Required Rescue Analgesia Research Articles

Effects of anterior quadratus lumborum block versus erector spinae plane block on postoperative acute pain in percutaneous nephrolithotomy: a prospective, observational study

BackgroundThe study aimed to compare the pain-relieving effectiveness of anterior quadratus lumborum block (QLB3) and erector spinae plane block (ESPB), both of which have been documented to provide relief during abdominal surgery.MethodsThis prospective observational study, conducted between February and July 2023, included 96 patients who had undergone percutaneous nephrolithotomy (PCNL). Patients were divided into three groups: QLB3, ESPB, and control (no block) and received the corresponding nerve block in the preanesthetic room for regional block. Cumulative morphine consumption during the initial 24 h after PCNL, numerical rating scale resting/movement scores, intraoperative remifentanil usage, rescue analgesic requirements, time when the first analgesic was requested, and postoperative nausea and vomiting scores were documented and compared between the groups.ResultsTotal median morphine consumption in the first 24 h postoperatively was similar in the QLB3 and ESPB groups but higher in the control group (QLB3, 7 mg [(Q1-Q3) 7–8.5]; ESPB, 8 mg [6.5–9]; control, 12.5 [10–17]; P < 0.001). Similarly, median intraoperative remifentanil consumption did not differ between the block groups but was higher in the control group (QLB3, 1082 µg [IQR 805.5–1292.7]; ESPB, 1278 µg [940.2–1297.5]; control, 1561 µg [1315–2068]; P < 0.001). The number of patients receiving rescue analgesic medication was similar in the block groups but higher in the control group (QLB3, n = 9 [30%]; ESPB, n = 14 [46.7%]; control, n = 21 [70%]; P = 0.008).ConclusionsQLB3 and ESPB were adequate and comparable in providing postoperative analgesia as part of multimodal analgesia after PCNL.Trial registrationThe study was registered on ClinicalTrials.gov (Identifier: NCT05822492).

Use of a quadratus lumborum block in queens undergoing ovariectomy: a randomised controlled trial.

The aim of the study was to evaluate the perioperative analgesic effect of a quadratus lumborum (QL) block in queens undergoing ovariectomy. A total of 37 healthy queens admitted for elective ovariectomy were randomised into two groups: control (CTRL, n = 19) and QL block (QL, n = 18). All cats were premedicated with dexmedetomidine 0.005 mg/kg, alfaxalone 1 mg/kg and methadone 0.1 mg/kg IM. Under general anaesthesia, cats allocated to the QL group received a bilateral ultrasound-guided QL block with 0.4 ml/kg of ropivacaine 0.4% (3.2 mg/kg). No treatment was administered to cats in the CTRL group. Intraoperative rescue fentanyl boluses were administered if haemodynamic and/or respiratory parameters exceeded 30% of the pre-incisional values. Postoperative methadone boluses were administered based on Feline Grimace Scale scores. Demographics, baseline vital parameter values, requirement for rescue analgesia, incidence of hypotension, sialorrhoea, vomiting and dysphoria, and number of cats accepting food at 6 h after extubation were compared between groups. A higher number of queens required intraoperative fentanyl in the CTRL group (14/18, 77.8%) compared with the QL group (1/19, 5.3%) (P <0.001). The median total fentanyl dose was 4 µg/kg (range 0-4) in the CTRL group and 0 µg/kg (range 0-4) in the QL group (P <0.001). No statistically significant difference was found between groups when comparing the number of animals requiring postoperative methadone, total methadone dose, episodes of hypotension, sialorrhoea, vomiting and dysphoria, and number of queens accepting food at 6 h postoperatively. No adverse effect or complication potentially related to the block was recorded. The QL block resulted in a lower intraoperative fentanyl requirement in queens undergoing ovariectomy. Further studies are needed to clarify the postoperative analgesic effect of this technique in cats.

Assessing the Efficacy of Thoracic Erector Spinae Plane Block for Postoperative Analgesia in Lumbosacral Spine Surgery: A Prospective Quasi-experimental Study.

Background and aims Optimal postoperative care and analgesia are the key factors in the management of cases of lumbosacral spine surgery. The erector spinae plane (ESP) block is a recently evolving entity and has a dynamic role in postoperative pain management. However, its role in the management of pain in lumber spinal surgeries is still not clear, and the literature remains anecdotal. Therefore, we planned to study the efficacy of ultrasound-guided preoperative ESP block at the T12 level using levobupivacaine for perioperative analgesia in lumbosacral spine surgeries. Methods A total of 60 patients scheduled for elective or emergency lumbosacral spine surgery were divided into two groups - the GA group received standard general anesthesia (GA)and the GA+ESP group received standard general anesthesia along with ultra-sound guided ESP block at the T12 level with a bilateral injection of20 ml 0.25% levobupivacaine. Perioperative analgesia was assessed by total intra-operative fentanyl dose and frequency, intra-operative hemodynamic parameters, post-operative numeric rating scale (NRS) scores, time of first systemic rescue analgesia, tramadol usage, mobilization day, and hospital stay duration. Results Intraoperative fentanyl sparing was observed in 83% of the GA+ESP group compared to 33% in the GA group. Postoperative tramadol sparing was observed in 80% of the GA+ESP group compared to 26.7% of the GA group. Twenty-four-hour postoperative NRS scores >3/10 were observed in 20% of the GA+ ESP group compared to 73.3% of the GA group. Conclusion In this study, superior perioperative analgesia, opioid-sparing effect, and decreased requirement of postoperative rescue analgesia were observed with ESP block.

The comparison of erector spinae plane block and caudal block for postoperative analgesia in paediatric surgery - meta-analysis.

To assess the efficacy of Erector Spinae Plane Block (ESPB) compared to caudal block in reducing postoperative pain in paediatric surgery. An electronic literature search was conducted using the Cochrane Library, PubMed, and Google Scholar databases, with data collected from January 2018 until September 2023. This meta-analysis includes English-language randomized controlled trials (RCTs) studies contrasting ESPB with caudal block in paediatric patients. The primary outcome was the 24-hour post-operative pain scores. The secondary outcome included the time to rescue analgesia, the number of patients requiring rescue analgesia, and the occurrence of post-operative nausea and vomiting (PONV) and urinary retention. Five RCTs with 295 samples were included. The results showed no significant difference between ESPB and caudal block in postoperative pain scores at 1st hour SMD (standardized mean difference) of -0.17 (95% CI -0.70, 0.36; I2=76%; p= 0.53), 2nd hour of SMD: -0.50 (95% CI -1.21, 0.21; I2=88%; p=0.17), 6th hour SMD -1.09 (95% CI -2.21, 0.03; I2=95%; p = 0.06), 12th hour SMD -0.77 (95% CI -1.75, 0.21; I2=93%; p=0.12), and the 24th hour SMD -0.13 (95% CI -0.39, 0.12;, I2=2%; p=0.30) were found. Furthermore, there was no significant difference in the time first to rescue analgesia, the number of patients requiring analgesia rescue, PONV occurrence, and urinary retention. ESPB and caudal block showed equivalent analgesia efficacy and safety in paediatric surgery.

STUDY OF COMPARISON BETWEEN BUPIVACAINE 0.5% &amp; ROPIVACAINE 0.5%IN ULTRASOUND GUIDED AXILLARY BRACHIAL PLEXUS FOR ELECTIVE UPPER LIMB SURGERIES

Background: This study contains comparison between Bupivacaine 0.5% &amp;Ropivacaine 0.5% in ultrasound guided axillary brachial plexus block in elective upper limb surgeries. It is safer technique compared to GA .Study aims comparison of both local anaesthetic drugs in terms of volume , onset of motor &amp; sensory blockade, duration of motor &amp; sensory blockade &amp; duration of analgesia. Methods: This randomized, controlled, double blinded study at tertiary care center compared effect of bupivacaine 0.5% and ropivacaine 0.5%. Adults meeting specific inclusion criteria were divided in 2 equal groups 30 patients in each. All patients were given USG guided axillary block. Group A received Inj. Bupivacaine 0.5% 2.5-3 mg/kg (20-30 ml) while group B received Inj. Ropivacaine 0.5% 2-3 mg/kg (20-30 ml). Outcome measured included volume of drug, onset of motor &amp; sensory blockade, duration of motor &amp; sensory blockade. Hemodynamic parameters, VAS score, requirement of rescue analgesic (VAS &gt;4) observed during perioperative period at different intervals. Sensory &amp; motor block were assessed by 3-point scale.VAS score is evaluated by asking the patients to describe their pain between 0 to 10. p-value ≤0.05was considered statistically significant. Results: Comparison between both groups showed that onset of motor blockade (11.3 ±1.48 min ) &amp; sensory blockade (7.46 ± 1.40 min ) was slower in group A , whereas onset of motor blockade (6.91± 1.39 min) &amp; sensory blockade (3.13 ± 0.84 min) was faster in group B. While duration of motor blockade (681.16 ± 15.23 min) &amp; sensory blockade (745 ± 25.12 min) was prolonged in group A compared to shorter duration of motor blockade (480.83 ± 31.67 min ) &amp; sensory blockade (550.16 ± 39.62 min ) in group B. Duration of Analgesia was longer in group A(1388.83 ± 162.85 min ) compared with group B (856.16 ± 139.51 min ). Conclusion: Ropivacaine 0.5% is associated with faster recovery of sensory &amp; motor function with better safety profile compared to Bupivacaine 0.5%.

Comparison of the Efficacy Between Ultrasound-Guided Paravertebral Block and Erector Spinae Block for Postoperative Analgesia in Percutaneous Nephrolithotomy Using Levobupivacaine: A Prospective and Randomized Study.

Introduction Various techniques have been developed in the current era of regional anesthesia practice. With the advent of ultrasound, the visualization of needle and pleura in real time enables a better outcome with negligible adverse events. This study was designed to compare the efficacy between ultrasound-guided erector spinae plane block (ESPB) and paravertebral block (PVB) in percutaneous nephrolithotomy (PCNL) for the duration of postoperative analgesia with levobupivacaine, a local anesthetic with higher lipid solubility, making it more potent and resulting in a longer duration of action. Methods This prospective randomized single-blinded study enrolled 50 patients of ASA grades I and II, aged between 20 and 60 years, who were scheduled for PCNL under general anesthesia. Patients were divided into two groups of 25 each: group ESPB andgroup PVB, and 25 mL of 0.25% levobupivacaine was administered to both groups. They were primarily evaluated for the duration of postoperative analgesia. Total rescue analgesic requirements, hemodynamic parameters, and any adverse effects were also assessed. Results Both ESPB and PVB provided a significant duration of analgesia postoperatively. Demographic characteristics in both groups were comparable. The duration of postoperative analgesia in group ESPB was 746 ± 58.6 minutes when compared to group PVB, which is 768 ± 68.6 minutes (p = 0.08). Intravenous (IV) paracetamol was used as a rescue analgesic. The doses used were also comparable in both groups, with the visual analog score (VAS) being high after around 12 hours of surgery. The total rescue analgesic requirement was similar in both groups (group ESPB, 2.0 ± 1.6; group PVB, 2.2 ± 1.4; p = 0.51). There were no significant hemodynamic or other adverse effects in either group. Conclusion We conclude that both ESPBand PVB using isobariclevobupivacaine 0.25% as a local anesthetic are equally efficacious in providing effective postoperative analgesia in patients undergoing PCNL under generalanesthesia.

A Comparative Study of Combined Spinal Epidural Anesthesia Versus Spinal Anesthesia in Major Lower Limb Orthopedic Surgeries.

Background Neuraxial blockade includes epidural and spinal anesthesia (SA) that have gained wide acceptance for major lower limb orthopedic surgery. Both techniques are competent in rendering surgical anesthesia and pain relief, with specific advantages and disadvantages. SA has the merits of rapid onset and adequate anesthesia with a small volume of the drug but has significant hypotension and unpredictable duration. Epidural anesthesia allows for finer control over analgesia and the duration of anesthesia but requires more substantial volumes of drugs and is slower in onset. Combined spinal-epidural anesthesia (CSEA) combines the rapid commencement of action of SA with flexibility in epidural anesthesia, thus optimizing the management of the intraoperative and postoperative phases. This study aims to evaluate hemodynamic changes, compare the severity and duration of sensory and motor block, and track any problems related to CSEA and SA in major lower limb orthopedic procedures. Additionally, this study contrasts the hemodynamic, motor, and sensory changes in the two groups. Methodology A total of 30 individuals were randomized to one of two groups in this prospective comparative trial, which included 60 patients receiving major lower limb orthopedic surgery and meeting the American Society of Anesthesiologists physical status I-II criteria. Group A received CSEA, and Group B received SA. The degree and duration of sensory and motor blockade, hemodynamic changes, and complications were all recorded. A p-value of less than 0.05 was used to evaluate statistical significance using Student's t-test and chi-square test. Results The onset of sensory block in our study was earlier in Group B compared to Group A. In both groups, hemodynamic stability was maintained throughout the study. We recorded the onset/duration of sensory and motor block and hemodynamic changes and took mean values to find any significant difference. Postoperative complications and rescue analgesic requirements were monitored and managed and were a part of our study. Conclusions This study compared CSEA and SA regarding the severity and duration of sensory and motor block, hemodynamic stability, and associated complications in major lower limb orthopedic surgeries. The results shed light on the advantages and shortcomings of each anesthesia technique and, therefore, will help choose the correct method of anesthesia in a given surgery.

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.

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.

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

The effect of longer epidural duration after open pancreaticoduodenectomy on pain and mobilisation: A retrospective single-centre analysis.

The optimal length of epidural use following open pancreaticoduodenectomy has not been defined. The aim of this study was to investigate whether the length of patient-controlled epidural analgesia affected pain and ability to mobilise on epidural termination following open pancreaticoduodenectomy in the context of enhanced recovery after surgery. A retrospective single-centre cohort analysis was performed between November 2015 and December 2021 on patients who underwent open pancreaticoduodenectomy. As part of a continual review process of the enhanced recovery after surgery protocol, patient-controlled epidural analgesia duration changed allowing stratification of patients into either three- or five-day patient-controlled epidural analgesia groups. Of the 196 patients identified, 157 were included with 80 (50.9%) and 77 (49.1%) allocated to the three-day and five-day patient-controlled epidural analgesia groups, respectively. Patient-controlled epidural analgesia termination on postoperative day 3 was associated with transiently higher pain and less mobilisation, although no greater rescue analgesia requirement. Conversely, longer patient-controlled epidural analgesia usage following open pancreaticoduodenectomy was associated with less pain and greater mobilisation in the immediate postoperative period. Earlier patient-controlled epidural analgesia termination transiently leads to increased pain and decreased mobilisation following open pancreaticoduodenectomy. Ensuring appropriate analgesia requirements or longer patient-controlled epidural analgesia usage should be considered to avoid patient discomfort and enhance recovery.

Evaluation of preoperative rectus sheath block with bupivacaine for analgesia in cats undergoing ovariohysterectomy: a cadaveric and randomized clinical study

ObjectivePhase 1: to determine the feasibility of desensitizing ventral branches of spinal nerves within the rectus sheath using an ultrasound-guided rectus sheath block (USRSB). Phase 2: to determine the effect of preoperative USRSB on intraoperative responses to surgical stimulation and postoperative pain. Study designCadaveric study and prospective, randomized, blinded, parallel-arm clinical trial. AnimalsA group of five cat cadavers and 37 shelter-owned cats undergoing ovariohysterectomy. MethodsPhase 1: anatomical dissection was performed on one uninjected cadaver. Abdominal walls were dissected in four cadavers (eight hemiabdomens) following bilateral USRSB using 1:1 new methylene blue and 0.5% bupivacaine (0.8 mL kg–1 total). Phase 2: preoperative bilateral USRSB was performed with 0.8 mL kg–1 of 0.25% bupivacaine (RSB) or equivalent volume of 0.9% saline (CONTROL). Intraoperative systolic arterial blood pressure (SAP), heart rate (HR), respiratory rate (fR) and vaporizer setting (vap%) were recorded before skin incision, during celiotomy and abdominal wall closure. In recovery, cats were administered robenacoxib (2 mg kg–1; CONTROL) or 0.9% saline (0.1 mL kg–1; RSB) subcutaneously. Postoperative pain was evaluated for 6 hours using the Glasgow Composite Measure Pain Scale. ResultsPhase 1: spinal nerves T9–L3 were identified within the rectus sheath, and stained in 0%, 40%, 63%, 75%, 100%, 88%, 50% and 13% of hemiabdomens, respectively. Phase 2: 37 cats were included (RSB, n = 17; CONTROL, n = 20). Intraoperatively, SAP, HR and fR were not significantly different between groups. Vap% was significantly lower in RSB during celiotomy (p = 0.036) and closure (p = 0.044). Postoperatively, RSB cats were 5.3 times (95% CI 1.8–8.3) more likely to require rescue analgesia than CONTROL cats. Conclusions and clinical relevanceDuring surgery, USRSB with bupivacaine offered minor benefits and provided markedly less postoperative analgesia than robenacoxib, indicating that relying on USRSB provides insufficient postoperative analgesia for ovariohysterectomy in cats.

Pain Management Following Intracavitary Brachytherapy Procedures: A Prospective, Randomized, Double-Blind Study.

Background and objectives Intracavitary applicators are a source of significant discomfort after brachytherapy procedures while undergoing subsequent radiation treatment. With strides towards opioid-sparing anesthesia and analgesia, it's essential to find appropriate substitutes. This procedure requires adequate relaxation of pelvic muscles during the procedure and proper analgesia after the procedure, with the presence of intracavitary applicators, needed for radiation treatment. We studied the day-case safety and analgesic efficacy of adjuvants dexmedetomidine 3 µg and fentanyl 15 µg intrathecally to low-dose 0.5% hyperbaric bupivacaine. Methods Seventy females scheduled for brachytherapy procedures were randomly allocated to receive either Group I (0.5% hyperbaric bupivacaine (1.8 ml) plus 3µg dexmedetomidine (0.3ml)) or Group II (0.5% hyperbaric bupivacaine (1.8 ml) plus 15µg fentanyl (0.3ml)). The primary outcome was to assess and compare the brachytherapy (day-case) feasibility with 3µg dexmedetomidine and 15µg fentanyl (time taken to meet hospital discharge criteria). The secondary outcomes were the absolute duration of spinal analgesia, pain scores, patient satisfaction scores, and any associated adverse events. Data analysis was done using IBM SPSS software for Windows, version 21.0 (IBM Corp., Armonk, NY). Results All patients in Group I were discharged on the same day without any adverse effects. They underwent an intracavitary brachytherapy procedure under spinal anesthesia with stable hemodynamics successfully. The mean time taken to meet hospital discharge criteria in Group II was shorter than in Group I (258.43 ± 27.460 vs. 335.71 ± 21.114). The mean absolute duration of spinal analgesia was significantly longer in Group I as compared to Group II (406.82 ± 51.78 mins vs. 267 ± 16.23 mins) (p<.001). Seventeen patients required rescue analgesia in Group II versus eight in Group I (p<0.025). Conclusion Patients in both groups received excellent analgesia with enhanced patient satisfaction. Three µg intrathecal dexmedetomidine as an adjuvant to low-dose hyperbaric bupivacaine can be used safely in day-case brachytherapy procedures. It provides adequate anesthesia and prolonged spinal analgesia as compared to 15 µg fentanyl.

A PROSPECTIVE, RANDOMIZED STUDY COMPARING THE ANALGESIC EFFICACY OF SCALP BLOCK WITH 0.25% BUPIVACAINE VS PRE-INCISIONAL LOCAL INFILTRATION WITH 0.25% BUPIVACAINE WITH ADRENALINE (1:400,000) IN PATIENTS UNDERGOING ELECTIVE CRANIOTOMIES

Background and Aims: Pain is often referred to as the fifth vital sign. Pain management in patients undergoing craniotomies pose a great challenge to the anaesthesiologists. Scalp block forms an important aspect in the multimodal approach to the post-craniotomy pain. The following study compares the analgesic efficacy of Scalp block with traditionally used local wound infiltration technique in providing analgesia to craniotomy patients. Methods: Performed double blinded, prospective, randomized controlled trial on 60 patients undergoing elective craniotomies divided into 2 groups comparing the analgesic efficacy of Scalp block with 0.25% Bupivacaine vs Pre- incisional wound infiltration with 0.25% Bupivacaine with Adrenaline (1:400,000). Results:There were significant differences in intra-operative hemodynamics between the two groups. Scalp block resulted in statistically significant reduction in HR, SBP, DBP &amp; MAP. There was increased duration of post-operative analgesia in scalp block group when compared with the local infiltration group. The opioid requirement in the intra-operative period was significantly lesser in scalp block group when compared with the local infiltration group. Requirement of rescue analgesic is significantly lesser during early post-operative period (Upto 8 hours) in the scalp block group when compared with local infiltration group. Conclusion :Scalp block with 0.25% Bupivacaine is effective and superior to Pre-incisional Local infiltration with 0.25% Bupivacaine with 1:400,000 Adrenaline in attenuating hemodynamic responses, providing increased duration of post-operative analgesia, significant reduction in intra-operative opioids and post-operative rescue analgesic requirements.

Evaluation of Postoperative Pain When Adding a Tibial Nerve Block to the Femoral Nerve Block for Total Knee Arthroplasty.

Background: The aim of this study was to compare the postoperative analgesic efficacy when a tibial nerve block was added to the femoral nerve block for total knee arthroplasty (TKA). Methods: A total of 60 patients were randomly assigned to the experimental group (EG) or the control group (CG) in a 1:1 ratio. The thirty patients who formed the CG underwent an ultrasound-guided femoral nerve block together with neuraxial anaesthesia and the administration of opioids and NSAIDs through an intravenous elastomeric pump for the management of the postoperative pain; the other thirty, who formed the EG, underwent neuraxial anaesthesia together with femoral and tibial nerve blocks. The efficacy of the analgesic effect was evaluated based on the numerical pain rating scale (NPRS) and on the need for analgesic rescue at different time intervals within 48 h after surgery. Results: At 24 h, the mean NPRS score in the EG and CG at rest was 1.50 ± 1.19 and 1.63 ± 1.60 [U = 443.5, p = 0.113], respectively. With joint movement, the mean NPRS score was 2.80 ± 1.49 and 3.57 ± 1.79 [U = 345, p = 0.113], respectively. Ten patients in the EG [33.3%] and 24 in the CG [80%] required rescue analgesia [Phi = 0.471, p < 0.001]. At 48 h, the mean NPRS score in the EG and CG at rest was 0.33 ± 0.60 and 0.43 ± 0.72 [U = 428, p = 0.681], respectively. With movement, the mean NPRS score was 1.03 ± 0.99 in the EG and 1.60 ± 1.07 in the CG [U = 315, p = 0.038]. No patient in the EG group required rescue analgesia, while three patients in the CG [10%] did [Phi = 0.229, p = 0.076]. The mean opioid dosage in the CG was 300 mg, whereas in the EG it was 40 mg ± 62.14 [U < 0.05, p < 0.001]. Conclusions: Adding a tibial nerve block to the femoral nerve block in TKA may achieve the same analgesic efficacy within 48 h after surgery and would reduce the systematic use of opioids.

Efficacy and Safety of Extended-Release Dinalbuphine Sebacate for Postoperative Analgesia: A Systematic Review and Meta-analysis

Abstract Background Multimodal analgesia, which combines multiple medications with different analgesic mechanisms, is recommended for optimizing postoperative pain control and minimizing opioid-related side effects. Dinalbuphine sebacate (DNS), a prodrug of nalbuphine, has a 7-day long-acting analgesic effect on moderate to severe postoperative pain. We conducted a systematic review and meta-analysis to analyze the efficacy and safety of dinalbuphine sebacate for postoperative pain management. Materials and Methods We systematically searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials to identify randomized controlled trials (RCTs) of DNS for postoperative analgesia. We assessed the quality of all included studies using the risk-of-bias tool. The primary outcome was postoperative pain score, and the secondary outcomes included analgesic consumption, need for rescue analgesics, adverse events, and length of hospital stay. A meta-analysis was performed for the pooled data, and the level of evidence was rated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Results We included five RCTs with 497 patients who underwent surgery. Compared with the control group, DNS significantly reduced the visual analog scale (VAS) through postoperative 48 hours {mean difference (MD) -37.54 (95% confidence interval [CI]: -70.47, -4.62)} to 7 days [MD -165.99 (95% CI: -231.44)], and decreased the requirement for rescue analgesics [RR 0.89 (95% CI: 0.81, 0.97)]. No significant difference was noted in VAS scores within postoperative 24 hours [MD -10.13 (95% CI: -30.11, 9.85)] or in total analgesic consumption. Patients receiving DNS had a higher risk of dizziness and injection site reactions, without an increased occurrence of other adverse events. Conclusions With a low-to-moderate level of evidence, intramuscular DNS provides long-lasting analgesia from postoperative 48 hours to 7 days and may reduce the requirement for postoperative rescue analgesics. However, DNS does not offer additional pain relief within the first 24 hours postoperatively. Further high-quality studies are warranted. International Prospective Register of Systematic Reviews (PROSPERO) registry: identifier: CRD42023494130

A novel simplified sonographic approach with fluoroscopy-controlled L5 transforaminal epidural injections in patients with high iliac crest: a retrospective study

BackgroundTo explore a novel ultrasound (US) modality for lumbar transforaminal epidural injections (TFEIs) in patients with low back pain (LBP) and L5 radicular pain combined with high iliac crest (HIC).MethodsOne-hundred and forty-one patients were retrospectively stratified into two groups based on the treatment they received: novel group, receiving US-guided and fluoroscopy (FL)-controlled TFEIs using a sagittal oblique approach between the superior articular process of L5 and S1, and control group, receiving US-guided TFEIs with conventional transverse approach combined with FL confirmation. Accuracy of contrast dispersing into lumbar epidural space was set as the primary endpoint. Radiation dosages, procedure time, numeric rating scale (NRS) scores, Modified Oswestry Disability Questionnaire (MODQ) scores, adverse events, and rescue analgesic requirement were also recorded. The generalized liner mixed model (GLMMs) was employed to compare the repeatedly measured variables between groups, taking individual confounding factors as covariance.ResultsThe accuracy of TFEIs was 92.8% and 65.2% in novel and control group, with a significant difference of 26.7% (95% CI: 15.4%, 39.8%) between two modalities (p < 0.001). Significant pain relief was observed in novel group as opposed to control group after one injection. Procedure time in novel group (8.4 ± 1.6 min) was shorter than control group (15.8 ± 3.5 min) (p < 0.001) with less radiation dosage (3047 ± 5670 vs. 8808 ± 1039 μGy/m2, p < 0.001). Significantly, lower incidence of L5 paresthesia occurred in novel group. Statistical differences of NRS scores between the novel and control group were reached at 1 week after procedure (1 (IQR: − 1–3) vs. 3 (IQR: − 1–7), p = 0.006), while not reached at both 1- (1 (IQR: 0–2) vs. 1 (IQR: − 1–3), p = 0.086) or 3-month follow-up (0 (IQR: − 1–1) vs. 1 (IQR: 0–2), p = 0.094). Both groups showed similar functional improvement (F = 0.103, p = 0.749) during follow-up.ConclusionsThe novel sonographic technique provided superior accuracy needle placement and better pain-relieving effect through one injection as compared to the routine transverse approach. Consequently, in situations where the HIC imposed limitations for TFEIs performance on L5, the novel technique should be recommended to consider increasing accurate puncture, minimizing radiation exposure, consuming procedure time, and reducing the risk of neuraxial injury.

Efficacy and safety of diclofenac suppository for postoperative pain relief after diagnostic hystero-laparoscopy and dye test: A double-blind, placebo-controlled, randomized trial

ObjectiveTo determine the efficacy and safety of rectal diclofenac for relieving postoperative pain following diagnostic hystero-laparoscopy and dye test (dHLD). MethodsA prospective, double-blind, placebo-controlled, randomized trial was conducted among women who underwent dHLD to evaluate fertility. The women received either rectal diclofenac with intramuscular pentazocine or intramuscular pentazocine with rectal placebo for postoperative analgesia. The median pain scores at different time points were assessed as the primary outcome measures using the Numerical Rating Scale for pain. The secondary outcome measures were analgesic consumption, time at which first analgesic was requested, satisfaction with pain relief and any adverse events. ResultsIn total, 108 participants were analysed (54 in each group, 1:1 ratio). The median score for postoperative pain was lower for the diclofenac group compared with the placebo group at 4 h (52.53 vs 56.47; p = 0.507), 6 h (50.48 vs 58.52; p = 0.174), 8 h (51.42 vs 57.65; p = 0.296), 10 h (51.35 vs 57.65; p = 0.285) and 12 h (52.45 vs 56.55; p = 0.485) post surgery, although the difference was not significant (p > 0.05). Seventeen participants required rescue analgesia with 30 mg of pentazocine: 11 at 4 h post surgery [5 (62.5 %) vs 6 (66.7 %)], three at 6 h post surgery [2 (25.0 %) vs 1 (11.1 %)], two at 8 h post surgery [1 (12.5 %) vs 1 (11.1 %)], and one at 12 h post surgery [0 vs 1 (11.1 %)] for the diclofenac and placebo groups respectively (p = 0.713). There were no significant differences in postoperative adverse effect profiles, overall patient satisfaction, and need for rescue analgesia between the two groups (p > 0.05). ConclusionsPostoperative use of rectal diclofenac and pentazocine is safe, but did not significantly improve pain scores, patient satisfaction and need for rescue analgesia following dHLD, compared with patients who received pentazocine and placebo. While a multi-modal approach to pain relief following dHLD does not appear to be significantly beneficial, a multi-centre study is needed to confirm or refute these findings.

Application of ultrasound-guided thoracic paravertebral block or intercostal nerve block for acute herpes zoster and prevention of post-herpetic neuralgia: A case-control retrospective trial.

Ultrasound (US)-guided intercostal nerve block (ICNB) is an easier approach with a very low incidence of complications for different surgeries; nevertheless, only a few studies estimate the effect of ICNB for acute HZ. To explore the US-guided ICNB for management of herpes zoster (HZ)-related acute pain and possible prophylaxis for post-herpetic neuralgia (PHN) taking the conventional thoracic paraverteral block (TPVB) as control. A total of 128 patients with HZ were retrospectively stratified into antiviral treatment (AVT) plus US-guided TPVB (TPVB group), AVT plus US-guided ICNB (ICNB group) or AVT alone (control group) based on the treatment they received. HZ-related illness burden (HZ-BOI) over 30 days after inclusion as the primary endpoint was determined by a severity-by-duration composite pain assessment. Rescue analgesic requirement, health-related quality of life, PHN incidence, and adverse events were also recorded. Significantly lower HZ-BOI scores within post-procedural 30 days using the area under the curve were reported with TPVB and ICNB compared with the control group: mean difference of 57.5 (p < 0.001) and 40.3 (p = 0.003). No difference was reported between TPVB and ICNB (p = 1.01). Significant greater improvements in PHN incidence, EQ-5D-3L scores, and rescue analgesic requirements were observed during follow-up favoring two trial groups, while comparable between two trial groups. No serious adverse events were observed. US-guided ICNBs were as effective as TPVBs for acute HZ. The ICNB technique was an easier and time-efficient approach as opposed to conventional TPVB, which might be encouraged as a more accessible preemptive mean for preventing PHN.

Comparison of Butorphanol, Methadone, and Pethidine in Combination with Alfaxalone for Premedication in Isoflurane-Anesthetized Cats Undergoing Ovariectomy.

The aim of this study was to compare three different anesthetic protocols administered intramuscularly (IM) in cats undergoing elective ovariectomy, while evaluating the quality of sedation, antinociceptive, isoflurane-sparing effect, and analgesia in the intra-operative and post-operative phases. A total of 71 female cats were sedated IM with alfaxalone (3 mg/kg) combined with either butorphanol (0.3 mg/kg), methadone (0.3 mg/kg), or pethidine (5 mg/kg). During surgery, vital parameters were constantly monitored; at the end of the procedure, the quality of recovery was assessed through a specific form and each cat was scored for perceived pain using the UNESP-Botucatu scale for 5 days, and rescue analgesia was provided with buprenorphine IM when indicated. Moreover, differences between two different post-operative resting regimens (hospital kennels vs. home) were also assessed. A significant difference emerged for the amount of IM dexmedetomidine required to achieve an adequate level of sedation for intravenous catheterization, highlighting a greater need in the pethidine group (p = 0.021). There was no significant difference between opioid groups for the requirement of intra-operative rescue analgesia, and the clinical parameters were kept within physiological ranges regardless of the opioid used in premedication. Lastly, differences between the UNESP-Botucatu scores were detected from day 3 to day 5 post-operatively, with lower scores in cats with home resting regimens compared to the hospitalized animals, likely due to the presence of an unfamiliar condition and the absence of a cat-friendly environment.