Regional Anesthesia and Pain Medicine最新文献

Background: This study assessed the effect of perineural dexamethasone on block duration, opioid requirement, blood glucose levels, and stress response to surgery as measured by the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR), following pediatric foot and ankle surgery.

Methods: In this parallel, double-blinded randomized controlled trial, 90 children (ages 2-5 years, >5 kg) scheduled for foot or ankle surgery under spinal anesthesia with ultrasound-guided single-shot popliteal sciatic nerve block were randomized into 3 groups: 0.5% ropivacaine with saline (control), 0.5% ropivacaine plus dexamethasone 0.1 mg/kg (DEX0.1), and 0.5% ropivacaine plus dexamethasone 0.05 mg/kg (DEX0.05). Primary outcome was the time to first rescue opioid analgesia. Secondary outcomes included motor block duration, pain scores, NLR, PLR, and blood glucose levels.

Results: Time to first rescue opioid analgesia was significantly longer in the DEX0.1 group compared with the DEX0.05 group (18.4 hours, SD 2.6 hours vs 16 hours, SD 2.8 hours), with a mean difference of 2.2 hours (95% CI 0.7 to 3.6), p<0.01; and the control group (8.5 hours, SD 1.5 hours), with a mean difference of -9.9 (95% CI -11.4 to -8.4), p<0.001. Motor block was significantly longer in the DEX0.1 group (17.3 hours, SD 2.5 hours) compared with the DEX0.05 (15.2 hours, SD 2.7 hours; p<0.01) and control groups (7.8±1.1, p<0.001). Total opioid consumption was significantly lower in the DEX0.1 group compared with the control group (p=0.01). NLR, PLR, and glucose levels did not differ significantly between the groups at baseline, 24 hours, and 48 hours post surgery.

Conclusions: Perineural dexamethasone significantly prolonged postoperative motor block duration and did not influence blood glucose, NLR, or PLR levels.

Trial registration number: NCT06086418.

Background: Needle trauma has been associated with peripheral nerve injury and neurological dysfunction. However, inadvertent needle puncture is frequent while postblock dysfunction is rare. We conducted a cadaveric study to evaluate the association between needle puncture and fascicular injury.

Methods: Five median and five ulnar (isolated) nerves were obtained from fresh human cadavers. Four different needles were used for the transfixing punctures: A 30° beveled (22G) nerve block needle, and 15° beveled (22G, 25G and 27G) Quincke spinal block needles. 10 transfixing punctures were made with each needle type on each nerve (40 punctures per nerve). Samples were then immersed in 5% formaldehyde solution for 30 days. Perpendicular cross-sections of the punctured segments were obtained. Samples were embedded in paraffin and analyzed under light microscopy with H&E staining. On each slice, the following variables were obtained: ratio of fascicular/epineurial tissue, the number of fascicles per nerve and the number of injured fascicles.

Results: A total of 400 punctures were made (200 median and 200 ulnar) and 144 histological nerve sections analyzed (74 median and 70 ulnar). The median number of fascicles per section was 16 (range 7-23) and 17 (range 8-27) with a fascicular/epineural tissue ratio of 45% (range 35%-52%) and 44% (range 39%-54%) for median and ulnar, respectively. Three fascicular injuries were identified: one in ulnar and two in median. All injuries were caused by a 15° beveled needle, the ulnar with a 22G and the median with a 22G and a 27G.

Conclusions: Fascicular injury is rare following needle transfixion. Needle injury alone is unlikely to explain postblock neurological dysfunction.

Background and objectives: Few cadaveric studies have evaluated the dye spread with superficial parasternal intercostal plane (SPIP) blocks. In this study, we examined the dye spread of an ultrasound-guided SPIP block in a human cadaveric model with single and double injection techniques.

Methods: Seven single and four double ultrasound-guided SPIP blocks were performed in seven unembalmed human cadavers using an in-plane approach with the transducer oriented parasagitally 1 cm lateral to the sternum. For the single SPIP, 20 mL of 0.166% methylene blue was injected in the second or third intercostal space into the plane between the Pec major muscle and internal intercostal muscles. For the double SPIP, 10 mL of 0.166% methylene blue was injected in the SPIP at one intercostal space with an additional 10 mL injected in the SPIP two intercostal spaces caudally. The extent of dye spread was documented.

Results: For all SPIP injections, there was consistent mediolateral spread from the sternum to the mid-clavicular line, with many extending laterally to the anterior axillary line. There was craniocaudal spread to a median of 2 intercostal muscles with a single SPIP and 3 intercostal muscles with a double SPIP. There was a median spread to 1 intercostal nerve for the single SPIP and 1.5 intercostal nerves with the double SPIP.

Conclusions: The SPIP block demonstrated limited spread in this cadaver study. A single injection of this block may be of limited value and multiple SPIP injections may be needed to have adequate spread for anterior thoracic procedures.

Background: Up to 30% of patients with knee osteoarthritis (KOA) have evidence of sensitization, with a similar proportion experiencing severe pain during procedures. Most patients with KOA are elderly and often develop side effects from intravenous sedation. Our study investigated the effectiveness of a methoxyflurane inhaler combined with local anesthesia in reducing procedural pain from genicular nerve block compared with local anesthesia alone.

Methods: 42 adults with refractory KOA were randomized into two groups. Methoxyflurane group received a self-titrated methoxyflurane inhaler with local anesthesia whereas lidocaine group received local anesthesia only. The primary outcome was pain score on a 0-10 verbal numerical rating scale (VNRS) during the procedure. Secondary outcomes included changes in VNRS and behavioral pain scale (critical care pain observational tool) during the procedure, hemodynamic changes, anxiety level, sedation score, and adverse events.

Results: 42 patients with a mean age of 66±12 years participated in this study. There were no significant baseline differences. During the procedure, the methoxyflurane group experienced a significantly greater VNRS pain reduction from baseline (2 (1, 4) vs -1 (-2, 0); p<0.01) and greater VNRS reduction over time (p=0.01) compared with the lidocaine group, with a higher sedation score (p<0.01). Immediately postprocedure, anxiety levels were lower in the methoxyflurane group compared with the lidocaine group (median State-Trait Anxiety Inventory score 21 (IQR 20, 24) vs 27 (23, 29); p=0.02), but the median reduction in anxiety level was not significant (6 (1, 12) vs 5 (0, 14); p=0.61). There were no differences in behavioral pain scores, hemodynamic parameters, recovery or discharge times, and adverse effects between the two groups.

Conclusion: A methoxyflurane inhaler combined with local anesthesia provided better procedural pain control than local anesthesia alone with no observable differences in adverse effects. Future studies evaluating the impact of a methoxyflurane inhaler on different types of painful procedures are warranted.

Introduction: Both thoracic epidural analgesia and thoracic paravertebral analgesia are effective techniques to control pain and minimize the stress response following thoracic surgery. We hypothesized that continuous neuraxial techniques may be associated with a decrease in the incidence of postoperative mortality after thoracotomy. Additionally, we aimed to identify subgroup populations that may benefit more from neuraxial anesthesia.

Method: 1620 patients who underwent open thoracotomy were included in this retrospective study from the German Thoracic Registry database at four university hospitals. All-cause inpatient mortality was determined for patients who had and did not have neuraxial anesthesia. Logistic regression was used to adjust for and explore various covariates.

Results: Continuous neuraxial analgesia was associated with a lower overall mortality in the postoperative period (2.9%, 23/796 vs 5.3%, 44/824, p=0.02) only after the univariate analysis but not the multivariable analysis (OR 0.49, 95 % CI 0.237 to 1.12, p=0.15). In patients with epidural or paravertebral catheters, mortality was significantly lower in the following subgroups: age >75 (5/113 vs 18/77, OR 0.1, 95% CI 0.02 to 0.67, p=0.02), American Society of Anesthesiologists Performance Score >III (11//97 vs 33/155, OR 0.32, 95% CI 0.11 to 0.89, p=0.03), chronic kidney disease (5/83 vs 16/77, OR 0.16, 95% CI 0.03 to 0.82, p=0.03), and postoperative sepsis (9/21 vs 17/25, OR 0.13, 95% CI 0.07 to 0.44, p<0.01).

Conclusions: Neuraxial analgesic techniques are associated with reductions in postoperative mortality after open thoracic surgery in selected patients.