Peripheral Blocks Research Articles

Comparitive Study between Dexamethasone versus Fentanyl as Adjuvant to Local Anesthesia in Supraclavicular Nerve Block in Upper Limb Surgery

Abstract Background Peripheral nerve block as an anesthetic technique plays an important role in modern regional anesthesia. Upper limb surgeries are mostly performed under peripheral blocks such as the brachial plexus block. Peripheral nerve blocks not only provide intra-operative anesthesia, but also extend analgesia in the post-operative period without major systemic side-effects by minimizing stress response and using minimal anesthetic drugs. Objective To evaluate the effects of adding dexamethasone and fentanyl to bupivacaine in ultrasound guided supraclavicular brachial plexus block for upper limb surgery versus bupivacaine alone. Patients and Methods After obtaining approval from the medical ethical committee in Al-Matareya Teaching Hospital, this study was conducted in Al-Matareya Teaching Hospital in cooperation with Ain Shams University. It was include patients undergoing elective upper limb surgery. A written informed consent was obtained from every patient after explaining the procedure. A randomized double-blinded controlled study is thought to be the most suitable design to achieve the study objectives. Results The present study showed that addition of dexamethasone and fentanyl to bupivacaine in ultrasound-guided supraclavicular nerve block shortened the onset times of both sensory and motor blocks and significantly prolonged their duration compared to bupivacaine olny. Conclusion In the current study, the addition of dexamethasone or fentanyl to bupivacaine for supraclavicular brachial plexus block make the onset of sensory & motor block faster and prolongation of motor and sensory block duration and prolongation of duration of analgesia more than using bupivacaine only. But onset of motor and sensory block was shorter in fentanyl group than dexamethasone group and duration of sensory and motor block more in dexamethasone rather than fentanyl.

Postoperative Analgesic Efficiency of Quadratus Lumborum Block III versus Peritubal Local Infiltration in Patients Undergoing Percutaneous Nephrolithotomy Operation: A Randomized Controlled Trial

Abstract Background The postoperative pain after percutaneous nephrolithotomy (PCNL) can be managed by many peripheral blocks techniques (e.g., paravertebral and quadrates lumborum block), and local anesthesia infiltration. Therefore, this prospective study was conducted to evaluate the effect of quadratus lumborum type III versus peritubal local infiltrating on postoperative analgesia for patients undergoing PCNL under general anesthesia. Methods Eligible subjects after exclusion of COVID-19 patients, with renal stones less than 2 cm undergoing PCNL surgery under general anesthesia. Exclusion criteria were: 21<years of age or > 60 years of age; bleeding disorders; allergies to local anesthetics; psychiatric patients; and American Society of Anesthesia (ASA) physical status III and IV. Eighty patients were randomly allocated to 2 equal groups. In the Quadratus group, participant received 20 mL of bupivacaine 0.25% in the fascial plane between the quadratus lumborum and Psoas muscle; and in the peritubal group, patients received 10 mL of bupivacaine 0.25% around the nephrostomy tube at 6 and 12 o’clock positions (total 20 mL). The quadratus lumborum block and peritubal infiltration were performed by the primary investigator and the urologist, respectively. All patients received standard postoperative analgesia (paracetamol, ketorolac, and morphine via patient-controlled analgesia. Both patients and Data collecting staff were blinded to study group. Primary outcome was the visual analogue score at rest and on coughing or movement at 2, 4, 6, 12, and 24 hours. Secondary outcomes were 24 hours total morphine consumption, 1st use of morphine pump, incidence of side effects (pruritis and nausea and vomiting) and patient satisfaction. Results Data were analyzed from 78 patients (39 patients in each group). The mean resting VAS score in quadratus group at 6 and 12 hours was (3), while the mean VAS in peritubal group was (5) and (6) at 6 and 12 hours, respectively. Dynamic VAS score in peritubal group at 6 hours was (mean 6) with p<0.0001 when compared to resting value. The 24 hours’ morphine consumption was 8.5-11 mg and 1619 mg, in quadratus and peritubal group, respectively (the difference in mean of 9 at the 95% confidence interval; p<0.0001). patients start to use morphine pump after 121.4 min and 180.2 min in group peritubal and quadratus, respectively. Patients in group quadratus were statistically more satisfied, in both groups incidence of complication was low. Conclusion Quadratus Lumborum block was more effective than Peritubal LA infiltration regarding postoperative VAS score both at rest and during movement with lower postoperative morphine consumption and more satisfaction in patients undergoing PCNL surgery. Trial registration This prospective randomized trial was registered at Clinical Trials.gov in December, 2019. https://clinicaltrials.gov/ct2/show/NCT04215705.

Comparison between peripheral nerve stimulator-guided serratus anterior plane block versus transversus abdominis plane block for postoperative analgesia in laparoscopic cholecystectomy under general anaesthesia: A double-blind randomised controlled trial.

Laparoscopic cholecystectomy (LC) is a widely accepted surgical procedure associated with postoperative pain. This study was done to compare peripheral nerve stimulator (PNS)-guided serratus anterior plane block (SAP) and transversus abdominis plane (TAP) block for postoperative analgesia for patients undergoing LC. Following approval from the ethical committee, 70 patients for LC were randomly assigned to Group S: SAP block and Group T: TAP block. The blocks were performed under PNS guidance, and 20 ml of 0.375% ropivacaine was administered. The severity of pain was measured using a visual analogue scale (VAS). The study's primary objective was the evaluation of the postoperative VAS score. The time of the first dose of rescue analgesia and total tramadol consumption for 24 h postoperatively were secondary objectives. All the statistical calculation was done using statistical analyses for Social Sciences for Windows version 23.0 (IBM Corp, NY, USA). Lower VAS score was seen in patients of TAP block at rest as well as movement at 6 h (P = 0.001), 12 h (P = 0.001) and 18 h (P = 0.001) postoperatively compared with SAP. The TAP group showed a significantly increased time of first rescue analgesic compared to the SAP group (7.97 ± 0.51 vs. 5.89 ± 1.45, P = 0.001). Tramadol usage was significantly higher in the SAP group than in the TAP group (128.9 ± 36.22 vs. 72.43 ± 44.80, P = 0.001). TAP block guided by the PNS improves postoperative pain with less tramadol consumption and during the postoperative period without significant complications.

Ayak cerrahisinde kullanılan periferal sinir blok uygulamasında iki metodun karşılaştırılması: USG yardımlı ve anatomic landmark yardımlı.

Aim: Ankle peripheral nerve block is applied by two methods. These are peripheral block that is performed using USG-assisted and anatomical landmarks that do not require the use of Ultrasonography (USG). In our study, we aimed to compare these two methods applied in foot surgeries retrospectively. Methods :Peripheral block patients performed with the USG-guided (group 1) were 20, anatomical landmarks- guided (group 2) were 20. In both groups, 40 cc of anesthetic mixture was used (bupivacaine + lidocaine). The recorded information of the patients were as follows: Block application time (BAT), surgery readiness time (SRT), duration of surgery (DoS), duration of block anesthesia (DBA) and intraoperative-postoperative Visual Analogue Scale (VAS). The results of the VAS applied to the patients postoperatively were obtained. Patients were contacted by phone and asked if they were satisfied with the anesthesia. Results : The BAT and DBA values of the patients in Group 1 were high. SRT and VAS 6 values of the patients in group 2 were high. No significant difference was found between the groups in other parameters. No additional dose of anesthetic was needed in group 1 during the intraoperative period. In group 2, local additional dose was administered to 3 patients. Conclusion: Peripheral block preparation USG-guided takes a long time. However, it is more comfortable during surgery. The USG-guided peripheral nerve block is more advantageous when considering the possibility of prolonging the duration of surgery for any reason and early postoperative pain control after surgery.

Regional anesthesia for transplantation surgery - A white paper part 1: Thoracic transplantation surgery.

Transplantation surgery continues to evolve and improve through advancements in transplant technique and technology. With the increased availability of ultrasound machines as well as the continued development of enhanced recovery after surgery (ERAS) protocols, regional anesthesia has become an essential component of providing analgesia and minimizing opioid use perioperatively. Many centers currently utilize peripheral and neuraxial blocks during transplantation surgery, but these techniques are far from standardized practices. The utilization of these procedures is often dependent on transplantation centers' historical methods and perioperative cultures. To date, no formal guidelines or recommendations exist which address the use of regional anesthesia in transplantation surgery. In response, the Society for the Advancement of Transplant Anesthesia (SATA) identified experts in both transplantation surgery and regional anesthesia to review available literature concerning these topics. The goal of this task force was to provide an overview of these publications to help guide transplantation anesthesiologists in utilizing regional anesthesia. The literature search encompassed most transplantation surgeries currently performed and the multitude of associated regional anesthetic techniques. Outcomes analyzed included analgesic effectiveness of the blocks, reduction in other analgesic modalities-particularly opioid use, improvement in patient hemodynamics, as well as associated complications. The findings summarized in this systemic review support the use of regional anesthesia for postoperative pain control after transplantation surgeries. Part 1 of the manuscript focuses on regional anesthesia performed in thoracic transplantation surgeries, and part 2 in abdominal transplantations.

Nasotracheal intubation awake in a patient with multiple fractures of the maxilla and cervical spine: A case report.

Nasotracheal intubation is an advanced airway modality used in specific contexts, such as limited mouth opening, macroglossia, cervical spine instability. In addition, it can be performed with the patient awake, especially when predictors a difficult airway are unknown. A 41-year-old male with a lesion in the C1 cervical vertebra, associated with a fracture of the right maxilla, was intubated through the nasopharyngeal route while awake. The forms of induction were discussed. Based on the mechanism of trauma and on the report of pain, associated with imaging examination, fracture of the body of the right maxilla and a complex fracture of the anterior arch of the C1 cervical vertebra were diagnosed. In this case, we present a patient with trauma to the face and spine who was intubated through the nasopharyngeal route while awake and guided by video laryngoscopy and using a rigid cervical collar. The patient was operated on under total general anesthesia (propofol and remifentanil) and plates and screws were placed for maxillary osteosynthesis. The pain was alleviated with a peripheral block of the trigeminal nerve of the maxillary branch with 0.5% levobupivacaine. The patient woke up from surgery, was extubated uneventfully and without pain. Cervical spine injuries were followed up by the neurosurgery team for conservative treatment. Patients with neck injury and facial trauma may need a definitive airway either for emergencies or for elective procedures. Intubating the awake patient may be an option when the anatomy of the cavity is unknown, and inducing the anesthetic act without this knowledge may be a inappropriate option, due to the risk of intubation/ventilation difficulties.

Mechanisms of sensitivity to platinum-based chemotherapy in PD-1 blockade-refractory head and neck cancer.

e18003 Background: Our clinical observation from recurrent/metastatic head and neck patients who treated with platinum based combination after progression on pembrolizumab showed a striking response rate of 80% (8 out of 10 patients), this impressive ORR is dramatically higher than the historical ORR of 27% in the first-line setting. Our mouse model of ‘immune-cold’ head and neck cancer is developed to investigate the mechanism of sensitivity to platinum- based chemotherapy in PD-1 blockade-refractory head and neck cancer. Methods: For ‘immune-cold’ syngeneic model of HNSCC, C57BL/6 mice were injected with 5 × 104 MOC2 tumor cells in the right flank. After 11 days, mice with palpable tumors were randomized and treated concurrently with 4 groups (n = 5 per group): control, anti–PD1 antibody (200 mcg three times/week × 3 cycles), cisplatin (3mg/kg) +paclitaxel (5mg/kg) once a week x 3 cycles, or anti-PD1 antibody (200 mcg three times/week × 1 cycle) followed by cisplatin (3mg/kg) + paclitaxel (5mg/kg) once a week x 2 cycle. Cisplatin + paclitaxel arm received total of 4 cycles of treatment, while PD-1 followed by cisplatin and paclitaxel arm received total of 3 cycles of cisplatin and paclitaxel, this schedule was set up to maintain every 3 week regimen with same duration of treatment time to mimic patient’s treatment schedule in clinic setting. Tumor volume was measured 3 times per week. Results: Our initial pilot mouse model study showed similar tumor response seen in patient population. Starting on D24, average tumor size of PD1 inhibitor followed by cisplatin+paclitaxel group is significantly decreased compared to PD1 inhibitor or cisplatin+paclitaxel group and the difference is statistically significant. Most of mice in control and PD1 inhibitor group died at day 24 due to tumor progression. Our IHC data showed that the expression levels of immune markers such as CD8+, CD4+ and PDL1 in tumors treated with PD1 inhibitor followed by cisplatin and paclitaxel were increased, compared to almost no or scant expression (CD8+, CD4+) and lower expression (PDL1) in tumors treated with cisplatin and paclitaxel alone. With our expansion cohort, we will be further exploring key changes in immune signatures using both peripheral blood samples and tumor blocks for flow cytometry (myeloid/lymphoid subtypes, alterations in cytokine expression and circulating tumor DNA levels) and RNA sequencing analysis. Conclusions: We successfully established an ‘immune-cold’ mouse model of head and neck and reproduced similar tumor response seen in clinic. Preliminary data showing increased expression of immune makers such as CD8+, CD4+ and PDL warrants further investigation on tumor immune microenvironment remodeling as a potential mechanism of sensitivity to platinum-based chemotherapy in PD-1 blockade-refractory head and neck cancer.

ID: 206101 Acute Local Anesthetic Systemic Toxicity From Hypogastric Nerve Block for Chronic Pelvic Pain

Chronic pelvic pain (CPP) poses significant diagnostic and treatment challenges. One potential intervention is superior hypogastric nerve block for management of sympathetically-mediated pelvic pain. The hypogastric nerve supplies several sympathetic pain pathways of pelvic organs and has demonstrated use in conditions including post-operative, fibroid, and endometriosis-related CPP. Peripheral blocks of the hypogastric plexus under fluoroscopy serve as both diagnostic and therapeutic interventions for some patients managing CPP. However, complications such as local anesthetic systemic toxicity can occur.

Truncal Blocks for Emergency Laparotomy in a High-Risk Patient: A Case Report and Literature Review.

In critically ill patients undergoing laparotomy, both general anesthesia (GA) and central neuraxial block (CNB) may pose significant risks. Peripheral truncal blocks have been reported to provide effective postoperative analgesia following laparotomy. However, there are a limited number of reports describing this technique as surgical anesthesia for laparotomy. An 86-year-old man with non-specific interstitial pneumonia under home oxygen therapy and aortic valve stenosis was diagnosed with an incarcerated inguinal hernia. Because of these comorbidities, both GA and CNB were considered relatively contraindicated. Thus, we chose an ultrasound-guided transverse abdominis plane block and ilioinguinal/iliohypogastric block supplemented with neuroleptanesthesia as surgical anesthesia for emergency laparotomy. The surgery was uneventful using this technique. Truncal blocks supplemented with titrated intravenous sedatives/analgesics could be an alternative in high-risk patients undergoing laparotomy in whom both GA and CNB are considered relatively contraindicated.

A Change in the Educational Landscape of Regional Anesthesia: A National Survey of Anesthesiology Residency Programs to Assess the Correlation Between the Frequency of Teaching a Block Technique and Clinical Importance.

Introduction Variability regarding which blocks are performed most often can be quite high amonganesthesiology residency training programs. Which techniques are viewed by residency programs as "critical" for their graduates to know can also be inconsistent. We administered a national survey to investigate correlations between the cited importance of techniques and the relative frequency with which they are being taught. Materials and methods A three-round modified Delphi method was used to develop the survey. The final survey was sent to 143 training programs across the United States. The surveys collected information on the frequency with which thoracic epidural blocks, truncal blocks, and peripheral blocks were taught. The respondents were also asked to rate how critical each technique is to learn during residency. A correlation between the relative frequency of block teaching and cited importance to education was calculated using Kendall's Tau statistic. Results Among truncal procedures, transversus abdominis plane (TAP) block and thoracic epidural blocks were frequently viewed as "indispensable for daily practice." Among peripheral nerve blocks, interscalene, supraclavicular, adductor, and popliteal blocks were frequently viewed as indispensable. All truncal blocks showed a strong correlation between the relative frequency of block teaching and cited importance to education. However, the frequency of teaching interscalene, supraclavicular, femoral, and popliteal blocks failed to correlate with their reported importance ranking. Conclusions Perceived importance was significantly associated with the reported frequency of block teaching for all truncal and peripheral blocks except for interscalene, supraclavicular, femoral, and popliteal. The lack of correlation between the frequency of teaching and perceived importance is reflective of a changing educational landscape.

Three-Dimensional Imaging of Commonly Performed Peripheral Blocks: Using a Handheld Point-of-Care Ultrasound System.

Handheld ultrasound devices have become popular among clinicians due to their affordability and compatibility with tablets and smartphones. Several handheld ultrasound devices have the capability to construct three-dimensional (3D) images using a traditional two-dimensional (2D) ultrasound transducer. The current study aimed to construct 3D images of common peripheral nerve and fascial plane blocks using a handheld ultrasound device with a 2D ultrasound probe. A total of 10 patients who were scheduled to receive ultrasound-guided peripheral nerve blocks for outpatient surgery and classified as the American Society of Anesthesiologists physical status I or II with a body mass index of ≤ 30 kg/m2 were included in the study. Patients who presented with anatomical variations during the initial ultrasound scanning were excluded. This study successfully constructed 3D images of 10 peripheral nerve blocks. The average time to complete each 3D scan was less than 5 seconds per attempt, with fascial plane blocks requiring twice the amount of time to complete. All the nerve blocks provided effective postoperative analgesia without complications. The 3D images were successfully captured in all patients. The 3D images provide clinicians with valuable information on the anatomical boundaries of the injectate that can further direct needle direction and placement of local anesthetic to achieve visual confidence of anesthetic spread.

Real-time evaluation of the independent analgesic efficacy of dexmedetomidine

BackgroundDexmedetomidine has analgesic properties, but the intraoperative analgesic effect of dexmedetomidine is often masked by the effects of other general anaesthetics. Therefore, the degree to which it reduces intraoperative pain intensity remains unclear. The objective of this double-blind, randomised controlled trial was to evaluate the independent intraoperative analgesic efficacy of dexmedetomidine in real-time.MethodsThis single-centre study enrolled 181 patients who were hospitalised for below-knee orthopaedic surgeries between 19 January 2021 to 3 August 2021 were eligible for this is single-centre study. Peripheral neural block was performed on patients scheduled for below-knee orthopaedic surgeries. Patients were randomly assigned to the dexmedetomidine or midazolam group and were intravenously administered with 1.5 µg kg−1 h−1 dexmedetomidine or 50 µg kg−1 h−1 midazolam, respectively. The analgesic efficacy was evaluated using the real-time non-invasive nociception monitoring. The primary endpoint was the attainment rate of the nociception index target. The secondary endpoints included the occurrence of intraoperative hypoxemia, haemodynamic parameters, the consciousness index, electromyography and patient outcomes.ResultsOn Kaplan–Meier survival analysis, the defined nociception index target was attained in 95.45% and 40.91% of patients receiving dexmedetomidine and midazolam, respectively. Log-rank analysis revealed that the dexmedetomidine group attained the nociception index target significantly faster and the median attainment time of the nociception index target in the dexmedetomidine group was 15 min. Dexmedetomidine group was associated with a significantly lower incidence of hypoxemia. There was no significant difference in blood pressure between the dexmedetomidine and midazolam groups. Further, the dexmedetomidine group had a lower maximum visual analogue scale score and lower analgesic consumption postoperatively.ConclusionsDexmedetomidine has independent analgesia and systemically administered as an adjuvant agent has better analgesic efficacy than midazolam without severe side effects.Trial registrationclinicaltrial.gov Registry Identifier: NCT-04675372.Registered on 19/12 /2020.

Magnesium as an adjunct in regional anesthesia: literature review

Neringa Umaraitė1, Audronė Grigaliūnaitė2, Ramūnas Tamošiūnas2 1Lithuanian University of Health Sciences, Academy of Medicine, Faculty of Medicine, Kaunas, Lithuania 2Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Department of Anesthesiology, Kaunas, Lithuania Abstract Background. High-quality regional anesthesia should ensure good operating conditions and effective, long-lasting analgesia after surgery. Ways to prolong analgesia in order to allow early patient mobility and rehabilitation procedures are constantly being sought. Magnesium sulfate (MgSO4) as an adjunct to local anesthetics solutions is an attractive option and is being extensively studied. The aim: to review the scientific literature on usage of MgSO4 as an adjunct in regional anesthesia and to provide clinical conclusions for the application of MgSO4 in this anesthesia. Methods: The search of the scientific literature was performed in PubMed, Google Scholar online databases, using the following keywords and their combinations: ,,magnesium“, ,,peripheral nerve block“, ,,brachial plexus block“, ,,TAP block”, ,,spinal anesthesia“, ,,epidural anesthesia“, ,,neuraxial anesthesia“. 19 publications were included. Descriptive analysis was used to analyze the literature. Results. Regardless of type of regional anesthesia, magnesium combined with a local anesthetic shortens the duration of analgesic onset, prolongs both sensory and motor block durations, alleviates postoperative pain. Furthermore, less analgesics are consumed during surgery and postoperative period. Also, magnesium has advantage over some adjuvants to complement the action of local anesthetics or to avoid certain adverse effects. However, there is no consensus on what concentrations and volumes of MgSO4 solution should be used for different types of regional anesthesia. Conclusions. MgSO4, when used as an adjunct in regional anesthesia, enhances the action of local anesthetics without increasing the frequency of adverse effects. Keywords: magnesium sulfate, regional anesthesia, peripheral blocks, neuraxial anesthesia. Full article https://doi.org/10.53453/ms.2023.2.18

Reconstruction of the proto-type basin and tectono-paleographical evolution of Tarim in the Cenozoic

The Tarim Basin is the largest sedimentary basin in China, and it has experienced a complex tectonic evolutionary history. Reconstruction of the proto-type basin and tectono-paleogeography is helpful to understand the different stages of evolution of the sedimentary basin and basin-mountain relationship. It is significant to combine the basin with the regional tectonic background to discuss the process of basin-mountain coupling and the tectonic evolution of the peripheral orogenic belts. With a reliable residual thickness map and lithofacies map of the Tarim Basin in the Cenozoic, based on the amount of shortening we quantified from previous works and 81 balanced cross-sections, we restored the original range and compiled the proto-type basin map of Tarim Basin. From a compilation of previous studies on the lithofacies of peripheral blocks, the tectono-paleogeography of the Tarim Basin in Cenozoic has been reconstructed. The Indian Plate collided with the Eurasian continent at ∼45–40 Ma. The remote effect of the collision led to the resurrection and reactivation of the Kunlun and Tianshan Mountains. The Southwest Tarim and Kuqa rejuvenated foreland basins separately developed along the north front of the Kunlun Mountains and the south front of the Tianshan Mountains. The tectonic evolution process of the Tarim Basin in the Cenozoic was divided into two stages: 1) in the Paleogene, the Neo-Tethys Ocean retreated stepwise westward from the Southwest of the Tarim Basin, and the sedimentary lithofacies of the Southwest Tarim Depression were bay lagoon facies and lake facies; 2) the Neo-Tethys Ocean retreat finally occurred in the Tarim Basin during the Late Oligocene to Early Miocene, and it became an almost closed terrestrial basin, with the deposition of fluvial facies and lacustrine facies. The Cenozoic tectono-paleogeography of the Tarim Basin is closely related to the closure of the Neo-Tethys Ocean and the reactivation of the Kunlun and Tianshan Mountains.

Association of Adjuvants (dexamethasone X dexmedetomidine) in peripheral never block: a literature review

Objective: to investigate in the literature the effects of the association of dexamethasone and dexmedetomidine adjuvants in peripheral nerve blocks with local anesthetics. Method: This is a systematic literature review, through the search in the databases, namely: Medical Literature Analysis and Retrieval System online (MEDLINE/PubMed), Latin American Literature in Health Sciences (LILACS), Scientific Electronic Library Online (SCIELO). Data collection took place from September to November 2022. The inclusion criteria were: randomized, retrospective, prospective, cross-sectional and case report studies, without distinction of gender or race, which used dexamethasone or dexmedetomidine or both for blockade of the peripheral nerves and published in the last 10 years (2012-2022). Regarding the exclusion criteria were: the use of other substances that are not characterized as anesthetics or vasoconstrictors; memorials, editorial letters, reviews, research with individuals who had comorbidities, such as peripheral vascular disease, allergy to local anesthetics, pregnant women, history of cardiovascular or liver disease, and studies with more than 10 years of publication. Results: 532 relevant studies were identified from the searched databases, of which 329 were excluded after checking the titles, and 203 of the remaining articles were analyzed based on the title and its compatibility with the inclusion and exclusion criteria. These had their abstracts read, 09 of which were selected for full-text evaluation for eligibility and subsequently included in the qualitative analysis. Conclusion: The review demonstrated that dexamethasone and dexmedetomidine are good adjuvants when used in peripheral nerve blocks, increasing the duration of analgesia, but with some differences in effects.

The Role of Lipids in Local Anaesthetic Intoxication (Intralipids in Short Supply)

Systemic toxicity of local anaesthetics (LA) is a rare but often serious event. The clinical cases reported in the literature show that its clinical expression can be very polymorphous. The use of a peripheral block with ultrasound guidance reduces the incidence of vascular puncture and systemic toxicity Systemic toxicity is often delayed after L A injection. Therefore, close monitoring during the first 30 minutes after ALR (especially with ultrasound guidance) seems recommended. In case of a systemic accident, the administration of an intravenous lipid emulsion ELI is now part of the recommendations to be followed in case of cardiorespiratory arrest induced by a systemic overdose of local anaesthetic. The mechanisms of ELI are complex and probably multiple. Their use should therefore not replace other means of resuscitation, but appears to be an effective additional element. Further experimental studies and a clinical case registry will probably make it possible to better characterise the effects of an ELI-AL combination and to better understand the elements which, today, maintain the controversy of their use.

DEXAMETHASONE ADDED TO LEVOBUPIVACAINE IN TRANSVERSUS ABDOMINIS PLAIN BLOCK INCREASED THE DURATION OF POSTOPERATIVE ANALGESIA AFTER CAESAREAN SECTION DELIVERIES

Introduction: When Dexamethasone added to local anaesthetics, it can prolong the duration of peripheral blocks. Dexamethasone has a long and efcient glucocorticoid structure and having anti-inammatory properties.The aim of this study is to determine the effect of Dexamethasone on the block duration when added to Levobupivacaine used for transversus abdominis block (TAP) applied to patients who underwent caesarean section. Methods: 28 patients with spinal anaesthesia in an American Society of Anesthesiologists (ASA) I and II Risk group were included in the study and divided into two groups. Bilateral 30ml 0.25% Levobupivacaine and 2 ml 0.9% NaCl for the Levobupivacaine group and bilateral 30 ml 0.25% Levobupivacaine and 2 ml Dexamethasone (8mg) for the Dexamethasone group were administered in a TAP block performed. The time need for the rst analgesic in the postoperative period was recorded. The time before Result: the administration of the rst additional analgesic dose was prolonged signicantly in the Dexamethasone group in compared to Levobupivacaine group. The Conclusion: utilization of Dexamethasone, which has a prolonging effect on the TAP block, may be alternative to epidural opioid analgesia in caesarean section.

Combination of peripheral blocks as a part of enhanced rehabilitation in total knee replacement: a prospective comparative open randomized study

BACKGROUND: The patients recovery after total knee replacement (TKR) is long and is associated several potentially serious complications. The optimal solution to this problem is the introduction of regional blocks of the lower limb into anesthesiologic practice, which can contribute to enhanced rehabilitation and fewer complications.
 AIM: To perform a prospective comparative analysis of the anesthesia outcomes of patients who received a combination of prolonged femoral nerve blockade (CFNB) with catheter insertion and infiltration between the popliteal artery and capsule of the knee (IPACK), with the results in patients receiving prolonged epidural analgesia (PEA) as postoperative analgesia for TKR.
 MATERIALS AND METHODS: Eighty patients were included and distributed according to the required planned surgical intervention (TKR). The duration of the inclusion period was 3 months (from March to May 2022). Patients were observed up to 48 h after surgery, with control points every 8 h. The patients were divided into two groups: group 1 (PEA, n=40) underwent subarachnoid anesthesia in combination with PEA, and group 2 (n=40) underwent subarachnoid anesthesia as a combination of CFNB and IPACK. To compare the groups, the following main indicators were used: severity of pain syndrome (visual analog scale [VAS], from 0 to 10 cm), muscle strength on the Medical Research Council (MRC) scale, duration of patients stay in the intensive care unit, duration of hospitalization, and presence of postoperative complications.
 RESULTS: The highest average score for VAS was recorded at 32 h in group 1, and it was 3.6 cm. The lowest average score for VAS (1.11.2 cm) was noted in the first 8 h and after 48 h in group 1. In group 2, this value was 0.91.5 cm in the first 16 h, and at 48 h, the pain syndrome was more pronounced in group 2, making up 2 cm on VAS. Compared with the PEA group, the CFNB group had statistically higher values of the indicators of the motor strength of the leg muscles on the MRC scale at all stages of the study. The PEA group stayed in the intensive care unit statistically significantly longer than the PBN group: 210 (189260) and 180 (154185) min, respectively (p 0.001).
 CONCLUSION: The results of this study showed that the use of multimodal analgesia as a combination of CFNB and IPACK is a reliable anesthetic support for TKR, with an efficiency not inferior to classical epidural analgesia. The use of this combination of peripheral blockades contributes to the early activation and rehabilitation of patients after TKR.

An Overview of the Treatment Strategies of Extremities Ischemia in the Intensive Care Unit.

To investigate the effect of the peripheral block on peripheral ischemia on the extremities of patients in the intensive care unit (ICU). Sixty-two patients with ischemic peripheral vascular disease were divided retrospectively into two groups; Group 1 (patients who underwent USG-guided infraclavicular or femoral block, n=20) and Group 2 (patients who did not experience any block, n=42). The demographic characteristics of the patients, the diagnosis of hospitalization, the day when the circulatory disorder developed, laboratory tests at the time of diagnosis, other medical treatments applied, presence of inotropic support, the response of ischemia on extremities, amputation, duration of hospital stay, discharge and mortality were compared. The most common reason for hospitalization was cerebrovascular disease. There was no statistical difference between the groups regarding age, gender, height, body weight, and diagnosis. There was no statistical difference between the groups regarding hematocrit, lactate, creatinine, and albumin values, the day when the peripheral ischemia developed in extremities, inotropic and prednisolone use, presence of cannulation, length of hospital stays, and mortality. The number of patients discharged from the intensive care unit in Group 1 was significantly higher than in Group 2 (p=0.048). Amputation was performed on one patient in Group 1 and two patientsin Group 2. There was a decrease in peripheral ischemia in 14 (70%) of the patients in Group 1 and 25 (59.5%) of the patients in Group 2. Targeted peripheral block techniques for peripheral circulatory disorders for selected ICU patients in conjunction with preventive and medical treatments may decrease peripheral ischemia in extremities and increase ICU discharge.

Ultrasound-guided Musculoskeletal Interventional Procedures Around the Hip: A Practical Guide.

Several studies have shown that ultrasound guidance may contribute to improved safety, effectiveness and accuracy of musculoskeletal interventional procedures performed around the hip if compared to those performed with a landmark-guided technique. Different approaches and injectates can be used for treating hip musculoskeletal disorders. These procedures may involve injections in the hip joint, periarticular bursae, tendons, and peripheral nerves. Intra-articular hip injections are mostly used as a conservative approach for treating patients affected by hip osteoarthritis. Ultrasound-guided injection of the iliopsoas bursa is performed in patients with bursitis and/or tendinopathy, to treat those with painful prosthesis due to iliopsoas impingement, or when the lidocaine test is indicated to identify the iliopsoas as a source of pain. Ultrasound-guided interventions are routinely used in patients with greater trochanteric pain syndrome having as target the gluteus medius/minimus tendons and/or the trochanteric bursae. Ultrasound-guided fenestration and platelet-rich plasma injection are applied in patients with hamstring tendinopathy with good clinical outcomes. Last but not least, ultrasound-guided perineural injections can be used for peripheral neuropathies or blocks of the sciatic, lateral femoral cutaneous, and pudendal nerves. In this paper, we discuss the evidence and technical tips for musculoskeletal interventional procedures performed around the hip, highlighting the added value of ultrasound as an imaging guidance modality.