Onset Time Of Sensory Blockade Research Articles

Evaluating the impact of ultrasound-guided subsheath versus extrasheath sciatic nerve block on postoperative wound pain in tibial and foot surgeries: A systematic review and meta-analysis.

This systematic review and meta-analysis evaluate the impact of ultrasound-guided subsheath versus extrasheath sciatic nerve blocks on postoperative wound pain in tibial and foot surgeries, crucial for effective pain management and patient recovery. Adhering to PRISMA guidelines, this study used a PICO framework, focusing on patients undergoing tibial and foot surgeries and comparing the efficacy and safety of subsheath and extrasheath sciatic nerve blocks. The literature search spanned four databases without time restrictions, assessing various outcomes like success rate, onset time, duration of analgesia and complication rates. Quality assessment employed the Cochrane Collaboration's risk of bias tool, and statistical analyses included heterogeneity assessment, fixed-effect and random-effects models, sensitivity analysis and publication bias evaluation using funnel plots and Egger's linear regression test. From an initial pool of 1213 articles, six met the inclusion criteria. The subsheath group showed a significantly higher success rate of complete sensory blockade within 30 min compared with the extrasheath group (OR = 5.39; 95% CI: 2.82-10.28; p < 0.01). No significant differences were found in procedure duration or incidence of nerve-related complications between the two techniques. The subsheath approach also demonstrated a quicker onset time of sensory blockade (MD = -8.57; 95% CI: -11.27 to -5.88; p < 0.01). Sensitivity analysis confirmed the stability of the results, and no significant publication bias was detected. Ultrasound-guided subsheath sciatic nerve blocks are more effective than extrasheath blocks in achieving rapid and complete sensory blockade for tibial and foot surgeries, with a quicker onset time and comparable safety profile. Subsheath injections are thus recommended as a preferred method for anaesthesia and postoperative pain management in these surgical procedures, enhancing overall patient outcomes.

Ntrathecal Hyperbaric Bupivacaine 0.5% with Varying Dose of Buprenorphine in Elective Adult Lower Limb Orthopaedic Surgeries: A Randomised Control Study

Introduction: Postoperative pain is a universal phenomenon and usually under treated and its intensity varies widely among patients. Spinal anaesthesia with opioid and local anaesthetics to prolong postoperative analgesia is common practice in recent years. Buprenorphine is an agonist - antagonist opioid. Intrathecal buprenorphine (30-150 µg) along with local anaesthetics is safe and known to increase the postoperative analgesia without affecting sensory or motor blockade and with lesser side effects. Aim: To compare the anaesthetic characteristics and its side effects in subarachnoid block with bupivacaine 0.5% heavy and varying dose of buprenorphine (90 µg and 120 µg). Materials and Methods: This randomised control study was conducted in the Jhalawar Medical College, Jhalawar, Rajasthan, India, from March 2019 to November 2019. The study included 90 patients belonging to American Society of Anaesthesiologists (ASA) class I and II of either sex age between 18 to 60 years posted for elective lower limb orthopaedic surgeries.The patients were divided into three groups; group A which included a patient count of 30 received plain hyperbaric bupivacaine 0.5% (2.5mL) with 0.5 mL saline. Group B which included 30 patients, receive plain hyperbaric bupivacaine 0.5% (2.5 mL) along with buprenorphine 90 µg diluted in 0.5 mL saline. Group C with a patient count of 30 received hyperbaric bupivacaine 0.5% (2.5 mL) with buprenorphine 120 µg mixed with 0.5 mL saline. Analgesic characteristics, haemodynamic parameters, side effects, sedation scores by Ramsay sedation score and pain scores by Visual Analogue Score (VAS) (0-10) were measured postoperatively till 24 hours.Statistical analyses of data were done by one Way Analysis of Variance (ANOVA) test and chisquare test where p-value less than 0.05 was considered to be a statistically significant value. Results: The onset time of sensory blockade (group A: 5.14±1.34, group B: 4.54±1.10, group C: 4.50±1.18 in minutes), time of onset of motor blockade (group A: 10.10±1.00, group B: 9.43±1.30, group C: 9.21±1.49 in minutes) and maximum level of sensory block at T6 level (group A: n-01/30, group B: n-04/30, group C: n-04/30) were comparable between the three groups and were not statistically significant. Sensory recovery time was significantly (p&lt;0.0001) delayed in group B and C (178.9±7.18 min and 189.23±7.4), while in group A it was 152.86±8.9 min. Duration of postoperative analgesia was significantly (p&lt;0.0001) prolonged in group C (group A 165.53±8.5, group B 391.49±19.8, group C 493.23±18 in minutes). Side-effects like Postoperative Nausea and Vomiting (PONV) and sedation were increased with dose of buprenorphine but easily treatable and not significant (p&gt;0.05). Conclusion: A higher dose of buprenorphine shows to provide an adequate and longer postoperative analgesia without any major side effects.

A Comparative Study of Alkalined and Plain Local Anesthetic on Onset, Duration and Quality of Bracheal Plexus Block by Supraclavicular Approach.

Introduction: Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in term of such damage. The relief from pain is the essence of anesthesia. Peripheral nerve blocks provide longer and more localized pain relief than neuraxial techniques while also avoiding the side effects of systemic medication. This study was aimed to find the effectiveness of Study solution (addition of Sodium bicarbonate to 0.375% Bupivacaine) on onset time, duration and quality of Brachial Plexus Block. Material and methods: This study was conducted among 60 different patients undergoing surgical procedure of the upper limb. They were categorized into two different groups. The first group (Group 1), 30 patients received Brachial Plexus block with 30 ml of study solution (0.375% Bupivacaine with 2 ml of Sodium bicarbonate7.4%). The second group (Group 2) received 30 ml of 0.375 % plain bupivacaine only and the differences in onset, duration and quality of blockade were studied. Result: The similarity of age between the two groups can be seen. In Group 1 the mean onset time of sensory blockade was 9.43 minutes and motor blockade was 10.43 minutes when compared to Group 2 having sensory onset of minutes 23.93 and motor onset of 26.33 minutes. Similarly, In Group I the mean duration of sensory blockade was 477.67 minutes and motor blockade were 467.67 minutes when compared to Group 2 having sensory duration of 215.67 and motor duration of 205.67 minutes. The quality of sensory blockade was also better in group1 (P-Value:0.006). Conclusion: Addition of Sodium bicarbonate to bupivacaine had significant clinical advantage over plain bupivacaine on onset time, duration and quality of sensory and motor blockade in brachial plexus block.

Ultrasonography guided supraclavicular brachial plexus block: comparison of sensori-motor blockade and duration of postoperative analgesia between ropivacaine and levo-bupivaine

The study was conducted to compare the onset time, duration and quality of analgesia between 0.5% levo-bupivacaine and 0.5% ropivacaine given in brachial plexus. This prospective, triple blind randomized controlled trial was conducted between January 2020 to December 2021. Seventy patients were randomly allocated into two groups of 35 patients each to receive USG guided brachial plexus block with 30 ml of 0.5% levo-bupivacaine or 30 ml of 0.5%ropivacaine. Blinded observer recorded the onset time and duration of brachial plexus block. Patient characteristics regarding age, weight, and surgical time were comparable in the two groups. The mean onset time of sensory blockade with 0.5% ropivacaine and 0.5%levo-bupivacaine was clinically comparable in our present study. The mean duration of sensory block with 0.5% ropivacaine and 0.5% levo-bupivacaine was also comparable in study. The mean onset time for motor block with 0.5%levo-bupivacaine was lesser than 0.5% ropivacaine. The mean duration of motor block observed in present study with 0.5% ropivacaine was lesser than 0.5% levo-bupivacaine. Mean duration of post operative analgesia of 485.0 ± 76.90 mins (8.08 hrs) was noted with 0.5%ropivacaine and 491.91 ± 92.99 mins (8.2 hrs) with 0.5%levo-bupivacaine which was clinically comparable and the difference was statistically insignificant.

ADDITION OF DEXMEDETOMIDINETO LIGNOCAINE FOR INTRAVENOUS REGIONAL ANESTHESIA IN UPPER EXTREMITY ORTHOPAEDIC SURGERIES

Objective: The objective of this study was to determine the duration of onset and regression time of sensory and motor blocks, the quality of anesthesia, and post-operative analgesia by the addition of dexmedetomidine to local anesthetic solution in intravenous regional anesthesia (IVRA) in upper extremity orthopedic surgeries. Methods: This is a prospective, randomized, and double blind clinical trial. Ninety American Society of Anaesthesiologists Grade I and II patients of either gender between 18 and 60 years of age scheduled for elective upper extremity orthopedic surgeries lasting for &lt;90 min were included in the study. Patients were randomly allocated to two Groups A and B of 45 each. Group A received 3 mg/kg preservative free lignocaine alone and Group B received 3 mg/kg preservative free lignocaine with dexmedetomidine, 0.5 μg/kg in IVRA. Result: Onset time of sensory blockade in Group A and B was 5.6±0.93 min and 3.9±0.63 min, respectively. Onset time of motor blockade in Group A and Group B was 15.01±4.53 min and 10.74±3.64 min, respectively. The difference in onset time of sensory and motor blockade between the two groups was statistically significant (p&lt;0.05). Sensory blockade recovery time after release of tourniquet was 6.9±0.53 min in Group A and 29.21±5.23 min in Group B. Motor blockade recovery time was 4.35±0.76 min for Group A and 12.32±7.23 min for Group B. The difference in sensory and motor blockade recovery time between the two groups was statistically significant (p&lt;0.05). Conclusion: Dexmedetomidine on addition to lignocaine for IVRA provided rapid onset of sensory and motor blockade, prolonged duration of sensory and motor blockade, and reduced tourniquet pain.

Single dose perioperative intrathecal ketamine as an adjuvant to intrathecal bupivacaine: A systematic review and meta-analysis of adult human randomized controlled trials

Study objectiveTo identify whether adding intrathecal ketamine to intrathecal bupivacaine prolongs the time to first analgesic request in adult humans. DesignA meta-analysis of randomized controlled trials in humans. SettingThe majority of data was obtained in an operating room and postoperative recovery area. PatientsA total of 750 ASA physical status I and II patients were included in the study. Procedures performed include: cesarean section, lower abdominal surgery, lower limb surgery, and urologic surgery. InterventionsDatabases including PubMed, Embase, Web of Science, and Cochrane were searched. Google Scholar was also queried. Multiple reviewers screened the papers for inclusion. MeasurementsThe primary outcome assessed was time to first analgesic request. Secondary outcomes included onset of sensory blockade, onset of motor blockade, duration of sensory blockade, and duration of motor blockade. Data were extracted to include means, 95% confidence intervals, tests for heterogeneity, and use of the Cochrane Collaboration guidelines to assess for publication bias. Main resultsEleven randomized controlled trials met inclusion criteria. When comparing intrathecal bupivacaine plus ketamine to intrathecal bupivacaine alone, the time to first analgesic request was prolonged (effect size = 58.23 min (95% CI 37.36 to 79.10) p < 0.0001). Secondary outcomes showed the onset time of sensory blockade was shortened (effect size = −0.87 min (95% CI -1.361 to 0.378) p = 0.0005), the onset time of motor blockade was reduced (effect size = −0.88 min (95% CI -1.77 to 0.013) p = 0.05), the duration of sensory blockade was prolonged (effect size = 39.73 min (95% CI 15.97 to 63.50) p = 0.001), and the duration of motor blockade was prolonged (effect size = 4.02 min (95% CI 3.27 to 4.78) p < 0.0001). Studies were shown to have high heterogeneity. Egger tests for all outcomes were non-significant and funnel plots assessing publication bias were all asymmetrical. ConclusionsThe studies analyzed suggest there may be a benefit to using intrathecal ketamine as an adjunct to bupivacaine. Additional studies are warranted to optimize dosing, clarify the safety and efficacy of this intrathecal drug combination, and examine the various ketamine formulations as intrathecal bupivacaine adjuvants.

COMPARISON OF TRAMADOLAS AN ADJUVANT TO INTRATHECAL ISOBARIC LEVOBUPIVACAINE FOR ELECTIVE LOWER LIMB SURGERIES UNDER SPINAL ANESTHESIA

Background: Long acting local anesthetics are used in subarachnoid block to increase the duration of anesthesia. Adjuvants are added to improve the duration of analgesia. The objective of this study was to evaluate the efcacy of tramadol as an intrathecal adjuvant to levobupivacaine in terms of duration of analgesia, onset of sensory blockade, onset of motor blockade, and duration of motor blockade. Methodology: After obtaining the Institutional Ethical Committee approval and informed consent, sixty patients posted for infraumbilical surgeries were recruited. Randomization was done using a sealed envelope technique. Patients were divided into two groups: LTreceived 2.5 ml of 0.5% isobaric levobupivacaine with tramadol 25 mg (0.5 ml) and LS received 2.5 ml of 0.5% isobaric levobupivacaine with 0.5 ml of normal saline. Duration of analgesia, onset of sensory blockade, and onset and duration of motor blockade were recorded. Results: There was no statistical difference in demographic data between the two groups. The mean onset time of sensory blockade in Group LS was 7.17±3.07 min and for Group LT was 8.53 ± 2.47 min, which was not statistically signicant between two groups (P = 0.064). The mean onset time of motor blockade in Group LS was 9.76 ± 3.18 min and for Group LT was 11.23 ± 2.47 min, which was statistically signicant between the two groups (P = 0.050). The mean time duration of analgesia in Group LS was 265.60± 39.18 min and for LT was 304.30 ± 24.88 min. There was mild prolongation of analgesia in Group LT, but it was statistically signicant (P &lt;0.001). The mean duration of motor blockade in Group LS was 197.93 ± 4.41 min and Group LT was 236.20 ± 33.89 min, which was statistically signicant between the two groups (P &lt;0.001). Conclusion: Tramadol as an adjuvant to isobaric intrathecal levobupivacaine does prolong analgesia signicantly.

English

BACKGROUND Shivering is commonly encountered complication following spinal anaesthesia leading to discomfort and interference with monitoring during caesarean section. There is no definite aetiology for this and hence no definite treatment is available. Hence, we wanted to study effect of temperature variation of spinal inject on post spinal shivering during caesarean section. METHODS This prospective randomized double-blind study was conducted on 80 parturients posted for elective caesarean section allocated to two groups of 40 each receiving 2.0 mL of 0.5 % hyperbaric bupivacaine with temperature of 220 C (group I) or 370 C (group II) intrathecally at L3 - L4 interspace. Onset of shivering, its severity and incidence were noted. Data was analysed using various tests and P-value &lt; 0.05 was considered as significant and P-value &lt; 0.01 was considered highly significant. RESULTS Demographic characters, surgical parameters as well as onset time of sensory blockade, maximum sensory blockade, time to achieve maximum sensory and motor blockade were comparable in the two groups. Shivering was present in 57.5 % of patients in group I and 32.5 % in group II and this difference was statistically significant. Overall, shivering percentage was 45 % although difference in mean onset time was not significant in the two groups. Grades of shivering were comparable in both groups. CONCLUSIONS Warm solutions used intrathecally can reduce incidence of shivering following spinal anaesthesia in caesarean section although it doesn’t influence intensity of shivering. KEY WORDS Neuraxial Anaesthesia, Temperature Variation, Post Spinal Shivering

Comparison Study of Lignocaine-Bupivacaine with Normal Saline and Lignocaine-Bupivacaine Along with Fentanyl in Supraclavicular Brachial Plexus Block in Mid Arm Surgeries

Background and Objective: brachial plexus block by supraclavicular approach achieve good motor, sensory&#x0D; &amp; sympathetic blocked in mid arm surgeries. Several adjuvants have been added to enhance effect of local&#x0D; anaesthetic agent in peripheral nerve block. We performed a prospective randomized study to compare&#x0D; lignocaine-bupivacaine with normal saline and lignocaine-bupivacaine along with fentanyl for onset, quality&#x0D; &amp; duration of block as well as post-operative analgesia.&#x0D; Method: Randomized controlled study was carried act among 50 patients of either sex aged 20-50 asa grade&#x0D; 1 &amp; 2 undergoing mid arm surgeries. patient was randomly divided in two groups. Group 1: 20ml of 0.5%&#x0D; bupivacaine + 10ml of 2% lignocaine + 1 ml of normal saline Group 2: 20ml of 0.5% bupivacaine + 10ml&#x0D; of 2% lignocaine + 1 ml of fentanyl (50 mcg)&#x0D; Time taken for onset of sensory &amp; motor as well as complete duration of block were noted in both groups.&#x0D; Any complication during procedure during surgery as well as post operatively were noted &amp; treated.&#x0D; Result: Addition of fentanyl (50 mcg) to bupivacaine + lignocaine in peripheral nerve block cause early&#x0D; onset for sensory block.&#x0D; Mean duration of sensory blockade 440+/-62 in group 1 while 635+/-84 in group 2. mean duration of&#x0D; analgesia 400+/-68 in group1 while 685+/-90 in group 2&#x0D; It suggests that duration of sensory block and analgesia was prolonged in group 2&#x0D; Conclusion: The addition of small-dose fentanyl to lignocaine solution in brachial plexus block can increase&#x0D; the success rate and prolong the duration of analgesia, [16]with early onset time of sensory blockade as&#x0D; compared with that achieved by the same doses of local anaesthetics used in combination.

Ketorolac versus Magnesium Sulphate as an Adjuvant to Lidocaine in Intravenous Regional Anesthesia for Upper Limb Surgeries

Background: intravenous regional anesthesia (IVRA) was first described almost a century ago by August Bier and has been used for the past 50 years. It is a safe anesthetic technique for upper or lower distal limb surgery. Purpose: to compare the onset time of sensory blockade when adding ketorolac versus adding magnesium to the IVRA solution, and to compare the duration of postoperative analgesia. Material and Methods: this is a randomized controlled trial in two groups. The study was performed in Ain Shams University Hospitals. Study period range was 1-2 years. Results: there are 146 patients participated in our study, patients were allocated to two groups 73 patients in each group, a group of which received magnesium sulphate solution and the other received ketorolac solution. Conclusion: we evaluated the effects of adding ketorolac and compared it to the effects of adding magnesium sulphate to the anesthetic solution used in IVRA and we found that magnesium sulphate addition can be of benefit in faster onset of sensory block in the operative limb. However, magnesium sulphate in the used concentration (10 ml MgSo4 10% in 40 ml solution) appeared to cause burning pain varying in intensity while injecting the anesthetic solution.

Postoperative Analgesic Efficacy of Intrathecal Fentanyl Compared to Nalbuphine with Bupivacaine in Spinal Anesthesia for Lower Abdominal Surgeries.

Context:Subarachnoid block or spinal anesthesia is a commonly used technique for lower abdominal and lower limb surgeries. Bupivacaine is the commonly used cost-effective drug which gives satisfactory analgesia for 90–120 min. Additives such as opioids and α2 agonists extend the analgesia in the postoperative period. In this study, we compared the effects of nalbuphine with fentanyl.Aims:The aim of this study is to compare the effects of intrathecal nalbuphine and fentanyl as adjuvants to hyperbaric bupivacaine in regard to time of onset of sensory blockade, duration of sensory blockade, two-segment sensory regression time, duration of effective postoperative analgesia, and incidence of side effects.Settings and Design:This was a prospective, randomized double-blind study.Subjects and Methods:After ethical committee permission and patient consent, 124 patients aged 18–55 years with American Society of Anesthesiologists physical status I and II were randomly divided into two groups – Group N: hyperbaric bupivacaine with nalbuphine (300 μg); Group C: hyperbaric bupivacaine with fentanyl (25 μg).Results:Duration of onset of sensory blockade was 3.9 ± 0.35 min in Group C and 3.1 ± 0.18 min in Group F. Two-segment sensory regression time was prolonged in Group C (193.16 ± 39.55) compared to Group F (167.41 ± 30.17 min).Conclusions:Intrathecal nalbuphine at a dose of 300 μg in 3 ml 0.5% heavy bupivacaine in patients undergoing elective lower abdominal surgeries showed delay in onset time for sensory blockade and produced prolonged postoperative analgesia, prolonged sensory blockade, and minimal bradycardia which could be easily managed.

Evaluating the Efficacy of Tramadol as an Adjuvant to Intrathecal Isobaric Levobupivacaine for Elective Infraumbilical Surgeries.

Background:Long-acting local anesthetics are used in subarachnoid block to increase the duration of anesthesia. Adjuvants are added to improve the duration of analgesia.Settings:Randomized controlled trial was conducted in the Department of Anesthesiology in a tertiary care hospital.Aims and Objectives:The objective of this study was to evaluate the efficacy of low-dose tramadol as an intrathecal adjuvant to levobupivacaine in terms of duration of analgesia, onset of sensory blockade, onset of motor blockade, and duration of motor blockade.Methodology:After obtaining the Institutional Ethics Committee approval and informed consent, sixty patients posted for infraumbilical surgeries were recruited. Randomization was done using a sealed envelope technique. Patients were divided into two groups: LT received 3 ml of 0.5% isobaric levobupivacaine with tramadol 10 mg (0.2 ml) and LS received 3 ml of 0.5% isobaric levobupivacaine with 0.2 ml of normal saline. Duration of analgesia, onset of sensory blockade, and onset and duration of motor blockade were recorded.Results:There was no statistical difference in demographic data between the two groups. The mean onset time of sensory blockade in Group LS was 12.7 ± 9.81 min and for Group LT was 12.9 ± 0.81 min, which was not statistically significant between two groups (P = 0.93). The mean onset time of motor blockade in Group LS was 13.4 ± 10 min and for Group LT was 14.4 ± 10 min, which was no statistically significant between the two groups (P = 0.71). The mean time duration of analgesia in Group LS was 170.3 ± 59 min and for LT was 198.9 ± 57.33 min. There was mild prolongation of analgesia in Group LT, but it was not statistically significant (P = 0.0615). The mean duration of motor blockade in Group LS was 170.23 ± 58 min and Group LT was 190.76 ± 4 min, which was not statistically significant between the two groups (P = 0.14).Conclusion:Low-dose tramadol as an adjuvant to isobaric intrathecal levobupivacaine does not prolong analgesia significantly.

A Comparitive Study of Bupivacaine 0.5% versus Ropivacaine 0.5% for Supraclavicular Brachial Plexus Block in Adult Patients

Introduction: Peripheral nerve blocks have become important in clinical practice because of their role in post-operative pain relief, shortening of patient recovery time & avoiding risks and adverse effects of general anaesthesia. Bupivacaine is a long acting local anaesthetic. Due to its long duration of action and combined with its high quality sensory blockade compared to motor blockade it has been the most commonly used local anaesthetic for peripheral nerve blocks. Ropivacaine is a newer, long acting local anaesthetic whose neuronal blocking potential used in peripheral nerve blockade seems to be equal or superior to bupivacaine. Studies show that it has significantly greater safety margin over bupivacaine. Hence here is an attempt through the study to compare bupivacaine with ropivacaine in supraclavicular brachial plexus block in adult patients. Aims and Objectives: To compare the effect of bupivacaine 0.5% & ropivacaine 0.5% used for supraclavicular approach to brachial plexus block with respect to onset time of sensory blockade, onset time of motor blockade, duration of sensory blockade, duration of motor blockade, duration of analgesia, side effects/ complications. Method of Collection of Data: Sixty patients aged between 18 years and 60 years, of physical status ASA grade 1 and ASA grade 2 undergoing elective upper limb surgeries lasting more than 30 minutes were included in the study after getting ethical clearance. Each patient was randomly allocated to one of the two groups of 30 patients each. The patients were explained about the procedure and premedicated with tab alprazolam 0.5mg, and tab ranitidine 150 mg. The anesthetic technique employed was supraclavicular brachial plexus block using 30 ml of either 0.5% bupivacaine or 0.5% ropivacaine

Sacral spinal anaesthesia

Sacral spinal anaesthesia

Infraclavicular brachial plexus block for regional anaesthesia of the lower arm

Several approaches exist to produce local anaesthetic blockade of the brachial plexus. It is not clear which is the technique of choice for providing surgical anaesthesia of the lower arm, although infraclavicular blockade (ICB) has several purported advantages. We therefore performed a systematic review of ICB compared to the other brachial plexus blocks (BPBs). This review was originally published in 2010 and was updated in 2013. The objective of this review was to evaluate the efficacy and safety of infraclavicular block (ICB) compared to other approaches to the brachial plexus in providing regional anaesthesia for surgery on the lower arm. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2013, Issue 5); MEDLINE (1966 to June 2013) via OvidSP; and EMBASE (1980 to June 2013) via OvidSP. We also searched conference proceedings (from 2004 to 2012) and the www.clinicaltrials.gov trials registry. The searches for the original review were performed in September 2008. We included any randomized controlled trials (RCTs) that compared ICB with other BPBs as the sole anaesthetic technique for surgery on the lower arm. The primary outcome was adequate surgical anaesthesia within 30 minutes of block completion. Secondary outcomes included sensory block of individual nerves, tourniquet pain, onset time of sensory blockade, block performance time, block-associated pain and complications related to the block. In our original review we included 15 studies with 1020 participants and excluded two. In this updated review we included seven new studies and excluded six, bringing the total number of included studies to 22 and involving 1732 participants. The control group intervention was the axillary block in 14 studies, supraclavicular block in six studies, mid-humeral block in two studies, and parascalene block in one study. One study compared ICB to both axillary and supraclavicular blocks. Nine studies employed ultrasound-guided ICB. The risk of failed surgical anaesthesia 30 minutes after block completion was similar for ICB and all other BPBs (11.4% versus 12.9%, risk ratio (RR) 0.88, 95% CI 0.51 to 1.52, P = 0.64), but tourniquet pain was less likely with ICB (11.9% versus 18.0%; RR of experiencing tourniquet pain 0.66, 95% CI 0.47 to 0.92, P = 0.02). Subgroup analysis by method of nerve localization, and by control group intervention, did not show any statistically significant differences in the risk of failed surgical anaesthesia. However when compared to a single-injection axillary block, ICB was better at providing complete sensory block of the musculocutaneous nerve (RR for failure 0.46, 95% CI 0.27 to 0.60, P < 0.0001). ICB had a slightly longer sensory block onset time (mean difference (MD) 1.9 min, 95% CI 0.2 to 3.6, P = 0.03) but was faster to perform than multiple-injection axillary (MD -2.7 min, 95% CI -3.4 to -2.0, P < 0.00001) or mid-humeral (MD -4.8 min, 95% CI -6.0 to -3.6, P < 0.00001) blocks. ICB is as safe and effective as any other BPBs, regardless of whether ultrasound or neurostimulation guidance is used. The advantages of ICB include a lower likelihood of tourniquet pain during surgery, more reliable blockade of the musculocutaneous nerve when compared to a single-injection axillary block, and a significantly shorter block performance time compared to multi-injection axillary and mid-humeral blocks.

The Effects of Low Dose Levobupivacaine with or without Sufentanil Intrathecally in Transurethral Resection of Prostate

Aim: We aimed to compare the clinical efficacy of levobupivacaine alone and levobupivacaine/sufentanil combination in spinal anesthesia for transurethral resection of the prostate (TURP) in elderly patients. Method: Ninety patients were randomly assigned into two groups to receive either levobupivacaine 10 mg (Group L) or levobupivacaine 7.5 mg combined with 2.5 μg sufentanil (Group LS) for spinal anesthesia. The dermatome level and upper level of sensory blockade, time to develop a sensory block to T10, duration of sensory and motor blockade, Bromage score at the end of surgery, two- segment sensory regression time, and side effects were recorded. The quality of anesthesia was evaluated and rated after the surgery. Result: There were no significant differences between groups in demographic data or hemodynamic variables in terms of sensory blockade, onset time of sensory blockade to T10 dermatome, and two-segment regression. Bromage score at the end of surgery was significantly higher in Group L (p<0.05). The number of patients with maximum motor block was significantly higher in Group L (p<0.05). Complete motor block resolution time was longer in Group L (p<0.05). There were no significant differences in side effects between groups except for pruritus (p<0.05). There were no significant differences between groups in quality of anesthesia. Conclusion: It was shown that 10 mg levobupivacaine and 7.5 mg levobupivacaine combined with 2.5 μg sufentanil were considered to be convenient for clinical use in TURP surgery with spinal anesthesia; both treatments provided adequate anesthesia with hemodynamic stability in elderly patients.

Infraclavicular Brachial Plexus Block for Regional Anaesthesia of the Lower Arm

Several approaches exist to produce local anaesthetic blockade of the brachial plexus. It is not clear which is the technique of choice for providing surgical anaesthesia of the lower arm although infraclavicular blockade (ICB) has several purported advantages. We therefore performed a systematic review of ICB compared to the other brachial plexus blocks (BPBs). To evaluate the efficacy and safety of ICB compared to other BPBs in providing regional anaesthesia of the lower arm. We searched CENTRAL (The Cochrane Library 2008, Issue 3), MEDLINE (1950 to September 22nd 2008) and EMBASE (1980 to September 22nd 2008). We also searched conference proceedings (from 2004 to 2008) and the www.clinicaltrials.gov registry. No language restriction was applied. We included any randomized controlled trials (RCTs) that compared ICB with other BPBs as the sole anaesthetic techniques for surgery on the lower arm. The primary outcome was adequate surgical anaesthesia within 30 minutes of block completion. Secondary outcomes included sensory block of individual nerves, tourniquet pain, onset time of sensory blockade, block performance time, block-associated pain and complications related to the block. We identified 15 studies with 1020 participants, of whom 510 received ICB and 510 received other BPBs. The control group intervention was the axillary block in 10 studies, mid-humeral block in two studies, supraclavicular block in two studies and parascalene block in one study. Three studies employed ultrasound-guided ICB. The risk of failed surgical anaesthesia and of complications were low and similar for ICB and all other BPBs. Tourniquet pain was less likely with ICB (risk ratio (RR) 0.47, 95% CI 0.24 to 0.92, P = 0.03). When compared to a single-injection axillary block, ICB was better at providing complete sensory block of the musculocutaneous nerve (RR for failure 0.46, 95% CI 0.27 to 0.60, P < 0.0001) and the axillary nerve (RR of failure 0.37, 95% CI 0.24 to 0.58, P < 0.0001). ICB was faster to perform than multiple-injection axillary (mean difference (MD) -2.7 min, 95% CI -4.2 to -1.1, P = 0.0006) or midhumeral blocks (MD -4.8 min, 95% CI -6.0 to -3.6, P < 0.00001) but this was offset by a longer sensory block onset time (MD 3.9 min, 95% CI 3.2 to 4.5, P < 0.00001). ICB is a safe and simple technique for providing surgical anaesthesia of the lower arm, with an efficacy comparable to other BPBs. The advantages of ICB include a lower likelihood of tourniquet pain during surgery, and more reliable blockade of the musculocutaneous and axillary nerves when compared to a single-injection axillary block. The efficacy of ICB is likely to be improved if adequate time is allowed for block onset (at least 30 minutes) and if a volume of at least 40 ml is injected. Since publication of many of the trials included in this review, it has become clear that a distal posterior cord motor response is the appropriate endpoint for electrostimulation-guided ICB; we recommend it be used in all future comparative studies. There is also a need for additional RCTs comparing ultrasound-guided ICB with other BPBs.

The Addition of Fentanyl to Local Anesthetics Affects the Quality and Duration of Cervical Plexus Block

Cervical plexus block is frequently associated with unsatisfactory sensory blockade. In this randomized, double-blind, placebo-controlled trial, we examined whether the addition of fentanyl to local anesthetics improves the quality of cervical plexus block in patients undergoing carotid endarterectomy (CEA). Seventy-seven consecutive adult patients scheduled for elective CEA were randomized to receive either fentanyl 1 mL (50 microg) or saline placebo 1 mL in a mixture of 10 mL bupivacaine 0.5% and 4 mL lidocaine 2% for deep cervical plexus block. Superficial cervical plexus block was performed using a mixture of 10 mL bupivacaine 0.5% and 5 mL lidocaine 2%. Pain was assessed using the verbal rating scale (0-10; 0 = no pain, 10 = worst pain imaginable), and propofol in 20-mg IV bolus doses was given to patients reporting verbal rating scale >3 during the procedure. Rescue medication consumption during surgery and analgesia requirements over the next 24 hours, as well as onset of sensory blockade, were recorded. A P value <0.05 was regarded as statistically significant. Fewer patients in the fentanyl group (4 of 38, 10.5%) required propofol compared with the placebo group (26 of 39, 66.7%; P < 0.001). In comparison with the placebo group, the fentanyl group consumed less propofol (median 0 [0-60] vs 60 [0-160] mg, respectively; P < 0.001), required postoperative analgesia less frequently (22 of 38 patients, 57.9% vs 35 of 39 patients, 89.7%, respectively; P = 0.002), and requested the first analgesic after surgery later (median 5.8 [1.9-15.6] vs 3.1 [1.0-11.7] hours, respectively; P < 0.001), whereas the onset time of sensory blockade was similar in both groups (median 12 [9-18] vs 15 [9-18] minutes, respectively; P = 0.18). The addition of fentanyl to local anesthetics improved the quality and prolonged the duration of cervical plexus block in patients undergoing CEA.

QX-314 Produces Long-lasting Local Anesthesia Modulated by Transient Receptor Potential Vanilloid Receptors in Mice

The quaternary lidocaine derivative QX-314 is now known to produce long-lasting local anesthesia despite its positive charge. However, recent research suggests that the transient receptor potential vanilloid receptor agonist, capsaicin, should reduce the onset and offset times, whereas the transient receptor potential vanilloid receptor antagonist, capsazepine, should delay the onset time of sensory blockade by QX-314. Sensory blockade in the tail of the conscious mouse was investigated using QX-314 2.5% in combination with capsaicin 0.1% and/or capsazepine (50 microg/ml). After tail injection, onset and offset times of local anesthesia were measured using the hot water tail-flick latency test. Capsaicin reduced the onset time of local anesthesia by QX-314 by more than 75% (Mann-Whitney test, P = 0.007; n = 10 per group) with no effect on the offset time of QX-314. For QX-314 without capsaicin, the onset and offset times were 23 min (interquartile range 15-30 min) and 300 min (interquartile range 285-375 min), respectively. For QX-314 with capsaicin, the onset and offset times were 4 min (interquartile range 3-8 min) and 360 min (interquartile range 285-435 min), respectively. In the antagonist study, capsazepine without added capsaicin decreased QX-314's efficacy, as 6 out of 9 mice did not develop sensory blockade after 90 min (Fisher exact test, P = 0.009). We have confirmed in a sensory blockade model that QX-314 is a local anesthetic with a slow onset and a long duration of reversible blockade. Capsaicin, a transient receptor potential vanilloid receptor agonist, accelerated QX-314's onset kinetics, whereas capsazepine, a transient receptor potential vanilloid receptor antagonist, decreased QX-314's efficacy. These observations raise the possibility that endovanilloids may modulate cell entry of QX-314.

Comparative Evaluation between intrathecal sufentanil with bupivacaine to fentanyl with bupivacaine and bupivacaine alone for intraoperative and postoperative analgesia in infraumblical surgeries

This study was conducted to compare sufentanil & fentanyl in combination with bupivacaine for infra-umbilical surgeries. Sixty ASA I and II patients for elective intra-umbilical surgeries under spinal anaesthesia were divided into three groups to receive 15 mg bupivacaine alone, 10 g sufentanil & 25 g fentanyl in combination with 15mg bupivacaine. Onset time of sensory blockade, Duration of side effects, surgical conditions, and quality of the anaesthesia was assessed. The duration of effective analgesia of bupivacaine alone was prolonged with the addition of sufentanil and fentanyl by 179% and 141% respectively. No patient is the sufentanil and fentanyl groups required additional intra-operative analgesics compared with 17.6% of patients in the bupivacaine alone group. There was an increase in incidence of desaturation in the sufentanil group (45%) and fentanyl group (5.6%) compared with the bupivacaine only group (0%). The incidence of pruritus was 35% with sufentanil, 27.8% with fentanyl against 0% with bupivacaine alone. The addition of 10 g of sufentanil and 25 g of fentanyl to improved intraoperative analgesia. However, the incidence of pruritus and episodes of desaturation were increased more with 10 g sufentanil than with 25 g fentanyl.