Daily Anesthesiology Research Analysis

INTRODUCTION: The Procedure Specific Postoperative Pain Management (PROSPECT) collaboration develops evidence-based recommendations integrating analgesic efficacy, safety and functional recovery. Since publication of the 2021 PROSPECT guidelines for total hip arthroplasty, new evidence, particularly on motor-sparing regional techniques, has emerged. This systematic review updates the 2021 recommendations for postoperative pain management after elective primary total hip arthroplasty. METHODS: Databases were searched systematically for randomised controlled trials and systematic reviews published between January 2020 and June 2024 evaluating peri-operative analgesic or surgical interventions for total hip arthroplasty. Studies involving non-randomised designs or lacking validated pain outcomes were not included. Evidence was synthesised according to PROSPECT methodology, focusing on pain within 24 h; opioid consumption; functional recovery; and adverse effects. Recommendations were graded by expert consensus. RESULTS: A total of 103 studies were included. Core recommendations remain unchanged: scheduled paracetamol and non-steroidal anti-inflammatory drugs, combined with a single intravenous dose of dexamethasone (≤ 10 mg). Low-dose intrathecal morphine (0.1 mg) may be considered with spinal anaesthesia in hospitalised patients. Among regional techniques, supra-inguinal fascia iliaca compartment block and pre-operative pericapsular nerve group block provided the most consistent analgesia. Quadratus lumborum and lumbar erector spinae plane blocks showed inconsistent efficacy and increased risk of motor weakness and are not recommended. Single-shot local infiltration analgesia remains an alternative when regional techniques are unavailable. DISCUSSION: In addition to previous recommendations, supra-inguinal fascia iliaca compartment block and pre-operative pericapsular nerve group block are recommended as preferred regional techniques for total hip arthroplasty, with single-shot local infiltration analgesia as an alternative when regional anaesthesia is not feasible. WHAT WE DID: A group of researchers looked at all the best available studies about pain relief after hip replacement surgery. They reviewed research published since 2020 and combined the findings to update earlier recommendations on how to manage pain after surgery. WHY DID WE DO IT: Hip replacement surgery can be painful, and good pain relief helps people recover more quickly and comfortably. New research has become available in recent years, so the researchers wanted to find out which treatments work best and update advice for doctors and patients. WHAT WE FOUND: The researchers found that regular pain medicines, such as paracetamol and anti‐inflammatory drugs, should still be used as the main treatment after hip replacement surgery. A steroid medicine called dexamethasone may also help reduce pain. Some types of nerve blocks around the hip were found to work well and are recommended when possible. However, other nerve block techniques did not show clear benefits and are not routinely recommended. Overall, the updated recommendations aim to provide safe and effective pain relief to help patients recover after hip replacement surgery.

OBJECTIVES: Anesthesia induction is a key risk factor for intraoperative hypotension due to the cardiovascular system's suppression of induction anesthetics, and intraoperative hypotension significantly affects mortality linked to traumatic brain injury (TBI). Topical airway anesthesia could optimize intubation conditions with less induction anesthetic. This study aimed to determine whether topical airway anesthesia for tracheal intubation can prevent intraoperative hypotension by reducing the need for induction anesthetics in TBI patients. METHODS: A total of 120 patients with severe TBI who underwent craniectomy without preoperative intubation were randomized into the standard anesthesia (C) group or the topical airway anesthesia for intubation (T) group. The patients in the C group received standard anesthesia induction, and those in the T group received topical airway anesthesia without standard induction anesthetics. Intraoperative systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) were recorded at the designated time points. In-hospital mortality, ICU morbidity, ICU stay duration, and neurological outcomes at discharge and 6 months postoperatively were evaluated. Postoperative injury to the heart, kidney, and liver was assessed. RESULTS: A total of 52 patients in the C group and 51 in the T group completed the trial. After intubation, the SBP and DBP in the T group were significantly greater than in the C group (P<0.05). The in-hospital mortality and ICU morbidity rates in the T group were lower than in the C group (P<0.05). The T group also had lower postoperative injury rates to the heart, kidney, and liver in was lower (P<0.05). While neurological recovery at discharge was improved in the T group, the difference was not statistically significant (P>0.05), except for the number of moderate and severe comas (P<0.05). The neurological score at 6 months postoperatively was increased in the T group (P<0.05). CONCLUSIONS: Topical airway anesthesia for tracheal intubation was associated with higher intraoperative blood pressure, lower in-hospital mortality and ICU morbidity rates, and improved neurological outcomes in patients with severe TBI. These findings suggest that reducing induction anesthetics through topical airway anesthesia may be a promising strategy for managing anesthesia in TBI patients, though confirmation in larger multicenter trials is warranted.

BACKGROUND: Postoperative pain is common in children, yet its relationship to age and sex remains underexplored. OBJECTIVES: We hypothesise that postoperative pain intensity varies across age groups. The objective is to identify ages at which high pain with functional impairment is most prevalent and assess any sex difference in the association between age and postoperative pain. DESIGN: Cohort study. SETTING: Data were extracted from the paediatric PAIN OUT registry, an international registry. Data were prospectively collected at hospitals in Germany, the Netherlands and Austria. PATIENTS: The study includes 2005 patients aged 4 to 18 years who underwent appendectomy, tonsillectomy, hernia repair, orthopaedic, or spinal fusion surgery. MAIN OUTCOME MEASURES: Postsurgical pain scores (Faces Pain Scale 0 to 10) were compared between surgical procedures, stratified by sex, and age. The association between the primary outcome, 'worst pain' score on the first day after surgery, and age and sex was analysed using regression models adjusted for confounding factors: surgery type, duration, perioperative opioid consumption, and use of regional anaesthesia. RESULTS: Postoperative pain intensity was high with 79% of children experiencing moderate to severe pain, increasing with age, peaking around 12 years, particularly in girls. The regression model confirmed an age-related increase in pain intensity in females (interaction coefficient: 0.08, 95% confidence interval 0.02 to 0.15, P = 0.017). Appendectomy and not receiving regional anaesthesia were associated with higher pain intensity. Higher mean oral morphine equivalent doses were given to patients aged 12 years or older for appendectomy (0.57 ± 0.52 vs. 0.60 ± 0.66 mg kg-1, P = 0.003) and spine surgery (2.1 ± 1.6 vs. 2.7 ± 2.4 mg kg-1, P = 0.038), with comparable doses between the sexes. CONCLUSIONS: In this paediatric cohort, 79% experienced moderate to severe postoperative pain, with higher scores in children aged 12+ and a peak in girls around the onset of puberty. These findings emphasise the need for improved paediatric pain management with consideration for age and sex-related differences.