Parturients with both ankylosing spondylitis (AS) and SARS-CoV-2 Infection (COVID-19) present unique challenges to anesthesiologists. Neuraxial analgesia for labor remains the gold standard in obstetric patients. However, in patients with AS, this approach may be deemed difficult to impossible. Administration of systemic opioids for labor analgesia can be an option, bearing in mind the potential respiratory depressant effect to both the mother and the fetus, especially in the setting of concomitant COVID-19. This paper reports the successful management of such a patient using patient-controlled analgesia (PCA) with intravenous remifentanil.

BACKGROUND: Postoperative pain is one of the main factors that delays recovery after prosthetic knee surgery. The use of sufentanil sublingual tablet systems (SSTS) can effectively relieve postoperative pain, but their value in facilitating early mobilization has been little studied so far. Our aim here was to assess whether their use could facilitate recovery after knee arthroplasty in an enhanced recovery program.
METHODS: In a prospective observational single-center study, thirty patients operated on for primary knee arthroplasty in the enhanced recovery pathway were included. Patients who received the SSTS (n=15) were compared with those who received an intravenous morphine patient-controlled analgesia (PCA) (n=15). Our recovery program included in particular the use of an adductor canal block, periarticular infiltration of local anesthetic by the surgeon, removal of the venous cannula from the recovery room if possible, the use of an SSTS when available or an IV morphine PCA otherwise, and early physiotherapy. Recovery parameters including the Timed-Up and Go test, pain scores at rest and on exertion, knee flexions, complications, and lengths of hospital stay were not significantly different between the two groups. However, the postoperative opioid consumption in morphine equivalents was significantly greater in the SL-sufentanil group and these patients had their venous cannula removed earlier than in IV-morphine group.
CONCLUSIONS: In our center, the use of a SSTS was suitable for treating postoperative pain after knee arthroplasty, but it did not improve early recovery in comparison with a morphine PCA.

UNASSIGNED: Patient-controlled analgesia with morphine is routinely used for postoperative pain management. Due to the safety profiles of the technique, which are patient/disease related or technique/equipment related, severe respiratory depression requiring opioid antagonists or airway management are uncommon.
UNASSIGNED: The case of a patient with right colon carcinoma who was operated on for hemicolectomy under general anaesthesia and who presented with apnoea, after postoperatively receiving an initial bolus of 1mg of morphine. A large post-traumatic porencephalic cyst of the left brain hemisphere, previously undiagnosed, was found on the computed tomography scan. We excluded human errors, technique and equipment factors, and the patient did not have any other predisposing conditions like sleep apnoea, obesity, recent head injury or concurrent use of other sedatives. Previously the patient had been entirely asymptomatic, and her increased susceptibility to respiratory depression was the only clinical manifestation of porencephaly.
UNASSIGNED: Adult acquired porencephaly is seldom reported in the literature, clinical manifestations depending on the location and size of the cyst. In the present reported case, increased susceptibility to low-dose opioids might be associated with the structural and functional reorganisation of the brain after head trauma with the occurrence of the porencephalic cyst of the brain.

METHODS: A retrospective case-control study.
OBJECTIVE: To evaluate the effect of nitrous oxide and anesthetic and operative factors associated with severe pain in the early postoperative period after thoracolumbar spine surgery.
BACKGROUND: Thoracolumbar spine surgery is the most common procedure in spine surgery, and up to 50% of the patients suffer from moderate to severe pain. Nitrous oxide has analgesic, anxiolytic, and anesthetic effects; nevertheless, its benefits for early postoperative pain control and opioid consumption remain to be established.
METHODS: The medical records of eligible participants who underwent thoracolumbar spine surgery between July 2016 and February 2017 were reviewed. Enrolment was performed consecutively until reaching 90 patients for the case (severe pain) group (patients with a pain score of >7 out of 10 at least once during the post-anesthesia care unit [PACU] admission), and 90 patients for the control (mild-to-moderate pain) group (patients with a pain score of <7 in every PACU assessment). The data collected comprised patient factors, anesthetic factors, surgical factors, PACU pain score, and PACU pain management.
RESULTS: A total of 197 patients underwent thoracolumbar spine surgery with an incidence of early postoperative severe pain of 53.3%. The case-control study revealed no differences in the factors related to pain intensity. A subgroup analysis was performed for failed back surgery syndrome (FBSS), spinal stenosis, and spondylolisthesis. After multivariate analyses, only the age group of 19-65 years and the baseline Oswestry Disability Index (ODI) were found to be significant risk factors for early postoperative severe pain in the PACU (odds ratio [OR], 2.86; 95% confidence interval [CI], 1.32-6.25; OR, 1.03; 95% CI, 1.01-1.05, respectively).
CONCLUSIONS: Nitrous oxide, anesthetic agents, and surgical techniques did not affect the early postoperative pain severity. Age under 66 years and the baseline ODI were the significant risk factors for pain intensity during the early postoperative period of the FBSS, spinal stenosis, and spondylolisthesis subgroups.

Fentanyl iontophoretic transdermal system (ITS) [IONSYS®, The Medicines Company, Parsippany, NJ, USA] is a needle-free, patient-controlled, postoperative opioid pain management treatment. It is indicated for the short-term management of acute postoperative pain in adults requiring opioid analgesia in the hospital. The safety and effectiveness of fentanyl ITS for acute postoperative pain management has been demonstrated in a range of surgery and patient types studied in seven phase 3 trials (three placebo-controlled trials and four active-comparator trials). The majority of the patients in the phase 3 trials had undergone either abdominal/pelvic, orthopedic, or thoracic surgery. Consistent with the prescribing information, physicians in clinical practice may treat patients with this system following any type of surgery including those that may not have been included in the phase 3 trials. The purpose of this case series is to illustrate how fentanyl ITS is being utilized for postoperative pain management in real-world clinical practice following a variety of surgeries and in current pain management protocols that may have evolved since the completion of the phase 3 program. There are seven cases from three clinical centers described within this case series, each using fentanyl ITS according to the prescribing information. The surgery types included are bariatric (N = 3), prostate (N = 2), colorectal (N = 1), and perirectal abscess drainage (N = 1). A systematic review of each patient chart was conducted via a standardized retrospective assessment by the clinicians who managed each patient. Additionally, each healthcare professional was interviewed regarding their overall experience and key learnings using fentanyl ITS. Overall, fentanyl ITS was effective and well tolerated in these case reports in current-day clinical practice settings. These case studies are informative about fentanyl ITS use shortly after product approval and set the stage for additional clinical research.

Anaphylaxis is a severe and life-threatening systemic hypersensitivity reaction. Ketorolac is a popular drug used for patient-controlled analgesia. Although anaphylactic reaction to ketorolac has not been frequently reported, it can develop by way of several mechanisms. A 41-year-old male patient was scheduled for laparoscopic correction of a perforated gastric ulcer. Emergency surgery was performed under general anesthesia with no complications. Near the end of anesthesia administration, ketorolac in a loading dose was administered intravenously in order to launch patient-controlled analgesia. Following injection, urticaria-like skin lesions, including rashes and wheels appeared systemically; tachycardia and breathing difficulty with oxygen desaturation also developed. Through additional inquiry into the patient\'s drug history, past experience with ibuprofen allergy was identified. Antihistamine, steroid, and aminophylline were administered, and continuous positive airway pressure by full facial mask was applied to relieve bronchospastic symptoms. The patient recovered without further complications.