Local and Regional Anesthesia最新文献

Objective: To evaluate the efficacy of modified cocktail analgesia in relieving pain after minimally invasive chevron osteotomy for hallux valgus.

Methods: A retrospective cohort study was conducted to analyze the clinical data of 90 patients with moderate to severe hallux valgus admitted to our hospital from January 2020 to December 2023. Based on the treatment method and the number of affected limbs, the patients were divided into three groups: the modified group (Imp) treated with minimally invasive chevron and Akin (MICA) osteotomy combined with modified cocktail therapy, the traditional group (Tro) treated with MICA osteotomy combined with conventional cocktail therapy, and the control group (NC) treated with MICA osteotomy alone without cocktail therapy. The visual analog scale (VAS) scores for ankle-foot pain from 6 hours preoperatively to 14 days postoperatively, the need for postoperative rescue analgesia, adverse reactions, and complications were observed and compared among the three groups.

Results: There were no significant differences in basic conditions such as age and BMI among the three groups. It is in line with the epidemiological statistics of hallux valgus in terms of gender. The VAS scores at 6 hours and 1 day postoperatively were significantly lower in the modified group [(0.67±0.60), (0.68±0.59) respectively] compared to the traditional group [(0.82±0.50), (0.78±0.90) respectively] (P < 0.05). There were no statistically significant differences in VAS scores between groups at 6 hours preoperatively and 7 days and 14 days postoperatively (P > 0.05). Five patients (5.56%) in the modified group required postoperative rescue analgesia, which was significantly fewer than the 12 patients (13.33%) in the traditional group (P < 0.05).

Conclusion: Based on the comprehensive statistical results and clinical significance, the modified cocktail therapy has certain clinical reference value in the short-term analgesia management after MICA. It is beneficial for the early postoperative rehabilitation functional exercise of patients and has a good safety effect. It can be used as an optional option for early postoperative pain control. However, it is necessary to objectively recognize the timeliness of its therapeutic advantages. Its long-term analgesic effect shows no significant clinical difference from the traditional cocktail therapy and the simple MICA procedure.

Purpose: Peripheral nerve block safety and pharmacology for patients with inherited antithrombin III (ATIII) deficiency remains unclear because of the rarity of the disease. Here, we report a case of unexpectedly prolonged motor and sensory inhibition following single-shot femoral and sciatic nerve blocks in a patient with inherited ATIII deficiency. We hypothesized that venous stasis, microcirculatory impairment, elevated peripheral venous pressure, and increased local tissue pressure might have contributed to prolonged nerve dysfunction and peripheral nerve injury.

Case report: The patient was a 58-year-old man (170 cm, 69 kg) with inherited ATIII deficiency. He was scheduled for 1-hour surgical debridement of recurrent venous stasis ulcers with microcirculatory impairment on his lower left leg. Nerve blocks resulted in motor and sensory deficits in the lower leg that lasted 2 and 8 days, respectively. The prolonged duration of this nerve block might have been related to his inherited ATIII deficiency. This condition can contribute to thrombosis of vessels such as the inferior vena cava, potentially leading to venous microcirculatory impairment in the lower limbs and complex coagulopathy.

Conclusion: While peripheral nerve blocks are widely used for their efficacy and safety, the risk-benefit profile of regional anesthesia may be atypical in patients with coagulation disorders. This case highlights the need for cautious nerve block administration in patients with inherited ATIII deficiency.

Background: Despite its association with severe postoperative pain, the use of regional anesthesia techniques for penile-inversion vaginoplasty surgery is understudied. This retrospective study aimed to assess the analgesic effects of a saddle block (ultra-low dose hyperbaric spinal anesthesia) with intrathecal (IT) morphine in transgender females undergoing penile inversion vaginoplasty.

Methods: We performed a single-centre, retrospective chart review of 72 patients who underwent penile-inversion vaginoplasty with or without saddle block with IT morphine at our institution over a 26-months period. All patients received standard multimodal intravenous analgesia, and the surgeon administered both a pudendal nerve block and a spermatic cord block as part of routine care. Our primary outcome was cumulative opioid consumption (oral morphine equivalent) at 24h postoperatively. Secondary outcomes included postoperative pain severity, duration of stay in the postoperative care unit and in-hospital, time to first opioid request and incidence of opioid- and block-related side effects.

Results: 30 patients received a saddle block with IT morphine and 42 patients received standard analgesia. We found no statistical difference in cumulative opioid consumption at 24h postoperatively (control group: 17.7 mg [5.6, 30.8] vs intervention group 12.5 mg [7.5, 22.5] P: 0.249). The addition of a saddle block was associated with clinically and statistically significant improvements in short-term postoperative pain-related outcomes in the recovery room, including mean and maximum pain severity scores, time to first analgesic request, and duration of stay. While no difference in pain scores was detected at the 24-hour time point, mixed-effects modelling demonstrated lower pain trajectories over time among patients in the intervention group, suggesting a time-dependent benefit. However, the significant time-by-group interaction (p = 0.024) indicates that the difference in pain scores between groups decreased over time. We found no differences in the rates of nausea and vomiting between groups. No saddle block procedure-related complications were reported.

Conclusion: This retrospective study suggests that despite no statistically significant difference in 24-hour opioid consumption, the addition of a saddle block with 100 mcg of IT morphine is associated with improved PACU pain scores, a longer time to first analgesic request, and a shorter PACU stay. These findings are hypothesis-generating and merit further investigation in a prospective double-blind randomized controlled trial.

Purpose: External oblique intercostal (EOI) block has recently emerged as a promising analgesic method for the upper abdominal surgery. This study aimed to assess the effect of EOI block on postoperative analgesia and early recovery following open liver resection (OLR).

Patients and methods: In this prospective, randomized, controlled trial, 64 patients scheduled for OLR were randomly allocated into EOI group and control group. EOI group received 30 mL of 0.25% ropivacaine bilaterally 30 min before induction of general anesthesia, whereas control group did not receive any block. The primary outcomes were sufentanil consumption 24 h after surgery. The secondary outcomes mainly included: the visual analogue scale (VAS) pain scores at rest and on coughing at 2, 12, 24, 48 h postoperatively; number of analgesia pump compression 24 h postoperatively; quality of recovery-15 (QoR-15) scale score 48 h after surgery; Pittsburgh sleep quality index (PSQI) score the first night postoperatively; and plasma levels of norepinephrine (NE), cortisol (Cor), high mobility group box protein 1 (HMGB1), tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) 1h before surgery and 6 h postoperatively.

Results: A total of 60 patients had completed the study (n = 30 per group). Sufentanil consumption 24 h postoperatively in EOI group was less than that in control group (mean difference: 4.45 μg, 95% CI, 1.6-7.2, P=0.003). The VAS scores at 2, 12, 24 h postoperatively; number of analgesia pump compression; and PSQI scores were significantly lower in EOI group than in control group. QoR-15 scale scores were higher in EOI group. The plasma levels of NE, Cor, HMGB1, TNF-α and IL-6 at 6 h postoperatively in EOI group were significantly lower than in control group.

Conclusion: EOI block given to patients undergoing OLR could provide effective postoperative analgesia, enhance the quality of postoperative recovery, and attenuate postoperative stress and inflammation.

Introduction: Recently, concerns have been raised regarding the impact of anesthetic choice on outcomes for patients undergoing hypospadias repair. It has been suggested that caudal epidural anesthesia (CEA) may be associated with increased postoperative complications, such as urethrocutaneous fistula and glanular dehiscence. However, subsequent studies have found no association between CEA and increased complications. Spinal anesthesia (SA) is another technique that can provide surgical blockade during hypospadias repair. However, no studies have examined outcomes for pediatric patients undergoing hypospadias repair under awake SA.

Methods: We performed a single-center retrospective review on all patients who underwent single-stage primary hypospadias repair from 2016 until 2023. Data collected included patient demographics, anesthetic details, severity of hypospadias, duration of procedure, and postoperative complications.

Results: 805 patients underwent single-stage hypospadias repair during the study period. 117 (14.5%) had GA alone, 563 (70%) had GA with CEA, and 125 (15.5%) had SA. Duration of surgery was significantly longer for patients in the GA and CEA groups compared to the SA group, and more patients in the GA and CEA groups had a higher severity of hypospadias. We did not find significant differences in the odds ratio for postoperative complications between groups.

Discussion: In our retrospective analysis, we did not find a difference between anesthetic groups in the rate of postoperative complications. Patients who had SA were younger and had a shorter median surgical time. Because SA has a limited duration, patients with more complicated pathologies may not be offered SA as an option. SA is an underutilized technique for pediatric urologic procedures, but has several benefits over GA for infants and young children.

Conclusion: SA can be successfully utilized for hypospadias surgery in pediatric patients without an increase in postoperative complications. Future studies on this topic are warranted due to significant baseline differences between patient groups.

Purpose: This study examined whether chronic opioid use reduces the effectiveness of brachial plexus block in patients undergoing upper extremity surgery.

Patients and methods: Patients undergoing surgery with brachial plexus blocks were divided into two groups: opioid-dependent (daily opioid use for ≥1 month) and control (no opioid use for ≥3 months). Pain scores and opioid use were recorded over 72 hours postoperatively.

Results: Forty-six patients were included (23 opioid-dependent and 23 control). The median (IQR) NRS scores upon PACU arrival were 0 (0-0) in the control group and 0 (0-5) in the opioid group (p=0.0101). The duration of the nerve block was shorter in opioid-dependent patients (14 versus 22 hours; p=0.0035).

Conclusion: Chronic opioid users experienced shorter brachial plexus block duration and more postoperative pain after being discharged home.

Background: Both selective nerve root blocks and erector spinae plane blocks are common regional blocks in clinical practice, and they have both been shown to relieve acute and chronic pain from herpes zoster. Although selective nerve root block (SNRB) may be the theoretically most effective method of drug delivery to the DRG and requires only a small dose of drug with few complications associated with it, it does not provide effective analgesia for a prolonged period of time. However, continuous erector spinae plane block is considered to be one of the most promising minimally invasive means of analgesia that not only provides prolonged analgesia but is simple to perform, has fewer complications, and facilitates indwelling catheters. In this case report, we describe the possible synergistic mechanism of action of SNRB, continuous erector spinae plane block, and effective relief of postherpetic neuralgia with improved patient outcome.

Case presentation: In this case report, we present the case of an 81-year-old woman with comorbidities including diabetes mellitus, hypertension, and a history of multiple surgeries. She suffered from postherpetic herpes zoster pain in her left thoracic back. Despite trying various treatments such as antiviral medication, physical therapy, traditional Chinese medicine, and a single thoracic paraspinal nerve block, the pain persisted. In consultation with her anesthesiologist, the patient opted for a nerve root block combined with a continuous erector spinae plane block. The erector spinae plane catheter was removed after 14 consecutive days of infusion, although hemolytic Staphylococcus was found in the wound secretions sent for examination, antibiotic treatment was not required. At the 2-year follow-up, the patient remained free of pain recurrence.

Conclusion: Selective nerve root block combined with continuous erector spinae plane block relieves herpes zoster acute phase pain and herpes zoster neuralgia and improves patients' quality of life.

Background and aim: Interscalene Brachial Plexus Block (ISBPB) is commonly used for shoulder surgery anesthesia to reduce opioid use and general anesthesia complications. However, it may cause diaphragmatic paresis due to phrenic nerve involvement. This study compares the incidence of hemidiaphragmatic paralysis and the frequency of side effects-including hemodynamic changes and postoperative complications-between the Extrafascial (ExF) and Intrafascial (InF) approaches for ISBPB using reduced anesthetic volume. The aim is to assess whether the ExF approach may be preferable in patients with reduced cardiopulmonary reserve (eg, COPD or heart failure).

Methods: A retrospective study was conducted at Federico II University in Naples, Italy, including 61 patients undergoing shoulder surgery from January 2024 to October 2024. About 33 patients received ExF while 28 received InF ISBPB, all with Ropivacaine 0.5% (10 mL), Mepivacaine 2% (5 mL), and Dexamethasone (4 mg). The primary outcome was the incidence of hemidiaphragmatic paralysis, evaluated via ultrasound pre and 30 minutes after the block by assessing diaphragm excursion, thickness, and thickening fraction. Secondary outcomes included intraoperative hemodynamic changes and postoperative complications: pain (NRS), analgesic/antiemetic requests, PONV, pruritus, shivering, anxiety, and discomfort.

Results: The TF significantly decreased after the block in both groups (p < 0.001), with no intergroup. Diaphragm paralysis occurred in 28 patients in each group (p = 0.093), without clinical respiratory effects. The InF group had more hypotension episodes (100% vs 30.3%, p = 0.002), and significantly lower mean and systolic blood pressure values at 1 and 2 hours after-block. No cases of anxiety, pruritus, shivering, or discomfort were observed. NRS was higher in the InF group at 6 hours but lower at 12 and 24 hours. Analgesic/antiemetic needs were similar; PONV was more frequent in the ExF.

Conclusion: Both approaches resulted in similar rates of hemidiaphragmatic paralysis. However, ExF was associated with fewer hemodynamic effects, suggesting potential benefit in high-risk cardiopulmonary patients.

Background: The influence of nerve blocks on treatment bias, a form of implicit bias where patient characteristics lead to inequal treatment, remains unexplored.

Methods: This was a pilot study that utilized a survey to collect data from nurses at a single academic medical center. The following information was collected from the respondents: age (years); gender (male, female, other); nursing experience (years); specialization (surgery, medicine, emergency, perioperative, other); prior formal training on pain management in patients with or without nerve blocks; and how frequently they encounter patients with nerve blocks. Hypothetical clinical scenarios were presented to investigate pain medication dosing strategies that were rated with a 3-point Likert scale (more, equal, or less medication). Impacts of various patient conditions (alcohol abuse, anxiety, depression, marijuana use, nerve block, opioid abuse, and substance abuse) on pain medication and opioid dosing strategies were further investigated with a 5-point Likert scale (ranging from strongly disagree to strongly agree).

Results: Overall, the survey had a 32.59% response rate. Treatment bias towards patients with nerve blocks was evident in 21.43% (9/42) and 11/30 (36.67%) of respondents for pain medications and opioids, respectively.

Conclusion: This pilot study suggests that patients with nerve blocks may be treated differently than those without blocks, regardless of their reported pain. However, given the study's exploratory design, these findings should be interpreted as hypothesis-generating.

Purpose: Substantial understanding of anatomic landmarks remains mandatory for regional anesthesia procedures of the lower limbs, even in times of ultrasound-guided techniques. Theoretically, applying a diagonal vector (DIVE) from the posterior superior iliac spine towards the spinous process of lumbar vertebra 3 leads to a higher error tolerance and closer nerve approximation when compared to Chayen's approach. The purpose of this study was to compare both techniques regarding clinical applicability, accuracy and risk profile.

Patients and methods: Lumbar plexus block was performed bilaterally according to Chayen's technique and the DIVE method in embalmed bodies donated to science. The posterior medial half of the psoas major muscle was predefined as the puncture target area. Essential anatomical landmarks were labelled, photographed and a computer-aided analysis of the images was conducted. Both approaches were compared regarding the puncture success rate, spatial nerve approximation and complications such as vessel or kidney punctures.

Results: Both techniques were applied bilaterally on 34 embalmed bodies (50% male, mean age ± standard deviation 82 ± 8 years, height 167 ± 10cm) and led to similar success rates of a psoas muscle hit (Chayen vs DIVE 86.3% vs 82.8%). DIVE punctures were more often localized in the medial third of the psoas (p<0.001), whereas the risk for vessel or kidney punctures was similar (p=0.473; p=0.367, respectively).

Conclusion: Punctures according to the DIVE method resulted in a higher puncture accuracy compared to Chayen's technique with comparable practicability and risk profile. When using the DIVE Block, a window for a successful puncture can be expected between a quarter and a third of the PSIS- L3SP distance.