Local and Regional Anesthesia最新文献

Purpose: Magnesium sulfate (MgSO4) may enhance the effects of local anesthetics when used as an adjuvant in peripheral nerve blocks. Our objective was to evaluate efficiency and safety of utilizing MgSO4 alongside levobupivacaine in bilateral ultrasound-guided transversus abdominis plane (US-TAP) block for postoperative pain in pediatric cancer patients who underwent abdominal surgery.

Methodology: A randomized double-blinded controlled trial at South Egypt Cancer Institute, Assiut University, Assiut, Egypt, included that 40 pediatric patients with Wilms' tumor or neuroblastoma were randomly allocated to get bilateral (US-TAP) block and divided into two groups; M group: received US-TAP with 0.6 mL/kg levobupivacaine 0.25% + 2 mg/kg MgSO4 and C group: received with 0.6 mL/kg levobupivacaine 0.25% only. FLACC scores (Face, Leg, Activity, Cry, Consolability) were used to evaluate post-operative pain, first analgesic request, total analgesic consumption, adverse effects, as well as hemodynamics were monitored for 24 h and recorded at time points (2, 4, 6, 8, 12, 18, and 24h). Parent's satisfaction at discharge, also, was evaluated.

Results: FLACC score in M group was significantly lower than in C group from 4 h to 24 h with the first analgesic request being longer (15.95 ± 1.99 vs 7.70 ± 0.80 (h); p < 0.001) and lower total analgesic consumption (231.75 ± 36.57 vs 576.00 ± 170.71 (mg); p < 0.001) when comparing M group to C group, respectively. Both groups had insignificant differences regarding hemodynamics, parent satisfaction, postoperative agitation, and side effects except vomiting occurred in two patients in the C group and one patient in the M group.

Conclusion: We conclude that adding magnesium sulphate as an adjuvant to local anaesthetic in US-TAP block for pain management in pediatric abdominal cancer surgeries resulted in better and longer analgesia, with less consumption of rescue analgesics with no serious side effects.

Objective: This prospective study aimed to compare the analgesic efficacy and adverse effects of intrathecal morphine, dexmedetomidine, and a combination of both in patients undergoing total knee replacement (TKR).

Patients and methods: This randomized prospective study was carried out in Tanta university hospital in orthopedic surgery for 6 months on 105 adult patients with American Society of Anesthesiologists Physical Status Class II and III, aged > 50 years, and scheduled for total knee replacement surgery randomly allocated into morphine group received 0.5% heavy bupivacaine plus 0.1 mg of morphine, morphine/ dexmedetomidine group, received 0.5% heavy bupivacaine plus 0.1 mg of morphine and 5 mcg of dexmedetomidine and dexmedetomidine group received 0.5% heavy bupivacaine plus 5 mcg of dexmedetomidine. The time of the first required analgesia, postoperative pain severity, the total dose of morphine, postoperative complication, and the patient's level of sedation were recorded.

Results: About half of the patients in the dexmedetomidine group requested first rescue analgesia 6 hours after the operation, significantly shorter than the other two groups. On the other hand, the other two groups show no significant difference between them regarding the first required analgesia. At rest, the dexmedetomidine group have significantly higher VAS with a significant increase in patients who required morphine as rescue analgesia than the other two groups. While at movement, patients in the dexmedetomidine group felt pain at 4 hrs postoperatively with significantly higher VAS than the other two groups. At the same time, the sedation score was significantly lower in the dexmedetomidine group than in the other two groups. 22.2% of cases in the morphine group developed nausea and vomiting with a significant difference between the three groups.

Conclusion: Despite the absence of substantial side effects, our findings did not suggest enhanced analgesia with the combination of intrathecal morphine and dexmedetomidine.

Purpose: A subcostal flank incision is required for open radical nephrectomy, which is a surgical procedure used to remove tumors of the kidney that are malignant. The erector spinae plane block (ESPB) and continuous catheter use in children are receiving more and more support by paediatric regional anaesthesiologists. Our objective was to compare systemic analgesic to continuous ESPB for pain relief in paediatric patients undergoing open radical nephrectomy.

Methods: Sixty children with cancer ASA I or II and undergoing open radical nephrectomy between the ages of two and seven participated in this prospective, randomized, controlled, and open label study. The cases were divided into two equal groups (E and T groups); Group E received ipsilateral continuous ultrasound-guided ESPB at T₉ (thoracic vertebrae), with a bolus of 0.4 mL/kg bupivacaine 0.25%. Immediately postoperatively, Group E (ESPB group) received continuous ESPB with a PCA (patient controlled analgesia) pump at a rate of 0.2 mL/kg/hour bupivacaine 0.125%. Group T (Tramadol group), Tramadol hydrochloride was administered intravenously at a dose of 2 mg/kg/8hour, which could be increased to 2 mg/kg/6hours. Then, we followed up on patients' total analgesic consumption for 48 hours following surgery, as well as the time it took for them to request rescue analgesic, their FLACC and sedation scores, and their hemodynamics and side effects immediately following surgery as well as at 2, 4, 6, 8, 12, 18, 24, 36, and 48 hours.

Results: A highly significant difference in total tramadol consumed in group T 11.97 ± 1.13 mg/kg while group E was 2.07± 1.54 mg/kg (p < 0.001). 100% patients in group T requested analgesia compared to 46.7% patients in group E (p < 0.001). From 2 to 48 hour, FLACC significantly decreased in E compared to T group (p≤ 0.006) at all-time points.

Conclusion: Ultrasound-guided continuous ESPB significantly provided better postoperative pain relief, reduced postoperative tramadol consumption and reduced pain scores compared with the use of tramadol alone, in paediatric cancer patients undergoing nephrectomy.

Background: Erector spinae plane block (ESPB) a new block described for post-operative analgesia. Since 2016 the block has become a common practice in many institutions globally. Evidence has shown that ESPB is superior to truncal and abdominal wall blocks for many thoracic and abdominal surgeries.

Case presentation: A 29-year-old male, ASA (American Society of Anesthesiologists) IIE patient presented with acute appendicitis. Patient was scheduled to undergo Laparoscopic Appendicectomy under general anesthesia (GA) with ESPB for post op analgesia. In the operating room after induction of GA patient received an ultrasound (US) guided bilateral ESPB at T10 level of the spinal cord with 20 mls of 0.25% levobupivacaine on each side. Intraoperatively the appendix was found to be normal and there was an incidental finding of perforated superior/first part of duodenum (D1). The duodenum was repaired. Patient remained hemodynamically stable intraoperatively. No intraoperative morphine was required. After uneventful extubation, the patient was transferred to post-operative anesthesia care unit (PACU). Patient reported pain score of zero on a 11-point numerical rating scale (NRS) in PACU. No morphine was required in the next 24 hours on the ward either.

Conclusion: ESPB can provide opioid free analgesia for laparoscopic repair of perforated duodenal ulcer both intra and postoperatively.

Background and aim: Percutaneous nephrolithotomy (PCNL) under epidural anesthesia has been reported to have few advantages over general anesthesia, like lower postoperative pain and less need for analgesics. There are limited studies on PCNL being performed under neuraxial anesthesia in supine position. Hence the present study was conceived to compare hemodynamic parameters in patients undergoing percutaneous nephrolithotomy (PCNL) in the supine position under combined spinal-epidural with general anesthesia (GA).

Material and methods: A prospective, randomized control trial was conducted among 90 patients who were posted to undergo elective percutaneous nephrolithotomy in the the supine position, after obtaining Institutional Ethical Committee (IEC) approval and CTRI (Clinical Trial Registry - India) registration. Patients were randomly allotted to undergo surgery either under general anesthesia (group GA) or combined spinal epidural anesthesia (group CSE) by computer-generated random number method. Hemodynamic parameters, postoperative analgesic requirement and incidence of blood transfusion were recorded and analyzed.

Results: There was no significant difference between the two groups with respect to gender, ASA grade, surgery duration, calculus size and pulse rate. There was a statistically significant reduction in mean arterial pressure from 5 to 50 minutes of surgery and less incidence of blood transfusion in patients in the CSE group. Patients who underwent PCNL in the supine position under CSE required lesser analgesics postoperatively compared to those under general anesthesia.

Conclusion: Combined spinal epidural analgesia can be used as an alternative to general anesthesia for patients undergoing PCNL in the supine position in view of less MAP and reduced postoperative analgesic and blood transfusion requirement.

Background: Successful brachial plexus blockade produces sympathetic blockade, resulting in increased skin temperature in the blocked segments. This study aimed to evaluate the accuracy of infrared thermography in predicting failed segmental supraclavicular brachial plexus block.

Methods: This prospective observational study included adult patients undergoing upper-limb surgery under supraclavicular brachial plexus block. Sensation was evaluated at the dermatomal distribution of the ulnar, median, and radial nerves. Block failure was defined as absence of complete sensory loss 30 min after block completion. Skin temperature was evaluated by infrared thermography at the dermatomal supply of the ulnar, median, and radial nerves at baseline, 5, 10, 15, and 20 min after block completion. The temperature change from the baseline measurement was calculated for each time point. Outcomes were the ability of temperature change at each site to predict failed block of the corresponding nerve using area under receiver-operating characteristic curve (AUC) analysis.

Results: Eighty patients were available for the final analysis. The AUC (95% confidence interval [CI]) for the ability of temperature change at 5 min to predict failed ulnar, median, and radial nerve block was 0.79 (0.68-0.87), 0.77 (0.67-0.86), and 0.79 (0.69-0.88). The AUC (95% CI) increased progressively and reached its maximum values at 15 min (ulnar nerve 0.98 [0.92-1.00], median nerve 0.97 [0.90-0.99], radial nerve 0.96 [0.89-0.99]) with negative predictive value of 100%.

Conclusion: Infrared thermography of different skin segments provides an accurate tool for predicting failed supraclavicular brachial plexus block. Increased skin temperature at each segment can exclude block failure in the corresponding nerve with 100% accuracy.

Introduction: Rib fractures are a common sequelae of chest trauma and are associated with significant morbidity. The erector spinae nerve block (ESB) has been proposed as an alternative first-line regional technique for rib fractures due to ease of administration and minimal complication profile. We aimed to investigate the current literature surrounding this topic with a focus on pain and respiratory outcomes.

Methods: A comprehensive literature search was performed on the Medline, Embase, Web of Science, Scopus, and Cochrane databases. Keywords of "erector spinae block" and "rib fractures" were used to form the search strategy. Papers published in English investigating ESB as an analgesic intervention for acute rib fracture were included. Exclusion criteria were operative rib fixation, or where the indication for ESB was not rib fracture.

Results: There were 37 studies which met the inclusion criteria for this scoping review. Of these, 31 studies reported on pain outcomes and demonstrated a 40% decrease in pain scores post administration within the first 24 hours. Respiratory parameters were reported in 8 studies where an increase in incentive spirometry was demonstrated. Respiratory complication was not consistently reported. ESB was associated with minimal complications; only 5 cases of haematoma and infection were (incidence 0.6%) reported, none of which required further intervention.

Discussion: Current literature surrounding ESB in rib fracture management provides a positive qualitative evaluation of efficacy and safety. Improvements in pain and respiratory parameters were almost universal. The notable outcome from this review was the improved safety profile of ESB. The ESB was not associated with complications requiring intervention even in the setting of anticoagulation and coagulopathy. There still remains a paucity of large cohort, prospective data. Moreover, no current studies reflect an improvement in respiratory complication rates compared to current techniques. Taken together, these areas should be the focus of any future research.

Background and aim: Ultrasound-guided continuous adductor canal block (cACB) is a conventional choice in patients undergoing total knee arthroplasty (TKA) for the management of the postoperative pain. This study aims to compare different catheter tip locations for cACB relative to the saphenous nerve (anteriorly vs posteriorly) in terms of efficacy and complications.

Methods: At the department of Surgical Sciences, Orthopedic Trauma and Emergencies of the University of Naples Federico II (Naples, Italy), between January 2020 and November 2021, retrospective comparative study was executed. Patients planned for TKA were included in the study if they met the follow inclusion criteria: patients undergone TKA; aged 50-85 years; body mass index (BMI) of 18-35 kg/m2; American Society of Anesthesiologists (ASA) physical status classification from I to III; subarachnoid technique for anesthesiology plane; continuous adductor canal block performed by an anesthetist with considerable experience. Patients were assigned to receive cACB with the catheter tip located anteriorly (Group 1, G1) or posteriorly to the saphenous nerve (Group 2, G2). Postoperative pain, ambulation ability, episodes of pump block and rate of catheter dislodgement and leakage were evaluated and analyzed.

Results: Altogether, 102 patients were admitted to the study (48 in G1 and 54 in G2). After the first 8 postoperative hours, in G1 17 patients (35.4%) had a VAS greater than 4, while in group 2 only 3 patients (5.6%) had a VAS greater than 4 (p-value <0.01). All patients of both groups showed ambulation ability in the postoperative period. No episode of leakage was recorded. While the catheter displacement rate was similar in the two groups (2.1% for G1 vs 3.7% for G2; p-value >0.05), the episodes of pump block were significantly less in G2 than in G1 (3.7% vs 20.8%; p-value <0.01).

Conclusion: In cACB for TKA, we found that positioning the catheter tip posteriorly to the saphenous nerve may lead to a greater postoperative analgesia and reduce the risk of pump block compared to placing the catheter tip anteriorly to the nerve.