Search Results (53)

Background: The opioid epidemic has highlighted the need for alternative pain management modalities in postoperative patients. Peripheral nerve blocks (PNBs) have been shown to reduce opioid consumption in the immediate postoperative period, but limited data exists on their impact on chronic opioid use. Objective: The present investigation focused on the use of preoperative PNB utilization in orthopedic surgeries and its association with chronic opioid use. Methods: A retrospective cohort study was conducted on 533 patients that had a total shoulder arthroplasty, reverse total shoulder arthroplasty, or knee arthroscopy between July 2021 and July 2024. Patients were grouped based on whether they received a preoperative PNB. Opioid prescription data were collected at 1-, 3-, and 6-month postoperative periods. In addition, a subset of patients completed a questionnaire to assess self-reported opioid consumption and other analgesic usage. Results: Patients who received a PNB were significantly less likely to report continued opioid use at one month postoperatively compared to those who did not (32.8% vs. 61.9%). Additionally, PNB recipients more often declined additional opioids due to a lack of need (p = 0.025), while those without a PNB cited other reasons, including fear of addiction or poor pain control (p = 0.033). Conclusions: The results of the present investigation suggest that preoperative PNBs may be associated with reduced chronic opioid use and have an important role in prescribing practices and pain management strategies following orthopedic surgery. Limitations: The limitations are as follows: retrospective design; potential recall and selection bias from questionnaire use; lack of data confirming actual opioid prescription fills; inclusion of patients with chronic pain comorbidities requiring long-term opioid use. Full article

Background: Effective postoperative pain management is essential in femoral limb lengthening surgery. Although regional nerve blocks reduce pain and opioid use, their benefit in antegrade femoral intramedullary limb lengthening is unclear. This study compares postoperative pain and opioid consumption in patients receiving general anesthesia (GA) alone versus GA with a preoperative femoral or fascia iliaca nerve block. Methods: A retrospective review included 192 patients who underwent femoral lengthening with intramedullary telescoping nails between January 2012 and October 2023 at a single center. Patients were categorized into Group A (GA alone, n = 131) and Group B (GA plus nerve block, n = 61). Primary outcomes were postoperative mean and maximum pain scores in the first 24 h, total opioid pills prescribed at discharge, and total morphine milligram equivalents (MMEs) used in the Post-Anesthesia Care Unit (PACU). Non-inferiority was defined by a margin of one standard deviation for pain scores and opioid usage. Results: Demographics were similar between groups. Maximum PACU pain scores were 3.8 for Group A and 3.3 for Group B (p > 0.05); mean pain scores were 2.1 and 1.9, respectively (p > 0.05). GA alone was non-inferior for pain control. However, total opioid pills prescribed at discharge were higher in Group A (23.2) than Group B (10) (p < 0.05). PACU MME usage was also higher in Group A (26 vs. 18.4 ± 15 mg, p < 0.05), though non-inferiority criteria were met. Conclusions: GA alone is non-inferior to GA with nerve block for postoperative pain management following antegrade femoral intramedullary limb lengthening. Although patients without a nerve block received more opioids at discharge, their pain control remained similarly effective. Given potential risks and the lack of clear pain reduction benefits, routine nerve block use may not be warranted. Decisions regarding nerve block application should be individualized, considering patient preferences, surgeon recommendations, and anesthesiologist input. Full article

Effective postoperative pain management is crucial for optimizing recovery and clinical outcomes in living donor kidney transplantation (LDKT). This retrospective study compared the efficacy and safety of transversus abdominis plane (TAP) block and local wound infiltration (LWI) for postoperative analgesia. A total of 524 LDKT recipients, matched through propensity scoring, were analyzed (262 per group). Pain intensity was assessed using the visual analog scale (VAS) at multiple postoperative time points, while opioid consumption was evaluated based on intravenous patient-controlled analgesia (IV-PCA) usage and rescue fentanyl doses. The TAP block group had significantly lower VAS pain scores at 1, 4, and 8 h postoperatively (p < 0.001) and required fewer opioids, as evidenced by reduced IV-PCA usage (55.9 ± 10.2 mL vs. 69.7 ± 18.2 mL; p < 0.001) and lower rescue fentanyl doses (67.7 ± 30.6 µg vs. 119.1 ± 71.8 µg; p < 0.001). Despite these differences in analgesic efficacy, no significant differences were observed between the groups in terms of postoperative nausea and vomiting or complications such as systemic toxicity and nerve injury. These findings suggest that the TAP block provides more effective early postoperative pain relief and reduces opioid requirements without increasing adverse events. Given its favorable safety profile and effectiveness, the TAP block is a valuable component of multimodal analgesia in LDKT recipients, supporting enhanced recovery while minimizing opioid-related complications. Full article

Background/Objectives: Dyspnea accompanies end-of-life in many cancer patients, with around 50% experiencing moderate/severe dyspnea, and is an independent factor for poor prognosis and declining quality of life. Managing dyspnea becomes a key component of palliative treatment and end-of-life support for cancer patients. Opioids seem to be the obvious choice in cancer patients as they also address the pain component (often important in such patients). Evidence-based conclusions on the effectiveness/safety of opioids in dyspnea management are scarce, and the results are still controversial. We aim to address this knowledge gap. Methods: In order to achieve the objective of this paper, we conducted a comprehensive search of international databases (PubMed, Medline, Embase, and Cochrane Library) for randomized controlled trials on the use of opioids to treat refractory dyspnea in adult cancer patients, and we performed a pooled meta-analysis of the results. Results: The effect of opioids on the relief of dyspnea was significant (SMD −0.44, 95% CI [−0.75,−0.12], p = 0.007). The significance of the opioid effect is maintained only for morphine administration (SMD −078, 95% CI [−1.45,−0.10], p = 0.02) and only for exertional dyspnea (SMD −1.00, 95% CI [−1.98, −0.03], p = 0.04). No correlation was noted between fentanyl/hydromorphone and dyspnea relief or opioids administered for dyspnea at rest. The subcutaneous route seems to be significantly correlated with dyspnea relief (SMD −0.73, 95% CI [−1.27, −0.19], p = 0.008), while the other administration modalities lack such an effect. No significant correlation was present between the usage of morphine/fentanyl and increased odds of severe adverse effects (OR 1.48, 95% CI [0.57,3.86], p = 0.42); however, fentanyl seems to be associated with increased somnolence. Although we aimed to evaluate how opioids impact the quality of life of cancer patients with dyspnea, we were unable to obtain such results due to the absolute lack of the literature available discussing QoL. Conclusions: Although we managed to provide some insights into the efficiency and safety of opioids usage for dyspnea management in cancer patients, the evidence based on the available literature is low grade. There is a marked need to address this knowledge gap with future high-quality studies with large sample sizes and standardized protocols. Full article

Background: The mechanisms underlying the progression and metastasis of triple-negative breast cancer (TNBC) in the context of extended morphine exposure remain poorly understood. Morphine consumption has been a pressing issue in many countries. While the physiological impact of extended morphine use is multifaceted, cancer patients with a history of extended morphine usage often have a poor prognosis. Methods: In this study, we investigated the impact of extended morphine treatment on the transcriptional profiles of TNBC. To this end, mice were administered morphine intraperitoneally for 14 days, followed by the implantation of EO771 cells, which are triple-negative breast cancer cells, into their mammary fat pad. After primary tumors were removed on the 38th day, a subset of mice was continuously given saline or morphine until the 68th day. Tumor size, organ metastasis, and tumor RNA expression were analyzed. Results: Our findings showed that extended exposure to morphine led to an increase in lung metastasis in the mouse model of triple-negative breast cancer. We analyzed RNA sequencing on tumors to compare their transcriptional profiles with or without metastasis. Through pathway analysis, we specifically examined the novel impact of morphine on the downregulation of taurine/hypotaurine biosynthesis. Given that morphine, droperidol (a dopamine receptor antagonist), and naloxone (an opioid receptor antagonist) might act through either opioid receptors or dopamine receptors, we further demonstrated that taurine mitigated EO771 cell invasion induced by morphine but not by droperidol or naloxone treatment. Additionally, morphine treatment markedly decreased the expression of GAD1, one of the enzymes essential for taurine biosynthesis, whereas droperidol and naloxone did not. Conclusions: The findings of morphine-induced reduction in GAD1 levels and the inhibition of invasion by taurine treatment suggest that taurine could serve as a potential supplement for triple-negative breast cancer patients who require morphine as part of their treatment regimen or due to their circumstances. Full article

Background: The direct superior approach (DSA), a muscle-sparing technique derived from the posterior approach (PA), has received little attention despite its potential advantages. This study compared the impact of the DSA and PA on patient-reported pain and postoperative opioid consumption with medical and surgical complications. Methods: We reviewed 451 primary total hip arthroplasties for osteonecrosis of the femoral head and osteoarthritis between January 2016 and December 2022, which were categorized as DSA or PA. Demographic data, including age, sex, preoperative opioid usage, smoking status, chronic alcoholism, and underlying diseases, were collected. Propensity score matching balanced the DSA and PA groups. The maximum and minimum pain score on the postoperative day (POD) and total opioid consumption were compared between the two groups. Inflammation-related serum markers, medical and surgical complications, and the length of hospital stay were also analyzed. Results: After matching, 139 patients were included in each group. Patients with the DSA reported a lower average maximum pain on POD #1 and #4 and a lower average minimum pain on POD #1, #2, and #4. The DSA group showed a significant reduction in opioid consumption. In addition, the DSA led to a significant reduction in C-reactive protein (CRP) on POD #5, 14, and 28 after the index surgery compared to the PA. Postoperative delirium (3.6 vs. 9.4%, p = 0.05) and length of stay (5.4 vs. 8.4 days, p < 0.001) were significantly different between the two groups. No significant differences were observed in chronic opioid use, medical complications, or other surgical complications. Conclusions: The DSA was associated with lower patient-reported pain and a marked reduction in opioid consumption, delirium, and length of hospital stay. Full article

Background: Metastatic bone disease (MBD) presents significant challenges in patient management, leading to skeletal-related events (SREs), compromised health-related quality of life, and heightened pain experiences. Denosumab (Dmab) and zoledronic acid (ZA) are bone-modifying agents (BMAs) commonly employed to mitigate the sequelae of MBD. Previous meta-analyses have assessed primary outcomes such as overall survival, pathological fractures, radiation to bone, and the time to SREs within studies. However, a single comprehensive analysis comparing their efficacy across multiple primary and secondary outcomes, as well as cost-effectiveness in specific cancer types, has not yet been conducted. Methods: A literature search identified relevant randomized controlled trials (RCTs), and the primary outcomes included overall survival, pathologic fractures, radiation to bone, and the time to SREs within studies. Secondary outcomes included adverse events, pain, analgesia usage, quality of life, and cost. Results: Meta-analysis revealed that Dmab effectively reduced the need for bone-targeted radiation therapy and was superior to ZA in delaying the time to SREs, except in multiple myeloma. Dmab also reduced pathological fracture incidences in breast cancer patients by 39%. Conclusions: Our analysis suggests that while both agents similarly impact overall survival and disease progression, Dmab offers advantages in SRE reduction and improved HRQoL and pain outcomes with lower rates of opioid usage, albeit with higher risks of hypocalcemia and osteonecrosis in some subgroups. The consensus on cost-effectiveness is mixed and varies based on the cancer type and healthcare system, with some studies favoring Dmab’s superior efficacy and safety, while others find ZA more cost-effective due to its lower cost. This study underscores the potential of Dmab as a preferred BMA for MBD management, especially for high-risk skeletal complications, while highlighting cancer-specific safety considerations. Further research is warranted to refine cancer-specific BMA use and optimize MBD management strategies. Full article

Objectives: To investigate the correlation between baseline serum concentrations of 25-hydroxyvitamin D (25-OHD) and quality of life (QoL), as well as pain perception in patients with chronic pain with long-term prescription opioid usage before opioid detoxification. Methods: We prospectively studied 45 patients with chronic pain with long-term prescription opioid usage who were selected for elective detoxification. Baseline serum 25-OHD levels were measured prior to detoxification, classifying patients as either vitamin D deficient (<75 nmol/L) or sufficient (≥75 nmol/L). QoL was assessed using the SF-36v2^TM questionnaire, while pain levels were assessed using Visual Analogue Scale (VAS) scores before treatment. Results: Mean pain scores before detoxification of the patients with sufficient baseline 25-OHD levels vs. those with deficient levels were, respectively, 6.06 ± 2.32 vs. 6.86 ± 2.10 (normalized scores 1.22 ± 0.571 vs. 0.950 ± 0.632; p = 0.164). The analysis of SF-36v2™ questionnaire scores revealed minimal variation between groups (35.00 ± 14.198 vs. 34.97 ± 13.52), indicating no significant association between Vitamin D levels and QoL (p = 0.913). Conclusions: The analysis of baseline 25-OHD levels in relation to QoL assessments and pain scores did not reveal a statistically significant association, indicating that variations in baseline vitamin D levels may not substantially impact QoL or pain perception. Further studies may help determine how to assess and optimize vitamin D levels in patients with chronic pain on long-term prescription opioids. Full article

Background: While multimodal analgesia is the standard of care for postoperative pain relief, opioid medications continue to be a part of the treatment regimen, especially for more invasive surgeries such as spinal fusion, craniofacial reconstruction, laparotomy, and others. In pediatric patients, safe usage, storage, and dosing are especially important, along with clear instructions to caregivers on how to manage their child’s pain. Combination opioids such as hydrocodone with acetaminophen and acetaminophen with codeine are the most commonly prescribed opioid medications for postoperative pain control. However, these combination products can lead to acetaminophen toxicity, limit the ability to prescribe acetaminophen or ibuprofen, and add to caregiver confusion. Administering acetaminophen and ibuprofen individually rather than in combination products allows the maximal dosing of these nonopioid medications. The primary aim of this quality improvement (QI) project was to increase the utilization of single-agent opioids for postoperative pain control, primarily oxycodone, by the various surgical groups here at Cook Children’s Medical Center (CCMC). Methods: The project setting was a tertiary-level children’s hospital with a level 2 trauma center, performing over 20,000 surgeries annually. The opioid stewardship committee (OSC) mapped the steps and overlapping activities in the intervention that led to changes in providers’ prescription practices. A Plan–Do–Study–Act continuous improvement cycle allowed for an assessment and modification of implementation strategies. Statistical control process charts were used to detect the average percentage change in surgical specialties using single-agent opioid therapy. Data were monitored for three periods: one-year pre-intervention, one-year post-intervention, and one-year sustainment periods. Results: There were 4885 (41%) pre-intervention procedures, 3973 (33%) post-intervention procedures, and 3180 (26%) sustainment period procedures that received opioids. During the pre-intervention period, the average proportion of single-agent opioids prescribed was 8%. This average shifted to 89% for the first five months of the post-intervention period, then to 91% for the remainder of the study. Conclusions: The methodical application of process improvement strategies can result in a sustained change from outpatient post-surgical combination opioid prescriptions to single-agent opioid prescriptions in multiple surgical departments. Full article

The onset, progression, and severity of pain following rattlesnake envenomation are highly variable between patients. Pain can be severe and persistent, seemingly refractory to opioid analgesics. The ability of antivenom to directly relieve pain has not been well studied. We reviewed poison center charts of rattlesnake envenomations between 1 January 2018, and 31 December 2022. Demographic data as well as details of antivenom usage and pain severity were collected. Patients were coded in one of three categories: without pain (Pain 0), well controlled pain (Pain 1), and opioid refractory pain (Pain 2). A total of 289 patients met the inclusion criteria, with 140 receiving Anavip antivenom and 149 receiving Crofab. Patient characteristics were different between both cohorts. There were no significant differences in the number of Anavip vials used between the Pain 1 and Pain 2 groups. However, patients in the Crofab Pain 2 group received more antivenom compared to Pain 1. Importantly, Pain 3 patients were treated with the highest amount of antivenom in both the Crofab and Anavip cohorts. Despite the higher doses of antivenom used, these patients also experienced the greatest pain. These data suggest that antivenom alone may have minimal analgesic benefits. Full article

Background: Sickle cell disease (SCD) is a genetic hematological disorder associated with significant mortality and a range of complex complications that manifest differently across various age groups. Methods: This study aimed to evaluate the demographic, clinical, and laboratory characteristics of SCD patients in Taif City, Saudi Arabia, with a focus on variations among children, adolescents, adults, and middle-aged individuals. A multicenter retrospective cohort study included 129 patients with confirmed diagnosis of SCD between January 2018 to October 2023 and divided into 4 cohorts. The analysis compared hospital stay durations, admission rates, SCD complications, and medication usage. Results: Among the participants, 35 were children (27%), 18 adolescents (14%), 63 adults (49%), and 13 middle-aged individuals (10%). Clinical complications as splenic disease in children (34.3%) were more frequent compared to adolescents (5.6%) and adults (4.8%). Additionally, chronic kidney disease was more prevalent in middle-aged patients (15.4%). Pain was reported in 65.1% of patients, with vascular occlusive crises occurring in 41.1%. Treatment adherence varied, with children showing higher penicillin use (74.3%), while opioid usage was greater in middle-aged patients (76.9%). Conclusions: The findings underscore the necessity for age-specific management strategies in SCD. Further research with larger populations is suggested to enhance the understanding of disease progression and treatment efficacy across different age groups. Full article

Background/Objectives: Abdominoplasties are prevalent surgical procedures for improving lower abdominal contours, necessitating effective pain management. Insufficient management can increase opioid usage, dependency risks, and adverse effects. This review investigates various strategies in abdominoplasty pain management, aiming to reduce opioid dependence and improve patient care. Methods: A comprehensive systematic literature search (MEDLINE, Cochrane, PubMed, Web of Science, EMBASE) was conducted, spanning from their inception to January 2024, using keywords such as ‘abdominoplasty’ and ‘postoperative pain management’. Included studies focused on nonopioid interventions in adults, encompassing various study designs. Non-English publications and those not meeting outcome criteria were excluded. Bias in studies was assessed using specific tools for randomized and non-randomized trials. Results: Thirty-five studies, published between 2005 and 2024, were included, involving 3636 patients with an average age of 41.8. Key findings highlighted the effectiveness of transversus abdominis plane blocks in reducing opioid use and pain. Pain pump catheters also showed promise in improving pain management and reducing opioid dependency. Local anesthetics demonstrated varying degrees of efficacy, while other alternatives like ketamine and NSAIDs successfully reduced postoperative pain and opioid requirements. The bias assessment of the RCTs revealed “low” and “some concerns” ratings, indicating a need for more detailed methodology reporting and management of missing data. The cohort studies generally attained “moderate” risks of bias, primarily due to confounding variables and outcome data reporting. Conclusions: Nonopioid analgesics show potential in postoperative pain management for abdominoplasties, but further research is needed to confirm their effectiveness and optimize patient care. Full article

Opioids are commonly used to reduce pain after surgery; however, there are severe side effects and complications associated with opioid use, with addiction being of particular concern. Recent practice has shifted to reduce opioid consumption in surgery, although a specific protocol for rhinoplasty is still in progress. This paper aims to expand on the protocol previously established by the senior author based on updated evidence and details. This was accomplished by first high-lighting and summarizing analgesic agents with known opioid-reducing effects in the surgical field, with a particular focus on rhinoplasty, then compiling these analgesic options into a recommended protocol based on the most effective timing of administration (preoperative, intraoperative, postoperative). The senior author’s previous article on the subject was referenced to compile a list of analgesic agents of importance. Each analgesic agent was then searched in PubMed in conjunction with “rhinoplasty” or “opioid sparing” to find relevant primary sources and systematic reviews. The preferred analgesic agents included, as follows: preoperative, 1000 mg oral acetaminophen, 200 mg of oral celecoxib twice daily for 5 days, and 1200 mg oral gabapentin; intraoperative, 0.75 μg/kg of intravenous dexmedetomidine and 1–2 mg/kg injected lidocaine with additional 2–4 mg/kg per hour or 1.5 cc total bupivacaine nerve block injected along the infraorbital area bilaterally and in the subnasal region; and postoperatively, 5 mg oral acetaminophen and 400 mg of oral celecoxib. When choosing specific analgesic agents, considerations include potential side effects, contraindications, and the drug-specific mode of administration. Full article

Background: Sleeve gastrectomy is the most common bariatric procedure worldwide, yet postoperative pain management remains a concern. This study aimed to compare pain medication usage and pain scores between laparoscopic sleeve gastrectomy (LSG) and robotic sleeve gastrectomy (RSG) patients, addressing the potential benefits of RSG in postoperative pain control. Methods: A retrospective review of our institutional bariatric surgery registry included 484 patients (435 LSG, 49 RSG) who underwent surgery between September 2015 and November 2020. Pain management medications, including opioid use converted to morphine milligram equivalents (MMEs), and Numerical Rating Scale (NRS) scores were analyzed postoperatively using mixed-effects models. Results: RSG patients reported lower pain scores in the initial 24 h post-surgery and received significantly lower doses of morphine equivalents compared to LSG patients (median 7.5 mg vs. 12.5 mg, p < 0.001). RSG procedures had longer operative times (122.5 ± 27.1 vs. 89.9 ± 30.5 min, p < 0.001) but a shorter average length of stay (2.24 ± 0.60 vs. 2.65 ± 1.49 days) compared to LSG. Conclusions: These findings suggest that RSG may lead to reduced immediate postoperative pain and lower opioid requirements compared to the laparoscopic approach, despite longer operative times. Further randomized controlled trials are needed to confirm these observations and evaluate long-term outcomes. Full article

Respiratory failure is a common perioperative complication. The risk of respiratory failure can be reduced with effective preoperative evaluation, preventative measures, and knowledge of evidence-based management techniques. Effective preoperative screening methods include ARISCAT scoring, OSA screening, and the LAS VEGAS score (including the ASA physical status score). Evaluation by the six-minute walk test and a routine pulmonary physical exam has been shown to be effective at predicting postoperative pulmonary complications, whereas evidence on the predictive power of pulmonary function tests and chest radiography has been inconclusive. Preoperative smoking cessation and lung expansion maneuvers have been shown to decrease the risk of pulmonary complications postoperatively. Intraoperative management techniques that decrease the pulmonary complication risk include neuromuscular blockade reversal with sugammadex, limiting surgical times to less than 3 h when possible, lung-protective ventilation techniques, and multimodal analgesia to decrease opioid usage. In the immediate postoperative period, providers should be prepared to quickly treat bronchospasm, hypoventilation, and upper airway obstruction. For post-surgical patients who remain in the hospital, the risk of pulmonary complications can be decreased with lung expansion techniques, adequate analgesia, automated continuous postoperative ward monitoring, non-invasive ventilatory support, and early mobilization. This article was written to analyze the available literature on this topic in order to learn and practice the prevention of perioperative respiratory failure when caring for patients on a daily basis. Full article