Nerve Block Group Research Articles

Effect of Pudendal Nerve Block versus Perineal Local Infiltration of Analgesia In Post Episiotomy Pain Relief A randomized Controlled Clinical Trial

Abstract Background Episiotomy or tearing of perineal tissues during childbirth is associated with significant pain in the postpartum period. Although the use of episiotomy is often debated, it remains the most common surgical procedure experienced by women. Pain from episiotomy is poorly treated, though it may be severe and can result in significant discomfort and interference with basic daily activities and adversely impact motherhood experiences. Local infiltration analgesia is the most commonly used method of analgesia during normal labor. This type of local analgesia is achieved by injecting the analgesic agent into the perineum just before delivery with crowning of the fetal head. It is also widely used just before an episiotomy. This study compares the efficacy and duration of pudendal nerve block versus local infiltration on post episiotomy pain relief. Aim of the Work: This study aims to compare the effect of Pudendal Nerve Block with perineal local infiltration of analgesia in post episiotomy pain relief. Study design:Prospectiverandomizedcontrolledclinicaltrial. Patients & Methods The current study was conducted in Ain Shams University Maternity Hospital in the period between August 2018 and Jan 2019. It included 100 primigravida women in labor meeting inclusion criteria attending the causality of Ain Shams Maternity Hospital. Results Our study showed statistically significant decrease mean of study group compared to control group according VAS score from after 1hr to after 6hrs. Also there was statistically significant decrease in patients' need for analgesia in study group compared to control group from after 1hr to after 6hrs. Patients were asked about episiotomy pain and were advised not to be distracted by pain of uterine contraction or any other pain she complains of as much as possible not to alter the study results Regarding the pudendal nerve block group none of the patients receiving effective bilateral pudendal nerve block asked for analgesia during the first hour post injection. Two patients representing 4.4% of the study group asked for analgesia after two hours post injection, by the 3rd hour 6 patients representing 13.3% of the study group asked for analgesia. After completing 6 hours post injection follow up only 21 patients asked for analgesia representing 46.7% of the study group while 24 patients (53.3%) did not require any analgesia for the first 6 hours after injection of pudendal nerve block Conclusion There is statistically significant decrease in mean VAS in pudendal nerve block compared to local perineal infiltration of analgesia from after 1hr to after 6hrs of injection. Also there is statistically significant decrease in patients' need for analgesia in case of pudendal nerve block compared to local perineal infiltration of analgesia from after 1hr to after 6hrs of injection. There is highly statistically significant increase mean of delivery time after injection (min) in pudendal nerve block compared to local perineal infiltration of analgesia but it has no clinical significance. There are no neonatal side effects or complications of pudendal nerve block.

This Month in Anesthesiology

This Month in Anesthesiology

Comparative study between ultrasound-guided pudendal nerve block and caudal epidural block anesthesia in children undergoing hypospadias surgery

BackgroundThe aim of the study is to compare the effectiveness and safety of ultrasound-guided pudendal nerve block versus caudal epidural block as a part of multimodal analgesia in children undergoing hypospadias surgery.In this prospective, single-blinded study, 50 patients were randomized into 2 groups (25 each group) either receiving ultrasound-guided pudendal nerve block group A or caudal epidural block group B. In the pudendal nerve block group, patients were injected with 0.3 mL/kg 0.25% bupivacaine and 1 ug/kg fentanyl. In the caudal epidural group, patients were injected with 1 mL/kg 0.25% bupivacaine and 1 ug/kg fentanyl. Consumption of paracetamol was assessed during the first 24 h postoperatively. The “objective pain scale” done by Hannalah and Broadman was used to assess postoperative pain.ResultsThis prospective randomized controlled single-blind clinical study was performed on total (50) ASA status I or II patients, of age 3 to 6 years scheduled for hypospadias surgery.For the primary outcome, there was no statistically significant difference found between the two studied groups regarding objective pain score at arrival to PACU with p value = 1.000 while there was a statistically significant increase in pain score in group B than group A at 6 h and 12 h with p value = 0.017 and 0.003, respectively. Also, no statistically significant difference found between the two groups after 18 h with p value = 0.238 may be due to receiving acetaminophen dose in group B. Finally there was a statistically significant increase found in objective pain score in group B at 24 h than group A with p value = 0.015. And there was a statistically significant increase in time to first analgesia in group A than group B with p value < 0.001 while there was a statistically significant increase in total dose of acetaminophen in group B than group A with p value < 0.001.ConclusionBoth ultrasound-guided pudendal block and caudal epidural block are effective and safe methods for postoperative analgesia for children undergoing hypospadias surgery but ultrasound-guided pudendal block gives more postoperative pain control.

Obturator nerve block does not provide analgesic benefits in total hip arthroplasty under multimodal analgesic regimen: a randomized controlled trial

Background and objectivesAlthough regional analgesia is considered an important component of optimal pain management, use of peripheral nerve blocks for total hip arthroplasty remains controversial. Since the obturator nerve innervates...

Hepatic Hilar Nerve Block for Hepatic Interventions: Anatomy, Technique, and Initial Clinical Experience in Thermal Ablation of Liver Tumors.

Background Image-guided procedures for treatment of liver diseases can be painful and require heavy sedation of the patient. Local-regional nerve blocks improve pain control and reduce oversedation risks, but there are no documented liver-specific nerve blocks. Purpose To develop a safe and technically simple liver-specific nerve block. Materials and Methods Between March 2017 and October 2019, three cadavers were dissected to evaluate the hepatic hilar anatomy. The hepatic hilar nerves were targeted with transhepatic placement of a needle adjacent to the main portal vein, under US guidance, and evaluated with use of an injection of methylene blue. A hepatic nerve block, using similar technique and 0.25% bupivacaine, was offered to patients undergoing liver tumoral ablation. In a prospective pilot study, 12 patients who received the nerve block were compared with a control group regarding complications, safety, pain scores, and intraoperative opioid requirement. Student t tests were used to compare the groups' characteristics, and Mann-Whitney U tests were used for the measured outcomes. Results Cadaver results confirmed that the hepatic nerves coursing in the hepatic hilum can be targeted with US for injection of anesthetic agents, with adequate spread of injected methylene blue around the nerves in the hepatic hilar perivascular space. The 12 participants (mean age ± standard deviation, 66 years ± 13; eight men) who received a hepatic hilar block before liver thermal ablations demonstrated reduced pain compared with a control group of 12 participants (mean age, 63 years ± 15; eight men) who received only intravenous sedation. Participants who received the nerve block had a lower mean visual analog scale score for pain than the control group (3.9 ± 2.4 vs 7.0 ± 2.8, respectively; P = .01) and decreased need for intraprocedural fentanyl (mean dose, 152 μg ± 78.0 vs 235.4 μg ± 58.2, respectively; P = .01). No major complications occurred in the hepatic hilar nerve block group. Conclusion A dedicated hepatic hilar nerve block with 0.25% bupivacaine can be safely performed to provide anesthesia during liver tumoral ablation. © RSNA, 2021.

INTRA-ARTICULAR MORPHINE AND ROPIVACAINE INJECTION PROVIDES EFFICACIOUS ANALGESIA COMPARED TO FEMORAL NERVE BLOCK IN THE FIRST 24 HOURS POST-OPERATIVELY AFTER ACL RECONSTRUCTION WITH BTB IN AN ADOLESCENT COHORT

Background:Opioid consumption and patient satisfaction are influenced by a surgeon’s pain management protocol and the use of adjunctive pain mediators. Two commonly utilized adjunctive pain modifiers for anterior cruciate ligament (ACL) reconstruction include femoral nerve blockade and intra-articular injection; however, debate remains as to the most efficacious methodology.Hypothesis/Purpose:We hypothesize that intra-articular injection with ropivacaine and morphine is as efficacious as a femoral nerve block injection of ropivacaine, dexamethasone, and dexmedetomidine for post-operative pain management in the first 24 hours after bone-patellar tendon-bone (BTB) ACL reconstruction.Methods:Charts were retrospectively reviewed for a single pediatric orthopedic surgeon performing BTB ACL reconstructions from 2013-2019. One hundred sixteen patients were identified, of whom 58 received intra-articular injection and 58 received single shot femoral nerve block. All patients were admitted for 24 hours. Pain scores were assessed every 4 hours. Morphine milligram equivalents (MME) consumed were tabulated for each patient.Results:Opioid use was 24.3 MMEs in patients treated with intra-articular injection vs 28.5MMEs in those with peripheral block (p=0.108). Consumption of MMEs was greater in the intra-articular group in the 0-4 hours period (7.1 MMEs vs. 4.6 MMEs, p=0.008). There was significantly less MME consumption in patients receiving intra-articular injection compared with peripheral block at 16-20 and 20-24 hours (3.2 MMEs vs. 5.6 MMEs, p=0.01; 3.8 MMEs vs. 6.5 MMEs, p<0.001 respectively). Mean pain scores were not significantly different over the 24-hour period (peripheral block=2.7, intra-articular injection=3.0, p=0.19).Conclusion:Moving away from the use of peripheral nerve block as an analgesic modality may be challenging given the multidisciplinary role of pain management in these patients. However, as Ramlogan et al. succinctly noted in their recent editorial “Anterior cruciate ligament repair and peripheral nerve blocks: time to change our practice?” in the British Journal of Anesthesia, both orthopedic and anesthesia colleagues alike are beginning to recognize that it is a change that may benefit our patients. Our study strengthens this argument and shows that there is no significant difference in MME consumption between the femoral nerve block and intra-articular injection groups in the first 24 hours post-operatively. While peripheral block is associated with lower opioid consumption in the first 4 hours after surgery, patients receiving intra-articular block require less opioids 16-24 hours post-operatively. Given these findings, we propose that intra-articular injection is a viable alternative for analgesia in pediatric patients undergoing BTB ACL reconstruction.Figure 1.2.Morphine milligram equivalent consumption trend during 24-hour post-operative period. PB=peripheral nerve block; IA=intra-articular injection

ISOKINETIC STRENGTH IS COMPARABLE AMONG ADOLESCENT PATIENTS WHO HAD EITHER A SINGLE INJECTION FEMORAL NERVE BLOCK OR CONTINUOUS FEMORAL NERVE CATHETER DURING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

Background:Single injection femoral nerve blocks or continuous femoral nerve catheters are commonly used during anterior cruciate ligament reconstruction (ACLR). However, both single injection and continuous femoral nerve catheters have been associated with decreased quadriceps strength and function up to 6 months postoperative compared to no regional anesthesiaPurpose/Hypothesis:We compared isokinetic limb asymmetry 5-10 months post-surgery between patients who received either single injection or continuous femoral nerve block during ACLR. We also assessed patient characteristics potentially associated with strength deficits. We hypothesized that patients with continuous femoral nerve catheters would demonstrate decreased quadriceps function due to increased local anesthetic.Methods:We reviewed medical records of patients ages 10-19 years who completed isokinetic testing 5-10 months following quadricep tendon ACLR by a single surgeon. Patients were excluded for previous lower limb surgery. We grouped patients based on whether they received a single injection femoral nerve block (FNB group) or a continuous femoral nerve catheter (FNC group) intraoperatively. Using isokinetic data at 60, 180, and 300 degrees per second, we calculated maximum torque percent deficit of the involved compared to the uninvolved leg, as well as compared peak torque extensor and flexor deficits (% difference between operative/non-operative sides) between groups.Results:Sixty-two patients were included: 50 who received FNC and 12 who received FNB (Table 1). There were no significant differences between continuous femoral nerve block and single-shot femoral nerve block groups for extensor deficits at any speed (Figure 1) or for flexor deficits at any speed (Figure 2). At 60 degrees/s (p=0.006) and 180 degrees/s (p=0.017), longer time since surgery was associated with smaller extensor deficits (Table 2). At 180 degrees/s (p=0.008) older age was associated with greater extensor deficits (Table 2). At 60 degrees/s (p=0.017) skeletal maturity was associated with greater extensor deficits (Table 2). At all speeds, an injured dominant limb was associated with smaller flexor deficits (Table 3). Older age was associated with greater flexor deficits at 60 deg/s (Table 3).Conclusion:No apparent significant isokinetic strength differences were found between groups 5-10 months postoperatively. Longer time from surgery was significantly associated with decreased extensor deficits among both groups at slower isokinetic test speeds. Our data suggest increased isokinetic strength recovery over the 5-10-month timeframe. The surgeon, anesthesia team, and patient should choose the pain management protocol based on resource and patient factors.Tables and Figures:Figure 1.Mean values (error bars represent 95% confidence intervals) for Peak Torque (ft-lb) extensor % deficits (% change between surgically affected and unaffected sides) between continuous femoral nerve block and single-shot femoral nerve block groups at each of the isokinetic test speeds.Figure 2.Mean values (error bars represent 95% confidence intervals) for Peak Torque (ft-lb) flexor % deficits (% change between surgically affected and unaffected sides) between continuous femoral nerve block and single-shot femoral nerve block groups at each of the isokinetic test speeds.

EFFECTIVENESS OF ULTRASOUND-GUIDED MODIFIED PECTORAL NERVE BLOCK (PECS II) FOR POST-OPERATIVE PAIN RELIEF AFTER MODIFIED RADICAL MASTECTOMY (MRM)

Objective: To find the effectiveness of ultrasound guided modified pectoral nerve block (PECS II) versus conventional analgesics for post-operative pain relief in women undergoing modified radical mastectomy.&#x0D; Study Design: Quasi experimental study.&#x0D; Place and Duration of Study: Department of Anaesthesia, Pak Emirates Military Hospital Rawalpindi Pakistan, from May 2018 to Oct 2019.&#x0D; Methodology: A total of 74 adult female patients scheduled for elective unilateral modified radical mastectomy under general anaesthesia were randomized into two groups, pectoral nerve block II (P) group (n=37) and control (C) group (n=37). An ultrasound-guided pectoral nerve block II block was performed using 30 ml of 0.25% Bupivacaine in pectoral nerve block II group after induction of general anaesthesia. In control group (C), patients received only general anaesthesia. Primary outcome measure was opioid consumption in first 24 hours, and the secondary outcome was pain at the breast and axillary region measured using the numerical rating scale (NRS) in first 24 hours at fixed intervals after surgery. Patient satisfaction was evaluated upon discharge using a 4-point scale.&#x0D; Results: Nalbuphine consumption was significantly reduced in pectoral nerve block group as compared to control group. Patients in pectoral nerve block II group experienced much less pain because their numerical rating scale was lower than the control group in postoperative period. Patient satisfaction was found to be high in pectoral nerve block II group.&#x0D; Conclusion: The pectoral nerve block II block is a simple block which provides excellent analgesia for modified radical mastectomy. It can be used for balanced anaesthesia.......

Pectoral Nerve Blocks for Breast Augmentation Surgery: A Randomized, Double-blind, Dual-centered Controlled Trial.

Pectoral nerve blocks have been proposed for analgesia during and after breast cancer surgery, but data are conflicted in aesthetic breast surgery. This trial tested the primary hypothesis that adding a preincisional pectoral nerve block is superior to systemic multimodal analgesic regimen alone for pain control after breast augmentation surgery. A second hypothesis is that rescue opioid consumption would be decreased with a long-lasting effect for both outcomes during the following days. Seventy-three adult female patients undergoing aesthetic breast augmentation surgery under general anesthesia were randomly allocated to receive a pectoral nerve block versus no block. Both groups received standard care with protocolized multimodal analgesia alone including systematic acetaminophen and nonsteroidal anti-inflammatory drugs. The primary outcome measure was the maximal numerical rating scale in the first 6 h after extubation. Secondary outcomes included intraoperative remifentanil consumption and from extubation to day 5: maximal numerical rating scale, postoperative cumulative opioid consumption and postoperative opioid side effects, and patient satisfaction recorded at day 5. The maximal numerical rating scale score in the first 6 h was lower in the pectoral nerve block group compared with the control group (3.9 ± 2.5 vs. 5.2 ± 2.2; difference: -1.2 [95% CI, -2.3 to -0.1]; P = 0.036). The pectoral nerve block group had a lower maximal numerical rating scale between days 1 and 5 (2.2 ± 1.9 vs. 3.2 ± 1.7; P = 0.032). The cumulative amount of overall opioids consumption (oral morphine equivalent) was lower for the pectoral nerve block group from hour 6 to day 1 (0.0 [0.0 to 21.0] vs. 21.0 [0.0 to 31.5] mg, P = 0.006) and from days 1 to 5 (0.0 [0.0 to 21.0] vs. 21.0 [0.0 to 51] mg, P = 0.002). Pectoral nerve block in conjunction with multimodal analgesia provides effective perioperative pain relief after aesthetic breast surgery and is associated with reduced opioid consumption over the first 5 postoperative days.

Phrenic nerve block during nonintubated video-assisted thoracoscopic surgery: a single-centre, double-blind, randomized controlled trial

There has been interest in the use of nonintubated techniques for video-assisted thoracoscopic surgery (VATS) in both awake and sedated patients. The authors’ centre developed a nonintubated technique with spontaneous ventilation for use in a patient under general anaesthesia using a phrenic nerve block. This treatment was compared with a case-matched control group. The authors believe that this technique is beneficial for optimizing anaesthesia for patients undergoing VATS. The patients were randomly allocated (1:1) to the phrenic nerve block (PNB) group and the control group. Both groups of patients received a laryngeal mask airway (LMA) that was inserted after anaesthetic induction, which permitted spontaneous ventilation and local anaesthesia in the forms of a paravertebral nerve block, a PNB and a vagal nerve block. However, the patients in the PNB group underwent procedures with 2% lidocaine, whereas saline was used in the control group. The primary outcome included the propofol doses. Secondary outcomes included the number of propofol boluses, systolic blood pressure (SBP), pH values of arterial blood gas and lactate (LAC), length of LMA pulled out, length of hospital stay (length of time from the operation to the time of discharge) and complications after 1 month. Intraoperatively, there were increases in lactate (F = 12.31, P = 0.001) in the PNB group. There was less propofol (49.20 ± 8.73 vs. 57.20 ± 4.12, P = 0.000), fewer propofol boluses (P = 0.002), a lower pH of arterial blood gas (F = 7.98, P = 0.006) and shorter hospital stays (4.10 ± 1.39 vs. 5.40 ± 1.22, P = 0.000) in the PNB group. There were no statistically significant differences in the length of the LMA pulled out, SBP or complications after 1 month between the groups. PNB optimizes the anaesthesia of nonintubated VATS.

The impact of ultrasound-guided transmuscular quadratus lumborum block combined with local infiltration analgesia for arthroplasty on postoperative pain relief

Study objectiveThis study aimed to evaluate the efficacy of ultrasound-guided transmuscular quadratus lumborum block (QLB) combined with local infiltration analgesia (LIA) for pain management and recovery in patients who have undergone total hip arthroplasty (THA) via a posterolateral approach. DesignThis was a prospective, randomized controlled trial. SettingWe collected data in the preoperative area, operating room, and bed ward. PatientsA total of 80 patients with American Society of Anesthesiology functional status scores of II-III were included and assigned to two groups, and all 80 patients were included in the final analysis. InterventionsAll included patients were randomly assigned to the nerve block (group N) or the control group (group C). Patients in the group N received transmuscular QLB combined with LIA, while patients in the group C received only LIA. MeasurementsThe primary outcome was postoperative pain during the first active motion: it was measured at six hours after surgery and assessed using a visual analog scale (VAS). Secondary outcomes were the resting VAS scores in the post-anesthesia care unit (PACU) and at 2, 6, 12, 24, 48, and 72 h after surgery; VAS scores during motion at 12, 24, 48, and 72 h after surgery; intraoperative consumption of opioids; postoperative consumption of morphine hydrochloride; frequency of sleep interruption due to pain on the night of surgery; time until the first “walk out of the bed” after surgery; muscle strength of the quadriceps femoris; and postoperative adverse effects. Main resultsCompared to the group C, patients in the group N had significantly lower VAS scores during motion at 6, 12, and 24 h after surgery, as well as lower resting VAS scores in the PACU and at 2, 6, 12, and 24 h after surgery. Patients in the group N also consumed significantly smaller amounts of intraoperative opioids and morphine after surgery. Patients in the group N reported significantly fewer interruptions in sleep due to pain on the night of surgery and were able to “walk out of the bed” significantly earlier than those in the group C. There was no significant difference between the two groups in muscle strength of the quadriceps femoris or incidence of postoperative adverse effects. ConclusionsCompared to treatment with LIA alone, ultrasound-guided transmuscular QLB combined with LIA can provide better postoperative pain relief and enhance the recovery of THA patients, since it does not cause quadriceps femoris muscle weakness and is associated with significantly lower need for intraoperative opioids.

Prospective randomized trial of continuous femoral nerve block with posterior capsular injection versus periarticular injection for analgesia in primary total knee arthroplasty.

Background:Femoral nerve block (NB) and periarticular injection (PI) are 2 common options for pain control after total knee arthroplasty (TKA). We performed a prospective triple-blinded randomized trial comparing continuous femoral NB to PI, with follow-up to 1 year.Methods:Patients younger than 70 years of age who were scheduled to undergo elective primary TKA under spinal anesthesia between 2009 and 2010 were randomly allocated to receive either continuous femoral NB or PI. Patients in the NB group received ropivacaine through an NB catheter and a sham saline PI. The PI group received a PI of ropivacaine, morphine, ketorolac and epinephrine, and a sham saline infusion via an NB catheter. Both groups had standardized oral analgesia preoperatively, spinal anesthesia and sedation, and postoperative analgesia. Surgeons, anesthesiologists, patients and assessors were blinded to group assignment. Pain was measured twice daily on postoperative days 1 and 2, at rest and with motion, with a numeric rating scale. Patient satisfaction, pain (Oxford Knee Score) and range of motion were assessed at 1 year.Results:There were 39 participants in the NB group and 35 participants in the PI group. There were no statistically significant differences between the groups at baseline. Statistically but nonclinically significant reductions in pain scores on postoperative day 2 and in narcotic need on the day of surgery were found in the PI group. Patient-reported satisfaction did not differ at any time point. At 1 year, knee flexion was significantly greater in the NB group than in the PI group (mean range of motion 120° v. 110°, p = 0.03).Conclusion:There was no demonstrated improvement in pain control with the use of an NB versus PI when used with multimodal analgesia. Clinicians should opt for the modality that has the best efficiency for their surgical environment. ClinicalTrials.gov # NCT00869037

Comparison between circumferential local anesthesia and dorsal penile nerve block in circumcision procedure

Objectives: To compare circumferential local anesthesia and dorsal penile nerve block with regard to pain control during adult circumcision. Materials and Methods: A randomized, controlled clinical trial was conducted and 30 men were randomly assigned into one of the following groups: circumferential local anesthesia (LA) and dorsal penile nerve block (DNB). Patients in both groups were injected with 0.2 ml/kg of 2% lidocaine without epinephrine before circumcision using the different techniques. During the operation, pain score was evaluated in accordance with the Numerical Rating Scale (NRS) and the data were compared using the Mann-Whitney test. Results: The patients in the LA group felt more pain than those in the DNB group during anesthetic injection (4.73 vs 3.7, p&lt;0.05) but the pain scores were lower than in the DNB group during the outer prepuce incision (0.47 vs 3.93, p&lt;0.05), inner prepuce incision (0.33 vs 1.47, p&lt;0.05) and incision near/at Frenulum (0.33 vs 4.47, p&lt;0.05). Overall pain score was higher in the dorsal penile nerve block group (1.53 vs 2.6, p &lt;0.05). The circumferential local anesthesia is equally effective through all stages of the circumcision whereas the dorsal penile nerve block was not effective at the ventral surface of penis. Conclusion: For pain control in circumcision, circumferential local anesthesia is more effective than dorsal penile nerve block.

Ultrasound-guided genicular nerves block: an analgesic alternative to local infiltration analgesia for total knee arthroplasty: A noninferiority, matched cohort study.

Standard analgesic strategies for total knee arthroplasty employ local infiltration analgesia. Blockade and radiofrequency ablation of the genicular nerves are effective treatments for patients with chronic pain because of knee osteoarthritis. To test the noninferiority of the analgesic effect of genicular nerves block in comparison with local infiltration analgesia after 24 h of total knee arthroplasty. Prospective cohort study. Perioperative setting. Thirty-five patients scheduled for total knee arthroplasty were prospectively included in the study and compared with 35 patients in a retrospective cohort. Genicular nerve blocks in the prospective cohort were compared with local infiltration analgesia in the retrospective cohort. The pain numeric rating scale and the cumulative opioid consumption in oral morphine equivalents during the first 24 h. We conducted propensity score-matched analyses of patients using acute postoperative pain-related risk covariates. After one-to-one propensity score matching, 21 patients were included in the local infiltration analgesia group and 21 in the genicular nerve block group. The median difference in numeric rating score at rest at 24 h was -0.99 [95% confidence interval (CI), -1.99 to 0.5, P = 0.012] on the unmatched cohort and -1.9 (95% CI, -2 to 0, P = 0.002) on the matched cohort (meeting the noninferiority criteria, Δ=1). The median difference in cumulative opioid consumption was 2.5 mg (95% CI, -13.5 to 2.5, P < 0.001) for the unmatched cohort and 4.99 mg (95% CI, -11.5 to 2.5, P < 0.001) on the matched group (meeting the noninferiority criteria, Δ = 21 mg). Local infiltration analgesia and genicular nerve block are comparable in terms of analgesic results. Therefore, genicular nerves block is an alternative to local infiltration analgesia in patients undergoing total knee arthroplasty. Clinicaltrials.gov identifier: NCT04024319.

Efficacy of Two Unique Combinations of Nerve Blocks on Postoperative Pain and Functional Outcome After Total Knee Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Study

BackgroundThis study aimed to explore the efficacy of two unique combinations of nerve blocks on postoperative pain and functional outcome after total knee arthroplasty (TKA). MethodsPatients scheduled for TKA were randomized to receive a combination of adductor canal block (ACB) + infiltration between the popliteal artery and capsule of the posterior knee block (IPACK) + sham obturator nerve block (ONB) + sham lateral femoral cutaneous nerve block (LFCNB) (control group), or a combination of ACB + IPACK + ONB + sham LFCNB (triple nerve block group), or a combination of ACB + IPACK + ONB + LFCNB (quadruple nerve block group). All patients received local infiltration analgesia. Primary outcome was postoperative morphine consumption. Secondary outcomes were the time until first rescue analgesia, postoperative pain assessed on the visual analog scale (VAS), QoR-15 score, functional recovery of knee, and postoperative complications. ResultsCompared with the control group, the triple and quadruple nerve block groups showed significantly lower postoperative morphine consumption (17.2 ± 9.7 mg vs. 11.2 ± 7.0 mg vs. 11.4 ± 6.4 mg, P = .001). These two groups also showed significantly longer time until first rescue analgesia (P = .007 and .010, respectively, analyzed with Kaplan-Meier method), significantly lower VAS scores on postoperative day 1 (P < .01), significantly better QoR-15 scores on postoperative days 1 and 2 (P < .001), and significantly better functional recovery of knee including range of motion (P = .002 and .001 on postoperative days 1 and 2), and daily ambulation distance (P < .001 and P = .004 on postoperative days 1 and 2). However, the absolute change in morphine consumption, VAS scores, and QoR-15 scores did not exceed the reported minimal clinically important differences (MCIDs) (morphine consumption: 10 mg; VAS scores: 1.5 at rest and 1.8 during movement; QoR-15 scores: 8.0). The MCIDs of other outcomes have not been reported in literature. The triple and quadruple nerve block groups showed no significant differences in these outcomes between each other. The three groups did not show a significant difference in complication rates. ConclusionAdding ONB or ONB + LFCNB to ACB + IPACK can statistically reduce morphine consumption, improve early pain relief, and functional recovery. However, the absolute change in morphine consumption, VAS scores, and QoR-15 scores did not exceed the MCIDs. Based on our findings and considering the sample size of this study, there is not enough clinical evidence to support the triple or quadruple nerve block use within a multimodal analgesic pathway after TKA.

Role of Superficial Cervical Plexus Nerve Block as an Adjuvant to Local Anesthesia in the Maxillofacial Surgical Practice

Infiltration techniques are used as an adjuvant to regional anesthesia. In this study, we evaluated the efficacy of the superficial cervical plexus nerve block, as an alternative to local infiltration techniques; in the management of mandibular fractures and peri-mandibular space infections. A prospective randomized controlled trial was conducted on 24 patients having either mandibular fractures or peri-mandibular space infections; and were scheduled for surgery under regional anesthesia (eg, inferior alveolar nerve block, long buccal nerve block). The control group involved delivering a combination of regional anesthesia along with local infiltration. The experimental group received regional anesthesia with a superficial cervical plexus nerve block. The following parameters were studied: pain, onset and duration of anesthesia, time interval until first analgesic request, pulse rate and blood pressure [at different time intervals]. Intergroup comparison was done using unpaired t-test. Intragroup comparison was done using repeated measures ANOVA (for >2 observations), followed by a post hoc test. The superficial cervical plexus nerve block group showed highly statistically significant (P < .01) improvement in terms of intra-operative pain at 30 minutes, duration of anesthesia, intraoperative anesthetic requirement, time interval until first analgesic request and intraoperative diastolic blood pressure at 10 minutes. It can be concluded that the combination of a regional anesthesia technique with a superficial cervical plexus nerve block is an alternative and safe technique for patients undergoing surgery for mandible fractures and perimandibular space infections, with clear advantages over local infiltration.

Hepatic Hilar and Celiac Plexus Nerve Blocks as Analgesia for Doxorubicin-Eluting Microsphere Chemoembolization Procedures for Hepatocellular Carcinoma: A Nonblinded Randomized Clinical Trial

PurposeTo investigate whether hepatic hilar and celiac plexus nerve blocks provide safe and effective analgesia to patients undergoing doxorubicin-eluting embolics transarterial chemoembolization (DEE-TACE) for hepatocellular carcinoma. Materials and MethodsIn this prospective, randomized trial, 92 patients undergoing DEE-TACE for hepatocellular carcinoma were enrolled. The control group received standard intraprocedural local anesthetic, intra-arterial lidocaine, and intravenous analgesia; the study group underwent additional hepatic hilar and celiac plexus nerve blocks. Intra-arterial lidocaine, intravenous and oral narcotic and antiemetic requirements after the procedure, pain, patient satisfaction, adverse events, and hospital stay were compared. ResultsThe nerve block group reported less pain during and after the procedure at days 1 and 7 (P < .001), although differences resolved by week 2. The control group received more intra-arterial lidocaine (P < .001) and required approximately double the amount of narcotic analgesia during and after the procedure, extending to 3 weeks after the procedure (P < .001), as well as less antiemetics (P < .001). No differences in adverse events, hospital stay, and overall patient satisfaction were noted. ConclusionsHepatic hilar and celiac plexus nerve blocks before procedures can result in lower pain during and after procedures in patients undergoing DEE-TACE. Furthermore, nerve blocks result in lower opioid consumption and opioid-related complications for 3 weeks following procedures.

TO COMPARE THE EFFICACY OF GENICULAR NERVE BLOCK AND INJECTION OF HYLAN G-F 20 VERSUS GENICULAR NERVE BLOCK ONLY FOR IMPROVING PAIN AND FUNCTION OF GRADE-II AND GRADE-III OSTEOARTHRITIS KNEE

Introduction: Osteoarthritis (OA) of knee joint is a degenerative joint disease; heterogeneous and progressive in nature. Clinically presented with stiffness, swelling and pain which leads to a decrease in the quality of life. The presence of chronic knee pain has been found to be a strong predictor of future disability and dependency in older adults. Usually managed conservatively but if conservative treatment fails, Total Knee Replacement (TKR) is traditionally considered. This is associated with multiple perioperative morbidities. On the contrary, many patients are not suitable for surgical procedure and some do not want to go for surgical intervention. As many patients are not surgical candidates due to co-morbidities or unwillingness; other treatment options available are being sought for. The genicular nerve block (GNB) reduces pain and improves patient functions by blocking pain transmission of the sensory nerves. Combining this genicular nerve block with viscosupplementation (Injection Hylan G-F 20) appears to play a role and can be tried in patients suffering in grade II and grade III (radiological grading) osteo arthritis. There is paucity of information so as to compare the efcacy of genicular nerve block and injection of Hylan G-F 20 versus genicular nerve block only. Material And Methods: This Parallel group open label randomized controlled trial was done between July, 2018 to December, 2019 (Eighteen months). Patients with knee pain in grade II and III, OA knee attending the PMR OPD in IPGME&amp;R, Kolkata in the specied tenure was considered for the study. The selected patients were allotted by random table. All the procedures were performed by single person. A total number of 60 patients with knee osteoarthritis of grade II and III, who did not respond with conservative management were included. Combined therapy of intra-articular injection of Hylan G-F 20 and genicular nerve block in Group 1 (Genicular Nerve Block and Injection Hylan G-F 20) and Genicular Nerve Block only in Group 2, performed to 30 patients in each arm. The three branches of the genicular nerve [superior lateral (SL), superior medial (SM), and inferior medial (IM) genicular nerves] were selected. Patients were evaluated initially (0 week) and at the 4th and 12th week followed up after intervention using VAS and WOMAC scale. Ultrasound guided genicular nerve block conducted under strict asepsis after proper dressing and draping with the visualization of genicular nerves (upper medial, upper lateral and lower medial quadrant) by musculoskeletal probe of Ultrasound machine (SAMSUNG/ Model PT60A/Musculoskeletal probe 12MHz). Injection Hylan G-F 20 (6 ml) intra-articular injection was given under strict asepsis. Results: 47% patients in group 1 and 67% patients in group 2 were in between 60-69 years. There is female preponderance in both the groups. WOMAC-pain score for dual intervention at 4th week was statistically signicantly lower compared to WOMAC-pain score obtained at any time of observation and any type of intervention. WOMAC- stiffness score for dual intervention at 4th week was statistically signicantly lower compared to WOMAC- stiffness score obtained at any time of observation. WOMAC SCORE: The changes in each intervention group at 0-week, 4th week and 12th week were statistically signicant. Statistically signicant difference of two groups were lost during 4th and 12th weeks observation. VAS: During 4th and 12th weeks observation, statistically signicantly different VAS score was observed among the two interventions; Genicular nerve block with injection consistently had a lower VAS score. This nding imply that Genicular nerve block alone did reduce the pain; however, reduction was greater in case of Genicular nerve block with Injection Hylan G-F 20 in both 4th and 12th week of observation. Conclusion: Genicular Nerve Block with injection HYLAN GF 20 (Combined Therapy Group) and Genicular Nerve Block alone are effective method of pain reduction in osteoarthritis knee. Combined Therapy doesn't have an added advantage as per WOMAC Score. But Combined therapy has a denite advantage over Genicular Nerve Block alone as per VAS Score.

A single injection of saphenous nerve block reduces postoperative bleeding after total knee arthroplasty

In elderly patients, the vital parameters tend to fluctuate based on the blood volume status, which may cause sudden hypovolemic shock if the postoperative bleeding continues. Particularly, those who undergo surgery for arthritis needs to pay extra attention because the bleeding may persist over the joints after the surgery. Therefore, appropriate pain control is required to reduce the postoperative blood loss. This retrospective chart review study was conducted to assess the postoperative pain control and reduction of blood loss with a single injection of saphenous nerve block (SNB) in elderly patients with osteoarthritis. We reviewed the electronic medical records of patients who underwent knee total arthroplasty with spinal anesthesia between January and May 2016. A total of 51 patients participated in this study. All patients were treated with intravenous patient-controlled analgesia for the postoperative pain control, and additional analgesic agents were administered at a visual analogue scale above a score of 6. In 25 patients, SNB was performed using ultrasound with the administration of 0.75% ropivacaine (15 mL) after the surgery. Patients who received additional analgesics were significantly low in the nerve block group (P=0.009). Additionally, the volume of blood loss from catheter drainage was significantly low at 2 and 3 days postoperatively (P=0.013 and P=0.041, respectively) in the nerve block group. In patients who underwent total knee arthroplasty with osteoarthritis, only a single injection of saphenous nerve block was sufficient for the postoperative pain control and reduced bleeding. Key words: Nerve block, Pain management, Postoperative blood loss, Total knee arthroplasty

Clinical study of age-related sensory innervation of the anterior hard palate

The present study aimed to explore the innervation of the anterior hard palatine and its relationship with individual development stage. Specifically, the effects of anesthesia on patients of different ages were observed, and neurodevelopment in the maxillofacial region was invesitgated. References that are helpful in selecting local anesthesia were provided. A total of 182 patients with mixed dentition were randomly divided into the nasopalatine nerve block and greater palatine nerve block groups. Then, 219 patients with permanent dentition were divided into an adolescent group (13-18 years old) and adult group (over 19 years old), all of whom underwent bilateral greater palatine nerve block. Palatal mucosal pain sensation was tested pre- and post-anesthesia with Von Frey hairs. Among the children with mixed dentition, bilateral greater palatine nerve block tended to result in better anesthetic effects than nasopalatine nerve block (P<0.05), except in the incisive papilla. No difference in anesthetic effect was observed between adolescents and adults (P>0.05). The bilateral greater palatine nerve block was more effective in inducing an anesthestic effect in the anterior hard palatine in mixed dentition than in permanent dentition (over 13 years old; P<0.05). The sensation of the anterior hard palatine seems mainly dominated by the greater palatine nerve until mixed dentition and gradually shifted to the nasopalatine nerve in conjunction with maxillary development and tooth replacement. Hence, the innervation of the anterior hard palatine induce a secondary development during the development of the maxilla.