Neuromuscular Blockade Research Articles

Comparison of Fentanyl With Midazolam As Adjuvants to Levobupivacaine in Spinal Anesthesia for Cesarean Sections: A Randomized Controlled Trial.

Background and objectives Spinal anesthesia stands as a cornerstone for patients undergoing lower segment cesarean section (LSCS), offering advantages like faster onset and high block density. Levobupivacaine, known for its high potency and long-acting nature, has a slower onset. The safety of intrathecal fentanyl or midazolam is evaluated as an adjuvant to levobupivacaine in parturients. This study aims to compare the duration of postoperative analgesia provided by fentanyl or midazolam added to 0.5% hyperbaric levobupivacaine in elective cesarean sections. Secondary objectives include evaluating the onset and duration of sensory and motor blockade and the incidence of nausea and vomiting. Identifying the more effective adjuvant will help optimize spinal anesthesia protocols, improve postoperative outcomes, and enhance patient comfort and recovery. Methods This study was conducted at SRM Medical College Hospital and Research Centre, Chennai, India, over six months (May 1, 2023, to October 1, 2023). A total of 90 patients undergoing elective LSCS received spinal anesthesia in a prospective randomized double-blinded controlled trial. Patients were allocated to three groups: Group A received levobupivacaine with fentanyl, Group B received levobupivacaine with midazolam, and Group C received levobupivacaine with normal saline. Block characteristics, postoperative analgesia, hemodynamic stability, and complications were assessed. Assessments were conducted at specified time points: intraoperatively, every five minutes for the first 30 minutes, every 10 minutes for the next hour, every two hours for six hours, and every four hours up to 24 hours postoperatively. Statistical analysis utilized one-way analysis of variance (ANOVA). Results Group B (levobupivacaine with midazolam) exhibited a shorter time to sensory block onset (88 seconds) compared to Groups A and C (both 145 seconds) (p < 0.001). Group A (levobupivacaine with fentanyl) showed a shorter time to maximum motor block (p = 0.045) than Groups B and C. The sensory block duration was significantly longer in Group A (127.5 minutes) compared to Group B (60 minutes) and Group C (69 minutes) (p < 0.001). Motor block duration was also prolonged in Group A (251 minutes) compared to Group B (147 minutes) and Group C (177 minutes) (p = 0.045). The first analgesic requirement was delayed in Group A (248 minutes), whereas Groups B (115 minutes) and C (90 minutes) (p < 0.001) required more frequent analgesia. Group A experienced a higher incidence of postoperative nausea and vomiting. Conclusion Midazolam accelerated sensory block onset, while fentanyl prolonged anesthesia duration without significantly affecting motor block. Fentanyl delayed the first analgesic requirement, whereas midazolam reduced postoperative nausea, vomiting, and shivering.

Peculiarities of anesthesia for caesarean section in patients with gestational diabetes mellitus

BACKGROUND: Women with gestational diabetes mellitus are at high risk of operative delivery. Meanwhile, hyperglycemia affects the metabolism of narcotic analgesics, while increasing their need. Thus, the anesthesiologist is faced with the question of what method of anesthesia to choose for a particular cesarean section. AIM: The aim of this study was to estimate the features of the perioperative period of cesarean section in patients with gestational diabetes mellitus. MATERIALS AND METHODS: This prospective, controlled, single-center study enrolled 101 patients who were delivered by planned cesarean sections from April to November 2023. Group 1 included patients with gestational diabetes mellitus on diet therapy (n = 28), group 2 comprised patients with gestational diabetes mellitus on insulin therapy (n = 29), and group 3 (control) included women with a normal pregnancy without carbohydrate metabolism disturbances (n = 44). RESULTS: The highest initial values of mean arterial pressure were in group 2 and amounted to 91.8 ± 7.0 mmHg. In group 1, the mean arterial pressure was within 89.1 ± 6.4 mmHg, and in group 3, that was 85.9 ± 9.1 mmHg, which was significant (p 0.05). The sympathetic block developed longer in patients of group 2. In group 1, the sensory block was recorded at the ThIV–ThV level after 10.1 minutes and the motor block (Bromage score 3) after 12.2 minutes compared to 7.8 and 8.6 minutes, respectively, in group 2, and 4.5 and 5.1 minutes, respectively, in group 3. In group 2, authors observed the most rapid regression of the block (79.4 minutes after the injection of local anesthetic), which required an earlier start of the transversus abdominis plane block (after 65.3 minutes). The sympathetic block regressed after 86.2 and 138.1 minutes in patients of groups 1 and 3, respectively (p 0.05), when the transversus abdominis plane block was performed. Thus, immediately after cesarean section, women with gestational diabetes mellitus (especially on insulin therapy) had a higher need for analgesics than those without gestational diabetes mellitus. CONCLUSIONS: During cesarean section under spinal anesthesia in patients with gestational diabetes mellitus, the rate of development of the sympathetic block is reduced (especially in women who received insulin therapy). At the same time, block regression in these patients occurs much faster, which requires an earlier start of postoperative anesthesia. An increased need for systemic analgesics has been demonstrated during the postoperative period in women with gestational diabetes mellitus, mainly with insulin therapy.

Adductor Canal Block Versus Femoral Nerve Block for Postoperative Pain Management in Anterior Cruciate Ligament Reconstruction: A Prospective Interventional Study.

Background A common knee joint disorder is injury to the anterior cruciate ligament (ACL), which often requires surgery. Proper pain control after the surgery facilitates fast recovery and prevents chronic pain. To provide analgesia for knee procedures, the use of opioids, non-steroidal anti-inflammatory medications, and regional techniques arecommonly employed. This study aims to evaluate the efficacy of adductor canal block (ACB) and femoral nerve block (FNB) for postoperative pain management after anterior cruciate ligament reconstructions (ACLRs). Methodology This prospective interventional study included 30 participants scheduled for patellar graft ACLR. They were assigned into groups, i.e., ACB and FNB, with 15 patients each. The evaluation occurred one day before the operation, and all surgical procedures were performed using spinal anesthesia. During the postoperative period, a 10-point visual analog scale (VAS) was utilized to quantify pain intensity at the end of the surgery and at various intervals after the surgery. Patients with a VAS score greater than 4 received either FNB or ACB using bupivacaine 0.125%. Duration of analgesia time, power of quadriceps muscle, and neurologic complications were documented. Results No statistically significant value was observed in the mean duration of analgesia between the patients in ACB (348.33 minutes) and the patients in FNB (363.06 minutes). No motor block was observed in 12 patients who received ACB, while only four patients had a motor-sparing effect among those who received FNB. No neurological adverse effects were observed in the study participants. Conclusions ACB provides an equal duration of analgesia similar to FNB, and ACB significantly spares motor strength and maintains higher quadriceps power than FNB.

Neurologic disease in the obstetric patient.

Neurologic disorders and complications during pregnancy are common, but guidelines and data are sparse. This review aims to give an overview of recent developments in neuroanesthesia and management of neuropathology during pregnancy, with the hope that these may fill the gaps in current guidelines and recommendations, as well as their implications for an anesthetic approach. Neuraxial and general anesthesia are safe in multiple sclerosis and myasthenia gravis, though neuromuscular blockade response is unpredictable and risk for exacerbation exists. Cerebral vascular pathology is common and carries a significant morbidity and mortality burden, but thrombolytic and endovascular therapies are often appropriate and safe. Instrumental vaginal delivery can minimize intracranial pressure shifts and is a viable option. Tumors and cerebral malformations require a complex multidisciplinary and anesthetic approach. While clinical trials remain sparse, larger population-based studies offer insight into the optimal approach to the parturient with neurologic disease.

Clinical effects of perineural dexmedetomidine or magnesium sulphate as adjuvants to ropivacaine in dogs undergoing tibial plateau leveling osteotomy

The study aimed to compare the quality of perioperative analgesia, the motor block duration, and the effects on main cardiovascular parameters of dexmedetomidine (1 μg/kg/nerve block) or magnesium sulphate (2 mg/kg/nerve block) as adjuvants to 0.3% ropivacaine for sciatic and saphenous nerves block in dogs undergoing tibial plateau leveling osteotomy (TPLO). Dogs randomly received perineural dexmedetomidine-ropivacaine (D group), magnesium sulphate-ropivacaine (M group), or ropivacaine (C group). Fentanyl was administered in case of intraoperative nociception. Postoperative pain was assessed using the Short Form-Glasgow Composite Measure Pain Scale (SF-GCMPS) and VAS scale. The duration of motor blockade and intra- and postoperative cardiovascular parameters were also recorded. Group M required significantly more fentanyl than D group (p = 0.04). Group M had a significantly higher SF-GCMPS score than group C at 4 (p = 0.002) and 5 h after extubation (p = 0.01), and a significantly higher VAS score than group D at 3 h after extubation (p = 0.03), and at 4 h if compared to group C (p = 0.009). No significant differences regarding the duration of motor blockade were detected between groups (p = 0.07). The heart rate was significantly lower in group D than in M and C groups intraoperatively and during the first 1.5 h post extubation. The addition of dexmedetomidine or magnesium sulphate as adjuvants to perineural ropivacaine did not improve the quality of perioperative analgesia and did not prolong the motor blockade in dogs undergoing sciatic and saphenous nerves block for TPLO surgery.

Comparison of inflammatory markers in low-pressure pneumoperitoneum with deep neuromuscular block versus standard pressure pneumoperitoneum among patients undergoing laparoscopic cholecystectomy for gallstone disease: a randomized control trial.

Low-pressure pneumoperitoneum (LPP) is an attempt to improve laparoscopic surgery. Lower pressure causes lesser inflammation and better hemodynamics. There is a lack of literature comparing inflammatory markers in LPP with deep NMB to standard pressure pneumoperitoneum (SPP) with moderate NMB in laparoscopic cholecystectomy. This was a single institutional prospective randomized control trial. Participants included all patients undergoing laparoscopic cholecystectomy for symptomatic gall stone disease. Participants were divided into 2 groups group A and B. Group A-Low-pressure group in which pneumoperitoneum pressure was kept low (8-10mmHg) with deep Neuromuscular blockade (NMB) and Group B-Normal pressure group (12-14mmHg) with moderate NMB. A convenience sample size of 80 with 40 in each group was selected. Lab investigations like CBC, LFT, RFT and serum IL-1, IL-6, IL-17, TNF alpha levels were measured at base line and 24h after surgery and compared using appropriate statistical tests. Other parameters like length of hospital stay, post-operative pain score, conversion rate (low-pressure to standard pressure), and complications were also compared. Eighty participants were analysed with 40 in each group. Baseline characteristics and investigations were statistically similar. Difference (post-operative-pre-operative) of inflammatory markers were compared between both groups. Numerically there was a slightly higher rise in most of the inflammatory markers (TLC, ESR, CRP, IL-6, TNFα) in Group B compared to Group A but not statistically significant. Albumin showed significant fall (p < 0.001) in Group B compared to Group A. Post-operative pain was also significantly less (p < 0.001) in Group A compared to Group B at 6h and 24h. There were no differences in length of hospital stay and incidence of complications. There was no conversion from low-pressure to standard pressure. Laparoscopic cholecystectomy performed under low-pressure pneumoperitoneum with deep NMB may have lesser inflammation and lesser post-operative pain compared to standard pressure pneumoperitoneum with moderate NMB. Future studies with larger sample size need to be designed to support these findings.

Indicators and effectiveness of sensory and motor blocking unilateral spinal anesthesia combined with unilateral epidural analgesia

Indicators and effectiveness of sensory and motor blocking unilateral spinal anesthesia combined with unilateral epidural analgesia

Comparison of Ropivacaine with or without Fentanyl in Spinal Anaesthesia for Lower Limb Surgeries

Introduction: Spinal anaesthesia is a preferred technique used for lower limb orthopaedic surgeries. Ropivacaine with its short duration of motor blockade and provision for early ambulation along with addition of spinal additives has proven beneficial to the patient. This prospective, double-blind, randomized controlled study set out to evaluate the effects of 0.75% isobaric ropivacaine with fentanyl versus 0.75% isobaric ropivacaine during lower limb orthopaedic surgeries performed under spinal anaesthesia. Methods: The study enrolled 74 patients, aged 18-65 years of either sex, ASA PS I and II, planned for lower limb orthopaedic surgeries. Patients were randomly allocated to receive either 2.5 ml of 0.75% isobaric ropivacaine and 0.5ml of normal saline (Group R) or 2.5 ml of 0.75% isobaric ropivacaine and 0.5ml of fentanyl (25mcg) (Group RF). Results: The demographic profile, onset time of sensory block to T10 dermatome, time for complete motor blockade, maximum block height, duration of motor block, and haemodynamic parameters did not significantly differ between the two groups. Group R took 200.27 ± 21.28 minutes for the S2 dermatome segment regression, while Group RF took 284.59 ± 32.88 minutes (p-value&lt;0.001). Group RF experienced analgesia for a longer duration (335.68±22.18 min) than Group R (240.00±28.28 min) (p-value&lt;0.001). Conclusion: Fentanyl greatly extends the duration of S2 segment regression and analgesia when combined with ropivacaine; the effects on haemodynamics and motor blockade is clinically negligible and side effects are minimal.

Effect of Atracurium and Rocuronium on the State and Response Entropy during Isoflurane Anesthesia: Randomized Prospective Study

Abstract Background Several researches have inspected the impact of inhalation anesthetics, intravenous anesthetics, and muscle relaxants on spectral entropy, but many didn’t evaluate the extent of neuromuscular block. Besides, they didn’t inspect the impact of distinct degrees of neuromuscular blockade on spectral entropy under dissimilar saturations of isoflurane inhalation. Hence, this study evaluated variant degrees of minimum alveolar concentration (MAC) to estimate the isoflurane concentration, along with various level of neuromuscular blockade. Aim of this study is to evaluate the effect of muscle relaxants (atracurium and rocuronium) on entropy readings (state, response entropy and response- state difference) during isoflurane anesthesia. This is a prospective randomized study where forty patients were included and divided into two study groups; patients in Group A received atracurium, while patients in Group R received rocuronium. State and response entropy were observed under MAC 0.8% and 1% under 50% and 100% neuromuscular blockage. Results There was a positive correlation between state (SE) and response entropy (RE) at baseline, different MAC, and different train of four (TOF) for both atracurium and rocuronium. State and response entropy decreased with increasing MAC of isoflurane (p &amp;lt; 0.001), while atracurium and rocuronium at TOF 50% and 100% showed no effect on SE or RE or RE-SE (P &amp;gt; 0.05). Conclusions State and response entropy can be used effectively to evaluate depth of anesthesia at different isoflurane MAC and atracurium or rocuronium doses. Registration number: ClinicalTrials.gov Identifier: NCT 05097508, Registered 5 October 2021 - prospectively registered, http://www.ClinicalTrial.gov

Intrathecal Dexmedetomidine versus Intrathecal Dexamethasone as Adjuvants to Hyperbaric Bupivacaine to Prolong the Duration of Sensory Block in Patients Undergoing Lower Abdominal Surgeries

Abstract Background Dexmedetomidine can be added to local anesthetics in spinal anesthesia to speed up the block, reduce postoperative pain, increase block duration, and reduce analgesic use. Dexamethasone is used intravenously to lessen shivering because it reduces the body's inflammatory response and tissue temperature gradient. It can also be safely injected into the cerebrospinal fluid as an adjuvant to local anesthetics to improve the quality of regional anesthesia. Intrathecal dexamethasone added to Bupivacaine increased spinal anesthetic sensory block duration without affecting onset time or consequences. Aim Comparing the onset and duration of sensory block and Analgesia and onset and duration of motor block and hemodynamic stability when intrathecal 5 mcg Dexmedetomidine added to 15mg heavy bupivacaine 0.5% to that of 4mg dexamethasone when added to 15 mg heavy bupivacaine 0.5% in patients underwent lower abdominal surgeries under spinal anesthesia. Subject and Methods This study was conducted at Faculty of Medicine; Ain-Shams University Hospitals on 50 patients. Results VAS was significantly lower in group B compared to group A at 8hr and 12hr measurements. there is a significant difference between the groups regarding sensory block duration, motor block duration, onset of sensory block, onset of motor block, time to 2 segment regression, and time to request of 1st analgesia. postoperative opioid consumption was significantly lower in group B always compared to group A. Conclusion adverse events. The current study showed that both Dexmedetomidine and dexamethasone were safe and effective as intrathecal adjuvants in lower abdominal surgeries. Both drugs resulted in comparable hemodynamic stability and incidence of

Impact of Intrathecal Dexmedetomidine versus Intrathecal Fentanyl as Adjuvants to Bupivacaine on Post Spinal Urinary Retention in Knee Joint Arthroscopic Surgeries

Abstract Background Patients undergoing orthopedic surgery are prone to developing postoperative urinary retention (POUR). They have an estimated relative risk of 8% to 55% higher than other surgical patients. This inability to void increases patient’s risk of urinary tract infections (UTIs) and bacteremia, and can lead to chronic voiding difficulties due to bladder architecture alterations. A great degree of variability exists among studies describing the prevalence and risk factors of postoperative urinary retention and its management strategies. Objective To compare the effects of Dexmedetomidine or Fentanyl added to intrathecal bupivacaine in knee arthroscopic procedures in terms of the occurrence of postoperative urinary retention. Patients and Methods This prospective randomized clinical study was conducted at tertiary care hospital at Ain Shams University hospitals from September 2021 till Mars 2022 and performed on a total of 70 patients who assigned for knee joints orthoscopic surgery. Results The current study results revealed that the incidence of postoperative urine retention in dexmedetomidine group was 5.7% while was 28.6% in Fentanyl group, the difference was statistically significant. however, the need to postoperative urinary catheterization was statistically non-significantly among the two groups. The current study results revealed that the Time to achieve maximum block was significantly shorter in dexmedetomidine group and the duration of motor block statistically was significantly longer in dexmedetomidine group. Conclusion On the basis of current evidence, when compared to fentanyl, our study revealed that intrathecal dexmedetomidine, as adjuvant to local anesthetics for intrathecal injection, can statistically significantly prolong the duration of sensory and motor block, as well as the pain free period, meanwhile significantly reducing the incidence of urinary retention. Intrathecal dexmedetomidine seems to be an attractive alternative as an adjuvant to spinal bupivacaine in surgical procedures, especially those requiring long time. It has excellent quality of postoperative analgesia with minimal side effects.

Comparison of Two Different Dexmedetomidine Doses and Their Effect on the Duration of Spinal Anesthesia in Lower Limb Amputation Surgeries

Abstract Background Spinal anesthesia is a very common technique used in lower limb surgeries. Dexmedetomidine is a highly selective α2-adrenergic agonist which has been used as pre-medication and as an adjuvant to general anesthesia. It is found that injection of dexmedetomidine intrathecally prolongs both sensory and motor block and has antinociceptive action for both visceral and somatic pain by depressing the release of nociceptive C fibers transmission and hyperpolarization of post synaptic dorsal horn cells. Objective To compare the effect of addition of different doses of dexmedetomidine to bupivacaine on the duration of spinal anesthesia, quality of block, intraoperative and postoperative complications and postoperative analgesia in patients undergoing lower limb amputation surgeries. Methods This prospective double blind randomized controlled clinical trial was done on sixty six adult patients of both sexes, aging from 21 to 60 years old, ASA I and II presented to Ain Shams University Hospitals for lower limb amputation surgeries were involved in this study during the period from July 2021 till May 2022. Results The addition of dexmedetomidine to bupivacaine in spinal anesthesia significantly prolonged both sensory and motor blockades duration compared with bupivacaine alone. It was significantly faster in group B (2.1 ± 0.124) compared with A and C groups (2.64 ± 0.34) and (4.72± 0.31) respectively and in group A compared with group C. They also prolonged the time of postoperative analgesia as evidenced by significantly longer time to first rescue analgesia Time to first call for rescue analgesia was significantly longer in group B (350 ± 45 mins) compared with A(287.41 ± 40.83 mins) and C(192 ± 42 mins) groups and in group B compared with group A. Also, there was significant difference in number of analgesic doses in group B compared to A and C groups and in group B compared to group A. Lower VAS scores with minimal adverse effects and hemodynamic stability. Comparing two different doses of dexmedetomidine showed that 15μg dexmedetomidine caused more prolongation of the spinal block duration and the time of postoperative analgesia than dexamethasone. It also decreased shivering during spinal anesthesia with only 4 patients compared to group A with 8 patients and group C with 9 patients. Conclusion 5μg dexmedetomidine seems to be an attractive as an adjuvant to spinal bupivacaine in surgical procedures. It provided good quality of intraoperative analgesia, hemodynamically stable conditions, minimal side effects, and excellent quality of postoperative analgesia. Unfortunately, it had not any effect on incidence or severity of phantom pain and sensation in lower limb amputation surgery, but 15μg had better time of analgesia and longer time till the patient needed rescue analgesia with lower VAS score with no remarkable difference in the side effect as revealed.

First-In-Human Demonstration of High Frequency Electrical Motor Nerve Block: Case Report.

This feasibility study tested the capability of high frequency stimulation (HFS) to block muscle contractions elicited by electrical stimulation of the same nerve proximally. During a tendon lengthening surgery in the forearm, the anterior interosseous nerve (AIN) was exposed. A specialized nerve cuff electrode was placed around the nerve, and a stimulating probe held on the nerve 1 cm proximal to the cuff electrode delivered pulses of current causing the pronator quadratus muscle to contract. Through the cuff electrode, 20 kHz HFS was delivered to the nerve for 10 seconds during proximal stimulation. HFS amplitudes between 5 and 10 mA peak-to-peak were tested to determine which produced complete and partial block of the electrically induced contractions. The minimum HFS amplitude that produced complete block was 8 mA, with lower amplitudes producing partial block. In all trials, muscle contractions resumed immediately after HFS was turned off. This demonstration of high frequency electrical nerve block is a milestone in the road to clinical implementation of HFS mediated motor block for spasticity.

Analysis of an Academic Medical Center’s Corrective Action Plan in Response to Fatal Medication Error Using the Institute for Safe Medication Practices’ Hierarchy of Effectiveness

Neuromuscular blocking agents (NMBAs) are high-alert medications that require special handling, necessitating a robust process that prevents medication error, identifies near misses, and ultimately protects patients from harm. One patient at a large academic medical center (AMC) was given vecuronium, a neuromuscular blocking agent, instead of midazolam, and died as a result. Thus, AMC was tasked by the Centers for Medicare &amp; Medicaid Services (CMS) to make a list of actions to prevent a subsequent incident. When assessing AMC’s corrective action plan in comparison to the Institute for Safe Medication Practices’ hierarchy of effectiveness of risk-reduction strategies, it was revealed that 76% of strategies were of low leverage, 16% were of medium leverage, and 8% were of high leverage. In this context, AMC’s corrective action plan should have integrated more system-based interventions, which include medium- or high-leverage strategies, rather than relying heavily on initiatives dependent on human action. Despite the lack of these systemic tools, CMS granted approval for the plan. Overlooking these systemic tools may amplify patient harm and negatively impact workforce satisfaction and efficiency. Moreover, the absence of a “just culture” also plays a role in patient harm. Therefore, recognizing that medication errors in healthcare are predominantly attributed to human error highlights the importance of fostering a just culture that advocates for system accountability to enhance patient safety.

Comparative clinical study of attenuation of hemodynamic response to laryngoscopy and endotracheal intubation using clinical assessment guidance versus neuromuscular block monitoring guidance

Background: The hemodynamic response to the stress of laryngoscopy and endotracheal intubation does not present a problem for most patients, except in cardiovascular or cerebral disease. Various anesthetic techniques and drugs are available to control the hemodynamic response to laryngoscopy and intubation. However administration of an additional drug may adversely affect hemodynamics of the patient or unnecessarily increase the depth of anesthesia. Hence a non pharmacological measure to reduce response is preferred. The purpose of this study was to compare the hemodynamic response during laryngoscopy and intubation when choice of the moment of intubation is directed by either clinical assessment and neuromuscular monitoring with train of four. Methods: A total of 60 patients were randomised into two groups. In Group M endotracheal intubation was done after train of four count became zero in adductor pollicis muscle. In Group C timing of intubation was determined clinically by assessment of jaw muscle relaxation. Changes in heart rate (HR), systolic BP (SBP), diasolic BP (DBP), mean arterial pressure (MAP), time between the administration of neuromuscular blocking agent and endotracheal intubation was recorded. Results were analysed by the analysis of variance and chi square test. Results: Heart rate, SBP, DBP and mean arterial pressure were significantly higher in Group C as compared to Group M after laryngoscopy and endotracheal intubation (P&lt;0.05). The mean time required for onset of intubation was significantly shorter in Group C compared to Group M. Conclusion: The objective assessment of neuromuscular relaxation prior to endotracheal intubation provides better attenuation of hemodynamic responses. Keywords: hemodynamic response; laryngoscopy; endotracheal intubation; neuromuscular block

Efficacy of ultrasound-guided classical versus parasacral parallel shift technique of sacral plexus block for lower limb surgeries - A randomised controlled trial.

Ultrasound-guided sacral plexus block has been used for anaesthesia and analgesia in lower limb surgeries. This study aimed to compare the block performance characteristics after ultrasound-guided (USG) sacral plexus nerve block (SNB) using the parasacral parallel shift (PSPS) approach versus the classical approach in patients undergoing orthopaedic below-knee limb surgeries. In this randomised study, 144 adult patients were randomised to receive USG SNB either by the classical approach (Group C) or the PSPS approach (Group P). A fixed dose of 20 ml of 0.5% ropivacaine was administered. Patients also received USG femoral nerve block with 10 ml of 0.5% ropivacaine. The primary outcome was the scanning time between the two groups. Secondary outcomes were the needling time, sensory and motor block onset and postoperative analgesic characteristics between the two groups. A P value of <0.05 was considered statistically significant. The needling time and the scanning time were significantly lesser in Group P than in Group C (P < 0.05). Complete sensory and motor nerve blockade of the sciatic nerve was significantly higher in Group P (P = 0.029). Block performance time, time for sensory block and time for motor block were significantly less in Group P compared to Group C (P < 0.001). The postoperative analgesic characteristics were comparable between the two groups. The sacral plexus block with ultrasound-guided parasacral parallel shift technique had a lower block performance time with lesser needling and scanning time than the classical approach.

A comparative study of efficacy of intravenous dexmedetomidine with perineural dexmedetomidine as adjuvant to ropivacaine in supraclavicular brachial plexus block in upper limb surgery

Background: In supraclavicular brachial plexus block, to prolong the duration of analgesia, many adjuvants have been tried in the past in many studies but an ideal adjuvant remains yet to be discovered. Dexmedetomidine, a selective Alfa-2 adrenergic agonist when added to local anesthetic has been reported to prolong the block duration and post-operative analgesia in various regional blocks. Aims and Objectives: The aims and objectives are to study the onset and duration of sensory and motor blockade, postoperative analgesia, and hemodynamic effects of addition of dexmedetomidine with ropivacaine in supraclavicular brachial plexus block. Materials and Methods: Sixty patients aged between 18 and 60 years, American Society of Anesthesiologists class I and II, of both sexes, scheduled for upper limb surgery under supraclavicular brachial plexus block were randomly allocated into 2 groups. Group-A received 20 mL of 0.5% ropivacaine in brachial plexus block with 1 μg/kg dexmedetomidine as adjuvant perineurally and Group-B received 20 mL 0.5% ropivacaine in brachial plexus block with dexmedetomidine intravenous infusion at 1 μg/kg over 10 min. Intraoperatively non-invasive blood pressure, heart rate, SpO2, and sedation were recorded every 5 min for the first 10 min and every 15 min thereafter till the end. Time of first rescue analgesic, intensity of postoperative pain, and total analgesic required were recorded. Results: Onset of sensory and motor block was faster in Group-A than Group-B. Duration of analgesia was prolonged in Group-A than Group-B. Hemodynamic stability was better maintained in Group-A than Group-B. Sedation was better in Group B. Conclusion: Dexmedetomidine as adjuvant to ropivacaine in supraclavicular brachial plexus block is more efficacious in providing faster onset of motor and sensory blocks and prolonging duration of postoperative analgesia with better hemodynamic stability.

Sugammadex vs Neostigmine, a Comparison in Reversing Neuromuscular Blockade: A Narrative Review.

The use of neuromuscular blocking agents (NMBA) has grown due to the development of laparoscopic and minimally invasive procedures. Respiratory insufficiency, an elevated risk of aspiration, postoperative pulmonary complications, and subsequent reintubation are among the risks linked to the residual block. The normal clinical practice calls for the pharmacologic "reversal" of these agents with either sugammadex or neostigmine prior to extubation. The administration of neostigmine is linked to a number of potential complications. In response, anaesthesiologists have begun to prescribe sugammadex more frequently for treating residual block and reversing blockade with NMBA. This review article compares and assesses neostigmine and sugammadex thoroughly in order to determine the extent to which they work as agents to reverse neuromuscular blockade. The review's findings highlight sugammadex's considerable advantages - Sugammadex's ability to quickly and reliably achieve desired train-of-four (TOF) ratios - over neostigmine in reversing neuromuscular blockade in a variety of surgical settings. In contrast, neostigmine's limitations regarding efficacy and rate of reversal were consistently noted in all of the reviewed studies, despite the fact that it is still widely used due to its lower cost and extensive clinical experience. Sugammadex is a superior option for reversing neuromuscular blockade, but incorporating it into standard clinical practice necessitates carefully weighing its potential benefits and drawbacks. Sugammadex provides notable benefits over neostigmine in terms of speed, predictability, and safety.

Efficacy and Safety of Adding Ketamine to Lidocaine in Intravenous Regional Anesthesia: A Meta-analysis of Randomized Controlled Trials

PurposeTo systematically evaluate the efficacy and safety of adding ketamine (K) to lidocaine (L) for intravenous regional anesthesia (IVRA). DesignA systematic review and meta-analysis. MethodsA comprehensive search of the Cochrane library, Embase, PubMed, Web of Science, and ProQuest databases, and the Google Scholar search engine was conducted from inception to March 2023. All retrieved articles were imported into Endnote X20 software and independently screened by two researchers according to predetermined inclusion and exclusion criteria. The data were analyzed using Revman 5.4 software and the assessed outcomes included the time of sensory and motor block onset, time of sensory and motor block recovery, fentanyl consumption, time of tourniquet pain onset, intraoperative and postoperative visual analog scale scores, and complications. FindingsA total of 532 patients from 11 randomized controlled trials were included in the meta-analysis. The results showed that the time of sensory (P < .00001) and motor block onset (P < .00001) were shorter in the L + K group than in the L-only group. The time of sensory (P = .01) and motor block recovery (P = .006) and time of tourniquet pain onset (P < .00001) were longer in the L + K group than in the L-only group. There was a significant reduction in fentanyl consumption (P = .0002) in the L + K group compared to the L-only group. Moreover, the visual analog scale scores in the L + K group were significantly lower than the L-only group 10 minutes (P = .04), 20 minutes (P = .0004), 30 minutes (P < .00001), and 40 minutes (P < .0001) after tourniquet inflation, and 5 minutes (P < .00001), 15 minutes (P = .04), 30 minutes (P = .008), 1 hour (P = .002), 2 hours (P < .00001), and 4 hours (P < .00001) after tourniquet deflation. There was no evidence that the use of K as an adjuvant in IVRA increased adverse effects. ConclusionsThe addition of K to L in IVRA shortened the onset time, prolonged the block time, and reduced intraoperative and postoperative pain without increasing complications.

Impact of Epidural Catheter-Incision Congruency on Postoperative Analgesia after Major Abdominal Surgery: An Observational Study in a Teaching Hospital.

To determine the frequency of appropriate epidural catheter-incision congruency in adult patients undergoing major abdominal surgeries, as well as the frequency of ineffective postoperative analgesia with continuous epidural infusion, side effects, and complications of epidural insertion and epidural catheter infusion. Observational study. Place and Duration of the Study: Department of Anaesthesiology, The Aga Khan University Hospital, Karachi, Pakistan, from September to November 2022. All adult patients who underwent elective major abdominal surgery under general anaesthesia with epidural analgesia were included in this study. Data were collected by chart review of the patients enrolled in Acute Pain Service for the study period. Intraoperative anaesthesia form, epidural infusion form and all records of acute pain service for the postoperative period were reviewed and recorded. One hundred and eighty-two patients were included in this study. The epidural catheter was inserted congruent to the surgical incision i.e. T10-T11 level or above in 43 (23.6%) patients only. In the postoperative period, overall effective epidural analgesia was observed in 79 (43.4%) of the patients. Motor block in lower limbs was observed in 66 (36.26%) of patients in the immediate postoperative period. The present study shows appropriate epidural catheter-incision congruency in only 23.6% of the patients. This could be one of the common reasons for ineffective postoperative pain relief via epidural analgesia in 56.6% of patients. Epidural catheter insertion site, Major abdominal surgeries, Postoperative analgesia.