Indian Journal of Anaesthesia最新文献

Posterior upper cervical spine surgeries are associated with significant postoperative pain due to extensive soft tissue and muscular dissection, leading to increased nociception transmitted via multi-segmental dorsal rami innervation. We describe the application of a novel ultrasound-guided cervical paraspinal interfascial plane [semispinalis obliquus plane (SOP)] block as a part of multimodal analgesia in ten patients undergoing occipitocervical or atlantoaxial procedures. All patients achieved adequate analgesia; 3 of 10 required minimal rescue fentanyl within the first 24 h, and no block-related complications were observed. The SOP block is a simple, safe, and potentially effective adjunct for perioperative multimodal analgesia in posterior upper cervical spine surgeries, warranting further evaluation.

Fascial plane blocks in children are defined as the administration of local anaesthetic into myofascial or aponeurotic planes to reach nerves traversing these planes. They have expanded rapidly from adult practice to paediatrics, with reported benefits across thoracic, abdominal, and lower-extremity surgery. Paediatric evidence now includes narrative reviews, randomised controlled trials, and meta-analyses; however, variability in nomenclature, dosing, and spread, and inconsistent comparators (caudal/neuraxial vs peripheral) continue to fuel controversy. This review synthesises current paediatric data on thoracic block like serratus anterior plane block, erector spinae plane block, abdominal-like rectus sheath block, transversus abdominal plane block, quadratus lumborum block, and lower-extremity (fascia iliaca, adductor canal) blocks. It highlights paediatric anatomical and physiological considerations and appraises safety (including local anaesthetic systemic toxicity) and catheter techniques. The review also maps limitations and research priorities.

The sciatic nerve block is a cornerstone of regional anaesthesia for lower limb surgeries, providing effective analgesia and anaesthesia. This narrative review explores the ultrasound-guided sciatic nerve block at proximal levels, emphasising anatomical considerations, sonoanatomy, and various approaches. A detailed understanding of the sciatic nerve's course and surrounding anatomy at different levels enables practitioners to select the most appropriate technique for optimal outcomes. This article, Part A, focuses on proximal approaches, discussing their advantages, technical nuances, and clinical applications. Dual guidance, which combines ultrasound and peripheral nerve stimulation, is emphasised for improved accuracy, safety, and enhanced success rates. High-resolution ultrasound imaging enhances precision, minimises complications, and ensures precise deposition of local anaesthetic. In the subsequent article (Part B), we will delve into the sciatic nerve block approaches at distal levels, completing a comprehensive guide to ultrasound-guided sciatic nerve blockade. This review aims to serve as a valuable, updated resource for regional anaesthesia enthusiasts and trainees seeking to enhance their knowledge and clinical expertise.

Background and aims: Paravertebral block (PVB) and erector spinae plane block (ESPB) are commonly used truncal blocks for thoracic and upper abdominal surgeries in adults and children. ESPB is a superficial block, easy to perform, and relatively safe with fewer complications compared to PVB, which is a deeper block, requiring more technical expertise. We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) to generate evidence on the analgesic efficacy of ESPB compared with PVB.

Methods: The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO). We systematically searched PubMed, Scopus, and Google Scholar for RCTs comparing ESPB with PVB in children from inception to date. Time to first rescue analgesic dose was taken as the primary outcome. Analgesic consumption in the first 24 h in the postoperative period, pain scores at different time intervals, and postoperative complications were recorded as secondary outcomes. Random-effects meta-analyses were performed in R (REML estimator), reporting pooled effect, 95% confidence interval (CI), τ², I², and the Q test for heterogeneity.

Results: Four trials (n = 252) were pooled for the time to first rescue analgesia. ESP block was associated with a shorter time to rescue versus PVB: mean difference (MD) = -0.50 h (95% CI: -0.84, -0.17) with negligible heterogeneity (τ² = 0; I² =0%; Q (3) = 0.93, P = 0.818). No significant differences were seen in the pain scores at 0 h SMD = -0.10 (95% CI: 0.41, 0.22); I² = 9.9% (Q (2) = 2.07, P = 0.354) and 12 h SMD = 0.20 (95% CI: -0.20, 0.61); I² = 43.2% (Q (2) = 3.47, P = 0.176). One study reported hematoma in 10% cases, and another study reported pneumothorax in 3% cases in the PVB group. No complications were seen in ESPB group.

Conclusion: The evidence suggests PVB prolongs postoperative analgesia compared to ESPB in children, but with an increased rate of complications.

Background and aims: The external oblique intercostal plane (EOIP) block targets the lateral and anterior branches of T6-T10 intercostal nerves, providing upper abdominal wall analgesia. Its superficial location and ease in the supine position make it a promising option for multimodal analgesia. This systematic review and meta-analysis evaluated its efficacy versus other fascial plane blocks, wound infiltration, or no block in adults undergoing abdominal surgery.

Methods: Following PRISMA guidelines (PROSPERO-CRD420251057391), databases were searched for randomised controlled trials (RCTs) comparing the EOIP block with other fascial plane blocks, wound infiltration, or no block. The primary outcome was 24-hour postoperative opioid consumption. The secondary outcomes were pain scores at rest and movement, intraoperative opioid use, time to first analgesic request, rescue analgesia needs, quality of recovery (QoR)-15 scores, and postoperative nausea and vomiting (PONV). Trial sequential analysis (TSA) was performed to assess the robustness of the primary outcome.

Results: Seventeen RCTs (n = 1032) were included. EOIP block significantly reduced 24-hour opioid consumption [standardised mean difference (SMD): -1.32; 95% confidence interval (CI): -1.83, -0.82; P < 0.001); lowered pain scores at 6, 12, and 24 hours; decreased intraoperative fentanyl use; prolonged analgesia duration; reduced rescue analgesia needs; improved QoR-15 scores; and lowered PONV incidence. TSA confirmed conclusive evidence for EOIP versus no block but indicated further trials are needed versus fascial plane blocks.

Conclusion: As compared to other fascial plane blocks, wound infiltration, or no block, the EOIP block provides opioid-sparing analgesia, sustained pain relief, and enhanced recovery in abdominal surgery. However, due to heterogeneity and a low-to-moderate certainty of evidence, further high-quality RCTs are warranted.

Background and aims: Inadequate pain control can cause a delay in recovery; hence, adequate analgesia is of much importance. The thoracolumbar interfascial plane (TLIP) block is a relatively newer block which has shown promising effects in pain control. In this study, we aim to determine the efficacy and safety of dexmedetomidine in enhancing the impact of local anaesthetic in TLIP block in patients undergoing lumbar surgeries.

Methods: 60 patients aged 18-70 years were randomised to Group Plain [modified TLIP block with 20 mL of 0.25% ropivacaine bilaterally with general anaesthesia (GA)] and Group Dexmed (modified TLIP block with 0.25% ropivacaine along with 0.5 µg/kg dexmedetomidine bilaterally with GA). The primary outcome was to assess the total perioperative opioid consumption in the first 24 h. The secondary outcomes were to assess pain score upon arriving in the post-anaesthesia care unit, time to first analgesic need after surgery, postoperative opioid consumption in 24 h, and incidence of adverse events, including nausea and vomiting. Continuous variables were analysed using an independent t-test. The variables which had a non-normal distribution were analysed using the Mann-Whitney U test. Paired continuous data following a normal distribution were analysed using the Paired T-test. Categorical variables were analysed using the Chi-square test. The statistical analysis was performed using Jamovi 2.4.

Results: The total perioperative opioid consumption in Group Plain was 653.33 [standard deviation (SD): 250.4 µg] and that in Group Dexmed was 523.6 (SD: 258.6 µg), with a mean difference of 129.67 [95% confidence interval (CI): -1.89, 261.22] (P = 0.053). However, the first request for analgesia was significantly prolonged in the Group Dexmed with a median of 180 minutes [interquartile range (IQR): 97.50-232.50; range (Min-Max: 30-360) min] vs 90 minutes in Group Plain [(IQR):45-120; range (Min-Max: 15-360) min], P = 0.001. Postoperative pain scores were comparable between both groups at different time points in 24 hours, except at 0 h rest and movement, and 3h at movement. The median highest postoperative nausea and vomiting (PONV) scores within the 24 h postoperative period did not differ significantly between the groups (P = 0.073).

Conclusion: TLIP block with dexmedetomidine as an adjuvant did not decrease cumulative fentanyl consumption as compared to TLIP block with ropivacaine alone. But the time to first request of analgesia was increased in the Group Dexmed.

Fascia iliaca compartment block (FICB) is a plane block, targeting the three main branches of the lumbar plexus, including the femoral nerve, lateral femoral cutaneous nerve, and obturator nerve. It is a useful regional anaesthesia technique for lower limb procedures, particularly for hip and knee surgeries. While both traditional landmark-based and newer ultrasound-guided approaches exist, the latter offers more reliable coverage of the target nerves. Through this narrative review, we wish to bring forth the anatomical considerations that need to be kept in mind, as well as the indications and contraindications of administering an ultrasound-guided FICB. The review describes in detail the two main approaches of ultrasound-guided FICB, including the infrainguinal and suprainguinal approaches, with emphasis on the fact that the suprainguinal approach provides a more extensive spread of local anaesthetic (LA), a more reliable blockade of the obturator nerve, greater pain relief, and reduced opioid consumption. Further, being a plane block, a large volume of LA needs to be administered for adequate effect. To conclude, ultrasound-guided FICB is a superficial, safe, and easy-to-learn block with a low complication rate.

Background and aims: The external oblique intercostal (EOI) plane block is a new interfascial plane block covering both the lateral and anterior cutaneous branches of the intercostal nerves. The literature on its use is scarce in paediatric abdominal surgeries.

Methods: Forty American Society of Anesthesiologists physical status I/II patients aged between 2 months and 7 years undergoing upper abdominal surgery with unilateral subcostal incision were randomised: Group E received an ultrasound guided unilateral EOI block using 0.5 mL/kg of 0.2% ropivacaine with general anaesthesia, whereas Group C received general anaesthesia (GA) only. All patients received GA in a standardised manner. Any increase in heart rate or mean arterial pressure of more than 20% was treated with intravenous (IV) fentanyl 0.5 µg/kg. Postoperatively, tramadol 1 mg/kg IV was given as rescue analgesia if the pain score was ≥4. The study's primary outcome was to assess the intraoperative fentanyl consumption. Secondary outcomes included postoperative pain score at 1, 4, 8, 16, and 24 h at rest, time to first rescue analgesic administration, 24 h tramadol consumption, and incidence of side effects such as nausea and vomiting. P <0.05 were considered statistically significant.

Results: The mean intraoperative fentanyl consumption was lower in Group E: 12 [standard deviation (SD: 10.1] [95% confidence interval (CI): 7.3, 16.7] µg as compared to Group C: 20.5 (8.35) [95% CI: 16.7, 24.3] µg (P = 0.005). Total mean 24 h tramadol consumption was statistically lower in Group E: 29.3 (SD: 12.5) [95% CI: 23.4, 35.2] mg vs 62.1 (SD: 19.7) [95% CI: 52.9, 71.3] (P < 0.001). Pain scores were lower in Group E at 1, 4, 8, 16, and 24 h.

Conclusion: The single-shot EOI block can decrease perioperative opioid requirement and pain score. It can form an integral part of a multimodal analgesic regime for upper abdominal surgeries in paediatric patients.