Regional Block Research Articles

In Response to: Determining Postoperative Analgesic Efficacy of Dexamethasone Plus Bupivacaine for Regional Block.

In Response to: Determining Postoperative Analgesic Efficacy of Dexamethasone Plus Bupivacaine for Regional Block.

Analgesia-nociception index accurately predicts inadequate pectoralis muscle fascia block (PECS) in patients undergoing breast surgery: A prospective observational study

BackgroundPostoperative opioid administration has been largely replaced by regional anesthesia techniques. We aimed to determine whether intraoperative Analgesia-Nociception Index (ANI) can aid in early evaluation of the effectiveness of regional blocks such as the pectoralis muscle fascia block (PECS, pectoserratus and interpectoral plane blocks) and predicting the need for analgesics postoperatively. MethodsThis prospective observational study enrolled 30 women (age: 20–80 years) undergoing unilateral, non-intubated, breast tumor excision alone or in conjunction with sentinel lymph node biopsy. PECS block was performed following sedation. ANI readings were obtained at 1-min intervals, and polar coordinates were assigned to the distance from the nipple (0.5-cm intervals) and o'clock position (15-min intervals) for each reading. Pain scores were assessed using a numeric rating scale from 0 to 10, and analgesics were administered depending on pain score post-operatively. Results8 (27%), 19 (63%), and 3 (10%) patients received morphine, tramadol, and no analgesics, respectively. In total, 954 ANI measurements were obtained. At the proposed cut-off of 50, the sensitivity and specificity of the ANI nadir for need of post-operative opioids were 0.875 and 0.932, respectively. Block effectiveness was most satisfactory in the upper lateral quadrant of the breast with nipple–areolar complex (NAC) sparing effect. Most average ANI measurements for the NAC were <50. No patient experienced postoperative nausea/vomiting, although one reported dizziness. ConclusionsThe intraoperative ANI nadir <50 was strongly correlated with need for postoperative opioids. The ANI may aid in objectively evaluating the effectiveness of pectoralis muscle fascial blocks and predicting postoperative need for analgesics.

Analysis of Community Institutions in the Management of KPHP Awota: A Case Study in Indonesia

Institutions can be interpreted as an instrument that regulates relationships between people or groups. The existence of the community in the forest area, with all the potential resources that have been owned and managed so far, is of course under the auspices of an institution. This paper aims to provide information about the institutional potential of the farming community in the empowerment block and certain areas in KPHPAwota area in Wajo Regency, South Sulawesi Province. The research was conducted in September 2016 - January 2017. Data collection was carried out through Observation, Resources Mapping, Indepth Interview, Focus Group Discussion (FGD), and documentation studies with farmer community groups in and around forest areas in empowerment blocks and regional blocks. certain. The results show that the institutional potential of farming communities in empowerment blocks and special region seeks the success of each business unit in the forest area which cannot be separated from the role of counselor and farmer activity at each stage.

Analysing the interplay between energy transition, resource consumption, deforestation, and environmental factors on agricultural productivity: Insights from APEC countries

The growing focus on regional and international environmental cooperation has helped further discussions about environmental sustainability. This study evaluates agricultural economic productivity and how it is affected by natural resource consumption, energy transition, deforestation, global trade integration and environmental degradation in Asia-Pacific Economic Cooperation (APEC) countries. Our empirical findings from CS-ARDL, AMG and CCEMG help us reveal that environmental degradation, deforestation and natural resource abundance lower agricultural productivity, while energy transition and global trade integration improve agricultural productivity. Additionally, despite being highly integrated within global economic structure, APEC countries have not been able to boost agricultural productivity more than other regional blocks. We propose novel policy recommendations for APEC policymakers to improve environmental sustainability and agricultural productivity.

Assessing postoperative analgesic efficacy of a new regional block for video-assisted thoracoscopic surgery.

Assessing postoperative analgesic efficacy of a new regional block for video-assisted thoracoscopic surgery.

Erector spinae plane block for postoperative pain.

Erector spinae plane block for postoperative pain.

Retrospective analysis of regional anaesthesia in hip surgery: A clinical audit

IntroductionTotal hip arthroplasty is one of the most frequent surgical interventions in the hospital setting. Nonetheless, the ideal method to manage post-operative pain is still unknown. Multimodal analgesia techniques based on regional anaesthesia are amongst the most promising solutions. ObjectivesThe aim of this study was to evaluate postoperative pain after total hip arthroplasty according to whether peripheral nerve block was performed (femoral block, fascia iliaca block and pericapsular nerve group block). Intravenous morphine consumption during the patient’s stay in the post-anaesthesia care unit was measured, as well as the number of opioid rescues at 24 and 48 h post intervention. As secondary objectives, the prevalence of nerve injury, prolonged quadricipital block, and morphine consumption were established according to other variables of interest. Materials and methodsIn this observational retrospective study, data was collected from the electronic medical record of 656 traumatological surgery patients from April 2018 to August 2020, with the following inclusion criteria: over 18 years old, ASA I–III, primary total hip arthroplasty under general anaesthesia or subarachnoid anaesthesia (only with hyperbaric bupivacaine) and use of levobupivacaine for peripheral nerve block. ResultsA total of 362 patients were selected. The main surgical indication was coxarthrosis (61.3%), followed by hip fracture (22.6%). Peripheral nerve blocks were performed on 169 patients (66.3% femoral, 27.7% PENG, and 6.0% fascia iliaca). Mean postoperative opioid consumption in PACU was lower in patients in who received a PENG (2.2 mg) or a femoral (3.27 mg) block, compared to those who received neither (6.69 mg). There were no differences in opioid rescues at 24 and 48 h after the procedure. Nerve injury incidence was low (.8%), and not associated with nerve blocks. The incidence of prolonged quadricipital paralysis was also low (1.3%), and was mainly associated with femoral nerve block (75% of cases). ConclusionsThis retrospective study supports the use of regional blocks as opioid-sparing techniques, highlighting their role in rapid functional recovery with no motor impairment.

Comparison of the Efficacy Between Regional Nerve Block and Ring Block as Local Anesthetic Techniques for Platelet-Rich Plasma Treatment.

Introduction Platelet-rich plasma (PRP), a solution of concentrated platelets, has been widely used to promote wound repair and tissue regeneration. In the treatment of pattern hair loss, platelets in PRP secrete an abundance of growth factors, including platelet-derived growth factor (PDGF), fibroblast growth factor(FGF), and many more, which stimulate and increase signaling molecules and accelerate cell proliferation. In the PRP treatment for hair regrowth, the supratrochlear nerve (STN) block and supraorbital nerve (SON) block are given to anesthetize the scalp up to the vertex except for the temporal region. The ring block is the common local anesthetic technique usedby infiltrating local anesthetic agents around the target area. The primary objectives were to compare the pain and anesthetic success rates produced by regional nerve blocks and ring blocks. Materials and methods A sample size of 100 patients undergoing PRP treatment for hair regrowth were taken as the subjects for the study. Patients were allotted into two groups by randomization. Group 1 was given regional nerve blocks as the anesthetic technique used for local anesthesia, and group 2 was given ring blocks. In the study group, STN and SON blocks as the regional nerve blocks were given 2% lignocaine with 1:80000 adrenaline to anesthetize the area, and the PRP was injected from the anterior hairline up to the vertex of the scalp, not involving the occipital and temporal regions. In the control group, a ring block was given for the same procedure. Participants from both groups were assessed for the pain and analgesia caused by ring block and regional nerve blocks using the visual analog scale (VAS). Results A mean rank of 30.28 was observed for the regional nerve block technique, and a mean rank of 70.72 was observed for the ring block technique. A p-value of 0.00 that is <0.05 was observed, which shows there is a significant difference in the pain and the analgesia experienced by the subjects between the two groups, during and three hours after the procedure. Conclusion PRP is one of the most commonly used treatments for hair regrowth. The ring block is the common local anesthetic technique used for producing anesthesia, while regional nerve blocks are more effective in producing local anesthesia. This study proves that STN and SON blocks are better anesthetic techniques than the ring block technique for PRP treatment in hair growth.

Combined rectus sheath block with transverse abdominis plane block by one puncture for analgesia after laparoscopic upper abdominal surgery: a randomized controlled prospective study

BackgroundRectus sheath block (RSB) and transversus abdominis plane block (TAPB) have been shown to reduce opioid consumption and decrease postoperative pain scores in abdominal surgeries. However, there are no reports about the one-puncture technique of RSB combined with TAPB for perioperative pain management during laparoscopic upper abdominal surgery.MethodsA total of 58 patients were randomly assigned to the control group (C), the TAP group (T), and the one-puncture technique of RSB combined with TAPB group (RT). The patients in group C did not receive any regional block. The patients in group T received ultrasound-guided subcostal TAPB with 30 mL of 0.33% ropivacaine on each side. The patients in the RT group received a combination of RSB and TAPB with 15 mL of 0.33% ropivacaine in each plane by one puncture technique. All patients received postoperative patient-controlled intravenous analgesia (PCIA) after surgeries. The range of blocks was recorded 20 min after the completion of the regional block. The postoperative opioid consumption, pain scores, and recovery data were recorded, including the incidence of emergence agitation (EA), the times of first exhaust and off-bed activity, the incidence of postoperative nausea and vomiting, dizziness.ResultsThe range of the one-puncture technique in group RT covered all areas of surgical incisions. The visual analogue scale (VAS) score of the RT group is significantly lower at rest and during coughing compared to groups T and C at 4, 8, 12, and 24 h after surgery, respectively (P < 0.05). The consumption of sufentanil and the number of postoperative compressions of the analgesic pumps at 24 and 48 h in the RT group are significantly lower than those in groups T and C (P < 0.05). The incidence of EA in the RT group is significantly lower than that in groups T and C (P < 0.05).ConclusionThe one-puncture technique of RSB combined with TAPB provides effective postoperative analgesia for laparoscopic upper abdominal surgery, reduces the incidence of EA during PACU, and promotes early recovery.Trial registrationChiCTR, ChiCTR2300067271. Registered 3 Jan 2023, http://www.chictr.org.cn.

Erector spinae plane block as an anesthesia technique for an emergent thoracotomy; a case report

BackgroundThe erector spinae plane block (ESPB) is a novel regional block technique for pain management following thoracic surgeries. However, there are minimal cases in which the technique was used as the main anesthesia technique during surgery.Case presentationHere, we report the successful use of ESBP for applying anesthesia in a case during an emergent thoracotomy for performing pericardiotomy and loculated tamponade evacuation.ConclusionsUsing ESPB with a higher concentration of local anesthetics, in this case, prepared appropriate anesthesia for performing an emergent thoracotomy while avoiding multiple needle insertions and the risk of further hemodynamic instability.

Evaluation of the effects of the local anesthetics on immunity during mastectomy

Background &amp; objective: Surgery and some anesthetic techniques can contribute to tumor cells dissemination. It is known that the use of local anesthetics and regional blocks during mastectomy preserved the immune function. We evaluated and compared, the levels of some cytokines (IFNγ, TNFα, IL2, IL12) responsible for immune function, as well as the level of leukocytes before and after breast carcinoma surgery; and to find out and compare the effects of local anesthetics on blood pressure (BP) and on postoperative complications, e.g., pain, vomiting, headache, the need for analgesia and surgical complications. Methodology: In this randomized prospective study, 45 patients were allocated in 3 equal groups: Group GA (n = 15) for standard general anesthesia; Group LA (n = 15) for general anesthesia and infusion of lidocaine; Group PECS (n = 15) for pectoralis I/II block with bupivacaine and general anesthesia. Blood samples were taken to ascertain cytokines and leukocytes levels before surgery and 24 h after surgery. Results: Lidocaine caused fall of BP (P = 0.002t), but bupivacaine (PECS I/II block) produced stable BP during mastectomy (P = 0.1). A significant increase of leucocytes after surgery was seen in Group PECS compared to Group GA (P = 0.033). In 24-h intervals after surgery, lidocaine and bupivacaine produced an increase of TNFα (P &lt; 0.05). Bupivacaine showed a significantly low intensity of postoperative pain compared to other techniques and zero postoperative complications. Conclusion: Local anesthetics lidocaine and bupivacaine enhance the immune response and produce more stable hemodynamics compared to general anesthesia alone during mastectomy in patients with breast carcinoma. Abbreviations: CTL- Cytotoxic T Lymphocytes; IFNγ- Interferon Gamma; TNFα- Tumour Necrosis Factor α, IL2- Interleukin-2; NKCs- Natural Killer Cells; Th1- Type 1 T Helper Cells; VAS- Visual Analog Scale Keywords: Breast Carcinoma; Lidocaine; Bupivacaine; PECS I/II block; Cytokines Citation: Angjushev DL, Sholjakova MV, Kartalov A, Kuzmanovska B, Kishman A, Demjanski V, Srceva MJ, Kokareva A, Angjushev MK. Evaluation of the effects of the local anesthetics on immunity during mastectomy. Anaesth. pain intensive care 2024;28(1):108−114; DOI: 10.35975/apic.v28i1.2383 Received: November 14, 2023; Reviewed: November 17, 2023; Accepted: December 09, 2023

Comparing analgesic effect of regional blocks after hip arthroscopy

Comparing analgesic effect of regional blocks after hip arthroscopy

VARIOUS TYPES OF LOCOREGIONAL ANALGESIA IN PEDIATRIC PATIENTS

The regional blocks, as a part of multimodal analgesia, can improve pain managementin the postoperative period and reduce the rate of complications that arise when usinga single anesthesia regimen.The aim of the study – to compare the efficacy of various regional analgesia techniques.Materials and Methods. All patients were divided into two groups: Group I included31 children who underwent anterior abdominal wall surgery under general anesthesiawith the transversalis fascia plane block (TFPB); Group II comprised 32 children whounderwent anterior abdominal wall surgery under general anesthesia with the TFPB,combined with the quadratus lumborum block 4 (QLB-4) via a single injection.Results. In children of the I group, the pain intensity indicator on the visual analog scale(VAS) after one hour constituted 4.6±0.16 points, while in the children of the II group it was 3.5±0.15 (р&lt;0.05). The assessment of pain intensity according to VAS in thedynamics of the postoperative period showed that children of group I 6 hours aftersurgery have 1.2 times higher pain indicators compared to children of group II (p&lt;0.05),after 12 hours – by 1.7 times, after 24 hours – 1.6 times, after 36 hours – 1.5 times,and at discharge – 1.6 times (р&lt;0.001). According to the results of the LIKERT scale,significantly higher pain indicators were established in children of group I after surgeryand at the time of discharge (10.12±0.15 and 5.45±0.22 compared to 5.93±0.19 and3.50±0 .15 in children of group II (p&lt;0.001). The smallest volume of paracetamol usedfor pre-emptive and multimodal analgesia in children of group I was 95 ml, while inchildren of group II it was 40 ml. The largest volume, required by the children duringanalgesia was 220 mL and 150 mL in groups I and II, respectively.The mean time tocomplete the QLB-4 was 117.3±1.76 sec, while the TFPB was 121.8±3.56 sec (p =0.27).The duration of postoperative analgesia after performing the combined locoregionaltechnique was 32.56±0.5 hours, while when using the TFPB monoblock it was 22.9±0.57hours (p&lt;0.001).Conclusions. The use of a combined block for regional analgesia during operations onthe anterior abdominal wall is accompanied by: a lower indicator of pain intensity in thepostoperative period (p&lt;0.001); reducing the need to use «rescue doses of analgesics» inthe postoperative period (p&lt;0.001); the spread of the sensory block at the level of T7-L2dermatomes; an increase in the duration of postoperative analgesia (p&lt;0.001) comparedto the corresponding indicators when using the TFPB monoblock.

Research design is important in comparing the analgesic efficacy of different regional blocks following modified radical mastectomy.

Research design is important in comparing the analgesic efficacy of different regional blocks following modified radical mastectomy.

Research design justification for different regional blocks following modified radical mastectomy.

Research design justification for different regional blocks following modified radical mastectomy.

Prospective single-center study on the reliability of ipsilateral cerebral oximetry using near-infrared spectroscopy as a predictor for selective shunting during carotid endarterectomy.

Many techniques are available for the intraoperative assessment of brain perfusion during carotid endarterectomy, such as carotid stump pressure, near-infrared spectroscopy, somatosensory evoked potentials, transcranial Doppler, electroencephalography, and clinical assessment. The decision for selective carotid shunt insertion is dependent on clinical deterioration or the detection of cerebral hypoperfusion after cross-clamping of the internal carotid artery. Monitoring cerebral oximetry using near-infrared spectroscopy is a noninvasive technique for cerebral oxygen saturation measurement, reflecting changes in cerebral blood flow during carotid endarterectomy. The aim of this study was to evaluate the reliability of near-infrared spectroscopy as a predictor of selective shunting during carotid endarterectomy. In total, 47 conventional carotid endarterectomy surgeries were performed at our hospital between March 2016 and December 2021. All surgeries were performed under a regional cervical block supplemented with local infiltration anesthesia. All patients were monitored by cerebral oximetry using bilateral near-infrared spectroscopy probes and clinical assessment through communication with the patient (numerical, visual, and verbal) to indicate a selective shunt. Near-infrared spectroscopy values were recorded before and after internal carotid cross-clamping and after declamping. Any decrease in ipsilateral cerebral oximetry-near-infrared spectroscopy values equal to or more than 20% from the pre-clamping baseline reading associated with deterioration in neurological status (hemiparesis, aphasia, or deterioration in level of consciousness) after internal carotid artery cross-clamping was considered an indication for intraluminal carotid shunting. After internal carotid artery cross-clamping, 5 of 47 patients (10.6%) developed a significant drop in cerebral oxygen saturation associated with obvious clinical assessment deterioration in verbal communication and weakness in contralateral arm power. A Pruitt-Inahara carotid shunt was subsequently inserted, and 42 patients remained stable throughout surgery. The average decline in ipsilateral near-infrared spectroscopy values was 23.8% in patients with clinical deterioration. The average decline was 8.6% in patients who remained stable. Monitoring ipsilateral cerebral oximetry using near-infrared spectroscopy is an easy and reliable method for indicating selective shunting during carotid endarterectomy. A 20% decrease in ipsilateral brain tissue oximetry after internal carotid artery cross-clamping provides a reliable cut-off value for selective intraluminal carotid shunting during carotid endarterectomy.

The impact of biological sex in peripheral nerve blockade: A prospective pharmacodynamic, pharmacokinetic and morphometric study in volunteers.

The impact of biological sex in peripheral regional anaesthesia is largely unknown. We therefore designed a prospective study in volunteers to investigate the impact of biological sex on pharmacodynamic, pharmacokinetic and morphometric characteristics for peripheral nerve blockade. The initial study plan was powered to include 90 volunteers to find a difference of 35 min in duration of sensory block (primary outcome variable) with 80% power and alpha error at 5%. After discussions in ethical review, a pilot study of 2 x 12 volunteers from each sex were studied. Female and male volunteers received ultrasound guided nerve blockade with 3.0 mL ropivacaine 7.5 mg mL-1. Sensory duration of blockade, as the primary outcome, was evaluated by pinprick testing. Secondary outcomes were sensory onset time of blockade, pharmacokinetic characteristics and the visibility of ulnar nerves using ultrasound. Analyses included Mann-Whitney U-statistics with P<0.05 (two-sided) as significant. After 24 participants, the median (IQR) duration of sensory blockade was 450 (420; 503) min in women and 480 (450; 510) min in men (P = 0.49). Sensory onset time of blockade, and ultrasound visibility of nerves were also similar between the study groups. The total drug exposure across time (AUC0-infinity) was significantly higher in women (P = 0.017). After a the planned power re-analysis after these 24 study paticipants, which suggested that > 400 subjects would be required with 80% power and alpha error of 5% to find significance for the primary outcome parameter for marginal differences, we terminated the study at this point. We did not detect significant differences between female and male study participants in terms of pharmacodynamic and morphometric characteristics after ultrasound guided ulnar nerve blocks. Women did show significantly greater pharmacokinetic ropivacaine exposures. The results of this study indicate that peripheral regional block pharmacodynamic characteristics are independent of the biological sex, whereas pharmacokinetic parameters are sex-dependent.

The anatomical variations of median nerve in Shiraz, Iran.

The origin and distribution of median nerve varies among the different individuals. The median nerve variations in axillary region were reported by many authors previously. Understanding of these variations is especially necessary for clinicians to prevent iatrogenic nerve damage. The current work aimed to evaluate the possible anatomical variations of median nerve in the axillary region in a sample of the Iranian cadavers (Shiraz, Fars). We dissected 26 upper limbs from 13 male cadavers to investigate the different variations of median and musculocutaneous nerves according to Venieratos and Anagnostopoulou classification. In 23.07% of specimens (n=6), the medial root united with 2 lateral roots and formed the median nerve proximal to the coracobrachialis muscle. In one case, a communicating branch separated from the musculocutaneous nerve distal to the coracobrachialis and connected to the median nerve in upper arm. Our results suggest that there are anatomical variations of the median nerve in terms of its origin and its communication with the musculocutaneous nerve in the population of southern Iran. The anatomical knowledge of the median nerve variations is important for clinicians to improve patient health outcome. Theses variations of the median nerve should be considered during surgical procedures of the axillary region and nerve block of the infra clavicular part of the brachial plexus.

Influence of Circle of Willis Anatomy on the Safety of Carotid Endarterectomy under Regional Block

Influence of Circle of Willis Anatomy on the Safety of Carotid Endarterectomy under Regional Block

Analysis of biomarkers of stress in the perioperative period during surgical treatment for abdominal wall hernias

Background. Pain impairs the patient’s quality of life after surgery and, causing a significant stress, affects life expectancy. Many biomarkers (albumin, hemoglobin, glucose level, C-reactive protein) are used to objectively assess stress, but their levels depending on the type of analgesia and their role in predicting the course of the postoperative period have not been fully studied. Aim: to conduct a comparative analysis of biomarkers of stress in patients undergoing surgery for abdominal wall hernias depending on the type of perioperative analgesia. Materials and methods. Sixty-three patients who underwent surgical treatment for abdominal wall hernias took part in the study. They were divided into 3 groups according to the method of anesthesia (general, neuraxial and regional blockades). At different stages of the perioperative period, the dynamics of stress biomarkers such as cortisol and blood glucose was studied. Results. Before the operation, the blood glucose level did not differ significantly in three groups. During the traumatic period of surgical treatment, stress-induced hyperglycemia developed, its level did not depend on the type of anesthesia performed, and 24 hours after the operation, the level of glycemia significantly decreased to normal one. A significant increase in cortisol was registered in group 1. At the same time, on the contrary, the blood cortisol level decreased in patients of groups 2 and 3. After 24 hours, the blood cortisol level decreased to normal values, and in all groups, it was lower than that before surgery. Conclusions. Regardless of the type of anesthetic management, an increase in blood glucose levels was recorded in patients of all three groups during surgical treatment for abdominal wall hernias. Patients undergoing regional abdominal wall blocks had lower levels of stress biomarkers after surgery and 24 hours postoperatively compared to general anesthesia.