Introduction. Peri-articular local anesthetic injections reduce post-operative pain in total knee arthroplasty and assist recovery. It is inconclusive whether intra-operative injection of peri-articular morphine is locally effective. The aim of this study is whether the addition of morphine to peri-articular injections in only unilateral knee improves post-operative pain, range of motion, swelling in patients with simultaneous bilateral total knee arthroplasty. Materials and Methods. A prospective single-center double-blinded randomized controlled trial was undertaken to assess the local efficacy of adding morphine to intra-operative, peri-articular anesthesia in simultaneous bilateral total knee arthroplasty. Twenty eight patients with 56 TKAs were randomly divided into 2 groups, unilateral TKA with intraoperative peri-articular injection with adding morphine and the other side TKA without adding morphine. The morphine group received an intraoperative, peri-articular injection of local anesthetic (Ropivacaine 150mg), epinephrine (50μg), ketoprofen (25mg) and methylpredonisolone sodium (20mg) plus 0.1mg/kg of morphine. The no-morphine group received the same amount of local anesthetic, epinephrine, ketoprofen and methylpredonisolone sodium without morphine. The operating surgeon, operating staff, patients, physiotherapists, ward nursing staff and data collectors remained blinded for the duration of study. All surgeries were performed by the same operating team. A standard medial parapatellar approach was used in all operations. Post-operative analgesia was standardized to all participants with celecoxib daily for 3 weeks. Primary outcomes included visual analog pain scores (VAS), ROM and swelling of the thigh. Secondary outcomes included WOMAC and adverse outcomes. Result. There were no significant differences between two groups for pre-operative ROM, pre-operative pain VAS or the circumference of the thigh. There were no statistically significant differences in primary and secondary outcomes between two groups (Figure 1, 2, 3). Discussion. Multiple studies have demonstrated the clinical efficacy of multimodal peri-articular injection of analgesics in TKA for pain relief. However, the opioids often lead to nausea as an adverse effect, which is reported from 25% to 56%. The mechanism of pain relief by morphine is mainly the efficacy through the opioid receptor in central nerve system, and the other mechanism through local opioid receptor (μ-receptor) is rarely revealed for pain relief. Our study used morphine in unilateral TKA and no-morphine in the other side TKA and showed no significant difference in primary and secondary outcomes. These results revealed that the efficacy for pain relief in peri-articular injection without morphine is the same as that in no-morphine group. In conclusion, adding morphine in peri-articular injection could not be locally effective for pain relief

Previous authors have suggested that the analgesic effects of intra-articular morphine may be beneficial. Clonidine has been found to potentiate the analgesic effect of morphine. Following knee arthroscopy, morphine has demonstrated equivocal effect in comparison to bupivicaine for analgesia while circumventing the issue of chondrotoxicity. There have been no studies evaluating the effect of intra-articular morphine following hip arthroscopy. The purpose of this study was to evaluate the efficacy of intra-articular morphine in combination with clonidine on pain and narcotic consumption following hip arthroscopy surgery for femoroacetabular impingement. A retrospective review was performed on 43 patients that underwent hip arthroscopy between September 2014 and May 2015 at our institution for femoroacetabular impingement. All patients received preoperative Celebrex and Tylenol per our anesthesia protocol, and 22 patients received an additional intra-articular injection of 10 mg morphine and 100 mcg of clonidine at the conclusion of the procedure. Narcotic consumption, duration of anesthesia recovery, and perioperative pain scores were compared between the two groups. We found that patients who received intra-articular morphine and clonidine used significantly less opioid analgesic in the PACU, with 23 mEq of morphine equivalents required in the intra-articular morphine and clonidine group compared to 40 mEq of opiod equivalents in the non-injection group (p=0.0259). There were no statistically significant differences in time spent in recovery prior to discharge or in VAS pain scores recorded immediately post-operatively and at one hour following surgery. In conclusion, we found that an intraoperative intra-articular injection of morphine and clonidine significantly reduced the amount of narcotic requirement following hip arthroscopy. We do believe that there may be significant benefits to this, including less systemic effects from overall narcotic usage in the perioperative period. Our study demonstrated a beneficial effect of intra-articular morphine that may help with overall pain improvement, less narcotic consumption, and improved patient satisfaction following outpatient hip arthroscopy. This study provides the foundation for future research currently being conducted in a randomised-control setting

Purpose: Postoperative pain is common following posterior spinal fusion (PSF) and segmental spinal instrumentation (SSI) for idiopathic scoliosis (IS). It is often treated with intravenous morphine patient controlled analgesia (PCA), but no studies have examined continuous morphine infusion. The purpose of this study was to identify the safety and efficacy of continuous morphine infusion without PCA for post-operative pain management in these patients. Method: We retrospectively reviewed 338 consecutive patients from 1992 to 2006 who received continuous morphine infusion. Following induction of general anesthesia and prior to surgical incision, patients received intrathecal morphine for preemptive analgesia. Anesthesia was maintained with 50% nitrous oxide and up to 0.6% isoflurane, with minimal or no intravenous opioids. Following surgery, pre-ordered morphine infusion (0.01 mg/kg/hr) began when patients first reported pain. The infusion rate was titrated using a strict protocol based on frequent assessment of vital signs, Wong-Baker visual analog pain scores (VAS), and clinical status. The infusion continued until patients were able to take oral analgesics at postoperative day 2–3. Factors analyzed included patient demographics, intrathecal morphine dosage, intraoperative intravenous opioid dosage, pain scores through the third postoperative day, interval to start of morphine infusion, total morphine requirement in the first 48 postoperative hours, and postoperative complications. Results: Mean intrathecal morphine dose was 15.45 mcg/kg and mean interval to start of morphine infusion was 15:45 hours. Mean VAS pain scores were 3.05, 4.48, 4.48, and 4.60 at 12 hours, 1, 2, and 3 days postoperatively. The total mean dosage of morphine in the first 48 hours postoperatively was 0.03 mg/kg/hr. Nausea/vomiting, pruritis, respiratory depression, and PICU admissions related to the morphine drip occurred in 13.3%, 4.1%, 0%, and 0% of the patients during the same time period. Conclusion: A low frequency of adverse events and a mean postoperative pain score of 5 or less demonstrates that continuous postoperative morphine infusion is a safe and effective method of pain management in children following PSF and SSI for IS. Continuous morphine infusion without PCA is a safe, alternative method of pain control for postoperative patients with IS

Background: Better postoperative pain, functional outcomes and patient satisfaction have been reported using spinal anaesthesia when compared with general anaesthesia. However, higher levels of urinary retention with spinal anaesthesia can lead to delayed discharge in microdiscectomy surgery. Anecdotally, we believe that further improvements to patient satisfaction and a reduction in the need for urinary catheterisation can be found in patients receiving fentanyl intrathecally as opposed to morphine. Methods: Seventy consecutive patients were recruited and prospectively randomised into two equal groups, with half the patients receiving intrathecal fentanyl with the spinal anaesthetic and the remainder receiving morphine. A comprehensive post operative evaluation was carried out documenting any anaesthetic complications, post operative analgesic requirement, physiological and functional recovery, need for urinary catheterisation and patient satisfaction. Results: Both groups were equally matched for age and gender. Mean age was 43 years in fentanyl group and 50 years in the morhhine group. All patients were discharged on day one post surgery. 3 patients in the fentanyl group and 11 patients in the morphine group required urinary catheterisation. No intra-operative anaesthetic or surgical complications were noted. Mean Visual Analogue score for pain was lower in the fentanyl group [2.46] compared to morphine group [2.70]. Conclusion: Lumbar spinal microdiscectomy can be safely performed as a short stay procedure under spinal anaesthesia using intrathecal fentanyl or morphine. Post-operative pain and functional out comes were comparable between the two groups but lower incidence of post-operative nausea, vomiting, itching and urinary catheterisation can be expected with use of fentanyl

Arthroscopic procedures may be associated with considerable pain in the first 24 hours. Intra-articular bupi-vacaine provides good analgesia but is short lasting. Intra-articular morphine has been shown to prolong postoperative analgesia in knee and ankle arthroscopy. The aim of this study is to assess the safety and analgesic effect of intra-articular morphine following day case wrist arthroscopy. Ethical approval was firstly obtained. 31 patients were randomly assigned to one of 2 groups in a double blind clinical study. Group 1 received 5ml of 0.5% bupi-vacaine intra-articularly with 5mg of morphine subcutaneously. Group 2 received 5ml of 0.5% bupivacaine and 5mg of morphine intra-articularly. There were 15 patients (mean age 41.2 years) in group 1, and 16 patients (mean age 38.9 years) in group 2. Postoperatively pain was assessed using a 100mm visual analogue pain scale (VAPS) at 1, 2, 6 and 24 hours. Analgesia requirements were recorded at these times post operatively. The presence of nausea, vomiting, other complications and patient satisfaction were recorded. Visual analogue pain scores did not show any significant difference between the groups at 1, 2, 6 and 24 hours. Supplementary analgesic consumption over the 24 hour period was slightly greater in group 1 than in group 2. None of the patients who had intra-articular Morphine had vomiting nor any other complications and did not require anti-emetics. Most patients in either group were satisfied with the level of postoperative analgesia. Intra-articular bupivacaine with or with out morphine provides adequate postoperative pain relief following wrist arthroscopy. There seems to be little difference between the two methods studied

Fascia iliaca compartment block (FIB), performed in the Emergency Department (A&E) in patients presenting with femoral neck fracture, has gained increasing recognition as an adjunctive analgesic. The purpose of this study was to investigate whether FIB significantly reduced the requirement for systemic opiates in the pre-operative setting. Analgesia requirements for all patients admitted with fractured neck of femur to one unit over a four month period were gathered prospectively. 33% patients had received FIB at diagnosis in ED, dependant on the expertise of the attending physician. Morphine requirements on arrival on the ward between groups were analysed. Over a four month period 144 patients were admitted with fractured neck of femur. Over this time period, introduction of an informal educational programme in A&E increased the incidence of FIB provision at diagnosis and reduced the average amount of morphine administered. Administration of FIB reduced the average morphine requirement in A&E by 56%, when compared with those who received systemic analgesia alone (CI 0.4–3.5, p=0.014). No adverse effects were reported with FIB. Fascia Iliaca Compartment Block is a safe and effective method of providing analgesia to patients with fractured neck of femur and reduces morphine requirement

Purpose: Do children from different gender or racial groups receive different analgesic doses for the same acute pain condition? We previously reported on intra-thecal morphine for preemptive analgesia in children undergoing posterior spinal fusion (PSF) and segmental spinal instrumentation (SSI) for idiopathic scoliosis (IS). We determined the optimal dose range to maximize analgesia while minimizing adverse effects. The purpose is to ensure this adopted protocol is equally effective across gender and racial groups. Method: We studied 407 intrathecal morphine patients. Those given a moderate dose of 9–19 mcg/kg (n=293) had the most effective and safe postoperative pain relief. This group consisted of 246 female and 47 male patients. There were 224 Caucasian (CA) and 63 African-American (AA) patients. Other ethnicities were excluded. Factors analyzed included postoperative Wong-Baker visual analog pain scores (VAS), time to first opioid rescue dose, total morphine dose over the first 48 hours, and postoperative complications. Results: For female and male gender, mean VAS pain scores in post-anesthesia care unit (PACU) were 0.48 and 0.56, mean times to first opioid rescue dose were 999.1 and 1003.3 minutes, and total morphine over the first 48 hours were 1.5mg/kg in both groups, respectively. Respiratory depression and PICU admission occurred in 2 (4.2.%) and 4 (1.6%) patients, respectively. For CA and AA patients, mean VAS pain scores in PACU were 0.48 and 0.46, mean times to first opioid rescue dose were 991.7 and 1031.9 minutes, and total morphine over the first 48 hours were 1.5mg/kg and 1.3mg/kg, respectively. Respiratory depression occurred in 5 (2.2.%) and 2 (3.2%) patients and PICU admission occurred in 4 (1.8.%) and 4 (6.3%) patients, respectively. StudentÂ’s t-test and Fisher exact test demonstrated no significant differences between genders for all variables, and no significant differences between races except less total morphine for AA patients over the first 48 hours (p=0.0024). Conclusion: An optimal intrathecal morphine dose range of 9–19 mcg/kg provides effective and safe postoperative pain relief in children undergoing PSF and SSI for IS, regardless of gender or race. Intrathecal morphine can be given with the assurance that it does not discriminate against gender or provide less optimal analgesia to AA patients

Intrathecal morphine (IM) is a common adjunct in paediatric spinal deformity surgery. We previously demonstrated with idiopathic scoliosis it provides safe and effective analgesia in the immediate postoperative period. This study represents our 25 year experience with IM in all diagnostic groups. Our prospective Pediatric Orthopaedic Spine Database (1993–2018) was reviewed to identify all patients undergoing spinal deformity surgery who received IM and who did not. Patients 21 years of age or less who had a posterior spinal fusion (PSF) with segmental spinal instrumentation (SSI), and received 9–19 mcg/kg (up to 1 mg) of IM were included. Early onset scoliosis surgical patients were excluded. We assessed demographics, pain scores, time to first dose of opioids, diagnoses, surgical time, paediatric intensive care unit (PICU) admission and IM complications (respiratory depression, pruritus, nausea/ vomiting). There were 986 patients who met inclusion criteria. This included 760 patients who received IM and 226 who did not. IM was not used for short procedures (< 3 hrs), respiratory concerns, unsuccessful access of intrathecal space, paraplegia, and anesthesiologist decision. Both groups followed the same strict perioperative care path. The patients were divided into 5 diagnostic groups (IM / non IM patients): idiopathic (578/28), neuromuscular (100/151), syndromic (36/17), and congenital scoliosis (32/21) and kyphosis (14/9). Females predominated over males (697/289). The first dose of opioids after surgery was delayed for a mean of 10.6 hrs in IM group compared to 2.3 hrs in the non-IM group (p=0.001). The postoperative pain scores were significantly lower in the IM groups in the Post Anesthesia Care Unite (p=0.001). Only 17 IM patients (2%) were admitted to the PICU for observation secondary to respiratory depression, none required re-intubation. None of the IM group were re-intubated. Forty-nine patients (6%) experienced pruritus in the IM group compared to 4 of 226 patients (2%) in the non IM group. There were 169 patients (22%) of the IM patients and 21 patients (9%) of the non IM had nausea and vomiting postoperatively. Three patients (0.39%) had a dural leak from the administration of IM but did not require surgical repair. There were no other perioperative complications related to the use of IM. There were no significant group differences. Pre-incision IM is a safe and effective adjunct for pain management in all diagnostic groups undergoing spinal surgery. The IM patients had lower pain scores and a longer time to first administration of post-operative opioids. Although there is an increased frequency of respiratory depression, pruritus, and nausea/vomiting in the IM group, there were no serious complications

Aim: The purpose of the study is to determine the opioid Ð sparing effect of Rofecoxibe and Lornoxicam in comparison to placebo in total knee arthoplasty. Method: This was a prospective, randomized, double-blind study. 82 patients with mean age of 70 years old (±3.5) and weight 82 (±4) were included. The operation was done under spinal anaesthesia. All patients after the operation were transferred to the Orthopaedic High Dependency unit where PCA morphine with a bolus of 1 mgr and lock-out interval of 8 min was started. There were randomized to receive 50 mgr of Rofecoxibe orally the morning of the operation or 8 mg of Lornoxicam I.V. twice a day. The third group did not receive any additional analgesic. After 24 hours the consumption of morphine and the evaluation of pain according to VAS scale were recorded. The evaluation of pain was done by the same doctor. Results: There was no statistically signiþcant differences between the three groups either in the consumption of morphine or the pain intensity (Wilcoxon test)Conclusions: Our study showed that the administration of Rofecoxibe 50 mg per os, Lornoxicam 8 mg I.V/b.d. or placebo makes no difference either in the consumption of morphine or the pain intensity during the þrst 24 hours

Introduction and Objectives: Orthopaedic surgery is associated with significant pain in the immediate postoperative period. Management of this pain often requires the administration of opiates. The goal of this study is to evaluate the efficacy of analgaesic treatment with intravenous morphine hydrochloride in a nurse-controlled analgaesia (NCA) system during the first day postoperative in children in general hospital wards. Materials and Methods: The study included 69 consecutive patients, all under 6 years of age, who underwent scheduled orthopedic surgery. All patients were treated postoperatively using intravenous morphine hydrochloride using the NCA system according to the following protocol: loading dose: 50–100 μg/kg; continuous infusion: 10–20 μg/kg/h; bolus dosage: 4- μg/kg: closure time: 20”; maximum dose: 400 μg/kg/4h. The following variables were evaluated: 1). Intensity of pain: none = 0 / mild = 1 / moderate = 2 / very intense = 3; 2). Side effects: a) nausea and vomiting: none =0 / 1 episode in 4 hours = 1 / more than 1 episode in 4 hours = 2. b) Urinary retention: none = 0 / spontaneous micturition after less than 8 h = 1/ draining catheter required = 2; 3). Average morphine chloride dose/kg of weight. Results: Average age was 24.3 months (range: 4 months – 6 years). Average weight: 12.7 kg. Results showed no case of excessive sedation or respiratory depression. Average morphine hydrochloride dosage per kg body weight was 365.5 μg (± 402.5 μg). Discussion and Conclusions: The guidelines of our I.V. morphine hydrochloride protocol for NCA yielded satisfactory control of post-operative pain after trauma surgery in children under 6 years old. No major side effects were noted in our patients, and the protocol may be safely used

Objective: To evaluate a new system of prescribing and administering IV morphine introduced by our Paediatric Pain Service for paediatric patients undergoing corrective spinal surgery. Design: An audit of post-operative pain management was conducted retrospectively on patients who had undergone scoliosis correction between November 1999 and September 2001. Subjects: Sixteen patients between the ages of nine and seventeen years who had undergone spinal scoliosis correction during the study period were evaluated. Outcome measures: The average post-operative IV morphine consumption, the pain and sedation scores, the incidence of side effects, and the use of adjuvant analgesics were analysed. Statistical evaluation was carried out using the Student’s T test and the Mann-Whitney U test. Results: Morphine consumption was significantly higher in the first post-operative twenty-four hour period, as well as in the over 13 year-old age group. There was no significant difference in morphine consumption between genders or ASA physical status. The pain scores were significantly higher in males compared to females on day one post-operatively. There was no statistical difference in sedation scores. Conclusions: An audit of the post-operative pain regimen for patients undergoing spinal scoliosis correction provided by the Paediatric Pain Management Service has shown that it is both efficient and safe. We recommend an anticipated pain management pathway of recovery following spinal fusion for idiopathic adolescent scoliosis

Aim: This prospective study set out to establish whether a 10 mg dose of intra-articular morphine in combination with 0.5% Bupivicaine was more efficacious than a 5mg dose following therapeutic knee arthroscopy. Methods: Sixty patients were randomised to receive either 5mg or 10mg intra-articular morphine in combination with Bupivicaine at the end of a therapeutic arthroscopy. Patients completed pain scores at regular intervals over 5 post operative days. Results: There was no significant difference in both analgesic effect and side effect profile between the two different doses of intra-articular morphine. Conclusion: 5mg intra-articular morphine in combination with 0.5% Bupivicaine provides effective post operative analgesia in patients having had a therapeutic knee arthroscopy. A 10 mg dose provides no added benefit

Purpose: Harvesting of iliac crest graft for spinal fusions is associated with a number of patients reporting residual pain at the harvest site. Various interventions have been proposed to minimize the pain associated with this. The purpose of this study was to evaluate the efficacy of intra-operative infiltration of morphine into the iliac crest harvest site for reduction of postoperative pain. Method: A double-blinded, placebo controlled study was performed comparing intraoperative infiltration of 5mg of morphine (treatment) vs. saline (placebo) into the iliac crest harvest site for patients undergoing elective spinal surgery. Patients with myelopathy, excessive preoperative opiod use (60mg equivalent morphine/day or more), or multilevel (greater than 3 levels) spinal surgery were excluded. Postoperative administration of morphine (recovery room and PCA) was standardized. Numerical pain scores specific for the iliac crest site were determined in the immediate postoperative period and at 3, 6 and 12 months. Ad hoc power analysis demonstrated that 36 patients would be able to detect a clinically significant difference of 2.4 points on a 10 point numerical pain scale (alpha = 0.05, power = 80%). Results: 37 patients were randomized and evaluated with a minimum of one year follow-up. The groups were similar in baseline age, gender and comorbidity. There was no significant difference between groups in total use of postoperative morphine during the first 24 hours (treatment: 320mg +/− 268mg, placebo: 293mg +/− 182mg, p = 0.73). There was no significant difference in iliac crest activity pain scores at 1 year (treatment: 1.7 +/− 3.0, placebo: 1.1 +/− 2.4, p = 0.48) or at any of the earlier time points. The proportion of patients with moderate to severe iliac crest pain at one year follow-up was the same between both groups. Conclusion: This study has demonstrated that there are no additional benefits for the use of intra-operative infiltration of morphine into the iliac crest harvest site during spinal fusions

Background. Total knee arthroplasty is associated with early postoperative pain. Appropriate pain management is important to facilitate postoperative rehabilitation and positive functional outcomes. This study compares outcomes in TKA with three techniques; local infiltration analgesia, single shot femoral nerve block and intrathecal morphine. Methods. Forty-five patients undergoing elective primary Total Knee Arthroplasty (TKA) with were randomized into one of three groups in a double blind proof of concept study. Study arm 1 received local infiltration analgesia ropivacaine intra-operatively, an elastomeric device of ropivacaine for 24 hours post-op. Study arm 2 received a femoral nerve block of ropivacaine with placebo local infiltration analgesia and placebo intrathecal morphine. Study arm 3 received intrathecal morphine, placebo femoral nerve block and placebo local infiltration analgesia. All patients received standardized pre-operative, intraoperative and Post-operative analgesic medication. Participants were mobilized at 4 hrs, 24hrs and 48 hrs post operation. Range of Motion, Visual Analogue Scale (VAS) pain intensity scores and two minute walk test and Timed Up and Go test were performed. Postoperative use of analgesic drugs was recorded. Knee Society Score (KSS), Oxford Knee Score and Knee Injury and Osteoarthritis Outcome Score (KOOS) were completed at preoperative and 6 weeks post op. Results. Assessment of the efficacy of analgesia will be conducted using VAS pain scores collected preoperatively, 0–24hrs and 24–48 hours postoperatively between the three randomized groups. Frequency of use of other analgesia and need for PCA will be compared between groups at 0–24hr and 24–48hrs post operatively. The assessment of functional outcomes will be measured between the three groups by comparing the ability to mobilize the first 4 hrs after surgery, maximal flexion and extension, two minute walk test and timed up-and-go preoperatively, on postoperative day 1 and 2 and 6 weeks. Patient reported outcome measures KSS, Oxford Knee score and KOOS will be compared for the three study arms. Conclusion. Results from the study will provide important information for the management of TKA in the hospital setting. The comparison of the three commonly used analgesic techniques and mobilization outcomes are pertinent for physiotherapy and rehabilitation management, anaesthetic specialists, nursing staff, orthopaedic surgeons and patients

Regional anaesthesia is integral to best practice analgesia for patients with neck of femur fractures (NOFFs). These patients are generally frail and are vulnerable to side effects of opioid analgesia. Femoral nerve block (FNB) or fascia-iliaca block (FIB) can reduce opioid requirement. Literature supports good efficacy for extra-capsular NOFFs however it is acknowledged to be suboptimal for intracapsular fractures. We present a novel technique, using point of care ultrasound guidance to perform hip ultrasound guided haematoma (HUSH) aspiration, and injection of local anaesthetic (block) for intracapsular NOFFs. This a case control series. A consecutive series of cognitively intact patients, with an isolated intra-capsular NOFF, received a HUSH block using 10mls of 0.75% Ropivicaine. Haematoma was aspirated and volume recorded. This was performed in addition to standard NOFF pathway analgesia that includes a FIB and multimodal analgesia including opioids. Visual Analogue Scale (VAS)pain scores at rest and on movement were recorded pre and post procedure as well as combined morphine equivalent units administered post HUSH block. The control arm was a retrospective group of similar patients who followed the routine care pathway including a FIB. VAS pain scores from observation charts and usage of morphine equivalent units were calculated. Ten patients consented to receive HUSH blocks and we included thirty-eight patients in our control series. The HUSH block group showed mean VAS pain score of 4.2/10 at rest and 8.6 on movement prior to block. In the time after the block, VAS pain scores reduced to 1.5 at rest (p=0.007) and 3.1 on movement (p=0.0001) with a mean total morphine equivalent use of 8.75mg. This is significantly different from the control group's mean VAS pain at rest score 6.9 (p=0.0001) and 24.1mg total morphine equivalent (p=0.07). HUSH Block in addition to fascia iliaca block appears to significantly better pain relief in intracapsular neck of femur fracture patients when compared to fascia iliaca block alone. We believe it is relatively easy to perform with readily available ultrasound scanners in emergency departments

Introduction and Objective. Postoperative pain control in shoulder surgery is challenging even in arthroscopic procedures. Acute postoperative pain can last up to 48hrs despite using multimodal analgesia. Different techniques have been used to control acute pain following shoulder surgery. The most common technique currently used in shoulder surgery at the elective orthopaedic centre in Leeds is a combination of general anaesthetic (GA) and interscalene block (ISB). ISB maybe very effective, however, carries many risks and potential side effects such as brachial plexus injury and paralysis of the vagus and laryngeal recurrent nerves as well as cervical sympathetic nerve and pneumothorax. ISB can also be associated with higher incidence of neurological deficit compared to other peripheral nerve blocks; up to 14% at 10 days in some cases. As such we decided to examine the use of ISB for achieving pain control in our elective unit. Materials and Methods. A prospective consecutive series of 217 patients undergoing shoulder surgery were studied. These were grouped into 10 groups. All procedures were arthroscopic apart from shoulder arthroplasty procedures such as hemiarthroplasty and total shoulder replacements (TSRs). The choice of regional anaesthesia was ISB with GA as standard practice. Visual analogue scores (VAS) at 0hrs, 1hr, 2hrs, 4hrs and 6hrs; and total opiates intake were recorded. A one-way single factor ANOVA was used as preferred statistical analytical method to determine whether there is a difference in VAS scores and total opiates intake amongst the groups. Postoperative analgesics were used for pain relief, although these were not standardised. Results. In total shoulder replacement group, although the RSR group used more morphine on average compared to the ASR group (Mean morphine intake 6.5mg vs 3mg), this was not statistically significant (F<Fcrit; p value= 0.19). When comparing all the arthroplasty groups, the difference in mean morphine intake was also statistically not significant (F<Fcrit; p value=0.24). However, when comparing all 10 groups’ morphine intake there was a statistically significant difference amongst these groups (F>F crit; p value=0.03). Interestingly, there was a statistically significant difference in VAS at 0hrs (F>Fcrit p value=0.01); 1hrs (F>Fcrit; p value=0.00), and at 6hrs (F>Fcrit; p value=0.02) when comparing all 10 groups. Conclusions. ISB is an effective technique in achieving pain control in shoulder surgery; however, there are still variations in analgesic needs amongst groups and the use of alternative techniques should be thus explored. A future prospective study looking at acute pain for a longer period of time after shoulder surgery would explore the effectiveness of ISB in achieving pain control consistent with rehabilitation requirements

Objectives. Effective analgesia after total knee arthroplasty (TKA) improves patient satisfaction, mobility and expedites discharge. This study assessed whether continuous femoral nerve infusion (CFNI) was superior to a single-shot femoral nerve block in primary TKA surgery completed under subarachnoid blockade including morphine. Methods. We performed an adequately powered, prospective, randomised, placebo-controlled trial comparing CFNI of 0.125% bupivacaine versus normal saline following a single-shot femoral nerve block and subarachnoid anaesthesia with intrathecal morphine for primary TKA. Patients were randomised to either treatment (CFNI 0 ml to 10 ml/h 0.125% bupivacaine) or placebo (CFNI 0 ml to 10 ml/h normal saline). Both groups received a single-shot femoral nerve block (0.25% 20 ml bupivacaine) prior to placement of femoral nerve catheter and subarachnoid anaesthesia with intrathecal morphine. All patients had a standardised analgesic protocol. The primary end point was post-operative visual analogue scale (VAS) pain score over 72 hours post-surgery. Secondary outcomes were morphine equivalent dose, range of movement, side effects, and length of stay. Results. A total of 86 patients were recruited. Treatment and placebo groups were comparable. No significant difference was found in VAS pain scores, total morphine equivalent requirements, side effects, range of movement, motor block, or length of hospital stay. Conclusion. No significant advantage was found for CFNI over a single-shot femoral block and subarachnoid anaesthesia after TKA. Cite this article: Bone Joint Res 2015;4:11–16

The current study aims to find the role of Enhance Recovery Pathway (ERP) as a multidisciplinary approach aimed to expedite rapid recovery, reduce LOS, and minimize morbidity associated with Non Fusion Anterior Scoliosis Correction (NFASC) surgery. A retrospective analysis of 35 AIS patients who underwent NFASC with Lenke 1 and Lenke 5 curves with a minimum of 1 year of follow-up was done. Patient demographics, surgical details, postoperative analgesia, mobilization, length of stay (LOS), patient satisfaction survey score with respect to information and care, and 90 days complications were collected. The cohort included 34 females and 1 male with a mean age of 15.2 years at the time of surgery. There were 16 Lenke 1 and 19 Lenke 5 in the study. Mean preoperative major thoracic and thoracolumbar/lumbar Cobb's angle were 52˚±7.6˚ and 51˚±4.5˚ respectively. Average blood loss and surgical time were 102 ±6.4 ml and 168 ± 10.2 mins respectively. Average time to commencing solid food was 6.5±1.5 hrs. Average time to mobilization following surgery was 15.5± 4.3 hrs. The average duration to the stopping of the epidural was 42.5±3.5 hrs. The average dose of opioid consumption intraoperatively was 600.5±100.5 mcg of fentanyl i.v. and 12.5±4.5 mg morphine i.v. Postoperatively opioids were administered via an epidural catheter at a dose of 2 mg of morphine every 24 hours up to 2 days and an infusion of 2mcg/hr of fentanyl along with 0.12-0.15% ropivacaine. The average duration to transition to oral analgesia was 55.5±8.5 hrs .20 patients had urinary catheter and the average time to removal of the catheter was 17.5±1.4 hrs. 25 patients had a chest tube and the average time to remove of chest tube was 25.5±3.2 hrs. The average length of hospital stay was 3.1±0.5 days. No patient had postoperative ileus or requirement of blood transfusion or any other complications. No correlation was found between LOS and initial cobb angle. The application of ERP in AIS patients undergoing NFASC results in reduced LOS and indirectly the cost, reduced post-operative opioid use, and overall improve patient satisfaction score

Introduction. Thoracic wall surgery can cause severe pain and inhibition of coughing with effects. (1) Various local anaesthetic (LA) techniques have been tried successfully to mitigate the use of opioids alone. We believe this is the first time that a serratus plane block using an epidural catheter (SABER)has been studied in anterior spinal fusion (ASF) procedures. Our aim was to ascertain how it would affect ASF compared to gold standard posterior spinal fusion (PSF) surgery. Materials and Methods. We identified 43 patients from the years 2017 to 2019. 24 had ASF and 19 had PSF. Detailed data were collected on local anaesthetic infusion (LAI) SaBER, mean pain scores(MPS), morphine, chirocaine usage and hospital length of stay (HLOS). We divided the patients into 4 groups: Short PSF (SPSF), Long PSF (LPSF), Thoracic anterior fusion (TA) and Thoracolumbar anterior fusion (TLA) surgery. 4 patients in the SPSF and 4 in the LPSF group had LAI because they had a costoplasty. All patients in the anterior group had SaBER. Results. Mean morphine usage was higher in the ASF group. Mean LA usage was lowest in the TLA and highest in the LPSF group (see table). 12 and 24 hour MPS were lower in both anterior groups compared to posterior. Mean HLOS was similar in all groups. Conclusion. Despite painful costoplasties in the anterior group, LAI enabled lower MPS overall and similar HLOS between PSF and ASF groups. Consequently, ASF (with fewer fusion levels) can replace equivalent PSF with resultant less stiffness and increased mobility. Reduction in MPS may be further improved by investigating detailed protocols whereby boluses of LA are given in addition to LAI. This may lead to morphine sparing in the anterior group as has been seen in other studies on thoracic wall procedures. (2). For any figures or tables, please contact the authors directly

Background. Orthopedic trauma patients can have significant pain management requirements. Patient satisfaction has been associated with pain control and narcotic use in previous studies. Due to the multifactorial nature of pain, various injury patterns, and differences in pain tolerances the relationship between patient factors and narcotic requirements are poorly understood. The purpose of this study is to compare patient demographics for trauma patients requiring high doses of narcotics for pain control versus those with more minimal requirements. Methods. Our study sample included 300 consecutive trauma activations who presented to our emergency department during the 2015 calendar year. Opioids given to the patients during their hospital stay were converted to oral morphine equivalents using ratios available from the current literature. Patients were placed into two groups including those who were in the top 10% for average daily inpatient oral morphine equivalents and the other group was composed of the remaining patients. In addition to morphine equivalents, patient age, gender, injury severity score, length of stay, number of readmissions and urine toxicology results were also recorded. Injury severity score (ISS), morphine equivalents, and patient age were evaluated with the Shapiro-Wilk test of normality. Comparisons were performed with the Mann-Whitney U test. Between group comparisons for positive urine toxicology screen and gender were performed with Chi square and Fisher exact test. Pearson correlations were calculated between injury severity score, average daily oral morphine equivalents, and length of stay. P-value of 0.05 was used to represent significance. Statistical comparisons were made using SPSS version 23 (IBM, Aramonk, NY). Results. Median average daily morphine equivalents in the 10% of patients receiving the highest doses was 86.30 and 12.95 for the bottom 90%. The difference was statistically significant (p<0.001). The median ISS between the 2 groups was significant (p=0.018). There was no significant difference in age, readmission rate, and urine toxicology results. Patients in the top 10% were more likely to be male (p=0.003). Median length of stay for the top 10% group and bottom 90% group was 4 days and 2 days, respectively (p=0.005). No correlation between injury severity score and length of stay was found (p=0.475). A weak correlation of 0.115 was found between morphine equivalents and length of stay (p=0.047). Discussion. Our study shows male gender and ISS were correlated with higher oral morphine equivalents for the 10% of patients receiving the highest daily amounts when compared to the reaminder of the cohort. There was a significantly increased length of stay in the patients receiving higher narcotic doses. Whether this is due to ISS or increase in narcotics is unclear. However, positive correlation was not found between ISS and length of stay