Ketorolac

In Yuan et al study,^{[29 (link)]} patients received standardized general anesthesia and basic analgesic protocol. Intraoperatively, all patients received general anesthesia which was induced by sufentanil 0.5 μg/kg, midazolam 0.04 mg/kg, propofol 1 to 2 mg/kg, and Cisatracurium 2 μg/kg intravenously, followed by continuous intravenous infusion of remifentanil 0.1 to 0.3 μg/(kg·min), propofol 2 to 5 mg/(kg·hr) and inhalation of sevoflurane to maintain anesthesia. Since postoperative day 1, the protocol of oral celecoxib restarted till postoperative 3 weeks when the patients came back to the hospital for taking out the stitches. In Yadeau et al 2016 study,^{[6 (link)]} patients received a standardized anesthetic and multimodal analgesic protocol. In Yadeau et al 2022 study,^{[28 (link)]} patients received a standard intraoperative and postoperative multimodal anesthetic protocol: a spinal-epidural (subarachnoid mepivacaine, 45–60 mg); adductor canal block (ultrasound-guided; 15 cc bupivacaine, 0.25%, with 2 mg preservative-free dexamethasone). For postoperative pain management, patients were scheduled to receive the study medication once daily for 14 days; 4 doses of 1000 mg IV acetaminophen every 6 hours followed by 1000 mg oral acetaminophen every 8 hours; 4 doses of 15 mg IV ketorolac followed by 15 mg meloxicam every 24 hours; and 5 to 10 mg oral oxycodone was given as needed for pain. Patients could have pain medications adjusted as indicated. In Koh et al study,^{[12 (link)]} all patients had a postoperative intravenous patient-controlled anesthesia (PCA) pump that administered 1 mL of a 100-mL mixture containing 2000 mg of fentanyl on demand. In Kim et al study,^{[27 ]} all patients received intravenous PCA encompassing delivery of 1 mL of a 100 mL solution containing 2000 µg of fentanyl postoperatively. In Ho et al study,^{[26 (link)]} patients were routinely offered a single shot spinal anesthesia consisting of an intrathecal dose of bupivacaine 10 to 12.5 mg with fentanyl 10 mg. After surgery, pain treatment consisted of PCA with intravenous injection of morphine. The settings were 1 mg bolus, 5 minutes lockout time, and a maximum hourly limit of 8 mg. All patients were also given acetaminophen 1 g 6 hourly.

This study was conducted after obtaining approval from the institutional review board of our hospital (YUMC-2019-09-052) and informed consent from the patients. This study was registered in ClinicalTrials.gov (registration number: NCT05320783). Using a prospective, randomized, controlled clinical protocol, 82 patients (aged 20–65 years), American society of anesthesiologists physical status I and II, undergoing gynecological laparoscopic surgery were included in the study. The exclusion criteria were as follows: any hearing impairment, known psychiatric or memory disorder, alcohol or analgesic abuse, and inability to complete the questionnaires.
Patients were allocated to the music intervention group (group M, n = 41) or control group (group C, n = 41) using a random number sequence, which ensured adequate concealment. The patients did not receive any premedication. Routine monitoring was initiated, and anesthesia was induced with propofol and maintained with sevoflurane in 50% oxygen/air, with an adjuvant infusion of remifentanil to maintain intraoperative bispectral index values (40–60) and hemodynamic stability.
After induction, headphones were placed on each patient. The classical music selected by the investigator was started in group M patients with an individual comfortable volume. Preoperatively, each patient was asked to choose a comfortable sound volume. The sound was maintained throughout the surgical procedure. Likewise, headphones were also placed on patients in group C, but the player was not started. Approximately 30 minutes before the completion of surgery, ketorolac and ramosetron were administered for postoperative pain and nausea control, respectively. All anesthetics, including sevoflurane, were discontinued at the end of the surgery, and residual neuromuscular blocking was reversed. Tracheal extubation was performed, and the patient was transferred to the postanesthetic recovery unit (PACU).
In the PACU, postoperative pain was assessed using a numeric rating scale (NRS, 0–10) at 30 minutes. At 3, 24, and 36 hours postoperatively, the pain score was also assessed using NRS in the ward. Rescue analgesics (fentanyl 50 µg) were administered when the NRS score was > 4 or patients requested. The incidence of nausea and vomiting was measured at 30 minutes and 3, 24, and 36 hours after surgery, and a rescue drug, metoclopramide 10 mg, was administered, if needed. An anesthesiologist who was blinded to the study protocol estimated the overall data.
At 24 hours postoperatively, QoR-40 was surveyed by an anesthesiologist who was not assigned to the patient group. The questionnaire contained a total of 40 items regarding the quality of recovery that were classified into 5 dimensions, namely, emotion, physical comfort, psychological support, physical independence, and pain, comprising 9, 12, 7, 5, and 7 items, respectively. Each item was rated on a 5-point scale, with the sum scores ranging from 40 (poor quality of recovery) to 200 (excellent quality of recovery).

The study was reported according to CONSORT statement. Eligibility criteria for this study were patients aged between 40 and 80 years who were diagnosed with primary osteoarthritis of the knee scheduled to undergo unilateral TKA. The exclusion criteria were (i) severe deformity that required stem or metal augmentation, (ii) previous knee surgery, (iii) allergy to the drug used in the study, (iv) chronic kidney disease (estimated glomerular filtration rate < 60 mL/min), (v) liver cirrhosis, and (vi) refusal to participate. The patients were blinded to the intervention and randomly assigned into 2 groups: epinephrine (EN) and control (C) groups. A block-of-4 randomized sequence was generated using www.randomization.com and concealed by opaque envelopes. The process was done by a research coordinator who was not involved in the study. The flow of patients in this study is summarized in Figure 1.
3 experienced arthroplasty surgeons (RN, KC, and CP) performed all the procedures with the same surgical techniques. All operations were carried out under spinal anesthesia and adductor canal block. A tourniquet pressure of 300 mmHg was inflated before skin incision and deflated after skin closure. A mini-medial parapatellar approach was used (5 (link)). The neutral mechanical axis of the lower limb was restored. After trial components removal, a scrub nurse, who did not take part in the study, opened the concealed envelope and assigned the patients to the allocated treatment.
LIA, including 20 mL 0.5% bupivacaine, 30 mg ketorolac, and 0.6 mg epinephrine (1:1000) was used in the EN group while in the C group similar ingredients without epinephrine were used. LIA in each group was diluted with normal saline until the total volume was 100 mL. The surgeon was blinded to the intervention and injected LIA into 4 areas (25 mL per area); (i) posterior, posteromedial and posterolateral capsules, (ii) medial gutter, (iii) lateral gutter, and (iv) quadriceps muscles, retinacular tissue, pes anserinus, suprapatellar and infrapatellar fat pads (6 (link)). Cemented Nexgen LPS-Flex fixed bearing prostheses (Zimmer, Warsaw, IN, USA) were implanted without patellar resurfacing. A vacuum drain was placed intra-articularly and retained for 48 hours after surgery. The same rehabilitative program was started on the 1st postoperative day. For postoperative pain management until 48 hours after surgery, all patients received intravenous parecoxib (40 mg) every 12 hours and oral acetaminophen with codeine (300/15 mg) every 6 hours. Intravenous morphine (2 mg) every 2 hours was given as a rescue drug. All patients and outcome assessors were blinded to the intervention. Postoperative visual analog pain score (VAPS, ranging from 0 [no pain] to 10 [extreme pain]) and morphine consumption were recorded every 6 hours until 48 hours after TKA. Before discharge, postoperative range of motion (ROM) and complications including infection, skin necrosis, and wound complication were also recorded.