Local Infiltration Research Articles

Efficacy of adductor canal and popliteal plexus block combined with local anesthetic injection in the interspace between the popliteal artery and posterior capsule of the knee and local infiltrative analgesia for postoperative pain and functional outcome after total knee arthroplasty: A randomized controlled study

BackgroundAdductor canal block and periarticular infiltration analgesia (PIA) have been shown to relieve pain in total knee arthroplasty (TKA) effectively. However, their analgesic effectiveness has some limitations. Thus, we considered a novel blocking site that could achieve analgesia without affecting the muscle strength of the lower limbs. MethodsSeventy-two patients undergoing primary unilateral total knee arthroplasty were randomized into two groups. One group was treated with adductor canal and popliteal plexus (APB) combined with interspace between the popliteal artery and posterior capsule of the knee (iPACK) and local infiltration anesthesia (LIA) and the other was treated with PIA. The primary outcomes included postoperative pain, as assessed by the visual analog scale (VAS), and the consumption of oral tramadol. Secondary outcomes included functional recovery and daily ambulation distance. Tertiary outcomes included postoperative adverse effects. ResultsThe APB group had lower VAS scores after surgery at rest and during motion. Compared with the PIA group, the walking distance of the APB group on the second day was greater. The muscle strength of the APB group was lower than that of the PIA group at the early stage. Patients in the APB group also consumed less tramadol than those in the PIA group. There was no difference in the incidence of adverse events between the two groups. ConclusionsAPB combined with iPACK and LIA is a novel block for TKA, and it can reduce postoperative pain sooner after TKA without affecting postoperative functional recovery or increasing complications.

Use of intermediate cervical plexus block in carotid endarterectomy –an alternative to deep cervical plexus block: a case series

IntroductionCarotid endarterectomy is performed for patients with symptomatic carotid artery occlusions. Surgery can be performed under general and regional anesthesia. Traditionally, surgery is performed under deep cervical plexus block which is technically difficult to perform and can cause serious complications. This case series describes 5 cases in which an intermediate cervical plexus block was used in combination with a superficial cervical plexus block for Carotid endarterectomy surgery.MethodsFive patients who were classified as American Society of Anesthesiologists 2–3 were scheduled for Carotid endarterectomy due to symptoms and more than 70% occlusion of the carotid arteries. The procedures were carried out in the University Teaching Hospital- Peradeniya, Sri Lanka. All patients were given superficial cervical plexus block followed by intermediate cervical plexus block using 2% lignocaine and 0.5% plain bupivacaine.ResultsAdequate anesthesia was achieved in 4 patients, and local infiltration was necessary in 1 patient. Two patients developed hoarseness of the voice, which settled 2 h after surgery. Hemodynamic fluctuations were observed in all 5 patients. No serious complications were observed. All 5 patients had uneventful recoveries.DiscussionsRegional anesthesia for CEA is preferable in patients who are medically complicated to undergo anesthesia or in patients for whom cerebral monitoring is not available. Intermediate cervical plexus block is described for thyroid surgeries in literature, but not much details on its use for carotid surgeries. Deep cervical plexus blocks has few serious complications which is not there with the use of ICPB making it a good alternative for CEA surgeries .ConclusionsSuperficial cervical plexus block and intermediate cervical plexus block can be used effectively for providing anesthesia for patients undergoing Carotid endarterectomy. It is safe and easier to conduct than deep cervical plexus block and enables monitoring of cerebral function.

Comparison of the Incidence of Surgical Site Infection in Abdominal Wound Closure: Antibiotic-Coated Polyglactin 910 Suture Versus Polyglactin Suture With Local Infiltration of Antibiotic Along the Incision Line.

Aim and objectives The purpose of this study is to compare the incidence of surgical site infection (SSI) rates in abdominal wound closure utilizing antibacterial-coated(triclosan-coated) suture material versus conventional suture material with subcutaneous antibacterial infiltration along the incision line. Materials and method This prospective and comparative (randomized, non-blinded clinical trial) was conducted at the Postgraduate Department of Surgery, Swaroop Rani Nehru Hospital, associated with Motilal Nehru Medical College, Prayagraj, India. The sample size was calculated to be one hundred. The patients in Group A underwent laparotomy using polyglactin 910 coated with triclosan. The patients in Group B underwent normal suture closure and local infiltration of broad-spectrum antibiotics (1 gram of ceftriaxone in 10 ml distilled water, along with the incision). Results There was no discernible difference between the various groups onpostoperativeday (POD) 14, 21, and 30. In Group A, 100.0% of individuals had healed wound status (POD 30). Group B had healed wound status among the 96.0% of members (POD 30). Twenty percent of the people in Group A had SSI whereas 38.0% of the participants in Group B had SSI. There was no discernible difference between the two groups regarding the distribution of culture (χ² = 7.741, p = 0.127). Conclusion Triclosan-coated sutures are more effective than subcutaneous antibiotic infiltration along the incision line in lowering the frequency of SSI during primary laparotomy wound closure.

A Rare Complication in the Oral Local Infiltration Anesthesia.

The present report describes a rare complication named Kuhn anemia, which happened during local infiltration anesthesia of maxillary wisdom tooth. A 24-year-old male was referred for residual crown of left maxillary wisdom tooth and therefore required extraction. Oral examination revealed a buccal impacted left maxillary wisdom tooth (28), severe caries affecting the dental pulp, and pain with percussion. This case was diagnosed as impacted wisdom tooth 28 and pulpitis. Thus, the authors performed an extraction of the 28. After injection of articaine hydrochloride (68mg:1.7mL) containing epinephrine (1:100,000) as local anesthetic, the patient felt pain and heat in the left cheek, and an irregularly shaped pale area appeared on the left cheek. The authors stopped the surgery and comforted him. After a 30-minute break, the cheek turned normal, and abnormal sensation was no longer felt.

Local Infiltration Analgesia Is Superior to Regional Nerve Blocks for Total Hip Arthroplasty: Less Falls, Better Mobility, and Same-Day Discharge.

Background: Multimodal analgesia in total hip arthroplasty (THA) provides better pain control, mobility, and reduced side effects compared to monotherapies. Local infiltration analgesia (LIA) and regional nerve blocks (RNBs) are commonly used throughout these protocols. This study aimed to compare these procedures as part of a multimodal analgesia protocol for patients undergoing THA. Materials and Methods: A retrospective review of 1100 consecutive elective primary THAs was performed in 996 patients between June 2018 and December 2021. The RNB consisted of a preoperative continuous femoral nerve catheter and single-shot obturator nerve block, and LIA consisted of the intraoperative infiltration of weight-based bupivacaine. Results: A total of 579 (52.6%) patients received RNB, and 521 (47.4%) received LIA. Mean oral morphine equivalents (OMEs) during the first four hours postoperatively were significantly lower for LIA group (p < 0.001). However, the numeric pain rating scale in the post-anesthesia care unit (PACU) was similar between groups. Patients with LIA had significantly greater first ambulation distance in the PACU (p < 0.001), higher successful same-day discharge rate (p = 0.029), fewer falls (p = 0.041), and less refill OMEs post-discharge (p < 0.001) than RNB. Conclusions: In the setting of similar pain management between groups and better functional outcomes for LIA, the use of minimally invasive procedures like LIA for pain control following THA is favorable.

PAIN RELIEF AFTER INSTRUMENTED SPINAL SURGERY

BackgroundOver 55,000 spinal operations are performed annually in the NHS. Effective postoperative analgesia facilitates early mobilisation and assists rehabilitation and hospital discharge, but is difficult to achieve with conventional, opioid-based, oral analgesia. The clinical and cost-effectiveness of two alternative techniques, namely intrathecal opioid and the more novel erector-spinae plane blockade, is unknown. The Pain Relief After Instrumented Spinal Surgery (PRAISE) trial aims to evaluate these techniques.MethodsPRAISE is a multicentre, prospective, parallel group, patient-blinded, randomised trial, seeking to recruit 456 adult participants undergoing elective, posterior lumbar-instrumented spinal surgery from up to 25 NHS hospitals. Participants will be randomised 1:1:1 to receive (1) Usual Care with local wound infiltration, (2) Intrathecal Opioid plus Usual Care with local wound infiltration or (3) Erector Spinae Plane blockade plus Usual Care with no local wound infiltration. The primary outcome is pain on movement on a 100mm visual analogue scale at 24 hours post-surgery. Secondary outcomes include pain at rest, leg pain, quality of recovery (QoR-15), postoperative opioid consumption, time to mobilisation, length of hospital stay, health utility (EQ-5D-5L), adverse events and resource use. Parallel economic evaluation will estimate incremental cost-effectiveness ratios.ResultsDifferences in the primary outcome at 24 hours will be estimated by mixed-effects linear regression modelling, with fixed effects for randomisation factors and other important prognostic variables, and random effects for centre, using the as-randomised population. Treatment effects with 95% confidence intervals will be presented.ConclusionThe study is due to open in May 2024 and complete in 2026.Conflicts of InterestNo conflicts of interest declaredSources of FundingNIHR Health Technology Award – grant number NIHR153170Trial presentations so farAPOMP 2023 and 2024; RCOA conference, York, November 2023; Faculty of Pain Management training day, London, February 2024.

Comparison of Infiltration and Inferior Alveolar Nerve Block Injection Techniques in Periodontal Flap Surgery in the Mandible

Abstract Introduction: The efficacy of infiltration versus inferior alveolar nerve block (IANB) injection techniques during periodontal flap surgery in the mandible is crucial for optimising patient care. This comparative study aims to evaluate the pain management, ease of administration and clinical outcomes associated with both anaesthetic methods. Infiltration anaesthesia involves localised administration, targeting specific sites, whereas IANB provides a broader anaesthetic effect by numbing the entire mandibular nerve. Understanding the advantages and limitations of each technique will enhance procedural efficiency and patient comfort. This research contributes valuable insights into best practices for periodontal surgeries. Materials and Methods: Twenty-five subjects who required periodontal flap surgery were included in the study to treat chronic periodontitis in the mandibular jaw. The surgery was performed under local infiltration of an anaesthetic agent on one side of the jaw and by an IANB on the other side. Pain perception was evaluated using the Visual Analogue Scale (VAS) score at various intervals during periodontal flap surgery. The effect of anaesthesia between the two techniques was compared and evaluated by analysis of variance using IBM Corp. IBM Statistical Package for Social Sciences (SPSS) Statistics for Windows [Version 25]. Armonk, New York, USA. IBM Corp; 2017. Results: Analysis determined the onset, duration and termination of anaesthesia induced by infiltration and the IANB technique. The onset and duration of anaesthesia by both techniques were comparable. The pain perception evaluated using the VAS score while using both anaesthesia techniques was also comparable. Conclusion: Infiltration anaesthesia can be used as an alternative to overcome the disadvantages and complications of IANB for periodontal surgery in the mandibular jaw.

A comparative evaluation of 0.25% bupivacaine and 0.25% levobupivacaine in peritubal infiltration in percutaneous nephrolithotomy

Background: Percutaneous nephrolithotomy (PCNL) is a routine endourologic procedure in patients with renal calculi. Although it is less painful than open surgery, pain around the nephrostomy tube is a clinical problem; therefore, good post-operative analgesia is required to alleviate pain. Peritubal infiltration can be one of the choices to alleviate pain around the nephrostomy tube. Aims and Objectives: The aim of this study was to evaluate the efficacy of peritubal infiltration of local anesthetics for post-operative pain following PCNL. Materials and Methods: A total of 60 patients with American Society of Anesthesiologists Grade I/II scheduled for elective PCNL surgeries were randomly allocated into two groups. Group L received levobupivacaine 0.25% (30 mL) and Group B received bupivacaine 0.25% (30 mL). The duration of rescue analgesia, total dose of tramadol consumption in 24 h, hemodynamic parameters, and adverse events during the post-operative period were noted. Results: The mean duration of rescue analgesia in Group L was 274.50±24.89 min and in Group B was 275.33±23.04 min which was not significant (P&gt;0.05). Conclusion: Peritubal infiltration of 0.25% levobupivacaine and 0.25% bupivacaine is efficient in alleviating post-operative pain after PCNL. Both drugs can be used for infiltration around nephrostomy tubes in PCNL surgeries safely and are associated with minimal side effects.

Fascial Plane Blocks With Glucocorticoids or Liposomal Bupivacaine Versus Local Infiltration for Laparoscopic Non-donor Nephrectomy: A Propensity Score-Weighted Study.

Study objective The purpose of this study is to investigate the analgesic efficacy of ultrasound-guided fascial plane blocks (FPBs) versus local infiltration in patients undergoing laparoscopic non-donor nephrectomy. This study specifically compares the efficacy of FPBs with liposomal bupivacaine (LB) versus FPBs with dexamethasone sodium phosphate (DXP) and methylprednisolone acetate (MPA) versus surgical site local anesthetic infiltration without FPBs. Design This is a retrospective cohort study conducted over a five-year period (January 2018-December 2022). Setting The study was conducted in a tertiary care, academic, multi-hospital healthcare system. Participants Patients who underwent elective radical or partial laparoscopic non-donor nephrectomy were included in the study. Intervention Patients either received preoperative FPBs without intraoperative surgical site local anesthetic infiltration or received surgical site local anesthetic infiltration without FPBs (n = 141) at participating hospitals. Measurements The primary endpoint of this study was postoperative opioid use, measured as oral milligram morphine equivalents (MME). Secondary endpoints included postoperative pain scores, length of hospital stays, and significant adverse events within 30 days. The impact of medications utilized in FPBs was determined by univariate and multivariable analyses with covariates balancing propensity score weighting. Main results Patients undergoing non-donor laparoscopic radical or partial nephrectomy who received FPBs with bupivacaine or ropivacaine plus glucocorticoids DXP and MPA were more likely to be opioid-free 24-48 hours postoperatively compared to those who received FPBs with LB or surgical site local anesthetic infiltration without FPBs (40.5% vs. 30% vs. 13.9%, respectively; p = 0.017). Patients who received FPBs with glucocorticoids also reported the lowest pain scores at rest and with activity 0-12 hours postoperatively as compared to patients who received LB or local infiltration (p = 0.006 and p = 0.014, respectively). Additionally, patients who received FPBs with glucocorticoids received over 30% fewer opioids during the first 48 hours postoperatively compared to patients who received surgical site local anesthetic infiltration alone (30 MME vs. 44 MME, respectively). However, there was no significant difference in total opioid use during the first 48 hours postoperatively between patients who received FPBs with bupivacaine plus glucocorticoids and those who received FPBs with bupivacaine plus LB (mean ratio: 0.91, (95% CI: 0.05 ~ 15.97); p = 0.948). There was also no difference in the length of hospital stays or rate of adverse events between the groups. Conclusion Perioperative FPBs for non-donor laparoscopic nephrectomy using glucocorticoids as an adjuvant to long-acting local anesthetics may decrease postoperative opioid use and reduce pain scores as compared to FPBs with LB or surgical site local anesthetic infiltration. Bupivacaine or ropivacaine combined with DXP and MPA is a safe and effective alternative to LB for FPBs in laparoscopic nephrectomy.

Comparison of the Effect of Scalp Block With Ropivacaine vs. Ropivacaine and Clonidine on Postoperative Pain in Patients Undergoing Craniotomy Surgery Under General Anesthesia.

Introduction Clonidine, an α2 agonist known for its hypotensive and analgesic effects, has proven beneficial in various routes of administration such as oral, intravenous, and local infiltration. Scalp blocks enhance hemodynamic stability during surgery and reduce intraoperative opioid requirements compared to controls in numerous studies. Additionally, they are effective in managing postoperative pain, resulting in reduced opioid consumption. Research has shown that clonidine can enhance and prolong the effects of intrathecal, epidural, and peripheral nerve blocks (e.g., brachial plexus, peribulbar). Here, we investigated the impact of adding clonidine at a dose of 1 μg/kg to scalp blocks performed with 0.5% ropivacaine for supra-tentorial craniotomy Material and methods This study was conducted on 60 patients under theAmerican Society of Anesthesiologists (ASA) grade I and II who were scheduled for elective supratentorial craniotomy. Patients were divided into two equal groups of 30 and received a scalp block following general anesthesia. Patients in Group A (n=30) received a scalp block of 0.5% ropivacaine plus 1 ml of normal saline (total 21 cc). Patients in Group B (n=30) received a scalp block of 0.5% ropivacaine and clonidine (1 μg/kg) combined with 0.5 ml of normal saline (total 21 cc). Blood pressure, heart rate, peripheral oxygen saturation (SpO2), visual analog score, Ramsay sedation score, duration of analgesia, and analgesia requirement in the first 24 hours were recorded from baseline and postoperatively. Results The duration of first rescue analgesia for Group A was 4.30 ± 1.5 hours and that of Group B was 9.10 ± 1.4 hours. Duration of analgesia was significantly prolonged in patients receiving ropivacaine with clonidine for scalp nerve block. The amount of tramadol given in the first 24 hours in Group A, 62.50 ± 25.00 mg, was highcompared to Group B, 57.14 ± 18.89 mg. The mean arterial blood pressure differed significantly in both groups at 30 minutes, 1 hour, 3 hours, and 12 hours after scalp block postoperatively and lower in Group B. Although changes in pulse rate, and SpO2 were not statistically significant in both groups, patients were hemodynamically stable and did not require any ionotropic support. Ramsay sedation score and visual analog score postoperatively were not significant. There were no significant adverse effects noted in any groups. Conclusion Our study concluded that administering clonidine at a dosage of 1 μg/kg, in combination with 0.5% ropivacaine for scalp nerve block procedures, significantly extends the duration of analgesia and enhances its quality, all while maintaining stable hemodynamic parameters.

Retrospective review of surgeon administered transversus abdominis plane blocks at emergency caesarean.

Effective analgesics with minimal side effects are imperative for patient and neonate wellbeing postpartum. Post-caesarean section ultrasound-guided transversus abdominis plane (TAP) blocks have proven safety and efficacy. Surgical TAP blocks appear effective and require little time and equipment. No previous examination of surgical TAP blocks in patients having undergone emergency caesarean section has been undertaken. To investigate surgical TAP block and multimodal analgesic use during emergency caesarean section, the effect on surgical time, post-operative analgesia use, and admission length. We performed a retrospective review of 250 patients who underwent emergency caesarean in 2022. Surgical TAP blocks were performed with 20 mL of 0.375% ropivacaine either side. Primary outcomes included surgical time, length of admission, time to first request of rescue opiate, opiate use in first post-operative 24 h, total dose used during admission, and opiates prescribed on discharge. Ninety-six patients received surgical TAP blocks, and 154 did not. There were no statistically significant differences in the primary outcomes. Subgroup analyses were performed in patients who did not receive intrathecal morphine, body mass index over 30 kg/m2, for patients whom this was their first caesarean, and for TAP blocks versus local infiltration to the wound. There were no significant differences in the primary outcomes in these subgroups. Surgical TAP blocks did not prolong surgical time or decrease post-operative analgesia use or admission length in patients having undergone emergency caesarean. Patient-tailored multimodal analgesia is encouraged, although more research is needed.

Study of Efficacy of Extraosseous Local Infiltration of Multimodal Drug Cocktail for Pain Management After Total Joint Arthroplasty in Lower Limb.

Background Osteoarthritis (OA) is a chronic debilitating condition involving joints that ultimately leads to chronic pain, restricted mobility, and functional impairment of the joint. The gold standard treatment of end-stage OA is arthroplasty. Following arthroplasty surgery, patients might have excruciating pain in the postoperative period. Our study aimed to evaluate the beneficial effects of a multimodal drug cocktail in patients who underwent arthroplasty surgery concerning postoperative pain and knee range of motion during the healing period. Materials and methods In this randomised case-control study, we enrolled 32 patients, of which 16 patients had knee arthritis and underwent total knee replacement. In contrast, the other 16 patients had hip arthritis and underwent total hip replacement. Randomisation was done using simple random sampling (envelope method), and patients were divided into groups A and Baccordingly. Group A consists of a postoperative pain management modality using epidural analgesia with a top-up at a 12-hour interval. Group B consists of a postoperative pain management modality using an extraosseous multimodaldrugcocktail consisting of clonidine, cefuroxime, tramadol, bupivacaine, adrenaline, and normal saline in specific quantities. Visual analogue scale (VAS) was assessed post-surgery for walking and resting. Joint range of movement and walking distance were assessed post-surgery and compared between the two groups. Results A total of 32 patients who had OA and underwent total knee arthroplasty (TKA) and total hip arthroplasty (THA) were selected and divided into case and control groups of eight, each by simple random sampling (envelope method).The mean preop VAS scores for the epidural and cocktail groups were 7.88 ± 0.61 and 7.44 ± 0.62, respectively, with p = 0.057, which is insignificant. However, when the groups were compared based on VAS score while standing at 24, 48, and 72 hours, the standing VAS score was found to be significantly higher among subjects, given epidural analgesia with p-values of 0.001, 0.001, and 0.001 at 24, 48, and 72 hours, respectively, which is significant in our study. Also, postoperatively, at 24, 48, and 72 hours, the mean degree of movement was found to be significantly higher among subjects, given cocktail analgesia with p-values of 0.013, 0.001, and 0.001, respectively. Conclusion As a result of early postoperative pain alleviation, the current study concludes that multimodal pain control procedures, which combine more than two medications with distinct mechanisms of action, successfully increase patient satisfaction. A multimodal medication conjunction administered locally to patients resulted in improved functional outcomes, faster recovery, and better rehabilitation.

A PROSPECTIVE, RANDOMIZED STUDY COMPARING THE ANALGESIC EFFICACY OF SCALP BLOCK WITH 0.25% BUPIVACAINE VS PRE-INCISIONAL LOCAL INFILTRATION WITH 0.25% BUPIVACAINE WITH ADRENALINE (1:400,000) IN PATIENTS UNDERGOING ELECTIVE CRANIOTOMIES

Background and Aims: Pain is often referred to as the fifth vital sign. Pain management in patients undergoing craniotomies pose a great challenge to the anaesthesiologists. Scalp block forms an important aspect in the multimodal approach to the post-craniotomy pain. The following study compares the analgesic efficacy of Scalp block with traditionally used local wound infiltration technique in providing analgesia to craniotomy patients. Methods: Performed double blinded, prospective, randomized controlled trial on 60 patients undergoing elective craniotomies divided into 2 groups comparing the analgesic efficacy of Scalp block with 0.25% Bupivacaine vs Pre- incisional wound infiltration with 0.25% Bupivacaine with Adrenaline (1:400,000). Results:There were significant differences in intra-operative hemodynamics between the two groups. Scalp block resulted in statistically significant reduction in HR, SBP, DBP &amp; MAP. There was increased duration of post-operative analgesia in scalp block group when compared with the local infiltration group. The opioid requirement in the intra-operative period was significantly lesser in scalp block group when compared with the local infiltration group. Requirement of rescue analgesic is significantly lesser during early post-operative period (Upto 8 hours) in the scalp block group when compared with local infiltration group. Conclusion :Scalp block with 0.25% Bupivacaine is effective and superior to Pre-incisional Local infiltration with 0.25% Bupivacaine with 1:400,000 Adrenaline in attenuating hemodynamic responses, providing increased duration of post-operative analgesia, significant reduction in intra-operative opioids and post-operative rescue analgesic requirements.

A Case of Optimizing Anesthetic Management for an Elderly Patient with Severe Left Ventricular Dysfunction Through a Multi-disciplinary Treatment Approach

This case report presents a multi-disciplinary treatment (MDT) approach to optimize anesthetic management for an elderly patient with a giant inguinal hernia and severe left ventricular dysfunction. The patient, a 68-year-old male, had a 30-year history of a large inguinal hernia and was diagnosed with left ventricular hypertrophy and cardiac insufficiency, with an ejection fraction of 24%. Given the patient&amp;apos;s complex comorbidities and the risks associated with anesthesia, a MDT was formed to develop a personalized treatment plan. The team included gastrointestinal surgeons, anesthesiologists, cardiovascular specialists, and intensive care physicians who collaborated to mitigate perioperative risks. The MDT strategy involved continuing preoperative cardiovascular medications, selecting anesthesia techniques to minimize impact, and maintaining strict fluid management during surgery. The patient underwent a successful tension-free repair of the inguinal hernia with the aid of an ultrasound-guided nerve block and local infiltration anesthesia. Throughout the procedure, vital signs remained stable, and the patient experienced no discomfort or complications related to anesthesia. The patient recovered well and was discharged after five days. The effectiveness of MDT in overseeing the care of elderly patients with high-risk conditions throughout the perioperative anesthesia phase is underscored. It underscores the importance of a collaborative approach to ensure patient safety and optimal outcomes in complex surgical cases. The MDT framework helps to prevent treatment deviations and delays, reducing patient anxiety and improving the overall quality of care.

Comparison of analgesic efficacy of combined external oblique intercostal and rectus sheath block with local infiltration analgesia at port site in patients undergoing laparoscopic cholecystectomy: a randomized controlled trial.

Conventional fascial plane block approaches for upper abdominal surgeries spare the lateral cutaneous nerve. An external oblique intercostal block (EOIB) may be suitable for upper abdominal incisions as it blocks the lateral and anterior branches of the intercostal nerves T6-T10. However, there is a paucity of studies evaluating this block in clinical settings. The study aimed to compare the analgesic efficacy of combined EOIB and rectus sheath block with local infiltration analgesia (LIA) in laparoscopic cholecystectomy (LC). After obtaining written informed consent, 70 patients were randomly allocated to undergo right-sided EOIB with 20 ml and left-sided RSB with 10 ml of 0.25% bupivacaine at the end of surgery (group ER, n = 35). Patients in the LIA group (n = 35) underwent local infiltration at the port site using 20 ml of the same solution (group LIA, n=35). The visual analog scale scores with combined EOI and RSB were significantly lower than those with LIA at 1, 2, 4, 8, and 12 h (P < 0.001). Rescue analgesics were required by 65.7% and 14.3% of the patients in the LIA and block groups, respectively (P < 0.001). The time to first rescue analgesic was significantly greater in the ER group than that in the LIA group (2.8 ± 1.10 vs. 1.6 ± 0.50 h; P = 0.012). The number of times rescue analgesia was required was significantly lower in the ER group than that in the LIA group (1.00 ± 0.00 vs. 1.83 ± 0.72; P = 0.015). Nausea and vomiting scores were higher in the LIA group than those in the ER group (P < 0.001). Patient satisfaction scores were higher in the ER group than those in the LIA group. EOIB combined with RSB provides superior analgesia compared with LIA and should be considered for LC.

Effects of Local Wound Infiltration Post-Mastectomy Using Bupivacaine Alone, Bupivacaine With Ketamine, and Bupivacaine With Dexmedetomidine: A Randomized Double-Blind Study.

Background and aim While the infiltration of surgical incisions with local anesthetics is not a new practice, it remains a crucial component of contemporary multimodal analgesia protocols. This study aimed to evaluate the efficacy and safety of using adjuvants in combination with local anesthetic wound infiltration for pain management in patients undergoing mastectomy surgery. Methods Eighty-one patients aged 18-60 years, classified as American Society of Anesthesiologists (ASA) grade I or II, were scheduled for unilateral mastectomy and randomly assigned to three groups of 27 each. The groups were designated as Group C (bupivacaine alone), Group D (bupivacaine with dexmedetomidine), and Group K (bupivacaine with ketamine). Group C received 0.25% bupivacaine alone, Group D received 0.25% bupivacaine with 1 mcg/kg dexmedetomidine, and Group K received 0.25% bupivacaine with 1 mg/kg ketamine. The time to achieve a Visual Analogue Scale (VAS) score of 3 following local wound infiltration was recorded for each group. Additionally, total postoperative fentanyl intake during the first 24 hours, as measured by the patient-controlled analgesia (PCA) pump, was compared among the groups. Sedation levels were assessed using the Ramsay Sedation Scale (RSS). Data were analyzed using the Chi-Square test and one-way ANOVA in IBM SPSS Statistics for Windows, Version 28.0 (Released 2021; IBM Corp., Armonk, NY, USA). Results Demographic factors were similar across the three groups. Analysis of the VAS scores revealed that the ketamine group provided better postoperative pain control than the dexmedetomidine group (p < 0.001). Groups D (71.72 ± 71.73) and K (3.53 ± 13.42) had significantly lower 24-hour fentanyl intake (in mcg) compared to Group C (the control group), as measured by PCA. Additionally, Group C had a significantly lower RSS at the sixth hour (p = 0.003) compared to both Groups D and K. Conclusion Ketamine, when used as an adjuvant to bupivacaine for local infiltration, enhances the effectiveness and prolongs postoperative analgesia more effectively than dexmedetomidine in patients undergoing mastectomy.

Laparoscopy-guided transverse abdominis plane block versus port site infiltration for post-operative pain relief after laparoscopic cholecystectomy.

Post-operative analgesia is an important component of patient satisfaction and early discharge from the hospital. A variety of modalities have been tested and are still evolving. The present study is one such evaluation of a novel technique of laparoscopy-guided transverse abdominis plane (LTAP) block for post-operative analgesia in laparoscopic cholecystectomy. A prospective randomised control trial was conducted to verify the effectiveness of LTAP block over port site local anaesthesia infiltration (PSLAI) for post-operative analgesia in patients undergoing laparoscopic cholecystectomy. This study was done over a period of 18 months in a tertiary hospital. A total of 84 patients were recruited and were divided equally into two groups (LTAP and PSLAI). There was no statistical difference between the two groups with respect to gender distribution, comorbidities, number of gallstones, duration of symptoms and surgery time. The rescue dose of diclofenac requirement was less for the LTAP group in comparison to the PSLAI group. No difference was observed in the pain score at 1st h. However, LTAP proved efficient later in the post-operative course (6 h, 24 h and at discharge). There was significant a difference in the pain scores between the two groups, favouring the LTAP group. Hospital stay in the LTAP group was less in comparison to the PSLAI group. LTAP block is an effective method of post-operative analgesia. It impacts analgesia to the whole anterior abdominal wall for a prolonged period when compared to the PSLAI without adding any extra procedural time.

The Association of Chronic Pulmonary Aspergillosis and Chronic Pulmonary Histoplasmosis with MDR-TB Patients in Indonesia.

In Indonesia, 2.4% of all new tuberculosis patients had multi-drug resistant disease (MDR-TB); an estimated 24,000 incidences. Historical case series of MDR-TB described a high frequency of cavitation and poor prognosis. The diagnosis of chronic pulmonary aspergillosis (CPA) relies on raised levels of Aspergillus IgG antibodies, and detectable Histoplasma IgG antibodies are suspicious for chronic pulmonary histoplasmosis (CPH). We investigated whether MDR-TB patients might have concurrent CPH or CPA. This was a cross-sectional study with 50 MDR-TB patients. ELISA was used to detect Histoplasma IgG antibodies and lateral flow assay was used to detect Aspergillus IgG/IgM antibodies. Several other possible disease determinants were assessed by multivariate analysis. Of the 50 MDR-TB patients, 14 (28%) and 16 (32%) had positive Histoplasma or Aspergillus serology; six patients (12%) had dual antibody reactivity. Radiological abnormalities in positive patients included diffuse or local infiltrates, nodules, consolidation, and apical cavities, consistent with CPH and CPA. Patients with detectable fungal antibodies tended to have worse disease, and 4 of 26 (15.3%) died in the first 5 months of dual infection (p = 0.11 compared with no deaths in those with only MDR-TB). The criteria for the diagnosis of CPH and CPA were fulfilled in those with moderately and far advanced disease (13 of 14 or 93%) and 12 of 16 (75%), respectively. Damp housing was the only determinant associated with Histoplasma antibodies (PR 2.01; 95%CI 0.56-7.19), while pets were associated with the Aspergillus antibody (PR 18.024; 95%CI 1.594-203.744). CPA or CPH are probably frequent in MDR-TB patients in Indonesia and may carry a worse prognosis.

Comparison of the postoperative effects of the erector spinae plane block and local infiltration analgesia in patients operated with lumbotomy surgery incision: Randomized clinical study.

Our aim was to observe the effects of local infiltration analgesia (LIA) or erector spinae plane block (ESPB) methods, which we applied preemptively in patients who were scheduled for surgery with a lumbotomy surgical incision and on intraoperative remifentanil consumption, and to compare the postoperative numerical rating scale (NRS), morphine demand, consumption, and pain degrees. Sixty American Society of Anesthesiologists I to III patients aged 18 to 75 years who were due to be operated on with a lumbotomy surgical incision were included in the study. The present study was conducted via prospective, randomized controlled, double-blind trials. After the induction of standard anesthesia, LIA was applied to 30 patients and ESPB was applied to 30 patients preemptively. The dose of remifentanil consumed in the intraoperative period was measured, and the hemodynamic parameters were measured every 5 minutes. Morphine bolus treatment with the postoperative patient-controlled analgesia and rescue analgesia with paracetamol were planned for the patients. Postoperative morphine and additional analgesia consumption, NRS, hemodynamic parameters, and complications were recorded for 48 hours. There was no difference between the groups in terms of demographic and hemodynamic data. The mean consumption of remifentanil was measured as 455 ± 165.23 µg in the intraoperative ESPB group and 296.67 ± 110.59 µg in the LIA group, and a statistical difference was observed (P = .001). In the postoperative follow-ups, the ESPB group drug consumption and NRS score averages were significantly lower at all times (P = .01; patient-controlled analgesia-morphine, 41.93 ± 14.47 mg vs 57.23 ± 15.5 mg and additional analgesic-paracetamol: 2.1 ± 1.06 vs 4.27 ± 1.14 g). The mean duration of additional analgesic intake of the groups was 10.6 ± 8.1 in the LIA group, while it was 19.33 ± 8.87 in the ESPB group, a significant difference. The patient satisfaction questionnaire was also significantly in favor of ESPB (P = .05). In conclusion, it has been shown that the intraoperative LIA method is more effective in terms of remifentanil consumption and in controlling pain in operations performed with a flank incision, but the ESPB method provides longer and more effective pain control in postoperative follow-ups.

Transversus Abdominis Plane with Rectus Sheath Blocks Versus Port Site Infiltration of Local Anaesthesia in Emergency Laparoscopic Cholecystectomy—Does It Reduce Postoperative Opiate Requirement? A Pilot Study

Transversus Abdominis Plane with Rectus Sheath Blocks Versus Port Site Infiltration of Local Anaesthesia in Emergency Laparoscopic Cholecystectomy—Does It Reduce Postoperative Opiate Requirement? A Pilot Study