Postoperative Analgesia Research Articles

Ultrasound-guided subcostal transversus abdominis plane block versus erector spinae plane block for post-operative pain after percutaneous nephrolithotomy: A comparative observational study

In India, about 12% of the population has kidney stones, and out of these about 50% may end up with some kidney function loss or renal damage percutaneous nephrolithotomy (PCNL) is accepted as the procedure of choice for large or complex renal stones. Significant post-operative pain can occur after PCNL in first 24 hours due to distension in the renal capsule and pelvicalyceal system. The study aim was to compare the efficacy of ultrasonography guided subcostal transversus abdominis plane block with erector spinae plane block in PCNL. This observational study included 67 consecutive cases (16-65 years, ASA grade I-II) divided into 2 groups. Group A (n=33) received subcostal transversus abdominis plane (SCTAP) block and Group B (n=34) received erector spinae plane block (ESPB). Post operative pain in terms of pain scores, opioid consumption, requirement of rescue analgesic in first 24 hours was noted. Quality of recovery and any adverse events were also noted. Post-operative opioid consumption was significantly less in ESPB group (34.41 ± 27.32 mcg), compared to SCTAP Group (270.91 ± 121.41 mcg). Group B patients had better post operative quality of recovery compared to Group A patients. VAS pain scores at almost all time-points were lower in the ESPB group. ESPB provided effective postoperative analgesia and reduced fentanyl consumption postoperatively compared to SCTAP block.

Parasacral ischial plane block for lower limb surgeries: A case series

The para-sacral ischial plane block (PIP block) is a novel fascial plane approach targeting the sacral plexus. This technique simplifies the process as direct visualization of the sacral plexus or sciatic nerve is unnecessary. This retrospective case series includes ten patients with American Society of Anesthesiologists (ASA) physical status II-IV, aged over 18 years, undergoing elective or emergency lower limb surgeries such as debridement and below-knee amputation between May 2023 and November 2023. The block was performed in ≤ 6 minutes for all patients. Onset of subjective analgesia was almost immediate in those presenting with pain. Sensory loss occurred within 9 to 12 minutes. Motor block in the sciatic nerve distribution did not reach Grade 2 in any patient. Hemodynamic stability was notably maintained in all high-risk cases. Intraoperative supplementation with ketamine was required for one patient. The PIP block is a quick, easy-to-perform technique that offers satisfactory surgical conditions and hemodynamic stability in high-risk patients undergoing lower limb surgeries. It also provides prolonged postoperative analgesia and early resumption of oral intake with minimal procedural discomfort.

A comparative evaluation of ultrasound guided dual transversus abdominis plane block versus erector spinae plane block for postoperative analgesia in patients undergoing laparoscopic cholecystectomy: A randomised prospective study

: Effective pain control after laparoscopic cholecystectomy (LC) is crucial for early patient mobilization, facilitating a speedy recovery and avoiding several complications. Ultrasound (USG) guided bilateral dual transversus abdominis plane block (DTAPB) and erector spinae plane block (ESPB) are effective for providing postoperative pain relief after LC.A prospective randomised, study comprising of 100 patients posted for elective LC. To compare the effectiveness of USG-guided DTAPB and ESPB for providing postoperative pain relief in patients undergoing LC. A total of 100 patients aged 18-70 years, were included in the study and divided into two groups of 50 patients each. Group DTAPB received bilateral DTAPB and group ESPB received bilateral ESPB, using 50 ml of 0.25% ropivacaine with 8 mgs of dexamethasone. Post operative visual analogue score (VAS) score, time to first analgesia request, total number of analgesic doses required in 24 hours (hrs) and complications if any were noted. VAS score was higher in DTAPB group than ESPB group at 1,2,6,8 and 14 hrs. In DTAPB group patients requested analgesia after an average of 8 ±2.0 hrs, whereas in ESPB group they requested after 12 ± 3.16 hrs. In ESPB group 45 patients needed single analgesic dose and only 5 needed second analgesic doses. However, in DTAPB group 35 patients received single and 15 patients received second analgesic dose. Side effects were comparable in both the groups.USG-guided bilateral ESPB with 50 ml of 0.25% ropivacaine plus dexamethasone is an effective approach in reducing postoperative pain following LC.

Comparison of analgesic effect of modified superior trunk block and traditional interscalene brachial plexus block with liposomal bupivacaine after arthroscopic rotator cuff repair

Objective: To compare the postoperative analgesic effect of modified superior trunk block and traditional interscalene brachial plexus block in arthroscopic rotator cuff repair. Methods: A total of 40 patients undergoing arthroscopic rotator cuff repair in the Second Affiliated Hospital of Wenzhou Medical University from October to November 2023 were prospectively included, whose American Society of Anesthesiologists (ASA) grade were Ⅰ-Ⅱ. They were divided into modified superior trunk block group (group S) and interscalene brachial plexus block group (group I) by random number table according to different nerve block methods, with 20 cases in each group. Local anesthetics was a mixture of 1.33% liposomal bupivacaine and 0.5% levobupivacaine hydrochloride injection in equal volume. Patients in group S were injected 5 ml mixture for ultrasound-guided modified superior trunk block, and patients in group I were injected with 15 ml mixture for ultrasound-guided traditional interscalene block respectively. Both groups underwent superficial cervical plexus block (5 ml mixture). Standardized general anesthesia and standardized postoperative analgesia were followed. The primary outcome measures included 48 h resting numerical rating scale (NRS) scores after surgery and the incidence of hemidiaphragmatic paralysis (HDP) at 30 min after block. The secondary outcome measures included resting NRS scores during the post anesthesia care unit (PACU), 12, 24, and 36 h after surgery, postoperative opioid consumption and satisfaction with analgesia, pulse oxygen saturation (SpO2) at 30 min after block, sensory and motor block duration, and the incidence of perioperative adverse reactions. The non-inferiority cut-off value of resting NRS scores for patients in group S was set as"1 point"at each observation time point after surgery. Results: In group S, one patient was excluded because the target nerve was blocked by the subclavian vein and could not be blocked, nineteen patients [11 males and 8 females, aged (52.2±9.0) years] were eventually included. In group I, there were 7 males and 13 females, aged (55.0±5.1) years. Resting NRS scores of group S and Group I at 48 h after surgery were 0 (0, 0) and 0 (0, 0.8) point, respectively, with no statistical significance (P>0.05). The median difference was 0 (95%CI:0-0) point and the upper 95%CI was 0 point, which was lower than the preset non-inferiority cut-off value"1 point"(non-inferiority P<0.001). The incidence of HDP in group S and group I were 5% (1/19) and 75% (15/20), respectively, with statistically significant (P<0.001). There were no significant differences in resting NRS scores at PACU and 12, 24, 36 h after surgery, opioid dosage, satisfaction with analgesia, SpO2 at 30 min after block, sensory and motor block duration between two groups (all P>0.05). No respiratory adverse events such as hypoxemia and airway spasm occurred in two groups after extubation. One patient in group I showed symptoms of breath shortness when entering PACU, and 3 patients felt uncomfortable due to prolonged numbness and weakness of the blockade limb (>2 days). No nerve block procedures and opioid drugs relative adverse reactions and no neurological complications happened in both groups. Conclusion: Liposomal bupivacaine usage for modified superior trunk block can provide long-term postoperative analgesic effects which is noninferior to traditional interscalene brachial plexus block and causes less HDP in patients undergoing arthroscopic rotator cuff repair.

Ropivacaine combined with dexmedetomidine in ultrasound-guided axillary brachial plexus block in children, a randomized controlled trial

ObjectiveIn this study, we evaluated the efficacy and safety of 1 μg/kg dexmedetomidine as an adjuvant treatment to ropivacaine in children undergoing upper limb surgeries under ultrasound-guided axillary brachial plexus blocks and general anesthesia.MethodsWe enrolled 90 children (aged 1–8 years; ASA I-II) undergoing closed reduction and internal fixation for upper extremity fractures at the Xiamen Children's Hospital and randomly assigned them to one of two groups: L (injection with 0.25% ropivacaine) or D (injection with 0.25% ropivacaine containing 1 μg/kg dexmedetomidine) using the random number table method. The main outcome indicators recorded were the facial expression, leg activity, position, crying, and Face, Legs, Activity, Cry, and Consolability (FLACC) scale scores of children after surgery and the duration of block and analgesia maintenance. The secondary outcome indicators were vital sign data at the time of ultrasound probe placement (T1), at the time of block completion (T2), prior to the beginning of surgery (T3), 5 min after the beginning of surgery (T4), and at the end of surgery (T5), as well as the time of postoperative recovery, the number of cases of remedial analgesia, and complications.ResultsThere was no statistical difference between the two groups in terms of general data, block completion time, postoperative recovery time, and complications (P > 0.05). Compared to the L group, the D group had significantly lower FLACC scores at 6 h after surgery, as well as significantly lower systolic blood pressure, diastolic blood pressure, and heart rate values at T4 and T5, and significantly longer duration of postoperative analgesia maintenance (all P < 0.05).ConclusionDexmedetomidine (1 μg/kg) as a local anesthetic adjuvant to ropivacaine can alleviate pain at 6 h postoperatively, prolong analgesia maintenance, and reduce intraoperative blood pressure and heart rate in pediatric patients undergoing closed reduction and internal fixation for upper extremity fractures, with no obvious complications or delayed recovery.Clinical registry numberRegistration website: www.chictr.org.cn, Registration number: ChiCTR2200065163, Registration date: October, 30, 2022.

Comparison ultrasound-guided adductor canal block and surgeon-performed block for pain management after total knee arthroplasty: a prospective randomized controlled study

ObjectiveAdductor canal block (ACB) is widely performed for postoperative analgesia for total knee arthroplasty (TKA). The aim of this study is to compare surgeon-assisted and anesthesiologist-assisted (ultrasound-guided) adductor blocks in terms of postoperative analgesic efficacy.MethodsThis study was designed as a double-blind, prospective and randomized trial. A total of 240 participants were randomly allocated to three groups: one where the surgeon performed the adductor canal block (ACBs), another where it was conducted by an anesthetist with ultrasound guidance (ACBa), and a third group without the adductor block. The follow-up management after the Total Knee Arthroplasty (TKA) procedure occurred on the first, third, and tenth days, as well as the twelfth week. Outcome measures comprised pain assessment using the Visual Analog Scale (VAS) and monitoring opioid analgesic consumption.ResultsNo significant differences in demographic profiles were observed between the groups. Groups ACBa and ACBs exhibited significantly lower VAS scores compared to the control group at both 3 and 12 h after surgery, with group ACBa showing the lowest VAS scores among all groups. However, at 1 day, 3 days, 10 days and 12 weeks after surgery, there was no significant difference in VAS scores between the ACBa and ACBs groups. On the first three days, the ACBa group had the lowest opioid consumption and the lowest total opioid consumption. The differences in VAS scores between the groups began to decrease on the first day after surgery.ConclusionThe adductor canal block (ACB) has been demonstrated to be an effective method of reducing pain in patients undergoing total knee replacement (TKR) in the postoperative period. Nevertheless, despite the pronounced impact that ACB performed by an anesthesiologist under ultrasound guidance has on VAS scores according to intraoperative ACB by surgeons, its effect on clinical outcomes has not been demonstrated.Trial registrationsThis study was retrospectively registered with the Clinical Trials Registry Platform on July 31, 2024 (NCT06533085).

Comparative evaluation of intrathecal hyperbaric bupivacaine alone versus combined with dexmedetomidine for cesarean sections

Background &amp; Objective: This study examined the use of dexmedetomidine 5 μg as an adjuvant to 10 mg of intrathecal hyperbaric 0.5% bupivacaine in elective cesarean sections and aimed to assess dexmedetomidine’s impact on block characteristics and post-operative pain management. As spinal anesthesia is commonly employed for cesarean deliveries, the study seeks to determine whether the addition of dexmedetomidine as an adjuvant can prolong the duration and enhance the quality of the block, leading to improved post-operative pain relief. Methodology: This randomized controlled trial included 100 parturients undergoing elective cesarean section over a period of six months. Participants were allocated to either Group B or Group D using a non-random consecutive sampling technique. In Group D, 2 mL of 0.5% bupivacaine mixed with 0.05 mL of dexmedetomidine (5µg) was injected intrathecally, while Group B received 2 mL of 0.5% hyperbaric bupivacaine along with an equivalent volume of saline. Sensory and motor block assessments were conducted prior to the start of surgery. Post-operatively, the duration of motor block and post-operative pain relief were assessed. Results: The addition of dexmedetomidine as an adjuvant to intrathecal bupivacaine resulted in significant reductions in the onset time of sensory block (4.22 ± 0.79 min vs 5.66 ± 1.21 min) and motor block (4.20 ± 0.81min vs 6.32 ± 1.20 min) (P &lt; 0.001). Furthermore, the duration of motor block was longer in the dexmedetomidine + bupivacaine group compared to the bupivacaine alone group (7.32 ± 0.95 h vs 4.38 ± 1.27 h). Additionally, patients who received intrathecal dexmedetomidine as an adjuvant to bupivacaine experienced significantly longer durations of post-operative analgesia (7.32 ± 0.95 h) as compared to the bupivacaine alone group (4.38 ± 1.27 h) (P &lt; 0.001). Conclusion: Dexmedetomidine as an intrathecal adjuvant to hyperbaric bupivacaine extends the duration of analgesia and motor block, providing prolonged pain relief. Additionally, it exhibits an early onset of sensory and motor block, ensuring prompt pain relief and rapid anesthesia onset. Clinical Trial Registration: [www.clinicaltrials.gov], identifier: ID NCT05469529 Abbreviations: CS - cesarean section; OT - Operation Theater; SA - Spinal anesthesia; VAS - visual analogue scale; Keywords: cesarean section, dexmedetomidine, bupivacaine, spinal anesthesia Citation: Qureshi RA, Jadoon H, Shabbir M. Comparative evaluation of intrathecal hyperbaric bupivacaine alone versus combined with dexmedetomidine for cesarean sections. Anaesth. pain intensive care 2024;28(5):866−870. DOI: 10.35975/apic.v28i5.2558 Received: December 03, 2023; Reviewed: December 15, 2023; Accepted: August 16, 2024

Assessing the Analgesic Efficacy of Lumbosacral Epidural Morphine in Cats Undergoing Ovariohysterectomy: A Comparative Study of Two Doses.

Opioids are administered epidurally (PV) to provide trans- and postoperative analgesia. Twenty healthy female cats aged between 6 and 24 months and weighing between 2 and 3.7 kg, undergoing elective ovariohysterectomy (OVH), were induced with propofol (8 mg/kg), followed by continuous infusion (0.1-0.4 mg/kg/min). Three groups were defined: CG (0.1 mL/kg of iodinated contrast, n = 6), G0.1 (0.1 mg/kg of morphine, n = 7), and G0.2 (0.2 mg/kg of morphine, n = 7) per VP. All received 0.1 mL/kg of iodinated contrast per VP and injection water to obtain a total of 0.3 mL/kg. Heart rate (HR), systolic blood pressure (SBP), temperature, expired CO2, oxygen saturation, and number of rescue analgesics were monitored. Postoperatively, a multidimensional scale was used to assess acute pain in cats for 12 h. The mean HR and SBP in the CG were higher at the time of maximum noxious stimulation and required fentanyl in all groups. Postoperatively, 83%, 28%, and 7% of the animals in CG, G0.1, and G0.2, respectively, received rescue analgesia. In cats undergoing OVH, epidural morphine at doses of 0.1 and 0.2 mg/kg did not prevent the need for intraoperative rescue analgesia but reduced the postoperative analgesic needed.

Assessing the impact of opioid-free anesthesia using the modified Mulimix technique on postoperative pain in bariatric surgery patients: a correlative randomized double-blinded trial

Background &amp; objective: The effective management of postoperative pain in bariatric surgery poses significant challenges to the anesthesiologists and the surgeons. Opioids have been the mainstay of postoperative pain management; but recently, opioid-free anesthesia (OFA) has been a popular option in an effort to prevent the opioid related side-effects. The objective of this study was to assess the effects of OFA utilizing the modified mulimix technique on the levels of plasma interleukin-2 (IL-2) and interleukin-6 (IL-6). In addition, the study aimed to evaluate the duration of analgesia and the analgesic requirements during the first 24 hours postoperatively. Methodology: A total of 60 patients were randomly assigned to the OFA Group, which received opioid-free anesthesia, and the OBA Group, which received Opioid-Based Anesthesia. The modified Mulimix technique was used in both groups. Serum samples were collected from all patients during skin incision and after the surgical procedure. Subsequently, these samples were assessed for IL-2 and IL-6 levels. The postoperative analgesic consumption was compared in both groups. Results: Regarding serum IL-2 and IL-6 levels in the two study groups, there was a statistically significant difference after the conclusion of surgery, and the skin incision was made. Regarding the initial rescue analgesia postoperatively assessment, the OBA group demonstrated a substantially greater overall consumption of analgesics within the first 24 h. The study revealed a significant difference in VAS values between the OBA Group and the OFA Group at 2 h, 4 h, and 6 h postoperatively. Conclusion: The modified mulimix technique effectively reduces postoperative plasma inflammatory mediators, interleukin-2 and interleukin-6, and results in decreased postoperative pain, thus reducing the postoperative analgesia consumption Abbreviations: OBA - Opioid based anesthesia; OFA - opioid-free anesthesia; IL-2 - interleukin-2; IL-6 - interleukin-6; VAS - visual analogue scale Keywords: Bariatric surgery, interleukin, Mulimix, opioid, pain, immunological response. Citation: Seyam SHA, Hassan AE, Elsayed MM. Assessing the impact of opioid-free anesthesia using the modified Mulimix technique on postoperative pain in bariatric surgery patients: a correlative randomized double-blinded trial. Anaesth. pain intensive care 2024;28(4):721−726; DOI: 10.35975/apic.v28i4.2516 Received: March 04, 2024; Reviewed: May 18, 2024; Accepted: May 19, 2024

Post-surgical photobiomodulation therapy improves outcomes following elective gastropexy in dogs

PurposeTo evaluate the effect of post-surgical photobiomodulation therapy in dogs.MethodsTwenty dogs were selected for elective gastropexy and randomly divided into a control (CG, n = 10) and a PBMT group (PBMTG, n = 10). Pre‑medication consisted of medetomidine and butorphanol. Meloxicam was administered before the procedure. Induction was performed with propofol and maintained with sevoflurane. Local blocks with lidocaine were used. Incisional gastropexy was performed in all animals. PBMTG received PBMT immediately after surgery. The need for postoperative rescue analgesia, if the animal had eaten by the evaluation momen, and pain scores were collected using the Glasgow Composite Measure Pain Scale – Short Form (CMPS‑SF) at 1, 2, 4, 6, 8, 12, 16, 20, and 24 h post‑endotracheal extubation. CMPS‑SF scores were compared with the Mann-Whitney Test and proportions of animals that required rescue analgesia and had eaten with a χ2 test. P was set at < 0.05.ResultsNo rescue analgesia was needed for any animal. Still, significant differences were observed in CMPS-SF scores between CG and PBMTG between 1 and 4 h post-extubation. PBMTG had a significantly higher proportion of animals eating up to the 8 h post-extubation evaluation moment.ConclusionAdding post-surgical photobiomodulation to a standard anesthesia and analgesia protocol reduced CMPS-SF scores and increased the proportion of animals that resumed eating compared to the standard protocol alone.

Combined nefopam-fentanyl use in PCA for postoperative analgesia in spinal surgery patients: a randomized, controlled, single-blind trial

Background &amp; objective: The use of fentanyl to manage postoperative pain in spinal surgery patients is common, although there have been concerns about potential of drug abuse and dependence. We investigated the effects of the combined administration of nefopam and fentanyl through intravenous (IV) patient-controlled analgesia (PCA) on early postoperative pain and possible side effects in patients undergoing spinal surgeries. Methodology: In this randomized, controlled study, 70 patients were allocated to receive either fentanyl 10 µg/mL (Group F) or fentanyl 10 µg/mL with nefopam 1.2 mg/mL (Group FN), with a total PCA volume of 100 mL per infusion bag. Patients received a background dose of 0.25 µg/kg/h and bolus dose of 0.5 mL SOS (fentanyl 5 µg). The lockout interval was set at 10 min and upper limit was set at 15 mL/4 h. The PCA parameters were set according to the body weight of each patient. Results: The cumulative postoperative fentanyl consumptions after 48 h for Group F and Group NF were reported as 744.6 ± 94.2 µg and 631 ± 62.5 µg (P &lt; 0.05) respectively. The average number of bolus doses requested by the patients in Group F and FN were 20.8 ± 11.0, and NF 11.4± 7.6). The A/D ratio of both groups for the bolus doses were 70%. Group NF consistently scored a lower VAS and VAS-D score during the 48-hour postoperative period. However, the VAS scores significantly differ statistically between groups at 1, 6, 9, and 12 hours. Within group differences, the VAS score differed significantly statistically during the 0-1, 1-2, and 2-3 hours for Group F, while 24-36 hours for Group NF. Conclusion: The inclusion of nefopam in patient-controlled analgesia for spine surgery patients significantly reduced total use of fentanyl within the 48 hours postoperatively after the surgery. Patients receiving fentanyl with nefopam consistently had lower VAS scores at different time points. Abbreviations: PCA - patient-controlled analgesia; VAS - Visual Analogue Scale Keywords: postoperative pain, fentanyl, nefopam, patient-controlled analgesia Citation: Le XD, Nguyen ML, Nguyen DT, Do TH, Nguyen HG. Combined nefopam-fentanyl use in PCA for postoperative analgesia in spinal surgery patients: a randomized, controlled, single-blind trial. Anaesth. pain intensive care 2024;28(4):687−691; DOI: 10.35975/apic.v28i4.2370 Received: January 06, 2024; Reviewed: April 14, 2024; Accepted: April 14, 2024

Effect of Ketamine as an Adjuvant to Bupivacaine in Ilioinguinal and Iliohypogastric Nerve Block for Postoperative Analgesia after Inguinal Hernia Repair

Ilioinguinal and Iliohypogastric nerve block is one of the methods exercised widely to reduce postoperative pain after inguinal hernia repair. Several initiatives are ongoing to prolong the duration of postoperative analgesia by adding various adjuvants to the local anaesthetic agents in different nerve blocks. In this study ketamine has been added as an adjuvant to local anaesthetic bupivacaine in Ilioinguinal and Iliohypogastric nerve blocks. Our study aims to evaluate the effect of adding ketamine to local anaesthetic bupivacaine in ultrasound guided Ilioinguinal and Iliohypogastric nerve block in patient scheduled for inguinal hernia repair under subarachnoid block. This randomized control trial was carried out among 94 patients scheduled for elective inguinal hernia repair under subarachnoid block in Dhaka Medical College Hospital, Dhaka, Bangladesh. Two nerves, Ilioinguinal and Iliohypogastric were blocked by 0.25% bupivacaine under ultrasound guidance after the completion of surgery for postoperative analgesia. The study population was divided equally into two groups having 47 patients in each. Patients of group-A was received 20 ml of 0.25% bupivacaine and 2ml normal saline in the block procedure. Another group, group B patients received 20ml of 0.25% bupivacaine and 1mg/kg of ketamine in the same nerve block. Demographic profiles had no significant differences between two groups (p&gt;0.05). Mean duration of the analgesia or the time of first rescue analgesic requirement were significantly higher in ketamine group (595.24±15.90 minutes) than normal saline group (226.4±20.6 minutes). (p&lt;0.05); Postoperative total analgesic (pethidine) requirement within first 24 hours (178.3±18.3 vs. 92.3±15.3) milligrams, (p&lt;0.05) was higher in normal saline group. Our data suggests that ketamine when used as an adjuvant to bupivacaine for ilioinguinal and iliohypogastric nerve block prolongs the time to first analgesic request as well as decreases the analgesic requirement during postoperative period. CBMJ 2024 July: vol. 13 no. 02 P: 203-212

PAIN RELIEF AFTER INSTRUMENTED SPINAL SURGERY

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

Haemodynamic Responses Following Lidocaine Infusion on Hypertensive Patient Undergoing Laparoscopic Cholecystectomy

Many pharmacological methods have been evaluated to attenuate the adverse haemodynamic responses resulting from airway manipulation and pneumoperitoneum. Intravenous lidocaine infusion is one of them; bolus dose of intravenous lidocaine is used to reduce haemodynamic changes resulting from intubation and extubation reflex whereas intraoperative infusion of lidocaine has been used for post-operative analgesia in laparoscopic cholecystectomy. This randomized controlled trial was conducted to observe the effectiveness of lidocaine infusion in obtundation of haemodynamic responses on hypertensive patient undergoing laparoscopic cholecystectomy. A total number of 80 patients were enrolled in this study. Patients were allocated into two groups by computer generated random chart according to a 1:1 ratio. The patients of group A were given general anaesthesia with placebo normal saline infusion and the patients of group B were given general anaesthesia with lidocaine infusion (1.5mg/kg). Mean differences of blood pressure (SBP &amp; MAP) and heart rate at different time periods from baseline were compared between two groups. The demographic profiles were almost similar between the groups (p&gt;0.05). In comparison between two groups, heart rate, systolic blood pressure and mean arterial pressure rise from baseline value was more in normal saline group (group A) than lidocaine test group (group B) during peri-intubation, pneumoperitoneum and peri-extubation period. Statistical difference was significant between two groups (p&lt;0.05) in different haemodynamic parameters. Adverse events such as tachycardia premature ventricular contraction (PVC) and hypertension were observed much more in group A, which was higher than that of group B. We observed that administration of lidocaine infusion attenuates haemodynamic responses of hypertensive patient during laparoscopic cholecystectomy. CBMJ 2024 July: vol. 13 no. 02 P: 148-157

Preoperative anxiety, postoperative pain tolerance and analgesia consumption: A prospective cohort study.

Anxiety affects the patient's perception of postoperative pain and causes a significant increase in the consumption of analgesia postoperatively. This study assesses the relationship between preoperative anxiety, postoperative pain and postoperative pethidine consumption. A prospective cohort design was used. Data were collected from 100 patients who were undergoing a laparoscopic cholecystectomy at St Joseph Hospital, Jerusalem. Pain-controlled analgesia with pethidine was utilised to manage pain throughout the postoperative period. The visual analogue scale scores and pethidine consumption of all patients were recorded. Participants' mean level of pain was higher in the preoperative period (mean visual analogue scale = 1.3) compared with their mean level of pain in the postoperative period (mean visual analogue scale = 0.5). There is a statistically significant difference between the participants' level of anxiety and postoperative pain level (p < 0.001). Gender, weight, level of education and smoking were predictors of developing preoperative anxiety. Also, gender, smoking and medication were statistically significant predictors of developing postoperative pain. Furthermore, gender, medical history and medication were statistically significant predictors of pethidine consumption postoperatively. The preoperative anxiety reduction intervention should be promoted and implemented as routine care for all surgical patients.

Optimal approach to ultrasound-guided quadratus lumborum blocks for postoperative analgesia in elective caesarean section: protocol for systematic review and meta-analysis

IntroductionUltrasound-guided quadratus lumborum blocks are commonly used for postoperative analgesia during caesarean section. Ultrasound-guided quadratus lumborum blocks can be performed through four approaches, including lateral, posterior, anterior, and intramuscular quadratus...

Comparison of the effect of intrathecal fentanyl citrate and magnesium sulfate as adjuvants to hyperbaric levobupivacaine 0.5% for spinal anesthesia in patients undergoing lower limb orthopedic surgeries

Background: Subarachnoid blockade is a safe, reliable, and inexpensive technique that provides surgical anesthesia along with prolonged post-operative analgesia. The quality of subarachnoid block is enhanced by the addition of intrathecal adjuvants, such as fentanyl citrate and magnesium sulfate to hyperbaric levobupivacaine. Aims and Objectives: The aim of this study was to compare the effects of fentanyl and magnesium sulfate as adjuvants to 0.5% hyperbaric levobupivacaine in orthopedic surgeries under subarachnoid block. Materials and Methods: This prospective randomized study included 90 American Society of Anesthesiologists Grade I and II patients aged 18–60 years undergoing orthopedic surgeries. Group LS received 3 mL 0.5% levobupivacaine heavy+0.5 mL normal saline. Group LF received 3 mL 0.5% levobupivacaine heavy+fentanyl 25 μg, and Group LM, 3 mL 0.5% levobupivacaine heavy+magnesium sulphate 50 mg+0.4 mL normal saline. The onset and duration of sensory and motor block and intraoperative hemodynamics were recorded. In the post-operative period, duration of analgesia, Visual Analog Scales scores, and side effects were observed. Results: The onset of sensory block was 4.04±0.74 min in Group LM (P&lt;0.001) as compared to Groups LF (2.01±0.23 min) and LS (2±0.24 min). The onset of motor blockade took 5±1.14 min in the control group, 7.01±0.94 in group LF, and 8.11±1.33 min in group LM (P&lt;0.001). The duration of analgesia in group LS was 183.73±12.08 min, 317±18.6 min in group LF, and 219.43±20.89 in group LM (P&lt;0.001). Conclusion: The addition of fentanyl and magnesium as adjuvants enhanced the quality of subarachnoid block when added to hyperbaric levobupivacaine. The duration of analgesia was longest in fentanyl, followed by magnesium and then control. The incidence of side effects was greatest in fentanyl, followed by control and nil in magnesium.

The median effective concentration of epidural ropivacaine with different doses of dexmedetomidine for motor blockade: an up-down sequential allocation study.

Recent studies have shown that dexmedetomidine can be safely used in peripheral nerve blocks and spinal anesthesia. Epidural administration of dexmedetomidine produces analgesia and sedation, prolongs motor and sensory block time, extends postoperative analgesia, and reduces the need for rescue analgesia. This investigation seeks to identify the median effective concentration (EC50) of ropivacaine for epidural motor blockade, and assess how incorporating varying doses of dexmedetomidine impacts this EC50 value. Prospective, double-blind, up-down sequential allocation study. Operating room, post-anesthesia care unit, and general ward. One hundred and fifty patients were allocated into five groups in a randomized, double-blinded manner as follows: NR (normal saline combined with ropivacaine) group, RD0.25 (0.25 μg/kg dexmedetomidine combined with ropivacaine) group, RD0.5 (0.5 μg/kg dexmedetomidine combined with ropivacaine) group, RD0.75 (0.75 μg/kg dexmedetomidine combined with ropivacaine) group, RD1.0 (1.0 μg/kg dexmedetomidine combined with ropivacaine) group. The concentration of epidural ropivacaine for the first patient in each group was 0.5%. Following administration, the patients were immediately placed in a supine position for observation, and the lower limb motor block was assessed every 5 min using the modified Bromage score within 30 min after drug administration. According to the sequential method, the concentration of ropivacaine in the next patient was adjusted according to the reaction of the previous patient: effective motor block was defined as the modified Bromage score > 0 within 30 min after epidural administration. If the modified Bromage score of the previous patient was >0 within 30 min after drug administration, the concentration of ropivacaine in the next patient was decreased by 1 gradient. Conversely, if the score did not exceed 0, the concentration of ropivacaine in the next patient was increased by 1 gradient. The up-down sequential allocation method and probit regression were used to calculate the EC50 of epidural ropivacaine. Adverse events, hemodynamic changes, demographic data and clinical characteristics. The EC50 of epidural ropivacaine required to achieve motor block was 0.677% (95% CI, 0.622-0.743%) in the NR group, 0.624% (95% CI, 0.550-0.728%) in the RD0.25 group, 0.549% (95% CI, 0.456-0.660%) in the RD0.5 group, 0.463% (95% CI, 0.408-0.527%) in the RD0.75 group, and 0.435% (95% CI, 0.390-0.447%) in the RD1.0 group. The EC50 of the NR group and the RD0.25 group were significantly higher than that of the RD0.75 and the RD1.0 groups, and the EC50 of the RD0.5 group was significantly higher than that of the RD1.0 group. The EC50 of epidural ropivacaine required to achieve motor block was 0.677% in the NR group, 0.624% in the RD0.25 group, 0.549% in the RD0.5 group, 0.463% in the RD0.75 group, and 0.435% in the RD1.0 group. Dexmedetomidine as an adjuvant for ropivacaine dose-dependently reduce the EC50 of epidural ropivacaine for motor block and shorten the onset time of epidural ropivacaine block. The optimal dose of dexmedetomidine combined with ropivacaine for epidural anesthesia was 0.5 μg/kg.

Comparison of postoperative analgesia effects between subcostal anterior quadratus lumborum block and transversus abdominis plane block in bariatric surgery: a prospective randomized controlled study

BackgroundCurrently, the prevalence of obesity is on the rise annually. Bariatric surgery stands out as the most efficacious approach for addressing obesity. Obese patients are more prone to experience moderate to severe pain after surgery due to lower pain thresholds. Regional block, as an important component of multimodal analgesia in bariatric surgery, is crucial in reducing opioid consumption and alleviating postoperative pain in patients undergoing bariatric surgery.Transversus abdominis plane block (TAPB) has gained widespread utilization in bariatric surgery; however, its limitation of inadequate reduction of visceral pain in obese patients remains a significant concern. Therefore, it is imperative to explore new and more efficient strategies for analgesia. Quadratus lumborum block (QLB) has emerged as a popular nerve block in recent years, frequently utilized in conjunction with general anesthesia for abdominal surgery. In the cadaver study of QLB, it was confirmed that the dye level could reach up to T6 when using the subcostal anterior quadratus lumborum muscle approach, which could effectively reduce the incision pain and visceral pain of bariatric surgery patients during the perioperative period.However, there is currently a lack of research on the use of subcostal anterior QLB in patients undergoing bariatric surgery. Our study aims to investigate whether subcostal anterior QLB can provide superior perioperative analgesic efficacy for bariatric surgery under general anesthesia compared to TAPB, leading to reduced postoperative opioid consumption and a lower incidence of postoperative nausea and vomiting (PONV).Methods and designThis study is a prospective, randomized controlled trial aiming to recruit 66 patients undergoing bariatric surgery. The participants will be randomly allocated into two groups in a 1:1 ratio: subcostal anterior QLB group (n = 33) and TAPB group (n = 33). The study aims to investigate the efficacy of subcostal anterior QLB and TAPB in obese patients who are scheduled to undergo bariatric surgery. Our primary outcome is to observe the amount of opioids used in the two groups 24 h after operation. The secondary outcomes included VAS of pain during rest/activity after operation, the type and dose of additional analgesics, the occurrence and severity of PONV, the type and dose of additional antiemetic drugs, postoperative anesthesia care unit (PACU) time, time of first postoperative exhaust, time to first out of bed activity, time to first liquid diet and postoperative admission days.DiscussionOpioid analgesics are prone to causing adverse reactions such as nausea, vomiting, and respiratory depression, especially in obese patients. Multimodal analgesia, including nerve block, can effectively reduce the dose of opioids and alleviate their adverse effects. Currently, TAPB is the most prevalent nerve block analgesia method for abdominal surgery. Recent studies have indicated that subcostal anterior QLB offers advantages over TAPB, including a wider block plane, faster onset, and longer maintenance time. It is not clear which of the two nerve block analgesia techniques is better for postoperative analgesia in patients undergoing bariatric surgery. Our objective in this investigation is to elucidate the superior method between TAPB and subcostal anterior QLB for postoperative pain management in bariatric surgery.Trial registrationChiCTR ChiCTR2300070556. Registered on 17 April 2023.

A comparative study to assess the effects of intrathecal fentanyl and intrathecal tramadol combined with 0.5% bupivacaine heavy in patients undergoing elective urological surgeries: A prospective randomized study

Background: Urological operations frequently involve the use of spinal anesthesia. In the present scenario, adding different adjuvants to local anesthetic improve its quality and duration has become common. Aims and Objectives: In patients undergoing elective urological procedures, the purpose of this study was to assess the effects of intrathecal fentanyl or tramadol with 0.5% bupivacaine heavy. Materials and Methods: Patients were divided into two groups of 30 patients each, a total of 60 patients aged 20–60 years undergoing elective urological surgeries participated in this prospective, randomized study in which 25 μg fentanyl and 2.5 mL of 0.5% bupivacaine heavy were given to Group F, while 25 mg tramadol and 2.5 mL of 0.5% bupivacaine heavy were given to Group M. The onset and duration of sensory and motor blockage, the duration of analgesia, post-operative Visual Analog Scale score, hemodynamic changes, and adverse effects were evaluated. Results: Fentanyl had a lower mean time of onset for sensory (2:33±0:22 min vs. 4:50±0:33 min) and motor block (3:36±0:28 min vs. 5:52±0:38 min) (P&lt;0.001), the duration of sensory (185.67±3.155 min vs. 152.60±4.264), motor block (172.00±4.177 min vs. 136.40±5.575 min), and post-operative analgesia was longer in the fentanyl group (P&lt;0.001), whereas the incidence of adverse effects such as pruritus, shivering, and nausea was lower in the tramadol group. Conclusion: The quality and duration of spinal anesthesia were found to be significantly increased by the use of fentanyl as an adjuvant in our study. However, tramadol also produced stable hemodynamics and exhibited fewer adverse effects than fentanyl.