Effectiveness of oral versus intravenous tranexamic acid in primary total hip and knee arthroplasty: a randomised, non-inferiority trial.

BACKGROUND: Tranexamic acid (TXA) reduces rates of blood transfusion for total hip arthroplasty (THA) and total knee arthroplasty (TKA). Although the use of oral TXA rather than intravenous (i.v.) TXA might improve safety and reduce cost, it is not clear whether oral administration is as effective. METHODS: This noninferiority trial randomly assigned consecutive patients undergoing primary THA or TKA under neuraxial anaesthesia to either one preoperative dose of oral TXA or one preoperative dose of i.v. TXA. The primary outcome was calculated blood loss on postoperative day 1. Secondary outcomes were transfusions and complications within 30 days of surgery. RESULTS: Four hundred participants were randomised (200 THA and 200 TKA). The final analysis included 196 THA patients (98 oral, 98 i.v.) and 191 TKA patients (93 oral, 98 i.v.). Oral TXA was non-inferior to i.v. TXA in terms of calculated blood loss for both THA (effect size=-18.2 ml; 95% confidence interval [CI], -113 to 76.3; P<0.001) and TKA (effect size=-79.7 ml; 95% CI, -178.9 to 19.6; P<0.001). One patient in the i.v. TXA group received a postoperative transfusion. Complication rates were similar between the two groups (5/191 [2.6%] oral vs 5/196 [2.6%] i.v.; P=1.00). CONCLUSIONS: Oral TXA can be administered in the preoperative setting before THA or TKA and performs similarly to i.v. TXA with respect to blood loss and transfusion rates. Switching from i.v. to oral TXA in this setting has the potential to improve patient safety and decrease costs.

Retrospective study of the effect of opioid prescribing guidelines on prescribing practices in pediatric orthopedic sports medicine patients having knee surgery: A single institution's experience.

OBJECTIVE: Guidelines for opioid prescription post-operatively exist; however, the majority of these are for adults. Nevertheless, opioid risks are present for pediatric patients also. This study investigates the effect of a single institution's guidelines on post-operative opioid prescribing for pediatric orthopedic patients undergoing knee surgery. We hypothesized that a standardized set of prescribing guidelines would result in a decrease in opioids prescribed at discharge home after these surgeries. DESIGN: Retrospective observational. SETTING: Urban, tertiary care, academic orthopedic hospital. PATIENTS: Pediatric, sports knee surgery, 23-month period. INTERVENTIONS: Guidelines were implemented institutionally for post-operative opioid prescribing practices. We reviewed all post-operative opioid prescriptions for pediatric patients undergoing sports knee surgery with two pediatric sports surgeons for the 11 months prior to the guidelines and 12 months afterwards, totaling 316 surgeries. MAIN OUTCOME MEASURE: Oral morphine equivalents (OMEs) prescribed on discharge from the hospital before and after implementation of guidelines. RESULTS: There was a significant reduction in OMEs from 229 OMEs to 175 OMEs before and after opioid prescribing guidelines (p < 0.001). This is a decrease in approximately seven 5 mg oxycodone tablets per patient. CONCLUSIONS: This study demonstrates that at our institution, with a pediatric patient population having sports knee surgery, prescribing guidelines reduced the number of opioids prescribed at discharge.

More than half of opioids prescribed to pediatric patients after ambulatory knee surgery are unused.

OBJECTIVE: To determine the number of opioid pills remaining after pediatric ambulatory knee surgery to provide insight into how many pills are actually used. DESIGN: Prospective observational cohort study. Participants who were expected to be prescribed 20 (Group 1) versus 40 (Group 2) opioid pills according to the institutional policy (based on the type of surgery) were studied. Patient's reported pain, medication use, and number of opioid pills remaining at post-operative days (PODs) 7 and 14. Participants were not randomly assigned to groups and no intervention was applied. SETTING: An urban tertiary care musculoskeletal institution. PARTICIPANTS: Sixty adolescents between the ages of 12 and 19 undergoing ambulatory knee surgery. INTERVENTIONS: Observational study, no experimental study intervention. MAIN OUTCOME MEASURE: The total number of opioid pills remaining. RESULTS: By POD7, more than 70 percent of patients had stopped taking their prescribed opioid medication mainly because their knee pain was tolerable either without the opioid or by using other medications. By POD14, the mean number of pills taken was 6.3 ± 5.3 for Group 1 and 18.4 ± 13.9 for Group 2. The mean number of unused opioids was 13.5 ± 7.2 for Group 1 and 17.9 ± 13.7 for Group 2. CONCLUSIONS: Even with prescribing practice guidelines in place, opioids may be overprescribed and could be given in a smaller quantity without affecting the quality of acute postoperative pain control in adolescents undergoing ambulatory knee surgery. However, one needs to consider that some patients may need a larger than average amount in order to be appropriately treated for their level of pain and thus prescription amounts-preferably after reevaluation-should be individualized.

A Comprehensive Enhanced Recovery Pathway for Rotator Cuff Surgery Reduces Pain, Opioid Use, and Side Effects.

BACKGROUND: Patients often have moderate to severe pain after rotator cuff surgery, despite receiving analgesics and nerve blocks. There are many suggested ways to improve pain after rotator cuff surgery, but the effects of adopting a pathway that includes formal patient education, a long-acting nerve block, and extensive multimodal analgesia are unclear. QUESTIONS/PURPOSES: (1) Does adoption of a clinical pathway incorporating patient education, a long-acting nerve block, and preemptive multimodal analgesia reduce the worst pain during the first 48 hours after surgery compared with current standard institutional practices? (2) Does adoption of the pathway reduce opioid use? (3) Does adoption of the pathway reduce side effects and improve patient-oriented outcomes? METHODS: From September 2018 to January 2020, 281 patients scheduled for arthroscopic ambulatory rotator cuff surgery were identified for this paired sequential prospective cohort study. Among patients in the control group, 177 were identified, 33% (58) were not eligible, for 11% (20) staff was not available, 56% (99) were approached, 16% (29) declined, 40% (70) enrolled, and 40% (70) were analyzed (2% [4] lost to follow-up for secondary outcomes after postoperative day 2). For patients in the pathway cohort, 104 were identified, 17% (18) were not eligible, for 11% (11) staff was not available, 72% (75) were approached, 5% (5) declined, 67% (70) enrolled, and 67% (70) were analyzed (3% [3] lost to follow-up for secondary outcomes after postoperative day 2). No patients were lost to follow-up for primary outcome; for secondary outcomes, four were lost in the control group and three in the pathway group after postoperative day 2 (p = 0.70). The initial 70 patients enrolled received routine care (control group), and in a subsequent cohort, 70 patients received care guided by a pathway (pathway group). Of the 205 eligible patients, 68% (140) were included in the analysis. This was not a study comparing two tightly defined protocols but rather a study to determine whether adoption of a pathway would alter patient outcomes. For this reason, we used a pragmatic (real-world) study design that did not specify how control patients would be treated, and it did not require that all pathway patients receive all components of the pathway. We developed the pathway in coordination with a group of surgeons and anesthesiologists who agreed to apply the pathway as much as was viewed practical for each individual patient. Patients in both groups received a brachial plexus nerve block with sedation. Major differences between the pathway and control groups were: detailed patient education regarding reasonable pain expectations with a goal of reducing opioid use (no formal educational presentation was given to the control), a long-acting nerve block using bupivacaine with dexamethasone (control patients often received shorter-acting local anesthetic without perineural dexamethasone), and preemptive multimodal analgesia including intraoperative ketamine, postoperative acetaminophen, NSAIDs, and gabapentin at bedtime, with opioids as needed (control patients received postoperative opioids but most did not get postoperative NSAIDS and no controls received gabapentin or separate prescriptions for acetaminophen). The primary outcome was the numerical rating scale (NRS) worst pain with movement 0 to 48 hours after block placement. The NRS pain score ranges from 0 (no pain) to 10 (worst pain possible). The minimum clinically important difference (MCID) [12] for NRS that was used for calculation of the study sample size was 1.3 [18], although some authors suggest 1 [13] or 2 [5] are appropriate; if we had used an MCID of 2, the sample size would have been smaller. Secondary outcomes included NRS pain scores at rest, daily opioid use (postoperative day 1, 2, 7, 14), block duration, patient-oriented pain questions (postoperative day 1, 2, 7, 14), and patient and physician adherence to pathway. RESULTS: On postoperative day 1, pathway patients had lower worst pain with movement (3.3 ± 3.1) compared with control patients (5.6 ± 3.0, mean difference -2.7 [95% CI -3.7 to -1.7]; p < 0.001); lower scores were also seen for pain at rest (1.9 ± 2.3 versus 4.0 ± 2.9, mean difference -2.0 [95% CI -2.8 to -1.3]; p < 0.001). Cumulative postoperative opioid use (0-48 hours) was reduced (pathway oral morphine equivalent use was 23 ± 28 mg versus 44 ± 35 mg, mean difference 21 [95% CI 10 to 32]; p < 0.01). The greatest difference in opioid use was in the first 24 hours after surgery (pathway 7 ± 12 mg versus control 21 ± 21 mg, mean difference -14 [95% CI -19 to -10]; p < 0.01). On postoperative day 1, pathway patients had less interference with staying asleep compared with control patients (0.5 ± 1.6 versus 2.6 ± 3.3, mean difference -2.2 [95% CI -3.3 to -1.1]; p < 0.001); lower scores were also seen for interference with activities (0.9 ± 2.3 versus 1.9 ± 2.9, mean difference -1.1 [95% CI -2 to -0.1]; p = 0.03). Satisfaction with pain treatment on postoperative day 1 was higher among pathway patients compared with control patients (9.2 ± 1.7 versus 8.2 ± 2.5, mean difference 1.0 [95% CI 0.3 to 1.8]; p < 0.001). On postoperative day 2, pathway patients had lower nausea scores compared with control patients (0.3 ± 1.1 versus 1 ± 2.1, mean difference -0.7 [95% CI -1.2 to -0.1]; p = 0.02); lower scores were also seen for drowsiness on postoperative day 1 (1.7 ± 2.7 versus 2.6 ± 2.6, mean difference -0.9 [95% CI - 1.7 to -0.1]; p = 0.03). CONCLUSION: Adoption of the pathway was associated with improvement in the primary outcome (pain with movement) that exceeded the MCID. Patients in the pathway group had improved patient-oriented outcomes and fewer side effects. This pathway uses multiple analgesic drugs, which may pose risks to elderly patients, in particular. Therefore, in evaluating whether to use this pathway, clinicians should weigh the effect sizes against the potential risks that may emerge with large scale use, consider the difficulties involved in adapting a pathway to local practice so that pathway will persist, and recognize that this study only enrolled patients among surgeons and the anesthesiologists that advocated for the pathway; results may have been different with less enthusiastic clinicians. This pathway, based on a long-lasting nerve block, multimodal analgesia, and patient education can be considered for adoption. LEVEL OF EVIDENCE: Level II, therapeutic study.

Standardized Perioperative Patient Education Decreases Opioid Use after Hand Surgery: A Randomized Controlled Trial.

BACKGROUND: Despite the growing hand surgery literature on postoperative opioid use, there is little research focused on patient-centered interventions. The purpose of this randomized controlled trial was to create a standardized patient education program regarding postoperative pain management after hand surgery and to determine whether that education program would decrease postoperative opioid use. METHODS: Patients scheduled to undergo ambulatory hand surgery were recruited and randomized to standardized pain management education or standard of care. All patients received a webinar with instructions for study participation, whereas the education group received an additional 10 minutes of education on postoperative pain management. All patients completed a postoperative daily log documenting opioid consumption. The total number of opioid pills consumed was compared between groups. The authors constructed a linear regression model to determine risk factors for postoperative opioid use after surgery. RESULTS: A total of 267 patients were enrolled in the study. One hundred ninety-one patients completed the study (standardized education, n = 93; control group, n = 97). Patients in the standardized education group were more likely to take no opioid medication (42 percent versus 25 percent; p = 0.01) and took significantly fewer opioid pills (median, two) than those in the control group (median, five) (p < 0.001). Standardized education predicted decreased postoperative opioid pill consumption, whereas higher number of pills prescribed and a history of psychiatric illness were risk factors for increasing opioid use. CONCLUSION: Perioperative patient education and limitation of postoperative opioid prescription sizes reduced postoperative opioid use following ambulatory hand surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

The prescription opioid crisis: role of the anaesthesiologist in reducing opioid use and misuse.

Reports of strategies to prevent and treat the opioid epidemic are growing. Significant attention has been paid to the benefits of opioid addiction research, clinical prescribing, and public policy initiatives in curbing the epidemic. However, the role of the anaesthesiologist in minimising opioid use and misuse remains underexplored. For many patients with an opioid use disorder, the perioperative period represents the source of initial exposure. As perioperative physicians, anaesthesiologists are in the unique position to manage pain effectively while simultaneously decreasing opioid consumption. Multiple opportunities exist for anaesthesiologists to minimise opioid exposure and prevent subsequent persistent opioid use. We present a global strategy for decreasing perioperative opioid use and misuse among surgical patients. A historical perspective of the opioid epidemic is presented, together with an analysis of opioid supply and demand forces. We then present specific temporal strategies for opioid use reduction in the perioperative period. We emphasise the importance of preoperative identification of patients at risk for long-term opioid use and misuse, review the evidence supporting the opioid sparing capacity of individual multimodal analgesic agents, and discuss the benefits of regional anaesthesia for minimising opioid consumption. We describe postoperative and post-discharge tools, including effective multimodal analgesia and the role of a transitional pain service. Finally, we offer general institutional strategies that can be led by anaesthesiologists, identify gaps in knowledge, and offer directions for future research.

Pain Management After Outpatient Foot and Ankle Surgery.

BACKGROUND: The number of opioids prescribed and used has increased precipitously over the past 2 decades for a number of reasons and has led to increases in long-term dependency, opioid-related deaths, and diversion. Most studies examining the role of prescribing habits have investigated nonoperative providers, although there is some literature describing perioperative opioid prescription and use. There are no studies looking at the number of pills consumed after outpatient foot and ankle surgeries, nor are there guidelines for how many pills providers should prescribe. The purpose of this study was to quantify the number of narcotic pills taken by opioid-naïve patients undergoing outpatient foot and ankle surgeries with regional anesthesia. METHODS: Eighty-four patients underwent outpatient foot and ankle surgeries under spinal blockade and long-acting popliteal blocks. Patients were given 40 or 60 narcotic pills, a 3-day supply of ibuprofen, deep vein thrombosis prophylaxis, and antiemetics. Patients received surveys at postoperative day (POD) 3, 7, 14, and 56 documenting if they were still taking narcotics, the quantity of pills consumed, whether refills were obtained, their pain level, and their reason for stopping opioids. RESULTS: Patients consumed a mean of 22.5 pills, with a 95% confidence interval from 18 to 27 pills. Numerical Rating Scale pain scores started at 4 on POD 3 and decreased to 1.8 by POD 56. The percentage of patients still taking narcotics decreased from 55% on POD 3 to 2.8% by POD 56. Five new prescriptions were given during the study, with 3 being due to side effects from the original medication. CONCLUSIONS: Patients receiving regional anesthesia for outpatient foot and ankle surgeries reported progressively lower pain scores with low narcotic use up to 56 days postoperatively. We suggest that providers consider prescribing 30 pills as the benchmark for this patient population. LEVEL OF EVIDENCE: Level II, prospective comparative study.

A Review of Opioid-Sparing Modalities in Perioperative Pain Management: Methods to Decrease Opioid Use Postoperatively.

There is an epidemic of opioid use, abuse, and misuse in the United States, which results in significant morbidity and mortality. It may be difficult to reduce perioperative opioid use given known acute surgical trauma and resultant pain; however, the discrete and often limited nature of postoperative pain also may make management easier in part by utilizing nonopioid modalities, such as regional anesthesia/analgesia, and multimodal analgesia, which may decrease the need for powerful opioids. This article reviews the relevant literature describing the use of adjunct medications, regional anesthesia and analgesic techniques, and regional block additives in the context of providing adequate pain control while lessening opioid use.

Unused Opioid Pills After Outpatient Shoulder Surgeries Given Current Perioperative Prescribing Habits.

BACKGROUND: In the past 16 years, the number of prescription opioids sold in the United States, as well as deaths from prescription opioids, has nearly quadrupled. However, the overall amount of pain reported by patients has not changed significantly. Specific information about opioid prescriptions in the perioperative period is lacking. Of the studies that have been published, investigators have shown that the majority of patients have unused postoperative opioid pills. Moreover, patients appear to lack information about disposal of unused opioid pills. PURPOSE: To compare the number of pills prescribed versus the numbers left unused after outpatient shoulder surgeries at an orthopaedic surgery institution. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: In this prospective, observational study, 100 patients (age >18 years) undergoing outpatient shoulder surgery (rotator cuff repair, labral repair, stabilization/Bankart repair, debridement) were enrolled. Follow-ups were conducted via surveys on postoperative days (PODs) 7, 14, 28, and 90. The primary outcome was the number of unused pills from the originally prescribed medication. RESULTS: For all procedure types, the median (Q1, Q3) number of prescribed pills was 60 (40, 80). On POD 90, patients reported a median (Q1, Q3) of 13 (0, 32) unused pills; patients who underwent rotator cuff repairs had the lowest number of pills remaining (median [Q1, Q3], 0 [0, 16]), whereas patients who had stabilization/Bankart repairs had the highest number of unused pills (median [Q1, Q3], 37 [29, 50]). Patient satisfaction with pain management ranged from an average of 70% to 90%. Only 25 patients received instructions or education about opioid disposal. CONCLUSION: Most outpatient shoulder surgery patients who underwent certain operations were prescribed more opioid analgesics than they consumed. Patient education regarding the disposal of opioids was lacking.

Analgesic efficacy of intravenous naloxone for the treatment of postoperative pruritus: a meta-analysis.

OBJECTIVES: Pruritus may be a significant problem for patients in the postoperative period. There are many options for the treatment of pruritus including intravenous (IV) naloxone. However, it is not clear whether the use of IV naloxone may also affect analgesia or other opioid-related side effects. The authors have performed a systematic review to further examine this issue. METHODS: Systematic literature searches of the National Library of Medicine's PubMed and EMBASE databases were conducted using terms related to postoperative use of IV naloxone. Only randomized controlled trials comparing IV naloxone used either as a continuous infusion or part of an IV patient-controlled analgesia (PCA) regimen after surgical procedures were considered. The data on pertinent study characteristics and relevant outcomes were extracted from accepted articles. There was no restriction on language for inclusion. Meta-analysis was performed using the Review Manager 4.2.10 (The Cochrane Collaboration, 2004). A random effects model was used. RESULTS: The literature searches yielded eight articles that met all inclusion criteria. There were a total of 424 subjects in the naloxone group and 376 in the saline group. The authors found that the use of naloxone was associated with a decreased risk for pruritus (odds ratio [OR] = 0.40, 95% confidence interval [CI] = 0.21-0.79, p = 0.006] and nausea [OR = 0.62, 95% CI = 0.43-0.89, p = 0.009]. However, the use of IV naloxone (vs no naloxone) did not significantly influence the risk of postoperative emesis [OR = 0.97, 95% CI = 0.70-1.33, p = 0.83], opioid consumption [OR = 0.29, 95% CI = -3.54-4.13, p = 0.88], or sedation [OR = 0.82, 95% CI = 0.38-1.74, p = 0.60]. Finally, the use of IV naloxone did not appear to be associated with any significant change in visual analog score pain scores at 24 hours postoperatively (weighted mean difference = -0.14, 95% CI = -0.50-0.23, p = 0.46). CONCLUSIONS: Our pooled analysis examining the analgesic efficacy of IV naloxone (either as a continuous infusion or IV PCA) revealed that naloxone was associated with a decrease in pruritus and nausea without any increase in pain scores. When compared with controls, the use of IV naloxone was not associated with any significant changes in opioid consumption or with the risk of sedation or emesis.

Analgesic efficacy of ultrasound-guided regional anesthesia: a meta-analysis.

STUDY OBJECTIVE: To determine if the use of ultrasound guidance (vs non-ultrasound techniques) improves the success rate of nerve blocks. DESIGN: Meta-analysis of randomized controlled trials (RCTs) in the published literature. SETTING: University medical center. MEASUREMENTS: 16 RCTs of patients undergoing elective surgical procedures were studied. Patients underwent ultrasound-guided or non-ultrasound techniques (nerve stimulation, surface landmark) for peripheral nerve blocks. Success rates were measured. MAIN RESULTS: Ultrasound guidance (vs all non-ultrasound techniques) was associated with a significant increase in the success rate of nerve blocks [relative risk (RR) = 1.11 (95% confidence interval [CI]: 1.06 to 1.17, P < 0.0001]). When compared with nerve stimulator techniques only, ultrasound guidance was still associated with an increase in the success rate (RR = 1.11 [95% CI: 1.05 to 1.17, P = 0.0001]). For specific blocks, ultrasound guidance (vs all non-ultrasound) was associated with a significant increase in successful brachial plexus (all) nerve blocks (RR = 1.11 [95% CI: 1.05 to 1.20, P = 0.0001]), sciatic popliteal nerve block (RR = 1.22 [95% CI: 1.08 to 1.39, P = 0.002]) and brachial plexus axillary nerve block (RR = 1.13 [95% CI: 1.00 to 1.26, P = 0.05]) but not brachial plexus infraclavicular nerve block (RR = 1.25 [95% CI: 0.88 to 1.76, P = 0.22]). CONCLUSIONS: Ultrasound-guided peripheral nerve block is associated with an increased overall success rate when compared with nerve stimulation or other methods. Ultrasound-guided techniques also increase the success rate of some specific blocks.

The effect of intravenous opioid patient-controlled analgesia with and without background infusion on respiratory depression: a meta-analysis.

BACKGROUND: Although the addition of a background infusion for intravenous patient-controlled analgesia (IV-PCA) has been identified as a risk factor for the development of respiratory depression, this has not clearly been examined in a systematic fashion. The authors undertook a systematic review and meta-analysis of available randomized controlled trials (RCTs) to examine whether the addition of a background or continuous infusion to an IV-PCA regimen would be associated with an increased risk of respiratory depression. METHODS: Studies were identified by searching the National Library of Medicine's PubMed database (1966 to November 30, 2008). Inclusion criteria were a clearly defined analgesic technique of demand-only IV-PCA versus IV-PCA utilizing both a demand dose and background infusion, opioid medication used, and randomized trials. Data were abstracted and analyzed with the RevMan 4.2.7 (The Cochrane Collaboration, 2004). RESULTS: The search yielded 687 abstracts from which the original articles were obtained and data abstracted with a total of 14 articles analyzed. There were 402 subjects in the continuous IV-PCA with demand group versus the 394 subjects in the demand-only IV-PCA group. Addition of a background infusion to the demand dose for IV-PCA with opioids was associated with a significant increased risk for respiratory depression (odds ratio [OR] = 4.68, 95% confidence interval [CI]: 1.20-18.21). Subgroup analysis revealed that this increased risk was seen in adult but not in pediatric patients. CONCLUSIONS: Our meta-analysis indicates that the addition of a continuous or background infusion to the demand dose for IV-PCA is associated with a higher incidence of respiratory events than demand IV-PCA alone in adult but not in pediatric patients; however, our overall results should be interpreted with caution due to the relatively small sample size and the wide range of definitions for respiratory depression in studies examined.

Meta-analysis of the effect of extended-release epidural morphine versus intravenous patient-controlled analgesia on respiratory depression.

OBJECTIVE: Extended-release epidural morphine (EREM) is a single-dose, extended-release epidural morphine formulation intended to provide postoperative pain relief over a 48-hour period. There have been a few randomized controlled trials investigating the use and safety of EREM versus intravenous patient-controlled analgesia with opioids (IV-PCA); however, the adverse event of respiratory depression of this treatment is unclear. The authors have undertaken a meta-analysis to examine this issue. METHODS: A systematic literature search of the National Library of Medicine's PubMed database was conducted for terms related to EREM. Only randomized controlled trials, in the English language, assessing the rates of respiratory depression of EREM to IV-PCA were included for analysis. Data on pertinent study characteristics and relevant outcomes were extracted from accepted articles. Meta-analysis was performed using the Review Manager 4.2.7 (The Cochrane Collaboration, 2004). A random effects model was used. RESULTS: The authors' literature search yielded three articles which met all inclusion criteria. All studied doses of EREM were evaluated. Pooled estimates (odds ratio) were made for rates of adverse events of respiratory depression. Use of EREM was associated with significantly higher odds of respiratory depression compared to IV-PCA (odds ratio = 5.74; 95% confidence interval: 1.08, 30.54, p = 0.04). Even when examining only Food and Drug Administration approved dosages for EREM, the use of EREM was associated with significantly higher odds of respiratory depression when compared with IV-PCA (odds ratio = 5.80; 95% confidence interval: 1.05, 31.93, p = 0.04). CONCLUSIONS: Although perioperative single-dose epidural EREM (versus IV-PCA) was effective for postoperative pain relief for up to 48 hours, it is associated with significantly higher odds of respiratory depression. Further examination of the issue of respiratory depression of epidural EREM may be warranted.

Regional techniques and outcome: what is the evidence?

PURPOSE OF REVIEW: Despite some controversy regarding the strength of the available data, the use of regional anesthesia and analgesia does provide improvement in patient outcomes. Although the majority of available data have examined the effect of epidural anesthesia and analgesia on patient outcomes, an increasing number of studies recently have investigated the effect of peripheral regional techniques on patient outcomes. RECENT FINDINGS: Data generally indicate that the perioperative use of regional anesthesia and analgesia may be associated with improvement in both major (e.g. mortality, major morbidity) outcomes and rehabilitation. The majority of evidence favors an ability of epidural analgesia to reduce postoperative cardiovascular and pulmonary complications and there is also consistent evidence that epidural analgesia with local anesthetics is associated with faster resolution of postoperative ileus after major abdominal surgery. Overall, regional analgesic techniques provide statistically superior analgesia compared with systemic opioids. SUMMARY: Perioperative use of regional analgesic techniques may provide improvement in conventional outcomes, although the benefit appears to be limited to high-risk patients and those undergoing high-risk procedures. The benefits conferred by perioperative regional anesthetic techniques need to be weighed against any potential risks and this should be assessed on an individual basis.

Postoperative pain management in the elderly undergoing thoracic surgery.

The management of postoperative pain in the elderly represents a considerable challenge because these patients are generally at higher risk for postoperative complications. There are several analgesic options, some of which may influence perioperative morbidity in this high-risk group of patients. Although use of regional analgesia, particularly epidural analgesia is associated with some benefits, including a decrease in perioperative morbidity, there are side effects and complications (eg, medication-related side effects, epidural hematoma, infection) from these and other techniques, and the clinician should evaluate the benefits and risks of each technique on an individual basis. Nevertheless, the available data suggest that use of regional analgesic techniques (ie, epidural and paravertebral catheters) is associated with a decrease in perioperative pulmonary complications.