BACKGROUND:The transversus abdominis plane (TAP) block is a novel approach for blocking the abdominal wall neural afferents via the bilateral lumbar triangles of Petit. We evaluated its analgesic efficacy in patients during the first 24 postoperative hours after abdominal surgery, in a randomized, c

The analgesic efficacy of transversus abdominis plane block after abdominal surgery: a prospective randomized controlled trial.

Delirium is a common mental disorder, which is distressing and has serious adverse outcomes in hospitalised patients. Prevention of delirium is desirable from the perspective of patients and carers, and healthcare providers. It is currently unclear, however, whether interventions for preventing delirium are effective.To assess the effectiveness of interventions for preventing delirium in hospitalised non-Intensive Care Unit (ICU) patients.We searched ALOIS - the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 4 December 2015 for all randomised studies on preventing delirium. We also searched MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), Central (The Cochrane Library), CINAHL (EBSCOhost), LILACS (BIREME), Web of Science core collection (ISI Web of Science), ClinicalTrials.gov and the WHO meta register of trials, ICTRP.We included randomised controlled trials (RCTs) of single and multi- component non-pharmacological and pharmacological interventions for preventing delirium in hospitalised non-ICU patients.Two review authors examined titles and abstracts of citations identified by the search for eligibility and extracted data independently, with any disagreements settled by consensus. The primary outcome was incidence of delirium; secondary outcomes included duration and severity of delirium, institutional care at discharge, quality of life and healthcare costs. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes; and between group mean differences and standard deviations for continuous outcomes.We included 39 trials that recruited 16,082 participants, assessing 22 different interventions or comparisons. Fourteen trials were placebo-controlled, 15 evaluated a delirium prevention intervention against usual care, and 10 compared two different interventions. Thirty-two studies were conducted in patients undergoing surgery, the majority in orthopaedic settings. Seven studies were conducted in general medical or geriatric medicine settings.We found multi-component interventions reduced the incidence of delirium compared to usual care (RR 0.69, 95% CI 0.59 to 0.81; seven studies; 1950 participants; moderate-quality evidence). Effect sizes were similar in medical (RR 0.63, 95% CI 0.43 to 0.92; four studies; 1365 participants) and surgical settings (RR 0.71, 95% CI 0.59 to 0.85; three studies; 585 participants). In the subgroup of patients with pre-existing dementia, the effect of multi-component interventions remains uncertain (RR 0.90, 95% CI 0.59 to 1.36; one study, 50 participants; low-quality evidence).There is no clear evidence that cholinesterase inhibitors are effective in preventing delirium compared to placebo (RR 0.68, 95% CI, 0.17 to 2.62; two studies, 113 participants; very low-quality evidence).Three trials provide no clear evidence of an effect of antipsychotic medications as a group on the incidence of delirium (RR 0.73, 95% CI, 0.33 to 1.59; 916 participants; very low-quality evidence). In a pre-planned subgroup analysis there was no evidence for effectiveness of a typical antipsychotic (haloperidol) (RR 1.05, 95% CI 0.69 to 1.60; two studies; 516 participants, low-quality evidence). However, delirium incidence was lower (RR 0.36, 95% CI 0.24 to 0.52; one study; 400 participants, moderate-quality evidence) for patients treated with an atypical antipsychotic (olanzapine) compared to placebo (moderate-quality evidence).There is no clear evidence that melatonin or melatonin agonists reduce delirium incidence compared to placebo (RR 0.41, 95% CI 0.09 to 1.89; three studies, 529 participants; low-quality evidence).There is moderate-quality evidence that Bispectral Index (BIS)-guided anaesthesia reduces the incidence of delirium compared to BIS-blinded anaesthesia or clinical judgement (RR 0.71, 95% CI 0.60 to 0.85; two studies; 2057 participants).It is not possible to generate robust evidence statements for a range of additional pharmacological and anaesthetic interventions due to small numbers of trials, of variable methodological quality.There is strong evidence supporting multi-component interventions to prevent delirium in hospitalised patients. There is no clear evidence that cholinesterase inhibitors, antipsychotic medication or melatonin reduce the incidence of delirium. Using the Bispectral Index to monitor and control depth of anaesthesia reduces the incidence of postoperative delirium. The role of drugs and other anaesthetic techniques to prevent delirium remains uncertain.

/pdf/interventions-for-preventing-delirium-in-hospitalised-non-47c6u5apac.pdf

Interventions for preventing delirium in hospitalised non-ICU patients

Objective:
To characterize the beneficial effects of perioperative systemic lidocaine on length of hospital stay, gastrointestinal motility, and the inflammatory response after colorectal surgery.

Systemic Lidocaine Shortens Length of Hospital Stay After Colorectal Surgery: A Double-blinded, Randomized, Placebo-controlled Trial

Summary Introduction The management of acute postoperative pain poses a significant challenge in surgical specialities. Despite the prevalence and impact of acute postoperative pain, there is a paucity of published data regarding its occurrence and sensory qualities after joint replacement. Hypothesis That a proportion of patients would experience severe acute postoperative pain at rest after total hip replacement (THR) and total knee replacement (TKR). Materials and methods Pain was assessed preoperatively, and then five times daily for the first three postoperative days in 105 THR and TKR patients. Pain severity was assessed using a pain Visual Analogue Scale and the sensory qualities of pain were assessed using the pain descriptors from the Short-Form McGill Pain Questionnaire. Results Median acute pain scores peaked on the first postoperative day, with 58% of TKR patients and 47% of THR patients reporting moderate-severe pain. Preoperative pain was most frequently described as aching, stabbing and sharp, whereas acute postoperative pain was described as aching, heavy and tender. Night pain disturbed between 44–57% of TKR patients and 21–52% of THR patients on postoperative nights 1–3. Discussion These findings demonstrate that acute postoperative pain at rest after joint replacement, particularly TKR, is poorly managed, although it does not reach the severity of preoperative pain. Level of evidence Level IV (observational cohort study).

Acute postoperative pain at rest after hip and knee arthroplasty: severity, sensory qualities and impact on sleep.

Over the last few years, there has been an increasing interest in the ethical aspects related to the use of animals in research, with particular attention to pain and distress associated with experimental procedures. Back in 1992, the National Research Council (NRC) published the report Recognition and Alleviation of Pain and Distress in Laboratory Animals. Although pain and distress are often addressed together as components of the animal’s wellbeing, they differ from the physiological and management point of view. The significant scientific progress made since the publication of the first report made an update necessary, and quite rightly, the NRC decided to address both arguments separately. In 2008 it published Recognition and Alleviation of Distress in Laboratory Animals and now comes the present title that deals with the recognition and alleviation of pain in various vertebrate species used in research. The two reports can be read independently but readers interested in animal welfare should benefit from reading both together. Contributions to the book came from members of the NRC’s Committee on Recognition and Alleviation of Pain in Laboratory Animals, and the draft report was peerreviewed by a group of individuals chosen for their diverse perspectives and technical expertise. This extensive review procedure combined with the participation of professionals in the field with different backgrounds ensures that the final report represents a broad view within the laboratory animal science community. The book starts with a very practical Glossary of commonly used terms followed by a brief Summary and Introduction that sets the background and states the purpose of the report. The report itself is organized into five chapters and takes the reader through a logical sequence. The first chapter introduces the definition of pain, underlining the differences between nociception and pain, and analyses the evidence available to support the underlying premise of the book that all vertebrates can experience (conscious) pain. The main argument dealt with on the second chapter is the physiological and anatomical basis of nociception and pain, helping to thoroughly understand the difference between both, and more importantly the implications for animal welfare. In the last part of the book, the authors deal with the more practical aspects and dedicate the next two chapters to recognize and assess the intensity of pain in animals and the strategies adopted to effectively manage pain in a research setting. The review includes all methods currently available such as behavioural assessment, measurement of nociceptive responses (analgesiometry tests), use of biomarkers and brain activity imaging. A broad range of pharmacological and non-pharmacological strategies to prevent or treat pain is described in depth. Last but certainly not least comes a chapter covering the important issue of humane endpoints, which in a research setting is central to any strategy dedicated to reduce or avoid unnecessary pain and distress, without compromising the scientific validity of the studies. In addition, specific issues in each chapter are further developed within boxes, and the chapter ends up with concise conclusions and recommendations, as well as an updated list of references. This structure has the advantage of allowing different reading levels according to the needs and interests of the readers. The book is well written and easy to follow, even for those readers not familiar with the subject. Each chapter can be read independently, with the disadvantage that some of basic concepts are treated more than once making it redundant on occasions (particularly at the beginning). The Commission has included information on the treatment and management of pain for the less common laboratory animal species (birds, fish, reptiles and amphibians) based on the wider availability of practical data for the most common species. I feel that the addition of an appendix including such data for all laboratory species would improve the final result and allow this report to become a reference handbook in the field. Although the conclusions and recommendations section at the end of each chapter represents the view of the authoring committee, the report leaves space to different views and to debate the more controversial or undefined issues. This approach together with the large number of references given allows the reader to enter into the arguments and develop a personal view. I would highly recommend this book to a wide audience, from laboratory animal veterinarians who need to keep abreast of new developments in the field, to researchers who want to find a deeper insight into the behaviour of the animals they use.

https://lan.sagepub.com/content/44/4/380.full.pdf+html

Recognition and Alleviation of Pain in Laboratory Animals

Postoperative symptoms and complications can be prevented by a suitable choice of anaesthetic and analgesic technique for specific procedures. The aim of analgesic protocols is not only to reduce pain intensity but also to decrease the incidence of side-effects from analgesic agents and to improve patient comfort. Moreover, adequate pain control is a prerequisite for the use of rehabilitation programmes to accelerate recovery from surgery. Thus, combining opioid and/or non-opioid analgesics with regional analgesic techniques not only improves analgesic efficacy but also reduces opioid demand and side-effects such as nausea and vomiting, sedation, and prolongation of postoperative ileus. Although all attempts to demonstrate that regional anaesthesia and analgesia decrease postoperative mortality are unsuccessful, there is evidence supporting a reduction in pulmonary complications after major abdominal surgery, and an improvement in patient rehabilitation after orthopaedic surgery. When such techniques are used, cost–benefit analysis should be considered to determine suitable analgesic protocols for specific surgical procedures.

F. Bonnet

Papers

Influence of anaesthetic and analgesic techniques on outcome after surgery