Anesthetic Spread Research Articles

Dermatomal spread in lateral quadratus lumborum blocks versus transversus abdominus plane blocks after laparoscopic colorectal surgery: a randomized clinical trial

IntroductionPostoperative pain after laparoscopic abdominal surgery remains complex. While lateral quadratus lumborum (QL) block and transversus abdominus plane (TAP) block are similar techniques, no studies have examined if one technique...

Ultrasound-guided Double-point Versus Single-point Serratus Anterior Plane Block for Modified Radical Mastectomy: A Randomized Controlled Trial.

The double-point serratus anterior plane block(SAPB) covers more area, including the axilla, than the single-point approach, potentially offering better pain relief after Modified radical mastectomy(MRM). Sixty women were randomly assigned to double or single-point groups. Double-point received SAPB at the third and fifth ribs, single-point at the fifth rib. Primary outcome: pain numeric rating scale (NRS) at rest and movement 24 hours post-surgery. Secondary outcomes: axilla comfort NRS, recovery quality, and adverse events. At 24 hours post-surgery, the double-point group compared to the single-point group showed movement pain NRS of 3 (2-3) vs. 3 (3-4) (P = 0.011) and rest pain NRS of 1 (1-1) vs. 2 (1-3) (P = 0.037). The difference between them did not exceed the MCID. The axillary comfort NRS in the double-point group was lower than the single-point group at 6 and 12 hours post-surgery, at 1 (1-2) vs. 2 (2-4) (P=0.001) and 1 (1-2) vs. 2 (2-4) (P=0.01) respectively, but there was no difference at 24 and 48 hours post-surgery. At 48 hours post-surgery, pain scores and opioid use were similar in both groups. Recovery scores, rescue analgesia timing, adverse events, and hospital stay length were similar in both groups. Double-point SAPB offers wider anesthetic spread but shows no significant clinical advantage in pain or axillary comfort over single-point SAPB after MRM.

Understanding the anatomy of pelvic fascia: implications for regional anesthesia.

The fascia, a continuous structure around the whole body across various anatomical locations, remains underexplored in regional anesthesia. The pelvic fascia is a particularly controversial and complicated anatomical structure. It holds significant relevance not only for surgeons but also in the realms of regional anesthesia and pain management. Many regional nerve blocking techniques in the pelvis are closely related to fascial anatomy, such as fascia iliaca compartment block, circum-psoas block, inferior hypogastric plexus block, and ganglion impar block. The continuity of fascia and interfascial spaces profoundly influences both the efficacy of blockades and the incidence of complications. A thorough understanding of pelvic fascia anatomy is crucial for understanding the potential pathways and barriers for spread of local anesthetics, enhancing analgesia, and minimizing side effects. Currently, a systematic discussion of pelvic fascia from the perspective of regional anesthesia and pain therapy is notably absent. This narrative review aims to consolidate knowledge on the anatomy of pelvic fascia pertinent to regional anesthesia and pain management, detailing relevant pelvic nerves, and associated peripheral nerve blocking techniques.

Effect of Abdominal Girth and Vertebral Column Length in Spread of Spinal Anesthesia for Lower Limb Surgery: A Prospective Study

Background: Subarachnoid spread of local anesthetics is quite erratic and is determined by several factors. There is a high predictive for the spread of spinal anaesthesia in terms of abdominal girth and vertebral column length. Our study is designed to determine the effect of abdominal girth and vertebral column length with cephalad spread of spinal anaesthesia for a given dose of 0.5% hyperbaric bupivacaine in Nepalese patients. Materials and Methods: In this prospective observational study, a total 100 patients of ASA PS I-II, aged16-65 years and undergoing lower extremity surgery under spinal anesthesia were enrolled. 2.8 mL of 0.5% hyperbaric bupivacaine was injected intrathecally at L3-4 interspace in sitting position. Extent of sensory blockade was assessed for 60 min. Simple linear regression, multiple linear regression and Pearson’s correlation coefficient analysis were performed to determine the correlation between patient variables viz abdominal girth, vertebral column length, height, weight, body mass index and age and maximum sensory block height. Results: Abdominal girth and vertebral column length correlated significantly with the maximal sensory block height after intrathecal administration of a fixed dose of 0.5% hyperbaric bupivacaine by all the three statistical tools used. Conclusion: Abdominal girth and vertebral column lengthcorrelate significantly with the maximal sensory block height in Nepalese patients receiving a fixed dose subarachnoid block with 0.5% hyperbaric bupivacaine

Precision in practice: Exploring the impact of AI and machine learning on ultrasound guided regional anaesthesia.

Ultrasound Guided Regional Anaesthesia (UGRA) is a commonly utilized practice in both elective and emergency situations during surgical procedures and for pain management. Its benefits include, being non-invasive, cost-effective, readily accessible, and providing the anaesthetist with clear visualization of essential anatomical landmarks, needle progression, and the spread of local anaesthetic. Ultrasonography has been shown to increase success rates for regional anaesthesia and decrease complications. One of the critical steps during UGRA is identifying relevant anatomical structures like nerves or vertebras. However, this aspect can be hindered by external influences such as variations in nerve structure and position, interference from noise, and positional instability. Machine learning is a promising branch of artificial intelligence. It is used to conduct predictive tasks without programming instructions by creating algorithms. Extensive research has been conducted to evaluate the influence of machine learning on innovative anaesthesia methods. In 2023, Lopez et al. published a systematic review on how Artificial Intelligence could positively impact traditional anaesthesia practices.1 Various studies included in the review employed different models to achieve variable targets during the induction of anaesthesia. In one experiment, Alkhatib et al. used Convolutional neural network (CNN) based deep trackers to track the median and sciatic nerve with a surprising accuracy of 0.87.2 Another study employed the same CNN model to locate and discriminate accurate images of sacrum, vertebral levels and intervertebral gaps during percutaneous spinal needle insertion.3 Another study used a different AI model called SVM (support vector machine) classification, image processing, and template matching to locate lumbar level L3-L4 and the ideal puncture site for epidural anaesthesia in real-time. In this experiment, anaesthetists with minimal experience in ultrasonography were able to successfully determine needle puncture sites accurately.4 All these studies utilizing AI models not only yielded beneficial results but also led to significant time savings. Considering this, anaesthesiologists nationwide must integrate effective AI models to improve their clinical practice. This would minimize adverse outcomes in regional anaesthesia and ultimately enhance patient care and satisfaction.

Optimizing peripheral regional anaesthesia: strategies for single shot and continuous blocks.

Regional anaesthesia is increasingly prominent within anaesthesia, offering alternative analgesic options amidst concerns over opioid-based analgesia. Since Halsted's initial description, the field has burgeoned, with ultrasound visualization revolutionizing local anaesthetic spread assessment, leading to the development of numerous novel techniques. The benefits of regional anaesthesia have gained increasing evidence to support their application, leading to changes within training curricula. Consequently, regional anaesthesia is at a defining moment, embracing the development of core skills for the general anaesthesiologist, whilst also continuing the advancement of the specialty. Recent priority setting projects have focussed attention on key aspects of regional anaesthesia delivery, including pain management, conduct and efficacy, education, and technological innovation. Developments in our current understanding of anatomy and pharmacology, combined with strategies for optimizing the conduct and maximizing efficacy of techniques, minimizing complications, and enhancing outcomes are explored. In addition, advancements in education and training methodologies and the integration of progress in novel technologies will be reviewed. This review highlights recent scientific advances in optimizing both single-shot and continuous peripheral regional anaesthesia techniques. By synthesizing these developments, this review offers valuable insights into the evolving landscape of regional anaesthesia, aiming to improve clinical practice and patient care.

The effect of hip shoulder width ratio and vertebral column length on sensory level in term participants posted for lower segment caesarean section under spinal anaesthesia in Indian population: A prospective observational study

Hypotension is the most common complication of spinal anesthesia with high intrathecal spread of local anaesthetic drug especially during caesarean section. Hip Shoulder width Ratio (HSWR) is one of the factors which affects spread of spinal anaesthesia.85 ASA II participants with singleton term pregnancy undergoing elective caesarean section received 12mg hyperbaric bupivacaine intrathecally with 26G Quincke’s spinal needle in L3-4 intervertebral subarachnoid space via midline approach. Post spinal anaesthesia haemodynamic parameters were monitored every 5 minutes for the first 20 minutes and at the end of surgery. Sensory level was assessed by a pinprick test every 5 minutes till 20 minutes and post-surgery. Hypotension was defined as 20% fall from baseline systolic blood pressure at 15 minutes post spinal anaesthesia.We found significant positive correlation between high shoulder width ratio and highest sensory level achieved (p - 0.0005) using mutiple regression analysis and pearson's correlataion. With every unit increased in high shoulder width ratio spinal level significantly increased by 5 units. Hip shoulder width ration and age were significantly correlatwd with incidence of hypotension.Hip-shoulder Width Ratio has a positive effect on cephalad spread of spinal anaesthesia and thus incidence of hypotension. By knowing the Hip-shoulder Width Ratio, it can help anaesthesiologists to predict the spread of spinal anaesthesia and titrate the dose of 0.5% hyperbaric bupivacaine.

Posteromedial Periarticular Injection in Total Knee Arthroplasty: A Cadaveric Study.

Achieving optimal pain control in total knee arthroplasty has improved with the use of regional anesthesia and periarticular injections (PAIs). When performing a PAI, the relative location of the anesthetic spread is not well defined in comparison with an adductor canal block (ACB). In this study, our aim was to evaluate the location of posteromedial PAI spread compared with a surgeon administered ACB. One PAI and one surgeon-administered ACB were performed in the contralateral limbs of four human cadavers. The injectate was composed of methylene blue dye to visually inspect the dye spread from the tip of the needle. Dissections were performed on each cadaver to quantify the dye spread from the tip of the needle and compare the location of the dye spread. Dye spread location was characterized as either entering the adductor canal or including the posterior capsule. The mean distance of dye spread from the needle tip to the proximal most aspect of the dyed tissue was 10.125 cm in the ACB group compared with 6.5 cm in the posteromedial PAI group. In the ACB group, 4 of 4 injections were present in the adductor canal block group compared with 3 of 4 in the posteromedial PAI group. The posteromedial PAI group also had 3 of 4 injections involve the area around the posterior capsule compared with 0 of 4 in the ACB group. Posteromedial PAI appears to provide local delivery to both the adductor canal and the posterior capsule. Intraoperative, surgeon-administered ACB reliably delivers injectate to the adductor canal only but may allow for more proximal dye spread. Posteromedial PAI may provide a benefit in delivering injectate to the posterior capsule in addition to the ACB. Additional clinical studies are necessary to determine the clinical effects of this finding.

Prophylactic infusion of norepinephrine does not affect the rostral spread of spinal anesthesia in pregnancy: a prospective, randomized, double-blinded study.

Background: The infusion of phenylephrine to prevent spinal-induced hypotension (SIH) in cesarean delivery may decrease the rostral spread of a spinal local anesthetic. We hypothesized that infusion of norepinephrine may decrease the rostral spread of spinal anesthesia, similar to that caused by phenylephrine. The aim of this study was to compare the block height of spinal anesthesia in the presence or absence of norepinephrine infusion administered to prevent SIH during cesarean delivery. Methods: Eighty patients were enrolled and allocated into groups receiving a norepinephrine infusion (group N) or saline infusion (group C). After intrathecal injection of hyperbaric bupivacaine 10mg, the block height for cold and pinprick sensation was checked 10 and 20min after the injection. The demographic characteristics, spinal anesthesia, side effects, and neonatal outcomes were also recorded. Results: The block height for cold and pinprick sensation was similar between the two groups, although the incidence of hypotension was significantly lower (p < 0.00) in group N than in group C. Systolic blood pressure was also more stable in group N than in group C, with the incidence of interventions being significantly lower in group N. There was no significant difference in patient satisfaction between the two groups. Conclusion: Evidence from this study suggested that prophylactic norepinephrine infusion does not reduce the rostral spread of spinal anesthesia in pregnancy. We suggest that it is not necessary to increase the dose of an intrathecal local anesthetic for cesarean delivery when prophylactic norepinephrine is administered. Clinical Trial Registration: https://www.chictr.org.cn/bin/project/edit?pid=152899, identifier [ChiCTR2200057439].

Comparison of levobupivacaine with dexamethasone versus levobupivacaine for ultrasound-guided transversus abdominis plane block in lower abdominal surgeries in a tertiary care hospital in Chengalpattu district – A randomized control trial

Introduction: Transversus abdominis plane (TAP) block is a regional technique for analgesia of the anterolateral abdominal wall. Ultrasound guidance is now considered the gold standard in TAP blocks. It involves the injection of a local anesthetic solution into a plane between the internal oblique muscle and transversus abdominis muscle. Since the thoracolumbar nerves originating from the T6 to L1 spinal roots run into this plane and supply sensory nerves to the anterolateral abdominal wall, the local anesthetic spread in this plane can block the neural afferents and provide analgesia to the anterolateral abdominal wall. Levobupivacaine is a local anesthetic from the amino amide class of medications. Adjuvants are drugs when added along with local anesthetics have a synergistic action to improve the duration and quality of analgesia. Objectives: The objective of this study was to study the effectiveness of ultrasound-guided transversus abdominis plane block using levobupivacaine with dexamethasone in terms of hemodynamic stability and duration of postoperative analgesia and pain scores (visual analog scale [VAS]), time of requirement of rescue analgesics among patients who have undergone lower abdominal surgeries. Methods: This is a double-blinded randomized control trial. This study was conducted among 60 patients who have undergone lower abdominal surgeries in a tertiary care hospital. Postsurgery, intraoperatively prior shifting out the patient, two groups received transversus abdominis plane block, one received 28 ml of 0.25% levobupivacaine with 2 ml of normal saline and another group received 28 ml of 0.25% levobupivacaine with 2 ml (8 mg) dexamethasone. Duration of postoperative analgesia and the efficacy between the two groups were compared with hemodynamic parameters and VAS score. Results: The study groups were not significantly different in terms of demographic data or the American Society of Anesthesiologists Grading. The mean onset of breakthrough pain was significantly higher in the L group. The time of requirement of rescue analgesics was also significantly shorter in the L group compared to the LD group. The VAS pain score was significantly lower in the Group LD as compared to the L group. Conclusion: Hence, it was noticed that dexamethasone when added to levobupivacaine had better hemodynamic stability in terms of blood pressure, heart rate, saturation, respiratory rate, and mean arterial pressure. The requirement of rescue analgesics was also reduced in this group and the time of breakthrough pain was also prolonged. This group had significantly lower pain scores.

Study of effectiveness of two syringe spinal anaesthesia technique for caesarean section

Spinal anaesthesia using hyperbaric bupivacaine is the most popular method for caesarean section. Adjuvents like fentanyl which enhances the sensory block and provide stable haemodynamics are usually premixed with bupivacaine in a single syringe. Fentanyl when added to hyperbaric bupivacaine, decreases the density of solution to extent of 0.0006 which alters the spread of local anesthetics in CSF. If we inject both the drugs separately in different syringe, it may minimize the effect of the changes in densities and PH of both the drugs and produce their maximum effect with minimal haemodynamic alteration. Therefore this study was conducted to see the quality of sensory block and haemodynamic response by sequential intrathecal administration of fentanyl and hyperbaric bupivacaine in two different syringe for patients undergoing caesarian section. This interventional study was carried out in Seventy nine Patients undergoing caesarean section under spinal anesthesia with 0.5% hyperbaric bupivacaine 9mg (1.8 ml) and fentanyl 20 mcg in two different syringe administered sequentially. Out of 79 parturients only 22 (27.85%) had hypotension requiring vasopressor treatment during caesarean section and maximum amount of vasopressor used was 15 mg of mephentermine. The mean level of maximum sensory block after 20 mins of spinal anaesthesia was T2 in 20 (25.32%) patients, T3 in 19 (24.05%) patients, T4 in 32 (40.51%) patients, T5 in 1 (1.27%) patient and T6 in 7 (8.86%) Patients. Intraoperative quality of surgical anaesthesia was very satisfactory to the patients. Only 6 (7.59%) patients had mild discomfort whithout requirement of any medical treatment. The result of this study concluded that separate intrathecal injection of fentanyl and hyperbaric bupivacaine provides better haemodynamic stability, improves quality of surgical anaethesia allowing it to work at higher levels in the spinal cord with minimal other side effects in patient undergoing caesarean section.

Visualizing Pain Management: A Comprehensive Examination of Radiological Techniques in Regional Anesthesia

This review explores the pivotal role of radiological techniques in enhancing precision and safety in regional anesthesia, aiming to provide a comprehensive understanding of their applications and advancements. The objectives are to evaluate the historical progression, current state, and future prospects of imaging modalities, including ultrasound, fluoroscopy, MRI, and CT scans, in the context of regional anesthesia. The methodology involves an extensive literature review, encompassing studies, case reports, and clinical trials related to the use of radiological techniques in regional anesthesia. Emphasis is placed on the outcomes of ultrasound-guided techniques, fluoroscopy applications, and the use of advanced imaging modalities, with a focus on their impact on procedural accuracy and patient outcomes. Key findings highlight the transformative influence of ultrasound guidance in peripheral nerve blocks and central neuraxial techniques, offering real-time precision. Fluoroscopy, integral in epidural and spinal anesthesia, is discussed in terms of its real-time visualization capabilities and recent technological advancements. MRI and CT scans, providing detailed anatomical imaging, contributes to evaluating anesthetic spread effectively. Contrast studies for visual confirmation and emerging technologies are also explored, paving the way for future innovations.

Factors influencing the spread of local anesthetic during the transverse abdominal plane block (study on unfixed corpses)

Introduction. Despite the proven clinical effectiveness of the transverse abdominal plane block (TAP block), the factors affecting the distribution of local anesthetic in the fascial case have not been fully studied, and there are no clear recommendations regarding the choice of the volume of local anesthetic taking into account anthropometry.The objective was to identify anthropometric factors influencing the choice of an adequate volume of local anesthetic for performing a TAP block.Materials and methods. In the pathology department, 40 upper and 40 lateral TAP blocks were performed in 20 corpses using ultrasound navigation. On the right side, 20 ml (block group A) of diamond green dye solution was injected, on the left side - 30 ml (block group B). The dependence of the area of distribution of the dye solution on the volume of the body, weight and height of the corpse was investigated. The analysis of the effect of damage in the execution zone on the area of dye distribution was carried out.Results. In the group B, the dye in 100 % of cases (n=18) spread to the nerve passage areas Th6 – Th9 in the upper TAP block and Th9 – L1 in the lateral TAP block. In group A, in 38.8 % of cases (n=7), the dye did not spread to the Th8-Th9 nerve passage area with the upper TAP block, as well as to the Th10 and Th12–L1 passage areas with the lateral TAP block. An inverse correlation of the growth and the dye distribution area was revealed (p &lt; 0.01). In all unfixed corpses whose height exceeded 179 cm, the dye could not compromise all the zones of passage of nerve structures. Tissue damage in the area of the block limited the spread of the dye.Conclusion. Adequate distribution of local anesthetic depends on the patient’s height. With the height of &gt;179 cm, 20 ml may not be enough to perform a TAP block, and &lt;177 cm – 30 ml may be excessive.

Comparison of the Low Back Pain Relief and Spread Level After Upper and Lower Lumbar Erector Spinae Plane Block

BACKGROUND: The erector spinae plane block (ESPB), which was introduced to manage the thoracic pain, is an ultrasound-guided technique that is relatively easy, less invasive, and safer. In spite of its technical ease and safety of ESPB, few studies have explored the analgesic efficacy and the exact spread level of injected local anesthetics. OBJECTIVES: The purpose of this study is to compare the analgesic efficacy and spread level of the upper and lower lumbar ESPBs . STUDY DESIGN: Prospective, randomized design. SETTING: The pain clinic of a tertiary university hospital. METHODS: This study included 84 patients with low back pain with or without leg pain who received lumbar ESPB at L2 (L2 ESPB group) or L4 (L4 ESPB group) using 10 mL of 0.2% ropivacaine mixed with 10 mL of the contrast medium. After finishing 20 mL of the local anesthetic mixture injection, a fluoroscopic examination was performed to evaluate the spread level. Analgesic efficacy was assessed using an 11-point Numeric Rating Scale (NRS-11) and a Back Pain Functional Scale. RESULTS: The number of patients who showed excellent-to-moderate low back pain relief was 35 (83.3%) and 36 (78.5%) in the L2 and L4 ESPB groups, respectively. Significant reductions in pain on the NRS-11 and improvements in disability were found in both groups. The total number of vertebral segments to which the anesthetic drugs spread was significantly higher in the L2 ESPB group than in the L4 ESPB group (2.7 ± 0.5 vs 2.0 ± 0.2, P = 0.002). LIMITATIONS: The analgesic efficacy of lumbar ESPB was evaluated with only short-term outcomes. CONCLUSIONS: Both the L2 and L4 ESPB groups demonstrated a significant reduction in low back pain and improvement in disability. The L2 ESPB group demonstrated a significantly increased spread level compared to the L4 ESPB group. KEY WORDS: Erector spinae plane block, spread level, low back pain, analgesic efficacy

Comparison of Labor Analgesia Efficacy Between Single-orifice and Multiorifice Wire-reinforced Catheters During Programmed Intermittent Epidural Boluses: A Randomized Controlled Clinical Trial

(Reg Anesth Pain Med. 2023;48:61–66) Programmed intermittent epidural bolus (PIEB) has been used since 2006 for labor analgesia. It is theorized that high-flow epidural catheters may be necessary for proper anesthetic spread dynamics within the epidural space. Epidural catheters have varying characteristics that may affect anesthesia administration. Studies show that multiorifice catheters were proven superior when compared with single-orifice catheters; however, due to flow dynamics, single-orifice catheters may be preferred to close-ended multiorifice catheters due to diffusion distance and area coverage. This study aimed to show a comparison between single-orifice and multiorifice catheters when used for intermittent high-rate bolus administration.

Relationship between injectate volume and disposition in erector spinae plane block: a cadaveric study

IntroductionErector spinae plane (ESP) blocks can be used to provide analgesia following thoracoabdominal and lumbar spine surgical procedures. However, the influence of injectate volume and injection location on the spread...

Anesthetic management of parturients with achondroplasia: a case series

Background Achondroplasia is the most common form of dwarfism, and cesarean delivery is often required in parturients with achondroplasia due to cephalopelvic disproportion. Given the challenges for both regional and general anesthetic techniques, there is no consensus on the optimal anesthetic management for cesarean delivery in these patients. Method A search of our electronic medical records for all female patients who had a diagnosis of achondroplasia and had a delivery in our health system from January 1, 2001 through June 16, 2023 was performed. Institutional review board exemption was obtained. Results We identified seven achondroplastic patients with 12 cesarean deliveries and described their anesthetic management during labor and delivery. Conclusion Despite the historical preference of general anesthesia in achondroplastic patients due to concerns of unpredictable spinal anatomy and unreliable local anesthetic spread, neuraxial anesthesia was successfully utilized in achondroplastic parturients and is a viable option in carefully selected patients. Reduction of intrathecal local anesthetic dose that minimizes the risk of high spinal and emergent intubation, as well as a titratable neuraxial technique, can be effective in this patient population.

Effect of local anesthetic volume (20 vs. 40 ml) on the analgesic efficacy of costoclavicular block in arthroscopic shoulder surgery: a randomized controlled trial.

Among the various diaphragm-sparing alternatives to interscalene block, costoclavicular block (CCB) demonstrated a low hemidiaphragmatic paresis (HDP) occurrence but an inconsistent analgesic effect in arthroscopic shoulder surgery. We hypothesized that a larger volume of local anesthetic for CCB could provide sufficient analgesia by achieving sufficient supraclavicular spreading. Sixty patients scheduled for arthroscopic rotator cuff repair were randomly assigned to receive CCB using one of two volumes of local anesthetic (CCB20, 0.75% ropivacaine 20 ml; CCB40, 0.375% ropivacaine 40 ml). The primary outcome was the rate of complete analgesia (0 on the numeric rating scale of pain) at 1 h postoperatively. The secondary outcomes included a sonographic assessment of local anesthetic spread, diaphragmatic function, pulmonary function, postoperative opioid use, and other pain-related experiences within 24 h postoperatively. The rates of complete analgesia were not significantly different (23.3% [7/30] and 33.3% [10/30] in the CCB20 and CCB40 groups, respectively; risk difference 10%, 95% CI [-13, 32], P = 0.567). There were no significant differences in other pain-related outcomes. Among the clinical factors considered, the only factor significantly associated with postoperative pain was the sonographic observation of supraclavicular spreading. There were no significant differences in the incidence of HDP and the change in pulmonary function between the two groups. Using 40 ml of local anesthetic does not guarantee supraclavicular spread during CCB. Moreover, it does not result in a higher rate of complete analgesia compared to using 20 ml of local anesthetic in arthroscopic shoulder surgery.

The Effect of Adding Magnesium Sulphate to Epidural Bupivacaine Compared to the Addition of Fentanyl to Epidural Bupivacaine in Patients Undergoing Lower Limb and Pelvic Orthopedic Surgery under Combined Spinal Epidural Anesthesia

Abstract Background Epidural anesthesia is safe and inexpensive technique with the advantage of providing surgical anesthesia and prolonged postoperative pain relief. Research continues concerning different techniques and drugs that could provide better surgical anesthesia and postoperative pain relief. Aim of the Work to investigate how the addition of magnesium sulphate to 0.5% bupivacaine affects duration, quality, complications and dermatome spread of anesthesia in comparison to fentanyl. Patients and Methods The current study included 50 patients who had been scheduled to undergo lower limb or pelvic orthopedic surgery under combined spinal - epidural anesthesia. The study had been done after approval of the local ethics committee and after obtaining written informed consent from all patients enrolled in the study; which had been held at Ain Shams Hospital, Faculty of Medicine. Results Pain assessment using VAS showed no statistically significant difference between the two studied groups in the first and second hours postoperative. Starting from the third hour statistical significant differences were observed between the two groups, VAS was higher in groups (M) than in group (F); (1.82 ±0.6 vs. 1.42 ±0.4 in both groups respectively. At the fourth hour; VAS was higher in groups (M) than in group (F); (2.80±0.8 vs. 1.76 ± 0.6 in both groups respectively. The incidence of complications was significantly lower among group (M) where 52% of patients had no complications at all. Conclusion the use of both magnesium and fentanyl as adjuvants to local anesthetics in epidural anesthesia is safe and effective. No significant differences regarding quality of motor block and hemodynamics. But the study shows that fentanyl is significantly a better adjuvant regarding postoperative analgesia and time for first analgesic dose. While magnesium is a significantly better adjuvant regarding complications such as nausea, vomiting and pruritis.

Anesthetic Spread of Ultrasound-Guided Paraspinal Blocks in Video-Assisted Thoracoscopic Surgery: A Three-Dimensional Reconstruction Image Study

BACKGROUND: Anesthetic spread of ultrasound-guided paraspinal blocks is still unknown. OBJECTIVES: To compare the drug diffusion qualities of intertransverse process block (ITPB) and erector spinae plane block (ESPB) in clinical practice. STUDY DESIGN: Prospective computed tomography (CT)-3-dimensional (3D) reconstruction image study. SETTING: Operation room in hospital. METHODS: Twenty patients undergoing thoracoscopic pulmonary wedge resection or segmentectomy were enrolled. These procedures require localization of pulmonary nodules using CT-guided needle puncture immediately before surgery. The patients were divided into 2 groups, each consisting of 10 patients. Group I underwent ITPB, while group E underwent ESPB. These interventions were performed 30 minutes before surgery using 20 mL of 0.25% bupivacaine with 2 mL iohexol. Sensory loss of the thoracic dermatomes was assessed using cold stimulation before general anesthesia. Patients’ CT localization images were used for 3D reconstruction after surgery, and the diffusion of the drug in each cross-section of the CT images was evaluated. RESULTS: Three-dimensional imaging of the drug showed that in group E, drug diffusion was improved in the cephalocaudal area compared to group I (10 vs 4.5 segments). Drug diffusion in group I was improved anteriorly and laterally ([10/10, 100%] in the paravertebral and intercostal spaces) and reached the front of the vertebral body along the thoracic fascia in certain segments (6/10, 60%). In group E, very few segments of the drug reached the paravertebral (2/10, 20%) and intercostal (3/10, 30%) spaces. All patients in group I had clear signs of loss of cold sensation on the lateral and anterior chest walls, with an average of 4 thoracic dermatomes. In group E, 3 patients had definite lateral and anterior chest wall cold stimulation signs, the thoracic dermatome was discontinuous, and the effect was only present between 1-2 segments. The blocking effect of the paraspinal zone was excellent (100%) in both groups. LIMITATIONS: However, this study has some limitations. First, the sample size was small, and clinical trials with larger samples are required to further verify the effects of ITPB and ESPB. Second, the same local anesthetic drug concentration and volume were used for both techniques in this study, and the effect of volume or concentration on drug diffusion was not further explored. CONCLUSIONS: Compared with ESPB, ITPB yielded increased stability in lateral and anterior chest wall block with improved anterior and intercostal spread, but reduced cephalocaudal spread. KEY WORDS: Erector spinae plane block, intertransverse process block, 3-dimensional imaging, paraspinal block, drug diffusion, video-assisted, thoracoscopic surgery, 3D reconstruction