JAIPUR AWARD ABSTRACTS: ACUTE / PERIOPERATIVE PAIN
Year : 2020 | Volume
: 64 | Issue : 13 | Page : 60--66
Jaipur Award Abstracts: Acute / Perioperative Pain
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. Jaipur Award Abstracts: Acute / Perioperative Pain.Indian J Anaesth 2020;64:60-66
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. Jaipur Award Abstracts: Acute / Perioperative Pain. Indian J Anaesth [serial online] 2020 [cited 2020 Aug 8 ];64:60-66
Available from: http://www.ijaweb.org/text.asp?2020/64/13/60/277898
Abstract ID: ISAP042 A Cadaver Study of four approaches of infraclavicular brachial plexus block – ultrasound characteristics and dissection findings
Vijayalakshmi Sivapurapu, Ravindra R Bhat, Joseph I Raajesh.
Institution: INDIRA GANDHI MEDICAL COLLEGE & RESEARCH INSTITUTE
Background & Aims: The ultrasound-guided infraclavicular brachial plexus block (USG ICBPB) is a popular technique for forearm surgeries distal to the elbow. Our study details the ultrasound characteristics of this block and the structures encountered by the needle in four approaches to the infraclavicular area – lateral (LICF) infraclavicular, costoclavicular (lateral to medial (CLM) and medial to lateral (CML) approaches) and retroclavicular by anatomical dissection.
Methods: USG ICBPB was performed in 10 cadavers – 5 on right side and 5 on left side by each of four approaches and with 18 gauge Tuohy needles kept in situ, and US characteristics were noted. Anatomical dissection was done and important structures were described in detail.
Results: Needle tip and shaft visibility was least with LICF approach and best in retroclavicular approach. Needle angle correlates with chest and neck circumference in LICF, CML and retroclavicular groups. During dissection, in all approaches, neuro-vascular structures have been observed in the near vicinity of the needle, especially the thoraco-acromial artery (TAA) or its branches. In retroclavicular approach, the 'blind spot' behind the clavicle is an area where neurovascular structures were present.
Conclusion: Retroclavicular approach gives a better visibility of needle shaft beyond the clavicle, but the clavicle, acts as a 'blind-spot' for the ultrasound beam hiding important neurovascular structures. Each of approaches has its own advantages, but the various structures the needle traverses or in immediate vicinity makes the LICF still a reasonable option.
Sancheti SF, Uppal V, Sandeski R, Kwofie MK, Szerb JJ. A cadaver study investigating structures encountered by the needle during a retroclavicular approach to infraclavicular brachial plexus block. Regional Anesthesia and Pain Medicine. 2018 Oct 1;43(7):752-5.Leurcharusmee P, Elgueta MF, Tiyaprasertkul W, Sotthisopha T, Samerchua A, Gordon A, Aliste J, Finlayson RJ, Tran DQ. A randomized comparison between costoclavicular and paracoracoid ultrasound-guided infraclavicular block for upper limb surgery. Canadian Journal of Anesthesia/Journal canadien d'anesthésie. 2017 Jun 1;64(6):617-25.
Abstract ID: ISAP316: Ultrasound-Guided Blocks - Erector Spinae Plane (ESB), Thoracic Paravertebral (PVB), Retrolaminar (RLB) and Mid-Point Transversus Process to Pleura (MTP) – Dye Spread Characteristics by Dissection - A Cadaver Study
Ravindra R Bhat, Vijayalakshmi Sivapurapu, Joseph I Raajesh, DeepakT Paulose.
Institution: Indira Gandhi Medical College And Research Institute, Puducherry
Background & Aims: Various truncal fascial plane blocks have been described recently with a varied range of clinical response by regional anaesthesia enthusiasts. Our aim was to identify the extent of dye spread in each of these four blocks so as to recognise the differences in exact location of drug action in each of them.
Methods: After obtaining Institute Ethics Committee approval, in four embalmed cadavers – 20mL of dye was injected – methylene blue on one side and eosin on the other side of trunk (ESP and PVB on either side in 2 cadavers, RLB and MTP on either side in 2 cadavers). Anatomical cross sections of trunk were taken and dissected to describe the exact extent of dye spread medially.
Results: PVB - Dorsal, ventral rami, dorsal root ganglion and sympathetic ganglia stained, not crossing midline to opposite side. ESP – Dorsal rami alone stained. Dorsal root ganglion, ventral rami and sympathetic ganglia not stained. RLB – Dorsal rami but not dorsal root ganglion stained. Ventral rami stained in one cadaver. No spread to sympathetic chain. MTP – Dorsal and ventral rami, dorsal root ganglion, sympathetic ganglia stained and crossing over to opposite side observed. Dura stained. Spinal cord not stained.
Conclusions: MTP was found to have more extensive spread medially as compared to PVB, the clinical repercussions of which need to be studied. RLB and ESP showed more or less similar staining patterns.
S. D. Adhikary, S. Bernard, H. Lopez, and K. J. Chin. Erector spinae plane block versus retrolaminar block: a magnetic resonance imaging and anatomical study. Regional Anesthesia and Pain Medicine.2018;43(7): 756–762J. Ivanusic, Y. Konishi, and M. J. Barrington. A cadaveric study investigating the mechanism of action of erector spinae blockade. Regional Anesthesia and Pain Medicine.2018;43(6):567–571
Abstract ID: ISAP608: Comparative study of ropivacaine vs bupivacaine for pain relief in postoperative total knee arthroplasty patients.
Deeksha R Nayak, Jagadish Hegde, Jyothi, Thirunavukkarasu Sivaraman.
Sparsh Hospital, Yeswanthpur, Bangalore
Background and Aims: Total knee arthroplasty which is a standard mode of treatment of advanced knee osteoarthritis is associated with significant amount of postoperative pain which hampers early mobility and causes prolonged hospital stay. ACB catheters have gathered attention for preserving quadriceps strength and have similar outcomes as opioids in pain management. The aim of this study was to compare the efficacy of two drugs ropivacaine and bupivacaine for ACB catheters in postoperative total knee arthroplasty patients.
Methods: The study included 50 patients schedulred for elective unilateral knee replacement, randomly divided into two groups. All patients underwent surgery under sub arachnoid block with a fixed dose of hyperbaric bupivacaine 0.5%, and a catheter was placed in adductor canal at the end of surgery under ultrasound guidance. One group received 0.2% ropivacaine, while the other group received 0.125% bupivacaine as infusion. Patients were studied for pain scores using 'numerical pain rating scale' and range of movements using goniometer on POD1,POD2 & POD3.
Results: Patients who received Ropivacaine had a longer duration of analgesia and lesser numerical pain rating score compared to Bupivacaine at Day 1, Day 2 and Day 3 (P< .005). There was no significant difference between them noted when comparing length of hospital stay. The level of satisfaction was higher for patients who received Ropivacaine(P <0.03). Range of movements better for patients who received Ropivacaine (P < 0.05).
Conclusion: 0.2% Ropivacaine is a promising drug which offers improved analgesia in the immediate postoperative period and may promote an early ambulation with better ROM compared to 0.125% Bupivacaine for ACB catheter in postoperative TKA patients.
Edward R. Mariano, Anahi Perlas; Adductor Canal Block for Total Knee Arthroplasty: The Perfect Recipe or Just One Ingredient?. Anesthesiology2014;120(3):530-532. doi: https://doi.org/10.1097/ALN.0000000000000121.Ludwigson JL, Tillmans SD, Galgon RE, Chambers TA, Heiner JP, Schroeder KM. A Comparison of Single Shot Adductor Canal Block Versus Femoral Nerve Catheter for Total Knee Arthroplasty. The Journal of Arthroplasty 2015; 30(9):68-71. https://doi.org/10.1016/j.arth.2015.03.044.
Abstract ID: ISAP185: Evaluation of Ultrasound-guided Quadratus Lumborum Block for Postoperative Analgesia in Unilateral Laparoscopic Renal Surgeries – A Randomized Control Trial
Rajagopalan Venkatraman, Ravi Saravanan, Mohana Vatsalya Koka, Anand Pushparani.
SRM Medical College Hospital And Research Centre, Chennai
Background and Aims: Quadratus lumborum block (QLB) is a novel anaesthetic technique for abdominal wall block providing excellent postoperative analgesia. The primary objective of this study was to evaluate the duration of postoperative analgesia with QLB in unilateral laparoscopic renal surgeries. The secondary objectives were to assess total Morphine consumption during the first 24 hours postoperatively and observe for complications.
Methods: Sixty patients undergoing unilateral laparoscopic renal surgeries were randomly divided into two groups with patients receiving QLB (Group A) or no block (Group B) at the end of surgery (CTRI/2019/01/017254). General anaesthesia was standardised in both groups. The pain was assessed by visual analog scale (VAS) of one to ten. The duration of analgesia was taken as time from extubation to VAS of ≥ 3. Morphine was administered in Patient-controlled analgesia (PCA) pump with a baseline infusion of 0.1mg/hr and bolus of 1mg and a lock-out interval of 10 minutes. The total morphine consumption was recorded. The statistical analysis was performed with the Student t-test and Chi-square test.
Results: The duration of postoperative analgesia was significantly prolonged in group A (1288±288.92) than group B (138±54.92). Morphine consumption was also less in group A (3.1±0.87) than group B (10.46±1.8). There was a significant difference in VAS score from sixth to twentieth hour. No complications were recorded.
Conclusion: Ultrasound-guided QLB after laparoscopic renal surgery is safer to perform, effective with an increased post-operative duration of analgesia, reduces the consumption of opioids and is associated with fewer side effects.
Warusawitharana C, Basar SH, Jackson BL, Niraj G. Ultrasound guided continuous transmuscular quadratus lumborum analgesia for open renal surgery: A case series. Journal of clinical anesthesia 2017; 42:100.Verma K, Malawat A, Jethava D, Jethava DD. Comparison of transversus abdominis plane block and quadratus lumborum block for post-caesarean section analgesia: A randomised clinical trial. Indian journal of anaesthesia 2019; 63(10):820.
Abstract ID: ISAP137: Comparison of general anesthesia with ultrasound guided pecs block and serratus anterior plane block using bupivacaine and dexmedetomidine versus general anesthesia alone in modified radical mastectomy patients
K. Sai Lakshmi, Ramya Parameswari A., C.R. Prabhu, Prabha Udayakumar.
Sri Ramakrishna Hospital, Vishakapatnam
Background and Aims: Breast cancer leads among common cancers in women worldwide. Patients undergoing breast cancer surgeries face significant postoperative pain nausea and vomiting. So we have aimed to compare the postoperative analgesic efficacy of pectoral nerve block and serratus anterior plane block, with our standard practice of opioids and nonsteroid anti-inflammatory drugs in mastectomy surgeries.
Methods: After Ethical Committee approval and CTRI registration, sixty ASA I and II female patients between age 18 and 60years scheduled for elective unilateral modified radical mastectomy were enrolled in this prospective randomised controlled study. They were allocated in to 2groups of 30each: Group C had received general anesthesia alone. Group BD had received general anesthesia followed by PEC I, II and serratus anterior plane block with 30ml of 0.25% Bupivacaine along with 0.5mcg/kg Dexmeditomidine (8ml,12ml and 10ml respectively in each block) with the help of ultrasound. Both the groups had received IV paracetamol 1gram 8thhourly for 24hour postoperative period. The rescue analgesia was provided with IV Tramadol 50mg every 6thhourly until VAS scores were< 4. The primary outcome was to determine 1strescue analgesia time and total requirement of tramadol in the first 24hours of postoperative period.
Results: There was delay in requirement of rescue analgesia in group BD(8.67+/-1.63hours) compared to group C(2.00+/-1.10 hours);(p<0.001). The total tramadol consumption in 24hours was less in group BD(57.14+/-18.90mg), compared to group C(90.00+/-27.54mg);(P=0.005).
Conclusion: Pectoral nerve block and serratus anterior plane block together provide excellent postoperative analgesia in the first 24hours in modified radical mastectomy patients.
Ali HassnAM, Zanfaly HE, Biomy TA. Pre-emptive analgesia of ultrasound-guided pectoral nerve block II with dexmedetomidine–bupivacaine for controlling chronic pain after modified radical mastectomy. Res OpinAnesth Intensive Care 2016;3:6-13.Khemka R, Chakraborty A. Ultrasound-guided modified serratus anterior plane block for perioperative analgesia in breast oncoplastic surgery: A case series. Indian J Anaesth 2019;63:231-4.
Abstract ID: ISAP152: Comparison of effect of intraperitoneal instillation of additional dexmedetomidine or clonidine along with bupivacaine for post-operative analgesia following laparoscopic cholecystectomy: a prospective, randomized, double blind, controlled study.
Kaarthika T, Aloka Samantaray, Sri Devi R, Hemalatha P,
Department of Anaesthesiology and Critical Care, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
Background and Aims: Despite advances in pain therapy, post-operative pain remains a major concern after laparoscopic cholecystectomy. This study aims to compare the effect of intraperitoneal instillation of bupivacaine in combination with alpha-2 agonists for post-operative analgesia following laparoscopic cholecystectomy.
Methods: One hundred and eight patients scheduled for elective LC were randomised to receive either 20 ml of 0.5% bupivacaine (Group B), 20ml of 0.5% bupivacaine with dexmedetomidine 1mcg/kg (Group BD) or 20ml of 0.5% bupivacaine with clonidine 1mcg/kg (Group BC). Study drug was instilled before removal of trocar at the end of surgery. Study drugs were made into equal volume of 40ml each by adding 0.9% normal saline. Primary outcomes of our study were assessment of pain score (numeric rating scale) at 30 minutes, 1, 2, 4, 6, 24 hours after surgery, time to first analgesic request, analgesic requirement in the first 24 hours post operatively.
Results: The NRS scores for pain intensity did not show any statistical significance at any of the predefined time points. Time to first request of analgesia was shortest in group BC (64.0±60.6 minutes) when compared to the other groups (B, 78.8±83.4 minutes; BD, 112.2±93.4 minutes; p < 0.05). Total amount of rescue fentanyl used in groups BD (16.8±29.0 micrograms) and BC (15±26.4 micrograms) was significantly less than B (35.7±40.0 micrograms); p < 0.05).
Conclusions: Addition of alpha-2 agonists to bupivacaine reduces the postoperative opioid consumption and dexmedetomidine appears to be superior to clonidine in prolonging time to first analgesic request.
Usha shukla, Prabhakar T, Kiran M, Dheeraj S, Kriti M. Intraperitoneal bupivacaine alone or with dexmedetomidine or tramadol for postoperative analgesia following laparoscopic cholecystectomy: A comparative evaluation. Indian J. Anaesth. 2015;59:234-9.Govil N, Kumar P. Intraperitoneal Levobupivacaine with or without Clonidine for Pain Relief after Laparoscopic Cholecystectomy: A Randomized, Doubleblind, Placebo-controlled Trial. Anesth Essays Res. 2017;11:125–8.
Abstract ID: ISAP420: Comparison of infraclavicular brachial plexus block success by posterior cord and lateral cord stimulation for upperlimb surgeries using ultrasound guidance and neurostimulation- a prospective randomized double blinded study.
Rameshram. M, J. Edward Johnson
Kanyakumari Government Medical College
Background & Aims: Infraclavicular blocks are often performed by localizing one cord of the brachial plexus and injecting local anesthetic at that location for upperlimb surgeries. The study is aimed to compare success rate of infraclavicular brachial plexus block by stimulation of lateral and posterior cord.
Methods: After ethical committee approval and written informed consent,88 patients belonging to ASA I/II scheduled for elective upper limb surgeries were randomised to groups A and B in a double blinded fashion. Group A and B received 20ml of 0.5% bupivacaine by stimulation of posterior and lateral cord under ultrasound and neurostimulation guidance. Block performance time, onset ,duration of sensory and motor block, extent of motor block and time taken for first rescue analgesia were recorded.
Results: The mean duration for block performance time was longer in GroupA (11.85±1.03min)compared to Group B(8.39±0.55min) (p<0.0001). The mean duration of onset of sensory (10.50±0.68min) and motor block (15.00±1.05min)in Group A was earlier when compared to Group B sensory (17.68±1.23min) and motor block(21.23±1.80 min) (p<0.0001). The mean duration of sensory b(658.63±40.14min)and motor block (532.38±18.71min) in Group A was longer when compared to Group B sensory (540.05±18.71min) and motor block(458.95±45.55min) (p<0.0001). The extent of motor block in Group A (3.93±0.27)was better as compared to Group B (3.42±0.50) p<0.0001). The mean time for first rescue analgesia request was earlier in GroupB (569.08±42.09min than GroupA(694.88±42.02min) (p<0.0001).
Conclusion: Infraclavicular brachial plexus block by posterior cord stimulation showed higher success rate inspite of longer time taken for block performance compared to lateral cord .
1. He W, Liu Z, Wu Z, Liu W, Sun H, Yang X. Role of positioning posterior cord on coracoid approach brachial plexus block guided by nerve stimulator: Compared with guided by ultrasound. Medicine (Baltimore). 2017;96(45):e8428. doi:10.1097/MD.0000000000008428Sharma D, Srivastava N, Pawar S, Garg R, Nagpal VK. Infraclavicular brachial plexus block: Comparison of posterior cord stimulation with lateral or medial cord stimulation, a prospective double blinded study. Saudi J Anaesth. 2013;7(2):134–137. doi:10.4103/1658-354X.114054
Abstract ID: ISAP521: Comparison of Laparoscopic-guided with Ultrasound-guided Subcostal Transversus Abdominis Plane Block for Postoperative Analgesia in Laparoscopic Cholecystectomy – A Prospective Randomized Study
Rajagopalan Venkatraman, Ravi Saravanan, Meshach Mesia Dhas, Anand Pushparani
SRM Medical College Hospital And Research Centre, Chennai
Background and Aims: Subcostal Transversus Abdominis Plane (TAP) block is usually given under ultrasound guidance in laparoscopic cholecystectomy. Laparoscopic-guided subcostal TAP block is an alternate technique where ultrasound is not available. Our primary objective was to compare the success rate of ultrasound and laparoscopic approaches to the subcostal TAP block. The secondary objectives were to assess the duration of postoperative analgesia and morphine consumption postoperatively for 24 hours.
Methods: Eighty patients undergoing laparoscopic cholecystectomy were randomly divided into two groups with patients receiving Ultrasound-guided (Group U) or Laparoscopic-guided (Group L) Subcostal TAP block at the end of surgery. The success rate was assessed by sensory blockade from T6 to T10 30 minutes after extubation. The duration of analgesia was taken as time from block administration to VAS of ≥ 3. Morphine was administered in a Patient-controlled analgesia (PCA) pump with a bolus of 1mg and a lock-out interval of 10 minutes. The total morphine consumption was recorded. The statistical analysis was performed with Student t-test and Chi-square test.
Results: The success rate of Group U (100%) was higher than Group V (88%) but it was not statistically significant. The duration of postoperative analgesia was significantly prolonged in group U (867.24±135.83min) than group L (751.31±311.22min). Morphine consumption was also less in group U (4.72±0.94mg) than group L (5.57±2.53mg). There was no significant difference in the VAS score.
Laparoscopic-guided subcostal TAP block is as effective as Ultrasound-guided block and can be utilised in places where ultrasonogram is not available.
Ravichandran NT, Sistla SC, Kundra P, Ali SM, Dhanapal B, Galidevara I. Laparoscopic-assisted tranversus abdominis plane (TAP) block versus ultrasonography-guided transversus abdominis plane block in postlaparoscopic cholecystectomy pain relief: randomized controlled trial. Surgical Laparoscopy Endoscopy & Percutaneous Techniques 2017; 27(4):228-32.Shin HJ, Oh AY, Baik JS, Kim JH, Han SH, Hwang JW. Ultrasound-guided oblique subcostal transversus abdominis plane block for analgesia after laparoscopic cholecystectomy: a randomized, controlled, observer-blinded study. Minerva anestesiologica. 2014; 80(2):185-93Presenter Name: DR NARENDRA PATIL
Abstract ID: ISAP598: Comparison of continuous pectoral block vs iv analgesics for post-operative pain management in modified radical mastectomy
Narendra Patil*, Snehalata Tavri, Jayshree Vaswani, R P Gehdoo
DR DY Patil Medical College, Navi Mumbai
Background and Aims: Post-operative pain relief in patients undergoing MRM reduces morbidity and mortality. We endeavored to test post-operative analgesic efficacy of Continuous Pectoral Block(I-II) by assessing VAS score.
Methods:Patients undergoing MRM surgery were randomly allotted into PEC group(n=25) and control group(n=25). Both groups had routine GA. Feeding-tubes were placed in PEC–I–II plane amongst PEC group, under direct vision by surgeon towards end of surgery. Both groups were observed for VAS score at 3,6,12,18,24,36,48 hr post-surgery. Patients with VAS score >2 were given 0.125% bupivacaine 10ml in PEC-1 and 12ml in PEC-II amongst PEC group and IV paracetamol(15mg/kg) in control group. Primary outcome was to check analgesic efficacy. Secondary observation was to find need of any rescue analgesia, number of topups, patient satisfaction or adverse event.
Results:Significant reduction in VAS score was noted in PEC group(4.18±0.80 to 0.88±0.61 vs 3.84±0.8 to 1.04±0.62)(pvalue 0.001).With each topup VAS score reduction was significant in PEC group(2.14±1.24 to 1.51±0.523 vs 2.37 ± 1.04 to 1.985 ± 0.615)(pvalue 0.042).In 48 hr,5.33% of PEC group and 28% of Control group required rescue analgesia.Significantly less patient had pain in ipsilateral UL in PEC group(0.66% vs 6%)(pvalue 0.016). Discharge was earlier for PEC group(3-4 vs 5-6 days).Patient satisfaction was significantly more amongst PEC group than control group. Adverse events like nausea, vomiting, fever etc. were 0.66% in PEC group and 8.66% in control group.
Conclusion: Continuous Pectoral Block is superior, compliant, adequately lasting, easy to perform, cheaper analgesic technique, needs negligible rescue therapy or adverse event.
Pectoral nerve block 1 versus modified pectoral nerve block 2 for post-operative pain relief in patients undergoing modified radical mastectomy: a randomized clinical trial; Goswami S. et. Al.; Br J Anaesth. 2017 Oct 1; 119(4); 830-835Newer Regional Analgesia interventions (fascial plane blocks) for breast surgeries: Review of literature; Rakesh Garg, Swati Bhan, Saurabh Vig; Indian Journal of Anaesthesia | Volume 62 | Issue 4 | April 2018; page 18-26
Abstract ID: ISAP231: Effect of perioperative duloxetine on postoperative analgesia in patients undergoing abdominal hysterectomy.
Sharmila R, Manjunath A.C, Prapti Rath
Ramaiah Medical College and Hospital, Bangalore.
Background & Aims: Surgical trauma can induce central and peripheral sensitization leading to neuropathic pain. The increased propensity for pain and emotional problems contribute to the poor postoperative recovery in female patients. Duloxetine when used as a premedication causes improved postoperative pain scores, better emotional status and hence better recovery. The present study aims to analyze the postoperative analgesia with duloxetine premedication in patients undergoing abdominal hysterectomy.
Methods: After obtaining Ethical Committee clearance and informed consent, the study was conducted in 64 ASA 1 & 2 patients, aged 18-60 years who were scheduled to undergo elective abdominal hysterectomy under spinal anaesthesia with 0.5% hyperbaric bupivacaine 15 mg and buprenorphine 90 mcg. They were randomly assigned into two groups to receive a single dose of duloxetine 60 mg or placebo 2 hours prior to surgery. The postoperative VAS scores in first 24 hours and total analgesic requirements was noted.
Results: Both the groups were similar with respect to the demographic characters. Postoperative VAS scores and analgesic requirements were comparable between the two groups. The VAS scores at rest at 0, 1, 6, 12 and 24 hours (0.00±0.00, 0.03±0.18, 4.34±1.10, 4.78±1.13 and 3.94±0.67 vs 0.00±0.00, 0.00±0.00, 4.22±1.04, 5.13±1.56 and 3.88±0.98), the VAS scores with cough at 0, 1, 6, 12 and 24 hours (0.00±0.00, 0.81±1.40, 5.38±1.13, 5.75±1.22 and 5.00±0.72 vs 0.00±0.00, 0.56±1.13, 5.28±0.99, 6.13±1.56 and 4.88±0.98), total analgesic requirement (4.94±0.84 vs 5.22±0.75) between duloxetine and placebo group were all comparable.
Conclusion: Single dose of perioperative duloxetine did not cause a statistically significant postoperative analgesia.
Saoud A. Effect of perioperative duloxetine on postoperative pain relief following anterior cervical microdiscectomy and fusion. A pilot study. World Spinal Column J 2013; 4: 15–24.Castro-Alves LJ, Oliveira de Medeiros AC, Neves SP, Carneiro de Albuquerque CL, Modolo NS, De Azevedo VL, et al. Perioperative Duloxetine to Improve Postoperative Recovery After Abdominal Hysterectomy: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Study. Anesth Analg 2016; 122: 98-104.