Local and Regional Anesthesia最新文献

Objective: Cervicogenic headache (CEH) is a condition resulting from upper cervical spine dysfunction and associated structural and soft tissue abnormalities, significantly impacting patients' quality of life. To acquire better therapeutic results, we presented a novel ultrasound-guided "three in one" approach plus interfascial plane (IFP) blocks for the treatment of CEH. This approach allows for the modulation of C2 dorsal root ganglion (DRG), third occipital nerve (TON), and C3 medial branch with one-point puncture. Additionally, it allows for IFP blocks between the upper neck and occipital muscles within the same scanning plane.

Patients and methods: We evaluated patients diagnosed with CEH from July 2021 to December 2022 in our pain clinic. We included those who did not respond to conservative treatment and single occipital nerve block, therefore received nerve block or pulsed radiofrequency (PRF) using the "Three in One" approach plus IFP blocks. The accuracy of the ultrasound-guided C2 DRG puncture procedures was confirmed through fluoroscopy with C-arm and the sensory testing of PRF. The therapeutic effect of these interventions was assessed using the numerical rating scale (NRS) scores during telephone follow-ups at 1, 3, and 6 months.

Results: Utilizing the "Three in One" approach, a total of 5 patients diagnosed with CEH underwent nerve block plus IFP blocks, while 2 patients underwent PRF plus IFP blocks. Employing ultrasound-guided C2 DRG puncture procedures, the needle tip's correct placement was confirmed through both fluoroscopy and sensory testing of PRF. Notably, none of the cases experienced any complications associated with the approach. Subsequent follow-up assessments revealed an improvement in the NRS scores for CEH in all patients.

Conclusion: The ultrasound-guided "Three in One" approach plus IFP blocks may be a potential effective method for the treatment of CEH.

Background: The aims of this study are to analyze the association between the number of recorded pain scores and baseline pain following surgery, analgesia technique, and patient demographics, as well as the substitution of missing data with the results from mean substitution, last observation carried forward, regression imputation, multiple imputation, and mixed models.

Methods: This retrospective chart review was approved by the Institutional Review Board (IRB). The following data were collected: patient demographics (age, gender, body mass index (BMI), race, and ethnicity); surgery type and date; analgesia with or without transversus abdominis plane (TAP) block; as well as the time, date, and value for all postoperative pain scores on the first postoperative day (POD). The following null hypotheses were tested: (1) the number of pain recordings will be independent of TAP block analgesia, baseline pain on POD 1, and patient demographics; and (2) there will be no significant differences in pain scores with and without TAP block analgesia following complete case analysis, mean substitution, last observation carried forward, regression imputation, multiple imputation, and mixed models.

Results: This study analyzed 486 patients including 2562 recorded pain scores. An increase in age by one year is, on average, associated with a 0.04 (95% confidence interval (CI) -0.060 to -0.025) decrease in the number of pain scores recorded (p < 0.001). Black race is associated with 0.763 less pain scores, on average (95% CI -1.49 to -0.039) and this value is statistically significant (p = 0.039). All datasets with substituted values for missing data yield lower pain scores for patients who did not receive TAP block. Significant differences in recorded pain scores are only noted for scores recorded between 0400 and 0759 and 1600-1959 in mixed models.

Conclusion: Discrepancies in pain score recordings among patients are associated with age and black race. When these discrepancies are addressed with statistical methods, clinically significant differences are appreciated.

Purpose: Neonates present unique challenges for pediatric surgical teams. To optimize outcomes, it is imperative to standardize perioperative care by using early extubation and multimodal analgesic techniques. The quadratus lumborum (QL) block provides longer duration and superior pain relief than other single-injection abdominal fascial plane techniques. The purpose of this case series was to report our initial experience with QL blocks in neonatal patients treated with intestinal ERAS.

Patients and methods: Ten neonates requiring intestinal surgery at a single tertiary care center who received QL blocks between December 2019 and April 2022 for enhanced recovery were studied. Bilateral QL blocks were performed with 0.5 mL/kg of 0.25% ropivacaine per side with an adjuvant of 1 mcg/kg of dexmedetomidine.

Results: Gestational age at birth ranged from 32.2 to 41 weeks. The median age, weight, and American Society of Anesthesiologists (ASA) score at the time of surgery was 5 days [range 7.5 hours, 60 days], 2.84 kg [range 1.5, 4.5], and 3, respectively. Bilateral QL blocks were performed without complications in all patients. Two patients were outside the neonatal range from birth to surgery, but were under 42 weeks gestational age when corrected for prematurity. All patients were extubated with well-controlled pain, and no patient required reintubation within the first 24 hours. Postoperatively, median cumulative morphine equivalents were 0.16 mg/kg [range 0, 0.79] and six patients received scheduled acetaminophen. Morphine (0.1 mg/kg) was administered to patients with a modified neonatal infant pain scale (NIPS) score greater than or equal to 4, and pain was reassessed 1 hour after administration (Appendix).

Conclusion: When developing intestinal ERAS protocols, Bilateral QL blocks may be considered for postoperative analgesia in the neonatal population. Further prospective studies are required to validate this approach in neonates.

Purpose: Procedure discomfort can limit electrodiagnostic studies. Reducing discomfort can maximize the benefits of these diagnostic tools. This study targeted the discomfort associated with nerve conduction studies (NCS).

Patients and methods: This was a prospective randomized double-blind placebo-controlled study comparing the effect of topical lidocaine gel (2%) versus analgesic-free lubricant gel (K-Y gel) on pain perception during NCS. Sequential patients (n=130) referred for routine NCS participated in the study. We applied 1 mL of lidocaine gel to one palm, and 1 mL of K-Y gel to the other as a control. After 20-45 min of application, graded increments of electrical stimulation intensity were delivered to record the median and ulnar mixed palmar nerve responses. Patients were then asked to score the degree of pain felt from electrical stimulation over each palm using the Wong-Baker Faces Pain Scale (WBFPS) and the Numeric Rating Scale (NRS), independent of baseline pain.

Results: Mean WBFPS and NRS scores for lidocaine-treated palms were significantly lower than those for controls using parametric paired t-test (3.79 vs 4.37 and 3.35 vs 3.78 respectively, all p-values<0.05). Subgroup analysis showed a significant decrease in mean scores in females, patients aged ≤50 years, patients without a history of previous NCS, and patients without comorbidities (all p-values<0.05). Median scores using nonparametric Wilcoxon ranked test also showed statistically significant differences (all p-values<0.05).

Conclusion: The results indicate that topical lidocaine 2% gel reduces discomfort associated with NCS. However, despite the statistical significance, clear clinical significance may be lacking. Clinical implementation may be considered for the subgroups that showed the greatest benefit. Further studies that incorporate more efficient drug delivery methods may yield better results.

Purpose: The study examined the pharmacokinetic profile of fixed formulation mixtures comprising 225 mg of ropivacaine for local infiltration analgesia with or without epinephrine, and femoral nerve block in older patients presenting for orthopedic surgery and explored potential influences of block type, age, and body weight on this profile.

Patients and methods: Twenty four patients scheduled for total knee arthroplasty were randomly assigned to three groups: femoral nerve block, local infiltration analgesia with epinephrine and local infiltration analgesia without epinephrine. Blood samples were collected at 10, 30, 60, and 120 min following the block and total plasma concentrations of ropivacaine were quantified by high performance liquid chromatography.

Results: The mean individual peak total plasma concentrations of ropivacaine in local infiltration analgesia with and without epinephrine, and femoral nerve block group were 0.334, 0.490 and 0.545 μg mL^-1 (p = 0.16). Local infiltration with epinephrine group had significantly lower plasma ropivacaine concentrations at 30, 60 and 120 minutes. The plasma ropivacaine concentrations exceeded 2.2 μg mL^-1 in one patient. Age, but not body weight, had a moderate correlation with peak plasma ropivacaine concentration (r = 0.37, p = 0.08).

Conclusion: Administration of a fixed 225 mg dose of ropivacaine for local infiltration analgesia with epinephrine and femoral nerve block results in plasma ropivacaine concentrations below the toxicity threshold, indicating their safety. The use of local infiltration analgesia with epinephrine provides a greater safety margin, as local infiltration analgesia without epinephrine may lead to ropivacaine concentrations associated with symptoms of local anesthetic toxicity.

Purpose: Several studies have applied lumbar spinal anesthesia (SA) with isobaric/hyperbaric bupivacaine and opioids in elective laparoscopic cholecystectomy (LC), documenting a superiority of the methodic over general anesthesia (GA) in terms of perioperative pain, nausea, and vomiting, though with a notable incidence of intraoperative right shoulder pain, potentially responsible for conversion to GA. This case series presents an opioid-free scheme of segmental thoracic spinal anesthesia (STSA) with hypobaric ropivacaine, reporting its benefits mainly in terms of shoulder pain occurrence.

Patients and methods: Hypobaric STSA was performed in nine patients undergoing elective LC between May 1 and September 1, 2022. The level of the needle insertion was included between T8 and T9, via a median or a paramedian approach. Midazolam (0.03 mg/kg) and Ketamine (0.3 mg/kg) were used as adjuvants for intrathecal sedation, followed by the administration of hypobaric ropivacaine 0.25% at a dose of 5 mg and then isobaric ropivacaine at a dose of 10 mg. Patients were placed in anti-Trendelenburg position for the entire duration of surgery. LC was conducted through the standard 3 or 4 ports technique with pneumoperitoneum maintained at a pressure of 8-10 mmHg.

Results: Mean patient age was 75.7 (±17.5) years, with a mean ASA score and Charlson comorbidity index (CCI) of 2.7 (±0.7) and 4.9 (±2.7), respectively. STSA was completed without complications in all patients, with no need for conversion to GA. Mean operative time and SA duration were 37.5 (±8.7) and 145.2 (±21.8) min, respectively. Intraoperatively, no shoulder or abdominal pain and nausea were reported, with only four and two patients requiring vasopressor and sedative intravenous drugs, respectively. Postoperatively, overall mean VAS pain score and within the first 12 hafter surgery were 3 (±2) and 4 (±2), respectively. Median length of stay was 2 (range = 1-3) days.

Conclusion: Hypobaric opioid-free STSA appears to be a promising approach for laparoscopic surgeries, with minimal to null occurrence of shoulder pain. Larger prospective studies are required to validate these findings.

One hundred ninety-five patients presenting with post-COVID symptomology, including parosmia and dysgeusia, underwent reversible stellate ganglion blockade. Stellate ganglion blockade was performed at an outpatient facility, and patients were evaluated via survey at seven days post-injection. Of the 195 participants, ages ranged from 18-69 years of age with the breakdown of sexes being females n = 157 and males n = 38. The most significant finding was a reported improvement in olfaction post-injection in 87.4% of subjects. The effectiveness of this novel treatment for post-COVID is promising and warrants further investigation.

Purpose: This study aims to evaluate if the addition of deep parasternal plane blocks to a pre-existing enhanced recovery pathway for pediatric cardiac surgery improves outcomes.

Patients and methods: A retrospective review through an EMR query from June 2019 to June 2021 was performed for patients less than 18 years of age who underwent cardiac surgery via median sternotomy and were extubated immediately following surgery in a single academic tertiary care hospital. Patients receiving deep parasternal blocks as part of an enhanced recovery protocol were compared to similar patients from the year prior to block implementation.

Results: The primary outcome was intraoperative and postoperative opioid consumption. Secondary outcomes were pain scores, intensive care unit (ICU) length of stay and time to first oral intake. There was a statistically significant reduction in intraoperative opioid administration and pain scores in the first 24 hours post-operatively. There was also a statistically significant reduction in ICU length of stay. There was no statistically significant difference in post-operative opioid consumption and time to first oral intake.

Conclusion: Bilateral deep parasternal blocks may reduce opioid consumption, provide effective postoperative pain control, and result in decreased length of intensive care unit stay across both simple and complex pediatric cardiac procedures when added to a pre-existing enhanced recovery protocol.

Purpose: The aim of this study was to evaluate the occurrence of early (<6 weeks) post-operative complications following ulnar nerve decompressions at the cubital tunnel performed under regional anesthesia compared to those performed under general anesthesia.

Methods: In situ ulnar nerve decompressions at the cubital tunnel performed at a single institution from 2012 through 2019 were retrospectively reviewed. Post-operative complications were compared between subjects who underwent the procedure with regional versus general anesthesia.

Results: Ninety-one ulnar nerve in situ decompressions were included in the study, which were performed under regional anesthesia in 55 and general anesthesia in 36 cases. The occurrence of post-operative complications was not significantly different between patients who received regional (n = 7) anesthesia and general (n = 8) anesthesia. None of the complications were directly attributed to the type of anesthesia administered. The change in pre- and post-operative McGowan scores were not significantly different between anesthesia groups (p = 0.81).

Conclusion: In situ ulnar nerve decompression at the cubital tunnel under regional anesthesia does not result in increased post-operative complications compared to those surgeries performed under general anesthesia. In situ ulnar nerve decompression performed under regional anesthesia is a safe and reliable option for patients who wish to avoid general anesthesia.

Level of evidence: III.