Pain

Acupuncture for Hip Osteoarthritis

A Cochrane review essentially finds little to no benefit for hip osteoarthritis acupuncture.

So many studies on acupuncture are confounded by poor methodology, placebo and expectation effects, sham acupuncture comparisons and multiple interventions. It is hard to find a convincing positive study and like many integrative practices, a driving factor seems to be to steer patients away from opioids.

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Liposomal Bupivacaine and Opioid Use

Strong marketing of liposomal Bupivacaine (Exparel) has occurred with its supposed long lasting effects. From local infiltration first, it was approved for nerve block based only on placebo comparison rather than existing regimes. This study of its use for total knee arthroplasty finds that liposomal bupivacaine was not associated with a clinically important reduction in inpatient opioid prescription, length of stay, or opioid-related complications in patients who received current multimodal pain management techniques including a peripheral nerve block. Its place in pain management has yet to be fully defined.

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IV Lidocaine for Analgesia

Lidocaine bolus and infusion are now frequently employed as an opioid sparing, anti-inflammatory and multimodal analgesia technique in major surgery and may hasten return of bowel function.

The current study shows benefits in the ER for severe pain and are another option in our war on opioids. The current enthusiasm for Lidocaine in fairly generous doses should be tempered by evaluation for cardiac disease or dysrhythmia, and the potential deleterious effects.

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Slow Release Opiods and Acute Pain

ANZCA release a position paper:

Slow-release opioids are not recommended for use in the management of patients with acute pain.
The inappropriate use of slow-release opioids for the treatment of acute pain has been associated with a significant risk of respiratory depression, resulting in severe adverse events and deaths. Immediate release opiods are the choice in acute pain, barring individual cases of prolonged pain and then  only after careful consideration and monitoring.

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Predicting Post Surgical Pain

An interesting blog on the need for better prediction tools to individualize surgery and anesthesia. Higher pre-surgical levels of pain catastrophizing and anxiety have been implicated in both acute and chronic post-surgical pain. PROMs (patient reported outcome measures) are increasingly used and need to incorporate these important emotional and psychological elements. Pinpointing them pre-operatively may lead to more focussed care.

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Chronic Post-Surgical Pain

A review describes persistent post surgical pain, which is not uncommon after procedures such as amputation, thoracotomy, hernia, Cesarean, cholecystectomy, hysterectomy, mastectomy and hip replacement.

Mechansisms of pain sensitization and hyperalgesia are discussed. Risk factors include pre-operative pain, opioid exposure and psychological factors, nerve damage and importantly the intensity of acute postoperative pain (whether causal or just a marker is unclear).

A thorough review of different modalities is presented: anti-inflammatories, steroids, local anesthetic infusions, nerve blocks and epidurals, wound infiltration and catheters, Ketamine, Dextromethorphan, Nitrous Oxide, Gabapentinoids, Clonidine and Dexmedetomidine.

While the evidence is inconsistent and no critical intervention is identified, all the above are clearly important in multimodal analgesia and limiting opioids and opioid induced hyperalgesia; minimizing acute postoperative pain may prevent sensitization.

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