Combined Anesthesia Research Articles

Developments in buffalo anaesthesia with special reference to diaphragmatic herniorrhaphy

Ruminants are poor subject for general anaesthesia. Diaphragmatic hernia (DH) is a common digestive disorder in buffaloes requiring balanced general anaesthesia for surgical repair. For premedication, initially, a combination of phenothiazine/chloralhydrate was used which was later replaced by alpha2 agonist like xylazine. Anticholinergics like atropine or glycopyrrolate were included in balanced anaesthetic protocols to reduce cardiac depression by alpha2 agonists. Thiobarbiturates historically were used for induction and maintenance but late recovery and cardiorepiratory depression lead to switch over to propofol. Maintenance of anaesthesia by top-up or continuous rate infusion (CRI) of propofol was not economical. The inclusion of opioids like butorphanol improved the analgesia as well as has dose sparing effect on induction and maintenance agent. The introduction of inhalants for maintenance significantly improved outcomes with the ease of change of depth of anaesthesia. It has also been observed that adrenocortical suppression by etomidate and mechanical intermittent positive pressure ventilation (IPPV) resulted in poor outcomes whereas maintaining the homeostasis and functional adreno-cortical axis of buffaloes under anaesthesia improves the success rate of DH surgeries. The balanced anaesthetic combination of Atropine/xylazine/ butorphanol/propofol/isoflurane has been found to be most satisfactory till date in buffaloes undergoing DH surgery. The studies on muscle relaxants, blood gas analysis and end tidal carbon dioxide (EtCO2) in buffaloes are scarce. Moreover, many drugs have been used in combinations in clinical cases on the basis of extrapolation from other species; but in buffaloes the effect of individual drug (like dose sparing effect of analgesics, minimum alveolar concentration (MAC) of inhalants) has to be still studied.

Combination of Local Anesthetics and Corticosteroids as Pain Management in Supraspinatus Tendinitis: A Case Report

Introduction: This study aimed to report the treatment of tendinitis in combination with local anesthetics and corticosteroids.
 Case presentation: A man, 34 years old, came to the hospital with complaints of pain in the right shoulder. This pain is felt especially when moving the right shoulder, and the patient also cannot raise his right hand. Pain when moving the right arm appeared after falling off a motorbike about 1 month ago. The intensity of pain has been getting higher for the last 14 days, especially when going to bed, so the patient complains of difficulty sleeping. The patient has been treated at the public health center for a month and has received pain relievers. Physical examination showed vital signs within normal limits and pain intensity of 8/10 based on the visual analogue scale. Examination of the extremity shows the abduction of pain starting at 60°-70° on activity and no pain on passive movement. In the special tests, the Neer test is positive, the Hawkin test is positive, and the Empty Can test is positive. The patient was diagnosed with supraspinatus tendinitis. The treatment for this patient is supraspinatus tendon injection. The anesthetic agent used was 2% lidocaine combined with 20 mg triamcinolone corticosteroids. This procedure is performed under ultrasound guidance for precise injection sites. Evaluation after the action found no side effects. After 1 month of action, the patient felt that the pain was greatly reduced (1/10) and the joint movement was not limited.
 Conclusion: The use of a combination of triamcinolone and lidocaine is beneficial in reducing pain in cases of supraspinatus tendinitis.

Pediatric anesthesia practices during the COVID-19 pandemic: A retrospective cohort study.

The onset of the coronavirus 2019 (COVID-19) pandemic brought together the American Society of Regional Anesthesia and Pain Medicine (ASRA) and the European Society of Regional Anaesthesia and Pain Therapy (ESRA) to release a joint statement on anesthesia use. Their statement included a recommendation to use regional anesthesia whenever possible to mitigate the risk associated with aerosolizing procedures. We sought to examine the utilization of anesthesia in pediatric patients undergoing a surgical procedure for fractures or ligament repairs before and during COVID-19. Using the Premier Health Database, we retrospectively analyzed pediatric patients undergoing a surgical intervention for fractures or ligament repair before and during COVID-19. We sought to determine if there were differences in anesthesia use among this cohort during the two time periods. Fracture groups included shoulder and clavicle, humerus and elbow, forearm and wrist, hand and finger, pelvis and hip, femur and knee, leg and ankles, and foot and toes. Ligament procedures included surgical intervention for the anterior cruciate ligament and ulnar collateral ligament repair. We identified a total of 5935 patients undergoing a surgical procedure for fractures or ligament repairs before and during COVID-19. After exclusion for unknown anesthesia use, 2,807 patients were included in our cohort with 81.5% (n = 2288) of patients undergoing a procedure under general anesthesia, 6.4% (n = 181) under regional anesthesia, and 12.0% (n = 338) under combined general-regional anesthesia. There did not appear to be a significant difference in the type of anesthesia used before and during COVID-19 (p = 0.052). Our study did not identify a difference in anesthesia use before and during COVID-19 among pediatric patients undergoing a surgical procedure. Further studies should estimate the change in anesthesia used during the time period when elective procedures were resumed.

Novel protocol to establish the myocardial infarction model in rats using a combination of medetomidine-midazolam-butorphanol (MMB) and atipamezole.

Myocardial infarction (MI) is one of the most common cardiac problems causing deaths in humans. Previously validated anesthetic agents used in MI model establishment are currently controversial with severe restrictions because of ethical concerns. The combination between medetomidine, midazolam, and butorphanol (MMB) is commonly used in different animal models. The possibility of MMB combination to establish the MI model in rats did not study yet which is difficult because of severe respiratory depression and delayed recovery post-surgery, resulting in significant deaths. Atipamezole is used to counter the cardiopulmonary suppressive effect of MMB. The aim of the present study is to establish MI model in rats using a novel anesthetic combination between MMB and Atipamezole. Twenty-five Sprague Dawley (SD) rats were included. Rats were prepared for induction of the Myocardial infarction (MI) model through thoracotomy. Anesthesia was initially induced with a mixture of MMB (0.3/5.0/5.0 mg/kg/SC), respectively. After endotracheal intubation, rats were maintained with isoflurane 1% which gradually reduced after chest closing. MI was induced through the left anterior descending (LAD) artery ligation technique. Atipamezole was administered after finishing all surgical procedures at a dose rate of 1.0 mg/kg/SC. Cardiac function parameters were evaluated using ECG (before and after atipamezole administration) and transthoracic echocardiography (before and 1 month after MI induction) to confirm the successful model. The induction time, operation time, and recovery time were calculated. The success rate of the MI model was also calculated. MI was successfully established with the mentioned anesthetic protocol through the LAD ligation technique and confirmed through changes in ECG and echocardiographic parameters after MI. ECG data was improved after atipamezole administration through a significant increase in heart rate (HR), PR Interval, QRS Interval, and QT correction (QTc) and a significant reduction in RR Interval. Atipamezole enables rats to recover voluntary respiratory movement (VRM), wakefulness, movement, and posture within a very short time after administration. Echocardiographic ally, MI rats showed a significant decrease in the left ventricular wall thickness, EF, FS, and increased left ventricular diastolic and systolic internal diameter. In addition, induction time (3.440 ± 1.044), operation time (29.40 ± 3.663), partial recovery time (10.84 ± 3.313), and complete recovery time (12.36 ± 4.847) were relatively short. Moreover, the success rate of the anesthetic protocol was 100%, and all rats were maintained for 1 month after surgery with a survival rate of 88%. Our protocol produced a more easy anesthetic effect and time-saving procedures with a highly successful rate in MI rats. Subcutaneous injection of Atipamezole efficiently counters the cardiopulmonary side effect of MMB which is necessary for rapid recovery and subsequently enhancing the survival rate during the creation of the MI model in rats.

Awake neuraxial anesthesia for infants undergoing infraumbilical surgery.

Awake neuraxial anesthesia techniques such as spinal anesthesia (SA) have been recently popularized and successfully used in infants for infraumbilical procedures. One caveat of these techniques is limited block duration. In this prospective study, we describe our single-center implementation of three approaches to awake neuraxial anesthesia (plain bupivacaine SA, bupivacaine with adjunctive clonidine SA, and combined spinal caudal anesthesia) based on expected surgical duration in 140 infants. We show that a wide range of infraumbilical procedures can be successfully performed in infants while maintaining the benefits of awake neuraxial anesthesia techniques. We hope our experience provides guidance to clinicians performing awake neuraxial anesthesia in infants in helping plan the appropriate anesthetic approach.

Effects of thoracic paravertebral block combined with s-ketamine on postoperative pain and cognitive function after thoracoscopic surgery

ObjectivesTo assess the effects of thoracic paravertebral block and s-ketamine on postoperative pain and perioperative neurocognitive disorder (PND) in video-assisted thoracoscopic surgery. MethodsPatients (n = 120) aged 45–65 undergoing video-assisted thoracoscopic surgery were allocated randomly into the following three groups: patients in the C group received general anaesthesia; patients in the thoracic paravertebral block group, i.e. the TP group, received general anaesthesia and ultrasound-guided paravertebral block; and patients in the s-ketamine combined with ultrasound-guided thoracic paravertebral nerve block group, i.e. the TS group, received combined anaesthesia, which was administered as follows: general anaesthesia + ultrasound-guided paravertebral block + perioperative s-ketamine (a bolus of 0.3 mg/kg, followed by an infusion of 0.2 mg/kg/h until 30 min before the end of the surgical procedure). ResultsCognitive function was measured using the Mini-Mental State Examination 1 day preoperatively, 1 day postoperatively, and 3 months postoperatively. Z-score was used to determine the incidence of PND. Postoperative pain was assessed using the visual analogue scale at 0.5 and 24 h postoperatively. The use of opioid drugs, intraoperative vital signs, and other secondary outcomes were also recorded. The final analysis included a total of 110 patients. The intraoperative heart rate and mean arterial pressure in the TS and TP groups were lower than that for group C (P＜0.05). After surgery, patients in the TS group exhibited significantly lower pain scores at 0.5 h and 24 h (P＜0.001 and P = 0.004,respectively) as well as significantly lower rates of postoperative nausea, vomiting, and pulmonary complications (P＜0.05). The incidence of PND in the TP and TS groups was lower than those who received general anaesthesia. However, there was no significant difference in the incidence of PND between the TP and TS groups (P＞0.05). ConclusionsUltrasound-guided paravertebral nerve block combined with s-ketamine decreased acute postoperative pain and improved the quality of recovery. However, perioperative s-ketamine did not improve cognitive function in patients under general anaesthesia with thoracic paravertebral block.

Low dose bupivacaine spinal anesthesia for emergency cesarean section in a patient with uncorrected tetralogy of fallot, presenting with placenta previa

Background: Pregnant women with congenital heart disease tetralogy of fallot who undergo cesarean section have their own challenges for the anesthesiologist, not to mention if they have pregnancy complications such as placenta previa. The choice of the safest anesthetic technique is still debated today. The anesthetic technique must be able to maintain systemic vascular resistance, avoid increasing pulmonary vascular resistance, and be aware of the threat of blood loss due to placenta previa. Case Report: 29 years old pregnant woman, weighing 46 kg and height 155 cm, G1P0A0, Gravida 27-28 weeks, single alive fetus, fetal distress, comes with complaints of shortness of breath, vaginal bleeding due to placenta previa with tetralogy of fallot planned emergency cesarean section. The patient presented with functional class NYHA II-III. We used low-dose spinal anesthesia with 5 mg bupivacaine 0.5% and 25 ug fentanyl as an adjuvant. Colloading was done with gelofusin colloid fluid to replace the amount of bleeding. Hemodynamics prior to anesthesia were BP 120/80, Heart Rate 80 x/minure, SpO2 72% with a non-rebreathing mask 10 litre/minute. There was no severe hypotension during surgery, and was hemodynamically stable with limited use of vasopressors. After the cesarean section was completed, the patient was transferred to the ICU and treated for 2 days, and was only discharged after 5 days of treatment without additional complications. Conclusion: The use of low-dose spinal anesthesia in combination with adjuvant fentanyl results in a relatively safe anesthetic technique with minimal hemodynamic changes and adequate analgesia for cesarean delivery.

Combined spinal and epidural anesthesia with dexmedetomidine sedation during hip and knee arthroplasty

Background. Hip and knee arthroplasty (HKA) is a common surgical procedure. One of the common diseases that negatively affect the results of these operations is diabetes. The aim of the study: to determine the effectiveness and safety of combined multimodal low-opioid anesthesia with dexmedetomidine sedation in patients undergoing HKA in concomitant diabetes mellitus. Materials and methods. In total, the study included 45 patients who underwent HKA. They were divided into 3 groups depending on the scheme of anesthesia. In group 1 (n = 15), multicomponent low-flow anesthesia with artificial lung ventilation was performed; in group 2 (n = 15), spinal anesthesia was used; in group 3 (n = 15), combined spinal and epidural anesthesia with dexmedetomidine sedation was performed. Results. The course of anesthesia in all groups was satisfactory, but patients in group 3 were less likely to experience hyperdynamic reactions (tachycardia and hypotension), postoperative nausea and vomiting. Only one person from group 3 required ondansetron for the treatment of postoperative nausea and vomiting against 3 and 2 patients from groups 1 and 2, respectively (p < 0.05). Conclusions. Any of the proposed techniques can be used for anesthesia in HKA, but the best results have been obtained in combined spinal and epidural anesthesia with dexmedetomidine sedation.

International Delphi-based consensus on the appropriate use and effect of Benzydamine hydrochloride in the treatment of sore throat

BackgroundBenzydamine hydrochloride is a locally-acting Non-Steroidal Anti-Inflammatory Drug (NSAID) with combined local anesthetic and analgesic properties, indicated for the symptomatic relief of pain in acute sore throat. The aim of this study was to obtain an European Consensus among pharmacists, general practitioners and pediatricians on the appropriate use of benzydamine hydrochloride in the treatment of sore throat.MethodsThe authors developed a Delphi questionnaire organized into 15 statements focused on 4 topics: the mechanism of action of benzydamine, the benzydamine treatment in an adult patient and in a pediatric patient, and the advantages of benzydamine over other topical treatments. The survey was administered to a panel of to 320 participants including general practitioners, pediatricians, and pharmacists from 6 European countries (Italy, Germany, Portugal, Romania, Russia, and Spain), who rated their level of agreement or disagreement with each statement on a 6-point Likert scale. Consensus was predefined as more than 66% of the panel agreeing/disagreeing with each statement.ResultsPanelists’ agreement on statements was very high. Consensus was reached for all 15 statements in the Delphi survey, with more than 98% positive agreement on topic 4, suggesting a shared view among European healthcare professionals (HCPs) about the advantages of benzydamine over other topical treatments. A strong consensus (> 99%) was reached for all the statements of topic 1 regarding the mechanism of action of benzydamine, except for its anesthetic properties (79%). Strong agreement was reached for all statements in topics 2 and 3 regarding the treatment of acute sore throat symptoms in the adult and pediatric patient, except for one on the efficacy of benzydamine in preventing post-operative sore throat, for which it was 67%.ConclusionBecause all relevant publications on benzydamine are dated and there are no recommendations on its use for the symptomatic treatment of sore throat in European guidelines, this Delphi-based international consensus may be important in reinforcing the appropriate use and effect of benzydamine in the treatment of sore throat among health care professionals.

Effect of combined application of sevoflurane and remifentanil on laparoscopic surgery, postoperative recovery time and stress response

Purpose: To investigate the effect of application of sevoflurane and remifentanil on laparoscopic surgery, and its effect on patients’ postoperative recovery time and stress response. 
 Methods: Ninety patients undergoing laparoscopic surgery in Zhongshan City People's Hospital, Guangdong Province, China were selected and randomly divided into propofol group (PG) and sevoflurane group (SG), with 45 patients in each group. Patients in PG were anesthetized with combination of propofol and remifentanil, while those in SG received combination of sevoflurane and remifentanil. Patients’ heart rate (HR), stroke volume (SV) and mean arterial pressure (MAP) were tested before anesthesia induction (T1), after intubation (T2), 15 min after pneumoperitoneum (T3), and after extubation (T4), in order to evaluate the stability of vital signs in the patients. 
 Results: At T2, T3, and T4, HR, SV, and MAP were more stable in SG than in PG (p < 0.05). At T3 and T4, the levels of ET-1, noradrenaline (NE) and cortisol (Cor) were significantly lower in SG than in PG (p < 0.05). Furthermore, postoperative recovery time, spontaneous breathing time, time taken to open the eyes under command, and orientation recovery time were shorter in SG than in PG (p < 0.05). After awakening, SG had significantly higher Ramsay score than PG (p < 0.05). 
 Conclusion: The combined use of sevoflurane and remifentanil for anesthesia in patients undergoing laparoscopic surgery results in stable vital signs, facilitates recovery after surgery, improve quality of recovery, and reduce stress response. Therefore, the combination anesthesia merits further mechanistic and large-scale investigation before clinical application.

Fractional-Order Control Strategy for Anesthesia–Hemodynamic Stabilization in Patients Undergoing Surgical Procedures

Fractional calculus has been opening new doors in terms of better modeling and control of several phenomena and processes. Biomedical engineering has seen a lot of combined attention from clinicians, control engineers and researchers in their attempt to offer individualized treatment. A large number of medical procedures require anesthesia, which in turn requires a closely monitored and controlled level of hypnosis, analgesia and neuromuscular blockade, as well maintenance of hemodynamic variables in a safe range. Computer-controlled anesthesia has been given a tremendous amount of attention lately. Hemodynamic stabilization via computer-based control is also a hot topic. However, very few studies on automatic control of combined anesthesia–hemodynamic systems exist despite the fact that hemodynamics is strongly influenced by hypnotic drugs, while the depth of hypnosis is affected by drugs used in hemodynamic control. The very first multivariable fractional-order controller is developed in this paper for the combined anesthesia–hemodynamic system. Simulation studies on 24 patients show the effectiveness of the proposed approach.

Towards the efficacy of erector spinae plane block in lumbar spinal fusion

AIM: This study aimed to assess the efficacy and safety of the erector spinae plane block (ESP-block) in lumbar spinal fusion in the perioperative period.
 MATERIALS AND METHODS: This prospective randomized study included 200 patients aged 4565 years undergoing decompression and lumbar spinal fusion. All the patients were divided into three groups depending on the anesthesia method. The first group received general anesthesia in combination with a single bilateral ESP-block; the second group received general anesthesia in combination with a prolonged bilateral ESP-block; the third (or, control) group was given general anesthesia. The parameters of intraoperative hemodynamics, the postoperative pain according to the visual analog scale, the need for opioid analgesics during and after surgery, the incidence of postoperative nausea and vomiting, and other anesthesia-induced adverse reactions were assessed.
 RESULTS: Patients who received the single bilateral ESP-block have exhibited adequate pain relief, leading to minimal opioid analgesic consumption in the early postoperative period. However, prolonged ESP-block with bilateral catheters is the most efficacious postoperatively, and patients hardly needed narcotic analgesics and featured a low incidence of postoperative nausea and vomiting (hazard ratio: 0.32; 95% confidence interval: 0.2130.464; р 0.001).
 CONCLUSION: The bilateral ultrasound-assisted ESP-block in lumbar decompression and spinal fusion ensures adequate pain relief both intra- and postoperatively, resulting in a reduced need for opioid analgesics and minimizing their related incidence of adverse reactions.

Periarticular Injection of Ranawat Suspension in Combination with Tranexamic Acid Reduces Bleeding and Postoperative Pain in Total Knee Arthroplasty

Objective: The benefits of periarticular injections of local anesthetic agents or tranexamic acid have been previously evaluated in terms of their effects on postoperative pain in a number of orthopedic studies. However, data is lacking on the efficacy of local anesthetic and tranexamic acid combinations that may be used for this purpose. We aimed to investigate the effects of periarticular injection of both tranexamic acid and Ranawat suspension on postoperative pain and bleeding in patients undergoing total knee arthroplasty.
 Methods: A total of 124 patients who underwent total knee arthroplasty were consecutively enrolled in this study. Patients were divided into two groups: those receiving the periarticular injection of a cocktail containing the combination of Ranawat suspension and Tranexamic acid and those receiving no injections. Postoperative pain, postoperative tramadol requirement and blood loss were compared between groups.
 Results: Hemoglobin and hematocrit levels were significantly higher at third day postoperatively in recipients of periarticular Ranawat suspension and tranexamic acid combination (p=0.044 and p=0.047, respectively). In addition, the amount of drainage blood loss (p

FEATURES OF REMOTE SEDATION OF THE NORTHERN FUR SEAL IN NATURAL HABITAT

One of the global environmental problems facing man is the pollution of the oceans by industrial and household garbage. Several hundred seals and sea lions injured by foreign objects are registered annually in reproductive rookeries. Without timely release, these animals are doomed to perish. In this regard, the purpose of the work was to test the technique of freeing injured marine mammals from foreign objects of anthropogenic origin using methods of remote sedation of animals. The problem of implementing measures for the release of marine mammals is associated, among other things, with the lack of proven methods and dosages of sedatives for these animals.In the course of this study, it was revealed that in order to carry out remote sedation, the following factors must be taken into account: weather conditions, distance to water, the presence of other animals between the object and the water, terrain features, danger from other animals, the place of the shot, the dose. The choice of an animal must be carried out depending on the period (harem / post-harem), age, psychological state, body weight and physical condition. In the course of working out the technique of freeing injured marine mammals from foreign objects of anthropogenic origin using methods of remote sedation of animals in a natural habitat, an algorithm for remote sedation using a Bushnell HOLO sight daninject 2528 mod jm remote injector was developed and tested (barrel diameter 11 mm, pressure in the applicator chamber 5 Bar (500 kPa), the size of the syringe-dart for sedation CMC 2-3 ml, needle length 4 cm), a scheme of combined anesthesia with the help of zoletil 100 (telazol) and medin (medetomedin) 1% has also been developed and successfully tested.

The effect of topical airway anesthesia on hemodynamic profiles during the induction period in patients undergoing cardiac surgery: Study protocol for a randomized controlled trial.

BackgroundPatients scheduled for cardiac surgery are often accompanied by cardiac dysfunction and hemodynamic instability. However, the conventional induction strategy for anesthesia using high-dose intravenous anesthetics is often associated with persistent and recurrent hypotension after tracheal intubation. The purpose of this study is to investigate the effects of topical airway anesthesia on the hemodynamic profile of patients undergoing cardiac surgery during the induction period.MethodsThis is a superiority, single-blind, randomized controlled study with two parallel groups. Participants scheduled to undergo elective cardiac surgery will be allocated into two blocks according to the New York Heart Association (NYHA) classification and then randomly assigned to the following two groups at a 1:1 ratio: the conventional induction group and the combined topical airway anesthesia induction group. The combined topical airway anesthesia induction strategy includes aerosol inhalation airway anesthesia, subglottic airway anesthesia, and general anesthesia induction using low-dose intravenous anesthetics. The primary outcome is the area under the curve (AUC) of blood pressure below baseline mean arterial pressure (MAP) from 3 to 15 min after endotracheal intubation. Secondary outcomes include the AUC above baseline MAP and below baseline MAP at other time points, the highest and lowest arterial blood pressure values during the induction period, type and dose of vasoactive drugs, incidence of arrhythmias, cardiac function, and the incidence of postoperative hoarseness and sore throat.DiscussionThe study will explore whether aerosol inhalation airway anesthesia and subglottic airway anesthesia could reduce the incidence and duration of hypotension during the induction period in patients undergoing cardiac surgery.Clinical Trial RegistrationThis trial was registered on www.ClinicalTrials.gov (NCT05323786).

Analysis of The Safety and Efficacy of Different Types of Anesthesiological Support During Aesthetic Interventions For The Breast Glands In Ukraine

In the prevailing era, mammoplasty is prevalent among women. Undeniable benefits of the method are the preservation of most anatomical structures and skin, and also better psychological status of patients after intervention. Hence, the present study intends to examine the features of aesthetic and reduction surgical interventions on the mammary glands in Ukraine. Materials and methods. The study was conducted by analyzing the inpatient ambulatory cards of 320 patients. Anesthesia was provided by propofol (n=130), sevoflurane (n=140) and combined use of sevoflurane and nalbuphine (n=50). The results of the study. It was found that usage of combined inhalation analgesia of sevoflurane with opioids was characterized by 41.9% less recovery time. It was found that 8 hours after surgery, the individual assessment of pain was lower in the group of combined analgesia with opioids relative to intravenous anesthesia with propofol (87.5%, p<0.05) and inhalation anesthesia with sevoflurane (71, 3%, p<0.05). After 24 hours all patients reported about pain below 1.0 point, however, in groups where sevoflurane and nalbuphine were used, the level of pain self-esteem was 2.61 and 3 times lower than after intravenous propofol. It was found that within 1 hour after surgery, the average cognitive score on the Montreal scale decreased in the group of intravenous propofol by 5.0% (p<0.05) and by 1.7% under inhalation anesthesia with sevoflurane. Under combined anesthesia the cognitive score remained at 12.0 points. The frequency of postoperative nausea was the highest level in the group of inhalation anesthesia - 16.7%. The addition of nalbuphine to sevoflurane significantly reduced the risk of postoperative nausea (? 2=7.250; p=0.007). Conclusions. Combined anesthesia with opioids is a highly effective anesthetic choice for aesthetic and reconstructive interventions on the mammary glands.

Contextual anaesthesia for a rare case of pycnodysostosis with myriad presentation: a case report

BackgroundPycnodysostosis is a rare inherited syndrome characterized by classical craniofacial defects and diffuse osteosclerosis disorder of bones with tendency for fractures after minor trauma.We describe the anaesthetic management of a parturient with pycnodysostosis with dual concerns of precious pregnancy and a fractured femur.Case presentationA 33-year-old primigravida with 31 weeks of gestation presented with subtrochanteric fracture of left femur. Clinico-radiological features of diffuse osteosclerosis suggested a diagnosis of pycnodysostosis, which was confirmed by genetic testing. We encountered challenges for sequential surgeries of lower segment caesarean section, surgical fixation of the fractured femur and surgical wound debridement in this patient in view of a difficult airway, short stature, physiological changes of pregnancy, difficulties in positioning and possibility of increased blood loss. A combination of general anaesthesia with either neuraxial anaesthesia or regional block was performed, which helped in the safe management of this syndromic patient.ConclusionsMultidisciplinary team dynamics, communication and expertise played a crucial role in the successful care of the patient. Planning anaesthesia contextually for each surgical setting was vital. Anaesthetic gadgets like fibre-optic bronchoscope and ultrasound were a boon to anaesthesiologist at every surgical procedure to aid the anaesthetic plan.

Combining Stellate ganglion block and intravenous regional anesthesia to treat complex regional pain syndrome: A 19-years' experience in a tertiary center.

To study reduction in pain score after treatment with intravenous regional anesthesia (IVRA) and Stellate ganglion block (SGB) combination on complex regional pain syndrome (CPRS) patients and to quantify patients' satisfaction with treatment and occurrence of complications. This is a record-based retrospective review carried out in 2020, targeting patients treated in the University of Jordan Hospital, Amman, Jordan, over the years 2002-2020. Among 99 patients, a significant drop in pain scores occurred in 88% of the patients' sample. Gender, age, type of CRPS, and duration of symptoms didn't affect statistical results. An average of 8.6 sessions needed to achieve 50% drop in pain score, and 2-3 sessions for first clinical improvement. Patients with previous application of plaster of Paris had increased success rates. We find it practical, inexpensive, safe, and straightforward to combine SGB with IVRA for CRPS patients.

Evaluation of the efficacy of paravertebral blockade as a component of combined anesthesia in the surgical treatment of pulmonary cancer

The aim. The paper evaluates the effectiveness of implemented combined anaesthesia (inhalation with paravertebral blockade) in comparison with inhalation anaesthesia (IA) and total intravenous anaesthesia (TVA) at the stages of surgery and the early postoperative period in the surgical treatment of cancer lungs.
 Methods. The study involved 60 patients with an average age of 55±5.6 years, physical status ASA II–III, who underwent open surgical interventions in the scope of frontal or pneumonectomy or resection of part of the lung. Patients were divided into 3 groups depending on the method of anaesthetic support at the stage of anaesthesia maintenance: I (n=20) – combined anaesthesia was used; II (n=20) – IA with sevoflurane; III (n=20) – TVA. In addition, the leading indicators of central hemodynamics were studied; oxygen saturation (SaO2), CO2 ET (concentration of CO2 in exhaled air), cortisol level, and indicators of acid-base status were determined. The effectiveness of analgesia in the early postoperative period was assessed using a visual analogue scale (VAS) at 10 control stages. Fasting intensity was recorded after waking up, after extubation, after 1 h. after surgery, on the first day after surgery every 3 h. and once a day from the 2nd day for 5-6 days.
 Results. The studied clinical and laboratory indicators indicated an adequate course of the applied type of anaesthesia. In the dynamics of pain syndrome (PS) in the postoperative period, a gradual subjective increase of pain syndrome was noted until the 3rd day, including a decrease in pain on the 4th - 6th day. It was established that when using combined anaesthesia, a less significant level of PS, according to VAS, was noted compared to inhalation anaesthesia and the use of TVA.
 Conclusions. Combined anaesthesia (inhalation with PVB) can more effectively prevent the development of post-thoracotomy pain syndrome (PTPS) compared to TVA and IA in the surgical treatment of lung cancer

Effect of a combination of general anesthesia and superficial cervical plexus block with ropivacaine on patients undergoing thyroidectomy

Purpose: To investigate the effect of a combination of general anesthesia and superficial cervical plexus block (SCPB) with ropivacaine on patients undergoing thyroidectomy.
 Methods: Ninety-six (96) patients undergoing thyroidectomy were randomly divided into control and study group. Both groups were subjected to SCPB in combination with general anesthesia. Ropivacaine was used for SCPB in the study group. Vital signs, visual analogue scale (VAS) scores, and serum interleukin 1β (IL-1β) levels were determined at various time points (T) after tracheal intubation. Occurrence of adverse reactions was recorded.
 Results: Compared with the control group, mean arterial pressure (MAP), heart rate (HR), diastolic blood pressure (DBP), and systolic blood pressure (SBP) levels from T1 to T5 were declined in study group (p < 0.01). VAS scores of study group were significantly lower at 12, 24, and 48 h after thyroidectomy than in control group (p < 0.05). At 5, 10 and 15 h after surgery, serum IL-1β level in study group was down-regulated (p < 0.05). Moreover, a marked decrease in the incidence of adverse reactions was also found in the study group post-surgery (p < 0.05).
 Conclusion: Ropivacaine is effective for SCPB in combination with general anesthesia in patients undergoing thyroidectomy. It is safer and more feasible in SCPB when combined with general anesthesia. However, further clinical trials are required to validate this technique.