Out of the 73 patients, 47 received a PECS I block and 26 received a PECS II Block. 70 of the blocks were administered after closure of the sternum while 3 were done before incision. The time to perform blocks took on average of 6 (±4) min. Mean operating room time was 7.5 h. Local anesthetics used for the blocks were as follows: Ropivacaine 0.2% (n = 54), Ropivacaine 0.5% (n = 18), and Bupivacaine 0.25% (n = 1). Twenty‐five out of 73 patients did not experience severe pain, defined as ≥7/10 on a numeric pain scale, at any point in the first 24 h following surgery. We describe the of use PECS I and II nerve block following pediatric sternotomy. Blocks were straight forward to perform, and typically took a short amount of time to administer (6 min), when compared to the total operating room time (7.5 h). While this study did not include a comparative group that did not receive a block, 34 percent of patients did not suffer from severe pain in the first 24 h following surgery. Further prospective studies are needed to assess the effectiveness of PECS blocks for pain relief following sternotomy in pediatric patients when compared to current standard of care. PECS blocks may be beneficial for a range of cardiac surgeries that typically result in severe postoperative pain.Regional anesthesia between the pectoralis major and minor was first described in 2011 as an alternative method to paravertebral blocks or epidurals for post‐operative mastectomies. Since then, the use of pectoral nerve (PECS) blocks for post‐operative pain management following thoracotomy, sternotomy, and other procedures in the anterior thorax has increased. While experience with this block is growing, the current understanding of its use in pediatric patients is limited. We reviewed pediatric cases at a single institution and provide a descriptive account of our use of PECS I and II blocks for post‐operative pain management following operations involving sternotomy in pediatric patients. We performed a retrospective database analysis of the use of PECS I and II blocks following procedures requiring sternotomy from 2018 to 2021 at St. Louis Children's Hospital. Patients 21 years old and younger who received either a PECS I or II block following a sternotomy for a cardiac procedure were included in the analysis. Patient's demographics, pre‐, intra‐, and post‐operative medications, operative time, extubation status, pain evaluations, and hospital course were assessed from the electronic medical record. From 2018 to 2021, 73 ultrasound‐guided PECS blocks were performed for pain relief for pediatric sternotomy. The most commonly performed operations were atrial septal defect closure ( These short procedures aim to decrease post‐operative pain and the use of medications for pain relief. Regional anesthesia can occur throughout the body toward many nerves for a variety of procedures.Fascial plane blocks between the pectoral muscles have been around for over 10 years and were originally described in 2011 by Blanco, who blocked the lateral and medial pectoral nerves during the perioperative period for breast surgeries.Traditionally, post‐operative pain relief options include epidurals and paravertebral blocks at the levels of the operation, parasternal blocks, pecto‐intercostal fascial blocks, transverse thoracic plane blocks, and erector spinae plane blocks.The authors provide a descriptive study of the use of PECS I and PECS II blocks for pediatric sternotomy surgeries.2This was a descriptive retrospective study that utilized the SlicerDicer tool within the Epic electronic medical record to identify patients who were under 21 years of age that were given a PECS I or II block following sternotomy for a cardiac procedure between January 1, 2018, and May 30, 2021, at St. Louis Children's Hospital. SlicerDicer is a tool within EPIC to find specific patients based on specific inclusion and exclusion criteria that has been validated by previous studies.3In total, 80 patients were obtained from the SlicerDicer search. After assessment of the patients, seven were removed as the blocks were not related to cardiac procedures. Therefore, 73 patients received PECS I or II blocks following sternotomy for cardiac procedures. Out of the 73 patients, 40 were male and 33 were female with an average age of 9 years and 99 days. Fifty‐nine out of 73 patients were classified as American Society of Anesthesiologists (ASA) level 3. The most frequent surgery performed was closure of atrial septal defect at 12 operations and repair of mitral valve and ventricular septal defect at 8. Fifty‐eight patients had a history of congenital heart disease as well. Demographics of the cohort is fully summarized in Table Out of the 73 patients, 66 had same day surgery and seven were inpatients prior to surgery. The average length of stay following surgery in the intensive care unit (ICU) was 2.24 days for same day patients and 1.14 days for inpatients. The average length of stay in the hospital for non‐ICU patients was 4.37 days for same day and 3.71 days for inpatient. The full hospital time course can be found in Table Out of the 73 patients, three received the block pre‐incision and 70 received the block post closure. Those who received the block pre‐incision were due to the expected operating time to short enough that the block would still be effective when they arrived to the post‐operative care unit. After initiation by the team, it took an average of 6.25 min to physically perform the block from ultrasound confirmation to block placement. Within the cohort, 47 patients received a PECS I block and 26 received a PECS II block. Fifty‐four patients received Ropivacaine 0.2% and 18 received Ropivacaine 0.5%. One patient was given Bupivacaine 0.25%. Full details of the PECS Block Placement can be found in Table Pain metrics were also recorded from the electronic medical record following surgery. Four pain scales were assessed on patients including rFLACC, FLACC, Faces, and Numeric scoring. Due to no standard protocol implemented on tracking pain levels within the institution, pain records were being done at any time and with whatever scale the nursing staff deemed appropriate at the time. Due to multiple scales being used on the same patient, the numerical value of 1–10 obtained from each scale was used as the pain metric regardless of the scale it came from. For example, a score of 7 on the FLACC scoring scale was equivalent to a score of 7 on the Faces scoring system. Out of the 73 patients described, 25 of them did not experience severe pain defined as ≥7/10 on our combined numeric rating scale at any point in the first 24 h following surgery.In total, four patients arrived at the ICU still intubated and 69 arrived extubated. Every patient received some type of pain medication in the ICU with an average time of 91 min before administration. The first pain medication given post‐surgery, pain medications given in the first 24 h, and extubation status were recorded in Table In the ICU, nine patients reported nausea with five of those patients vomiting. There were no obvious adverse outcomes that we could directly attribute to the administration of the block in the ICU and zero patients were readmitted to the ICU after being admitted to the floor. Only one patient had an emergency room visit related to the surgery within 30 days post discharge.4Our data show that the use of PECS I and II blocks for post‐operative pain relief for pediatric sternotomy operations may be a promising technique in the pediatric population. Congenital heart disease is one of the most common congenital disorders and requires a great deal of post‐operative recovery due to the nature of the disease.Results showed that blocks were straight forward to perform and only took a short time of 6 min compared to the total operating room time of 7.5 h. Despite this study being a descriptive study without a comparison group, these numbers show that this block takes a minimal amount of time to perform and may provide reduced pain in post‐operative recovery for these patients. In addition to the time aspect, no known complications could be directly linked backed to the block which suggests the relatively safe practice of performing this block. Despite these data coming from a single institution, the results can be applicable to other institutions due to the ease of the block performed and the experience of interventional pain teams at academic centers performing these cardiac operations.An unexpected observation from these data was the increased time spent in the ICU and floor in the same day patients vs the inpatient patients. While outliers within these groups may be a reason for these numbers, the potential recovery time is interesting to note and should be understood by the physician performing the block.A finding of these data is the need for clinicians and nurses to establish a consistent way to categorize pain. Pain scores in the Electronic Medical Record (EMR) were often recorded at variable time points, using multiple pain scores  within the same patient. There has been much education to our institution to improve this variance. Additionally, some patients had days where no pain score was recorded versus some patients that had a score being recorded every hour. Some patients had gone over 5 h initially in the ICU without a pain score observation. We recognize this may be because the patient is sedated but regardless, a system tracking and utilizing pain scores needs to be established. We also recognize the complexity of pain within the pediatric population and that individuals may not be able to verbally communicate with the care provider. That being said, the appropriate pain scale for varying cognitive levels and ages of patients' needs to be consistent among all providers. As a result of this inability to standardize the pain scores, we were forced to combine all pain scores regardless of measurement as a standard pain score. Despite this, it was found that 25 out of 73 patients did not experience severe pain, defined as ≥7/10 on the multiple pain scale that we had created at any point in the first 24 h following surgery. While the authors recognize the variability in practice of multiple pain scores for each patient, the pain scores recorded are still based on objective measures in the case of rFLACC and FLACC and subjective measures given by the patient in the cases of Faces or Numeric recordings. While this study does provide comparative results to other studies due to the combination of the scoring system utilized, the authors still believe that the measurements still hold validity and accurate pain measurements for the patients involved. A recent report outlining pediatric pain treatment and prevention for hospitalized children stated that pain in patients in children's hospitals is commonly under recognized and under reported.Literature review shows that despite the established use of PECS for breast surgeries, the understanding of its use in cardiac procedures is in its very early stages. A recent meta‐analysis conducted in 2020 by Jack et al. looking at all literature of PECS block usage found only 9 randomized control trials looking at the use of PECS blocks for cardiac procedures that encompasses only about 600 patients. Of those 9 trials, only one looked the use of PECS II blocks for post sternotomy analgesia. The others were for thoracotomy or video assisted thoracoscopic surgery.The use of an erector spinae plane block has been shown to reduce post‐operative pain following cardiac procedures. However, this block requires the patient to be turned following the operation which can cause an increased turnover time and can add further complications to the patient.The PECS block looks promising, but research still needs to be done on the exact analgesic, weight‐based dosing and location of the block. Additionally, provider variability and the exact location on ultrasound of the needle are all confounder variables in the efficacy of the PECS block. An anatomical study on PECS blocks conducted by Versyck et al. described that injection medial to the pectoral branch of the thoracoacromial artery only reaches the medial and lateral pectoral nerves. A lateral approach, which is lateral to the pectoral branch thoracoacromial artery, will also spread to the axilla and reach the intercostobrachial nerve.A recent double blind randomized controlled study was published that compared bilateral PECS II block vs intravenous analgesics for median sternotomy cardiac surgeries. The findings showed the PECS block group had lower Modified Objective Pain Score (MOPS), 2, 4, and 6 h post‐operatively. The PECS group also had a median utilization of 2.72 mic/kg of fentanyl in the first 24 h compared to 4.17 mic/kg in the control group, a 35% reduction. Despite the efforts within this study, it only involved 40 patients (20 per arm) of children ages 1–5 years old.There were several limitations within this study. The first and most important limitation was the lack of standardization in categorizing pain. Patients had multiple pain scores at varying time points, and it was difficult to gather any sort of trend within the cohort. As a result of the varying pain scales used for each patient, a spaghetti plot that is typical in pain related research was not able to be constructed for the cohort. Further prospective studies should implement 1 pain scale at standard intervals for each patient. An additional limitation is that this work is retrospective, and we are using patient charts and clinician/nursing recordings to interpret results instead of working with and speaking with the patients directly. Lastly, we recognize the subjective nature of pain studies and pain tolerance, especially in pediatric patients who may not be able to effectively communicate with providers.Future studies are needed to assess the effectiveness of PECS blocks for pain relief following sternotomy in pediatric patients when compared to the current standard of care.In conclusion, these findings show PECS I and II blocks for pediatric sternotomy as a promising technique for post‐operative pain relief. This study demonstrates the feasibility of the block but unfortunately showed significant variability in pain scores. Future prospective clinical trials should be utilized for the efficacy of this intervention within this population. Lastly, the need to standardize and categorize pain is of great importance to the medical community especially in the development of new techniques for pain management.This project was supported by a Medical Student Anesthesia Research Fellowship (MSARF) from the Foundation for Anesthesia Education and Research (FAER) to ZF.The authors have nothing to disclose.Table S1.Click here for additional data file.


Burn patients engage in repetitive painful therapeutic treatments, such as wound debridement, dressing changes, and other medical processes high in procedural pain. Pharmacological analgesics have been used for managing pain, but with ineffective results and negative side effects. Studies on pain management for burn patients suggested that Virtual Reality can treat procedural pain. This paper describes the process of designing, testing, and deploying a Virtual Reality system into a hospital setting. Firstly, a workshop was conducted to identify the most suitable types of Virtual Reality contents for the needs of burn-injured patients. Then, an experimental study, with 15 healthy adults, explored the analgesic impact of the Virtual Reality contents. The pain was induced through a cold pressor. Finally, we deployed the Virtual Reality system into the hospital to examine its efficiency on burn-injured inpatients. This study presents factors for the effective design and deployment of Virtual Reality for burn-injured patients residing in a hospital. Those factors refer to the use of cartoonish features and a choice of content based on each patient’s interests to increase the positive emotions and the use of interactive features, portable equipment to reduce pain and increase the feasibility of the technology in clinical settings. Finally, our results indicated that the extension of the VR use after the therapeutic session could support more effective pain treatment.Trial registration number Protocol ID: AA8434. Burn-injured patients’ rehabilitation requires dealing with painful therapeutic processes. Although these processes are fundamental for their recovery, by improving the functional outcomes and minimizing persistent disabilities, burn-injured patients often neglect to participate fully in their therapies  can be deployed into a hospital environment based on the restrictions such technology possesses and how to design effective Virtual Environments for burn-injured patients. The study aimed to contribute to research in the design community by presenting a long-term experimental study for the effective design of a more deployable VR system for burn-injured patients dealing with painful therapeutic processes within hospital environments.Most of the burn-injured patients undergo painful repetitive therapeutic processes, such as wound debridement, dressing changes, wound cleaning, limb mobility exercises and therapeutic skin stretching. The perception of pain associated with burn injuries has been reported as one of the most intense types of pain. Therefore, the pain that accompanies the burn injuries treatment presents an important challenge, met not only to the patients but also to the clinical staff . One was conducted without VR and one with VR, in a countered-balanced design. Decisions about the suitable timing of each were made between the patient, the clinical team and the researcher. Prior to the experiment, a familiarization session took place to ensure that the patient could use VR without any side effects.Phase 1 and Phase 2 were approved by the University’s Research Ethics Committee (PHE-298 and 328-FUR). Phase 3 was approved by the Patient and Public Involvement (PPI) Panel, Directorate of Therapeutics and Palliative Care, Sheffield Teaching Hospitals National Health Service (NHS) Foundation Trust, and NHS Research Ethics Committee (IRAS: 221071). Before giving written consent, participants were fully informed about the study, tried out a short VR experience and had the opportunity to ask questions. The study was performed in accordance with the Declaration of Helsinki.Phase 1 Seven professionals in game development (n = 1), psychology with expertise in burn care (n = 1), academia (n = 2) and nursing (n = 1) along with burn survivors (n = 2) participated in this the study. Participants were males = 3 and females = 4, aged between 25 and 65 years .Phase 2 Fifteen healthy participants  aged between 18 and 49 years  participated in this the study. All participants had normal or corrected to normal vision and no pre-existing painful conditions, such as fibromyalgia, sports or hand injuries, that could affect their perception of pain induced by the cold pressor. All participants had no history of mental health disorders, migraines, or nausea.Phase 3 Five inpatients at the Hospital’s Local Burns Unit who were undergoing regular dressing changes during the study period  aged between 19 and 68 years  participated to the study. Three out of five participants had flash burns on their hands, arms, and legs, and two out of five participants had scald burns on their legs, abdomen, and thighs. The percentage of flash burns was between 18–20%, and the percentage of scald burns was between 3–4%. Overall, the dressing changes time was between 12 min to 1-h and 10 min . Patients had none of the exclusion criteria: head and/or neck burns, wound infection, a current diagnosis of PTSD, active psychotic symptoms, or high levels of distress that could possess a risk for their well-being.Observation Notes were taken based on the workshop discussions. These observations aimed to identify potential VR environments and activities focussed on the patients’ needs.Semi-structured interviews were conducted with each participant by a clinical researcher after each virtual environment. The aim of these interviews was to gather comments regarding the experience including the following: virtual environment preference, enjoyment, objects appearance, immersion in the virtual environments, and perceived impact on pain.Quantitative measurements were also collected to assess the VR suitability: Pain Occurrence was measured in seconds and was the first point at which pain was reported by the patient. Pain tolerance was measured in seconds and was the duration before the pain became unbearable and the patient decided to end the session. Preference was measured using ordinal inputs by the user. Each user had to arrange the virtual environment in order based on his/her preference (1 = most liked and 4 = less liked).Observation notes were taken by an HCI researcher to classify the interactions and behavioural responses towards the VR experience. This was done to identify the design and deployment issues, which can help inform the VR design.Semi-structured interviews were conducted with each patient and clinical staff to identify their experience of each dressing change. Interviews contributed to increasing our awareness about the deployment challenges of the VR system in hospitals, where environmental and procedural restrictions exist.Quantitative measurements were also collected to assess the VR suitability in clinical settings for burn-injured patients: Pain was measured on a scale range 0–100 during (which referred to the level of pain the patient was feeling during the dressing changes) and after . Anxiety was measured in on a scale range 0–100 during the dressing changes.Phase 1 Observational notes were unpacked, and design principles were identified for the design of the virtual environments.Phase 2 To explore the suitability of the system based on the user experience and analgesic impact of VR in healthy adults where pain was induced via a cold pressor, descriptive statistics along with content analysis on the interviews data were used.Phase 3 To explore the suitability of the VR system, descriptive statistics were used. To understand the system’s deployment challenges and outline the solutions, content analysis was conducted.Phase 2 A cold pressor using an iced water tank, with water circulated to maintain a temperature of 4 °C was used to induce experimental pain to the subject. A digital thermometer with a calibration certificate was used to monitor the temperature. The subject was instructed to place the non-dominant hand into the iced water tank as the dominant hand was required to control the interactive virtual environments. It is noted that cold pressor has been used in several studies to induce pain to the subject as this temperature was found to provide an uncomfortable experience without causing tissue damage  system was used to stream the audial and visual content. An Oculus Rift remote along with Oculus head tracing was used as interactivity device to allow the user to navigate and interact with the virtual environments. The VR system was developed using the Unity 5.6 and Oculus SDK. The 3D models were sourced from the Unity asset store.The VR content was displayed on a laptop screen, mirroring the user’s real-time virtual interactions. Open Broadcaster Software 23.0.1 was used as a video screen recorder to record the virtual sessions, the interactions and the discussion between the user and the researcher. A digital recorder was used when interviewing the participants.A 120-min consultative workshop was conducted at a Burns Care Conference organized by the University. Attendees were a group of seven burn care specialists such as clinical psychologists, nurses and supervisors within burn healthcare. During the workshop, a game development researcher demonstrated the possibilities of VR technology using an Oculus Rift device. Afterwards, attendees suggested suitable VR content for the needs of burn-injured patients. Attendees suggested the following categories: (1) Entertainment ; (2) Nature ; (3) Calming Experiences ; (4) Ice-Cold Environments ; (5) Emotions (e.g. empathic videos were the patients will be able to connect their inner feelings with); (6) Funny Videos (e.g. humans laughing out loud); and (7) Hobbies and Sports . Based on the above categories and the strong clinical background in psychology among the professionals, the following criteria were agreed as avoidance factors: (1) Discordant Experiences ; (2) Crowded Environments ; (3) Disturbing Experiences ; (4) Warm Environments ; and (5) Emotions (e.g. anything that might upset the patient).Through the workshop and based on the technical experience of the researchers in the HCI and game development field, the following criteria were agreed in order to appropriately design or select the potential virtual environments: Videos must have: (1) High resolution appropriate to the hospital’s internet connection, to avoid blurry virtual environments; (2) Smooth transitions between scenes to avoid confusion, anxiety and distress; and (3) Stable camera recording to avoid causing motion sickness.Based on these criteria, four virtual environments were included in the study  were given shapes based on an abstract art style. Agents were coupled with sheep sound effects to reinforce the shapes representations   and strict edgy objects . Based on the Multiple Resources Theory  some participants did not report any pain at all. Those participants reached the maximal exposure of time, set to five minutes. The above findings were supported by the three virtual environments with slightly increased rates towards the interactive virtual environments : “the pain did not feel as bad as in the birthday celebration and the documentary” [Participant 7] and “not only the pain was not that strong in comparison to the other sessions [referring to the birthday celebration of a hedgehog and documentary on visual impairments] but also the duration of the episodes was quite brief” [Participant 4]. As participants suggested the increased tolerance to pain stimuli might have resulted by the fact that they were “much more concentrated” [Participant 6]. In particular, it was reported that being “much more focused, made me able to… last even longer than the allowed time” [Participant 5].Participants suggested that “challenging” [Participant 1 and 8] “competitive” [Participant 4], “interactive” [Participant 2 and 3], “highly immersive” [Participant 5 and 13], “real” [Participant 9], which “held the attention to the best” [Participant 11], “fun”  and “highly engaging” [Participant 15]. From all four virtual environments, basketball virtual experience had the most tolerant responses to pain. In particular, the subjective reports were positive with the participants suggesting that “it didn’t feel uncomfortable at all” [Participant 3]. The reported pain was much lower when compared to the other virtual environments  with most of the participants reporting that: “It took me some time to realize that I was feeling some pain” [Participant 7], “I kept waiting for the pain to come, but it was taking some time and then it wasn’t too bad, it was also felt kind of different from the pain I was feeling during the other sessions ” [Participant 1].Similar positive results to the puzzle-based virtual environment were reported by the subjects during their exposure to basketball virtual experience. As aforementioned, the participants found the basketball virtual experience to be “felt some pain every now and then, but it was easily ignored” [Participant 10], in other words, “the pain existed but I was noticing it less” [Participant 13] while some others suggested that they have “totally forgotten about their hand, as if it wasn’t hurt at all” [Participant 12] and that “compared to the other sessions  zero pain was felt at the beginning which lasted for a significant amount of time” [Participant 7]. Interestingly there was one participant who suggested that during the VR exposure she felt zero pain but once the HMD was removed and her hand was not any longer into the cold pressor, the pain occurred “I felt zero pain during the experiment, but once the experiment was over I felt some pain, around 40%” [Participant 6]. However, “overall it was a good distraction from pain, it made the process feel less painful” [Participant 11].Some participants suggested that they The above reports were in accordance with participants’ ratings of the preferable virtual environment. Participants selected as their first choice the basketball virtual experience, followed by the puzzle-based virtual environment. The two interactive virtual environments were then followed by the birthday celebration of a hedgehog choice. All the participants rated the documentary on visual impairments as their last choice.Based on the findings of experimental phase 2, the two interactive virtual environments  were selected for the clinical deployment of VR Fig. . Our finshe was not in the need of any extra analgesia during, before or after the dressing changes. Normally, she would have asked for some [Nurse 3]. At the same time, the nurses reported that during the VR exposure they were able to spend more time on dressing changes and remove more surgical staples which resulted in reducing the overall duration of the healing process. This was contrary to the normal dressing changes processes where the burn-injured patient requested to terminate the dressing session after a shorter time or increase the pharmacological analgesia intake: “He was a lot better with the VR on and I did pick quite a lot. Normally he does not allow the staff to do what we want to do because of the pain, whereas with the VR he allowed me to do that” [Nurse 1].Finally, it was quoted by the nursing staff that during the VR dressing changes less pharmacological analgesia was given to the burn-injured patients “Challenge 1—The Anxiety of Change Burn-Injured patients are dealing with painful therapeutic processes which support a bidirectional relationship between pain and anxiety  to increase the patient’s control of the cleaning procedure and reduce anxiety, VR prevents the user’s visual access to the body, which reduce patients control of the session and as a result helps reduce anxiety triggers. Patient 1 quoted that “control of the session was difficult. My suggestion is to increase control by reducing any kind of sounds incorporated to this [referring to the virtual environment], or it will be even better if the technology can detect speech and reduce the sounds during the talking. I would also like to be able to monitor the process, even though not being able to see what the nurse was doing reduced the pain I felt and so I allowed her [referring to the nurse] to do all the required steps. If I could have seen what she [referring to the nurse] was doing to my wounds I wouldn’t not let her to carry on”.Challenge 3—Space and Equipment Restrictions In contrast to deploying VR in other settings, we needed to understand the difficulties burn-injured patients encounter in physical moves and the hospital’s space restrictions. Some burn-injured patients are not able to get out of the bed and the only position comfortable to them is lying. As mentioned by patent 3, “bed’s position made it hard for me to look around and I felt that the equipment might cause some sort of difficulty to the nurse”. When we questioned whether the VR system caused difficulties to the nursing staff it was quoted that they found the process “a lot better with the VR on, since it lessened the patient’s anxiety” [Nurse 1]. Also, they found the overall experience “very positive and helpful, very good at distracting” [Nurse 2].: “I feel that there is a heat on the headset and this is making me nervous” [Patient 2] and “is a bit warm wearing it [referring to the headset]” [Patient 4]. Finally, it should be noted that patients with burn injuries to the face and area that the headset is worn on, were excluded from the study.On the other hand, and because the dressing change process took a substantial time some warmth was produced by the headset, which was spotted by the patientsChallenge 4—Carry-overs of Pain Even though positive results were reported during the dressing changes process, surprisingly once the dressing changes were over and the VR was removed from the burn-injured patients head, an increased pain occurred  compared to the normal care process . The pain was sharpened even more after two  and four  hours passed from the VR use, while this was not the case after two  and four  hours passed from the normal dressing changes, where pain faded. The above findings were further corroborated by the patients quotes who claimed that “Afterwards it was so painful and so I kept thinking of it [referring to the VR experience] to take my mind off and it took it” [Patient 4], “two hours letter the dressing changes I reflected back on the VR and it had an effect of taking you away from the immediate trauma” [Patient 5].Use cartoons to increase user’s positive emotional responses Based on the findings of the birthday celebration of a hedgehog virtual environment, we found that cartoons are an effective way to present virtual objects since that virtual environment was perceived to be a lovely environment by the users. Even though it didn’t prove to be as effective as the interactive virtual environments, however, it managed to increase user’s tolerance to pain. This is probably because cartoonish features can enhance tolerance to pain , which will decrease space restriction, but also will compromise the virtual environments’ quality and possibilities which have recently become available.Consider extending VR use after the dressing changes VR has been proved to be a successful solution for managing pain during painful wound debridement, dressing changes, wound cleaning, and other medical procedures  the use of cartoonish features to increase the patient’s positive emotions; (2) the use of a choice of content to match personal preference; (3) the use of interactive features to reduce the attentional resources to pain and increase the analgesia impact; (4) the portability of the equipment and the patient’s pre-exposure and familiarization; and (5) the extension of the VR use even after the therapeutic session is over.In addition, this study described the process of how VR can be designed, tested, and deployed into a hospital environment based on the restrictions that burn-injured patients possess. The study was limited to a relatively small sample of burn-injured patients, constrained by time barriers of the clinical consent process and exclusion criteria. Nevertheless, the study contributes to the research in the design community by presenting a long-term experimental study for the effective design of a deployable VR system for burn-injured in-patients dealing with painful therapeutic processes within hospital units. In the future, studies should examine the use of VR for clinical rehabilitation in a large-scale sample. An additional limitation of the study was the absence of quantitative measures to verify the quoted findings related to the need for less pharmacological analgesia during the VR enhanced therapy. Even though Likert scales were used to document the reduction in patient’s pain and anxiety, we did not manage to get access to quantitative data regarding the pharmacological intake. It is therefore recommended for future studies to enhance data collection with data from the patient’s medical record and to compare the regular pharmacological intake during the therapeutic session with the pharmacological dosage which is given to the patient during the VR enhanced therapy. Finally, VR has been proved to be a successful solution for managing pain during painful wound debridement, dressing changes, wound cleaning, and other medical procedures but with a detrimental effect on pain once those medical procedures are completed. Our findings suggested that intense pain which lasts for hours occurs to burn-injured patents when the VR is no longer in use. Therefore, we suggest future studies to examine the analgesic impact of offering extended VR exposure after the dressing changes.To conclude, this study contributes to the emerging body of research on the use of medical technology for burn-injured patients dealing with the painful therapeutic process in real-world clinical settings. The study presents the design process, the identification of the VR opportunities and the challenges we faced in the deployment of VR in the clinical settings. We believe this paper lays the foundations for the deployment of VR on a large scale in clinical environments and we can see a future where VR will be a part of the burn-injured patients’ medical therapies.


Since quantification and communication of ocular pain is important for a healthier patient follow-up and postoperative guidance, reliable measures like the Ophthalmic Pain Assessment Survey (OPAS) are needed to assess the outcome and management of different operations. To address that need, we carried out the adaptation of OPAS into Turkish to reach different age groups and backgrounds, widening the use of OPAS on patients who underwent an ophthalmic operation.  We used back-translation method and achieved cultural adaptation through content validity scoring by 5 independent ophthalmologists. The survey is then administered three times: preoperatively, postoperatively within 24 hours, and finally a week later in the follow-up visit. Validity is measured in comparison to Visual Analog Scale using Spearman's correlation coefficient and reliability is measured using Cronbach's alpha. Factor analysis is performed by principal component analysis and rotation is performed using Varimax method when necessary. n = 83), followed by PRK (n = 37). Overall, the T-OPAS demonstrated good reliability  and its correlation with the VAS was especially high (S. coeff. >0.5) in the first three sections in all three surveys. Factor analysis yielded 5 subscales, allowing us to shape the final form of T-OPAS.  We reached a total of 132 patients with a mean age of 64.2 years. Most of them underwent phacoemulsification ( Through this adaptation of OPAS into a foreign language, we present a reliable and valid tool for postoperative pain quantification, allowing objective measurement of pain in different populations such as the elderly. Ocular pain is an important finding in ophthalmology that can have both orbital and extra-orbital causes , 2. It cSeveral ophthalmic procedures are also known to cause ocular pain, mostly for a transient duration of time in the postoperative period. The type of the procedure, along with many other factors, influences the pain intensity and the associated symptoms such as light sensitivity (photophobia), foreign body sensation, burning, tearing, and itching. For instance, in refractive surgery , a very common intervention that involves laser treatment to the cornea, a considerable postoperative pain due to the stimulation of the corneal nerve endings is expected . The paiOphthalmologists therefore need to be vigilant about pain and related symptoms before, during, and after a procedure in order to detect and treat complications –16. OphtThe Ophthalmic Pain Assessment Survey (OPAS) has been proven to be a reliable and valid inventory to assess multidimensional orbital and extra-orbital pain . It helpIn Turkey, there is no standardized measure of pain in the ophthalmology practice. We believe that this is problematic in the daily practice since there are no means to quantify and compare the level of pain preoperatively and postoperatively for the same patient. There is also a lack of reporting on how this situation affects unnecessary presentations to the clinic or on the other hand, if there is any delay in the diagnosis of complications. In Turkey, some subspecialties have adapted international pain scales and used them in their daily practice successfully –23. SimiThe original Ocular Pain Assessment Survey is considered a gold standard in eye pain evaluation and consists of 6 sections and 24 questions in total , 19. In The adaptation process began by the translation of the survey into Turkish, following a back-translation method as established by similar validation studies –26. The In order to check for certain parameters of the survey, a cross-sectional scheme is constructed. The study included adult patients who underwent surgery after visiting the clinic from November 2020 to April 2021. All the participants were volunteers who provided formal consent upon written and verbal explanation prior to their surgery date. The patients who could not communicate in Turkish, had an extra-ocular procedure simultaneously or not long ago, had general anesthesia or did not show up to their follow-up visits have been excluded from this study.We planned to apply the same survey three times at different time-points as presurvey, postsurvey, and late-postsurvey  for painThe presurvey was administered to the patients 10 minutes before their planned surgery, whereas the postsurvey was administered the next morning during the first follow-up visit to cover the first postop for 24 hours. Late-postsurvey was administered a week later during the second follow-up visit. The last section that quantified improvement in the patient's pain is asked only in the late postsurvey since pain level was expected to rise postop.In our study, the responses given to quantify pain were considered as a continuous variable from 0 to 10, from which we calculated the mean, standard deviation, minimum, maximum, and median values. In addition to that, the frequency and percentage values are calculated to identify other categorical variables our survey measured such as the type of the surgery and the demographics of the patients. We used the Kaiser–Meyer–Olkin test to calculate the adequacy of our sample size. As generally accepted, a value between 0.8 and 1 indicated a good sample size.In order to develop an applicable survey that elicits consistent responses which correspond well with the pain and associated symptoms, we tested our adaptation's validity and reliability using established statistical methods –26.To determine the validity of our survey and how well it measures pain, we calculated the correlation of our adaptation with the gold standard Visual Analog Scale  by using Spearman's Rho coefficient. A higher correlation value indicated a relatively more successful measure of pain. We further analyzed the variability within our survey by using factor analysis with varimax rotation method, as in previous studies , 26. ThiWe measured the reliability of the items within the survey and how well the items were consistent with one another using the Cronbach's alpha coefficient, as in previous studies –26. A vap < 0.05.Statistical analysis of the collected data is performed using IBM SPSS statistics  for Windows. Level of statistical significance was determined as n = 83), PRK (n = 37), LASIK (n = 5), pterygium excision (n = 2), eyelid surgery (n = 2), intravitreal injection (n = 2), and trabeculectomy (n = 1). 29 of the refractive surgery patients underwent bilateral surgery; however, the rest of the patients had unilateral surgery . 44 of the patients  reported additional nonophthalmic pain prior to the surgery with headache being the most common  and neck pain being the second most common .The total number of patients included in the study was 132 with a mean age of 64.2. The patients underwent operations including phacoemulsification  within the postoperative 24 hours. It then decreased to preop values in the late-postsurvey within 1 week after surgery . This affected the 2-week pain levels as an increase in the past level of pain. Noneye pain also increased postop significantly . No statistically significant difference between the characteristics of the change in pain levels could be shown between the phacoemulsification and refractive surgery patients and therefore it is not shown here.As seen, daily pain (eye pain in 24 h) increased significantly  .Stronger correlations are observed in the first two sections asking directly about the eye pain over a period of 24 hours and 2 weeks. Correlations fall weaker in the last two sections asking about aggravating and associated factors. Especially in the late-postsurvey, aggravating factors were not statistically correlated with the gold standard measure of pain. Following that, noneye pain section in the postsurvey was also faintly correlated with VAS.Kaiser–Meyer–Olkin test to determine sample adequacy yielded a value of 0.851, indicating a good sample size. Following that, factor analysis was performed separately for the presurvey, postsurvey, and late-postsurvey. Postsurvey results are further individualized based on the type of the surgery, focusing especially on cataract patients who underwent phacoemulsification and patients of laser surgery. Among all these analyses, total postsurvey results had the best rotated component distribution and therefore chosen as the main guide for the sectioning of our adaptation . CumulatOur study revealed that the Turkish version of OPAS is a reliable and valid questionnaire to assess ocular pain and associated symptoms, widening the use of OPAS as a valid tool to remotely assess surgical pain of the orbit. Using this survey, ophthalmic pain can now be better expressed and followed easily by the physicians in the postoperative period and the general practice. It can also be used to compare the pain characteristics after different operations internationally and among different cultures, backgrounds, age groups, and methods.The patient population that we have included in this study was mostly in the 6th decade of life which is known to constitute a barrier on its own in verbal pain expression , 28. We The reliability of the survey was also found high as almost all items were between 0.7 and 1 . EspeciaCorrelation levels with the gold standard pain measure of VAS were measured the highest in the first subcategories and declined towards the subcategories 4 and 5, generally speaking . In addiThe KMO test revealed excellent results with regard to our sample size and the principal component analysis yielded 5 main subscales of our survey . The maiWe have certain limitations in this study. First of all, managing an elderly population—presenting usually with multiple co-morbidities—was especially challenging during the COVID19 pandemic. This also affected our patient diversity as elective operations were not preferred by most ophthalmology patients during this period. Secondarily, we did not consider any difference in education level, cultural background, socioeconomics, and certain other painful comorbidities like arthralgia which might have affected the patient's perception of pain. Physicians might need to take these into account when they administer this test in their practice or when they compare the results of different patient populations. Another limitation was the difference between the age groups undergoing a cataract surgery and the ones—who were younger—undergoing laser surgeries. Although no significant difference was seen between these two groups, their different pain thresholds might have influenced their answers .With this study, we present a reliable and valid Turkish form of the original OPAS developed by Hamrah et al. , 19 whicAdditionally, we believe this survey and its possible adaptations into other languages will be helpful in establishing a better line of communication with the clinic and the patient in the postoperative period. We aim that it helps with an easier recovery process and quicker detection of complications and secondary infections in especially risk-bearing populations.Finally, with its different sections, the survey targets multiple aspects of the postoperative period and therefore can be useful in providing a holistic summary of the patient's wellbeing. As pain is also a multidimensional concept with lots of associated symptoms in ophthalmology, we believe that such a tool can make it easier for the physicians to track their patient's overall experiences.


Background and Objectives: Lumbar spinal stenosis is one of the most common causes of disability in the elderly and often necessitates surgical intervention in patients over the age of 65. Our study aimed to evaluate the clinical efficacy of interlaminar stabilization following decompressive laminectomy in patients with lumbar stenosis without instability. Materials and Methods: Twenty patients with lumbar stenosis underwent decompressive laminectomy and interlaminar stabilization at our academic institution. Clinical outcomes were measured using the visual analog scale (VAS) and Oswestry disability index (ODI) at the 2-month, 6-month, and 1-year postoperative visits, and these outcomes were compared to the preoperative scores. Results: The average VAS scores for low back pain significantly improved from 8.8 preoperatively to 4.0, 3.7, and 3.9 at 2 months, 6 months, and 1 year postoperatively, respectively (p < 0.001). The average VAS scores for lower extremity pain significantly improved from 9.0 preoperatively to 2.7, 2.5, and 2.5 at 2 months, 6 months, and 1 year postoperatively, respectively (p < 0.001). The average ODI scores significantly improved from 66.6 preoperatively to 23.8, 23.3, and 24.5 at 2 months, 6 months, and 1 year postoperatively, respectively (p < 0.001). There was no statistical significance for difference in VAS or ODI scores between 2 months, 6 months, and 1 year. One patient had an intraoperative durotomy that was successfully treated with local repair and lumbar drainage. Another patient had progression of stenosis and had to undergo bilateral facetectomy and fusion. Conclusions: Decompressive laminectomy and interlaminar stabilization in patients with spinal claudication and low back pain is a good surgical option in the absence of instability and may provide significant clinical improvement of pain and functional disability. Lumbar spinal stenosis is a progressive narrowing of the spinal canal, typically due to degeneration and the aging spine . This meWhile age is the leading risk factor for lumbar stenosis, other risk factors include obesity, tobacco use, repetitive spinal stress with occupation, and congenital predisposition . The cliIn patients with diagnosed lumbar stenosis and neurogenic claudication who fail conservative management, the option to undergo surgery is next to be considered. If the patients have no axial low back pain, a simple lumbar decompressive laminectomy is sufficient. Patients with moderate to severe stenosis due to instability typically benefit from an instrumented fusion after decompression. This, of course, is a more laborious operation and carries a higher incidence of risks, including infection, potential for pseudoarthrosis, and need for reoperation . In patiInterlaminar stabilization with the Coflex device  provides optimal clinical outcomes in patients diagnosed with lumbar stenosis and presenting with neurogenic claudication and axial low back pain, in the absence of frank instability. Once surgical decompression has been performed, the interlaminar device is placed between two adjacent spinous processes, with flanges on the superior and inferior aspects of the device to anchor on the superior and inferior spinous processes, respectively. It offers dynamic stabilization by permitting some degree of motion in addition to distraction of the posterior spinal elements. In general, this has been reported to have less surgical complication than standard lumbar fusion ,9,10. InThe aim of the present study was to evaluate the clinical outcomes in patients who underwent lumbar laminectomy and interlaminar stabilization for symptomatic lumbar stenosis without major instability. We include a high-quality, two-dimensional operative video to supplement our detailed description of surgical technique for a thorough understanding of this surgical option.Clinical presentation with neurogenic claudication and significant axial low back pain;2 or less;Body Mass Index (BMI) of 35 kg/mEvidence of lumbar stenosis on magnetic resonance imaging (MRI);Absence of spondylolisthesis, or grade 1 spondylolisthesis unchanged on flexion-extension imaging;Failure of maximal conservative management for greater than six months;Decompressive laminectomy and interlaminar stabilization at one or two lumbar levels;Completed follow up at two months, six months, and possibly one year postoperatively.Each patient was evaluated extensively before reaching the decision to undergo decompressive laminectomy with Coflex. The inclusion criteria for patients in this study were as follows:Axial low back pain in this cohort was deemed to originate from the facet joints, as most of the patients reported temporary relief with facet blocks during their conservative management. Patients with previous spine surgery or significant trauma were excluded from the study. 2. Most operations occurred at a single lumbar level (70%), while the remainder occurred at two lumbar levels (30%). Of the single level operations, nine of them were at L4–5 (7%), with the other three being L3–4 (25%). See A total of 20 patients between September 2014 to August 2020 fulfilled these criteria and were included in this retrospective analysis. All patients who underwent decompressive laminectomy with Coflex at our academic institution within the study timeframe were included in this study. All operative interventions were performed at a single academic institution by a single academic neurosurgeon (GCT). Most of the cohort was male (72%) and over 60 years of age (75%). The cohort BMI was uniformly under 35 per the study inclusion criteria, with average BMI of 27.6 kg/mThe operative technique is presented for the L4–5 level. The patient is placed in prone position under general anesthesia. Lateral fluoroscopy is used to identify the level of interest (L4–5) and the skin incision is centered on the two respective spinous processes. The lumbar fascia is opened with the Bovie cautery and a subperiosteal dissection is performed in order to expose the L4 and L5 laminae. The microscope can now be brought into the operative field, although some surgeons may prefer to operate under loupe magnification. The supra- and interspinous ligament is removed with the Bovie cautery and then, using the high-speed drill, a partial caudal L4 laminectomy and cranial L5 laminectomy is performed. Particular attention is paid to try to preserve as much of the L4 spinous process as possible. The yellow ligament is exposed and then removed in a piecemeal fashion with the Kerrison 2 rongeurs, from its origin underneath the cranial aspect of the L5 lamina to its insertion under the mid-L4 lamina. The midline dura mater is initially exposed. The decompression is then carried out laterally into the neural foramina, and the take-off of the spinal nerves is thoroughly decompressed. We prefer to place a piece of Gelfoam over the exposed dura for hemostasis and protection. After this, an interspinous trial is placed between the spinous processes of L4 and L5 to determine the appropriate device size (between 8 and 16 mm). The interlaminar implant (Coflex) is then inserted under fluoroscopic guidance and the two flanges on both sides are squeezed onto the L4 and L5 spinous processes, respectively. This should allow for a solid anchoring of the implant. The procedure can be repeated in a similar fashion for the adjacent level . The wound is then closed in anatomical layers. The final placement of the interlaminar device(s) is confirmed by AP and lateral fluoroscopy. The surgical technique is illustrated in the operative video.To evaluate clinical efficacy, intraoperative and postoperative complications were recorded. Follow up clinic visits were completed at two months, six months, and one year. During the preoperative visit and follow up period, visual analog scale (VAS) and Oswestry disability index (ODI) scores were tabulated and recorded in the dataset for each patient. These scores were compared to determine the patients’ clinical progression. The VAS is a well-described and validated scale that utilizes an unmeasured, 10-cm instrument to measure pain intensity. To participate, patients indicate a point along the continuum correlating to their current level of pain. The continuum ranges from “no pain” on the left to “very severe pain” on the right. Acceptable cut points based on the distribution of VAS scores across various postsurgical patients have been recommended: no pain (0–0.4), mild pain (0.5–4.4), moderate pain (4.5–7.4), and severe pain (7.5–10.0) .The ODI is a validated outcome measure commonly used in the management of persistent spinal disorders . It is at-tests were used to identify differences between preoperative and follow up VAS and ODI scores. Two-sample t-tests with equal variances were used to identify whether VAS or ODI were different between genders. Linear regression was used to determine the relationship between VAS or ODI scores and age or BMI.Data were analyzed on STATA 17.0. Paired All 20 study participants were included in the statistical analysis. At the time of final follow up, no patients showed loosening of the Coflex device on flexion-extension X-ray (0.0%).Patients’ low back pain (VAS), lower extremity pain (VAS), and overall disability (ODI) were significantly improved postoperatively. However, there was no significant improvement in pain (VAS) or disability (ODI) over time after the initial 2-month period.p < 0.001). The average VAS score for lower extremity pain preoperatively was 9.0, which improved postoperatively to 2.7, 2.5, and 2.5 at 2 months, 6 months, and 1 year, respectively (p < 0.001)  .Using the ODI scale, the average preoperative patient classified as “crippled,” with a score of 66.6. Postoperatively, average ODI scores were reduced to the “moderately disabled” range, with scores of 23.8, 23.3, and 24.5 at 2 months, 6 months, and 1 year, respectively .p = 0.0087), meaning that older patients had more lower extremity pain before surgery. Postoperatively, however, there was no correlation between age and lower extremity VAS scores at 2 months, 6 months, or 1 year . There were no correlations between preoperative or postoperative VAS or ODI scores and BMI or gender. All p-values for linear regression and two-sample t-tests were above a significance level of 0.05. A positive correlation was found between age and preoperative lower extremity pain (VAS) . One patient had a small durotomy during the decompression stage of the operation, resulting in a cerebrospinal fluid leak. The leak resolved after direct intraoperative repair and placement of a lumbar drain. Another patient, upon follow up, re-presented with worsening low back pain. The patient was deemed to have recurrent stenosis and ultimately underwent an instrumented lumbar fusion. His low back pain resolved after the subsequent operation and was therefore deemed attributable to the lack of initial support provided by the Coflex device. The reoperation rate in our cohort was consequently 5.0%. The complication rate in our cohort is consistent with that of the existing literature, which reports rates up to 12.1% . However.0%. One 2. His neurological exam showed no focal deficits, and he had a negative straight leg raise test. The patient’s VAS scores for axial pain and lower extremity pain at presentation were 8.0 and 7.0, respectively. His ODI score at presentation was 58, classifying him as “severely disabled”. MRI of the lumbar spine showed a grade I spondylolisthesis at L3–4 with associated moderate-severe stenosis  patients presented with back pain VAS scores of ≥7.0 preoperatively, with the average being 8.8. Zero patients returned with back pain VAS of ≥7.0 at 2 months or 6 months postoperatively, with average back pain VAS scores being 4.0 and 3.7, respectively. One patient presented to the 1-year follow up appointment with a back pain VAS score of 8.0 and recurrent stenosis that was successfully treated with lumbar fusion. Despite this, the average back pain VAS score at 1 year postoperatively remained 3.9. These findings support the role and efficacy of laminectomy with Coflex in patients with severe preoperative back pain as measured by VAS scores. However, further studies including direct comparison with randomization would be needed to confirm the superiority of laminectomy with Coflex versus laminectomy alone.In our data, the lack of change in the VAS and ODI scores at 2, 6, and 1 year suggests that the benefit from decompression plus Coflex is obtained almost immediately and sustained over time. Therefore, in patients with significant back pain without overt instability on dynamic imaging, decompressive laminectomy with interlaminar stabilization remains a viable option to address claudication symptoms in combination with axial back pain, where decompression alone may not be effective. Interlaminar stabilization with the Coflex device offers an intermediate option between the simple decompression and the instrumented fusion. The addition of the Coflex device after laminectomy typically adds minimal operative time, with one study citing operative times of 141.91 ± 47.88 min for laminectomy with Coflex vs. 106.81 ± 41.30 min for laminectomy alone . In addi2 or less. This was done to avoid the overwhelming stress that a large upper body weight would inflict on the interlaminar device. In patients with BMI over 35 kg/m2, an instrumented fusion was offered if deemed necessary, especially in patients presenting with focal neurologic deficits or bowel or bladder incontinence. Otherwise, bariatric surgery with close clinical follow up was offered to decrease the risk of surgical complications that is well documented in this patient population [The Coflex device differs from previous interspinous implants  in that it is not rigid, and the connecting part of the device is located in between the remaining portion of the laminae following decompression, rather than the spinous processes, thus being closer to the axis of rotation. These differences represent a proposed mechanism of why the failure rate, though high with the interspinous devices, has been minimal with the interlaminar dynamic devices. Another reason for low failure rates observed with interlaminar stabilization may be the low level of activity in the elderly population. The average age of our patients was 63 years, and their preoperative activities were severely restricted by their lumbar symptoms, not uncommonly being wheelchair bound. After the operation, these patients progressively resume their daily activities, but these activities rarely amount to more than walking to the store or working in the garden. If the same symptoms occurred in younger individuals, an instrumented fusion may become the better option. Finally, success seen in our utilization of interlaminar stabilization with decompressive laminectomy can be related to the usage of this type of stabilization in patients with a body mass index of 35 kg/mpulation . There are limitations to this study. The main limitation is the short follow up period after surgery. Therefore, long-term outcomes on the time scale of five or more years in our specific cohort are not validated. However, there are a few existing studies that support its long-term efficacy in patients with lumbar stenosis, with successful follow up measured at 8 years and 12 years ,13. RegaDecompressive laminectomy and interlaminar stabilization in patients with spinal claudication and axial low back pain is a good surgical option in the absence of instability. Overall, VAS and ODI scores were significantly improved at 2 months, 6 months, and 1 year follow up in our study cohort. This technique may be particularly useful in elderly patients with limited physical activity.


We aimed to compare the effect of bupivacaine intraperitoneal with intra-abdominal bicarbonate in reducing postoperative pain in laparoscopic cholecystectomy.In this double-blind randomized clinical trial study, 58 patients underwent laparoscopic cholecystectomy referred to a hospital in Tehran, Iran (2019), were assigned into three groups: at the end of the surgery, spraying 50 cc of bupivacaine 0.2% through the laparoscopic port; or rinsing the abdomen with 5.7% bicarbonate dissolved in 1000 cc of normal saline; or abdominal lavage with normal saline. Pain of patients was evaluated according to visual analogue scale criteria and means Ramsay score in recovery times, 2, 8 and 24 h and post-operative analgesia satisfaction score at 2 and 24 h were also evaluated. The mean age of range was 44.26 ± 13.13 years, 44 female patients and 14 male patients. The mean Ramsay score in recovery, 2, 8 and 24 h postoperative times was not significantly different among the groups. Comparing post-operative analgesic satisfaction scores in recovery, 2 and 24 h revealed no significant difference among the groups. We found that use of bupivacaine intraperitoneal and intra-abdominal bicarbonate decreased pain after laparoscopic cholecystectomy but the decrease was more in bupivacaine group than bicarbonate group.Trial Registration: Retrospectively registered, IRCT20180723040570N1; date of registration: 2019-06-24. Pain is one of the complications of laparoscopic surgery. Untreated post-operative pain can interfere with sleep and physical activity and has negative effects on the patient's well-being . Many stBased on the patient’s preference and risk assessment there are several methods for controlling post-operative pain. These include systemic opioid and non-opioid analgesics, and regional, and neuroaxial analgesia. The use of local anaesthetics has been advocated as a method for reducing postoperative pain and drug use because it results in reducing drug-related side effects, improving patient recovery, and shortening of hospital stays , 7.Epidural or intrathecal analgesia is considered as the gold standard for pain management in abdominal surgeries  but concMost studies have discussed reducing postoperative pain for open surgeries  and the The aim of this study was to compare the effects of bupivacaine intraperitoneal with intra-abdominal bicarbonate on reducing postoperative pain in laparoscopic cholecystectomy surgery.The current study is a double-blind randomized clinical trial applied on 58 patients referred to the Rasool Akram Medical Complex in Tehran, Iran in 2019 for laparoscopic cholecystectomy. Inclusion criteria were age 17–60 years and ASA I and II. Exclusion criteria were patient dissatisfaction for participating in the study, opioid use within 24 h before the study, allergy to the drugs used in the study and alcohol use, chronic pain syndrome, neurological disease, steroid treatment, and the conversion of laparoscopic surgery to open surgery.2 (ET CO2). The ventilation condition was established so that the ET CO2 was maintained between 25 and 35. During the operation, the patient was placed in the trendelenburg reverse position and semi-sitting, and the intra-abdominal pressure was maintained between 15 and17 mmHg.Protocol of anaesthesia induction was standard for all patients and included midazolam 25 µg/kg, fentanyl 2 µg/kg, as premedication, and propofol 2 mg/kg, atracurium 5 mg/kg and lidocaine 1.5 mg/kg. Anaesthesia maintenance was done by propofol 150–100 µg/kg with control of hemodynamic symptoms. For anesthesia depth, atracurium 0.2 mg/kg every 30 min was prescribed and morphine sulfate 0.1 mg/kg at the beginning of surgery during intra-abdominal injection of bupivacaine was used. Routine monitoring included non-invasive blood pressure (NIBP), Pulse oximetry (POM), EKG, and End-tidal COThe required fluids were calculated according to the instructions for intraoperative fluid infusion. Patients were divided into three groups of normal saline, bicarbonate, and bupivacaine by permuted randomization. The patients and outcome assessors were unaware of the intervention type. The drug was administered during the surgery by a surgeon and the questionnaire was filled out by a nurse and she gave the researchers the questionnaire which had been assigned in three categories of A, B, C before the surgery. The evaluation after the surgery was performed by the researchers who were not aware of the categorization and they measured and screened the pain and satisfaction of the patients in recovery, 2, 8 and 24 h postoperative times. Also, if the patients had VAS higher than 3, pethidine was administered for their pain. All the patients received 2 g apotel.The amount of narcotics and analgesics prescribed during the surgery was equal. At the end of the surgery, in the first group, 50 cc of bupivacaine 0.2% was sprayed by the surgeon through the laparoscopic port to wash the incisions and anastomosis, and after three minutes the abdomen was completely emptied of gas. In the second group, the abdomen was rinsed with 5.7% bicarbonate dissolved in 1000 cc of normal saline. While changing the patient’s position, the rinsing fluid was distributed throughout the abdomen. The patient was placed in the right and left lateral positions and trendelenburg position, and the supine position.2 was drained from the peritoneal space. The anaesthesia was discontinued, and the patient was reversed with 40 µg/kg of neostigmine and 20 µg/kg of atropine, and then extubation was done. For all patients, an autofusor intravenous pain pump containing 2 g of apotel was administered within 24 h. The first request for analgesia was recorded by the nurse, and in case of pain in VAS more than 3, 0.5 mg/kg of pethidine was administrated. All surgeries were performed by one surgeon. Pain at recovery, 8, 12 and 24 h later were measured using VAS and patient’s satisfaction was measured by Ramsay score. Post-operation analgesic satisfaction score was also measured at the times for the three groups.The third group underwent abdominal lavage with normal saline. Afterwards, the COThe sample size was calculated based on the study by Oza et al.  and usinDescriptive results are presented as mean, standard deviation and frequency or percentage. Independent t-test was used to compare the two means. In case of abnormal data distribution, Mann–Whitney test was used. Also, Chi-square test was used to examine the differences of qualitative variables. Two-way Analysis of Variance Test (ANOVA) repeated measures analysis was used to evaluate the quantities between the groups and to examine the trend of intergroup pain. A P-value of less than 0.05 was considered statistically significant. All data were analyzed using SPSS software version 21.This study was performed on 58 patients underwent laparoscopic cholecystectomy in 2019. The mean age of patients was 44.26 ± 13.13 years; 44 (75.9%) patients were female, and 14 (24.1%) patients were male. The basic characteristics of the patients in the three groups are shown in Table The mean pain of the patient at all times was significantly different in the three groups (P < 0.05).The trends of intergroup pain in patients over time were evaluated, showing that the mean pain during the times had significant changes (P = 0.005). Results of intergroup effects showed that the differences between the two groups were statistically significant (P < 0.001) Fig. . The meaPost-operation analgesic satisfaction scores at 2 and 24 h was evaluated for the three groups. The results showed that the distribution for these variables was not different in the three groups (P > 0.05).Uncontrolled pain after laparoscopic surgery is a clinical challenge that affects patient’s well-being significantly, leading to myocardial infarction, cardiac arrhythmia, ileus, and poor wound healing , 5. NowaBupivacaine as a long-acting local anesthetic reduces sodium permeability, increases the threshold of action, and prevents the conduction of nerve waves. This drug has a relatively slow onset (15 min) and long effect time 360–720 min) [ min 20,. On the In a study by Stuhldreher et al. the effect of local anesthetic was evaluated on post-operative pain and the rate of drug use in patients underwent laparoscopic colorectal surgery. The first group received local anesthetic. The other group received both subcutaneous bupivacaine and intraperitoneal lidocaine. The study concluded that consumption of local anesthetics does not affect the amount of opioid required after the surgery .Considering that the site of surgery in laparoscopic cholecystectomy is in the lower part of the chest, the patient's pain increases with each breath and the pain might be greater than that in colorectal surgery, resulting in different results in pain between the two studies. Compared to our study, there was no significant difference in the need for pain killer in any group, which supports the results of Stuhldreher’s study .In another study, Joshi et al. managed pain after laparoscopic colorectal surgery by using ketorolac, methylprednisolone, intraperitoneal injection of ropivacaine, intravenous infusion of lidocaine, intrathecal morphine, and epidural anesthesia, which reduced the need for narcotics, and improved bowel function.In conclusion, this study recommended surgical wound infiltration with local analgesia, systemic steroids, Non-steroidal anti-inflammatory drugs (NSAIDs), and specific Cyclooxygenase-2 (COX-2) inhibitors in combination with paracetamol and opioids . ConsistA study by Butala et al.  evaluateThe results of the study showed that both methods, bupivacaine intraperitoneal and intra-abdominal bicarbonate, are effective in reducing opioid use and postoperative analgesia, leading to fewer side effects and better controlling the postoperative pain. In fact, the difference between the two methods is in the time of analgesia. In fact, the only difference between the two methods is in the time of analgesia.One limitation of the current study is that none of the two persons were responsible for observing postoperative pain, that is, the surgeon who uses the drug and a nurse who filled questionnaire, had no role in analyzing and reviewing the results. This means that researchers could not check inter observer variability.