Opioid-free versus opioid-based anesthesia in pancreatic surgery

Background Opioid-free anesthesia (OFA) is associated with significantly reduced cumulative postoperative morphine consumption in comparison with opioid-based anesthesia (OBA). Whether OFA is feasible and may improve outcomes in pancreatic surgery remains unclear. Methods Perioperative data from 77 consecutive patients who underwent pancreatic resection were included and retrospectively reviewed. Patients received either an OBA with intraoperative remifentanil (n = 42) or an OFA (n = 35). OFA included a combination of continuous infusions of dexmedetomidine, lidocaine, and esketamine. In OBA, patients also received a single bolus of intrathecal morphine. All patients received intraoperative propofol, sevoflurane, dexamethasone, diclofenac, neuromuscular blockade. Postoperative pain management was achieved by continuous wound infiltration and patient-controlled morphine. The primary outcome was postoperative pain (Numerical Rating Scale, NRS). Opioid consumption within 48 h after extubation, length of stay, adverse events within 90 days, and 30-day mortality were included as secondary outcomes. Episodes of bradycardia and hypotension requiring rescue medication were considered as safety outcomes. Results Compared to OBA, NRS (3 [2–4] vs 0 [0–2], P < 0.001) and opioid consumption (36 [24–52] vs 10 [2–24], P = 0.005) were both less in the OFA group. Length of stay was shorter by 4 days with OFA (14 [7–46] vs 10 [6–16], P < 0.001). OFA (P = 0.03), with postoperative pancreatic fistula (P = 0.0002) and delayed gastric emptying (P < 0.0001) were identified as only independent factors for length of stay. The comprehensive complication index (CCI) was the lowest with OFA (24.9 ± 25.5 vs 14.1 ± 23.4, P = 0.03). There were no differences in demographics, operative time, blood loss, bradycardia, vasopressors administration or time to extubation among groups. Conclusions In this series, OFA during pancreatic resection is feasible and independently associated with a better outcome, in particular pain outcomes. The lower rate of postoperative complications may justify future randomized trials to test the hypothesis that OFA may improve outcomes and shorten length of stay.

Efficacy And Safety of Wound Infiltration Modalities For Postoperative Pain Management After Cesarean Section: A Systematic Review, Meta-Analysis, And Trial Sequential Analysis Protocol

Background: Inadequately managed postoperative pain after cesarean section has a number of consequences to the mother in the postoperative period. Different postoperative pain management modalities have been practiced after cesarean section over the years. The opioid based analgesics and land mark techniques have undesirable consequences, regional analgesia technique with ultrasound requires resource and expertise while different wound infiltration techniques are new techniques with minimal side effect and easy to administer. However, the effectiveness of each technique is uncertain and needs further investigation.Objective: This systematic review will provide the most effective wound infiltration technique to prevent undesirable adverse effects of opioids and untreated painMethod: A comprehensive search will be conducted in PubMed/Medline, Cochrane, Science direct, CINHAL, and LILACS without date and language restriction. All randomized trials comparing the efficacy of wound infiltration for postoperative pain management after cesarean section will be included. The data will be extracted with two independent authors in a customized format. The methodological quality of included studies will be evaluated using the Cochrane risk of bias tool. The overall quality of the evidence will be determined by GRADEpro software. Trial Sequential Analysis will be conducted to investigate the necessity of further trials.Discussion: The incidence of postoperative acute as well as chronic pain is very high which has a tremendous impact on the mother, family, healthcare providers, and healthcare delivery. It is a basic human right to provide postoperative pain management to every patient that is feasible to everyone in terms of resources, technique, cost, and minimal adverse events profileRegistration: This systematic review protocol was registered in Prospero (CRD42021270710) on September 5, 2021

Analgesic Efficacy and Safety of Local Infiltration Following Lumbar Decompression Surgery: A Systematic Review of Randomized Controlled Trials

This systematic review aims to appraise available clinical evidence on the efficacy and safety of wound infiltration with adjuvants to local anesthetics (LAs) for pain control after lumbar spine surgery. A database search was conducted to identify randomized controlled trials (RCTs) pertinent to wound infiltration with analgesics or miscellaneous drugs adjunctive to LAs compared with sole LAs or placebo. The outcomes of interest were postoperative rescue analgesic consumption, pain intensity, time to first analgesic request, and the occurrence of adverse events. Twelve double-blind RCTs enrolling 925 patients were selected for qualitative analysis. Most studies were of moderate-to-good methodological quality. Dexmedetomidine reduced analgesic requirements and pain intensity within 24 h postoperatively, while prolonged pain relief was reported by one RCT involving adjunctive clonidine. Data on local magnesium seem promising yet difficult to interpret. No clear analgesic superiority could be attributed to steroids. Τramadol co-infiltration was equally effective as sole tramadol but superior to LAs. No serious adverse events were reported. Due to methodological inconsistencies and lack of robust data, no definite conclusions could be drawn on the analgesic effect of local infiltrates in patients undergoing lumbar surgery. The probable positive analgesic efficacy of adjunctive dexmedetomidine and magnesium needs further evaluation.

Role of loco-regional anesthesia for non-intubated video-assisted thoracoscopic surgery: A tertiary care hospital in northern Thailand

Background: A few studies have focused on the role of regional anesthesia for non-intubated thoracoscopic surgery (NIVATS) in Thailand. The purpose of the present study was to review the feasibility and safety of loco-regional anesthesia for NIVATS in a tertiary care hospital. Methods: All patients undergoing scheduled NIVATS under loco-regional anesthesia including thoracic epidural analgesia (TEA), intercostal nerve block (ICNB), thoracic paravertebral block, and local wound infiltration from 2018 to 2021 were assessed by a retrospective chart review. Sedation was performed with propofol infusion and bispectral index monitoring. Primary outcomes were the feasibility of surgery and safety related to loco-regional anesthesia techniques. Results: Twenty-three patients were included. The average age was 43 (26-59) years. The two most common regional anesthesia techniques in this study were TEA and ICNB. The most common surgical procedure was wedge resection (13 patients, 56.5%) followed by pleurectomy (5 patients, 21.7%). The overall median technical feasible scores were 3 (2-3). Intraoperative hypotension (62.5% for TEA vs 20% for ICNB) and urinary retention (25% for TEA vs 0 for ICNB) were found. Among four patients with severe cough, three patients received intrathoracic vagal block and one patient required general anesthesia due to severe hypoxemia. Patients with ICNB had a higher degree of incisional pain and a higher amount of postoperative morphine consumption. Conclusion: NIVATS under loco-regional anesthesia could be a feasible and safe technique. A further study is recommended to compare the efficacy and safety of TEA and ICNB for NIVATS.

Comparison of The Analgesic Outcomes of Local Wound Infiltration using Bupivacaine with Tramadol in Pediatric Inguinal Hernia Repair

Objective: To compare the time for first analgesic requirement after local wound infiltration with tramadol and bupivacaine in pediatric inguinal herniotomy. Materials and Methods: A total of 130 children aged 4 to 12 years who underwent inguinal herniotomy were included in this randomized comparative study. The study was conducted in anesthesiology unit of a tertiary care center in Qatar from Nov-2020 to July-2021. Patients in Group T received wound infiltration by Inj. Tramadol 2 mg/kg diluted in 10cc distilled water while patients in Group B received Inj. Bupivacaine 1mg/kg diluted in 10 cc distilled water. Postoperatively Pain score using Wong Baker Faces Scale was noted from ½ hour to 6 hours after surgery. Time of first rescue analgesia was noted. Results: The mean age was 7.98±2.40 years in group B versus 7.49±2.58 years in group T (p-value 0.26). There were 42 (64.6%) in group B versus 45 (69.2%) in group T (p-value 0.93). Mean surgery duration was 46.66±4.73 minutes in group T and 45.50±4.37 minutes in group B. The Wong-Baker pain score at different time intervals was significantly lower in group T in comparison to group B. Time of first analgesia requirement was 6.87±0.76 hours in group P versus 5.67±0.97 hours in group P, this duration was significantly prolonged in group T with p-value <0.001. Conclusion: Local wound infiltration with tramadol provides a longer time for first analgesic requirement as compared to the bupivacaine in children undergoing inguinal hernia repair. Keywords: Inguinal hernia, wound infiltration, tramadol, bupivacaine, post-operative pain.

A comparison of ultrasound guided bilateral single injection shot Erector Spinae Plane blocks versus wound infiltration for post-operative analgesia in laparoscopic assisted colonic surgery- a prospective randomised study

Background Both wound infiltration (WI) with local anaesthetic and Erector Spinae Plane block (ESPB) have been described for post-operative analgesia after abdominal surgery. This study compared the efficacy of WI versus ESPB for post-operative analgesia after laparoscopic assisted colonic surgery. Methods Seventy-two patients between 18 and 85 years of age undergoing elective surgery were randomised to receive either WI or ESPB. In the WI group a 40 ml bolus of 0.5% Ropivacaine, infiltrated at the ports and minimally invasive wound at subcutaneous and fascia layers. In the ESPB group at T8 level, under ultrasound guidance, a 22-gauge nerve block needle was passed through the Erector Spinae muscle to reach its fascia. A dose up to 40 ml of 0.5% Ropivacaine, divided into two equal volumes, was injected at each side. Both groups had a multimodal analgesic regime, including regular Paracetamol, dexamethasone and patient-controlled analgesia (PCA) with Fentanyl. The primary end point was a post-operative pain score utilising a verbal Numerical Rating Score (NRS, 0–10) on rest and coughing in the post anaesthetic care unit (PACU) and in the first 24 h. Secondary outcomes measured were: opioid usage, length of stay and any clinical adverse events. Results There was no significant treatment difference in PACU NRS at rest and coughing (p-values 0. 382 and 0.595respectively). Similarly, there were no significant differences in first 24 h NRS at rest and coughing (p-values 0.285 and 0.431 respectively). There was no significant difference in Fentanyl use in PACU or in the first 24 h (p- values 0.900 and 0.783 respectively). Neither was there a significant difference found in mean total Fentanyl use between ESPB and WI groups (p-value 0.787). Conclusion Our observations found both interventions had an overall similar efficacy. Trial registration The study was registered with the Australian New Zealand Clinical Trial Registry (ACTRN: 12619000113156).

Comparison of analgesic efficacy of transversus abdominis plane block with local wound infiltration using 0.25% levobupivacaine for post cesarean analgesia: A randomized controlled trial

The key component of Enhanced recovery after cesarian section (ERAC) is to improve maternal and child outcome and enhance recovery by dint of effective non opioid based pain control. We aim to compare the efficacy of Transverse abdominis plane (TAP) block with local wound infiltration for postoperative analgesia in cesarian section (CS).Eighty-two patients undergoing caesarean section under spinal anaesthesia were randomized to undergo local wound infiltration(Group I) (n=41) versus landmark guided bilateral TAP plane block (Group T) with 20ml of 0.25% levobupivacaine postoperatively Each patient was assessed post-operatively by a blinded investigator at regular intervals up to 24 h for visual analogue score (VAS). Requirement of analgesia, patient satisfaction, time for the first and second rescue analgesia, and the incidence of side effects was also noted. The median VAS was more in the group I compared to group II and was statistically significant (p=0.0032). The mean time to first rescue analgesia was prolonged in group I (4.060 ± 0.682 hrs) compared to group T (3.302 ± 0.519 hrs)(P&#60; 0.001). The mean total analgesic requirement in 24 hours was reduced in group T (89.63 ± 41.82) as compared to group I (137.2 ± 33.13) (P&#60;0.001. Group (T) compared to group I patient had a higher mean patient satisfaction score (1.487 ± 0.589) (2.097 ± 0.430) respectably (P &#60; 0.001).TAP block provides better quality of analgesia and can be safely incorporated as a part of multi-model analgesic regimen postoperative pain over local infiltration in cesarian section.

Updates on Wound Infiltration Use for Postoperative Pain Management: A Narrative Review

Local anesthetic wound infiltration (WI) provides anesthesia for minor surgical procedures and improves postoperative analgesia as part of multimodal analgesia after general or regional anesthesia. Although pre-incisional block is preferable, in practice WI is usually done at the end of surgery. WI performed as a continuous modality reduces analgesics, prolongs the duration of analgesia, and enhances the patient’s mobilization in some cases. WI benefits are documented in open abdominal surgeries (Caesarean section, colorectal surgery, abdominal hysterectomy, herniorrhaphy), laparoscopic cholecystectomy, oncological breast surgeries, laminectomy, hallux valgus surgery, and radical prostatectomy. Surgical site infiltration requires knowledge of anatomy and the pain origin for a procedure, systematic extensive infiltration of local anesthetic in various tissue planes under direct visualization before wound closure or subcutaneously along the incision. Because the incidence of local anesthetic systemic toxicity is 11% after subcutaneous WI, appropriate local anesthetic dosing is crucial. The risk of wound infection is related to the infection incidence after each particular surgery. For WI to fully meet patient and physician expectations, mastery of the technique, patient education, appropriate local anesthetic dosing and management of the surgical wound with “aseptic, non-touch” technique are needed.

Comparative Study Between Caudal Block And Local Wound Infiltration In Inguinal Hernia Repair In Pediatric Patients

Background Postoperative analgesia can be provided by a multimodal approach includes opioids, nonsteroidal anti-inflammatory drugs, paracetamol infusion and regional anesthetic techniques such as local infiltration or nerve blocks. In contrast to opioids, local anesthetics can be administered safely and in recent guidelines regional anesthesia is accepted as the cornerstone of postoperative pain relief in the pediatric patients. Objective Compare the postoperative analgesic effectiveness of local wound infiltration of bupivacaine against bupivacaine administered caudally in pediatric patients undergoing unilateral inguinal hernia repair. Patients and methods This study was carried out in Ain Shams University hospitals on 40 pediatric patients of both sexes aged from 6 months to 7 years belonging to ASA I or II undergoing elective unilateral inguinal hernia repair. They were randomly allocated into two groups: group C receiving caudal block, group L receiving local wound infiltration. Hemodynamic changes, postoperative pain score using FLACC pain score, postoperative analgesia and complications were recorded. Results There was no significant difference between the two groups as regard demographic data or hemodynamic variables. Pain score shows no statically significant differences between two groups in the first hour. But statistically significant decrease in FLACC score after (1, 2 and 3 hours) in group C in comparison with group L.decreased significantly in group C after 1 hour postoperative. Duration of analgesia longer in group C with no significant difference in total amount of postoperative analgesia. There was significant increase in incidence in complications in group C than group L Conclusion Caudal block provides better and longer analgesia but requires experience and may lead to complications. In contrast, wound infiltration is simple without significant side effects. Therefore, local wound infiltration may be a preferred technique for producing postoperative analgesia in pediatric inguinal hernia repair.