Perineural and Systemic Dexamethasone and Ulnar Nerve Block Duration: A Randomized, Blinded, Placebo-controlled Trial in Healthy Volunteers.

BACKGROUND: The authors hypothesized that both perineural and systemic dexamethasone as adjuncts to bupivacaine increase the duration of an ulnar nerve block compared with bupivacaine alone, and that systemic dexamethasone is noninferior to perineural dexamethasone. METHODS: The authors performed bilateral ulnar nerve blocks with 3 ml bupivacaine 5 mg/ml in 16 healthy volunteers on two trial days. According to randomization, subjects received adjunct treatment with 1 ml dexamethasone 4 mg/ml + 1 ml of saline (perineural condition) in one arm and 2 ml saline in the other arm (systemic condition, through absorption and redistribution of the contralaterally administered perineural dexamethasone) on one trial day; and 2 ml saline in one arm (placebo condition) and 2 ml of lidocaine in the other arm (lidocaine condition) on the other trial day. The primary outcome was the duration of the sensory nerve block assessed by temperature discrimination. RESULTS: Mean sensory block duration was 706 ± 94 min for the perineural condition, 677 ± 112 min for the systemic condition, and 640 ± 121 min for the placebo condition. The duration of the sensory nerve block was greater with perineural dexamethasone versus placebo (mean difference 66 min (95% CI, 23 to 108). Block duration was similar between systemic dexamethasone and placebo (mean difference 36 min; 95% CI, -30 to 103). CONCLUSIONS: Perineural dexamethasone as an adjunct to bupivacaine in healthy volunteers resulted in a greater duration of an ulnar nerve block when compared with placebo. Systemic dexamethasone resulted in a similar duration as placebo.

Postoperative Pain Management and Patient Evaluations After Five Different Surgical Procedures. A Prospective Cohort Study.

BACKGROUND: Sufficient pain management is a necessity and can play an important role in patients' contentment. AIMS: To investigate the instituted postoperative pain treatment, patients' levels of pain, opioid consumption, and patient contentment, supplemented with a questionnaire based on the International Pain Outcome (IPO). METHODS: This prospective observational cohort study was conducted at Zealand University Hospital Køge, Denmark (ZUHK) from March 8, 2017, to January 7, 2019, aiming for a consecutive inclusion of 200 patients, 40 from five major surgical procedures. The study was approved by the Danish Data Protection Agency (REG-121-2016) and registered at ClinicalTrials.gov (NCT03080272). The Research Ethics Committee of the Zealand Region was consulted, but approval was not needed according to Danish law (J.nr. 16-000014). RESULTS: We included 189 patients in total. We found a significant number of patients that did not achieve "no worse than mild pain" (Numeric Rating Scale ≤3) across surgical procedures. The provided pain treatment was heterogenic and inconsistent even among individuals who underwent similar surgical procedures. Although patients did not achieve "no worse than mild pain" (Numeric Rating Scale ≤3), the majority stated that they were content with their pain treatment. CONCLUSIONS: The analgesic treatment varied between procedures and patients and a significant number of patients did not achieve "no worse than mild pain" (Numeric Rating Scale ≤3). A significant association between patient contentment and experience of severe pain, pain relief, and involvement in own pain treatment, was found.

Postoperative pain treatment after spinal fusion surgery: a systematic review with meta-analyses and trial sequential analyses.

Patients undergoing spinal surgery are at high risk of acute and persistent postoperative pain. Therefore, adequate pain relief is crucial. This systematic review aimed to provide answers about best-proven postoperative analgesic treatment for patients undergoing lumbar 1- or 2-level fusions for degenerative spine diseases. We performed a search in PubMed, Embase, and The Cochrane Library for randomized controlled trials. The primary outcome was opioid consumption after 24 hours postoperatively. We performed meta-analyses, trial sequential analyses, and Grading of Recommendations assessment to accommodate systematic errors. Forty-four randomized controlled trials were included with 2983 participants. Five subgroups emerged: nonsteroidal anti-inflammatory drugs (NSAIDs), epidural, ketamine, local infiltration analgesia, and intrathecal morphine. The results showed a significant reduction in opioid consumption for treatment with NSAID (P < 0.0008) and epidural (P < 0.0006) (predefined minimal clinical relevance of 10 mg). Concerning secondary outcomes, significant reductions in pain scores were detected after 6 hours at rest (NSAID [P < 0.0001] and intrathecal morphine [P < 0.0001]), 6 hours during mobilization (intrathecal morphine [P = 0.003]), 24 hours at rest (epidural [P < 0.00001] and ketamine [P < 0.00001]), and 24 hours during mobilization (intrathecal morphine [P = 0.03]). The effect of wound infiltration was nonsignificant. The quality of evidence was low to very low for most trials. The results from this systematic review showed that some analgesic interventions have the capability to reduce opioid consumption compared with control groups. However, because of the high risk of bias and low evidence, it was impossible to recommend a "gold standard" for the analgesic treatment after 1- or 2-level spinal fusion surgery.

Short-Term and Long-Term Pain After Total Hip Arthroplasty: A Prospective Cohort Study.

BACKGROUND: Postoperative pain has a major influence on older adults' rehabilitation. There is a lack of knowledge regarding how older adults return to daily living after discharge. AIMS: The primary aim of this study was to examine the association between moderate to severe pain during the first 5 postoperative days and pain 1 year after discharge in older adults after total hip arthroplasty (THA). DESIGN: This was a prospective cohort study. METHODS: The study was conducted from August 2019 to February 2020, in a University Hospital in Denmark and included a 5-day diary and a telephone interview postoperatively. The following main areas were investigated: pain levels, pain management, side effects from opioids, mood, fatigue, quality of sleep, and functional level. Associations between moderate to severe pain levels at 5 days after surgery and persistent pain at 1 year were evaluated through correlation analyses. RESULTS: A total of 70 THA older adults returned the diary postoperatively. Thereafter, 62 participated in a 1-year follow-up interview. No associations were found between pain levels 5 days postoperatively and after 1 year. Fifteen older adults reported hip pain was present still 1 year after surgery, and 14 patients still used analgesics on daily basis. No correlation was found between levels of pain and quality of sleep 1 year after surgery. CONCLUSIONS: No association was found between older adults with moderate to severe levels of pain during the first 5 days postoperatively and 1 year after surgery. Proactive follow-up strategies for older adults after discharge following THA may be indicated to promote optimal rehabilitation.

Healthcare professionals' experiences during the initial stage of the COVID-19 pandemic in the intensive care unit: A qualitative study.

BACKGROUND: The COVID-19 pandemic called for rapidly considerable changes in the healthcare system. Healthcare professionals from different departments within the hospital settings were enrolled in the emergency preparedness. This study, therefore, aimed to explore the healthcare professionals' experiences attending the ICU-preparedness and caring for patients with COVID-19 during the initial stage of the pandemic. METHODS: A descriptive explorative qualitative study was conducted by interviewing healthcare professionals during spring 2020, exploring their experiences as part of the ICU-preparedness team and caring for patients with COVID-19 in the ICU. Healthcare professionals from different departments were recruited by purposive sampling. The interviews were transcribed verbatim and analysed using content analysis. FINDINGS: Sixteen nurses and four physicians from a university hospital in Denmark participated. The analysis revealed three main themes and eight sub-themes. The main themes were (1) Professionalism in work-life (adaption, the patient's welfare, insecurity, and security), (2) Community Spirit (responsibility and contribution), and (3) Institutional organisation (the role of management, loss of freedom, and information). INTERPRETATION: Despite work specialities and professions, the participants reported a uniformity of similar experiences of uncertainties, but also a sense of community arose during the first phase of COVID-19. RECOMMENDATIONS: To ensure resilience and mental health, and well-being for the healthcare professionals, comprehensive support should be provided. Guidelines for interventions and training are necessary to promote preparedness and reduce psychological stress.

Postoperative pain treatment after lumbar discectomy. A protocol for a systematic review with meta-analysis and trial sequential analysis.

BACKGROUND: Patients undergoing lumbar discectomy usually suffer from moderate to severe pain during the postoperative period. Multimodal, or balanced analgesia, is the leading treatment principle for managing postoperative pain. The rationale is to achieve optimal pain treatment through additive or synergistic effects of several non-opioid analgesics, and thereby, reducing the need for postoperative opioids, facilitating early mobilization and functional rehabilitation. For discectomy surgery, evidence of both the benefit and harm of different analgesic interventions is unclear. OBJECTIVES: This systematic review aims to investigate the benefits and harms of analgesic interventions in adult patients after lumbar discectomy. METHODS: This protocol for a systematic review is written according to The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. We will search The Cochrane Library's CENTRAL, PubMed, EMBASE, and ClinicalTrails.gov for published and ongoing trials. All randomized clinical trials assessing the postoperative analgesics effect of an intervention with a control or no-intervention group undergoing lumbar discectomy will be included. Two authors will independently screen trials for inclusion using Covidence, extract data and assess the risk of bias using Cochrane's risk-of-bias 2 tool. We will analyse the data using Review Manager and Trial Sequential Analysis. Meta-analysis will be performed according to the Cochrane guidelines. We will present our primary findings in a 'summary of findings' table and evaluate the overall certainty of evidence using the GRADE approach. DISCUSSION: This systematic review will assess the benefits and harms of analgesic interventions after lumbar discectomy and have the potential to improve best practices and advance research.

Using four different clinical tools as predictors for pain after total hip arthroplasty: a prospective cohort study.

BACKGROUND: Treatment of postoperative pain remains a significant clinical problem, and prediction of patients with a risk of higher postoperative pain levels is an important focus. We aimed to identify patients undergoing total hip arthroplasty (THA) with risk of higher pain levels at 24 h postoperatively by using four simple and easily available clinical tools. METHODS: This prospective observational cohort study included 102 patients having THA at Zealand University Hospital in Denmark. The following predictive tools were investigated for identifying patients with higher postoperative pain levels at 24 h postoperatively, both at rest and during mobilization: preoperative pain by peripheral venous cannulation (PVC) (dichotomized according to numerical rating scale pain ≤ 2/> 2 (PVC-Low/PVC-High) (primary outcome); the post anesthesia care unit (PACU) nurses' expectations of patients pain levels; patients early pain levels at the PACU; and patients own forecast of postoperative pain levels. The Mann-Whitney U test was used to analyze comparisons between prediction groups. For the primary outcome we considered a p-value < 0.01 as statistically significant and for other outcomes a p-value of 0.05. RESULTS: We found no significant differences between the PVC groups for pain during mobilization at 24-h postoperatively: PVC-Low: 6 (4-8) (median, (IQR)) versus PVC-High: 7 (5-8) (median, (IQR)), p = 0.10; and for pain at rest: PVC-Low 2 (0-3) (median, (IQR)) versus PVC-High 3 (2-5) (median, (IQR)), p = 0.12. Other comparisons performed between predictive groups did not differ significantly. CONCLUSIONS: In this prospective cohort study of 102 THA patients, we did not find that preoperative pain by PVC, when using a cut-off point of NRS ≤ 2, were able to predict postoperative pain at 24 h postoperatively. Neither did PACU nurses' prediction of pain, patients forecast of pain, nor did maximum pain levels at the PACU. TRIAL REGISTRATION: Retrospectively registered 20th February 2018 at ClinicalTrials.gov (NCT03439566).

Barriers in pain treatment in the emergency and surgical department.

INTRODUCTION: Post-operative pain is associated with poor patient satisfaction and severe complications. It is often underreported and poorly managed. The aim of this study was to investigate which factors influence and prevent optimal pain treatment according to healthcare providers. METHODS: We conducted an electronic questionnaire survey, which was distributed by e-mail to 364 doctors, nurses, dentists and social and healthcare assistants employed at the emergency and surgical departments of Zealand University Hospital, Koege, Denmark. The 15-item-questionnaire investigated which factors influenced pain treatment. RESULTS: A total of 124 of 364 (34%) healthcare providers completed the questionnaire. The four primary factors influencing pain treatment were sufficient time, inter-dis-ciplinary cooperation, patient involvement and staff edu-cation. The two primary barriers preventing optimal pain treatment were a high level of activity at the ward (40%) and a lack of knowledge (33%). CONCLUSIONS: Time, staff education, interdisciplinary cooperation and patient involvement were the primary factors influencing pain treatment. Insufficient time and limited knowledge on the part of the healthcare providers were the greatest barriers preventing good pain treatment in everyday practice. FUNDING: none. TRIAL REGISTRATION: not relevant.