Liposomal Bupivacaine Versus Bupivacaine and Dexamethasone Intercostal Nerve Blocks for Robotic Thoracic Surgery: A Randomized Clinical Trial.

Introduction For peripheral nerve blocks, using either the liposomal formulation of bupivacaine or plain bupivacaine with epinephrine and dexamethasone as an adjuvant has been shown to improve postoperative pain scores. In a single-blinded, randomized controlled study of patients undergoing robotic-assisted thoracoscopic surgery, we determined if bupivacaine with epinephrine and dexamethasone was noninferior to liposomal bupivacaine mixed with plain bupivacaine when administered intraoperatively as an intercostal nerve block (INB). Methods A total of 34 patients undergoing robotic-assisted thoracoscopic surgery were randomized to receive one of two injectate mixtures during their intraoperative INB. Group LB was administered 266 mg of 13.3 mg/mL liposomal bupivacaine with 24 mL of 0.5% plain bupivacaine, while Group BD was given 42 mL of 0.5% bupivacaine with epinephrine and 8 mg of dexamethasone. The primary outcomes were mean postoperative numerical pain ratings and mean postoperative opioid analgesic requirements. Secondary outcomes included adjuvant pain medication consumption, hospital length of stay, and total opioid use in oral morphine equivalents. Results Group LB exhibited no significant difference in pain scores (p = 0.437) and opioid analgesic requirement (p = 0.095) within the 72-hour postoperative period when compared to Group BD. The median total postoperative opioid requirement was 90 mg in Group LB, compared to 45 mg in Group BD. There were no significant differences in the use of postoperative adjuvant pain medications (gabapentin, p = 0.833; acetaminophen, p = 0.190; ketorolac, p = 0.699). Hospital length of stay did not differ between the groups. Conclusions INBs with the addition of dexamethasone as an adjuvant to 0.5% bupivacaine with epinephrine provided noninferior postoperative analgesia compared to liposomal bupivacaine mixed with plain 0.5% bupivacaine.

Effect of individualized anesthesia and analgesia on postoperative pain in patients stratified for pain sensitivity: A study protocol for the PeriOPerative individualization trial randomized controlled trial.

BACKGROUND: Despite advancements in surgical and anesthesia techniques, acute and persistent postoperative pain are still a common challenge. Postoperative pain has direct effects on individual patient care and outcome, as well as putting strain on limited health care resources. Several prediction methods for postoperative pain have been described. One such method is the assessment of pain during peripheral venous cannulation (VCP). It is not known if different approaches to anesthesia and analgesia, depending on the evaluation of risk for postoperative pain, can improve outcome. The aim of this study is to evaluate if individualized anesthesia and analgesia can affect postoperative pain and recovery after surgery, in patients stratified by VCP. METHODS: Adult patients scheduled for laparoscopic surgery undergo pain-sensitivity stratification using VCP on the day of surgery. Patients scoring VCP ≥2.0 on the visual analogue scale (pain-sensitive) are randomized to multimodal anaesthesia and analgesia with opioids or standard of care. Patients scoring VCP ≤1.9 (pain-tolerant) are randomized to opioid-free anaesthesia or standard of care. The primary outcome is acute postoperative pain measured with numeric rating scale in the postoperative care unit. Secondary outcomes include analysis of pain after 24 h, persistent postoperative pain and quality of recovery. DISCUSSION: Individualized perioperative pain management has the potential to improve patient care. This study will examine the impact of different anesthesia and analgesia regimes, in patients with differing pain sensitivity, on postoperative pain. TRIAL REGISTRATION: Prospectively posted at ClinicalTrials.gov, identifier NCT04751812.

Virtual reality exposure reduce acute postoperative pain in female patients undergoing laparoscopic gynecology surgery: A Randomized Control Trial (RCT) study.

STUDY OBJECTIVE: Few studies have focused on the effect of virtual reality (VR) exposure on postoperative acute pain in adult female patients undergoing gynecology surgery. DESIGN: A randomized control trial (RCT) study. SETTING: At Beijing Fuxing Hospital. PATIENTS: 115 patients aged between 20 and 60 years, American Society of Anesthesiologists (ASA) physical status I - II were consecutively enrolled and randomly divided into VR group (n = 58) or control group (n = 57). INTERVENTIONS: Patients in the VR group received 15 min of VR video viewing before surgery. MEASUREMENTS: The primary outcome was acute postoperative pain at 8 h which was measured by the Visual Analogue Scale (VAS) scores. The secondary outcomes including the use of analgesic drugs, the incidence of moderate pain and postoperative recovery which were recorded 24 h after surgery. The Hospital Anxiety and Depression Scale (HADS) was also used to evaluate patients' emotional status before surgery. MAIN RESULTS: The VAS scores at 30 min [2 (1,2) vs. 3 (2,3)], 2 h [2 (2,3) vs. 4 (3,4)], 4 h [3 (2,4) vs. 4 (4,5)], 8 h [3 (2,4) vs. 4 (4,5)], 12 h [2 (2,3) vs. 4 (3,4)], 24 h [1 (1,2) vs. 3 (2,3)] after surgery. Generalized estimation equation (GEE) indicated that VR intervention was negatively correlated with postoperative VAS values (ß = -0.830, S.E = 0.199, 95%CI (-1.220,-0.439), Wald χ2 = 17.359, p<0.05), in the meanwhile, VR also lower the incidence of moderate pain (VAS > 4) at 8 h postoperatively (12.1% vs 31.0%, p = 0.013). However, the 24 h tramadol usage remained unchanged. Patients in the VR group had better sleep quality (6.33 ± 2.3 vs. 4.12 ± 2.5, p < 0.001) and lower incidence of nausea (43.1% vs. 63.2%, p < 0.05), dizziness (0% vs. 14.0%, p < 0.05), and headache (12.1% vs. 29.8%, p < 0.05). VR could reduce the median HADS scores (9.81 ± 6.1 vs 3.14 ± 3.9, p < 0.001) and blood pressure preoperatively. CONCLUSIONS: VR intervention can reduce acute postoperative pain with better postoperative recovery and lower preoperative anxiety level in adult female patients undergoing laparoscopic gynecology surgery.

Risk Factors for Acute Postsurgical Pain: A Narrative Review.

Acute postsurgical pain (APSP) has received growing attention as a surgical outcome. When poorly controlled, APSP can affect short- and long-term outcomes in patients. Despite the steady increase in awareness about postoperative pain and standardization of pain prevention and treatment strategies, moderate-to-severe APSP is frequently reported in clinical practice. This is possibly because pain varies widely among individuals and is influenced by distinct factors, such as demographic, perioperative, psychological, and genetic factors. This review investigates the risk factors for APSP, including gender, age, obesity, smoking history, preoperative pain history, pain sensitivity, preoperative anxiety, depression, pain catastrophizing, expected postoperative pain, surgical fear, and genetic polymorphisms. By identifying patients having an increased risk of moderate-to-severe APSP at an early stage, clinicians can more effectively manage individualized analgesic treatment protocols with a combination of pharmacological and non-pharmacological interventions. This would alleviate the transition from APSP to chronic pain and reduce the severity of APSP-induced chronic physical disability and social psychological distress.

Analgesic Potential Comparison Between Piperine-Combined Curcumin Patch and Non-Piperine Curcumin Patch: A Pragmatic Trial on Post-Cleft Lip/Palate Surgery Pediatric Patients.

Purpose: Despite its well-acknowledged analgesic potential, curcumin's low bioavailability has been recognized. Piperine, a substance naturally contained in pepper, has been known for its effect on increasing curcumin bioavailability. To investigate the analgesic potential of curcumin and piperine addition to curcumin patch used as adjuvant therapy in the management of acute postoperative orofacial pain. Patients and Methods: This pragmatic trial recruited 75 patients that underwent oromaxillofacial surgery at Unpad Dental Hospital, Bandung, Indonesia. Research participants were randomly assigned to three different groups: the first group that did not receive any intervention other than the post-operative standard treatment (POST), the second group that received POST and non-piperine curcumin patch, and the third group that received POST and piperine-combined curcumin patch. Participants' pain intensity was evaluated by using the face, leg, activity, cry, and consolability (FLACC) pain scale and salivary prostaglandin-E2 (PGE2) level for two-time points, which were eight hours apart. All data were gathered and analyzed to compare the within and between-group differences. Results: Within groups comparison of the FLACC scores for two evaluation points showed significant differences for all groups (p < 0.01). For salivary PGE2 analysis, a comparison of the non-piperine group to the piperine group also showed significant results. Yet, when all three groups were compared, regardless of the differences, the results were not statistically significant. Conclusion: Despite of the proven efficacy of curcumin patch, the addition of piperine to the curcumin patch in the current study did not provide any significant effects. Further investigation is of importance.

Efficacy of ultrasound-guided stellate ganglion block in relieving acute postoperative pain: a systematic review and meta-analysis.

OBJECTIVE: The efficacy of ultrasound-guided stellate ganglion block (SGB) in alleviating postoperative pain remains unclear. This meta-analysis was performed to determine the efficacy of ultrasound-guided SGB in relieving acute postoperative pain in patients undergoing surgery with general anesthesia. METHODS: This systematic review and meta-analysis focused on randomized controlled trials comparing SGB with control or placebo. The primary outcome was the pain score at 24 hours after surgery. A random-effects model was used to calculate the mean difference (MD) or risk ratio with a confidence interval (CI) of 95%. RESULTS: Eight studies involving 470 patients were included in the meta-analysis. The results revealed that ultrasound-guided SGB was significantly associated with a lower pain score at 24 hours after surgery (MD = -0.74; 95% CI = -1.39, -0.08; I2 = 86%; low evidence) and at 8 hours after surgery (MD = -0.65; 95% CI = -1.03, -0.28; I2 = 29%; moderate evidence). CONCLUSION: Ultrasound-guided SGB is effective in alleviating acute postoperative pain. However, considering the limited number of trials performed to date, more large-scale and high-quality randomized controlled trials are required to confirm these findings.

Gestión del dolor agudo postoperatorio: condiciones para garantizar la seguridad y la efectividad de los tratamientos analgésicos / Management of acute postoperative pain: Conditions to guarantee the safety and effectiveness of analgesic treatments

La evidencia sobre la gestión del dolor postoperatorio presenta un grado de calidad bajo o insuficiente. El Grupo de Trabajo del Dolor Agudo SEDAR ha elaborado este documento-guía para aplicar la mejor evidencia científica disponible a la práctica clínica habitual, individualizándolo en función de factores propios del paciente y del procedimiento, y englobando las distintas opciones organizativas del control de dolor.El documento profundiza y actualiza conceptos y requisitos mínimos necesarios para una analgesia óptima postoperatoria, el abordaje multidisciplinar y la gestión del dolor agudo postoperatorio. Se definen y se describen líneas estratégicas y los distintos modelos de gestión. Se establece un plan de actuación general perioperatoria basado en la colaboración con los servicios quirúrgicos implicados, en la revisión conjunta de la evidencia y en la elaboración de protocolos por procedimiento. Finalmente, se presenta un plan de seguimiento y los indicadores mínimos necesarios para un control de calidad del dolor postoperatorio. (AU)

The evidence on postoperative pain management is of low or insufficient quality. The SEDAR Acute Pain Working Group has prepared this guideline-document to apply the best available scientific evidence to clinical practice, individualizing it based on factors specific to the patient and the procedure, and encompassing different organizational options, attempting to individualize it based on specific factors of the patient and the procedure, and encompassing the different organizational options for pain control.The document updates concepts and minimum requirements necessary for optimal postoperative analgesia, a multidisciplinary approach and the management of acute postoperative pain. Strategic lines and different management models are defined. A general perioperative action plan is established based on collaboration with the surgical departments involved, on the joint review of the evidence and on preparation of protocols by the procedure. Finally, a follow-up plan and a series of minimum indicators necessary for quality control of postoperative pain are presented. (AU)

The Effect of Depth of Anesthesia on Postoperative Pain in Laparoscopic Sleeve Gastrectomy: A Randomized Controlled Trial.

BACKGROUND: Patients with obesity are more sensitive to pain and more likely to have acute postoperative pain (APP). Studies have shown that the depth of anesthesia may affect the incidence of APP. The purpose of the study was to look into the connection between APP and depth of anesthesia in patients with obesity undergoing laparoscopic sleeve gastrectomy. METHODS: This is a prospective, double-blinded randomized clinical trial, 90 patients undergoing laparoscopic sleeve gastrectomy were randomly divided into two groups: the light anesthesia group (Bispectral Index of 50, BIS 50) and the deep anesthesia group (BIS 35). The degree of pain was evaluated by the visual analogue scale (VAS) at 0, 12, 24, 48, and 72 h after surgery. The use of analgesics, grade of postoperative nausea and vomiting (PONV), and the Quality of Recovery-15 (QoR-15) score were recorded. RESULTS: The VAS scores at rest or coughing at 0, 12, and 24 h after surgery in the BIS 35 group were lower than those in the BIS 50 group (P < 0.05). Fewer patients in the deep anesthesia group needed analgesia during the recovery period, and patient satisfaction was higher on the 3rd day after surgery (P < 0.015, P < 0.032, respectively). CONCLUSIONS: For patients with obesity, maintaining a deeper depth of anesthesia during surgery is beneficial to reduce APP causes less need for additional analgesic drugs, and improves patient satisfaction.

Usefulness of ultrasound-guided serratus-anterior block in prevention of postoperative pain after breast surgery. A cohort study.

OBJECTIVE: To evaluate superficial serratus anterior plane block's efficacy and side effects in preventing postoperative pain after breast cancer surgery. METHODOLOGY: A prospective cohort study was conducted on 195 adult patients undergoing breast oncological surgery under general anesthesia (Group G, n = 96) or combined general anesthesia with superficial serratus anterior plane block (Group L, n = 99). Validated preoperative data, which are predictors of chronic postoperative pain of patients, were recorded (type of surgery, age, pain in the area of the intervention and the other regions; anesthetic-surgical data, analgesic doses used, duration of surgery; pain intensity (EVN scale) at immediate postoperative period, 24 h, seven days and one month after the surgery, and complications. RESULTS: Pain intensity, measured by the EVN scale, had a mean of 1.02 +/- 1.656 in the Postoperative Unit; 1.20 +/- 1.448 at 24 h; 0.76 +/- 1208 seven days; and 0.34 +/- 0.757 one month after surgery. Patients were operated under general anesthesia (n = 96) or general anesthesia combined with the interfascial block (n = 99). Significant differences (p < 0.05) were found in age, height, and VAS scale in PACU. Ten complications were recorded, six in Group L and four in Group G. There were no differences between groups in complications. CONCLUSIONS: Superficial serratus anterior plane blocks are effective and safe in pain control in the immediate postoperative period for breast cancer surgery as a part of the multimodal approach. No significant differences were found one week and one month after surgery.

Postoperative pain-related outcomes and perioperative pain management in China: a population-based study.

Background: Postoperative pain poses a significant challenge to the healthcare system and patient satisfaction and is associated with chronic pain and long-term narcotic use. However, systemic assessment of the quality of postoperative pain management in China remains unavailable. Methods: In this cross-sectional study, we analyzed data collected from a nationwide registry, China Acute Postoperative Pain Study (CAPOPS), between September 2019 and August 2021. Patients aged 18 years or above were required to complete a self-reported pain outcome questionnaire on the first postoperative day (POD1). Perioperative pain management and pain-related outcomes, including the severity of pain, adverse events caused by pain or pain management, and perception of care and satisfaction with pain management were analyzed. Findings: A total of 26,193 adult patients were enrolled. There were 48.7% of patients who had moderate-to-severe pain on the first day after surgery, and pain severity was associated with poor recovery and patient satisfaction. The systemic opioid use was 68% on the first day after surgery, and 89% of them were used with intravenous patient-controlled analgesia, while the rate of postoperative nerve blocks was low. Interpretation: Currently, almost half of patients still suffer from moderate-to-severe pain after surgery in China. The relatively high rate of systemic opioid use and low rate of nerve blocks used after surgery suggests that more effort is needed to improve the management of acute postoperative pain in China. Funding: National Key Research and Development Program of China (No. 2018YFC2001905).

Opioid-free anesthesia reduces the severity of acute postoperative motion-induced pain and patient-controlled epidural analgesia-related adverse events in lung surgery: randomized clinical trial.

Background: Opioids have been used as pain relievers for thousands of years. However, they may also cause undesirable side effects. We therefore performed this study to compare the effect of opioid-free anesthesia (OFA) versus opioid-sparing anesthesia (OSA) on postoperative pain and patient-controlled epidural analgesia (PCEA)-related events. Methods: This is a single center randomized clinical trial that was recruited patients aged from 18 to 70 years who received video-assisted lung surgery between October 2021 and February 2022. Participants were 1:1 randomly assigned to OFA or OSA. Patients in the OFA group received propofol, rocuronium, esmolol, lidocaine, and magnesium sulfate intravenously with epidural ropivacaine. Patients in the OSA group received propofol, rocuronium, remifentanil, and sufentanil intravenously with epidural hydromorphone and ropivacaine. Results: A total number of 124 patients were randomly allocated to the OFA or OSA group. In the OFA group, the severity of pain during coughs on the first postoperative days (PODs; VAS score 1.88 ± 0.88 vs. 2.16 ± 1.1, p = 0.044) was significantly lower than that in the OSA group. The total ratio of PCEA-related adverse events in the OFA group [11 (19.6%) vs. 26 (47.3%), p = 0.003] was significantly lower than in the OSA group. Conclusion: OFA in patients who received video-assisted lung surgery led to lower severity of acute postoperative motion-induced pain and fewer PCEA-related adverse events on the first POD than in the patients in the OSA group. Clinical trial registration: clinicaltrials.gov, identifier (NCT05063396).

Risk factors predicting acute postoperative pain immediately after minimally invasive inguinal hernia repair.

Introduction: Acute postoperative pain remains one of the most common problems, even after laparoscopic or endoscopic hernia repair. Avoiding predictive factors for acute pain after surgery or prescribing additional analgesia for a patient who has risk factors that cannot be removed can be one of the options to reduce acute postoperative pain. However, there is a lack of clinical studies that evaluate the predictive factors of postoperative pain after transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) surgeries. Aim: To identify independent risk factors predicting pain after laparoscopic and endoscopic inguinal hernia repair. Material and methods: A prospective, randomized clinical trial was carried out by randomising patients into 2 groups (TAPP and TEP). Pre-operative and peri-operative findings were recorded. Postoperative pain was evaluated 3 h after the surgery using a visual analogue scale (VAS). Groups of patients who felt mild pain (VAS 0-2) and patients who felt average or severe pain (VAS 3-10) were compared. Results: A total of 132 male patients were included in the study. Disease duration of more than 1 year, smoking, and TAPP surgery significantly increase the risk of moderate and strong pain 3 h after surgery. Conversely, shorter duration of symptoms and physical occupation decrease the risk of acute pain score greater than 3 according to the VAS. Conclusions: The study shows that the duration since groin hernia appearance, smoking, physical occupation, and TAPP technique are possible predictive factors for acute postoperative pain after minimally invasive inguinal hernia repair. We suggest that for patients who have those predictors, some factors can be avoided or additional analgesia can be used.

Gender differences on preoperative psychologic factors affecting acute postoperative pain in patients with lumbar spinal disorders.

BACKGROUND: Psychosexual factors are one of the preoperative factors influencing acute postoperative pain. Because of gender differences in pain, the preoperative factors that influence acute postoperative pain may also differ between males and females. However, there have been no reports on such factors in patients with spinal disorders that focused on gender differences. Therefore, the purpose of this study was to examine the preoperative factors that influence acute postoperative pain, focusing on gender differences. METHODS: The subjects were 75 males and 60 females admitted for surgery for lumbar spinal disorders. Preoperatively, the following were assessed: low back pain using the Numeric Rating Scale (NRS); anxiety and depression using the Japanese version of the Hospital Anxiety and Depression Scale (HADS); catastrophic thinking using the Pain Catastrophizing Scale (PCS); psychiatric problems using the Brief Scale for Psychiatric Problems in Orthopaedic Patients (BS-POP); and neurological assessments. Acute postoperative pain was also assessed using the NRS within 48 h, postoperatively. Based on these data, we analyzed gender differences in preoperative factors affecting acute postoperative pain in patients with lumbar spinal disorders. RESULTS: Postoperative NRS and preoperative PCS scores were higher in females compared to males. In the males, the coefficient of determination of the multiple regression equation was 0.088, and PCS (ß = 0.323, p = 0.015) was extracted as a significant factor. In the females, the coefficient of determination of the multiple regression equation was 0.075, and BS-POP (ß = 0.300, p = 0.019) was extracted as a significant factor. CONCLUSION: Preoperative factors influencing acute postoperative pain for patients with lumbar spinal disorders vary by gender. It was suggested that males should be screened using PCS. In females, on the other hand, PCS alone is not sufficient for evaluation. It was suggested that evaluation using BS-POP should be considered in addition to PCS.

Tapentadol Immediate Release (IR) versus Morphine Hydrochloride for Postoperative Analgesia of Patients Undergoing Total Abdominal Hysterectomy-A Prospective Cohort Study.

Background and Objectives: This study aimed to examine the efficacy of tapentadol immediate release (IR) and morphine hydrochloride in the treatment of acute postoperative pain after total abdominal hysterectomy, as well as to examine the frequency of opioid-related side effects in observed patients. Materials and Methods: The prospective observational study was conducted over five months, and it included a total number of 100 patients. The two cohorts had different types of postoperative analgesia, and the effects were observed for 24 h postoperatively, by following the pain scores on NRS (Numerical Pain Scale), contentment with analgesia, and opioid-related side effects. Results: Statistical significance was found when assessing pain 24 h after surgery while coughing, where patients in the tapentadol IR group had significantly higher mean pain scores (p < 0.01). The subjective feeling of satisfaction with postoperative analgesia was statistically significant in the tapentadol IR group (p = 0.005). Vertigo appeared significantly more in patients from the morphine group (p = 0.03). Conclusions: Tapentadol IR (immediate release) and morphine hydrochloride are both effective analgesics used in the first 24 h after total transabdominal hysterectomy. Overall satisfaction of patients with analgesia was good. The frequency of side effects was higher in the morphine group, with statistical significance regarding the vertigo.

Advances in the Management of Acute Postsurgical Pain: A Review.

Despite the millions of surgeries performed every year around the world, postoperative pain remains prevalent and is often addressed with inadequate or suboptimal treatments. Chronic postsurgical pain is surprisingly prevalent, and its rate varies with the type of surgery, as well as with certain patient characteristics. Thus, better clinical training is needed as well as patient education. As pain can be caused by more than one mechanism, multimodal or balanced postsurgical analgesia is appropriate. Pharmacological agents such as opioid and nonopioid pain relievers, as well as adjuvants and nonpharmacologic approaches, can be combined to provide better and opioid-sparing pain relief. Many specialty societies have guidelines for postoperative pain management that emphasize multimodal postoperative analgesia. These guidelines are particularly helpful when dealing with special populations such as pregnant patients or infants and children. Pediatric pain control, in particular, can be challenging as patients may be unable to communicate their pain levels. A variety of validated assessment tools are available for diagnosis. Related to therapy, most guidelines agree on the fact that codeine should be used with extreme caution in pediatric patients as some may be "rapid metabolizers" and its use may be life-threatening. Prehabilitation is a preoperative approach that prepares patients in advance of elective surgery with conditioning exercises and other interventions to optimize their health. Prehabilitation may have aerobic, strength-training, nutritional, and counseling components. Logistical considerations and degree of patient adherence represent barriers to effective prehabilitation programs. Notwithstanding all this, acute postoperative pain represents a clinical challenge that has not yet been well addressed.

Management of acute postoperative pain: Conditions to guarantee the safety and effectiveness of analgesic treatments.

The evidence on postoperative pain management is of low or insufficient quality. The SEDAR Acute Pain Working Group has prepared this guideline-document to apply the best available scientific evidence to clinical practice, individualizing it based on factors specific to the patient and the procedure, and encompassing different organizational options, attempting to individualize it based on specific factors of the patient and the procedure, and encompassing the different organizational options for pain control. The document updates concepts and minimum requirements necessary for optimal postoperative analgesia, a multidisciplinary approach and the management of Acute Postoperative Pain. Strategic lines and different management models are defined. A general perioperative action plan is established based on collaboration with the surgical departments involved, on the joint review of the evidence and on preparation of protocols by the procedure. Finally, a follow-up plan and a series of minimum indicators necessary for quality control of postoperative pain are presented.

Cost-effectiveness of the Perioperative Pain Management Bundle a registry-based study.

Introduction: The Perioperative Pain Management Bundle was introduced in 10 Serbian PAIN OUT network hospitals to improve the quality of postoperative pain management. The Bundle consists of 4 elements: informing patients about postoperative pain treatment options; administering a full daily dose of 1-2 non-opioid analgesics; administering regional blocks and/or surgical wound infiltration; and assessing pain after surgery. In this study, we aimed to assess the cost-effectiveness of the Bundle during the initial 24 h after surgery. Materials and methods: The assessment of cost-effectiveness was carried out by comparing patients before and after Bundle implementation and by comparing patients who received all Bundle elements to those with no Bundle element. Costs of postoperative pain management included costs of the analgesic medications, costs of labor for administering these medications, and related disposable materials. A multidimensional Pain Composite Score (PCS), the effectiveness measurement, was obtained by averaging variables from the International Pain Outcomes questionnaire evaluating pain intensity, interference of pain with activities and emotions, and side effects of analgesic medications. The incremental cost-effectiveness ratio (ICER) was calculated as the incremental change in costs divided by the incremental change in PCS and plotted on the cost-effectiveness plane along with the economic preference analysis. Results: The ICER value calculated when comparing patients before and after Bundle implementation was 181.89 RSD (1.55 EUR) with plotted ICERs located in the northeast and southeast quadrants of the cost-effectiveness plane. However, when comparing patients with no Bundle elements and those with all four Bundle elements, the calculated ICER was -800.63 RSD (-6.82 EUR) with plotted ICERs located in the southeast quadrant of the cost-effectiveness plane. ICER values differ across surgical disciplines. Conclusion: The proposed perioperative pain management Bundle is cost-effective. The cost-effectiveness varies depending on the number of implemented Bundle elements and fluctuates across surgical disciplines.

Long-Term Outcomes of Breast Cancer Patients Receiving Levobupivacaine Wound Infiltration or Diclofenac for Postoperative Pain Relief.

Breast cancer is the most common malignant disease in women. Preclinical studies have confirmed that the local anesthetic levobupivacaine has a cytotoxic effect on breast cancer cells. We examined whether postoperative wound infiltration with levobupivacaine influences survival in 120 patients who were operated on for breast cancer and underwent quadrantectomy or mastectomy with axillary lymph node dissection. Groups with continuous levobupivacaine wound infiltration, bolus wound infiltration, and diclofenac analgesia were compared. Long-term outcomes examined were quality of life, shoulder disability, and hand grip strength (HGS) after one year and survival after 5 and 10 years. Groups that had infiltration analgesia had better shoulder function compared to diclofenac after one year. The levobupivacaine PCA group had the best-preserved HGS after 1 year (P = 0.022). The most significant predictor of the 5-year outcome was HGS (P = 0.03). Survival at 10 years was 85%, 92%, and 77% in the diclofenac, levobupivacaine bolus, and levobupivacaine PCA groups (ns. P = 0.36). The extent of the disease at the time of surgery is the most important predictor of long-term survival (P = 0.03). A larger prospective clinical study could better confirm the effect of levobupivacaine wound infiltration on outcomes after breast cancer surgery observed in this pilot study-trial number NCT05829707.