Adding a low-concentration sciatic nerve block to total knee arthroplasty in patients susceptible to the adverse effects of non-steroidal anti-inflammatory drugs (NSAIDs): a randomized controlled trial.

BACKGROUND: This study compared the effects of adductor canal blocks with those of a low concentration of popliteal-sciatic nerve block (SNB) and dexamethasone as an adjunctive technique for total knee arthroplasties (TKA) in patients susceptible to the adverse effects of NSAIDs. METHODS: A prospective, double-blinded, randomized controlled trial was performed in 50 patients susceptible to the adverse effects of NSAIDs undergoing unilateral TKAs. All patients received spinal anesthesia, adductor canal blocks, and periarticular infiltration. The 25 patients in the intervention group received SNB (0.125% bupivacaine [20 ml] and dexamethasone [5 mg]). RESULTS: The SNB group significantly had lower median resting pain scores at 6, 12, and 18 h: the control group, 1 (0-4.5), 3 (0-5), and 3 (2-5); the intervention group, 0 (0-0), 0 (0-3), and 1 (0-3); p-values, 0.012, 0.021, and 0.010, respectively. Movement-evoked pain scores at 6, 12, and 18 h were also lower: control group, 3 (0-5.5), 5 (2.5-6.5), and 7 (4-9); intervention group, 0 (0-1.5), 2 (0-4), and 3 (2-5); p-values, 0.019, 0.005, and 0.001, respectively. There were no differences in motor function. Moreover, the mean morphine consumption 24 h was also reduced in the SNB group: control group, 3.80 ± 2.48 mg; intervention group, 1.96 ± 2 mg; p-value, 0.005. CONCLUSION: For patients susceptible to the adverse effects of NSAIDs, a low concentration of SNB and dexamethasone is an effective adjunctive technique for early postoperative pain control (especially on movement) following TKAs, without an increase in motor weakness. TRIAL REGISTRATION: ClinicalTrials.gov , NCT03486548 , Registered 3 April 2018.

Low dose intraoperative ketamine infusion with multilevel paravertebral block for pain after video-assisted thoracic surgery: a randomized-controlled study.

BACKGROUND: Intraoperative low-dose ketamine infusion has been reported to be an effective adjuvant to opioids for postoperative pain control without major side effects, but it has not been tested in video-assisted thoracic surgery (VATS). The aim of this study was to examine the effect of low-dose intraoperative intravenous ketamine infusion on 24-hour morphine requirement and acute postoperative pain following VATS for lung resection. METHODS: This study was a single center, randomized, double-blind, placebo-controlled study. Thirty-two patients undergoing elective VATS for lung resection in a university hospital were included. Patients were randomly allocated (1:1 ratio) to receive either intraoperative low-dose ketamine (0.2 mg/kg/h) or normal saline infusion starting from intubation to the beginning of chest closure. All patients received multilevel thoracic paravertebral block (TPVB) and morphine was administered postoperatively via the patient-controlled analgesia pump using the same protocol. Time to first analgesia, postoperative cumulative morphine doses at 10, 30 minutes, and the consecutive 1, 2, 6, 12, 18, and 24 hours were recorded. Pain intensity during rest and deep breathing were also assessed by numeric rating scale (NRS) score at 1- and 24-hour postoperatively. RESULTS: There was no significant difference in median (P25, P75) cumulative 24-hour morphine requirement between the ketamine and the control groups [15 (5.5, 29.5) vs. 22.5 (15.3, 40.8) mg, P=0.090]. Patients in ketamine group had significantly longer median pain free time than the control group (27 vs. 2 minutes, P=0.006). No difference in overall NRS score at rest or during deep breathing at 1- and 24-hour postoperatively was demonstrated (P=0.861). CONCLUSIONS: Intraoperative low dose ketamine infusion in addition to TPVB does not reduce postoperative morphine consumption or pain intensity but may prolong pain free time in patients undergoing VATS for lung resection.

Bilateral posterior Quadratus Lumborum block for pain relief after cesarean delivery: a randomized controlled trial.

BACKGROUND: Achieving optimal analgesia with few side effects is the goal of pain management after cesarean delivery. Intrathecal (IT) morphine is the current standard but ultrasound-guided quadratus lumborum block (QLB) may offer superior pain control with fewer side effects. This study compared the pain-free period after cesarean delivery among parturients who received spinal block with IT morphine, with IT morphine and bilateral QLB, or only bilateral QLB. METHODS: Parturients having elective cesarean delivery under spinal block were randomized and allocated into IT morphine 0.2 mg with sham QLB (Group IT), IT morphine 0.2 mg and bilateral QLB with 0.25% bupivacaine 25 ml in each side (Group IT+QLB), or bilateral QLB with 0.25% bupivacaine 25 ml in each side (Group QLB). A PCA pump was connected after completion of the QLB or sham block. The first time to PCA morphine requirement was recorded and compared. RESULTS: Eighty parturients were included. Analysis of Group QLB was terminated early because at the second interim analysis, median pain-free period was significantly shorter in Group QLB [hours (95%CI): 2.50 (1.04-3.96) in Group IT vs. 7.75 (5.67-9.83) in IT+QLB vs. 1.75 (0.75-2.75) in QLB (p < 0.001)]. The median (min, max) amount of morphine required during 24 h was 5.5 (0-25) in Group IT vs. 5.0 (0-36) in IT+QLB vs. 17.5 (1-40) mg in Group QLB (p < 0.001). In the final analysis the median pain-free period was 2.50 (1.23-3.77) hours (95%CI) in Group IT (n = 27) vs. 8.02 (5.96-10.07) in IT+QLB (n = 28). (p = 0.027). CONCLUSION: US-QLB used in conjunction with IT morphine yielded a statistically significant longer median pain-free period compared with standard IT morphine alone. However, QLB alone provided inferior pain control compared with standard IT morphine. When combined with IT morphine, QLB could provide additional analgesic benefit as a part of multimodal analgesic regimen, especially during the early postoperative period. TRIAL REGISTRATION: ClinicalTrials.gov no. NCT03199170 Date registered on June 22, 2017. Prospectively registered.