Intraoperative Fentanyl Consumption Research Articles

A Comparative Study of Erector Spinae Block versus Serratus Anterior Plane Block for Pain Management Following Video Assisted Thorocoscopic Surgery

Abstract Background Pain is an everyday challenge during all surgeries and it is a chief postoperative complication, so pain management is a corner stone in anesthetic practice. Minimally invasive thoracic surgery (MITS) has become more common over the past decade, with the proportion of lung resections performed using this technique increasing from 16% in 2005 to 47% in 2015. MITS includes both video-assisted and robotic-assisted techniques, with smaller skin incisions and chest wall trauma compared with open thoracotomy, Benefits include reduced postoperative pain, morbidity, and shorter hospital stay. Objective To compare efficacy between Serratus anterior block and Erector supinae block in Video assisted thoracoscopic surgery for minimally invasive thoracic surgery as regard post operative opioid consumption. Patients and Methods The study was conducted in Ain Shams University Hospitals after approval of the ethics committee and written patients‟ consent. It included a total of 40 adult patients aged 18-70 years, Scheduled for video assisted thoracoscopic surgeries. Patients were randomly divided into two equal groups, 20each, according to the inclusion and exclusion criteria. Results Intraoperative fentanyl consumption, postoperative opioid consumption and 1st rescue analgesic use were significantly lower in the ESPB group (P < 0.05). NRS scores were significantly lower in the ESPB group (P < 0.05) than SAPB from 2 to 8 hour only, mean arterial pressure and Heart rate was significantly lower from 2hour to 8hour in ESPB than SAPB but there were no significant difference in hemodynamics intraoperative. Conclusion Clinicians could develop a preference for either ESPB or SAPB for pain control after VATS based on their clinical experiences and personal choices. However, our study showed that US-guided ESPB may provide better pain control than SAPB.

Comparative Study between Dexmedetomidine and Nitroglycerin as a Hypotensive Agent and Their Effects on Bleeding in Functional Endoscopic Sinus Surgery

Abstract Background Rhino-sinusitis is commonly treated with FESS. However, there can be serious complications associated with this procedure during peri-operative period like orbital cellulitis, optic nerve injuries, meningitis, etc. Their incidence increases with excessive bleeding during surgery. So Controlled hypotension is used reducing arterial blood pressure 30-40% below its normal range. Objective Primary aim: Comparing Dexmedetomidine and Nitroglycerine for inducing controlled hypotension in patients undergoing FESS with recording total intraoperative fentanyl consumption and recording of total local vasoconstrictor used by the surgeon. Secondary aim: Assessment of time to full recovery after extubation with recording of time to first analgesic used after recovery and its total dose for the first 24 hours. Materials and Methods In this study we compare Demedetomidine and Nitroglycerine in achieving hypotensive anaesthesia. The study is conducted in Anesthesiology Department, Faculty of medicine, Ain shams University. The study period is 6 months. The sample size is 50 patients divided in two groups randomly (Group I and Group II). Each group has 25 patients. Group I received Demedetomidine. Group II received Nitroglycerine. Results we find that the mean HR was significantly lower in Group I compared to Group II at all the times of measurements. The MAP was significantly lower in Group I compared to Group II after infusion of study drugs, after induction of anesthesia, after intubation and 5 min after intubation. However, the desired MAP for intra-operative induced hypotension could be achieved in all the two groups. Also we find that intra-operative Fentanyl requirement is significantly reduced in the Dexmedetomidine group as compared to the other group. The patients in group I had a longer time to full recovery. We also observe a significant delay in the first postoperative analgesic request in group I as compared to group II. It has been shown that perioperative analgesic requirements are significantly reduced with intra-operative use of Dexmedetomidine infusion. The patients in the Dexmedetomidine group had significantly higher sedation scores compared to group II. The incidence of postoperative shivering was significantly lower in the Dexmedetomidine group. The most frequent reported side-effect with Dexmedetomidine is dry mouth, which can be easily managed. Conclusion Dexmedetomidine provided better hemodynamic stability and comparable operative field visibility to nitroglycerine during FESS. Dexmedetomidine provides an additional benefit of reducing the analgesic requirements and providing postoperative sedation.

Bilateral ultrasound-guided erector spinae plane block for postoperative pain relief in major traumatic spine surgery: A randomized controlled trial

Introduction: Spine fixation surgery for traumatic vertebral fractures is associated with severe pain and is often difficult to control. Traditionally systemic opioids have been the mainstay of analgesia for these procedures, which can lead to hyperalgesia, nausea, ileus, sedation, cognitive impairment, dependence, etc., limiting usage of opioids. The Erector spinae plane block (ESPB) is a novel ultrasound-guided procedure with easily identifiable sonoanatomy. We hypothesized that a multimodal approach involving ESPB to a conventional analgesic regimen with local infiltration for patients undergoing major traumatic spine surgeries might provide better perioperative analgesia and reduce the need for postoperative opioid requirements. Material and Methods: A randomized control prospective trial was conducted on 34 ASA grade I –II patients aged 18 to 65 years who were scheduled to undergo elective posterior spine fixation surgery with ASIA B to E after traumatic spine fracture under general anesthesia. Patients were randomized to Group A which included patients who received general anesthesia with ESPB, and Group B, or the control group, included patients who received general anesthesia with systemic analgesics and postoperative local infiltration without ESPB. Intraoperative total fentanyl consumption, VAS score at 0, 3, 6, 12, 18, and 24 hours, time to activate patient-controlled analgesia (PCA) pump, total morphine consumption, and opioid-related side effects were monitored and compared in both groups. Results: Postoperative PCA morphine consumption was significantly lower in group A patients who received ESPB than those in the control group (17.06 ± 9.59 vs 37.82 ± 9.88 P value = <0.0001). VAS scores at rest and movement at 0, 3, 6, 9, 12, 18, and 24 hours were significantly lower (P value = 0.05) in the ESPB group compared with the control group at all time points. Conclusion: Bilateral ultrasound-guided Erector spinae plane block, when administered in traumatic spine patients undergoing spine fixation surgery, provides better analgesia with statistically decreased VAS scores and less postoperative opioid requirement.

The impact of erector spinae plane (ESP) block on neurophysiological monitoring in patients undergoing scoliosis repair

ABSTRACT Background Preventive analgesia is designed to ensure perioperative pain control. The erector spinae plane (ESP) block may abolish the neuroendocrine stress response and augments controlled hypotensive anesthesia. But to what extent does it interfere with spinal cord function. Methods The patient’s population is divided into Group N (control) and Group E (ESP Group). A baseline for the amplitude and/or latency of either somatosensory evoked potentials (SSEPs) or motor evoked potentials (MEPs) were collected (30 min after induction of anesthesia and after full reverse of muscle relaxant before performing ESP block) in group E, the change from the baseline was recorded as a percent decrease. The total dose of anesthetics, the adjuvant analgesics and the postoperative complications were recorded. Results The change in the latency and the amplitude of SSEPs and MEPs among the two groups showed a non-significant change from the baseline. The intra-operative fentanyl consumption was significantly lower in group E than in C. The mean was 21.5 ± 25 vs 178.2 ± 46 mg respectively. The total doses of propofol and dexmedetomidine were lower in group E than in C. 18% of the patients in group E requested a rescue analgesic at a median of 70 (65) min postoperatively vs 55% of those in group C that requested analgesics earlier at a median 16(6) min. Conclusion The ESP block can be safely used without interfering with the monitoring of the somatosensory and MEPs during complex spinal surgery.

Optimizing patient outcomes: the impact of multimodal preemptive analgesia in video-assisted thoracoscopic lobectomy.

The aim of this study was to evaluate the efficacy of a multimodal preemptive analgesia management approach, specifically incorporating ultrasound-guided thoracic paravertebral block (UG-TPVB) in conjunction with intravenous analgesia, after video-assisted thoracoscopic (VATS) lobectomy under the guidance of enhanced recovery after surgery. A total of 690 patients who underwent VATS lobectomy between October 2021 and March 2022 were divided into the UG-TPVB group (group T, n = 345) and the control group (group C, n = 345). Patients in group T received UG-TPVB prior to the induction of general anaesthesia, while group C did not undergo nerve block. A comparison was conducted between the 2 groups regarding various indicators, including postoperative sedation, static/dynamic numeric rating scale scores, intraoperative fentanyl consumption, duration of mechanical ventilation/anaesthesia recovery/hospitalization, postoperative complications and other relevant factors. The static/dynamic numeric rating scale scores of group T were lower than those of group C after surgery. Intraoperative fentanyl consumption in group T (0.384 ± 0.095 mg) was lower than that in group C (0.465 ± 0.053 mg). The duration of mechanical ventilation, anaesthesia recovery and hospitalization were significantly shorter in group T compared to group C. Patient satisfaction rate in group T (70.1%) was higher than that in group C (53.6%). All differences were statistically significant (P < 0.05). The multimodal preemptive analgesia management strategy effectively reduces postoperative pain, decreases opioid consumption and promotes faster recovery in patients undergoing VATS lobectomy.

Analgesic Efficacy of Thoracolumbar Interfascial Plane Block versus Standard Care in Patients Undergoing Lumbar Spinal Surgeries—A Randomized Controlled Trial

Abstract Background Patients who undergo spine surgery often experience severe pain postoperatively. Multimodal analgesia inclusive of a regional block provides optimal pain relief. Thoracolumbar interfascial plane (TLIP) block may provide promising analgesia in these patients. Materials Fifty consenting adults aged between 18 and 60 years undergoing elective lumbar spinal surgeries under balanced general anesthesia were divided into two equal groups (group T: received bilateral TLIP block, and group C: received conventional opioid analgesia). All the patients were taken care of by an independent anesthesiologist unaware of the study protocol in the postanesthesia care unit. The postoperative pain was assessed by visual analog scale (VAS). Time to first rescue analgesia, total morphine consumption, complications, and patient satisfaction were also recorded. Results Postoperative mean VAS scores till 12 hours were significantly higher in the control group. The mean time to the first analgesic requirement among group T and group C patients was 404.4 ± 25.1 and 150.2 ± 12.4 minutes, respectively (p &lt; 0.001). Morphine consumptions in 24 hours were also significantly higher in group C (3.36 ± 1.04 vs. 7.84 ± 1.43; p &lt; 0.001). Mean intraoperative fentanyl consumption was significantly more in group C (122.4 ± 16.4 µg and 140.4 ± 21.7 µg; p = 0.001). Complications were similar in both groups. However, patient satisfaction was significantly higher in group T (p &lt; 0.001). Conclusion TLIP block provided superior analgesia, decreased opioid consumption, and improved patient satisfaction as compared with patients receiving standard general anesthesia with opioid analgesics. Hence, TLIP block could be a component of multimodal analgesia in patients undergoing lumbar spine surgeries.CTRI No.: CTRI/2021/03/031682

Regional analgesia using ultrasound-guided intermediate cervical plexus block versus cervical erector spinae block for anterior cervical spine surgery: a randomized trial.

Regional analgesia techniques are crucial for pain management after cervical spine surgeries. Anesthesiologists strive to select the most effective and least hazardous regional analgesia technique for the cervical region. Our hypothesis is that an intermediate cervical plexus (IC) block can provide adequate postoperative analgesia compared to a cervical erector spinae (ES) block in patients undergoing anterior cervical spine surgery. In this double-blind prospective trial, 58 patients were randomly assigned into two equal groups prior to the administration of general anesthesia. Patients in the IC group (n = 29) underwent ultrasound-guided bilateral intermediate cervical plexus block with 15ml of bupivacaine 0.25% administered to each side. The ES group (n = 29) underwent ultrasound-guided bilateral cervical erector spinae plane blocks with 15ml of 0.25% bupivacaine administered to each side at the C6 level. The primary outcome was to record the time to the first call for rescue analgesia (nalbuphine), and the secondary outcomes were to measure the performance time, the onset of the sensory block, the intraoperative fentanyl consumption, postoperative pain intensity using VAS, the postoperative total nalbuphine consumption, and postoperative complications such as nausea, vomiting, hypotension, and bradycardia. The performance and onset of sensory block times were significantly shorter in the IC group compared to the ES group. The time to first call for nalbuphine was significantly shorter in the IC group (7.31 ± 1.34h) compared to the ES group (11.10 ± 1.82h). The mean postoperative VAS scores were comparable between the two groups at the measured time points, except at 8h, where it was significantly higher in the IC group, and at 12h, where it was significantly higher in the ES group. The total nalbuphine consumption was significantly higher in the IC group (33.1 ± 10.13mg) compared to the ES group (22.76 ± 8.62mg). For patients undergoing anterior cervical spine surgery, the intermediate cervical plexus block does not provide better postoperative regional analgesia compared to the cervical erector spinae block. Performance time and onset time were shorter in the IC group, whereas nalbuphine consumption was lower in the ES group. The trial was registered at clinicaltrials.gov. (NCT05577559, and the date of registration: 13-10-2022).

Comparing the Effectiveness of Oral Celecoxib with Oral Tramadol as Pre-Emptive Analgesia in Ambulatory Surgery

Nociception pathway is thought to be pre-emptively inhibited in hope to reduce acute pain in an anticipated procedural related tissue injury intraoperatively or postoperatively when pre-emptive analgesics are administered preoperatively. High intensity of pain is expected after surgical removal of the third molar which is associated with jaw swelling and limited opening of the jaw. We compared the pre-emptive analgesia effect of oral celecoxib and oral tramadol in elective ambulatory dental surgery under general anaesthesia. Informed consents were obtained from 84 patients with American Society of Anesthesiologists (ASA) physical status I or II and aged between 18 to 56 years. They were randomised to receive either oral celecoxib 200 mg (Group A) or oral tramadol 50 mg (Group B) one hour before induction of anaesthesia. Intraoperative and postoperative fentanyl consumption were compared. Numeric Rating Scale (NRS), ranging from 1 to 10, was used to assess postoperative pain scores. Group A showed a significant reduction in fentanyl consumption intraoperatively compared to Group B (p=0.047). Both groups of patients experienced mild pain at various times assessed postoperatively ranging between 0-2 NRS scores. Comparison between the groups did not detect significant reduction in pain scores and postoperative fentanyl consumption. We concluded that neither medication was found to be effective as pre-emptive analgesia, however, intraoperative fentanyl consumption was reduced by pre-emptive administration of oral celecoxib.

Assessment of ultrasound guided erector spinae plane block for early post-operative analgesia for modified radical mastectomy: a prospective, randomized, controlled study

Erector spinae plane block is a recently introduced block with a wide range of indications. The aim of the present study was to assess the efficacy and safety of ultrasound-guided erector spinae plane block on early post-operative pain relief in patients undergoing modified radical mastectomy. We conducted a prospective, randomized, controlled study in a tertiary care institute. Sixty-five patients were enrolled. Final analysis was performed on 58 patients randomized into two groups. Ultrasound-guided erector spinae plane block with 25 mL of 0.25% bupivacaine was given using a 18 gauge needle. No block was given in the other group. All patients received general anesthesia. Primary outcome measure was 24-hour analgesic consumption. Secondary outcome measures included intra-operative fentanyl consumption, time to first analgesic request, Visual Analog Scale score, nausea score, sedation score, wound quality and patient satisfaction score. Post-operative additional analgesics and intra-operative fentanyl were significantly reduced in patients receiving erector spinae plane block. Time to rescue analgesia was significantly delayed. Visual Analog Scale score was significantly lower at all time intervals. Post-operative nausea at various time intervals was also less. Patient satisfaction score was also noted on a 5-point scale and there was a statistical significant difference. We concluded that erector spinae plane block is a safe technique and provides good analgesia in breast surgery.

Retrospective comparison between low-volume high-concentration and high-volume low-concentration levobupivacaine for bilateral erector spinae plane block in dogs undergoing hemilaminectomy

ObjectiveTo compare the analgesic effect of a bilateral ultrasound-guided erector spinae plane block (ESPB) in dogs undergoing hemilaminectomy using either a low-volume high-concentration (LV-HC) or a high-volume low-concentration (HV-LC) local anaesthetic solution. Study designRetrospective observational equivalence trial. AnimalsA total of 391 client-owned dogs undergoing hemilaminectomy. MethodsDogs were assigned to group LV-HC or HV-LC depending on whether 0.2–0.25% levobupivacaine (0.4–0.5 mL kg–1) or 0.125–0.15% levobupivacaine (0.8–1 mL kg–1) was used to perform the ESPB, respectively. The number of dogs in which intraoperative rescue fentanyl boluses were administered, the total dose of fentanyl administered, the overall methadone consumption during the first 24 hours postoperatively and anaesthetic complications were recorded. Univariate and multivariate statistical analyses were performed considering p < 0.05 significant. ResultsA total of 248 and 143 dogs were assigned to groups LV-HC and HV-LC, respectively. In group HV-LC, the number of dogs requiring fentanyl intraoperatively (64.3%) was higher (p = 0.0001) than that in group LV-HC (43.5%). The overall intraoperative fentanyl consumption was higher in group HV-LC between the first skin incision and the end of the lamina drilling (p = 0.028). According to the regression analysis, the group allocation was the best variable to predict the intraoperative fentanyl consumption (p < 0.001).Antimuscarinic drugs were administered more frequently in group LV-HC (p < 0.02). However, the prevalence of hypotension and other pharmacological cardiovascular interventions did not differ between groups. No differences in methadone consumption during the first 24 hours postoperatively were found between the groups. Conclusionsand clinical relevanceWhen performing a bilateral ESPB in dogs undergoing hemilaminectomy, compared with HV-LC, the use of LV-HC local anaesthetic solution reduces the intraoperative fentanyl consumption without affecting the postoperative methadone requirement.

Inter-Semispinalis Plane Block Versus General Anesthesia for Postoperative Analgesia in Posterior Cervical Spine Surgery: A Randomized Controlled Trial.

Postoperative pain management is crucial for improving patient outcomes following posterior cervical spine surgery. Opioids are effective but carry a risk of respiratory depression. Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used but may not provide adequate pain relief and have potential complications. The inter-semispinalis plane (ISPB) block is a novel technique for postoperative analgesia in cervical spine surgery. This study aims to evaluate and compare the efficacy of the ISPB with general anesthesia in terms of analgesia, postoperative Visual Analog Scale (VAS) pain scores, patient-surgeon satisfaction levels, and the occurrence of postoperative complications. This double-blind, randomized controlled trial was blinded to both the patient and the assessor. Fifty adult patients (18 - 60 years old) undergoing elective posterior cervical spine surgery were enrolled. The participants were divided into 2 groups: The ISPB group (receiving bilateral ultrasound-guided ISPB at the C5 level) and the control group (receiving general anesthesia only), with each group comprising 25 patients. The study assessed intraoperative fentanyl use, postoperative VAS pain levels, the need for rescue analgesia, and complications. The ISPB group showed significantly lower intraoperative fentanyl consumption (median 100 vs. 100 - 150 μg, P = 0.022) and lower postoperative pain scores at 1, 8, 12, and 48 hours (P = 0.016, 0.009, 0.005, 0.016). Additionally, the ISPB group required less postoperative pethidine (20% vs. 64%, P = 0.002) and had a longer delay before requesting pethidine (hazard ratio 0.215, P = 0.001). Surgeon satisfaction was significantly higher in the ISPB group (P = 0.003). These results suggest that the ISPB can effectively reduce pain and analgesic requirements. The ISPB is an effective analgesic technique for posterior cervical spine surgery, reducing opioid consumption, providing better pain control, and enhancing surgeon satisfaction without increasing complications. This approach has the potential to improve postoperative care and patient outcomes in this surgical population.

Thoracotomy Patients Under General Anesthesia: A Comparison on Intra-Operative Anesthetic and Analgesic Requirements, When Combined with Either Epidural Analgesia or Continuous Unilateral Paravertebral Analgesia.

Regional analgesia is effective for post-thoracotomy pain. The primary objective of the study is to compare the intraoperative requirement of isoflurane and fentanyl between general anaesthesia (GA) with epidural analgesia and GA with paravertebral analgesia. A prospective observational comparative study was conducted on 56 patients undergoing open thoracotomy procedures. The patients were divided into two groups of 28 by assigning the study participants alternatively to each group: Group GAE - received thoracic epidural catheterization with GA, and Group GAP - received ultrasound guided thoracic paravertebral catheterization on the operative side with GA. Intraoperative requirement of isoflurane, fentanyl, postoperative analgesia, stress response, need of rescue analgesics and adverse effects were observed and analysed. 25 patients in each group were included in the data analysis. The intraoperative requirement of isoflurane (32.28 ± 1.88 vs 48.31 ± 4.34 ml; p < 0.0001) and fentanyl (128.87 ± 25.12 vs 157 ± 30.92 μg; p = 0.0009) were significantly less in the GAE group than in the GAP group. VAS scores and need of rescue analgesics and blood glucose levels were not statistically significant during the postoperative period (p > 0.05). The incidence of adverse effects was comparable except for hypotension and urinary retention which were significantly higher in the GAE group. GA with epidural analgesia resulted in significant reduction in the intraoperative consumption of isoflurane and fentanyl in comparison to GA with paravertebral analgesia. However, both the techniques were equally effective in the postoperative period.

Comparative study between the effect of dexmedetomidine and lidocaine infusion on intraoperative analgesic requirement and hemodynamics during craniotomy

Background: Nowadays, anesthesiologists are evaluating several analgesic adjuncts to minimize opioid use during craniotomy. Some studies have evaluated the analgesic-sparing effect of intravenous infusion of dexmedetomidine and lidocaine on intraoperative hemodynamics and post-operative analgesia. There is a paucity of studies focussing on the intraoperative analgesic requirement. Aims and Objectives: The present study compared dexmedetomidine and lidocaine infusion primarily for their effects on intraoperative fentanyl requirements during craniotomy. Materials and Methods: This study was done on 70 patients aged 18–80 years, the American Society of Anesthesiologists physical status I–II, having Glasgow Coma Scale 15, undergoing craniotomies. Patients were randomly allocated to receive either dexmedetomidine (group A, n=35) at a dose of 0.6 mcg/kg bolus over 10 min followed by 0.6 mcg/kg/h infusion or lidocaine (group B, n=35) at a dose of 1.5 mg/kg bolus over 10 min, followed by 1.5 mg/kg/h infusion till the end of skin suture, respectively. Study drugs were started 10 min before the start of surgery. Intraoperative total fentanyl and propofol consumption, intraoperative hemodynamics, recovery from hypnosis, and time to extubation were recorded. Results: The use of dexmedetomidine resulted in considerably less total fentanyl requirement (245.1 vs. 300.7 mcg, P&lt;0.0001) and total propofol requirement (172.7 vs. 236.7 mg, P&lt;0.0001) compared with lidocaine. Comparatively better hemodynamics were observed with the use of dexmedetomidine at all the points of observation. Conclusion: Dexmedetomidine as an analgesic adjunct can be a better alternative to lidocaine in terms of reduced fentanyl consumption, reduced propofol use and favorable hemodynamics, and early recovery from anesthesia.

Pre-emptive paracetamol reduces intra-operative opioid use in patients undergoing day-case oncologic breast surgery.

Minimization of intra-operative opioid use is an area of ongoing research interest with several potential benefits to the patient. Pre-emptive analgesia, defined as the administration of an analgesic before surgery to prevent establishment of central sensitization of pain, is one avenue that has been explored to achieve this. A retrospective observational study was undertaken to examine the effect of pre-emptive paracetamol on intra-operative opioid requirements. The medical and operative data of 156 patients who underwent day-case wide local excision and sentinel lymph node biopsy with and without regional block surgery at our center between October 2019 and May 2022 was carried out. Data were collected on demographics, total intra-operative and immediate post-operative opioid consumption. 57 patients did not receive pre-emptive paracetamol while 90 did. Baseline characteristics were similar. Our results showed a statistically significant reduction in morphine (p <0.029) and remifentanil (p <0.007) consumption in patients who received a regional block and pre-emptive paracetamol. Those who did not receive a regional block and were given pre-emptive paracetamol had a decrease in OxyNorm (p <0.022) requirements. A combination of general anesthesia (GA), regional block and pre-emptive paracetamol reduced intra-operative consumption of Fentanyl, OxyNorm, diclofenac, dexketoprofen, and clonidine (P <0.001) when compared to just GA alone. Use of pre-emptive paracetamol in reduction of intra-operative opioid requirements showed promising results but larger studies may strengthen the evidence for this association. A multimodal analgesic approach that utilizes pre-emptive paracetamol can be a viable method to decrease intra-operative of analgesic requirements.

Anestesia total intravenosa com propofol, cetamina e lidocaína associados à dexmedetomidina ou xilazina para cirurgia de ovário-histerectomia em cadelas

ABSTRACT: This study compared cardiovascular and respiratory effects of dexmedetomidine and xylazine in total intravenous anesthesia with propofol, ketamine, and lidocaine. Twenty-one female dogs were submitted to ovariohysterectomy, premedicated with acepromazine and anesthetized with propofol at a variable rate. The dogs were intubated and supplemented with 100% oxygen in a circuit without rebreathing gases in spontaneous ventilation. They were divided into three groups (n=21) after induction: control (CON) with ketamine (2 mg/kg + 0.6 mg/kg/h) and lidocaine (2 mg/kg + 3 mg/kg/h), DEX and XIL with the same drugs as CON, associated with dexmedetomidine (2 µg/kg + 1 µg/kg/h) or xylazine (0.2 mg/kg + 0.1 mg/kg/h). Propofol consumption, fentanyl analgesic rescue, and cardiorespiratory and blood gas parameters were evaluated during anesthesia. The DEX group had a lower consumption of propofol (0.16 ± 0.09 mg/kg/min) compared to CON (0.24 ± 0.09 mg/kg/min), both not differing from XIL (0.23 ± 0.09 mg/kg/min). The mean arterial pressure was higher after the initial bolus in DEX (107 ± 8 mmHg) and XIL (96 ± 11 mmHg) compared to the CON group (80 ± 10 mmHg). Higher accumulation of arterial carbon dioxide and a decrease in pH were observed in the CON group. The total number of fentanyl rescues did not differ between DEX (7) and XIL (6) and were lower than CON (16). Therefore, dexmedetomidine and xylazine reduced intraoperative fentanyl consumption compared to ketamine and lidocaine infusion alone. However, only dexmedetomidine promoted lower propofol consumption and higher blood pressure values.

Comparison of Multiple Injection Costotransverse Block and Erector Spinae Plane Block for Post-Sternotomy Pain Relief in Pediatric Patients Undergoing Cardiac Surgery: A Prospective Randomized Comparative Study

ObjectiveThe aim of this study was to evaluate efficacy of ultrasound-guided Multiple Injection Costotransverse block (MICB) and compare it with Erector spinae Plane block (ESPB) for post-sternotomy pain relief in paediatric cardiac surgical patients. DesignA prospective, randomized, double-blind, comparative study. SettingSingle-institution tertiary referral cardiac centre. ParticipantsStudy comprised of 90 children with acyanotic congenital heart disease requiring surgery via sternotomy. InterventionsChildren were randomly allocated to 1 of the 3 groups: ESPB (Group1), MICB (Group 2) or Control (Group 3). Participants in Group 1 and 2 received 4 mg/kg of 0.2% ropivacaine for bilateral ultrasound-guided block after induction of anaesthesia. Postoperatively, intravenous paracetamol was used for multimodal analgesia and fentanyl/tramadol was used for rescue analgesia. Measurements and Main ResultsModified objective pain score (MOPS) was evaluated at 0, 1, 2, 4, 6, 8, 10, and 12 hours post-extubation. After all exclusions, 84 patients were analysed. MOPS score was found to be significantly lower in ESPB and MICB Group compared to Control Group till 10 hours post extubation (p<0.05), with no statistically significant difference at 12th hour (p=0.2198). Total intraoperative fentanyl consumption (p=0.0005), need for fentanyl supplementation on incision (p<0.0001) and need for rescue opioid requirement in postoperative period (p=0.034) was significantly lower in both ESPB Group and MICB Group than Control Group. There was no statistically significant difference in both primary and secondary outcomes between ESPB and MICB Groups. ConclusionUltrasound guided MICB was effective and comparable to ESPB for post-sternotomy pain management in paediatric cardiac surgical patients.

A Randomized Clinical Study to Compare the Perioperative Analgesic Efficacy of Ultrasound-Guided Erector Spinae Plane Block Over Thoracic Epidural in Modified Radical Mastectomy.

Aim This study aims to compare the effectivenessof ultrasound-guided erector spinaeblock (ESB) with thoracic epidural (TE) in managing postoperative pain amongbreast cancer (BC) surgery patients. Methods A total of 42 patients wereenrolled and randomly divided into two groups, each comprising 21 participants. Primary endpoints assessed included intraoperative fentanyl consumption, postoperative pain scores,andthe need forrescue analgesia.Secondary endpoints encompassed intraoperative hemodynamic changesand theincidence of postoperative nausea and vomiting (PONV). Results Thestudy foundno significant difference inintraoperative fentanyl requirement (p=0.62) or postoperative pain scores measured using numerical rating scores (NRS)throughout the 48-hourpostoperative period. None of the patients in eithergrouprequired rescue analgesia.Notably, there was a statistically significant difference in postoperative nausea and vomitingat the two-hour mark, favoringthe erector spinae block. Both groups exhibited comparablehemodynamic changes during intraoperative monitoring. Conclusions Ourinvestigation concludes that theESF offersequivalentanalgesic efficacy to the thoracic epidural duringbothsurgery and thepostoperativeperiod withoutinducing any significant hemodynamic instability. Consideringthe lower complicationrate associated withparaspinal blocks compared to neuraxial blocks,the ESB presents itself as a promising alternative method for effectivepain reliefinmastectomy procedures.

Effect of Interpectoral-Pectoserratus Plane (PECS II) Block on Recovery Room Discharge Time in Breast Cancer Surgery.

Background and Objectives: The increase in the incidence and diagnosis rate of breast cancer demands the optimization of resources. The aim of this study was to assess whether the supplementation of the interpectoral-pectoserratus plane block (PECS II) reduces surgery and post-anesthesia care unit (PACU) time in patients undergoing breast cancer surgery. Materials and methods: This was a retrospective data-analysis study. In 2016, PECS II block was introduced as a supplement to general anesthesia for all mastectomies with or without axillary resections in South Jutland regional hospital, Denmark. The perioperative data of patients operated 3 years before and 3 years after 2016 was retrieved through the Danish anesthesia database and patient journals and systematically analyzed. Female patients aged over 18 years, with no use of muscle relaxant, intubation, and inhalation agents, were included. The eligible data was organized into two groups, i.e., Block and Control, where the Block group received PECS II Block, while the Control group received only general anesthesia. Parameters such as surgery time, anesthesia time, PACU time, opioid consumption, and the incidence of postoperative nausea and vomiting (PONV) in PACU were retrieved and statistically analyzed. Results: A total of 172 patients out of 358 patients met eligibility criteria. After applying exclusion criteria, 65 patients were filtered out. A total of 107 patients, 51 from the Block and 56 from the Control group, were eligible for the final analysis. The patients were comparable in demographic parameters. The median surgery time was significantly less in the Block group (78 min (60-99)) in comparison to the Control group (98.5 min (77.5-139.5) p < 0.0045). Consequently, the median anesthesia time was also shorter in the Block group (140 min (115-166)) vs. the Control group (160 min (131.5 to 188), p < 0.0026). Patients from the Block group had significantly lower intraoperative fentanyl consumption (60 µg (30-100)) as compared with the Control group (132.5 µg (80-232.5), p < 0.0001). The total opioid consumption during the entire procedure (converted to morphine) was significantly lower in the Block group (16.37 mg (8-23.6)) as compared with the Control group (31.17 mg (16-46.5), p < 0.0001). No statistically significant difference was found in the PACU time, incidences of PONV, and postoperative pain. Conclusions: The interpectoral-pectoserratus plane (PECS II) block supplementation reduces surgery time, anesthesia time, and opioid consumption but not PACU time during breast cancer surgery.

Rhomboid intercostal sub serratus plane block – Same bird with different horizons

Sir,We did a case series in five patients undergoing modified radical mastectomy who were given RISS for post-operative analgesia. We noticed that the intraoperative fentanyl consumption as well as the post-operative analgesic consumption was significantly less. The overall quality of life and satisfaction score for routine daily activities like wearing clothes was better in our patients. The importance and efficacy of these blocks are because of the continuity of the interfacial planes across varied anatomical tissues. These planes have various cutaneous as well as sympathetic branches and hence drug given spreads to cover a large dermatomal area. RISS has been proposed to cover lateral cutaneous branches of T2 to T11 that extend medially to cover dorsal rami deep to the errector spinae muscle plane (ESP). The site of injectate is at T5-T6. The dermatomal coverage is 4 cm lateral to the midline anteriorly, posteriorly 4 cm medial to the posterior axillary line, cranially up to serrated posterior superior caudally up to serratus posterior inferior. The advantages of RISS block are that the injection is far from the surgical site and hence the drug does not interfere with the surgical field or cautery if given preoperatively. After induction technically, it is more feasible than serratus plane block or pectoral blocks. Logistically prior catheterization is possible that does not interfere with the sterility of the surgical field. Despite the above advantages, the axillary coverage is inconsistent as it does not cover the intercostobrachial nerve (LCB of second ICN T2). The midline, thoracodorsal nerve, and long thoracic nerve are not covered. Complete analgesia is not provided for latissimus dorsi flap, segmental resection surgeries, lymph node dissections, or radical mastectomies. Dr. Tulgar, first-ever reported of the use of RIB in a patient of MRM and highlighted the superiority of peri-peri-paravertebral blocks apart from previously used ESP and paravertebral blocks for a similar condition. Altiparimak conducted an RCT on 30 MRM patients with axillary lymph node dissection. The patients had enhanced recovery and quality of life scores (QoR-40), especially in terms of pain and emotional status. RISS has proved its non-inferiority as compared to ESP, paravertebral, PEC, and SAP which are closer to neuroaxis, at non-compressible sites and difficult to execute in obese patients. Thus RISS is excellent as a part of MMA for post-operative pain management in MRM patients, who remain comfortable for up to 14 h and have an NRS score &lt;3 was seen in all of our five patients. The dynamic nature of pain was apparent at 14 h in three of the patients who had extensive axillary lymph node dissection. Is the journey of regional anesthesia just the replacement of “pops and clicks” with see it and block it? The renaissance in the era of blocks is visualizing an invention of a new block almost every month. We depend on the facial plane anatomy, its structure, and its relation to the surrounding organs and tissues to precisely disseminate the local anesthetic to its desired location. In this blind sheep race, enthusiasm should not blur our understanding of the basics. We should remember Triple A, improve health, enhance patient outcomes, and decrease the costs. We open the doors for larger studies with more patients, comparing different blocks with RIB/RISS blocks before generalizing the results. CONCLUSIONRhomboid intercostal subserratus plane block is an excellent option for intra and post-operative pain management as a part of multimodal analgesia in MRM patients.

Effect of preoperative ultrasound-guided thoracic interfacial plane block versus preoperative thoracic erector spinae plane block on acute and chronic pain after modified radical mastectomy: A randomized controlled trial

ABSTRACT Background More than 50% of individuals who have breast surgery have acute postoperative pain, and 8% among those patients endure persistent severe pain. The purpose of this study was to evaluate the efficiency of ultrasound-guided thoracic inter-fascial plane block (US-guided TIFPB) and ultrasound guided erector spinae plane block (US-guided ESPB) on acute and chronic pain following modified radical mastectomy (MRM) surgeries. Methods 90 female participants who were hospitalized for unilateral MRM surgery underwent this prospective randomized controlled trial. Patients were split into three equal groups at random: Group I: received preoperative TIFPB, group II: received preoperative ESPB, group III: received preoperative sham block (control group). Results VAS was considerably lower in group I at 12 h (P1 = 0.029) and when group III is compared with groups I and II at 2, 4, 6, 12, 18 and 24 h (P < 0.05). First analgesic requires was greatly delayed in time and total morphine consumption was significantly decreased compared to group III in groups I and II (P < 0.001) and was insignificantly different between both groups I and II. Chronic pain 3, 6 months postoperative was markedly decreased in comparison to group III in groups I and II (P < 0.05). Conclusions TIFPB and ESPB were comparable, both were superior to control in terms of lower intraoperative fentanyl consumption, pain score, first analgesic requirement onset is delayed, lower total consumption of morphine, chronic pain 3 and 6 months postoperatively. TIFPB showed a lower pain score at 12 hr. postoperatively compared to ESPB.