Bilateral ultrasound-guided TAP block is equivalent to local anesthetic infiltration of trocar insertion sites for overall postoperative pain in a heterogeneous group of patients undergoing laparoscopic cholecystectomy.

Some additives to local anesthetics can hasten the onset of nerve block, prolong block duration, or reduce toxicity. On the other hand, poorly selected or unnecessary additives may not have the desired effect and may even expose patients to unnecessary risks.

SUMMARY Background Traditionally, the use of ketamine for patients with traumatic brain injuries is contraindicated due to the concern of increasing intracranial pressure (ICP). These concerns, however, originated from early studies and case reports that were inadequately controlled and designed. Recently, the concern of using ketamine in these patients has been challenged by a number of published studies demonstrating that the use of ketamine was safe in these patients. Aims The purpose of this article was to review the current literature in regards to using ketamine in patients with traumatic brain injuries in different clinical settings associated with anesthesia, as well as review the potential mechanisms underlying the neuroprotective effects of ketamine. Results Studies examining the use of ketamine for induction, maintenance, and sedation in patients with TBI have had promising results. The use of ketamine in a controlled ventilation setting and in combination with other sedative agents has demonstrated no increase in ICP. Conclusions The role of ketamine as a neuroprotective agent in humans remains inconclusive and adequately powered; randomized controlled trials performed in patients undergoing surgery for traumatic brain injury are necessary.

IMPORTANCEThe opioid epidemic has reignited interest in opioid-sparing strategies in managing pain. However, few studies have focused on opioid use during perioperative care in patients undergoing head and neck surgery with free flap reconstruction.OBJECTIVES To examine the association between multimodal analgesia (MMA) administration and perioperative opioid requirements in patients undergoing head and neck surgery with free flap reconstruction and to investigate whether MMA alters the duration of stay in the postanesthesia care unit (PACU). DESIGN, SETTING, AND PARTICIPANTSIn this retrospective case-control study, data were collected between April 1, 2016, and December 31, 2017. The study was conducted at a single cancer center in the United States. Participants were 357 patients 18 years or older scheduled for head and neck surgery with free flap reconstruction.EXPOSURES Patients in the treatment group received oral celecoxib, gabapentin, and/or tramadol hydrochloride before surgery. Control group patients did not receive any of these medications. MAIN OUTCOMES AND MEASURESThe amount of opioid administered in the operating room and in the PACU was converted to morphine equivalent daily dose (MEDD) for comparison between the 2 groups. The duration of stay in the PACU was based on the start time and end time of PACU care recorded by nurses in the PACU. RESULTS Intotal, 149 patients (mean [SD] age, 60.3 [13.7] years; 104 [69.8%] men) were included in the treatment group, and 208 patients (mean [SD] age, 64.2 [13.6] years; 146 [70.2%] men) were included in the control group. The mean (SD) MEDD of opioid given during surgery was 51.7 (19.8) in the treatment group and 67.9 (24.7) in the control group, for a difference in the means (treatment vs control) of −16.17 (95% CI, −20.81 to −11.52). In the PACU, the mean (SD) MEDD of opioid given was 11.7 (13.3) in the treatment group and 14.9 (15.7) in the control group, for a difference in the means (treatment vs control) of −3.22 (95% CI, −6.40 to −0.03). The MMA treatment remained largely associated with reduced amount of opioid given during surgery, in the PACU, and both combined after controlling for other important factors.CONCLUSIONS AND RELEVANCE This case-control study found that the patients who received MMA before head and neck surgery with free flap reconstruction required less opioid medication. The treatment group also had shorter duration of stay in the PACU compared with the control group.

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