Rectus Sheet Block Analgesia For GYN Surgery

Noting that opioid-sparing pain management is important for enhanced recovery after surgery (ERAS), the authors randomized 74 women (ASA 1-2) undergoing elective midline laparotomy under general anesthesia to receive bupivacaine 0.25% (group A) or normal saline (group B) injection (both 20 mL) at the wound site every 6 hours for 48 hours postoperatively. The mean morphine consumption and the mean rating score were significantly reduced in Group A (p < 0.001). (See: Bakshi SG, Mapari A, Shylasree TS. Rectus sheath block for postoperative analgesia in gynecologic surgery (RESONS): a randomized controlled trial. Can J Anaesth. 2016:63(12):1335-1344.)-EAMF

Persistent Pain after Cesarean Delivery

A questionnaire regarding their pain experiences was distributed on postoperative day 2 to 1052 women who had given birth vaginally and to 502 women who had undergone cesarean delivery in Finland. A second questionnaire was mailed 1 year later. Results indicated that persistent pain was greater after cesarean delivery than after vaginal delivery (22% vs 8%), and pain occurred more frequently in primiparas and in patients with a previous pain history. At 1 year, the incidence of dyspareunia after vaginal delivery reached 41%, compared with 2% in those who undergone cesarean delivery. In both groups, severe pain immediately after delivery correlated with the development of persistent pain. (See: Kainu JP, Halmesmaki E, Korttila KT, et al. Persistent pain after cesarean delivery and vaginal delivery: a prospective cohort study. Anesth Analg. Nov 2, 2016 [publish ahead of print]. doi: 10.1213/ANE.0000000000001619.)-EAMF

Pros and Cons of Continuous Peripheral Nerve Blocks

The pros, from Macaire: Most surgeries are now done on an ambulatory basis and up to 9% of patients report mild to moderate pain days and 2% continue to have severe pain after 7 days. Continuous peripheral nerve block (CPNB) has been shown to be 50% more effective in managing pain than opioid-based analgesia at 24 to 72 hours after surgery. Nausea and vomiting and sleep disturbances are reduced and the ability to ambulate is reduced from 40 hours for those given patient-controlled morphine to 10 minutes in those with CPNB. The need for frequent adjustments to the infusion to prevent paresthesias and numbness can be addressed by remote-control pump, a system that relies on online patient responses to a 10-item questionnaire completed 3 times daily and reviewed by anesthesiologists.

The cons, from Pawa: Most ambulatory patients do well with a single shot block or surgical wound infiltration and oral multimodal analgesia affording good pain relief in 80% of patients at 12 hours. If patients require perineural catheters, than there are likely other health care situations that might benefit from hospital admission. Training and equipment required for CPNB are expensive. Staff must be available and on call. Catheters become dislodged in up to 15% of patients. Although rare, new neurologic complications have been described and associated with catheter placement. (See: Pawa A, Macaire P. Pros and cons of the use of continuous peripheral nerve blocks (CPNB). International Symposium of Ultrasound for Regional Anesthesia, Pain Medicine and Perioperative Application [abstract]. June 11-14, 2016, Toronto, Canada.)-EAMF

Effect of BMI and Psychosocial Traits on Knee Replacement Costs

In a study of 212 patients, the mean total cost of total knee replacement (TKR) was $30,831 (SD $9893). However, increased body mass index (BMI) (36), high anxiety levels, and decreased levels of positive social interactions raised costs to $58,447. Costs in patients with a lower range of normal BMI (19.5), high positive social interaction, and no anxiety were predicted at $22,247. Thus, preoperative interventions targeting obesity and anxiety may prove cost effective before TKR. (See: Waimann CA, Fernandez-Mazarambroz RJ, Cantor SB, et al. Effect of body mass index and psychosocial traits on total knee replacement costs in patients with osteoarthritis. J Rheumatol. 2016:43(8):1600-16066. doi: 10.3899/jrheum.151301.)-EAMF

Comparative Study of Cabbage Leaf Wraps for Knee Arthritis Pain

The study randomly assigned 81 patients to 3 groups: group A received 4 weeks of treatment with cabbage leaf wraps (daily for at least 2 hours); group B, topical pain gel (10 mg diclofenac/g, at least once daily); and group C, usual care (ice, heat, etc). At 4 weeks, patients in group A reported significantly less pain than those in group C but more pain than patients in group B. (See: Lauche R, Graf N, Cramer H, et al. Efficacy of cabbage leaf wraps (CLW) in the treatment of symptomatic osteoarthritis of the knee: a randomized controlled trial. Clin J Pain. 2016;32(11):961-971.)-EAMF