Regional Anesthesia and Pain Medicine最新文献

Background: Intraoperative stretching of the hip joint capsule often generates severe pain during the first 3 hours after hip arthroscopy. The short-lived severe pain mandates high opioid consumption, which may result in adverse events and delay recovery. The femoral nerve nociceptors are located anteriorly in the hip joint capsule. A femoral nerve block reduces pain and opioid demand after hip arthroscopy. It impedes, however, ambulation and home discharge after outpatient surgery. The iliopsoas plane block selectively anesthetizes the femoral sensory nerve branches innervating the hip joint capsule without compromising ambulation. We aimed to assess reduction of opioid consumption after iliopsoas plane block during the short-lived painful postsurgical period of time after hip arthroscopy.

Methods: In a randomized, triple-blind trial, 50 patients scheduled for hip arthroscopy in general anesthesia were allocated to active or placebo iliopsoas plane block. The primary outcome was opioid consumption during the first three postoperative hours in the postanesthesia care unit. Secondary outcomes included pain, nausea, and ability to ambulate.

Results: Forty-nine patients were analyzed for the primary outcome. The mean 3-hour intravenous morphine equivalent consumption in the iliopsoas plane block group was 10.4 mg vs 23.8 mg in the placebo group (p<0.001). No intergroup differences were observed for the secondary outcomes during the postoperative follow-up.

Conclusion: An iliopsoas plane block reduces opioid consumption after hip arthroscopy. The reduction of opioid consumption during the clinically relevant 3-hour postsurgical period of time was larger than 50% for active versus placebo iliopsoas plane block in this randomized, triple-blind trial.

Background and objectives: The evolving surgical techniques in thoracoscopic surgery necessitate the exploration of anesthesiological techniques. This study aimed to investigate whether incorporating a continuous erector spinae plane (ESP) block into a multimodal analgesia regimen is non-inferior to continuous thoracic epidural analgesia (TEA) in terms of quality of postoperative recovery for patients undergoing elective unilateral video-assisted thoracoscopic surgery.

Methods: We conducted a multicenter, prospective, randomized, open-label non-inferiority trial between July 2020 and December 2022. Ninety patients were randomly assigned to receive either continuous ESP block or TEA. The primary outcome parameter was the Quality of Recovery-15 (QoR-15) score, measured before surgery as a baseline and on postoperative days 0, 1, and 2. Secondary outcome parameters included pain scores, length of hospital stay, morphine consumption, nausea and vomiting, itching, speed of mobilization, and urinary catheterization.

Results: Analysis of the primary outcome showed a mean QoR-15 difference between the groups ESP block versus TEA of 1 (95% CI -9 to -12, p=0.79) on day 0, -1 (95% CI -11 to -8, p=0.81) on day 1 and -2 (95% CI -14 to -11, p=0.79) on day 2.

Conclusions: The continuous ESP block is non-inferior to TEA in video-assisted thoracoscopic surgery.

Trial registration number: Dutch Trial Register (NL6433).

Background: While many medical specialties have established links between bibliometric indices, academic rank, leadership roles, and National Institutes of Health (NIH) funding, there exists a gap within the field of pain medicine. The purpose of our study is to examine the impact of research productivity (h-index, m-index, publications, citations), professional degrees (PhD, MPH, MBA), leadership positions (program director, division chief, chairman), and faculty demographics (gender, nationality of training) on attaining NIH grant funding among pain medicine faculty.

Methods: A complete list of 98 civilian pain medicine programs was included in the study. Between September 1, 2022, and December 30, 2022, departmental websites were accessed to accrue a list of pain medicine faculty listings. Publicly available information was used to extract research productivities, professional degrees, leadership positions, faculty demographics, and NIH grant funding. Descriptive statistics were used for analysis, with NIH funding status as the primary outcome.

Results: A total of 696 pain physicians within the academic community were identified. Markers of research productivity such as a higher h- or m-index, larger number of publications and citations, PhD status, and being senior faculty (full professor, division chief, or chairman) were independently associated with NIH funding. There was no statistical difference (p>0.05) among males and females in the number of R grants received.

Conclusions: We have identified many factors associated with NIH funding status and failed to find significant gender disparities in NIH funding. These findings allow for chronic pain programs to have another set of tools to attract, promote, and retain faculty.

Background/importance: Opioids continue to play a key role in managing acute postoperative pain, but their use contributes to adverse outcomes. Buprenorphine may offer effective analgesia with a superior safety profile.

Objective: To compare the efficacy and safety of buprenorphine with other opioids for acute postoperative pain management in adults.

Evidence review: MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Web of Science were searched from inception to February 2024. Randomized controlled trials comparing buprenorphine with other opioids for acute postoperative pain management in adults were included. Of 2421 records identified, 58 studies met inclusion criteria. Two reviewers independently extracted data and assessed risk of bias. Random-effects meta-analysis was performed using Stata/BE V.18. The primary outcome was pain intensity. Secondary outcomes included rescue analgesia use, duration of analgesia, and adverse effects.

Findings: Analysis of 41 comparisons (2587 participants) showed buprenorphine significantly reduced pain intensity compared with all other opioids (Hedges's g=-0.36, 95% CI=-0.59 to -0.14, p<0.001, 95% prediction interval (PI)=-1.70 to 0.97). This effect persisted when compared with full agonist opioid (FAO) alone (standardized mean difference -0.34, 95% CI=-0.59 to -0.10, p<0.001, 95% PI=-1.76 to 1.07). Patients receiving buprenorphine were less likely to require rescue analgesia (OR=0.40, 95% CI=0.26 to 0.63, p<0.001, 95% PI=0.12 to 1.36). Mean duration of analgesia was 8.5 hours (SD 1.84). There were no significant differences in other adverse effects including nausea and respiratory depression. Inconsistency was significant for pain intensity (I²=86.28%, 95% CI=81.55% to 88.99%) and moderate for rescue analgesia (I²=38.93%, 95% CI=1.44% to 64.37%). Risk of bias was low in 19 studies, with some concerns in 37 studies, and high in two studies.

Conclusions: Buprenorphine demonstrated superior efficacy in managing acute postoperative pain compared with FAOs, with a favorable safety profile and longer duration of action. These findings support the use of buprenorphine as a first-line opioid analgesic for acute postoperative pain management requiring opioid analgesia, potentially reducing opioid-related harm in the postoperative period.

Prospero registration number: CRD42023447715.

Background: The effect of anesthesia methods on non-muscle invasive bladder cancer (NMIBC) recurrence post-resection remains uncertain. We aimed to compare the oncological outcomes of spinal anesthesia (SA) and general anesthesia (GA) in patients with NMIBC.

Methods: This prospective randomized controlled trial recruited 287 patients with clinical NMIBC at Seoul National University Hospital from 2018 to 2020. The patients underwent transurethral resection of the bladder tumor within 4 weeks of randomization. Intrathecal hyperbaric bupivacaine (0.5%) and a mixture of propofol (1-2 mg/kg) and fentanyl (50-100 μg/kg) were used as induction agents in the SA and GA groups, respectively, with desflurane or sevoflurane used for maintaining anesthesia. The primary and secondary outcome measures were disease recurrence and disease progression, respectively, at 2 years after resection. Cumulative incidence of outcomes was compared between the two groups using time-to-event analyses.

Results: 15 patients required alternative anesthesia owing to clinical needs such as SA failure or significant obturator reflex, resulting in a modified intention-to-treat (ITT) population of 272 patients. Time-to-event analysis showed a significantly lower recurrence of NMIBC in the SA group than in the GA group, in both ITT (27.4% vs 39.8%) and modified ITT populations (26.8% vs 39.6%). Disease progression occurred more frequently in the GA than in the SA group (15.2% vs 7.8%), although the difference was not statistically significant.

Conclusions: A notable reduction in the 2-year recurrence rate was observed in patients who underwent SA than in those who underwent GA. Thus, SA may be considered the preferred anesthetic approach.

Trial registration number: NCT03597087.

Introduction: Regional anesthesia is frequently used for upper limb surgeries and postoperative pain control. Different approaches to brachial plexus blocks are similarly effective but may differ in the frequency and severity of iatrogenesis. We, therefore, examined large-scale registry data to explore the risks of typical complications among different brachial plexus block sites for regional anesthesia.

Methods: 26,947 qualifying adult brachial plexus blocks (2007-2022) from the Network for Safety in Regional Anesthesia and Acute Pain Therapy registry were included in a retrospective cohort analysis. Interscalene, supraclavicular, infraclavicular, and axillary approaches were compared for block failure and bloody punctures using generalized estimating equations. For continuous procedures, we analyzed the influence of the approach on catheter failure, neurological disorders, and infections.

Results: The axillary plexus block had the highest risk of block failure (adjusted OR, 2.3; 95% CI 1.02 to 5.1; p=0.04), catheter failure (adjusted OR, 1.4; 95% CI 1.1 to 2.0; p=0.02), and neurological dysfunction (adjusted OR, 3.0; 95% CI 1.5 to 5.9; p=0.002). There was no statistically significant difference among block sites for bloody punctures, while infraclavicular blocks had the highest odds for catheter-related infections.

Discussion: The axillary approach to the brachial plexus had the highest odds for block failure and neurological dysfunction after catheter placement, as well as a significant risk for catheter failure. However, considering that the axillary approach precludes other complications such as pneumothorax, none of the four common approaches to the brachial plexus has a fundamentally superior risk profile.

Background: Innervation of the breast includes branches of thoracic intercostal nerves, the superficial cervical plexus, the brachial plexus, and the intercostobrachial nerve (ICBN). Commonly used blocks for breast surgery provide incomplete analgesia of the axillary region. This cadaveric study aims to identify and map the axillary sensory cutaneous nerves.

Methods: We conducted nine axillary dissections on cadavers of both sexes with cadavers in supine position and upper limbs abducted. Incisions along the anterolateral thorax and superior clavicle created laterally reflecting skin flaps, allowing visualization of the ICBN and brachial plexus. Photographs were taken during dissections to enabled three-dimensional reconstruction using imaging software 3D Slicer.

Results: In all dissections, an ICBN and a branch of the posterior cord were identified entering axillary subcutaneous tissue. A branch of the medial cord was identified entering axillary tissue in 5/9 (56%) cadavers. The ICBN remained localized to the anterior axillary base but demonstrated various extrathoracic branching patterns. The posterior cord branch arose from the proximal posterior cord before penetrating the axillary base at its posterior margin in all cadavers. When present, the medial cord branch arose from the proximal medial cord before penetrating the axillary base along the midaxillary line.

Conclusion: In addition to the ICBN, two branches of the brachial plexus were identified entering axillary subcutaneous tissue. These branches are not currently considered when providing analgesia for breast surgery and may contribute to pain following surgery that involves axillary dissection.