Percutaneous Cryoanalgesia: A New Strategy for Pain Management in Pectus Excavatum Surgery

Introduction In recent years, pain protocols for pectus excavatum (PE) have incorporated cryoanalgesia through thoracoscopic approach. Since 2019, ultrasound-guided percutaneous cryoanalgesia (PCr) has been applied at our institution, either on the same day as the Nuss procedure or 48 hours before surgery. We carried out a preliminary retrospective review of patients with PE in whom PCr prior to surgery was performed at our institution between 2019 and 2021. Materials and Methods Two groups were evaluated: PCr on the same day (PCrSD) and PCr 48 hours before surgery (PCr48). Despite PCr, patients were treated with “patient-controlled analgesia” (PCA) with opioids for at least 24 hours, switching to conventional intravenous analgesia and oral analgesia in the following days. Demographic, clinical-radiological variables, PCA opioid use, pain grade according to the visual analog scale (VAS), and length of stay (LOS) were compared between the groups. A total of 20 patients were included (12 with PCrSD and 8 with PCr48), without significant differences in demographics or clinical-radiological variables. The overall median time of PCr was 65 minutes (55–127), with no differences between the groups. Results PCr48 group presented with significantly lower median number of hours of continuous PCA (24 vs. 32 hours; p = 0.031), lower median number of rescue boluses (11 vs. 18; p = 0.042), lower median VAS in the early postoperative hours (2 vs. 5.5; p = 0.043), and lower median LOS (3.5 vs. 5 days). Conclusion PCr performed 48 hours prior to surgery is more effective in terms of PCA requirements, VAS, and LOS when compared with cryoanalgesia on the same day.

EP.FRI.309 Rib fractures – an overlooked part of general surgical take? An audit and creation of a local pathway

Introduction Battle et al devised a validated scoring system to stratify patients with rib fractures (RF) at risk of complications based on age; number of fractures; oxygenation; respiratory illness and anticoagulation use. Risk of complications increases with score e.g. ≤10 and ≥31 give estimated complications risk of 13% and 88% respectively (2). Method We conducted a local retrospective audit of 45 patients admitted with RF over 26 months. Initial and subsequent analgesia was recorded. Four subgroups were created based on Batlle score: ≤10, 11-20, 21-30, ≥31. Outcomes included complications, length of stay (LOS) and mortality. Results Whilst overall median score was 18, we observed 20% (n = 9) scored ≥31. Initially, oral analgesia alone was given to 64% of patients; 66% went on to require lidocaine patch and 15% required patient controlled analgesia. Only 2.2% (n = 1) received regional analgesia. Despite 35.6% (n = 16) scoring ≥21, only four proactive critical care referrals were made. Overall pneumonia rate was 20% (n = 9); 44% (n = 4) in the ≥31 group. There were two deaths overall, both in the ≥31 group. Median LOS was 3 days; however 44% (n = 4) of the ≥31 group required ≥7 days. Conclusion One in five RF cases scored ≥31 and consequently had the worst outcomes. There was initial suboptimal analgesia, inadequate early escalation of higher risk patients to critical care and low rates of regional blocks. Consequently, we have created a local pathway based on Battle score (2) to standardise risk stratification and management of these patients in order to improve outcomes.

Early recovery after surgery in elective obstetrics-gynaecology surgeries: prospective single-center pilot study

Background: Enhanced recovery after surgery (ERAS) programmes employed in elective colorectal, vascular, urologic and orthopaedic surgery has provided strong evidence for decreased hospital stay without increase in postoperative complications. The aim of the study was to explore role and benefits, if any, of ERAS/ERP (early recovery protocols) implemented in patients undergoing elective obstetrics-gynaecological surgeries.Methods: Prospective cohort of 48 consecutive patients undergoing elective obstetrics-gynaecological surgeries were included. ERP included early feeding, urinary catheter removal, mobilisation/physiotherapy, intravenous line removal and optimal oral analgesia. This was compared to control group of 50 patients undergoing similar operations prior to introduction of ERP, SPC group-standard perioperative care. Demographics and indications of surgeries were similar for both groups. The primary end-points were length of stay (LOS) and incidence of complications (Clavien-Dindo classification). Difference in means was tested using the t test assuming unequal variances. Statistical significance was defined as p<0.05.Results: Two groups, A (non-ERAS/SPC) and B (ERAS) were comparable with regards to demographics and indication of surgery. The mean time to solid diet, urinary catheter removal, mobilization, iv fluid removal and shift to oral analgesia was 2.57, 1.13 (p<0.00001), 1.99 ,1.03 (p<0.00268), 1.63, 1.2 (p<0.00001), 1.72, 1.14 (p<0.00001), 1.8, 1.37 (p<0.00001) days respectively. There were 31 and 21 complications in both groups, respectively (p<0.0097). Hospital stay was significantly shorter in the ERAS group, 2.87, 2.61 (p<0.0378).Conclusions: This pilot study shows that ERPs can be successfully implemented with significant shorter hospital stays without increase in postoperative complications in elective obstetrics-gynecology patients.

966 Implementation of Regional Scalp Blockade for Painless Removal of ICP Bolts: A Quality Improvement Project

Introduction Intracranial pressure (ICP) monitoring through insertion of a bolt is a common neurosurgical procedure for diagnosing cerebrospinal fluid disorders. The first step of our quality improvement project identified ICP bolt removal the most painful part of the procedure. We implemented and tested the efficacy of a scalp nerve block for bolt removal. Method Two groups were identified: (A) receiving oral analgesia only and (B) receiving ipsilateral supraorbital and supratrochlear nerve blocks. We then retrospectively compared satisfaction ratings of insertion versus removal process for the two bolt types using a telephonic questionnaire Results Eighty-five patients had ICP bolts (32M:53F, mean age 42.7±16.0 SD). Fifty-four were removed with oral analgesia (A) and 31 with oral and regional anaesthesia (B). Removal experience was reported as worse for group A than for group B (p &lt; 0.01). Most patients (66%) reported would have preferred local anesthetic during removal. No complications occurred from the block. Conclusions Regional nerve blocks are a safe and effective adjuvant for the painless removal of frontal ICP monitoring bolts. The final stage of the project was to implement nerve blocks as standard practice for bolt removal, to improve patient experience.

The analgesic efficacy of ultrasound-guided transversus abdominis plane (TAP) block combined with oral multimodal analgesia in comparison with oral multimodal analgesia after caesarean delivery: a randomized controlled trial

Background The transversus abdominis plane (TAP) block is used increasingly in parturients after caesarean delivery. This is a randomized controlled trial to evaluate the effectiveness of bilateral single-shot of TAP blocks in patients who received multimodal oral analgesia for postoperative pain relief. Methods Parturients who were scheduled for elective caesarean delivery under spinal anaesthesia were recruited and randomized to receive bilateral single-shot of TAP blocks or placebo in addition to multimodal oral analgesia which consisted of regular tramadol, celecoxib and paracetamol, with oral oxycodone used as a rescue for breakthrough pain. Only parturients in the TAP group would receive the TAP blocks with an injection of 15 ml (0.25%) ropivacaine on each side under aseptic techniques. All the parturients were evaluated for pain or related complications in the first 24 h after surgery. The primary outcome is the percentage of parturients who required oxycodone as a rescue analgesia. Results Eighty and 79 parturients were allocated to the TAP and placebo group respectively. Nine out of 79 (11.4%) parturients in the TAP group and 15 out of 73 (20.5%) parturients in the placebo group required oxycodone for breakthrough pain, P = 0.122. Conclusions Bilateral single-shot of TAP blocks confer little additional benefit when a multimodal oral analgesic regimen is used for pain control after caesarean section under spinal anaesthesia. Trial registration Clinical Trial Registry of China (http://www.chictr.org.cn) identifier: ChiCTR-INR-16010130, retrospectively registered on Dec 12, 2016.

The Analgesic Efficacy of Ultrasound-guided Transversus Abdominis Plane (TAP) Block Combined With Oral Multimodal Analgesia In Comparison With Oral Multimodal Analgesia After Caesarean Delivery: A Randomized Controlled Trial

Background: The transversus abdominis plane (TAP) block is used increasingly in parturients after caesarean delivery. This is a randomized controlled trial to evaluate the effectiveness of bilateral single-shot of TAP blocks in patients who received multimodal oral analgesia for postoperative pain relief.Methods: Parturients who were scheduled for elective caesarean delivery under spinal anaesthesia were recruited and randomized to receive bilateral single-shot of TAP blocks or placebo in addition to multimodal oral analgesia which consisted of regular tramadol, celecoxib and paracetamol, with oral oxycodone used as a rescue for breakthrough pain. Only parturients in the TAP group would receive the TAP blocks with an injection of 15ml (0.25%) ropivacaine on each side under aseptic techniques. All the parturients were evaluated for pain or related complications in the first 24 hours after surgery. The primary outcome is the percentage of parturients who required oxycodone as a rescue analgesia. Results: 80 and 79 parturients were allocated to the TAP and placebo group respectively. 9 out of 79 (11.4%) parturients in the TAP group and 15 out of 73 (20.5%) parturients in the placebo group required oxycodone for breakthrough pain, P = 0.122. Conclusions: Bilateral single-shot of TAP blocks confer little additional benefit when a multimodal oral analgesic regimen is used for pain control after caesarean section under spinal anaesthesia.Trial registration: Clinical Trial Registry of China (http://www.chictr.org.cn) identifier:ChiCTR-INR-16010130, retrospectively registered on Dec 12, 2016.

The Analgesic Efficacy of Ultrasound-guided Transversus Abdominis Plane (TAP) Block Combined With Oral Multimodal Analgesia In Comparison With Oral Multimodal Analgesia After Caesarean Delivery: A Randomized Controlled Trial

Background: The transversus abdominis plane (TAP) block is used increasingly in parturients after caesarean delivery. This is a randomized controlled trial to evaluate the effectiveness of bilateral single-shot of TAP blocks in patients who received multimodal oral analgesia for postoperative pain relief.Methods: Parturients who were scheduled for elective caesarean delivery under spinal anaesthesia were recruited and randomized to receive bilateral single-shot of TAP blocks or placebo in addition to multimodal oral analgesia which consisted of regular tramadol, celecoxib and paracetamol, with oral oxycodone used as a rescue for breakthrough pain. Only parturients in the TAP group would receive the TAP blocks with an injection of 15ml (0.25%) ropivacaine on each side under aseptic techniques. All the parturients were evaluated for pain or related complications in the first 24 hours after surgery. The primary outcome is the percentage of parturients who required oxycodone as a rescue analgesia. Results: 80 and 79 parturients were allocated to the TAP and placebo group respectively. 9 out of 79 (11.4%) parturients in the TAP group and 15 out of 73 (20.5%) parturients in the placebo group required oxycodone for breakthrough pain, P = 0.122. Conclusions: Bilateral single-shot of TAP blocks confer little additional benefit when a multimodal oral analgesic regimen is used for pain control after caesarean section under spinal anaesthesia.Trial registration:Clinical Trial Registry of China (http://www.chictr.org.cn, ChiCTR-INR-16010130). Retrospective registered on Dec 12, 2016

Short-Term Outcomes of Polycarbophil and Propionibacterium acnes Lysate Gel after Open Hemorrhoidectomy: A Prospective Cohort Study

Background: Pain is the most common complication after open excisional hemorrhoidectomy (OEH). We assessed the effectiveness of polycarbophil and Propionibacterium acnes lysate gel (Emorsan®Gel) on pain control after OEH. Research design and methods: Fifty consecutive patients undergoing OEH were included. All patients received stool softeners and oral analgesia in the post-operative period. Emorsan®Gel was also used topically by the last 25 patients (Emorsan®Gel group (EG)) until Post-Operative Day 20 (POD 20). The primary outcome was the effectiveness of Emorsan®Gel on pain relief using an 11-point visual analogue scale (VAS). Morbidity, wound healing (WH), and time to work were documented at POD 1, POD 10, POD 20, and POD 40. Results: Of the 50 patients enrolled, twenty-eight (56%) were males; median age, 49 (range, 28–73) years. The VAS score decreased over time in all patients, with significantly lower scores at POD 20 in the EG (1.44 (SD, 1.16) vs. 2.12 (0.93) in the control group (CG); p = 0.045). All patients in the EG achieved complete WH at last follow-up, compared to only 17 (68%) in the CG (p = 0.004). The likelihood of WH was 66% higher in the EG (OR, 1.66 [95%CI, 0.80–3.44; p = 0.172). Conclusions: Emorsan®Gel is safe and effective at reducing pain after EOH, promoting earlier WH compared to standard care treatment.