Pain

Regional anaesthesia is associated with less patient satisfaction

At a time where ultrasound guided regional nerve blockade has exploded in popularity for both extremity and trunk surgery, a caveat appears from this prospective study.

About a third of patients undergoing plexus block for upper extremity surgery reported not being fully satisfied; reasons for dissatisfaction following regional anaesthesia are reported as “insufficient anaesthesia prior to surgery”, and “the discomfort of having a long-lasting insensate extremity postoperatively”.

The authors advocate “stronger focus on patient counselling preoperatively, addressing the issues of block failure and prolonged postoperative sensory and motor block.”

There appears to be a mismatch between the enthusiasm of regional anesthesia practitioners and patients satisfaction, as well as the current mantra of “shared decision making”.

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Reducing pain in infants, children, and adolescents

This Cochrane Special Collection highlights the evidence for reducing both chronic and acute pain in infants, children, and adolescents.

Some areas are still devoid of good evidence, but this review includes links to a large number of topics. Chronic pain topics include the use of antidepressants, anti-epileptics, NSAIDS, acetaminophen, and opioids in non-cancer pain. A list of reviews of different opioids for cancer pain is included. Various opioids as well as psychological interventions are surveyed in acute pain management.

The list is comprehensive and full text is available at:

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Pectoralis-II Myofascial Block and Analgesia in Breast Cancer Surgery

The latest newcomer to regional anesthesia in breast cancer surgery is the PEC-2 Block.

This review and meta-analysis shows essentially an equivalence to Paravertebral Block.

“Petoralis-II blocks were noninferior to paravertebral blocks in reducing pain intensity and morphine consumption for the first 24 h after surgery and both were superior to systemic analgesia alone”.

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Ketamine Infusions for Chronic Pain

A series of Ketamine infusion treatments for chronic pain have sprouted “Ketamine Clinics” globally but the longer outcome has not clearly been defined. Ketamine as an opioid-avoiding modality has often spurred the movement.

This review and meta-analysis summarizes the data, finding benefit in the short term (a few weeks) with less confidence on longer term pain relief, as well as higher incidences of nausea and psychotomimetic side effects:

“Evidence suggests that IV ketamine provides significant short-term analgesic benefit in patients with refractory chronic pain, with some evidence of a dose–response relationship. Larger, multicenter studies with longer follow-ups are needed to better select patients and determine the optimal treatment protocol.”

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Preoperative Opioid and Benzodiazepine Prescription Patterns and Mortality After Noncardiac Surgery

The risks from opioid and benzodiazepines may begin even earlier than the perioperative period. This retrospective analysis examined patients that received prescriptions for either in the year before surgery.

They found “opioid and benzodiazepine prescription fills in the 6 months before surgery are associated with increased short-and long-term mortality and an increased rate of persistent postoperative opioid consumption.”

It is suggested: “These patients should be considered for early referral to preoperative clinic and medication optimization to improve surgical outcomes.”

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Gabapentinoids and suicidal behaviour, unintentional overdoses, injuries, road traffic incidents, and violent crime

A population study in Sweden raises concerns regarding the widespread use of gabapentinoids for pain, sometimes with poor evidence bases, and in an effort to curb opioid overuse. However they bring issues of their own in terms of adverse effects, drug interaction and even misuse (search this blog!).

“This study suggests that gabapentinoids are associated with an increased risk of suicidal behaviour, unintentional overdoses, head/body injuries, and road traffic incidents and offences. Pregabalin was associated with higher hazards of these outcomes than gabapentin.”

“When stratifying on age, increased hazards of all outcomes were associated with participants aged 15 to 24 years.”

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Gabapentinoids and Adverse Postoperative Respiratory Outcomes

This study examined the association between gabapentinoids on the day of surgery and adverse postoperative outcomes in patients undergoing colorectal surgery in the United States.

Their use was associated with only a slightly lower opioid use on the day of surgery but a higher odds of non-invasive ventilation and naloxone use after surgery.

It highlights the fact that before blindly implementing enhanced recovery protocols, a firm evidence base should be established, as opioid-phobia may paradoxically result in unintended adverse events.

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Chronic Post-Surgical Pain after TKR

This was a medical record study that sought to identify the pre-surgical risk factors for chronic post-surgical pain after total knee replacement.

Factors that could predict pain at 5 years in about a third included: fibromyalgia, chronic pain in body parts other than the knee, previous diagnosis of cancer, knee instability, younger age, and presurgical knee pain.

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Trajectories of Pain Intensity in Adults with Disabling Subacute or Chronic Neck Pain

A randomized study examined pain trajectories over one year in people with the common condition of subacute and chronic neck pain.

The conclusion informs prognosis : “Most individuals with disabling subacute or chronic neck pain show improvement in pain intensity over a year. However, a quarter present unfavorable trajectories. High pain intensity at baseline, depressive symptoms, younger age, female sex and sudden onset of pain are factors associated with unfavorable trajectories.”.

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