Influence of Centrally Mediated Symptoms on Postoperative Pain in Osteoarthritis Patients Undergoing Total Knee Arthroplasty: A Prospective Observational Evaluation. Evidence‐based management of pain after laparoscopic cholecystectomy: a PROSPECT review update Postoperative outcome in Chinese patients having primary total knee arthroplasty under general anaesthesia/intravenous patient-controlled analgesia compared to spinal-epidural anaesthesia/analgesia. Efficacy of periarticular multimodal drug injection in total knee arthroplasty. A randomized trial. Pain management after total knee arthroplasty using a multimodal approach. Auricular acupressure for analgesia in perioperative period of total knee arthroplasty. Comparison of Perioperative Oral Multimodal Analgesia Versus IV PCA for Spine Surgery Postoperative analgesia in total hip arthroplasty: A randomized double-blinded, placebo-controlled study on peroperative and postoperative ropivacaine, ketorolac, and adrenaline wound infiltration Intravenous versus epidural analgesia to reduce the incidence of gastrointestinal complications after elective pancreatoduodenectomy (the PAKMAN trial, DRKS 00007784): study protocol for a randomized controlled trial Use of Nonpharmacologic Interventions for Pain and Anxiety After Total Hip and Total Knee Arthroplasty The Efficacy of Periarticular Multimodal Drug Infiltration in Total Hip Arthroplasty [Postoperative analgesia after total knee arthroplasty: Continuous intra-articular catheter vs. continuous femoral nerve block]. An intervention study to enhance postoperative pain management. The effect of balanced analgesia on early convalescence after major orthopaedic surgery Prospective relation between catastrophizing and residual pain following knee arthroplasty: two-year follow-up. A prospective, randomized, double-blind, placebo-controlled trial of multimodal intraoperative analgesia for laparoscopic excision of endometriosis. Transversus abdominis plane block versus perioperative intravenous lidocaine versus patient-controlled intravenous morphine for postoperative pain control after laparoscopic colorectal surgery: study protocol for a prospective, randomized, double-blind controlled clinical trial
BACKGROUND Central sensitization plays an important role in the chronic pain experienced by osteoarthritis ( OA ) patients . In this prospect i ve observational study , we investigated the influence of the level of preoperative central ly mediated symptoms measured by the Central Sensitization Inventory ( CSI ) on pain intensity after total knee arthroplasty ( TKA ) for OA . METHODS Ninety-eight female OA patients undergoing TKA were enrolled in this study . We assessed CSI scores , pain-related data , and other clinical data preoperatively . All patients received spinal anesthesia and postoperative epidural analgesia .  Pain intensity ( at rest and on movement ) and rescue meperidine requirements were assessed during postoperative days 1 and 2 . Also , pain intensity and patient satisfaction were assessed 1 month and 3 months after surgery . After the completion of all postoperative assessment s , we separated the study population into a preoperative CSI score ≥40 and < 40 group . We assessed pain-related data between the 2 groups at each assessment time . RESULTS Ninety-one patients completed the postoperative assessment s ( a preoperative CSI ≥40 group ; n = 44 , CSI < 40 group ; n = 47 ) . Patients with preoperative CSI ≥40 complained of a greater pain intensity ( P = 0.001 ) during postoperative days 1 and 2 and required a higher dose of meperidine rescue ( P = 0.003 ) than those with a preoperative CSI < 40 . The high CSI score group also showed a less favorable outcome in terms of pain relief on follow-up at 1 month ( P = 0.006 ) and 3 months ( P = 0.002 ) after surgery . In multivariate analysis , a preoperative CSI score ≥40 was the strongest determinant with 5.091 of the highest odds ratio ( 95 % CI 1.324 to 19.523 , P = 0.016 ) for predicting a persistent pain 3 months after surgery among demographic and pain-related variables . CONCLUSIONS OA patients with high levels of comorbid central ly mediated symptoms showed severe pain and increased analgesic requirements after TKA in the early postoperative period . Moreover , these patients seemed to be at higher risk of persistent pain , and a high CSI score was predictive of low patient satisfaction in terms of pain relief after surgery Background : Significant pain can be experienced after laparoscopic cholecystectomy . This systematic review aims to formulate PROSPECT ( PROcedure SPECific Postoperative Pain ManagemenT ) recommendations to reduce postoperative pain after laparoscopic cholecystectomy . Methods : R and omised controlled trials published in the English language from January 2006 ( date of last PROSPECT review ) to December 2017 , assessing analgesic , anaesthetic , or operative interventions for laparoscopic cholecystectomy in adults , and reporting pain scores , were retrieved from MEDLINE and Cochrane data bases using PRISMA ( Preferred Reporting Items for Systematic Review s and Meta‐Analyses ) search protocol s. PROSPECT methodology was used , and recommendations were formulated after review and discussion by the PROSPECT group ( an international group of leading pain specialists and surgeons ) . Results : Of 1988 r and omised controlled trials identified , 258 met the inclusion criteria and were included in this review . The studies were of mixed method ological quality , and quantitative analysis was not performed because of heterogeneous study design and how outcomes were reported . Conclusions : We recommend basic analgesic techniques : paracetamol + NSAID or cyclooxygenase‐2 specific inhibitor + surgical site local anaesthetic infiltration . Paracetamol and NSAID should be started before or during operation with dexamethasone ( GRADE A ) . Opioid should be reserved for rescue analgesia only ( GRADE B ) . Gabapentanoids , intraperitoneal local anaesthetic  , and  transversus abdominis plane blocks  are not recommended ( GRADE D ) unless basic analgesia is not possible . Surgically , we recommend low‐pressure pneumoperitoneum , postprocedure saline lavage , and aspiration of pneumoperitoneum ( GRADE A ) . Single‐port incision techniques are not recommended to reduce pain ( GRADE A ) OBJECTIVE To compare postoperative outcomes in patients having primary total knee arthroplasty receiving general or regional anaesthesia .  DESIGN R and omised prospect i ve study . SETTING Regional hospital , Hong Kong . PATIENTS Patients having primary total knee replacement were r and omised to either general anaesthesia followed by postoperative intravenous patient-controlled analgesia with morphine , or combined spinal-epidural anaesthesia followed by postoperative epidural infusion of bupivacaine 0.1 % with fentanyl 2 microg/mL. MAIN OUTCOME MEASURES Visual analogue scale pain scores , perioperative blood loss , time to first meal and ambulation , and prevalence of postoperative complications . RESULTS Sixty consecutive patients were enrolled in this study . Postoperative median pain scores were consistently lower at 1 ( P<0.0001 ) , 6 ( P=0.08 ) , 12 ( P=0.003 ) , 24 ( P=0.14 ) , and 48 hours ( P=0.007 ) in those given regional anaesthesia . Although there was a trend towards fewer complications in the latter group , there were no statistically significant differences between the two groups with respect to the incidence of postoperative blood loss , haemodynamic instability , pruritus , nausea , vomiting , urinary retention , or other surgical/medical complications . Postoperatively , patients given regional anaesthesia also resumed meals earlier ( P<0.0001 ) , and showed a trend towards earlier ambulation and hospital discharge . CONCLUSION Chinese patients undergoing total knee arthroplasty with  regional anaesthesia/regionally delivered analgesia enjoyed better postoperative pain relief and resumed meals earlier than those receiving general anaesthesia/intravenous patient-controlled analgesia . The former also showed trends towards less adverse effects , postoperative complications , earlier ambulation , and earlier hospital discharge BACKGROUND Postoperative analgesia with the use of parenteral opioids or epidural analgesia can be associated with troublesome side effects . Good perioperative analgesia facilitates rehabilitation , improves patient satisfaction , and may reduce the hospital stay . We investigated the analgesic effect of locally injected drugs around a total knee prosthesis . METHODS Sixty-four patients undergoing total knee arthroplasty were r and omized either to receive a periarticular intraoperative injection containing ropivacaine , ketorolac , epimorphine , and epinephrine or to receive no injection . The perioperative analgesic regimen was st and ardized . All patients in both groups received patient-controlled analgesia for twenty-four hours after the surgery , and this was followed by st and ard analgesia .  Visual analog scores for pain , during activity and at rest , and for patient satisfaction were recorded preoperatively and postoperatively and at the six-week follow-up examination . The consumption of patient-controlled analgesia at specific postoperative time-points and the overall analgesic requirement were measured . RESULTS The patients who had received the injection used significantly less patient-controlled analgesia at six hours , at twelve hours , and over the first twenty-four hours after the surgery . In addition , they had higher visual analog scores for patient satisfaction and lower visual analog scores for pain during activity in the post-anesthetic-care unit and four hours after the operation . No cardiac or central nervous system toxicity was observed . CONCLUSIONS Intraoperative periarticular injection with multimodal drugs can significantly reduce the requirements for patient-controlled analgesia and improve patient satisfaction , with no apparent risks , following total knee arthroplasty Improvements in pain management techniques over the past decade have had a significant impact on the outcomes of total knee arthroplasty . Of these techniques , multimodal approaches have shown potential . The purpose of this study was to compare the results of periarticular injection ( PAI ) to a combination of patient-controlled epidural analgesia and femoral nerve block ( PCEA/FNB ) .  Ninety patients undergoing primary unilateral total knee arthroplasty between June 2010 and March 2011 were r and omized into 2 groups . The first group received the PCEA/FNB protocol , whereas the second group received the PAI .  Mean patient age was 66.1 ± 8.7 years . All patients were operated on using a similar st and ard medial parapatellar approach , and all received preemptive analgesia and postoperative pain protocol s. All patients were interviewed twice daily for the first 3 days postoperatively , once on day 7 , and once in month 6 . The 2 groups had similar readiness for discharge ( PCEA/FNB group , 3.3 ± 1.2 days ; PAI group , 3.2 ± 1.9 days ) . The results indicated no statistical difference between the 2 groups in 3 of 4 categories ( rest in the morning , rest in the evening , and ambulation in the morning ) . Pain on ambulation was the only category that was statistically lower in the PCEA/FNB group than in the PAI group . Although the study demonstrates similar results between the 2 groups , PAI can play a major role in postoperative pain control in institutions that may not have appropriately trained individuals , equipment , and re sources for PCEA/FNB . It also reduces many of the side effects and complications associated with regional anesthesia OBJECTIVE We examined whether auricular acupressure ( AA ) can alleviate postoperative pain and decrease narcotic consumption and its adverse effects for osteoarthritis patients after total knee arthroplasty ( TKA ) . DESIGN A prospect i ve , r and omized , sham control trial comparing AA and a sham control . SETTING Department of Orthopedics , the first Hospital affiliated to Zhejiang University of Traditional Chinese Medicine , Hangzhou , China . SUBJECTS Ninety patients with degenerative osteoarthritis undergoing TKA . INTERVENTIONS The AA group received true AA by embedding vaccaria seeds at four specific AA points ( knee joint , shenmen , subcortex , sympathesis ) ipsilateral to the surgery site , while the control group received four nonacupuncture points on the auricular helix . OUTCOME MEASURES Visual analog scale ( VAS ) , the consumption of analgesic via patient-controlled analgesia , the incidence of analgesia-related adverse effects , Hospital for Special Surgery scores ( HSS ) , and range of motion ( ROM ) were recorded . RESULTS VAS scores were similar at 12 , 24 , 36 , and 48 h postsurgery ( P > 0.05 ) , but AA group scores were lower than those of the control group at 3 , 4 , 5 , and 7 days ( P < 0.05 ) . Patients in the AA group consumed lower doses of analgesic than those in the control group after surgery ( P < 0.05 ) . The incidence of analgesia-related adverse effects in the AA group was lower than that in the control group ( P < 0.05 ) . Although HSS scores were similar in the two groups preoperatively and at 3 months postoperatively ( P > 0.05 ) , HSS scores 2 weeks postoperatively were higher in the AA group than in the control group ( P < 0.05 ) , but there was no difference between groups in ROM ( P > 0.05 ) . CONCLUSIONS Applying auricular acupoint acupressure in the perioperative period of TKA is favorable for alleviating postoperative pain , decreasing opioid consumption and its adverse effects , and promoting early rehabilitation . Also , this intervention has the advantage of lower costs , fewer complications , simple application , and high safety Study Design A preintervention and postintervention design was used to examine a total of 200 patients . Objective After successful implementation at our institution of a perioperative oral multimodal analgesia protocol in major joint arthroplasty , a modified regimen was provided to patients undergoing spine procedures . Summary of Background Data A proactive , multimodal approach is currently recommended for the management of acute postoperative pain . Inadequate postoperative analgesia can negatively influence surgical outcome and duration of rehabilitation . Routine use of intravenous patient controlled analgesia ( IV PCA ) after surgery can result in substantial functional interference , side effects , and lead to untoward events as a result of programming errors . Methods A preintervention and postintervention design was used to compare a  historical control group of spine surgery patients who received conventional IV PCA ( N=100 ) with a prospect i ve group  who received some form of perioperative oral multiodal analgesis ( N=100 ) . The new regimen included preoperative and postoperative scheduled extended-release oxycodone , gabapentin , and acetaminophen , intraoperative dolasetron and as-needed postoperative short-acting oral oxycodone . Patient surveys and chart audits were used to measure pain intensity , functional interference from pain , opioid consumption , analgesic-related side effects , and patient satisfaction over the first 24 hours postoperatively . Results Patients who received the new perioperative multimodal oral regimen had significantly less opioid consumption ( P<0.001 ) , lower ratings of Least Pain ( P<0.01 ) , and experienced less nausea ( P<.001 ) , drowsiness ( P<0.05 ) , interference with walking ( P=0.05 ) , and coughing and deep breathing ( P<0.05 ) compared with the IV PCA group . Conclusions This quality improvement study shows some safety and significant advantages of a multimodal perioperative oral analgesic regimen compared with st and ard IV PCA after spine surgery Background Comfort and lack of pain are important for optimal mobilization after hip replacement . We investigated the efficacy of double wound infiltration . Patients and methods 40 consecutive patients undergoing total hip replacement were r and omized into two groups in this double-blinded study . They received wound infiltration at the end of surgery and through an intraarticular catheter 24 h postoperatively . The catheter was placed at the end of surgery . One group received solutions of ropivacaine , ketorolac , and adrenaline . Patients in the control group were injected with saline instead . The observation period was 6 weeks . Results The patients who received the analgesic solution had less pain up to 2 weeks postoperatively . They reached an earlier and lower pain minimum during the first days postoperatively , had lower use of analgesia up to day 4 postoperatively , and were more satisfied . Use of analgesic solution result ed in less joint stiffness and better function 1 week postoperatively . Interpretation Operative and postoperative wound infiltration with multimodal drugs reduces pain and the requirement for analgesics after hip replacement , leading to faster postoperative mobilization Background Despite substantial improvements in surgical and anesthesiological practice s leading to decreased mortality of less than 5 % at high-volume centers , pancreatic surgery is still associated with high morbidity rates of up to 50 % . Attention is increasingly directed toward the optimization of perioperative management to reduce complications and enhance postoperative recovery . Currently , two different strategies for postoperative pain management after pancreatoduodenectomy are being routinely used : patient-controlled intravenous analgesia and thoracic epidural analgesia . Evidence is lacking to assess which strategy entails fewer postoperative complications . Methods / design The PAKMAN trial is design ed as an adaptive , pragmatic , r and omized , controlled , multicenter , open-label , superiority trial with two parallel study groups . A total of 370 patients scheduled for elective pancreatoduodenectomy will be r and omized after giving written informed consent , and 278 patients are needed for analysis . Patients with chronic pancreatitis , severe chronic obstructive pulmonary disease ( COPD ) , American Society of Anesthesiologists ( ASA ) physical status classification ≥ IV , or chronic pain syndrome will be excluded . The group A intervention includes intraoperative general anesthesia and postoperative patient-controlled intravenous analgesia ; the group B intervention comprises combined intraoperative general anesthesia and epidural analgesia with postoperative epidural analgesia . The primary endpoint of this trial is a composite of the gastrointestinal complications ( delayed gastric emptying , pancreatic fistula , biliary leak , gastrointestinal bleeding , and postoperative ileus ) up to postoperative day 30 . The aim is to investigate whether the frequency of gastrointestinal complications following pancreatoduodenectomy can be reduced by 15 % using postoperative , patient-controlled intravenous analgesia compared with epidural analgesia . Discussion Several previous studies investigating the two different strategies for postoperative pain management have mainly focused on their effectiveness in pain control . However , the PAKMAN trial is the first to compare them with regard to their impact on the surgical endpoint “ postoperative gastrointestinal complications ” after pancreatoduodenectomy . Trial registration German Clinical Trials Register , PURPOSE The purpose of this study was to compare pain and anxiety in orthopaedic patients scheduled for elective total hip or knee arthroplasty who have received a kit of nonpharmacologic strategies for pain and anxiety in addition to their regularly prescribed analgesics to those who receive the usual pharmacologic management alone . DESIGN Descriptive comparative and correlational design using surveys and chart audits . SAMPLE Sixty-five patients r and omized to receive usual care or usual care plus a kit of nonpharmacologic strategies .  FINDINGS Patients who received the kit used nonpharmacologic measures for pain and anxiety more often than patients who did not receive the kit . The kit group tended to use less opioid and have less anxiety on postoperative day 1 ( not statistically significant ) and use significantly less opioid on postoperative day 2 than the patients who did not receive the kit . There were no between-group differences in pain intensity . There were significant correlations among postoperative pain intensity , opioid use , and anxiety . The coping method of diverting attention was related to lower present ( now ) pain scores , and ignoring the pain was associated with higher worst pain . DISCUSSION Providing a kit of nonpharmacologic strategies can increase the use of these methods for postoperative pain and anxiety and decrease the amount of opioid taken . The influence of coping strategies in acute postoperative pain needs to be examined further Background Patient-controlled analgesia is a widely used and effective method of controlling pain after THA . This method is associated with substantial undesirable side effects . Local infiltration has been introduced in an attempt to reduce opioid requirements postoperatively , but its ability to reduce pain without complications is still question ed . Questions / Purpose sWe evaluated patient-controlled analgesia use , pain and satisfaction scores , complication rates , and ropivacaine levels associated with the use of periarticular multimodal drug infiltration in THA . Patients and Methods We r and omized 64 patients undergoing THA to receive a periarticular intraoperative multimodal drug injection or to receive no injection .  All patients received patient-controlled analgesia for 24 hours after surgery . The final assessment was at 6 weeks . Results Patients receiving the periarticular injection used less patient-controlled analgesia 6 hours postoperatively . The 24-hour patient-controlled analgesia requirement postsurgery also was less . The visual analog scale score for pain on activity in the postanesthetic care unit was less for patients who received an injection . The visual analog scale satisfaction score was similar in the two groups throughout the followup period . Recorded unbound ropivacaine levels were 2.5 times lower than toxic levels . Conclusions Periarticular intraoperative injection with multimodal drugs can reduce postoperative patient-controlled analgesia requirements and pain on activity in patients undergoing THA with no apparent increase in risk . Level of Evidence Level I , therapeutic study . See the guidelines online for a complete description of level of evidence BACKGROUND Postoperative pain management after total knee arthroplasty ( TKA ) remains a great challenge even today . In the context of new fast-track concepts , the importance of multimodal therapies for the effective treatment of pain and the reduction of side effects , as well as for the rapid ambulation of patients is increasing . Therefore , new continuous intra-articular catheter-systems ( IAC ) are under investigation . MATERIAL S AND METHODS A total of 120 patients receiving total knee replacement were included in a prospect i ve r and omized comparative study . In a st and ardized treatment regime 60 patients received an IAC ( group A ) , while in 60 patients a continuous femoral nerve block ( FNB ) was applied ( group B ) . All other perioperative therapy components were identical for all patients . In the first 5 days after surgery pain intensity ( VAS ) , passive and active flexion , opioid requirements , and self-initiated or hallway ambulation were investigated and documented . The initiation time , operation time , and length of hospital stay were recorded . RESULTS Regarding pain intensity no significant differences occurred ( mean 5.1 ± 2.5 vs. 4.6 ± 2.6 ; p = 0.27 ) . Also , additional opioid requirements and range of motion ( ROM ) showed no relevant distinctions of therapy . In the IAC group a much more rapid independent mobilization was achieved ( p < 0.001 ) . The mean initiation time before surgery decreased markedly compared to the FNB group by 11.9 min ( p < 0.001 ) . With respect to the operation time and duration of hospital stay there was no noticeable difference . The failure rate and the rate of dislocation of FNB appear to be increased . CONCLUSION The perioperative treatment with an IAC system is an easy technique , which ensures a markedly faster ambulation following TKA compared to the treatment with continuous FNB . Hence , its usage , especially in fast-track concepts can be recommended . In this study , a comparison of pain intensity , the additional requirement of opioids and early range of motion ( ROM ) offers no benefits compared to FNB . Due to time savings cost reduction can be achieved UNLABELLED This study , conducted before and after the implementation of an  acute pain service ( APS ) in a 1000-bed hospital , describes the process of the implementation of an APS . The nursing , anesthesia , and surgery departments were involved . In this study we sought to evaluate the results of a continuous quality improvement program by defining quality indicators and using quality tools . A quality program in accordance with current st and ards of acute pain treatment ( multimodal ) was worked out to enhance pain relief for all surgical in patients . A survey of nurses ' knowledge with regard to postoperative pain was conducted , and a  visual analog scale ( VAS ) was introduced to assess pain intensity . Both nurses and physicians became familiar with evidence -based guidelines concerning postoperative pain . The entire process was monitored in three consecutive surveys and enrolled 2383 surgical in patients .  Pain indicators based on VAS and analgesic consumption were recorded during the first 72 postoperative hours . After a baseline survey about current practice s of pain treatment , a nurse-based , anesthesiologist-supervised APS was implemented . The improvement in pain relief , expressed as VAS scores , was assessed in two further surveys . A quality manual was written and implemented . A major improvement in pain scores was observed after the APS inception ( P < 0.001 ) . IMPLICATION S The implementation of an acute pain service , including pain assessment by a visual analog scale , st and ard multimodal pain treatment , and continuous quality evaluation , improved postoperative pain relief . Establishing teams of surgeons , anesthesiologists , and nurses is the prerequisite for this improvement Forty – two patients scheduled for total knee arthroplasty ( n = 20 ) or hip arthroplasty ( n = 22 ) were r and omly allocated to receive either continuous epidural bupivacaine/morphine for 48 h postoperatively plus oral piroxicam , or general anaesthesia followed by a conventional intramuscular opioid and acetaminophen regimen .  Patients undergoing knee– or hip arthroplasty treated with epidural analgesia  had significantly lower pain scores during mobilization under the 48 h epidural infusion compared with patients receiving conventional treatment , while no important differences were observed after cessation of the epidural regimen . However , the achieved pain relief had no impact on postoperative convalescence parameters , such as ambulation , patient activity including need for nursing care , fatigue or hospital stay . Late postoperative pain , fatigue and conservative attitudes and routines in the postoperative care , were the most important reasons limiting mobilization and activity . We conclude that effective early ( 48 h ) postoperative pain relief with balanced analgesia does not per se lead to important improvements in convalescence and hospital stay BACKGROUND Pain is the primary indication for both primary and revision total knee arthroplasty ( TKA ) ; however , most arthroplasty outcome measures do not take pain into account . OBJECTIVE To document the prospect i ve pain experience following TKA , with subjective pain-specific question naires to determine if comorbidities , preoperative pain or preoperative pain catastrophizing scores are predictive of long-term pain outcomes . METHODS Fifty-five patients with a primary diagnosis of osteoarthritis of the knee , who were scheduled to undergo TKA , were asked to fill out the McGill Pain Question naire ( MPQ ) and the Pain Catastrophizing Scale ( PCS ) preoperatively and at three , 12 and 24 months follow-up . Comorbidities were extracted from the Queen Elizabeth II Health Sciences Centre health information system . RESULTS The overall response rate ( return of completed question naires ) was 84 % . There was a significant decrease in the MPQ scores ( P<0.05 ) postoperatively . PCS scores did not change over time . Receiver operating characteristic curves revealed the number of comorbidities per patient predicted the presence of pain postoperatively , as documented by the numerical rating subscale of the MPQ at 24 months ( P<0.05 ) . Receiver operating characteristic curves for preoperative PCS and rumination subscale scores predicted the presence of pain , as measured by the Pain Rating Index subscale of the MPQ at 24 months ( P<0.05 ) . Preoperative PCS scores and comorbidities were significantly higher in the persistent pain group ( P<0.05 ) . CONCLUSIONS The number of comorbidities predicted the presence of pain at 24 months follow-up and , for the first time , preoperative PCS scores were shown to predict chronic postoperative pain . This may enable the identification of knee arthroplasty patients at risk for persistent postoperative pain , thus allowing for efficient administration of preoperative interventions to improve arthroplasty outcomes OBJECTIVE To assess the efficacy of multimodal intraoperative analgesia in reducing postoperative pain and /or opioid requirements in women undergoing laparoscopic excision of endometriosis . DESIGN Prospect i ve , r and omized , double-blind , placebo-controlled trial . SETTING Endogynecologic department of a university teaching hospital . PATIENT(S ) Women booked for laparoscopic excision of endometriosis . INTERVENTION(S ) Intraoperative multimodal analgesia versus placebo . Analgesia consisted of Diclofenac sodium 100 mg suppository per rectum and 0.75 % Ropivacaine to portal sites , subperitoneally under excision sites and topically to each subdiaphragmatic area . MAIN OUTCOME MEASURE(S ) Postoperative total hospital opioid analgesic requirements and postoperative pain intensity . RESULT ( S ) The study was terminated prematurely , after a planned interim analysis ( which included 66 r and omized patients or 43 % of the planned number of patients ) found significantly less total hospital opioid requirements in the analgesic group compared with the placebo group ( 19.0 mg vs. 34.5 mg ; difference -14.0 mg [ 95 % confidence interval -26.0 to -2.0 mg ] ) . There was no difference in postoperative pain intensity between the two groups . CONCLUSION ( S ) The use of multimodal intraoperative analgesia at laparoscopic excision of endometriosis reduces postoperative opioid requirements Background Despite the laparoscopic approach becoming the st and ard in colorectal surgery , postoperative pain management for minimally invasive surgery is still mainly based on strategies that have been established for open surgical procedures . Patient-controlled epidural and intravenous analgesia are considered st and ard postoperative analgesia regimens in colorectal surgery . Epidural analgesia provides excellent analgesia , but is increasingly scrutinized in laparoscopic surgery since postoperative pain after the laparoscopic approach is significantly reduced . Moreover , epidural analgesia can be associated with numerous complications . Therefore , epidural analgesia is no longer recommended for the management of postoperative pain in laparoscopic colorectal surgery . Likewise , patient-controlled intravenous analgesia is subject to significant side effects . Given these important limitations of the traditional strategies for postoperative analgesia , effective and efficient alternatives in patients undergoing laparoscopic colorectal surgery are needed . Both the transversus abdominis plane block and systemically administered lidocaine have already been reported to effectively reduce pain after laparoscopic colorectal surgery . We hypothesize that the transversus abdominis plane block is superior to perioperative intravenous lidocaine . Methods / design One hundred and twenty five patients undergoing laparoscopic colorectal surgery will be included in this prospect i ve , r and omized , double-blind controlled clinical trial . Patients will be r and omly allocated to three different postoperative strategies : postoperative patient-controlled intravenous analgesia with morphine ( control group , n = 25 ) , a transversus abdominis plane block with ropivacaine 0.375 % at the end of surgery plus postoperative patient-controlled intravenous analgesia with morphine ( TAP group , n = 50 ) , or perioperative intravenous lidocaine plus postoperative patient-controlled intravenous analgesia with morphine ( LIDO group , n = 50 ) . As the primary outcome parameter , we will evaluate the opioid consumption during the first 24 postoperative hours . Secondary endpoints include the Numeric Rating Scale , time to return of intestinal function , time to mobilization , inflammatory response , incidence of postoperative nausea and vomiting , length of hospital stay and postoperative morbidity as assessed with the Clavien-Dindo classification . Discussion Recognizing the importance of a multimodal approach for perioperative pain management , we aim to investigate whether a transversus abdominis plane block delivers superior pain control in comparison to perioperative intravenous lidocaine and patient-controlled intravenous analgesia with morphine alone . Trial registration EudraCT Identifier : 2014 - 001499 - 73 ; 31 July 2014
Taking knee arthroplasty as an example , patients deemed at low risk of experiencing outcomes such as postoperative pain or chronic pain  may receive intra-articular local anaesthesia infiltration ;  patients at medium risk may obtain additional analgesia via a saphe-nous nerve catheter ; and patients at high risk may also receive nerve blocks and anti-hyperalgesics .
pain and function after fast-track hip and knee arthroplasty .
catastrophizing , response to experimental heat stimuli , and post-cesarean section pain .
In 1946 , Mendelson 1 showed that pulmonary complications and death could arise in pregnant women because of aspiration of gastric contents .
Since then , prevention of aspiration of gastric contents has contributed significantly to a decrease in maternal deaths .
Warner and colleagues 2 demonstrated in a large series from the Mayo Clinic that no aspiration occurred in pregnant or post-partum women ( probably because of the routine use of prophylactic measures ) , while both its occurrence and severity were significant in emergency procedures .
formation of large informatic data bases , or clinical quality registries , linking preoperative and intraoperative clinical data , imaging , genomics , and cancer and drug prescription data bases .
References 1 Fischer HB , Simanski CJ , Sharp C , et al. A procedure-specific systematic review and consensus recommendations for postoperative analgesia following total knee arthroplasty .
Postoperative pain management : number-needed-to-treat approach versus procedure-specific pain management approach .