Local and Regional Anesthesia最新文献

Thoracic epidural analgesia (TEA) is a standard procedure in multimodal analgesia applied in major thoracic and abdominal surgeries. Two cases are presented with serious complications related to TEA. In both cases, earlier reaction of the treating physicians to patient-reported sensory symptoms could have prevented the complicated course. The first case was a 73-year-old patient with bronchial carcinoma who underwent right lower lobe resection. In this case, dabigatran 150 mg/d (indication: permanent atrial fibrillation) had been discontinued 72 hours before surgery, and enoxaparin 80 mg (every 12 hours) had been started 11 hours after surgery. An epidural hematoma developed postoperatively. Magnetic resonance imaging (MRI) was performed only after paraplegia had developed the next day. Unfortunately, delayed hematoma evacuation could not prevent persistent paraplegia in this case, which was complicated by hospital-acquired pneumonia with sepsis and acute renal failure. The second case was a 39-year-old patient with ulcerative colitis and an initially undetected malposition of the epidural catheter. Immediately after test bolus injection, the patient reported paresthesia and overall discomfort, which however could not be safely attributed to either the test dose or the already started general anesthesia. The patient could only be extubated after stopping the epidural infusion. Accidental re-start of epidural infusion led to coma, conjugate eye deviation, and respiratory arrest, necessitating re-intubation. Computed tomography (CT) ruled out intracerebral pathology and showed a catheter position centrally in the spinal canal. Fortunately, no neurological deficits were detected after catheter removal.

Background and aims: Subcostal Transversus Abdominis Plane (TAP) block is the standard practice for postoperative analgesia following laparoscopic cholecystectomy. This study aimed to compare the efficacy of modified BRILMA Block (blocking the BRanches of Intercostal nerves at the Level of Mid-Axillary line) with Subcostal TAP block for pain relief following laparoscopic cholecystectomy.

Methods: Sixty cases scheduled for laparoscopic cholecystectomy were randomly divided into two groups: modified BRILMA block (Group B) and Subcostal TAP block (Group T). General anesthesia was standardized for both groups. Blocks were performed with 20 mL of 0.2% Ropivacaine under ultrasound guidance after induction of anesthesia. Patients were administered morphine through patient controlled analgesia (PCA) pump with a bolus dose of 1 mg, 10 min lockout interval, and a basal infusion rate of 0.1 mg/h. The pain was assessed by the Visual Analog Scale (VAS) scores of one to ten. The total morphine consumption, time to first request for rescue analgesia, and VAS scores at rest and with movement, and complications, if any, were recorded.

Results: The morphine consumption in Group B was 5.67 ± 1.98 mg and in Group T was 5.17 ± 1.85 mg, which was found to be statistically insignificant (p-value = 0.317). The time to first request for rescue analgesia was 759.33 ± 80.29 min in Group B which was comparable to 854 ± 93.01 min in Group T and statistically insignificant (p-value = 0.295). The average VAS scores at rest as well as on movement were comparable in both the groups during the entire 24 h postoperative period. No complications were encountered in our study.

Conclusion: Ultrasound-guided modified BRILMA block is equally efficacious as subcostal TAP block in providing postoperative analgesia with similar morphine consumption and no significant difference in VAS scores at rest and movement following laparoscopic cholecystectomy.

Trial registration number: CTRI/2020/02/023457.

Background: The epidural pressure is pulsatile and synchronized with arterial pulsations. Monitoring the epidural waveform has been suggested as a technique to reliably confirm the appropriate localization of the epidural catheter.

Objective: The aim of this study was to evaluate the sensitivity and specificity of the Computer Controlled Drug Delivery System with continuous pressure and waveform sensing technology (CCDDS) (CompuFlo^® CathCheck™) as an instrument to assess the correct placement of the catheter in the epidural space in parturients who have received combined spinal-epidural technique (CSE) for labor analgesia.

Methods: We enrolled 40 consecutive healthy patients undergoing CSE labor analgesia with successful analgesia. All the cases in which pulsatile waveforms in synchrony with heart rate were detected were considered to be true positives; all the cases in which there was the absence of pulsatile waves were followed up. If these patients had to eventually relocate or manipulate the epidural catheter, they were considered to be true negative. If the absence of pulse waves was observed in the presence of successful analgesia during labor, the patients were considered to be false negatives.

Results: Pulsatile waveforms synchronous with heart rate were observed in 33 cases associated with adequate analgesia. In 5 cases, the pulsatile waveforms were absent due to unilateral analgesia or catheter occlusion (true negatives). In 2 cases, the patients had effective analgesia but we were not able to observe a distinct pulsatile waveform. The pressure waveform analysis through the epidural catheter had a sensitivity of 95%, a positive predictive value of 100%, a specificity of 100% and a negative predictive value of 60%.

Conclusion: Pulsatile pressure waveform recording with CCDDS through the epidural catheter resulted in high sensitivity and positive predictive value which can help the proper placement of the epidural catheter.

Multiple vertebral compression and rib fractures in elderly patients with pre-existing chronic obstructive pulmonary disease is a common scenario associated with significant morbidity and mortality. Severe pain prevents normal ventilation and leads to atelectasis, consolidation, and pneumonia. Subsequently, these patients frequently develop respiratory failure and require intubation and critical care. Therefore, adequate analgesia is often a life-saving intervention. Anesthetic management of a 78-year-old kyphotic patient with T6, T7, and T9 rib fractures on the right and T10-12 vertebral compression fractures sustained in an accidental fall is presented. She had inadequate pain control and was unable to take a deep breath or cough. Her respiratory status was deteriorating, with tachypnea and worsening hypoxia, necessitating bi-level positive airway pressure (BiPAP) support. Since thoracic epidural analgesia was contraindicated owing to compressive vertebral fractures and to the pending respiratory failure, we opted for a unilateral erector spinae plane (ESP) block at the T7 level and bilateral retrolaminar (RL) blocks at the T10 level. Following the procedure, the pain was immediately relieved and the patient was able to take deep breaths. Shortly thereafter, her respiratory status improved, with the respiratory rate coming back close to the baseline. The patient was subsequently weaned from BiPAP support and discharged from the intensive care unit. While the combination of ESP and RL blocks is not routinely used in patients with multiple rib and vertebral compression fractures, our report indicates that it may be an excellent alternative for analgesia in situations where thoracic epidural and/or paravertebral blocks are contraindicated and when timely intervention could be potentially life-saving.

Posterior knee pain after total knee arthroplasty (TKA) is common despite multimodal analgesia and regional anesthesia use. This review included randomized controlled trials (RCTs) comparing analgesic outcomes after inclusion of local anesthetic infiltration between the popliteal artery and capsule of the knee (iPACK) block versus pathways without iPACK. Electronic databases (MEDLINE, Cochrane Library, Web of Science, Scopus) were searched from inception to 10/11/2020. Eligible studies evaluated iPACK use on primary outcomes: opioid consumption and pain scores with movement. Secondary outcomes included rest pain, patient satisfaction, length of stay (LOS), gait distance, knee range of motion (ROM), and complications. Bias and quality were appraised using the Cochrane Risk of Bias tool and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) guidelines. Eight RCTs (777 patients) were included. iPACK block use demonstrated similar opioid consumption in the PACU (4/7 RCTs) and 24 hours after TKA (5/7 RCTs) compared to without iPACK (moderate-quality GRADE evidence). Additionally, iPACK block use demonstrated lower movement pain scores in PACU (3/5 RCTs) but similar or higher pain scores after 24 hours (5/7 RCTs; low-quality GRADE evidence). Studies consistently reported no difference in gait distance (4/4 RCTs) or complications (7/7 RCTs) between treatment arms (high-quality GRADE evidence), although differing effect estimates were observed with resting pain, satisfaction, LOS, and knee ROM. This review provides a foundation of knowledge on iPACK efficacy. While evidence does not currently support widespread inclusion of iPACK within enhanced recovery pathways for TKA, limitations suggest further study is warranted.

Background: The aim of this study is to evaluate the effect of ultrasound-guided bilateral cervical plexus block on general anesthesia, postoperative analgesia, and surgical outcomes in patients undergoing total parathyroidectomy with autotransplantation.

Patients and methods: Forty-eight ASA III-IV patients with hyperparathyroidism secondary to renal failure were included: 24 patients received ultrasound-guided bilateral superficial and deep cervical plexus block combined with general anesthesia (group A), and 24 patients received general anesthesia alone (group B). Postoperative patient-controlled intravenous analgesia was provided with sufentanil 2 μg/kg. The primary outcome is the postoperative pain scores. Secondary outcomes include intraoperative remifentanil dosage, changes in hemodynamics, extubation time, and sufentanil consumption. Surgical outcomes regarding calcium, phosphorus and parathormone values were also noted.

Results: The patients in group A required less remifentanil than group B (2.56±0.92mg vs 3.38±0.84mg, P=0.002) and lower VAS scores at 1, 3, 10, 24, and 48h postoperatively (P < 0.001). While the systolic blood pressure in group A patients was significantly greater than that in group B at T3 (immediately after extubation, [138.33±11.36 vs 129.08±17.06 mmHg; P=0.032]), heart rates in group A were lower than in group B at 1 min before induction (T1 [89.46 ± 9.14 vs 96.71±14.19, P=0.042]) and 1 min after intubation (T2 [70.08 ± 5.35 vs 79.25 ± 11.81, P=0.002]). The extubation time in group A was shorter than that in group B (P < 0.001). There was no difference in calcium, phosphorus and parathormone values, nor in sufentanil consumption between the groups.

Conclusion: Ultrasound-guided bilateral superficial and deep cervical plexus block combined with general anesthesia for TPTA is an effective strategy to improve anesthesia management and achieve better postoperative analgesia, and has no impact on surgical outcomes.

Background: This study aimed to investigate the analgesic efficacy and motor block profile of single-shot transmuscular quadratus lumborum block (QLB) in comparison with those of suprainguinal fascia iliaca block (FIB) in patients undergoing hip arthroplasty.

Methods: This randomized, double-blinded, controlled trial included adult patients undergoing hip arthroplasty under spinal anesthesia. Patients were allocated to one of two groups according to the regional block received: FIB group (n=19) or QLB group (n=17). Both study groups were compared with regard to the duration of analgesia (primary outcome), block performance time, pain during positioning for spinal anesthesia, total morphine consumption in the first postoperative 24-h period, quadriceps muscle power, and static and dynamic visual analog scale.

Results: Thirty-six patients were included in the final analysis. Both study groups had comparable durations of analgesia. Postoperative visual analog scale (static and dynamic) values were comparable between the two groups in most readings. The block performance time was shorter in the FIB group. The number of patients with pain during positioning for the subarachnoid block was lower in the QLB group. The total morphine requirement during the first 24 h was marginally lower in the FIB group, whereas the quadriceps motor grade was higher in the FIB group than in the QLB group at 4 h and 6 h after surgery.

Conclusion: Both single-shot blocks, namely the suprainguinal FIB and transmuscular QLB, provide effective postoperative analgesia after hip arthroplasty. FIB showed slightly lower 24-h morphine consumption, while QLB showed better quadriceps motor power.

Clinical trial registration: The study was registered at clinical trials registry system before enrollment of the first participant (NCT04005326; initial release date, 2 July 2019; https://clinicaltrials.gov/ct2/show/NCT04005326).

The quadratus lumborum block is a novel truncal block where local anaesthetic is injected adjacent to the quadratus lumborum muscle. It is used for caesarean sections, hip arthroplasty, gynecologic surgery, colectomy, and recently nephrectomy. To date, there are no reviews that outline the efficacy and performance of the quadratus lumborum blocks in patients receiving laparoscopic nephrectomy. The objective of this project was to outline the current available data from both clinical trials along with case series and reports regarding the methods and utility of quadratus lumborum blocks for analgesia in patients receiving nephrectomy. For this literature review, we searched Pubmed, Embase, and Web of Science from their inception until 5/31/2020. Our search terms were as follows: "(nephrectomy OR laparoscopic nephrectomy) AND (QL block OR Quadratus Lumborum block OR QL OR TQL OR Thoracolumbar fascia block)." We analyzed all relevant clinical trials for quality using the Jadad scale. Our search yielded a total of 30 articles, 23 of which we ultimately reviewed for this manuscript. The qualitative sum of these data show that patients receiving quadratus lumborum block for nephrectomies have reduced opioid requirements, reduced pain scores, and improved side-effects relative to other analgesic modalities like epidurals. Based on these findings, we conclude that the quadratus lumborum block is a useful analgesic for patients undergoing nephrectomy.

Background: Spinal anesthesia block is the most widely practiced anesthesia technique due to its safety margin. It is an invasive procedure that could be associated with a variety of complications like total spinal, cardiovascular collapse, meningitis, paralysis, and even death. The aim of this study to assess the current practice of spinal anesthesia.

Methods: A Cross-sectional study design was conducted in Debre Tabor Comprehensive Specialized Hospital from November 01 to December 15, 2020. All anesthesia professionals who are working in the study Hospital were surveyed by the Purposive sampling technique. A standardized structured checklist prepared from recommendations of New York school of regional anesthesia guideline regarding the current Practice of spinal anesthesia was used to collect the data after taking written informed consent. Descriptive statistics were employed to summarize the results.

Results: A total of 24 anesthetists were observed of their practice before, during, and after administer of spinal anesthesia. All of the anesthetists were practicing the preparation and assembling of all necessary anesthesia equipments, resuscitation drugs, and basic monitors while all of the anesthetists did not wash their hands, wore a sterile gown, and draped the back of the patient with fenestrated drapes in a sterile fashion.

Conclusion: Most of the anesthesiology professionals in our setting have a good preparation of all necessary anesthesia equipments, and resuscitation drugs, while the assessment of patient's emotional reaction and pain during injection, the skin preparation allowed to being dry and assessment of the degree of sensory and motor block of the patient were insufficient.

Purpose: Continuous sciatic nerve blocks have proven benefits for postoperative analgesia after foot surgery. However, the optimal mode of administration remains a point of debate. Ultrasound guided subparaneural injection accelerates onset time and increases duration after a single shot sciatic nerve block. This double blind prospective randomized trial compares the 48-hour local anesthetic (LA) dose consumption of an automated intermittent bolus technique to a continuous infusion regimen in a subparaneural sciatic nerve catheter after hallux valgus surgery.

Patients and methods: Patients scheduled for hallux valgus surgery were randomized to receive either a continuous infusion of levobupivacaine 0.125% at 5mL/h (group A) or an intermittent automated bolus of 9.8 mL every 2 hours with a background of 0.1 mL/h (group B), both with a PCA bolus of 6 mL and lockout of 30 minutes. The 48 hour LA consumption, PCA boluses, Numeric Rating Scale (NRS), satisfaction and return of normal sensation were recorded.

Results: Sixteen patients were excluded because of protocol violation or technical problems and 42 patients remained for analysis. The 48 hour ropivacaine consumption was higher in group A (293 ±60 mL) than group B (257±33 mL). The median and highest NRS scores and patient satisfaction were not statistically different between groups. Normal sensation returned after 75 ± 22 hours (group A) and 70 ± 17 hours (group B).

Conclusion: Programmed bolus administration in subparaneural sciatic nerve catheters reduces LA consumption 48 hours after surgery with equal analgesia and patient satisfaction. Return of sensation is variable and can last more than 75 hours.