patients were assessed for pain scores, analgesic requirement, time to first analgesic request, hemodynamic variables, and any side-effects at 30 min, 1 h, 4 h, 8 h, 12 h, and 24 h post-operatively.
RESULTS
Cumulative morphine consumption over 24 h in the post-operative period was less in the group T (3.06 ± 1.53 mg vs 4.34 ± 1.53 mg; 0.001). Time to the first analgesic requirement was more in group T (10.44 ± 5.04 h vs 6.11 ± 2.73 h; < 0.001). Pain scores were significantly lower in the group T at all time points.
CONCLUSION
Tramadol, when used as an adjuvant to ropivacaine for SAM block reduces post-operative pain scores in the first 24 h and prolongs the time of first morphine requirement.
PubMed: 38919426
DOI: 10.4103/joacp.joacp_436_22 -
Journal of Anaesthesiology, Clinical... 2024Spinal and epidural blocks are commonly employed for pain relief during and following cesarean section. Intrathecal morphine (ITM) has been the gold standard for the... (Review)
Review
Spinal and epidural blocks are commonly employed for pain relief during and following cesarean section. Intrathecal morphine (ITM) has been the gold standard for the same for many years. In recent times, many peripheral nerve blocks (PNBs) have been tried for postoperative analgesia following cesarean delivery (PACD). This article has reviewed the common PNBs used for PACD. The role of PNBs along with ITM has been studied and the current best strategy for PACD has also been explored. Currently, Ilio-inguinal nerve and anterior transversus abdominis plane block in conjunction with intrathecal morphine have been found to be the most effective strategy, providing lower rest pain at 6 hours as compared to ITM alone. In patients not receiving intrathecal morphine, recommended PNBs are lateral transversus abdominis plane block, single shot local anesthetic wound infiltration, or continuous wound infiltration with catheter below rectus fascia. PNBs are recommended for PACD. They have an opioid-sparing effect and are devoid of adverse effects associated with central neuraxial blocks such as hypotension, bradycardia, and urine retention. However, caution must be observed with PNBs for possible local anesthetic toxicity due to the large volumes of drug required.
PubMed: 38919417
DOI: 10.4103/joacp.joacp_204_22 -
Journal of Cardiothoracic Surgery Jun 2024An optimal pharmacological strategy for fast-track cardiac anesthesia (FTCA) is unclear. This study evaluated the effectiveness and safety of an FTCA program using... (Observational Study)
Observational Study
Methadone in combination with magnesium, ketamine, lidocaine, and dexmedetomidine improves postoperative outcomes after coronary artery bypass grafting: an observational multicentre study.
BACKGROUND
An optimal pharmacological strategy for fast-track cardiac anesthesia (FTCA) is unclear. This study evaluated the effectiveness and safety of an FTCA program using methadone and non-opioid adjuvant infusions (magnesium, ketamine, lidocaine, and dexmedetomidine) in patients undergoing coronary artery bypass grafting.
METHODS
This retrospective, multicenter observational study was conducted across private and public teaching sectors. We studied patients managed by a fast-track protocol or via usual care according to clinician preference. The primary outcome was the total mechanical ventilation time in hours adjusted for hospital, body mass index, category of surgical urgency, cardiopulmonary bypass time and EuroSCORE II. Secondary outcomes included successful extubation within four postoperative hours, postoperative pain scores, postoperative opioid requirements, and the development of postoperative complications.
RESULTS
We included 87 patients in the fast-track group and 88 patients in the usual care group. Fast-track patients had a 35% reduction in total ventilation hours compared with usual care patients (p = 0.007). Thirty-five (40.2%) fast-track patients were extubated within four hours compared to 10 (11.4%) usual-care patients (odds ratio: 5.2 [95% CI: 2.39-11.08; p < 0.001]). Over 24 h, fast-track patients had less severe pain (p < 0.001) and required less intravenous morphine equivalent (22.00 mg [15.75:32.50] vs. 38.75 mg [20.50:81.75]; p < 0.001). There were no significant differences observed in postoperative complications or length of hospital stay between the groups.
CONCLUSION
Implementing an FTCA protocol using methadone, dexmedetomidine, magnesium, ketamine, lignocaine, and remifentanil together with protocolized weaning from a mechanical ventilation protocol is associated with significantly reduced time to tracheal extubation, improved postoperative analgesia, and reduced opioid use without any adverse safety events. A prospective randomized trial is warranted to further investigate the combined effects of these medications in reducing complications and length of stay in FTCA.
TRIALS REGISTRATION
The study protocol was registered in the Australian New Zealand Clinical Trials Registry ( https://www.anzctr.org.au/ACTRN12623000060640.aspx , retrospectively registered on 17/01/2023).
Topics: Humans; Male; Female; Retrospective Studies; Coronary Artery Bypass; Methadone; Dexmedetomidine; Ketamine; Middle Aged; Aged; Pain, Postoperative; Lidocaine; Magnesium; Analgesics, Opioid; Treatment Outcome
PubMed: 38918868
DOI: 10.1186/s13019-024-02935-0 -
PloS One 2024Opioids administered in hospital during the immediate postoperative period are likely to influence post-surgical outcomes, but inpatient prescribing during the admission...
BACKGROUND
Opioids administered in hospital during the immediate postoperative period are likely to influence post-surgical outcomes, but inpatient prescribing during the admission is challenging to access. Modified-release(MR) preparations have been especially associated with harm, whilst certain populations such as the elderly or those with renal impairment may be vulnerable to complications. This study aimed to assess postoperative opioid utilisation patterns during hospital stay for people admitted for major/orthopaedic surgery.
METHODS
Patients admitted to a teaching hospital in the North-West of England between 2010-2021 for major/orthopaedic surgery with an admission for ≥1 day were included. We examined opioid administrations in the first seven days post-surgery in hospital, and "first 48 hours" were defined as the initial period. Proportions of MR opioids, initial immediate-release(IR) oxycodone and initial morphine milligram equivalents (MME)/day were calculated and summarised by calendar year. We also assessed the proportion of patients prescribed an opioid at discharge.
RESULTS
Among patients admitted for major/orthopaedic surgery, 71.1% of patients administered opioids during their hospitalisation. In total 50,496 patients with 60,167 hospital admissions were evaluated. Between 2010-2017 MR opioids increased from 8.7% to 16.1% and dropped to 11.6% in 2021. Initial use of oxycodone IR among younger patients (≤70 years) rose from 8.3% to 25.5% (2010-2017) and dropped to 17.2% in 2021. The proportion of patients on ≥50MME/day ranged from 13% (2021) to 22.9% (2010). Of the patients administered an opioid in hospital, 26,920 (53.3%) patients were discharged on an opioid.
CONCLUSIONS
In patients hospitalised with major/orthopaedic surgery, 4 in 6 patients were administered an opioid. We observed a high frequency of administered MR opioids in adult patients and initial oxycodone IR in the ≤70 age group. Patients prescribed with ≥50MME/day ranged between 13-22.9%. This is the first published study evaluating UK inpatient opioid use, which highlights opportunities for improving safer prescribing in line with latest recommendations.
Topics: Humans; Analgesics, Opioid; Male; Female; Middle Aged; Aged; Retrospective Studies; Pain, Postoperative; Orthopedic Procedures; Adult; Electronic Prescribing; Inpatients; England; Hospitalization; Aged, 80 and over; Oxycodone; Adolescent
PubMed: 38917135
DOI: 10.1371/journal.pone.0305531 -
Global Spine Journal Jun 2024Meta-analysis. (Review)
Review
STUDY DESIGN
Meta-analysis.
OBJECTIVE
To compare the effectiveness of postoperative pain control between erector spinae plane block (ESPB) and thoracolumbar interfascial plane (TLIP) block in lumbar spine surgery.
METHODS
PubMed, Embase, and MEDLINE electronic databases were searched for articles containing randomized controlled trials (RCTs) published between January 1900 and January 2024. We extracted the postoperative mean pain score, the first 24-h postoperative morphine consumption, and their standard deviation from the included studies. Meta-analysis was performed using the functions available in the metafor package in R software. We pooled continuous variables using an inverse variance method with a random-effects model and summarized them as standardized mean differences.
RESULTS
Five RCTs that directly compared the ESPB and TLIP block in lumbar spine surgery were included, enrolling 432 participants randomly into the two groups with 216 participants in each group. The pooled analyses showed that there was no significant difference between the ESPB and TLIP groups in terms of lower pain scores during the early (1 h) (standardized mean difference [SMD] -1.49, 95% confidence interval [CI], -3.10; 0.11), middle (12 h) (SMD -3.12, 95% CI, -6.86; 0.61), and late (24 h) (SMD -1.38, 95% CI, -3.01; 0.24) postoperative periods. There was also no significant difference in the first 24-h postoperative morphine equivalent consumption between the ESPB and TLIP groups (SMD -0.46 mg, 95% CI -1.23; 0.31).
CONCLUSION
No significant difference was observed between the ESPB and TLIP block in terms of postoperative pain control and 24-h morphine equivalent consumption for lumbar spine surgery.
PubMed: 38914010
DOI: 10.1177/21925682241266518 -
Addiction Neuroscience Jun 2024Adolescence marks a sensitive period for neurodevelopment wherein exposure to drugs of abuse may disrupt maturation and induce persistent changes in neurophysiology...
Adolescence marks a sensitive period for neurodevelopment wherein exposure to drugs of abuse may disrupt maturation and induce persistent changes in neurophysiology which may exacerbate the risk for developing substance use disorders in adulthood. Adolescent nicotine exposure (ANE) enhances motivation to obtain drugs of abuse, particularly opioids, and increases vulnerability for the development of opioid use disorder (OUD). Here, we characterized ANE effects on learning about the adverse consequences of opioid consumption in adulthood in the absence of further nicotine administration. First, we show that ANE engenders punishment resistant fentanyl self-administration in a heterogenous seeking-taking chain schedule of reinforcement at least at the tested dose of fentanyl (0.75 μg/kg). We found that ANE rats consumed significantly more fentanyl and contingent foot shock punishment was less efficacious in limiting fentanyl seeking in ANE rats, relative to nicotine-naïve controls. Next, we demonstrated that ANE limits learning about the deleterious consequences of acute opioid intoxication in adulthood. In a combined conditioned taste avoidance and place preference paradigm we found that ANE resulted in significant reductions in the strength of morphine-induced CTA, and a simultaneous enhancement of CPP at a higher dose that was less capable of driving reinforcement in naïve controls. Finally, we examined the expression of perineuronal nets (PNNs) within insular cortex (IC) and found ANE rats to have increased density of PNNs across the anterior IC and significantly more parvalbumin-labeled IC cells relative to naïve controls. Together, these data lay the framework for a mechanistic explanation of the extreme comorbidity between nicotine use and development of OUDs.
PubMed: 38911872
DOI: 10.1016/j.addicn.2024.100150 -
Clinica Chimica Acta; International... Jun 2024The number of xylazine-involved overdose deaths tremendously increased from 2019 onwards in the US. This is due to the "tranq-dope" trend consisting in mixing opioids...
BACKGROUND AND AIMS
The number of xylazine-involved overdose deaths tremendously increased from 2019 onwards in the US. This is due to the "tranq-dope" trend consisting in mixing opioids with the sedative to reduce drug manufacturing costs and enhance their effects. In this study, we report the first fatality involving xylazine-adulterated heroin in the EU.
MATERIALS AND METHODS
The subject was a 33-year-old Caucasian male with a documented history of drug abuse who was found dead in a public area with puncture marks at the elbow. Peripheral blood and urine were collected at the autopsy and analyzed by liquid chromatography-high-resolution tandem mass spectrometry (LC-HRMS/MS) after protein precipitation.
RESULTS
6-Monoacetylmorphine, total/free morphine, and codeine blood concentrations of 20.3, 236/105, and 38.3 ng/mL, respectively, indicated recent heroin consumption. Methadone blood concentration was below 10 ng/mL. Alprazolam, nordiazepam, and flurazepam blood concentrations were 23.9, 61.4, and 55.0 ng/mL, respectively. Benzoylecgonine blood concentration was below 5 ng/mL. Xylazine blood and urine concentrations were 105 and 72.6 ng/mL, respectively.
CONCLUSION
The combination of central nervous system depressants, i.e., opioids, benzodiazepines, and xylazine, was the principal cause of death by cardiorespiratory failure. The case was promptly reported to the UE Early Warning System on drugs.
PubMed: 38909977
DOI: 10.1016/j.cca.2024.119826 -
Journal of Plastic, Reconstructive &... Jun 2024Protocols surrounding opioid reduction have become commonplace in plastic surgery to improve peri-operative outcomes. Within such protocols, opioid requirement is a... (Review)
Review
INTRODUCTION
Protocols surrounding opioid reduction have become commonplace in plastic surgery to improve peri-operative outcomes. Within such protocols, opioid requirement is a frequently analyzed outcome. Though often examined, there is no literature standard conversion for morphine milligram equivalents (MME) at present, leading to questionable external validity. We hypothesized significant heterogeneity in MME reporting would exist within plastic surgery literature.
METHODS
Following the PRISMA guidelines, the authors conducted a systematic review of 16 journals. Clinical studies focused on opioid reduction within plastic surgery were identified. Primary outcomes included reporting of morphine equivalents (ME) delivery (IV/oral), operative ME, inpatient ME, outpatient ME, timeline, and method of calculation.
RESULTS
Among the 101 studies analyzed, 73% reported opioid requirements in the form of ME. Among those that used ME, 3% reported IV ME, 41% reported oral, 32% reported both, and 25% gave no indication of either. Operative ME were reported in 19% of studies. Furthermore, 54% of studies reported inpatient ME whereas 32% of studies reported outpatient ME. Only 19% reported the number of days opioids were consumed postoperatively. Moreover, 27% of the studies reported the actual method of ME conversion, with 17 unique methods described. Only 8 studies (8%) reported using the Center for Disease Control and Prevention guidelines for ME conversion.
CONCLUSION
There is significant variability among the reported ME conversion methodology within plastic surgery literature. Highlighting these discrepancies is an essential step in creating and implementing a single, standard method to mitigate opioid morbidity in plastic surgery and to optimize enhanced recovery protocols.
PubMed: 38909598
DOI: 10.1016/j.bjps.2024.06.001