Regional Anesthesia and Pain Medicine最新文献

Background and objectives: The efficacy of a multilevel thoracic paravertebral block (6m-TPVB at T1-T6), as the sole anesthetic, for primary breast cancer surgery (PBCS) has been questioned. Current literature suggests that a significant number of patients may report pain during various stages of surgery, notably during the detachment of the breast base from the pectoralis major muscle and its fascia. Given that the pectoral muscles are innervated by nerves from the subpectoral plexus (C5-T1), which are not affected by a 6m-TPVB alone, we propose that an additional "subpectoral plexus block" (SPPB) may enhance the surgical anesthesia.

Methods: 60 patients undergoing PBCS under a 6m-TPVB were randomized to receive an SPPB (Gp-A, n=30) or a sham block (Gp-B, n=30). Midazolam (1-3 mg) and ketamine (10-20 mg) were administered intravenously for sedation and analgesia before the block placement and an infusion of dexmedetomidine (0.1-0.5 mcg/kg/h) was used to maintain conscious sedation during surgery. The 6m-TPVB was ultrasound guided, and 4-5 mL of 0.5% ropivacaine with 1:200 000 epinephrine was injected at each vertebral level (total volume used 25 mL). The SPPB was also ultrasound guided, and 5 mL of 0.25% ropivacaine was injected each near the origin of the thoracoacromial artery in the pectoserratus plane and between the two pectoral muscles (interpectoral plane) in Gp-A, at the level of the third rib. In Gp-B, 3-5 mL of normal saline (sham block) was injected into the pectoralis major muscle. Surgery commenced about 25-30 min after the completion of the SPPB. Ketamine (10-20 mg IV bolus) was used for rescue analgesia (our primary outcome variable) if the patient complained of pain during surgery to an arbitrary maximum of 100 mg, or the anesthesia was deemed inadequate, after which it was converted to general anesthesia.

Results: The two study groups were comparable with respect to demographic data, total dose of midazolam and dexmedetomidine used, duration of surgery, and overall patient satisfaction. Ketamine, as rescue analgesia, was required to complete surgery in both study groups, but fewer patients in Gp-A (56.7%) required rescue analgesia than in Gp-B (93.3%, p=0.002). Ketamine requirement (median (IQR)) was also significantly lower (p<0.001) in Gp-A (10 (0-40) mg) than in Gp-B (50 (20-70) mg). The surgeons were more (p=0.02) satisfied (mean±SD numeric rating scale, 0-100) with surgical conditions in Gp-A (77.29±10.63) than in Gp-B (65.83±21.38).

Conclusion: A SPPB enhances the surgical anesthesia produced by a 6m-TPVB for primary breast cancer surgery.

Trial registration number: https://www.chictr.org.cn/showprojEN.html?proj=5368, Trial ID No: ChiCTR-TRC-14004200; Date of Registration: 25 January 2014, Study commencement date: 28 February 2014.

Introduction: A high proportion of surgical patients has previous opioid exposure, which is associated with poorer recovery and increased morbidity. However, much less is known regarding the direct and indirect costs that are associated with healthcare utilization among individuals on preoperative opioid therapy.

Methods: We analyzed The Merative MarketScan Commercial Database linked with the Merative MarketScan Health and Productivity Management Database to include all adult patients admitted and discharged from common elective surgeries between January 1, 2018 and June 30, 2021. Patients were clustered by preoperative opioid exposure and estimates for total direct payments (in USD) generated and workplace absenteeism were assessed for a 6-month period.

Results: 10 737 patients were included in our cohort; 17.0% classified as 'low' preoperative opioid use (median oral morphine equivalents (IQR)=126 (75-225)), 5.0% as 'medium' (370 (225-640)) and 3.0% as 'high' (4500 (2120-10 908)). Compared with opioid naive or low preoperative use, individuals with high preoperative use had significantly higher estimated payments for care at 6 months ($4212 for high vs $2706 for naive (p=0.007) and $3059 for low (p=0.045)), while utilizing increased ambulatory care including clinic and outpatient visits after surgery. There was no significant difference in workplace absenteeism between groups.

Conclusion: High preoperative opioid use is associated with increased healthcare utilization and costs following common elective surgery. Future efforts should focus on this patient population to explore interventions that could optimize value-based care by improving outcomes and reducing costs.

Hemorrhagic complications associated with regional anesthesia are extremely rare. The fifth edition of the American Society of Regional Anesthesia and Pain Medicine's Evidence-Based Guidelines on regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy reviews the published evidence since 2018 and provides guidance to help avoid this potentially catastrophic complication.The fifth edition of the American Society of Regional Anesthesia and Pain Medicine's Evidence-Based Guidelines on regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy uses similar methodology as previous editions but is reorganized and significantly condensed. Therefore, the clinicians are encouraged to review the earlier texts for more detailed descriptions of methods, clinical trials, case series and pharmacology. It is impossible to perform large, randomized controlled trials evaluating a complication this rare; therefore, where the evidence is limited, the authors continue to maintain an 'antihemorrhagic' approach focused on patient safety and have proposed conservative times for the interruption of therapy prior to neural blockade. In previous versions, the anticoagulant doses were described as prophylactic and therapeutic. In this version, we will be using 'low dose' and 'high dose,' which will allow us to be consistent with other published guidelines and more accurately describe the dose in the setting of specific patient characteristics and indications. For example, the same 'high' dose may be used in one patient as a treatment for deep venous thrombosis (DVT) and in another patient as prophylaxis for recurrent DVT. Due to the increasing ability to obtain drug-specific assays, we have included suggestions for when ordering these tests may be helpful and guide practice. Like previous editions, at the end of each recommendation the authors have clearly noted how the recommendation has changed from previous editions.

Background and objectives: The transversus abdominis plane (TAP) block is the most widely used abdominal field block in colorectal surgery with a postoperative enhanced recovery pathway. We aimed to determine whether the laparoscopic-assisted and ultrasound-guided TAP (US-TAP) blocks provide superior pain relief compared with placebo. We separately investigated whether the laparoscopic-assisted technique was non-inferior to the ultrasound-guided technique in providing pain relief, with a non-inferiority margin of 10 mg morphine dose equivalents.

Methods: 340 patients undergoing elective minimally invasive colon surgery were randomly allocated to one of three groups: (1) US-TAP block, (2) laparoscopic-assisted TAP (L-TAP) block, or (3) placebo. Superiority and non-inferiority were tested for the primary outcome: 24-hour postoperative morphine equivalent consumption. Secondary outcomes, including patient-reported quality of recovery, were included in the superiority analysis.

Results: 127 patients were included in each block group and 86 in the placebo group. The US-TAP block was no different from placebo at -1.4 mg morphine (97.5% CI -6.8 to 4.0 mg; p=0.55). The L-TAP block was superior to placebo at -5.9 mg morphine (97.5% CI -11.3 to -0.5 mg; p=0.01) and non-inferior to the US-TAP block at -4.5 mg morphine (98.75% CI -10.0 to 1.1 mg).

Conclusion: The L-TAP block was superior to placebo and non-inferior to the US-TAP block. However, neither met our predetermined estimate of the minimal clinically important difference of 10 mg morphine.

Trial registration number: NCT04311099.

Background: Continuous spinal anesthesia (CSA) offers precise, prolonged neuraxial anesthesia suitable for high-risk patients. This technique minimizes hemodynamic instability but comes with notable challenges. Vigilant catheter management is crucial to avoid complications, including the risk of catheter retention. We report a case where the mechanical properties of a spinal catheter led to diagnostic uncertainty.

Case: An ASA4 patient underwent a revision of total knee replacement surgery under CSA using a Pajunk IntraLong catheter set. Following successful insertion, the surgery proceeded uneventfully. During catheter removal, the expected tip markings were absent, raising concern for a retained fragment. Imaging confirmed no retained foreign body. To investigate further, stretching of a new catheter replicated the disappearance of tip markings. This finding suggested that the catheter's material had the potential to stretch under tension, leading to fading of the markings and mimicking a retained fragment.

Conclusions: This case underscores the need for awareness of the mechanical properties of spinal catheters, especially their potential for stretching and loss of tip markings. Understanding these characteristics can prevent unnecessary imaging and reduce patient and clinician anxiety.