How to Modulate Peripheral and Central Nervous System to Treat Acute Postoperative Pain and Prevent Pain Persistence

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Opioid-Free Anesthesia and Postoperative Outcomes in Cancer Surgery : A Systematic Review

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Erector spinae plane versus fascia iliaca block after total hip arthroplasty: a randomized clinical trial comparing analgesic effectiveness and motor block

Background Ultrasound-guided supra-inguinal fascia iliaca block (FIB) provides effective analgesia after total hip arthroplasty (THA) but is complicated by high rates of motor block. The erector spinae plane block (ESPB) is a promising motor-sparing technique. In this study, we tested the analgesic superiority of the FIB over ESPB and associated motor impairment. Methods In this randomized, observer-blinded clinical trial, patients scheduled for THA under spinal anesthesia were randomly assigned to preoperatively receive either the ultrasound-guided FIB or ESPB. The primary outcome was morphine consumption 24 h after surgery. The secondary outcomes were pain scores, assessment of sensory and motor block, incidence of postoperative nausea and vomiting and other complications, and development of chronic post-surgical pain. Results A total of 60 patients completed the study. No statistically significant differences in morphine consumption at 24 h (P = 0.676) or pain scores were seen at any time point. The FIB produced more reliable sensory block in the femoral nerve (P = 0.001) and lateral femoral cutaneous nerve (P = 0.018) distributions. However, quadriceps motor strength was better preserved in the ESPB group than in the FIB group (P = 0.002). No differences in hip adduction motor strength (P = 0.253), side effects, or incidence of chronic pain were seen between the groups. Conclusions ESPBs may be a promising alternative to FIBs for postoperative analgesia after THA. The ESPB and FIB offer similar opioid-sparing benefits in the first 24 h after surgery; however, ESPBs result in less quadriceps motor impairment

Association between circulatory stability, pain and intensive support after major abdominal surgery

Introduzione: i pazienti sottoposti a interventi di chirurgia addominale maggiore sono ad alto rischio per lo sviluppo di complicanze postoperatorie, e sono quindi monitorati nel periodo postoperatorio in reparti di Terapia Intensiva Post Operatoria (TIPO). Il ricovero in TIPO; quando inappropriato, può esporre il paziente a complicanze maggiori come lo sviluppo di infezioni nosocomiali legate ad esempio all’utilizzo della ventilazione meccanica, oltre a sottrarre risorse necessarie per altri pazienti. Pertanto, per migliorare l’efficacia dell’assistenza, è importante identificare i pazienti con necessità di supporto intensivo prolungato. L’obiettivo dello studio è di descrivere il decorso postoperatorio e individuare i predittori di supporto intensivo prolungato nei pazienti sottoposti a chirurgia addominale maggiore laparotomica. Materiali e metodi: studio osservazionale pilota prospettico multicentrico (St Olav Hospital Trondheim- Norvegia e AUO di Parma, 2° UOC Anestesia e Rianimazione e Terapia Antalgica). Abbiamo arruolato pazienti maggiorenni, sottoposti a chirurgia addominale maggiore e destinati ad essere ricoverati in TIPO, dopo firma del consenso informato. Abbiamo registrato dati demografici preoperatori e dati di gestione intraoperatoria del paziente. Nel postoperatorio abbiamo rilevato: monitoraggio continuo dei parametri vitali registrati tramite telemetria in TIPO, supporto ventilatorio ed emodinamico tramite apposita CRF (case report form). I seguenti interventi terapeutici sono stati considerati come parametri di supporto intensivo: somministrazione di vasopressori, fluidi isotonici > 500 ml / h, alte dosi gli oppioidi (morfina > 7,5 mg / h EV), necessità di ventilazione meccanica. La stabilità circolatoria è stata valutata mediante modello statistico multi-stato, che include le variabili che riflettono lo stato circolatorio del paziente, rivalutato su base oraria fino al raggiungimento dello stato di “stabilità senza supporto”. E’ stato applicato il modello di regressione lineare di COX per valutare gli effetti delle variabili sulla durata del supporto intensivo. Risultati: sono stati arruolati 51 pazienti adulti sottoposti a chirurgia addominale maggiore (chirurgia epatica e delle vie biliari, gastrica, intestinale, riparazione di aneurisma dell’aorta addominale). Circa un terzo dei pazienti ha necessitato di supporto intensivo dopo le prime 6 ore postoperatorie, i restanti limitatamente alle prime 6 ore. Il provvedimento maggiormente attuato è consistito nell’infusione di noradrenalina. L’età > di 60 anni e una perdita ematica intraoperatoria > 750 ml sono significativamente correlati con un tempo più lungo di infusione di noradrenalina dopo l’intervento. Conclusione: Lo studio mostra che vi è una grande variabilità nella necessità di supporto intensivo dopo chirurgia addominale maggiore elettiva, soprattutto dopo le prime 6 ore postoperatorie. E’ necessario sviluppare ulteriori modelli di previsione che aiutino a valutare la necessità di supporto intensivo nei pazienti sottoposti a chirurgia maggiore

Genetics and Opioids: Towards More Appropriate Prescription in Cancer Pain

Opioids are extensively used in patients with cancer pain; despite their efficacy, several patients can experience ineffective analgesia and/or side effects. Pharmacogenetics is a new approach to drug prescription based on the “personalized-medicine” concept, i.e., the ability of tailoring treatments to each individual’s genetic/genomic profile. Pharmacogenetics aims to identify specific genetic variants that influence pharmacokinetics and pharmacodynamics of drugs, better determining their effectiveness/safety profile. Opioid response is a complex scenario, but some gene variants have shown a correlation with pain sensitivity, as well as with opioid metabolism and clinical efficacy/adverse events. Although questions remain unanswered, some of these gene variants may already be used to identify specific patients’ phenotypes that are more prone to experience better clinical response (i.e., better analgesia and/or less adverse events). Once adopted, this approach to opioid prescription may improve a patient’s outcome. This review summarizes the available data on genetic variants and opioid response: we will focus on basic pharmacogenetic and its impact in the clinical scenario discussing how they may lead to more appropriate opioid prescription in cancer patients

Opioid free anesthesia: evidence for short and long-term outcome.

The introduction of synthetic opioids in clinical practice played a major role in the history of anesthesiology. For years, anesthesiologists have been thinking that opioids are needed for intraoperative anesthesia. However, we now know that opioids (especially synthetic short-acting molecules) are definitely not ideal analgesics and may even be counterproductive, increasing postoperative pain. As well, opioids have revealed important drawbacks associated to poor perioperative outcomes. As a matter of fact, efforts in postoperative pain management in the last 30 years were driven by the idea of reducing/eliminating opioids from the postoperative period. However, a modern concept of anesthesia should eliminate opioids already intra-operatively towards a balanced, opioid-free approach (opioid-free anesthesia - OFA). In OFA drugs and techniques historically proven for their efficacy are combined in rational and defined protocols. They include ketamine, alpha-2 agonists, lidocaine, magnesium, anti-inflammatory drugs and regional anesthesia. Promising results have been obtained on perioperative outcome. For sure, analgesia is not reduced with OFA, but it is effective and with less opioid-related side effects. These benefits may be of particular importance in some high-risk patients, like OSAS, obese and chronic opioid-users/abusers. OFA may also increase patient-reported outcomes; despite it is difficult to specifically rule out the effect of intraoperative opioids. Finally, few data are available on long-term outcomes (persistent pain and opioid abuse, cancer outcome). New studies and data are required to elaborate the optimal approach for each patient/surgery, but interest and publication are increasing and may open the road to the wider adoption of OFA

Update on Selective Regional Analgesia for Hip Surgery Patients

: In hip surgery, regional anesthesia offers benefits in pain management and recovery. There are a wide range of regional analgesic options; none have shown to be superior. Lumbar plexus block, femoral nerve block, and fascia iliaca block are the most supported by published literature. Other techniques, such as selective obturator and/or lateral femoral cutaneous nerve blocks, represent alternatives. Newer approaches, such as quadratus lumborum block and local infiltration analgesia, require rigorous studies. To realize long-term outcome benefits, postoperative regional analgesia must be tailored to the individual patient and last longer

Inflammation-Based Scores: A New Method for Patient-Targeted Strategies and Improved Perioperative Outcome in Cancer Patients

Systemic inflammatory response (SIR) has actually been shown as an important prognostic factor associated with lower postoperative survival in several types of cancer. Thus, the challenge for physicians is to find specific, low-cost, and highlyreliable inflammatory markers, clearly correlated with prognosis and able to preoperatively stratify patient’s risk. Inflammation is a promising target to improve perioperative outcome, and data show that anti-inflammation techniques have a great potential in the perioperative period of cancer surgery. Inflammation scores could be useful to stratify patients with a potential better response to anti-inflammation strategies. Furthermore, inflammation scores could prevent failure of clinical trials by a better definition of patients to be included in such trials; inflammation scoring could clarify the real role of different drugs and techniques on outcome after cancer surgery, defining if different therapies are required for different patients. The role of this review is to focus on the currently available scores, in order to clarify their rationale and to analyze the actual evidence and limits, providing physicians with an updated overview of the possible inflammation-based prognostic scores for cancer patients undergoing surgery