Pain management in the emergency department: a clinical review

Pain is one of the most common reasons for patients to visit the emergency department. The ever-growing research on emergency department analgesia has challenged the current practices with respect to the optimal analgesic regimen for acute musculoskeletal pain, safe and judicious opioid prescribing, appropriate utilization of non-opioid therapeutics, and non-pharmacological treatment modalities. This clinical review is set to provide evidence-based answers to these challenging questions.

Postoperative Pain Control Following Cardiac Implantable Electronic Device Implantation

Postoperative pain following cardiac implantable electronic device (CIED) surgery may not always be adequately treated. The postoperative pain trajectory occurs over several days following the procedure with tenderness and limited arm range of motion lasting for weeks after surgery. Pain control typically commences in the perioperative period while the patient is in the hospital and may continue after discharge; outpatients may be given a prescription and advice for their analgesic regimen. It is not unusual for CIED patients to be discharged a few hours after implantation. While opioids are known as an effective analgesic to manage acute postoperative pain, growing scrutiny on opioid use as well as their side effects and potential risks have limited their use. Opioids may be considered for appropriate patients for a short course of treatment of acute postoperative pain, but other analgesics may likewise be considered.

Efficacy of interrupted cyclic treatment with prednisolone on cancer pain: a randomized crossover study

Background Interrupted cyclic treatment with a low oral dose of prednisolone combined with stepladder analgesics would reduce the pain scores in cancer patients with reported less side effects. Following ethical approval, 39 cancer patients were randomized to receive prednisolone 10 mg every other day or every 4th day for 4 successive weeks followed with tapering prednisolone by 2.5 mg every 4 days over 2 weeks after each interval, primary outcome visual analog score (VAS), and other secondary outcomes such as (A) patient demographics; (B) pain scores; brief pain inventory score (BPI), pain severity score (PSS), pain interference score (PIS), analgesia level score, pain level score (PLS), and pain management index (PMI)); and (C) patient safety (adverse effects) with interrupted cyclic treatment with low-dose prednisolone. Results Compared with baseline values, patients had statistically significant lower VAS and PSS pain scores at 14 and 28 days after starting the 2 days cyclic treatment with prednisolone. Patients had comparative VAS and PSS pain scores during the 4-day cyclic treatment with prednisolone. Compared with the 4-day cyclic treatment, patients in the 2-day cyclic treatment had significant statistically lower VAS pain scores at 28 days. Adverse effects showed no significant statistical differences during both study sequences. Conclusion Interrupted cyclic prednisolone 10 mg combined with stepladder analgesic regimen is effective and safe in terms on improved quality of analgesia for 28 days in cancer patients more when used every 2nd day than every 4th day with appetite improvement during both. Trial registration The study protocol was approved by the local Institutional Board Review Committee on 8-11-2019. The study was prospectively registered with the www.clinicaltrials.gov

Intraoperatively local infiltration anesthesia in hemiarthroplasty patients reduces the needs of opioids: a randomized, double-blind, placebo-controlled trial with 96 patients in a fast-track hip fracture setting

Background and purpose — Local infiltration analgesia (LIA) is commonly used as a component in multimodal analgesia. Pain management directed towards hip fracture patients operated on with hemiarthroplasty is often based on knowledge regarding pain treatment following elective surgery. In this elderly patient population, it is of value to clarify whether adding local infiltration analgesia (LIA) to the postoperative analgesic regimen might reduce postoperative pain or have an opioid-reducing effect. Patients and methods — 96 hip fracture patients undergoing hemiarthroplasty in spinal anesthesia were included. All patients received a multimodal pain regimen and were randomized to receive either ropivacaine or placebo. All patients received morphine depot-opioid and morphine as rescue medication postoperatively. The primary endpoint was pain during mobilization in the recovery unit on the day of surgery. Secondary endpoints were pain during mobilization the day after surgery and postoperative opioid requirements on the first postoperative day. Results — The levels of pain (NRS) during mobilization both in the recovery unit and on the day after surgery were similar in the 2 groups, with median 4 and 0.5 in the placebo group and median 3.5 and 1 in the ropivacaine group respectively. Total consumption of opioids on day 0 and day 1 were 4.6 mg lower in the ropivacaine group (p = 0.04). Pain during mobilization was registered for only 44 of 96 patients for several reasons, including lack of mobilization. Interpretation — There were similar pain scores in both the local infiltration and placebo group postoperatively. However, substantially reduced opioid consumption was found in patients receiving LIA.

Opioid-Free Thyroid and Parathyroid Operations: Are Patients Satisfied With Pain Control?

Background The aim of this study was to evaluate pain control and patient satisfaction using an opioid-free analgesic regimen following thyroid and parathyroid operations. Methods Surveys were distributed to all postoperative patients following total thyroidectomy, thyroid lobectomy, and parathyroidectomy between January and April 2020. After surgery, patients were discharged without opioids except in rare cases based on patient needs and surgeon judgment. We measured patient-reported Numeric Rating Scale (NRS) pain scores and satisfaction categorically as either satisfied or dissatisfied. Results We received 90 of 198 surveys distributed, for a 45.5% response rate. After excluding neck dissections (n = 6) and preoperative opioid use (n = 4), the final cohort included 80 patients after total thyroidectomy (26.3%), thyroid lobectomy (41.3%), and parathyroidectomy (32.5%).The majority reported satisfaction with pain control (87.5%) and the entire surgical experience (95%). A similar proportion of patients reported satisfaction with pain control after total thyroidectomy (90.9%), thyroid lobectomy (90.5%), and parathyroidectomy (80.8%), indicating the procedure did not significantly impact satisfaction with pain control ( P = .47). Patients who reported dissatisfaction with pain control were more likely to receive opioid prescriptions (30% vs 2.9%, P < .01), but the majority still reported satisfaction with their entire operative experience (70%). Discussion Even with an opioid-free postoperative pain regimen, most patients report satisfaction with pain control after thyroid and parathyroid operations, and those who were dissatisfied with their pain control generally reported satisfaction with their overall surgical experience. Therefore, an opioid-free postoperative pain control regimen is well tolerated and unlikely to decrease overall patient satisfaction.

Analgesic Outcomes of Tramadol Alone and in Combination with Butorphanol or Flurbiprofen Axetil after Caesarean Section: A Retrospective Study with Propensity Score Matching Analysis

Background: To our knowledge, the Society for Obstetric Anesthesia and Perinatology recommends a multimodal analgesic regimen for caesarean delivery analgesia. Therefore, this study aimed to compare the analgesic effects of tramadol alone and in combination with butorphanol or flurbiprofen axetil after caesarean section.Methods: We retrospectively analysed 2323 women with puerperas who had undergone caesarean section based on the electronic medical records of a teaching hospital in China from January 2018 to January 2020. We collected data on demographic characteristics, perioperative complications, surgical factors, and anaesthesia. We also recorded the postoperative analgesic solution, pain intensity (assessed by the numeric rating scale [NRS]) during the first 48 hours after surgery. Postoperative inadequate analgesia during the postoperative 48 hours was defined as an NRS score ≥4. We also collected data regarding off-bed activity and intestinal function recovery. Analgesic outcomes of three groups were compared using propensity score matching analysis.Results: Compared to the tramadol mixed with butorphanol group (group B), the incidence of inadequate analgesia at rest and while moving was lower in the tramadol combined with flurbiprofen axetil group (group F), and the relative risks (RRs) for women with puerperas suffering from inadequate analgesia at rest and while moving in group F were 0.34 (95% confidence interval [CI]: 0.21–0.54; P<0.001) and 0.24 (95% CI: 0.19–0.31, P<0.001), respectively. The percentage of intestinal function recovery and off-bed activity at 2 days postoperatively was higher in group B than in group F (74.1 versus [vs.] 66.4, P=0.006 and 79.4% vs. 66.4%, P<0.001, respectively). Group F was also associated with a lower incidence of inadequate control of pain at rest and while moving than group T (RR, 0.37 [0.23–0.60], P<0.001, and 0.43 [0.33–0.55], P<0.001, respectively). Group B was associated with a higher incidence of inadequate control of moving pain than group T (RR, 1.78, [1.40–2.26], P<0.001).Conclusions: A combination of tramadol and flurbiprofen axetil could enhance the analgesic effect and be safely used for analgesia after caesarean section, but the combination of tramadol and butorphanol may produce an antagonistic effect.Trial registration: Not applicable.

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.

Comparison of Analgesic Efficacy between Bupivacaine with Dexamethasone and Bupivacaine Alone in Caudal Block for Pediatric Patients Undergoing Open Inguinal Hernia Repair

Background Open inguinal hernial repair surgeries are one of the most frequently performed surgical procedures in the pediatric population. Using optimal analgesic regimen provide safe and effective analgesia, reduce postoperative stress response and accelerate recovery from surgery. Regional anesthetic techniques are commonly used to facilitate pain control in pediatric surgical procedures. The most used techniques in pediatrics is caudal block. Objective To evaluate the analgesic effect of dexamethasone when given caudally as an adjuvant to caudal block vs bupivacaine alone in caudal block for children undergoing open inguinal hernial repair surgeries. Methods The study is a prospective double – blinded randomized controlled trial conducted on 50 randomly chosen patients in Ain Shams University Hospitals after approval of the medical ethical committee. Patients were divided randomly into two groups; each group consisted of 25 patients. After preoperative assessment and obtaining baseline vital data, all patients received general anesthesia. Group BD who would receive caudal dexamethasone added to Bupivacaine and Group B who would receive caudal block with Bupivacaine. Results Dexamethasone addition shows statistically significance difference between two groups according to FLACC scale at 4h, 8h and 12h. The duration of adequate analgesia (FLACC pain score 4 or less) was significantly higher in group BD compared to group B. Conclusion Dexamethasone 0.1 mg/kg, when used as an adjuvant to caudal anesthesia, can significantly prolong the duration of postoperative analgesia. It is better than bupivacaine alone in caudal block at similar doses in controlling postoperative pain.

A comparative study between Levobupivacaine alone and in combination with Dexmedetomidine in caudal analgesia of hernia repair in pediatrics

Background Inguinal hernia repair is one of the most frequently performed surgical procedures in the pediatric population. Using optimal analgesic regimen provides safe and effective analgesia, reduce postoperative stress response and accelerate recovery from surgery. Aim of the Work to examine the effect of Dexmedetomidine as an adjuvant to Levobupivacaine in caudal anesthesia, mainly its effect in enhancing and prolonging post-operative analgesia. Patients and Methods The study was conducted on 50 randomly chosen patients in Ain Shams University Hospitals after approval of the medical ethical committee. Patients were divided randomly into two groups, each group consisted of 25 patients. After preoperative assessment and obtaining baseline vital data, all patients received general anesthesia. Group A: Patients in this group received caudal anesthesia with Levobupivacaine 0.25% at a dose of 2 mg·kg−1 (0.8 ml·kg−1) before the beginning of the procedure. Group B: Patients in this group received Levobupivacaine 0.25% at a dose of 2 mg·kg−1 (0.8 ml·kg−1) in addition to Dexmedetomidine 1 μg·kg−1 in 1 ml normal saline before the beginning of the procedure. Results The results of the study revealed that there was significant reduction in FLACC score in group B at 4, 8, and 12 hours postoperatively compared to group A, at the twenty-fourth hour there was no significant difference. Regarding the duration of analgesia postoperatively we found statistically significant increase in group B compared to that in group A (p-value &lt;0.001). Regarding the number of doses of analgesia required post operatively (Paracetamol 15ml/kg/dose) there was a statistically significant decrease in patients requirement in group B compared to that in group A (p-value &lt;0.001). Conclusion Dexmedetomidine as adjuvant to Levobupivacaine provided significantly prolonged postoperative analgesia, reduced the postoperative analgesic requirements and better parents’ satisfaction as compared with caudal analgesia using Levobupivacaine alone in children undergoing hernia repair.

Dexamethasone as an Analgesic Adjunct for Postcesarean Delivery Pain: A Randomized Controlled Trial

Objectives. Dexamethasone has been shown to have analgesic properties in the general surgical population. However, the analgesic effects for women that undergo cesarean deliveries under spinal anesthesia remain unclear and may be related to the timing of dexamethasone administration. We hypothesized that intravenous dexamethasone administered before skin incision would significantly reduce postoperative opioid consumption at 24 h after cesarean delivery under spinal anesthesia with intrathecal morphine. Methods. Women undergoing elective cesarean deliveries under spinal anesthesia were randomly assigned to receive 8 mg of intravenous dexamethasone or placebo prior to skin incision. Both groups received a standardized spinal anesthetic and multimodal postoperative analgesic regime. The primary outcome was cumulative opioid consumption at 24 h. Secondary outcomes included cumulative opioid consumption at 48 h, time to first analgesic request, and pain scores at rest and on movement at 2, 24, and 48 h. Results. 47 patients were analyzed—23 subjects that received dexamethasone and 24 subjects that received placebo. There was no difference in the median (Q1, Q3) cumulative opioid consumption in the first 24 hours following cesarean delivery between the dexamethasone group {15 (7.5, 20.0) mg} and the placebo group {13.75 (2.5, 31.25) mg} ( P = 0.740 ). There were no differences between the groups in cumulative opioid consumption at 48 h, time to first analgesic request, and pain scores. Conclusions. Intravenous dexamethasone 8 mg administered prior to skin incision did not reduce the opioid consumption of women that underwent cesarean deliveries under spinal anesthesia with intrathecal morphine and multimodal postoperative analgesic regimen.