Pain

Intravenous Dexmedetomidine and Dexamethasone for Postop Analgesia

Many agents have been added to peripheral nerve blocks to prolong analgesia. In some cases intravenous administration has been as successful without potential nerve toxicity concerns.

This small randomized study evaluated the difference in time to first rescue analgesic request between patients receiving co-administered intravenous dexamethasone and dexmedetomidine and patients receiving intravenous dexamethasone alone after single-shot interscslene brachial plexus block for arthroscopic shoulder surgery. Saline controls were used.

Co-administration of intravenous dexamethasone (0.11 mg kg−1) with dexmedetomidine (1.0 μg kg−1) significantly prolonged the time to first rescue analgesic request more than Dexamethasone alone, and both more so than saline controls. Also both groups had reduced postoperative opioid consumption, less sleep disruption and improved patient satisfaction compared with the control group.

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Intravenous Acetaminophen & Hip and Kneee Arthroplasty

Intravenous Acetaminophen was hailed as a useful addition to anesthesia care, but almost every study has shown little to be gained compared to oral Acetaminophen.

This latest, albeit a database study in total hip and knee arthroplasty, once again shows no (or less) benefit compared to oral Acetaminophen, which should always where possible be the first choice.

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Acute Pain Trajectories and Remote Pain Resolution

A secondary analysis of the Stanford Accelerated Recovery Trial assessed remote postoperative pain, opioid use, and recovery. The incidence of persistent postsurgical pain ranges from 10% to 50%, and 2% to 10% of patients report severe, chronic pain after surgery.

The study assessed high and low pain clusters in the first 10 days in a mixed surgical cohort. Numerous pain and other scores were administered. The authors identified worst pain over the past 24 hours reported on postoperative day 10 as a significant immediate postoperative predictor of remote pain resolution, opioid cessation, and complete surgical recovery.

The implications are summarized: “Ultimately, early identification of high-risk patients would facilitate personalized care with closer follow-up, earlier referral for specialist care, and extension of multimodal pain regimens”.

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Tramadol and Mortality Among Patients With Osteoarthritis

Tramadol has many drawbacks but is frequently prescribed as a perceived safer agent with less misuse potential.

This cohort study of nearly 89,000 patients aged 50 years and older with osteoarthritis found that initial prescription of tramadol was associated with a significantly higher rate of mortality over 1 year compared with commonly prescribed nonsteroidal anti-inflammatory drugs, but not compared with codeine.

The authors point out the risk of confounding by indication, and further research is needed to determine if this association is causal.

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Post-Herpetic Neuralgia

An article on post-herpetic neuralgia finds that most patients are still not managed on recommended first line therapies like Lidocaine patches, Gabapentin, Pregabalin, and antidepressants.

Ineffective treatment like NSAIDS are often used, and 22% started on opioids, certainly not a first line recommendation.

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Medical Cannabinoids Systematic Review

Yet another review weighs in to dispel hype and marketing from the huge cannabis industry.

The conclusion is: There is reasonable evidence that cannabinoids improve nausea and vomiting after chemotherapy. They might improve spasticity (primarily in multiple sclerosis). There is some uncertainty about whether cannabinoids improve pain, but if they do, it is neuropathic pain and the benefit is likely small. Adverse effects are very common, meaning benefits would need to be considerable to warrant trials of therapy.

No matter, the anecdotal based evidence will continue to be pushed by vested interests.

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Non‐pharmacological management of persistent headaches associated with neck pain

Guidelines from Ontario on the management of cervicogenic and tension type headaches. After ruling out pathology and other diagnoses, a number of guidelines are presented.

The non-pharmacological approaches recommended are that manual therapy can be considered as an adjunct therapy to exercise to treat patients with cervicogenic headaches, and that the management of tension‐type and cervicogenic headaches should be patient‐centred.

Unfortunately the evidence base is weak and the authors note that all recommended interventions provide small benefits at best.

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Nociception guided Anesthesia

The nociception level employs a finger monitor that combines information from the finger photoplethysmogram amplitude, skin conductance, skin conductance fluctuation, heart rate, heart rate variability, and their time derivatives into one index. This study used the Medasense monitor ( website )

The authors found that nociception level-guided analgesia during major abdominal surgery resulted in 30% less remifentanil consumption and less hypotension and vasopressor need. The standard care group also used BIS to titrate anesthesia and analgesia.

They did not find any differences in propofol requirements during anesthesia or differences in early postoperative outcome measures such as postoperative pain or opioid consumption in the PACU.

Comsidering opiod free anesthesia is now not uncommon, and hard clinical outcomes are yet to be determined, this intuitively attractive pain monitor will need further study and validation before its role is established.

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Intravenous Acetaminophen Before Pelvic Organ Prolapse Repair

This randomized study from the “green journal” compared preoperative intravenous acetaminophen 1g with placebo in women undergoing either laparoscopic or vaginal prolapse repair.

The findings were that “preoperative IV acetaminophen did not reduce pain scores or opioid use and had no effect on patient satisfaction or QOL. Routine use of preemptive IV acetaminophen alone is not supported by this study”.

This joins other studies showing little gain from intravenous acetaminophen.

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