Regional Anesthesia Techniques Research Articles

Ultrasound: Ankle and Foot Blocks

Ankle blocks are regional anaesthetic techniques used for foot surgery and pain management. Traditionally performed with anatomical landmarks, ultrasound-guided ankle and foot blocks have emerged as a pivotal technique in regional anaesthesia, offering enhanced precision and safety over traditional methods. This review article examines the current practices in ultrasound-guided ankle and foot blocks, including the necessary equipment, sonoanatomy, and injection techniques for various nerves. This comprehensive review aims to equip anaesthesiologists with the knowledge to effectively implement ultrasound-guided ankle and foot blocks, ultimately optimizing pain management and procedural success in lower extremity interventions. Keywords: Ankle block, Ultrasound guidance, Foot and ankle surgery

Shoulder Surgeries under Regional Anesthesia Approach and Outcome - A Case Series.

Shoulder surgeries (arthroscopic or open) are usually performed under general anesthesia or combined with regional anesthesia. Post-operative pain following shoulder surgery is usually very severe and hinders early mobility of joints and recovery; which is also a cause of mental stress for the patient. Regional anesthetic techniques are known to provide excellent pain control postoperatively, both at rest and on movement. It allows faster recovery with earlier mobilization of joints. Profound knowledge of neural innervation of the shoulder is very essential to provide successful regional anesthesia for shoulder surgeries. We underwent a case series of 10 patients with multiple comorbidities and were categorized as high-risk patients, posted for shoulder surgeries under regional anesthesia (PNS-guided interscalene brachial plexus block combined with suprascapular nerve block). Five out of ten patients were of the ASA 3 category, with multiple comorbidities. Shoulder surgeries (arthroscopic/open) were planned under regional anesthesia with mild sedation and resulted in better surgeon and patient satisfaction perioperatively. Interscalene nerve block combined with suprascapular nerve block should be considered an alternative approach to general anesthesia for shoulder surgeries. Thus sole regional anesthesia can be considered a novel approach for all types of shoulder surgeries and is significantly safer for ASA Grade III and IV patients.

Efficacy of Levobupivacaine in Regional Anaesthesia - A Narrative Review

Background: The pursuit of safer and more effective anesthetic agents continues to be a key focus in anesthesiology. Levobupivacaine, a purified derivative of bupivacaine, has emerged as a preferable alternative for regional anesthesia due to its enhanced safety profile. Clinical studies have shown that levobupivacaine provides similar efficacy to bupivacaine but with a more favorable pharmacokinetic profile. It has been well-tolerated in various regional anesthesia techniques, including bolus administration and continuous postoperative infusion, with few adverse drug reactions, typically linked to incorrect administration or pharmacological effects. Allergic reactions are rare. Comparative studies indicate that levobupivacaine and bupivacaine offer comparable surgical sensory blocks, adverse effects, and labour analgesia outcomes, with similar safety profiles for both maternal and fetal health. Objectives: This review aims to examine the pharmacokinetic and pharmacological benefits of levobupivacaine, highlighting its safety and clinical applications based on current evidence. Results: Levobupivacaine is generally more powerful than ropivacaine but less strong than bupivacaine, according to the majority of clinical investigations. A total of 60 studies were discovered. Some studies, such as those with unavailable full-text publications, were eliminated. Finally, 26 publications were chosen and studied since they were relevant to the current review aims. Sushma examined, in 60 patients receiving axillary block utilizing the nerve stimulation technique, the effects of 30 ml of 1.5% lidocaine with adrenaline compared to 30 ml of 0.333% levobupivacaine. Agarwal compared the effectiveness of bupivacaine and levobupivacaine in 56 patients receiving supraclavicular brachial plexus block. Levobupivacaine, according to the study, caused both motor and sensory blocks to start more quickly. Conclusion: Levobupivacaine is a long-acting local anesthetic that closely resembles bupivacaine in its clinical effects, but it offers specific advantages such as reduced cardiotoxicity.

Layered and Thoracic Segmental Spinal Anaesthesia in Patients with Kyphoscoliosis for Various Surgeries: A Case Series

Kyphoscoliosis involves exaggerated anterior and lateral curvatures of the spine, affecting the dorsolumbar spine. Associated multiple organ system dysfunctions cause difficulties with both general and regional anaesthetic techniques. Co-existing neuromuscular disorders, pulmonary infections, difficulties in securing the airway, postoperative pulmonary morbidities, and the need for mechanical ventilation associated with general anaesthesia make neuraxial anaesthesia the most widely used technique in these cases. Continuous neuraxial techniques in these patients offer advantages over single-shot spinal anaesthesia in achieving the desired level of anaesthesia, managing patchy blocks, extending the duration of anaesthesia, and providing postoperative analgesia, but they are technically more challenging. Single-shot spinal anaesthesia can be a simple, safer, and effective alternative for surgical procedures of shorter duration. Performing thoracic segmental spinal anaesthesia in these patients is very challenging due to the complete distortion of anatomy and possible obliteration of neuraxial spaces. Layered spinal anaesthesia involves combining multiple local anaesthetics with different baricities to produce a successful subarachnoid block. Present series is reported with successful and uneventful use of the layered and thoracic segmental spinal anaesthetic technique in patients with kyphoscoliosis for various surgeries, including laparoscopic procedures.

Study to compare the incidence of post-dural puncture headache in obstetric patients using cutting and pencil-point spinal needle in spinal anesthesia

Background: Spinal anesthesia is one of the most commonly used regional anesthesia techniques. Post-dural puncture headache (PDPH) is a well-known iatrogenic consequence of spinal anesthetic and diagnostic lumbar puncture, primarily caused by loss of cerebral spinal fluid. To reduce complications, spinal needles have undergone modifications. The two most important modifiable risk variables for PDPH were needle shape and size. In young expecting mothers, post-cesarean sections are associated with an increased incidence of PDPH. Aims and Objectives: The aims and objectives of the study are to compare the incidence of PDPH in obstetric patients using cutting and pencil-point spinal needles following spinal anesthesia. Materials and Methods: This 1-year double-blind study was carried out in the Department of Anaesthesia from August 2021 to July 2022. The study comprised obstetric patients who were scheduled for elective-segment cesarean section. The subarachnoid block needle was divided into Groups A and B at random: Group A 25-gauge Whitacre spinal needle with a pencil point, whereas Group B 25-gauge Quincke spinal needle with a cutting bevel. Records were kept on age, height, weight, and gestational age. A follow-up was conducted up until the discharge date. The incidence and severity of PDPH after spinal anesthesia were examined in both groups. The results were analyzed with SPSS 20.0, and the Fischer exact and Chi-square tests were used to look for statistical significance. Results: The current study included 120 patients in total, 60 patients in each of Groups A and B. When a pencil point Whitacre was used, the incidence of PDPH was 2 (3.3%), however, when a cutting Quincke needle was used, the incidence was 7 (10.8%). With a P < 0.05, the relationship between the two was considered statistically significant. The pain severity was mild in both patients of Group A. Of the seven patients in Group B, four had mild pain, two had moderate pain, and one had severe pain. Conclusion: The pencil-point 25-G Whitacre spinal needle has a lower incidence of PDPH than the traditional 25-G Quincke needle and was suggested for patients at risk of PDPH. In light of this, the current study suggested using pencil-point spinal needles for lumbar punctures and spinal anesthesia in obstetric patients.

Enhancing Pediatric Regional Anesthesia: A Narrative Review of Adjuvants used with Local Anesthetics

Abstract Pediatric regional anesthesia has become an integral part of perioperative pain management strategies in children. Adjuvants play a pivotal role in augmenting the efficacy and prolonging the duration of regional anesthesia techniques, thereby improving postoperative pain control, and reducing opioid consumption. This review provides a comprehensive overview of the various adjuvants utilized in pediatric regional anesthesia, highlighting their mechanisms of action, clinical applications, efficacy, and safety profiles.

Erector spinae plane block in spine surgeries: Single-level versus bi-level, single-shot versus continuous catheter technique.

Erector spinae plane block (ESPB) is one of the commonly preferred regional anesthesia techniques in the recent past for various procedures including spine surgeries. The main advantages of ESPB are the ease of performing the technique and the lesser chance of complications. Many studies have proven that ESPB plays an important role in reducing perioperative opioid consumption, postoperative nausea and vomiting, as well as the length of stay in the hospital. Thus it has been adopted as one of the measures for the enhanced recovery after surgery (ERAS) protocol. Nevertheless, the role of bi-level ESPB and a continuous catheter technique are the major research gaps and thus require further research in this population. The details of these two methods are discussed elaborately here.

Effectiveness of Consecutive Versus Premixed Administration of Fentanyl and Bupivacaine in Subarachnoid Block for Total Abdominal Hysterectomy

Background: Subarachnoid block (SAB) was a common regional anaesthetic technique, with opioids as adjuvants to enhance effectiveness and reduce hypotension. Objective: Comparison of the effectiveness of consecutive versus premixed administration of fentanyl and hyperbaric bupivacaine in subarachnoid block for TAH. Methods: This Quasi experimental study was carried out in 70 patients divided into two groups of 35 each: Group A received 0.5% hyperbaric bupivacaine 15mg (3ml) premixed with fentanyl 25µg (0.5ml) in a same syringe and Group Breceived fentanyl 25µg (0.5ml) in one syringe followed by 0.5% hyperbaric bupivacaine 15mg (3ml) in a separate syringe. The study compared the onset of sensory and motor block, reaching maximum sensory level, and complete motor block, as well as the time required for analgesia and ephedrine. Statistical significance was determined at a P-value < 0.05. Results: The study found that group B had significantly less time for onset of sensory block(3.45±0.41 vs 2.65±0.32min), motor block (4.51±0.53 vs 3.31±0.46min), and total ephedrine consumption (15.29±6.52 vs 11.86±5.95mg)compared to group A. Additionally, the time of sensory (236.8±21.7 vs 269.6±24.3 min) and motor block regression (203.8±18.6 vs 237.5±20.8min), and first required analgesia (248.2±23.3 vs 283.8±23.4 min)was longer in group B. Conclusion: Consecutive administration of fentanyl and hyperbaric bupivacaine is more effective than premixed administration in subarachnoid block for total abdominal hysterectomy.

Effectiveness of Prophylactic Ketamine on Shivering in Cesarean Section after Spinal Anesthesia

Background: Regional anesthesia, including spinal or epidural techniques, can disrupt the body's ability to regulate temperature, leading to a heightened risk of shivering. Studies have indicated that shivering occurs in up to 55% of patients undergoing procedures under regional anesthesia. To address this issue, numerous medications have been explored for their potential to prevent post-anesthetic shivering. Objective: To assess the effectiveness of prophylactic ketamine on shivering in cesarean section after spinal anesthesia. Study Design: Prospective, randomized, double blind, clinical trial. Settings: Department of Anesthesiology, Surgical Intensive Care Unit and Pain Management, Civil Hospital Karachi Pakistan. Duration: Six months from August 2019 to January 2020. Methods: A total of 60 patients undergoing spinal anesthesia for elective cesarean section were included in this study. Two groups A and B were formed and patients were equally divided into these groups by lottery method. Group A were treated with ketamine 0.5 mg/kg I/V and group B treated with normal saline 0.05ml/kg/I/V. Grade 0-1 shivering was labeled as effective and shivering grade 2, 3 or 4 at 15 minutes after administration of the drug, was considered ineffective. Results: The average age of the patients was 28.33 ± 5.67 Years. Rate of shivering was significantly high in patients who were treated with normal saline than ketamine in which shivering was not observed (53.3 vs. 0% respectively; P value of 0.0005). This implies that effectiveness was significantly high in groups A than group B (100% vs. 46.7%). Conclusion: Ketamine observed to be the effective drug for the treatment of postanesthetic shivering. It should be considered prophylactically in any patient undergoing spinal anesthesia.

Ultrasound-Guided Dorsal Penile Nerve Block in Children: An Anatomical-Based Observational Study of a New Anesthesia Technique.

Dorsal penile nerve block stands out as one of the commonly employed regional anesthetic techniques in children. Despite the large body of experience, failure rates are still significant. We included 20 children (median (SD) age of 73 (31) months) scheduled for circumcision without general anesthesia and secondary airway manipulation in a consecutive case series. Under ultrasound guidance and utilizing an in-plane needle guidance technique, the dorsal penile nerve block was administered with slight sedation, and spontaneous respiration was maintained in all cases. To investigate the underlying anatomy for dorsal penile nerve blockade, we dissected three cadavers. The primary study endpoint was the success rate of surgical blockade, meaning that the surgical procedure could be performed without additional general anesthesia and invasive airway management. The secondary endpoint was the requirement of analgesics until discharge from the post-anesthesia care unit. The primary endpoint was successfully met in all patients according to our strict definition without additional general anesthesia or airway manipulation. In addition, no child received analgesics until discharge from the recovery room. The anatomical investigation clarified the specific anatomy as baseline knowledge for an ultrasound-guided dorsal penile nerve blockade and enabled successful performance in 20 consecutive children where penile surgery was possible in light sedation without additional airway manipulation.

Multiple Thoracic Wall Blocks for Awake Breast Surgery: A Case Report.

Awake breast surgeries under nerve blocks have been a challenge for anaesthesiologists, and different block combinations have been used for surgery under sedation. Thoracic paravertebral block (TPVB) was thought to be sufficient alone for surgical anaesthesia of the breast. We performed a combination of TPVB, pectoralis nerve I block, and serratus anterior plane block for awake breast surgery in an elderly patient with serious comorbidities. Surgical anaesthesia was achieved, excluding skin incision. Any regional anaesthesia technique alone is not sufficient; rather, multiple thoracic wall blocks are needed for surgical anaesthesia of the breast.

Regional anesthesia for hip surgery in children: A review

Hip joint diseases are one of the most common and difficult problems in pediatric orthopedics, often requiring surgical treatment. In children, intra- and postoperative analgesia after hip surgery is more conservative and limited to epidural anesthesia, which has known disadvantages and limitations, despite the high quality of pain relief. Peripheral regional blocks in hip surgery are widespread in adults. Ultrasound navigation makes peripheral blockades safer and more effective. This largely influenced the spread of their use in children and contributed to the introduction of new methods of planar blockades into practice. The authors analyzed studies on the efficacy and safety of modern methods of peripheral regional blockade used in children during hip surgery. The literature search was conducted in the eLibrary, PubMed, and Scopus databases. By using keywords, 750 literature sources were found, and 65 sources relevant to the purpose of the study were included in the review. The lumbar plexus block and fascia iliaca block are the most studied regional techniques in children, which are not inferior in analgesic efficacy to lumbar epidural and caudal anesthesia. A new and promising method of regional anesthesia of the hip is the pericapsular nerve group block, which has been well studied in adults. However, none of the peripheral regional techniques used for analgesia after hip surgery, has not proven its advantages. Further clinical studies are needed to investigate peripheral regional anesthesia techniques and determine their efficacy and safety in pediatric hip surgery.

Regional anaesthesia practice in public hospitals in Botswana: A cross-sectional study.

Little is known about the regional anesthesia practice in low resources settings (LRS). The aim of this study was to describe the regional anesthesia capacity, characteristics of regional anesthesia practice, and challenges and solutions of practicing safe regional anesthesia in public hospitals in Botswana. This was a cross-sectional survey of anesthesia providers working in public hospitals in Botswana. A purposive sampling method of public hospitals was used to achieve representation of different hospital levels across Botswana. Paper-based questionnaires were sent to anesthesia providers from selected hospitals. Descriptive statistics were used for analysis. Questionnaires were distributed to 47 selected anesthesia providers from selected hospitals; 38 (80.9%) were returned. Most participants were nurse anesthetists and medical officers (57.8%). All hospitals perform spinal anesthesia; however, other regional techniques were performed by a small number of participants in one referral hospital. Most hospitals had adequate regional anesthesia drugs and sedation medications, however, most hospitals (except one referral hospital) lacked ultrasound machine and the regional anesthesia kit. The common challenges reported were lack of knowledge and skills, lack of equipment and supplies, and lack of hospital engagement and support. Some solutions were proposed such as regional anesthesia training and engaging the hospital management to get resources. The results of this study suggest that spinal anesthesia is the most common regional anesthesia technique performed by anesthesia providers working in public hospitals in Botswana followed by few upper limb blocks. However, most public hospitals lack enough training capacity, equipment, and supplies for regional anesthesia. More engagement of the hospital management, investment in regional anesthesia resources, and training are needed in order to improve the regional anesthesia capacity and provide safe surgery and anesthesia in Botswana.

Comparative Evaluation of Two Different Doses of Dexmedetomidine for Intra Operative Moderate Sedation During Spinal Anesthesia

Background: Intravenous (IV) sedation is often used to relieve anxiety or stress during surgery under regional anesthesia. Subarachnoid block is a widely followed regional anaesthesia technique, especially in lower abdominal and lower limb surgeries. Intense sensory and motor block, continuous supine position and the inability to move the body also brings a feeling of discomfort and phobia in many patients. Sedation has been shown to increase patient satisfaction during regional anaesthesia. Dexmedetomidine is well suited for conscious sedation as patient can be quickly aroused and oriented on demand. Aim of this study was to compare infusion doses of 0.3μg/kg/hr and 0.5μg/kg/hr, after loading dose of 1μg/kg of injection (inj).dexmedetomidine in order to obtain a better regimen for patients undergoing procedures under spinal anaesthesia in terms of sedation and hemodynamic stability.
 Objective: To compare efficacy of dexmedetomidine for intraoperative sedation and hemodynamic stability at doses of 0.3μg/kg/hr and 0.5μg/kg/hr after loading dose of 1 μg/kg in patients operated under spinal anaesthesia.
 Methods: Adult 80 Patients were randomly divided into two groups, (Group D-0.3) and (Group D-0.5). They were given spinal anaesthesia with 0.5% hyperbaric bupivacaine and initial dose of inj.dexmedetomidine 1 μg/kg was infused over 10 minutes. Group D-0.3 received maintenance dose of inj.dexmedetomidine of 0.3μg/kg/hr and Group D-0.5 received maintenance dose of 0.5μg/kg/hr. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), respiratory rate (RR), spO2 and sedation using observer’s assessment of alertness/sedation (OASS) were recorded at baseline, after loading dose, before spinal anesthesia, after spinal anesthesia at every 5 minutes upto 30 minutes, followed by every 15 minutes till the end of surgery and every 5 minutes upto 15 minutes after surgery. Data were compared using chi-square and unpaired t test. 
 Results: The mean age for Group D-0.3 is 43.9+11 and for Group D-0.5 is 35.3+20. There is no statistically significant difference in demographic profile between two groups. It was also observed that there is no statistically significant difference in HR, SBP, DBP, MAP, RR and SpO2 in all point of time (p>0.05). According to sedation score in group D-0.3 72% patients were sleeping comfortably but easily arousable and 8% patients were in deep sleep, while in group D-0.5 70% were sleeping comfortably but easily arousable and 15% in deep sleep.
 Conclusion: After a loading dose of 1 μg/kg intravenously, an iv infusion of dexmedetomidine at a lower rate, i.e. 0.3μg/kg/hr is equally effective in providing sedation for patients undergoing surgeries under spinal anesthesia as 0.5μg/kg/hr.

The effect of general anesthesia applied during cesarean section on newborn bilirubin

Aims: Today, delivery is often performed as normal spontaneous vaginal delivery (NSVD) and cesarean section operations. Deliveries with NSVD mostly take place in the delivery room without the need for additional anesthetic agents. General anesthesia and regional anesthesia techniques are applied in cesarean section operations. In this study; The aim of this study was to examine the effect of general anesthesia on newborn bilirubin and to compare it with the bilirubin level of babies born without general anesthesia with NSVD method. Methods: Between March 2022 and September 2022, 152 patients over the age of 18 with term pregnancy NSVD and elective cesarean section without complications were randomly included in the study. Cases diagnosed with liver and biliary tract disease, systemic liver and biliary tract effective drug use, DCOOMBS( +) and Covid (+) clinics were excluded. Results: Of the patients included in our study, 75 (49.3%) were given general anesthesia and 77 (50.7%) delivered with NSVD without general anesthesia. It was determined that the first hour bilirubin and the fourth hour bilirubin values were significantly higher (p <0.05) in the general anesthesia group compared to the group that did not receive general anesthesia. In the group that did not receive general anesthesia, the APGAR 5th min score was found to be significantly (p <0.05) higher than the general anesthesia group. APGAR 1 min value did not differ significantly (p > 0.05) between the anesthesia-free and general anesthesia groups. Neonatal weight, head circumference, and infant height did not differ significantly between the groups that did not receive general anesthesia and those who did not receive general anesthesia (p> 0.05). Conclusion: Among the groups that did not receive general anesthesia and anesthesia; Bilirubin value was found to be higher among babies born by cesarean section under general anesthesia. It seems that it is more beneficial to avoid systemic effects as much as possible and to disseminate NSVD.

Patient Satisfaction With, and Outcomes of, Ultrasound-Guided Regional Anesthesia at a Referral Hospital in Tanzania: A Cross-Sectional Study.

Regional anesthesia techniques are increasingly used in high-income countries (HICs) for both surgical anesthesia and postoperative analgesia. However, regional anesthesia has not been utilized to the same degree in low- to middle-income countries (LMICs) due to a lack of resources and trained personnel. This study evaluates patient satisfaction with, and outcomes of, ultrasound-guided regional anesthesia for extremity surgery at Kilimanjaro Christian Medical Center (KCMC) in the Northeastern zone of Tanzania. Study patients were ≥18 years of age; American Society of Anesthesiologists (ASA) physical status I, II, or III; and underwent extremity surgery under peripheral nerve block with ultrasound guidance at KCMC. After placement, blocks were assessed for effectiveness intraoperatively, as demonstrated by the need for supplemental analgesic or sedative medication or conversion to a general anesthetic. Postoperatively, patients were assessed for satisfaction with their nerve block and pain at 12 and 24 hours. Adverse events related to regional anesthesia were assessed immediately, 45 minutes after block placement, and at 12 and 24 hours postoperatively. The primary outcome was patient satisfaction at 12 hours. Secondary outcomes were block success rate and analgesia at 12 and 24 hours postoperatively. A convenience sample of 170 patients was included in the study, of whom 156 (95% confidence interval [CI], 87-95) were either satisfied or very satisfied with their block. Block placement was highly successful with only 8 of 170 participants (95% CI, 2.4-8.3), requiring conversion to a general anesthetic. Analgesia continued in the postoperative period, with 164 of 170 (95% CI, 93-98) patients and 145 of 170 (95% CI, 80-90) patients reporting acceptable analgesia at 12 and 24 hours, respectively. No major adverse events, such as local anesthetic toxicity, infection, bleeding, nerve injury, or pneumothorax, were observed. Our study found that ultrasound-guided regional anesthesia in a resource-constrained setting was effective for extremity surgery and resulted in high patient satisfaction. No complications occurred. The use of ultrasound-guided regional anesthesia shows promise for the safe and effective care of patients undergoing extremity surgery in LMICs.

Current pediatric pain practice in Nigeria, South Africa, Uganda, and Zambia: A prospective survey of anesthetists.

Children in hospital experience significant pain, either inherent with their pathology, or caused by diagnostic/therapeutic procedures. Little is known about pediatric pain practices in sub-Saharan Africa. This survey aimed to gain insight into current pain management practices among specialist physician anesthetists in four sub-Saharan African countries. A survey was sent to 365 specialist physician anesthetists in Nigeria, South Africa, Uganda and Zambia. Content analysis included descriptive information about the respondents and their work environment. Thematic analysis considered resources available for pediatric pain management, personal and institutional pain practices. One hundred and sixty-six responses were received (response rate 45.5%), with data from 141 analyzed; Nigeria (27), South Africa (52), Uganda (41) and Zambia (21). Most respondents (71.83%) worked at tertiary/national referral hospitals. The majority of respondents (130/141, 91.55%) had received teaching in pediatric pain management. Good availability was reported for simple analgesia, opioids, ketamine, and local anesthetics. Just over half always/often had access to nurses trained in pediatric care, and infusion pumps for continuous drug delivery. Catheters for regional anesthesia techniques and for patient-controlled analgesia were largely unavailable. Two thirds (94/141, 66.67%) did not have an institutional pediatric pain management guideline, but good pharmacological pain management practices were reported, in line with World Health Organization recommendations. Eighty-eight respondents (62.41%) indicated that they felt appropriate pain control in children was always/often achieved in their setting. This survey provides insight into pediatric pain practices in these four countries. Good availability of a variety of analgesics, positive pain prescription practices, and utilization of some non-pharmacological pain management strategies are encouraging, and suggest that achieving good pain control despite limited resources is attainable. Areas for improvement include the development of institutional guidelines, routine utilization of pain assessment tools, and access to regional anesthesia and other advanced pain management techniques.

COMPARATIVE CLINICAL EVALUATION OF CAUDAL BUPIVACAINE VERSUS BUPIVACAINE PLUS TRAMADOL FOR PEDIATRIC INFRAUMBILICAL SURGERIES: A STUDY ON POSTOPERATIVE ANALGESIA

Objective: Effective post-operative pain management is crucial in pediatric patients undergoing infraumbilical surgeries. Various regional anesthesia techniques, including caudal block, have been used to provide post-operative analgesia in children. The addition of tramadol, a synthetic opioid analgesic, to bupivacaine in caudal anesthesia has shown potential benefits. This study aims to compare the clinical efficacy of single-shot caudal bupivacaine alone versus bupivacaine plus tramadol for post-operative analgesia in pediatric infra-umbilical surgeries. Methods: A prospective, randomized, double-blinded clinical study was conducted at our institute. The present study will be carried out in 60 pediatric patients of the American Society of Anesthesiologists Grades I and II between the age of 1 and 8 years, undergoing infraumbilical surgeries. These children were randomly divided into 2 groups. Group B (n=30) received caudal block with 0.25% bupivacaine (1 mL/kg) and Group BT (n=30) received caudal block with 0.25% bupivacaine (1 mL/kg) with tramadol (1 mg/kg). The variables studied were hemodynamic changes, duration of analgesia, and incidence of side effects. Pain assessment was done at 1, 2, 3, 4, 8, 12, and 24 h post-operatively using modified objective pain scale. Results: It was observed that the mean duration of analgesia in Group BT (9.05±2.21) h was significantly longer (p=0.0001) than Group B (3.78±0.94) h. Hemodynamic parameters remained comparable during intraoperative and post-operative periods. There was no incidence of nausea, vomiting, bradycardia, hypotension, pruritus, or decrease in respiratory rate in the two groups. Conclusion: In our study, we concluded that a single-shot caudal block with 0.25% bupivacaine (1 mL/kg) plus tramadol (1 mg/kg) resulted in longer duration of analgesia when compared to 0.25% bupivacaine (1 mL/kg) alone with no incidence of any side effects.

Comparison of Pericapsular Nerve Group (PENG) Block Versus Quadratus Lumborum (QL) Block for Analgesia After Primary Total Hip Arthroplasty Under Spinal Anesthesia: A Retrospective Study.

Total hip arthroplasty (THA) is one of the most common operative procedures performed. Controlling postoperative pain following THA remains a challenge due to the complex innervation of the hip joint and the recent desire to preserve motor function following nerve blockade. Several nerve block techniques have been used for THA in the past, but the quadratus lumborum (QL) block and the blockade of the pericapsular nerve group (PENG) have emerged as opiate-sparing regional anesthesia techniques that preserve motor function. To date, little data comparing thetwo block techniques exists. The purpose of our study was to compare outcomes following these techniques in patients undergoing primary THA. This retrospective analysis utilized data from three distinct groups who underwent primary THA at our institution: 45 patients who received PENG block, 38 patients who received QL block, and 77 control patients. Chart review analysis was performed by authorized personnel to obtain cumulative oral morphine equivalent(OME) data at 24 and 48 hours postoperatively (primary outcomes). In addition, visual analog pain scale (VAS) scores in the post-anesthesia care unit (PACU) and at 12, 24, and 48 hours, ambulation distance, and length of hospital stay data were obtained (secondary outcomes). Group comparisons were conducted using either analysis of variance (ANOVA) with Tukey's multiple comparison test for parametric data or Krustal-Wallis with Dunn's multiple comparison tests for nonparametric endpoints. This study found a statistically significant difference in cumulative OME usage across all groups at 24 and 48 hours. Significant difference in OMEs was found between QL and control and PENG and control; however, no difference was found in OMEs between PENG and QL groups at either time point. There was a statistically significant difference in VAS scores in the PACU across all groups; QL showed significantly lower VAS scores in the PACU compared to PENG and control, while PENG only showed significantly lower VAS scores compared to control. There was a statistically significant difference in VAS scores at 24 hours across all groups; however, only QL showed significantly lower VAS scores compared to control at 24 hours. QL was associated with a statistically significant increase in the length of hospital stay compared to PENG. This study showed no difference between OME usage in patients who received PENG or QL nerve blocks for primary THA. VAS scores were similar between groups with the exception of QL outperforming PENG in the PACU. Optimizing postoperative pain via multi-approach strategies should remain a priority for patients undergoing THA.Future research is warranted in order to provide guidance on best practice for these patients.

Spinal Anesthesia Ambulation Time of Cervical Cancer Brachytherapy Outpatient Clinic: Comparison of 5 mg Hyperbaric Bupivacaine Fentanyl with 2,5 mg Hyperbaric Bupivacaine and 25 mcg Fentanyl

Introduction: Regional anesthetic techniques and local anesthesia have proven to be more effective than general anesthesia in the practice of ambulatory anesthesia. Spinal anesthesia is the technique of choice for ambulatory anesthesia in cervical cancer brachytherapy patients. Low-dose local anesthetics can speed up the ambulation time. This study aims to compare the ambulation time of low-dose spinal anesthesia with conventional doses. Fast ambulation time can speed up recovery time for patients, thereby reducing the patient's length of stay.
 Methods: This study was a double-blind, randomized controlled trial conducted in August – September 2022 at the Radiotherapy Installation of Dr. Mohammad Hoesin General Hospital (RSMH) Palembang. All cervical cancer patients undergoing brachytherapy in adults with ASA I-II physical status were included in the study sample. Samples will be randomized into two groups, namely a combination of hyperbaric bupivacaine 5 mg and fentanyl 25 mcg and a group of bupivacaine 2.5 mg and fentanyl 25 mcg. Patients with allergies, impaired motor function, spinal failure, block level not achieved, shock, apnea, respiratory depression, and experiencing pain during the procedure were excluded from the study.
 Results: Ambulation time in the hyperbaric bupivacaine 5 mg and 25 mcg fentanyl group was longer than the hyperbaric bupivacaine 2.5 mg and 25 mcg fentanyl (155.22 + 10.68 minutes versus 98.69 + 7.13 minutes) with a significance level of p<0.001. Spinal anesthetic drugs work in a dose-dependent manner. Increasing the dose will increase the duration of action of the spinal anesthetic. The only side effects found were hypotension and pruritus.
 Conclusion: Spinal anesthesia with hyperbaric bupivacaine 2.5 mg and fentanyl 25 mcg can accelerate the ambulation time of cervical cancer patients undergoing brachytherapy.