Pain

Chronic Pain Suicide Link

While this analysis is retrospective, it provides a concerning correlation between suicide and chronic pain, many dying from firearms or opioid overdose. Somewhere in the region of 10% had prior chronic pain. The study concludes: “Chronic pain may be an important contributor to suicide. Access to quality, comprehensive pain care and adherence to clinical guidelines may help improve pain management and patient safety.”

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Transversus Abdominis Plane Block in Children

“In children, quality of postoperative pain control provided by transversus abdominis plane (TAP) block using levobupivacaine 0.4 mg·kg−1 administered as either 0.2% or 0.4% did not differ and was associated with a very low risk of local anesthetic systemic toxicity”. The study involved inguinal day surgery and about 70% did not require any postoperative opioids. However the study only compared the two concentrations, there being no comparison with a control group not given the TAP block.

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Analgesic index using nasal photoplethysmography

Commercial analgesic indices exist in clinical settings to quantify acute pain objectively. The Surgical Pleth Index from GE uses photoplethysmography from an index finger, and is more accurate than conventional hemodynamic indices; it measures the change in the volume of arterial blood with each pulse beat – pain stimulation reduces photoplethysmographic amplitude and heart beat interval. It’s accuracy and usefulness are reported as variable.

This study used nasal photoplethysmography between the nasal septum and columella, postulating less interference and susceptibility to perfusion issues. It found that using diastolic peak point variation and heart beat interval variation resulted in greater accuracy than the Surgical Pleth Index. The measurements took place in the recovery period, and they plan further studies to assess its usefulness during general anesthesia, although it is unclear what pain (without the subjective experience) means under anesthesia – rather it is nociception, and how that may impact outcome or chronic pain remain to be seen

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Neonatal Circumcision Analgesia

A randomized study compares analgesic methods for neonatal circumcision. Options that were better than EMLA alone were EMLA in combination with a) oral sucrose, b) penile ring block, or c) dorsal penile nerve block.

The most effective analgesia of those tested was EMLA + sucrose + penile ring block. Multimodal wins again. It seems reasonable to add a block, although they were performed here by a Pediatric Urologist.

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Hypnosis and Breast Surgery Outcome

A randomized study using hypnosis before general anesthesia for minor breast surgery investigated outcomes – pain, nausea/vomiting, fatigue, comfort/well-being, anxiety, postanesthesia care unit length of stay, and patient satisfaction. The conclusion – “No benefit of hypnosis was found on postoperative breast pain; however, hypnosis seems to have other benefits regarding fatigue, anxiety, and patient satisfaction”.

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Lidocaine during Surgery and Quality of Recovery

The use of intravenous Lidocaine as an analgesic and as an adjunct during anesthesia is growing. This study focussed on other aspects of quality of recovery, and found improvements also in areas like emotional state, physical comfort, as well as pain. They used thyroid surgery as their subjects suggesting the benefits of Lidocaine are not confined to bowel surgery recovery. One group received Magnesium for comparison and the effects were not significantly better.

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Laparoscopic Cholecystectomy Pain

A ‘PROSPECT’ review of laparoscopic cholecystectomy pain makes the following procedure specific recommendations.

Acetaminophen (Paracetamol) + NSAIDs or CoX-2 Inhibitors + site local anesthetic infiltration.

They do not in general recommend TAP blocks, intra-peritoneal local anesthetic or gabapentinoids. Opioids are reserved for rescue analgesia.

They recommend low-pressure pneumoperitoneum, postprocedure saline lavage, and aspiration of pneumoperitoneum. Single-port incision techniques are not recommended to reduce pain.

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Epidural Depo-Medrol

In a word, don’t! Epidural Methylprednisolone (Depo-Medrol) has a very poor safety record. Concern has long existed in particular for particulate steroids embolizing into small arteries and causing serious neurological issues. This serious problem highlighted by the New York Times link

While non-particulate agents like Dexamethasone are considered safer by some, I do not consider the evidence for epidural off-label use in sciatica sufficient for any benefit as concluded in this meta analysis link

The opioid epidemic has unfortunately resulted in many ineffective alternatives.