Daily Anesthesiology Research Analysis

BACKGROUND: We hypothesized that pericapsular nerve group (PENG) block was non-inferior to intrathecal (IT) morphine regarding analgesia after total hip arthroplasty (THA) with no untoward effects on the motor function. METHODS: In a double-blind placebo-controlled non-inferiority trial, patients undergoing unilateral THA under spinal anesthesia were randomized to receive a PENG block (20 mL 0.5 % levobupivacaine +2 mg dexamethasone) or IT morphine (100 μg). They received multimodal oral postoperative analgesia with rescue intravenous morphine for breakthrough pain, and were repeatedly evaluated for pain over the first 48 postoperative hours using a 0-10 numerical rating scale (NRS), and for the straight leg raise test at 4, 6 and 12 h. Co-primary outcomes were (i) maximum pain at rest and (ii) at active hip flexion - estimated for the overall period based on three consecutive scores - and (iii) milligram morphine equivalents (MME) delivered over 48 h. Non-inferiority margins for the PENG block - IT morphine differences were 0.75 NRS points for the pain scores, and 10 for the cumulative MME (corresponds to one 4 mg intravenous morphine rescue dose). RESULTS: All randomized patients (N = 60, 1:1 ratio) completed all trial procedures. PENG block - IT morphine differences in the maximum pain at rest (difference = 0.182, 95 %CI -0.218 to 0.582) and at hip flexion (difference = -0.270, 95 %CI -0.990 to 0.453) were well below 0.75 NRS points, and the difference in MME (difference = -2.1, 95 %CI -6.5 to 1.9) was well below 10 MME. Age-adjusted straight leg raise test failure rates were similar in the two groups (11.7 % vs. 12.8 %, difference = -1.1, 95 %CI -9.7 to 7.5). CONCLUSION: Compared to IT morphine, PENG block provides non-inferior analgesia after THA under spinal anesthesia without additional compromise of the motor function. TRIAL REGISTRATION NUMBER: NCT05308420.

BACKGROUND: Peripheral nerve blocks have become popular in orthopaedic surgeries to improve acute postoperative pain. However, studies are mixed on their effectiveness in decreasing postoperative opioid consumption. A more comprehensive analysis is necessary to understand if peripheral nerve blocks reduce postoperative opioid exposure and risk for opioid dependence. METHODS: This retrospective cohort study evaluated electronic health record data for adults undergoing orthopaedic surgery with general anaesthesia from 2016 to 2020 at the Massachusetts General Hospital. Linear models were fitted on propensity-weighted data to characterise the association between single injection peripheral nerve blocks and clinical outcomes. Our primary outcomes were maximum pain score and cumulative opioid dose, quantified in morphine milligram equivalents, administered in the PACU. Post-discharge outcomes associated with pain and opioid consumption were also evaluated. RESULTS: Among 22 956 patients, peripheral nerve block administration was associated with lower maximum pain scores and lower probability of opioid administration in the PACU. However, it was associated with higher maximum pain scores and a 22.7% increase in opioid consumption during the hospital stay. Peripheral nerve blocks were associated with an increase in opioid prescriptions at 30 days after discharge, but no increase at 90 or 180 days, and with decreased chronic pain diagnoses 1 yr after operation. CONCLUSIONS: Although single injection peripheral nerve blocks were effective in reducing immediate postoperative pain and opioid consumption, they were associated with greater opioid consumption that could increase the risk for opioid dependence. Standardised protocols to mitigate the risk for rebound pain could help minimise postoperative opioid exposure.

BACKGROUND: Postoperative organ dysfunction remains a major challenge in adult cardiac surgery with cardiopulmonary bypass (CPB), frequently involving the kidneys, heart, and lungs. These complications are primarily driven by hemolysis, ischemia-reperfusion injury, and systemic inflammation triggered by CPB. Nitric oxide (NO), known for its vasodilatory, anti-inflammatory, and antioxidant properties, has been proposed as a perioperative strategy to protect vital organs. However, evidence regarding its efficacy remains inconclusive. METHODS: We followed PRISMA guidelines and systematically searched PubMed, Embase, Cochrane Library, and Web of Science for randomized controlled trials (RCTs) published up to March 1, 2025. Subgroup analyses were conducted based on NO dosage and timing of administration. To explore potential effect modifiers and assess subgroup interaction, we performed meta-regression analyses. The GRADE approach was used to assess the certainty of evidence. Sensitivity analyses and publication bias assessments (funnel plots and trim-and-fill method) were also conducted to evaluate the robustness of the findings. RESULTS: Ten RCTs involving 838 patients were included. NO administration was associated with a reduced incidence of acute kidney injury (AKI) (RR: 0.78; 95% CI: 0.64–0.94; CONCLUSION: Inhaled NO may offer organ-specific benefits in adults undergoing cardiac surgery with CPB, such as reduced AKI incidence and lower cTnI levels. However, these effects did not consistently translate into improved clinical outcomes. The observed reduction in MV duration was not significant after adjusting for publication bias, suggesting a possible overestimation. Current evidence is limited by small sample sizes and small-study effects. Further large, high-quality trials in high-risk populations are needed to confirm these findings. PROSPERO REGISTRATION: This review was prospectively registered in PROSPERO (ID: CRD42025649095). SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12871-025-03207-7.