Daily Anesthesiology Research Analysis

BACKGROUND: Postoperative pain relief after laparoscopic appendicectomy in children provided by transversus abdominis plane (TAP) block and local anaesthesia wound infiltration (LAWI) of trocar insertion sites has never been compared. OBJECTIVE: To investigate whether TAP block could decrease postoperative opioid requirements after laparoscopic appendicectomy in children compared with LAWI. DESIGN: Multicentre, double-blind, phase III randomised trial. SETTING: Two tertiary paediatric surgery centres. PATIENTS: Children aged 3 to 15 years admitted for laparoscopic appendicectomy. MAIN OUTCOME MEASURES: The primary outcome was the total dose of nalbuphine delivered within 24 h after surgery. Secondary outcomes were the Face Legs Activity Cry Consolability (FLACC) scale values at 1, 2, 6, 12 and 24 h, the time from levobupivacaine injection to the first dose of nalbuphine, and the time from the end of surgery to the first mobilisation. Patients received either ultrasound-guided TAP block (TAP group) or LAWI of trocar insertion sites (infiltration group) with 0.6 ml kg-1 of levobupivacaine 2.5 mg ml-1, combined with standardised systemic multimodal analgesia including paracetamol, ketoprofen, phloroglucinol and nalbuphine. RESULTS: Forty-six and 50 patients were analysed in the TAP and infiltration groups, respectively [age: 10 [7 to 12] versus 10 [8 to 12] years; females: 16 (35%) versus 25 (50%); duration of surgery: 71 [64 to 90] versus 69 [56 to 89] min]. The primary outcome (total nalbuphine dose) was 0.2 [0.0 to 0.2] and 0.2 [0.0 to 0.2] mg kg-1 in the TAP and infiltration groups, respectively (P = 0.95). FLACC scale values did not significantly differ between the two groups (P = 0.78). Time to the first dose of nalbuphine or to first mobilisation was not significantly different between groups (P value for log-rank test = 0.095 and 0.18, respectively). CONCLUSION: TAP block does not appear to provide a greater opioid-sparing effect than LAWI of trocar insertion sites after laparoscopic appendicectomy in children, when combined with systemic multimodal analgesia including nonsteroidal anti-inflammatory drugs. TRIAL REGISTRATION: ClinicalTrials.gov NCT04969133.

BACKGROUND: Previous studies provide conflicting evidence for ketamine's effectiveness in treating chronic pain, in the context of limited real-world evidence to augment clinical trial findings. We conducted a comparative effectiveness study with real-world data to assess the impact of ketamine infusions on pain-related healthcare utilization, to bridge the gap between clinical trials and real-life care. METHODS: We identified 118 subjects who received intravenous (IV) ketamine infusions for chronic pain between 2018 and 2022. Using the University of Pittsburgh's patient outcomes repository for treatment registry, we created a propensity score-matched control cohort of 118 subjects. Real-world data from the University of Pittsburgh Medical Center healthcare network was analyzed to compare unexpected pain-related healthcare utilization, including emergency room visits, urgent care visits, and hospital admissions. Utilization was assessed 6 months before and after ketamine infusion and compared with the matched control cohort. RESULTS: The ketamine cohort demonstrated a decrease in unexpected healthcare utilization 6 months after treatment compared with 6 months prior, while the control cohort showed an increase during the same period. Ketamine treatment was associated with a 45% reduction in pain-related visits compared with the control cohort (p<0.001). CONCLUSIONS: IV ketamine was more effective than conventional therapy in reducing unexpected pain-related healthcare utilization for over 6 months in patients with chronic pain. Our study highlights the value of using real-world data and comparative effectiveness research to supplement clinical trials and enhance our understanding of the possible effects of outpatient ketamine infusion therapy.

INTRODUCTION: Electroconvulsive therapy (ECT) triggers a pronounced sympathetic surge that may increase cardiovascular risk, especially in susceptible patients. Dexmedetomidine, an α2-adrenergic agonist with sympatholytic properties, has been proposed to blunt this response, but its overall clinical impact and optimal dosing remain unclear. METHODS: We conducted a systematic review and meta-analysis of double-blind randomized controlled trials evaluating dexmedetomidine administered before anesthesia induction in adult ECT. Primary outcomes were heart rate (HR) and mean arterial pressure (MAP). Secondary outcomes included seizure duration, recovery parameters, and adverse events. Random-effects models were applied, with prespecified subgroup analyses by dosage and anesthetic regimen. RESULTS: Twenty trials involving 1526 participants met eligibility criteria. Dexmedetomidine significantly attenuated the sympathetic response to ECT, reducing HR and MAP at most peri-procedure time points. The largest effects occurred 0 to 4 minutes after the electrical stimulus (mean difference for HR: -17.28 bpm; mean difference for MAP: -19.44 mmHg). Hemodynamic attenuation persisted for up to 30 minutes. Dexmedetomidine did not reduce seizure duration, prolong recovery milestones (spontaneous breathing, eye opening, following commands), or increase the incidence of hypotension or bradycardia. Subgroup analyses indicated that intermediate doses (0.25 to 0.5 µg/kg) provided the most consistent benefit, with no additional advantage at doses >0.5 µg/kg and stable effects across propofol-based induction regimens. DISCUSSION: Dexmedetomidine seems to be a safe and effective adjunct for mitigating the autonomic surge associated with ECT without compromising seizure quality or delaying recovery. Variability in dosing strategies and anesthetic protocols highlights the need for standardized approaches and further high-quality trials.