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Objective: While the pain threshold index (PTI) holds potential as a tool for monitoring analgesia-pain equilibrium, its precision in forecasting postoperative pain in children remains unconfirmed. This study's primary aim was to assess the PTI's predictive precision for postoperative pain. Methods: Children (aged 2-16 years) undergoing general surgery under general anesthesia were included. Within 5 min prior to the patient's emergence from surgery, data including PTI, wavelet index (WLI), heart rates (HR) and mean arterial pressure (MAP) were collected. Subsequently, a 15-min pain assessment was conducted following the patient's awakening. The accuracy of these indicators in discerning between mild and moderate to severe postoperative pain was evaluated through receiver operating characteristic (ROC) analysis. Results: The analysis encompassed data from 90 children. ROC analysis showed that PTI was slightly better than HR, MAP and WLI in predicting postoperative pain, but its predictive value was limited. The area under the curve (AUC) was 0.659 [0.537∼0.780] and the optimal threshold was 65[64-67]. Sensitivity and specificity were determined at 0.90 and 0.50, respectively. In a multivariable logistic regression model, a higher predictive accuracy was found for a multivariable predictor combining PTI values with gender, BMI, HR and MAP (AUC, 0.768; 95%CI, 0.669-0.866). Upon further scrutinizing the age groups, PTI's AUC was 0.796 for children aged 9-16, 0.656 for those aged 4-8, and 0.601 for younger individuals. Conclusions: PTI, when used alone, lacks acceptable accuracy in predicting postoperative pain in children aged 2 to 16 years. However, when combined with other factors, it shows improved predictive accuracy. Notably, PTI appears to be more accurate in older children.

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Background: Dexmedetomidine has been used as a perineural local anesthetic (LA) adjuvant to facilitate the potency of erector spinal plane block (ESPB). This quantitative review aimed to evaluate whether perineural dexmedetomidine for ESPB can improve the effects of analgesia compared to LA alone. Methods: Randomized controlled trials (RCTs) that investigated the addition of dexmedetomidine to LA compared to LA alone in ESPB were included. The pain scores, duration of sensory block, the time to first analgesia requirement, postoperative morphine consumption, rescue analgesia, and dexmedetomidine-related side effects were analyzed and combined using random-effects models. Results: A total of 823 patients from 13 RCTs were analyzed. Dexmedetomidine was used at the concentration of 0.5 µg/kg in three trials and 1 µg/kg in nine trials, and both in one trial. Both concentrations of dexmedetomidine perineurally administrated significantly reduced the rest VAS scores postoperatively at 12 h (0.5 µg/kg dexmedetomidine: MD = -0.86; 95% CI: -1.59 to -0.12; p = 0.02; 1 µg/kg dexmedetomidine: MD = -0.49; 95% CI: -0.83 to -0.16; p = 0.004), and 24 h (0.5 µg/kg dexmedetomidine: MD = -0.43; 95% CI: -0.74 to -0.13; p = 0.005; 1 µg/kg dexmedetomidine: MD = -0.62; 95% CI: -0.84 to -0.41; p < 0.00001). Both concentrations of dexmedetomidine added in LAs improved the dynamic VAS scores postoperatively at 12 h (0.5 µg/kg dexmedetomidine: MD = -0.55; 95% CI: -0.95 to -0.15; p = 0.007; 1 µg/kg dexmedetomidine: MD = -0.66; 95% CI: -1.05 to -0.28; p = 0.0006) and 24 h (0.5 µg/kg dexmedetomidine: MD = -0.52; 95% CI: -0.94 to -0.10; p = 0.01; 1 µg/kg dexmedetomidine: MD = -0.46; 95% CI: -0.75 to -0.16; p = 0.002). Furthermore, perineural dexmedetomidine prolonged the duration of the sensory block and the time to first analgesia requirement, reduced postoperative morphine consumption, and lowered the incidence of rescue analgesia and chronic pain. Conclusion: The meta-analysis showed that using perineural dexmedetomidine at either 0.5 µg/kg or 1 µg/kg doses in ESPB can effectively and safely enhance pain relief. Systematic review registration: PROSPERO (CRD42023424532: https://www.crd.york.ac.uk/PROSPERO/).

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INTRODUCTION: Transversus abdominis plane (TAP) block is a widely used anesthetic technique of the abdominal wall, where ultrasound guidance is considered the gold standard. In this study, we aimed to compare the effectiveness of laparoscopic-assisted TAP (LTAP) block with ultrasound-assisted TAP (UTAP) block for post-operative pain, nausea, vomiting, duration of the block, and bowel function. MATERIALS AND METHODS: This study included 60 patients who were randomly assigned to two groups to undergo either the LTAP or UTAP block technique after laparoscopic cholecystectomy. The time taken for administering the block, post-operative nausea and vomiting, post-operative pain, respiratory rate, bowel movements, and analgesia requirements were reported. RESULTS: The time taken for the LTAP block was shorter (p < 0.001). Post-operative mean tramadol consumption, paracetamol consumption, and analgesic requirement were comparable between the two groups (p = 0.76, p = 0.513, and p = 0.26, respectively). The visual analog scale at 6, 24, and 48 h was statistically not significant (p = 0.632, p = 0.802, and p = 0.173, respectively). Nausea with vomiting and the necessity of an antiemetic medication was lower in the UTAP group (p = 0.004 and p = 0.009, respectively). CONCLUSION: The LTAP block is an easy and fast technique to perform in patients as an alternative method where ultrasound guidance or an anesthesiologist is not available.

ANTECEDENTES: El bloqueo del plano transverso del abdomen (TAP) es una técnica anestésica de la pared abdominal ampliamente utilizada, en la cual la guía ecográfica se considera el método de referencia. OBJETIVO: Comparar la efectividad del bloqueo TAP asistido por laparoscopia (LTAP) con el bloqueo TAP asistido por ultrasonido (UTAP) para el dolor posoperatorio, las náuseas y los vómitos, y la función intestinal. MÉTODO: El estudio incluyó 60 pacientes que fueron asignados aleatoriamente a dos grupos para someterse a la técnica de bloqueo LTAP o UTAP después de una colecistectomía laparoscópica. Se informaron el tiempo de administración del bloqueo, las náuseas y los vómitos posoperatorios, el dolor posoperatorio, la frecuencia respiratoria, las evacuaciones y los requerimientos de analgesia. RESULTADOS: El tiempo de bloqueo LTAP fue menor (p < 0.001). El consumo medio de tramadol, el consumo de paracetamol y el requerimiento de analgésicos posoperatorios fueron comparables entre los dos grupos (p = 0.76, p = 0.513 y p = 0.26, respectivamente). El dolor en la escala analógica visual a las 6, 24 y 48 horas no fue estadísticamente significativo (p = 0.632, p = 0.802 y p = 0.173, respectivamente). CONCLUSIONES: El bloqueo PATL es una técnica fácil y rápida de realizar en pacientes como método alternativo cuando no se dispone de guía ecográfica o anestesióloga.

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INTRODUCTION: Hip fractures cause severe pain during positioning for spinal anesthesia (SA). Intravenous systemic analgesics can lead to various complications in elderly patients, hence peripheral nerve blocks are emerging as a standard of care in pain management for hip fractures, among which femoral nerve block (FNB) is widely known and practiced. Pericapsular nerve group (PENG) block is a recently described technique that blocks the articular nerves of the hip with motor-sparing effects and is used to manage positional pain in hip fractures. This study aims to evaluate the analgesic efficacy of PENG block over FNB in managing pain during positioning before SA in hip fractures. MATERIALS AND METHODS: This was a prospective, randomized, double-blinded study. After ethical clearance, 70 patients undergoing hip fracture surgery under SA in a tertiary-care hospital were recruited and randomized to receive either ultrasound-guided PENG block or FNB with 20 ml of 0.25% bupivacaine before performing SA. We compared pain severity using the visual analog scale (VAS) 15 and 30 minutes after the block and during positioning. The sitting angle, requirement of rescue analgesia for positioning, and anesthesiologist and patient satisfaction scores were also analyzed. Continuous data were analyzed with an unpaired t-test while the chi-square test was used for categorical data. RESULTS: There was a significant reduction in VAS scores after PENG block (PENG: 0.66 ± 1.05 and FNB: 1.94 ± 1.90; p = 0.001) with lesser requirement of rescue analgesia for positioning compared to FNB. The anesthesiologist and patient satisfaction scores were also significantly better in the PENG group. CONCLUSION: PENG block offers better analgesia for positioning before SA than FNB without any significant side effects, and improves patient and anesthesiologist satisfaction, thus proving to be an effective analgesic alternative for painful hip fractures.

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Introduction During spine surgeries, various levels of tissue injury can result in varying hemodynamic responses and significant postoperative pain. Perioperative pain management is essential to controlling hemodynamic responses and postoperative pain management. Erector spinae plane (ESP) blocks can help alleviate this pain by blocking the dorsal rami of the spinal nerve. This study aims to evaluate the efficacy of ESP by assessing the perioperative opioid requirement, hemodynamic parameters, and visual analogue score (VAS) during the postoperative period. Methods In this study, 56 patients underwent elective posterior spine fusion surgeries under conventional anaesthesia and were allocated into two groups: 28 patients were included in the conventional group (Group C) and 28 patients in the ESP group (Group E). Group C patients received 20 ml of 0.9% sodium chloride (NaCl) on each side, and Group E patients received 20 ml of 0.25% bupivacaine + 4 mg dexamethasone on each side under ultrasound sonography guidance. Postoperative pain was assessed using the VAS score. The hemodynamic parameters during the intraoperative period, the time for the first opioid analgesia requirement until 24 hours in the postoperative period, and the amount of cumulative opioid consumption during the perioperative period were observed. Results Postoperative VAS was lower in Group E (P < 0.001). There were significant differences in hemodynamic parameters: heart rate (P < 0.045), systolic blood pressure (P < 0.002), diastolic blood pressure (P < 0.003), and mean arterial pressure (P < 0.002) at the time of incision in Group E. Intraoperative opioid requirements at the time of incision (P < 0.036), 60th minutes (P < 0.023), 120th minutes (P < 0.023), and postoperative opioid requirements at the first hour (P < 0.001), sixth hour (P < 0.004), 14th hour (P < 0.025), 20th hour (P < 0.009), and 24th hour (P < 0.025) had lower opioid requirements in Group E than Group C. Conclusion ESP block is a more site-specific dorsal rami block with a better perioperative hemodynamic profile, a part of multimodal analgesia intraoperatively, and excellent postoperative analgesia with fewer postoperative opioid requirements in multilevel spine fusion surgeries.

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BACKGROUND: The efficacy of the erector spinae plane (ESP) block in mitigating postoperative pain has been shown for a range of thoracic and abdominal procedures. However, there is a paucity of literature investigating its impact on postoperative analgesia as well as its influence on weaning and subsequent recovery in comparison to thoracic epidural analgesia (TEA) in median sternotomy-based approach for open-cardiac surgeries and hence the study. METHODS: Irrespective of gender or age, 74 adult patients scheduled to undergo open cardiac surgery were enrolled and randomly allocated into two groups: the Group TEA (thoracic epidural block) and the Group ESP (bilateral Erector Spinae Plane block). The following variables were analysed prospectively and compared among the groups with regard to pain control, as determined by the VAS Scale both at rest (VASR) and during spirometry (VASS), time to extubation, quantity and frequency of rescue analgesia delivered, day of first ambulation, length of stay in the intensive care unit (ICU), and any adverse cardiac events (ACE), respiratory events (ARE), or other events, if pertinent. RESULTS: Clinical and demographic variables were similar in both groups. Both groups had overall good pain control, as determined by the VAS scale both at rest (VASR) and with spirometry (VASS) with Group ESP demonstrating superior pain regulation compared to Group TEA during the post-extubation period at 6, 9, and 12 h, respectively (P > 0.05). Although statistically insignificant, the postoperative mean rescue analgesic doses utilised in both groups were comparable, but there was a higher frequency requirement in Group TEA. The hemodynamic and respiratory profiles were comparable, except for a few arrhythmias in Group TEA. With comparable results, early recovery, fast-track extubation, and intensive care unit (ICU) stay were achieved. CONCLUSIONS: The ESP block has been found to have optimal analgesic effects during open cardiac surgery, resulting in a decreased need for additional analgesic doses and eliminating the possibility of a coagulation emergency. Consequently, it presents itself as a safer alternative to the potentially invasive thoracic epidural analgesia (TEA).

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BACKGROUND: A single injection of local anaesthetic (LA) in the erector spinae plane block (ESPB) can reduce pain after modified radical mastectomy (MRM) surgery, but the duration of analgesia is affected by the duration of the LA. The aim of this study is to investigate the effect of continuous ESPB on acute and chronic pain and inflammatory response after MRM surgery. METHODS: In this prospective, randomised, controlled trial, we will recruit 160 patients, aged 18-80 years, scheduled for elective MRM surgery under general anaesthesia. They will be randomly assigned to two groups: a continuous ESPB group (group E) and a sham block group (group C). Both groups of patients will have a nerve block (group C pretended to puncture) and an indwelling catheter fixed prior to surgery. Electronic pumps containing LA are shielded. The primary outcome is the total consumption of analgesic agents. The secondary outcomes include the levels of inflammation-related cytokines; the occurrence of chronic pain (post-mastectomy pain syndrome, PMPS); static and dynamic pain scores at 2, 6, 12, 24 and 48 h postoperatively; and post-operative and post-puncture adverse reactions. DISCUSSION: Analgesia after MRM surgery is important and chronic pain can develop when acute pain is prolonged, but the analgesic effect of a nerve block with a single injection of LA is limited by the duration of drug action. The aim of this trial is to investigate whether continuous ESPB can reduce acute pain after MRM surgery and reduce the incidence of chronic pain (PMPS), with fewer postoperative analgesic drug-related complications and less inflammatory response. Continuous ESPB and up to 12 months of follow-up are two innovations of this trial. TRIAL REGISTRATION: Chinese Clinical Trial Registry ( https://www.chictr.org.cn/ ) ChiCTR2200061935. Registered on 11 July 2022. This trial is a prospective registry with the following registry names: Effect of ultrasound-guided continuous erector spinae plane block on postoperative pain and inflammatory response in patients undergoing modified radical mastectomy for breast cancer.

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Thoracic paravertebral nerve block(TPVB)is a regional anesthesia technique that pro-vides ipsilateral somatosensory,motor and sympathetic nerves block segmentally by injecting local anesthetics in the paravertebral space.In recent years,there has been an increasing number of studies on the use of TPVB technique for anesthesia and analgesia in pediatric thoracic and upper abdominal surgery,showing good perioperative analgesic efficacy.This article intends to provide a review of the current applica-tion and progress of TPVB technique for pediatric perioperative analgesia in terms of medication regimens,drug diffusion routes,block methods,clinical application,and complications.

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OBJECTIVE: To study the effect of ultrasound-guided fascia iliaca compartment block on perioperative analgesia and postoperative complications in geriatric patients with hip fractures. METHODS: A total of 127 elderly patients undergoing hip fracture surgery from January 2021 to September 2021 were randomized to receive ultrasound-guided continuous fascia iliaca compartment block(group F) either intravenous analgesia control group(group C). There were 62 cases in group F, including 19 males and 43 females with an average age of (82.4±7.2) years old ranging from 66 to 95 years old, involving 25 femoral neck fractures and 37 femoral intertrochanteric fractures. There were 65 cases in control group, including 18 males and 47 females, with an average age of (81.4±8.7) years old ranging from 65 to 94 years old, involving 29 femoral neck fractures and 36 femoral intertrochanteric fractures. The visual analogue scale(VAS), minimental state examination (MMSE), observer's assessment of alertness/sedation(OAA/S) scale, modified Bromage score, postoperative complications and general conditions during hospitalization in two groups were observed. RESULTS: The resting and exercise VAS at 30 min after block, anesthesia placement and 6, 24 and 48 h after surgery were lower than those in group C(P<0.05). In group F, MMSE scores at 12 h before surgery, and 1, 3 d after surgery and OAA/S scores at 3 d after surgery were higher than those in group C(P<0.05). The incidence of adverse effects and the number requiring additional analgesia were lower than those in group C(P<0.05). Group F had better perioperative analgesia satisfaction and hospital stay than group C(P<0.05). But there was no significant difference regarding Bromage score and 30-day mortality between two group(P>0.05). CONCLUSION: Ultrasound-guided continuous fascia iliacus space block was safe and effective for elderly patients with hip fracture, and could significantly reduce perioperative pain, improve postoperative cognitive function, and reduce postoperative complications, thereby shortening hospital stay and improving the quality of life during hospitalization.

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BACKGROUND: The retrospective cohort study was conducted to estimate the opioid-sparing anesthesia and limited side-effects with ultrasound (US)-guided ESPB using programmed intermittent bolus (PIB) or continuous infusion (CI) and standard opioid-based anesthesia in patients undergoing video-assisted thoracoscopic lobectomy (VATS). METHODS: Patients underwent VATS were stratified into either control group or one of the two ESPB groups in a 1:2:2 ratio depending on whether PIB was implemented or not. The primary endpoint was intra- and post-operative opioids consumption over the first 48 h following surgery. RESULTS: A total of 180 cases were included in the analysis. Cumulative perioperative opioid administration was found to be significantly different between PIB, CI and control group (both p < 0.001), and between PIB and CI group (p = 0.028). More specifically, the mean was 305.30 ± 51.35 mg, 339.68 ± 56.07 mg and 468.91 ± 79.84 mg in PIB, CI and control group. NRS scores at rest across all postoperative times were comparable in two ESPB groups, while significantly lower than control group, however, scores during exercising at postoperative 3, 6, 12 h were significantly lower in PIB group as compared to CI group. A wider anesthetized dermatomes with PIB was observed at 6, 24 and 48 h as opposed to the CI. The mean of levobupivacaine plasma concentration was significantly lower for PIB at postoperative 0.5, 12, 24 and 48 h after initiation than CI. However, local anesthetic toxicity was not observed in any of the two ESPB groups. CONCLUSIONS: When US-guided ESPB using PIB was performed preoperatively, it contributed to the minimization of intra- and post-operative opioid consumption due to better analgesia with a wider anesthetic dermatome opposed to conventional CI, whereas, it was also associated with lower risk of local anesthetic toxicity because of lower plasma concentration of levobupivacaine.

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Introduction Pain management is a crucial aspect of patients' perioperative journey and a fundamental duty of every anesthetist. Throughout anesthesia training, there is an emphasis on the management of critical incidents, several of which surround pain management. With changes to the anesthesia curriculum over recent years, variable exposure to training opportunities, and a reduction in clinical hours during training, many trainees report feeling underprepared for their future roles as consultants. However, pain management remains a small fragment of the core anesthesia curriculum with no pain-focused simulation courses currently available across the UK. Simulation has proven to aid learning transfer in complicated and stressful scenarios with a substantial improvement in knowledge retention and prevention of skill loss while eliminating the risk of harm to patients. Aim A novel perioperative pain management simulation course was designed and implemented in the East of England to equip junior anesthesia trainees with the knowledge, skills, and confidence to manage perioperative pain and the associated critical incidents. Methods A multidisciplinary team (MDT) was involved in the course design. The faculty consisted of anesthesia consultants, trainees, pain nurses, and simulation technicians. The course ran twice over a six-month period both locally and regionally. A blended learning approach was adopted where 17 trainees attended PowerPoint presentations providing an overview of basic pain theories, perioperative pain management, regional anesthesia, and labor analgesia. Trainees then underwent telecasted simulation training using replicated patient notes, imaging, blood gas analysis, and a high-fidelity SimMan®. A debriefing period followed each scenario using Pendleton's model. An anonymized questionnaire was completed by all trainees before and after the course to assess improvement in their knowledge and confidence levels across four domains covering the management of perioperative pain. Results All 17 trainees completed the questionnaire; therefore, the entire dataset was analyzed. The pre-course questionnaire showed that using a scale of zero to 10, the vast majority of trainees reported low levels of confidence (<6/10) in the management of chronic pain during the perioperative period (82%), intraoperative pain management (76%), regional anesthesia (88%), and labor analgesia (65%). Following the simulation training, the results showed an overwhelmingly positive improvement in all 17 trainees' knowledge and confidence across all four tested domains. All 17 trainees (100%) also showed an improvement in their understanding of local pain protocols. The subjective feedback was positive, highlighting the overall usefulness of the course and that the tailored complexity of each simulation scenario was appropriate to each candidate's prior level of experience. Trainees also reported feeling more confident in starting their anesthesia on-calls. Conclusion This novel simulation course is the first of its kind in pain management. It has shown great improvements in trainee confidence in managing perioperative pain and the associated critical incidents. Subjective feedback has also been positively reassuring. Its inclusion into the East of England anesthesia training program and national training curriculum would greatly enhance trainee's knowledge and experience in pain management in the perioperative setting.

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Background: The postoperative acute pain caused by surgery has been a major problem plaguing anesthesiologists, and even some acute pain progresses to chronic pain syndrome, terribly reducing the quality of life of patients. To this end, increasing attention has been paid to the management of perioperative analgesia. At present, with the increase of research on perioperative analgesia, the understanding and solution of this clinical problem have been further developed. Bibliometrics can estimate research hot-spots and trends of related fields in a certain period of time. However, a systematic bibliometric analysis has not been conducted to explore current research hotspots and future development trends, which is thus the purpose of this study. Methods: Articles and reviews published from 2012 to 2021 were retrieved from the Web of Science Core Collection (WoSCC) database, and the bibliometric analysis of the keywords and references of articles was performed using VOSviewer1.6.18. Besides, the number of articles related to perioperative analgesia in term of countries, affiliations, authors, and journals were analyzed. Results: Finally, 3157 articles meeting the screening requirements were retrieved, and it was hereby found that the research on perioperative analgesia had received more attention and interest in the past 10 years, with the United States making more contributions, where there were eight of the top ten affiliations by the number of publications. Kaye AD was the most active researcher in this field. Most related articles were published in Anesthesia and Analgesia, accounting for 2.76% of all literature. Enhanced recovery after surgery, different types of anesthesia and multi-mode analgesic drug intervention were the main trends and hotspots. Conclusion: Perioperative analgesia has attracted considerable academic interest. In the past decade, the effects of enhanced recovery after surgery, different types of anesthesia and multi-mode analgesic drug intervention on perioperative analgesia have become the research hotspots, which are also likely to be the focus of future study.

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BACKGROUND: The aim of this study was to investigate the analgesic effect and safety of ultrasound-guided thoracic paravertebral block (UG-TPVB) in Chinese elderly patients undergoing video-assisted thoracic lobectomy (VATL) and to study the influence of aging factors on these effects. METHODS: This study was a single-center, single-blind, prospective, randomized, controlled trial. A total of 300 patients scheduled for VATL were recruited and randomly divided into the UG-TPVB group (T group) and conventional anesthesia group (C group) according to the recruitment order, and subgroups were set up according to whether the age was ≥65 years old or not. The postoperative 12, 24, and 48 h static/dynamic visual analog scale (VAS) scores, intraoperative fentanyl consumption, postoperative extubation time, post-anesthesia care unit (PACU) stay time, hospitalization days, postoperative complications, and other indicators were compared between the two groups. RESULTS: The postoperative 12, 24, and 48 h static/dynamic VAS scores of the T group were significantly lower than those of the C group. The intraoperative fentanyl consumption, postoperative extubation time, PACU stay time, and postoperative hospitalization days were significantly lower than those of the C group. The incidence of postoperative 48 h urinary retention in the T group was significantly lower than that in the C group. These advantages showed no significant difference or slight difference between elderly patients and nonelderly patients, indicating that UG-TPVB did not influence the analgesic effect and safety of VATL patients by age or age difference. CONCLUSION: UG-TPVB is an effective and safe perioperative analgesia method for elderly VATL patients. Its application improves the quality of life and prognosis of elderly VATL patients.

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Objective: The aim of this study was to systematically review the efficacy and safety of parecoxib and flurbiprofen axetil for perioperative analgesia in children through Bayesian network meta-analysis. Methods: We systematically searched PubMed, Embase, Cochrane Library, Web of Science, Sinomed, CNKI, VIP, and Wanfang Data databases on 18 July 2022 to obtain randomized controlled trials comparing perioperative parecoxib or flurbiprofen with placebo or standard treatment for pediatric analgesia. The outcomes were the postoperative pain score and the incidence of adverse events. The Gemtc package of R-4.0.3 and Stata 17.0 were used for Bayesian network meta-analysis. Results: We retrieved 942 articles and 49 randomized controlled trials involving 3,657 patients who met the inclusion criteria. Compared with children who received placebo treatment, those who received flurbiprofen axetil had lower pain sores at each time point within 24 h postoperatively, and those who received parecoxib had lower pain sores at each time point within 12 h postoperatively. Compared with children who received tramadol treatment, both the children who received flurbiprofen axetil or parecoxib had lower pain scores at 8 h postoperatively. The ranking results demonstrated that flurbiprofen axetil had significant superiority in reducing pain scores at 2, 4, and 12 h postoperatively, and parecoxib had significant superiority in reducing pain scores at 0, 0.5, 1, 6, 8, and 24 h postoperatively. In terms of safety, compared with children who received placebo, those who received flurbiprofen axetil or parecoxib had a lower incidence of total adverse events and postoperative agitation. Compared with tramadol, flurbiprofen axetil and parecoxib both significantly reduced the incidence of total adverse events and postoperative nausea and vomiting. Compared with flurbiprofen axetil or fentanyl, parecoxib significantly reduced the incidence of postoperative nausea and vomiting. The ranking results showed that parecoxib was advantageous in decreasing the incidence of total adverse events and postoperative nausea and vomiting. Conclusion: Flurbiprofen axetil was most effective at reducing pain scores at 2, 4, and 12 h postoperatively. Parecoxib had an advantage in terms of reducing pain scores at 0, 0.5, 1, 6, 8, and 24 h postoperatively, as well as the incidence of total adverse events and postoperative nausea and vomiting. Systematic trial registration: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=348886, PROSPERO (CRD42022348886).

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BACKGROUND: Interscalene nerve block (INB) is an effective technique to provide postoperative analgesia for total shoulder arthroplasty (TSA). However, the analgesic effects of the block typically resolve between 8 and 24 hours postadministration, which results in rebound pain and subsequent increased opioid use. The objective of this study was to address this issue by determining how adding an intraoperative periarticular injection (PAI) in combination with INB affects acute postoperative opioid consumption and pain scores in patients undergoing TSA. We hypothesized that compared with INB alone, INB + PAI will significantly reduce opioid consumption and pain scores for the first 24 hours postsurgery. METHODS: We reviewed 130 consecutive patients who underwent elective primary TSA at a single tertiary institution. The first 65 patients were treated with INB alone, followed by 65 patients treated with INB + PAI. The INB used was 15-20 mL of 0.5% ropivacaine. The PAI used was 50 mL of a combination of ropivacaine (123 mg), epinephrine (0.25 mg), clonidine (40 µg), and ketorolac (15 mg). The PAI was injected using a standardized protocol: 10 mL into the subcutaneous tissues prior to incision, 15 mL into the supraspinatus fossa, 15 mL at the base of the coracoid process, and 10 mL into the deltoid and pectoralis muscles-a protocol analogous with a previously described technique. For all patients, a standardized postoperative oral pain medication protocol was used. The primary outcome was acute postoperative opioid consumption represented by morphine equivalent units (MEUs), whereas the secondary outcome was visual analog scale (VAS) pain scores over the first 24 hours postsurgery, operative time, length of stay, and acute perioperative complications. RESULTS: No significant differences in demographics existed between patients who received INB alone vs. INB + PAI. Patients who received INB + PAI had a significantly lower 24-hour postoperative opioid consumption compared to the INB alone group (38.6 ± 30.5 MEU vs. 60.5 ± 37.3 MEU, P < .001). Additionally, VAS pain scores for the first 24 hours postsurgery in the INB + PAI group were significantly lower compared to those for the INB alone group (2.9 ± 1.5 vs. 4.3 ± 1.6, P ≤ .001). No differences existed between groups regarding operative time, length of inpatient stay, and acute perioperative complications. CONCLUSION: Patients undergoing TSA with INB + PAI demonstrated significantly decreased 24-hour postoperative total opioid consumption and 24-hour postoperative pain scores compared to the group treated with INB alone. No increase in acute perioperative complications related to PAI was observed. Thus, compared to an INB, the addition of an intraoperative periarticular cocktail injection appears to be a safe and effective method to reduce acute postoperative pain following TSA.

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Introduction Pain management in patients with chronic kidney disease is challenging. Due to impaired kidney function, analgesic options are limited. Postoperative analgesia in transplant recipients is further complicated by their vulnerability to infections, titrated fluid management and optimal haemodynamics to maintain graft function. Erector spinae plane (ESP) blocks have been used successfully in a variety of surgeries. This study is a quality improvement project aiming to assess the efficacy of continuous erector spinae plane catheter analgesia in the postoperative management of kidney transplant recipients. Methods We conducted an initial audit over a period of three months. All patients who underwent kidney transplantation under general anaesthesia with erector spinae plane catheters were included. Erector spinae plane catheters were secured prior to induction, and continuous local anaesthetic infusion was maintained postoperatively. Pain scores using the numerical rating scale (NRS) were recorded at intervals in the first 24 hours postoperatively, and supplementary analgesics given were noted. Following satisfactory results from the initial audit, we implemented erector spinae plane catheters as part of multimodal analgesia in transplant patients in our centre. We re-audited all transplants done over the next year to reassess the quality of postoperative analgesia. Results Five patients were audited during the initial audit. The average NRS score ranged from 0 at rest to a maximum of 5 during mobilisation. All patients were given only paracetamol to supplement analgesia, and none required opioids. During the re-audit, data was collected on postoperative pain management in 13 subsequent transplants conducted over the next year. The NRS scores ranged from 0 at rest to 6 on mobilisation. Two patients required boluses of fentanyl 25 mcg via the catheter, and the rest reported satisfactory analgesia with paracetamol as needed. Conclusion This quality improvement project changed our centre's practice in managing postoperative pain in kidney transplantations. We switched from securing epidural catheters to erector spinae plane catheters due to better safety profile, minimal use of opioids and lesser adverse effects. We shall continue to re-audit our practices for the best outcomes.

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Background: Since the application of ultrasound-guided erector spinae plane block (ESPB) in 2016, the approach has been gradually applied to perioperative analgesia in various surgeries. In recent years, more and more studies have focused on the effect of ESPB in perioperative analgesia of lumbar spinal surgery, but its clinical effect remains controversial. Objective: This systematic review and meta-analysis was designed to explore the efficacy and safety of ESPB used for perioperative pain management in lumbar spinal surgery. Methods: The Pubmed, Web of Science, Cochrane Library, and EMBASE databases were comprehensively searched for relevant articles from inception to March 2022. Randomized controlled trials (RCTs) comparing ESPB with placebo or without ESPB in lumbar spinal surgery were included. The Review Manager 5.3 software was employed for this meta-analysis. Results: Nineteen RCTs with 1381 participants were included for final analysis. ESPB group exhibited lower intraoperative consumption of sufentanil and remifentanil, lower total opioid consumption within 24 h and 48 h after surgery, lower incidence of rescue analgesia, longer time to first rescue analgesic and lower number of PCA button presses compared to the control group (P<0.05). Moreover, the ESPB group had significantly lower pain scores at rest and on movement within 48 h after surgery compared with the control group (P<0.05). In terms of opioid-related adverse reactions, ESPB reduced the incidence of postoperative nausea, vomitting, somnolence and itching in comparison to the control group (P<0.05). ESPB-related serious complications were not reported in included studies. Conclusion: This meta-analysis demonstrated that ESPB used in lumbar spinal surgery was effective in relieving postoperative pain, decreasing the perioperative consumption of opioids, as well as decreasing the incidence of postoperative opioid-related adverse reactions.

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BACKGROUND: Intravenous lidocaine is used as an adjuvant analgesic agent in perioperative settings. It has been investigated in various patient populations and surgical interventions, but there are limited data on its efficacy, particularly for patients undergoing bariatric surgery. Obese patients are at high risk of postoperative respiratory complications and can be expected to benefit from anaesthetic techniques that minimise opioid administration. METHODS: We studied administration of lidocaine hydrochloride 1% i.v. to general anaesthesia at a dose of 1.5 mg kg-1 (lean body mass×1.28) or placebo in patients undergoing bariatric surgery. Subjects randomly assigned to each group were surveyed for 48 h after surgery for experienced pain (primary outcome), and administered opioids, postoperative nausea and vomiting (PONV), resumption of bowel function, and length of hospital stay (secondary outcomes). RESULTS: We recruited and randomised 140 subjects to either the lidocaine or placebo group; 137 completed the study. Subjects with pain numeric rating scale (NRS) >3 within the first 4 h postoperatively were similar in both groups (proportion of any NRS >3 within first 4 h lidocaine group: 47/68 (69%) vs placebo group: 44/69 (63%), P=0.507; within first h P=0.177, within second h P=0.513, within third h P=0.145, within fourth h P=0.510). There was no difference in maximal pain score, opioid consumption, recovery of bowel function, incidence of PONV, or length of hospital stay. CONCLUSIONS: Lidocaine does not improve postoperative pain scores, analgesia, or any secondary outcomes in patients undergoing bariatric surgery. CLINICAL TRIAL REGISTRATION: NCT03667001.

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Perioperative medicine is a rapidly growing multidisciplinary field with significant advances published each year. In this review, we highlight important perioperative publications in 2022. A multi-database literature search from January to December of 2022 was undertaken. Original research articles, systematic reviews, meta-analyses, and guidelines were included. Abstracts, case reports, letters, protocols, pediatric and obstetric articles, and cardiac surgery literature were excluded. Two authors reviewed each reference using the Distiller SR systematic review software (Evidence Partners Inc., Ottawa, Ont, Canada). A modified Delphi technique was used to identify 8 practice-changing articles. We identified another 10 articles for tabular summaries. We highlight why these articles have the potential to change clinical perioperative practice and areas where more information is needed.

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BACKGROUND: The complex innervation of the hip joint may require a combined peripheral nerve block technique for perioperative effective analgesia and early recovery. The pericapsular nerve group (PENG) and suprainguinal fascia iliaca compartment blocks (SIFICB) are interfascial plane blocks aiming to involve the femoral, obturator, accessory obturator, and lateral femoral cutaneous nerves. The data still lacks in providing the standard of care for patients undergoing hip surgery. In this case series, we studied the efficacy of ultrasound-guided combined PENG block and SIFICB for perioperative analgesia and functional recovery in patients posted for hip surgery. METHOD: We studied 10 adults of either gender who underwent close reduction and internal fixation of hip fracture. Before receiving spinal anesthesia, all patients had PENG block and SIFICB with 10 ml and 20 ml of local anesthetics respectively. Patients were observed for ease of giving sitting position for spinal anesthesia (EOSP), visual analogue score (VAS) at rest and 15° leg elevation, duration of postoperative analgesia, the cumulative requirement of rescue analgesic at 48 hours and ability of patients to undergo weight-bearing trial postoperatively. RESULT: The static and dynamic VAS before receiving spinal anesthesia and postoperatively, was reduced compared to pre-block. The optimal position for delivering spinal anesthesia was possible to achieve as the patients were able to sit comfortably after 10 minutes of receiving both blocks. Duration of postoperative analgesia also extended up to 18 hours with the cumulative requirement of injection tramadol restricted to two doses postoperatively. All were able to walk down a minimum of 55 steps after 48 hours of completion of surgery. CONCLUSION: Combining PENG block along with SIFICB is effective in the provision of perioperative analgesia with a considerable reduction in opioids and enhanced functional recovery due to motor sparing effect after surgical repair of the hip fracture.