Wound Infiltration Research Articles

Comparison of analgesic modalities for patients undergoing midline laparotomy: a systematic review and network meta-analysis.

Midline laparotomy is associated with severe pain. Epidural analgesia has been the established standard, but multiple alternative regional anesthesia modalities are now available. We aimed to compare continuous and single-shot regional anesthesia techniques in this systematic review and network meta-analysis. We included randomized controlled trials on adults who were scheduled for laparotomy with solely a midline incision under general anesthesia and received neuraxial or regional anesthesia for pain. Network meta-analysis was performed with a frequentist method, and continuous and dichotomous outcomes were presented as mean differences and odds ratios, respectively, with 95% confidence intervals. The quality of evidence was rated with the grading ofrecommendations, assessment, development, and evaluation system. Overall, 36 trials with 2,056 patients were included. None of the trials assessed erector spinae plane or quadratus lumborum block, and rectus sheath blocks and transversus abdominis plane blocks were combined into abdominal wall blocks (AWB). For the co-primary outcome of pain score at rest at 24 hr, with a minimal clinically important difference (MCID) of 1, epidural was clinically superior to control and single-shot AWB; epidural was statistically but not clinically superior to continuous wound infiltration (WI); and no statistical or clinical difference was found between control and single-shot AWB. For the co-primary outcome of cumulative morphine consumption at 24 hr, with a MCID of 10 mg, epidural and continuous AWB were clinically superior to control; epidural was clinically superior to continuous WI, single-shot AWB, single-shot WI, and spinal; and continuous AWB was clinically superior to single-shot AWB. The quality of evidence was low in view of serious limitations and imprecision. Other results of importance included: single-shot AWB did not provide clinically relevant analgesic benefit beyond two hr; continuous WI was clinically superior to single-shot WI by 8-12 hr; and clinical equivalence was found between epidural, continuous AWB, and continuous WI for the pain score at rest, and epidural and continuous WI for the cumulative morphine consumption at 48 hr. Single-shot AWB were only clinically effective for analgesia in the early postoperative period. Continuous regional anesthesia modalities increased the duration of analgesia relative to their single-shot counterparts. Epidural analgesia remained clinically superior to alternative continuous regional anesthesia techniques for the first 24 hr, but reached equivalence, at least with respect to static pain, with continuous AWB and WI by 48 hr. PROSPERO (CRD42021238916); registered 25 February 2021.

Efficacy of different analgesia treatments for abdominal surgery: A network meta-analysis.

This study was designed to evaluate the efficacy of analgesia and incidence of postoperative nausea and vomiting (PONV) of several widely used clinical treatments for postoperative analgesia following abdominal surgery through network meta-analysis (NMA) based on published randomized controlled trials (RCTs). This NMA was registered on PROSPERO as CRD 42020169606. Primary outcomes were pain scores (visual analog scale) and accumulative opioid consumption, and secondary outcomes assessed the incidence of PONV at 24h after surgery. A total of 215 RCTs and 15,114 patients were identified in this NMA. In comparison with placebo, use of a preoperative paravertebral block (mean: -12.63, 95% CI: -21.12 to -4.13), continuous wound infiltration (mean: -9.68, 95%CI: -13.15 to -6.22) and postoperative wound infiltration (mean: -6.34, 95%CI: -10.59 to -2.08) had significantly lower pain scores, less opioid consumption (mean: -2.00, 95%CI: -3.52 to -0.48; mean: -1.34, 95%CI: -1.87 to -0.81; mean: -1.41, 95%CI: -2.07 to -0.74, respectively) and lower incidence of PONV (OR: 0.30, 95%CI: 0.13 to 0.67; OR: 0.49, 95%CI: 0.24 to 0.98; OR: 0.55, 95%CI: 0.34 to 0.89, respectively). The findings from our work provide evidence that preoperative paravertebral block was superior to continuous or postoperative wound infiltration to provide postoperative analgesia, nausea and vomiting after abdominal surgery.

Autologous matrix-induced chondrogenesis plus peripheral blood concentrate (AMIC+PBC) in chondral defects of the first metatarsophalangeal joint.

Chondral restoration in chondral defects of the 1st metatarsophalangeal joint (MTP1) using autologous matrix-induced chondrogenesis plus peripheral blood concentrate (AMIC+PBC). Chondral defects MTP1. Acute infection. Thigh tourniquet. Medial approach. Tenolysis of all tendons, arthrolysis, synovectomy. Bursectomy in case of bursitis. Resection osteophytes, optional cheilectomy. Debridement of chondral defects until surrounding cartilage stable. Microfracturing with 1.6 mm K‑wire. 15 cc peripheral venous blood harvested with double lumina syringe. Centrifugation (10 min, 1500 RPM). Aspiration of supernatant including the entire fluid layer directly above the erythrocyte layer (peripheral blood concentrate [PBC]). Chondro-Gide matrix was cut to size and impregnated in PBC 3 min (impregnation). Fixation of the matrix into the chondral defect with fibrin glue (AMIC+PBC). Joint motion to ensure stable fixation. Insertion drainage and wound infiltration catheter. Layer wise closure. Full weightbearing in adressing shoe. Joint motion exercise starting at the day of surgery. The aim of the study was to compare matrix-associated stem cell transplantation (MAST) with AMIC+PBC. Patients who were treated with MAST from October1, 2011 to July15, 2016 (n = 623) or with AMIC+PBC from July17, 2016 to March19, 2018 (n = 230) were included. In all, 480 (89%)/176 (89%) patients (MAST/AMIC+PBC) completed 2‑year follow-up. The average degree of osteoarthritis was 2.1/2.2. The chondral defect size was 0.9/1.0 cm2 on average. Visual Analogue Scale Foot and Ankle (VAS FA) and European Foot and Ankle Society score (EFAS score) improved to 72.4/74.1//16.8/17.1 (MAST//AMIC+PBC) at follow-up, respectively. No parameter significantly differed between the MAST and AMIC+PBC cohorts.

Comparison of The Analgesic Outcomes of Local Wound Infiltration using Bupivacaine with Tramadol in Pediatric Inguinal Hernia Repair

Objective: To compare the time for first analgesic requirement after local wound infiltration with tramadol and bupivacaine in pediatric inguinal herniotomy. Materials and Methods: A total of 130 children aged 4 to 12 years who underwent inguinal herniotomy were included in this randomized comparative study. The study was conducted in anesthesiology unit of a tertiary care center in Qatar from Nov-2020 to July-2021. Patients in Group T received wound infiltration by Inj. Tramadol 2 mg/kg diluted in 10cc distilled water while patients in Group B received Inj. Bupivacaine 1mg/kg diluted in 10 cc distilled water. Postoperatively Pain score using Wong Baker Faces Scale was noted from ½ hour to 6 hours after surgery. Time of first rescue analgesia was noted. Results: The mean age was 7.98±2.40 years in group B versus 7.49±2.58 years in group T (p-value 0.26). There were 42 (64.6%) in group B versus 45 (69.2%) in group T (p-value 0.93). Mean surgery duration was 46.66±4.73 minutes in group T and 45.50±4.37 minutes in group B. The Wong-Baker pain score at different time intervals was significantly lower in group T in comparison to group B. Time of first analgesia requirement was 6.87±0.76 hours in group P versus 5.67±0.97 hours in group P, this duration was significantly prolonged in group T with p-value <0.001. Conclusion: Local wound infiltration with tramadol provides a longer time for first analgesic requirement as compared to the bupivacaine in children undergoing inguinal hernia repair. Keywords: Inguinal hernia, wound infiltration, tramadol, bupivacaine, post-operative pain.

A comparison of ultrasound guided bilateral single injection shot Erector Spinae Plane blocks versus wound infiltration for post-operative analgesia in laparoscopic assisted colonic surgery- a prospective randomised study

BackgroundBoth wound infiltration (WI) with local anaesthetic and Erector Spinae Plane block (ESPB) have been described for post-operative analgesia after abdominal surgery. This study compared the efficacy of WI versus ESPB for post-operative analgesia after laparoscopic assisted colonic surgery.MethodsSeventy-two patients between 18 and 85 years of age undergoing elective surgery were randomised to receive either WI or ESPB. In the WI group a 40 ml bolus of 0.5% Ropivacaine, infiltrated at the ports and minimally invasive wound at subcutaneous and fascia layers. In the ESPB group at T8 level, under ultrasound guidance, a 22-gauge nerve block needle was passed through the Erector Spinae muscle to reach its fascia. A dose up to 40 ml of 0.5% Ropivacaine, divided into two equal volumes, was injected at each side. Both groups had a multimodal analgesic regime, including regular Paracetamol, dexamethasone and patient-controlled analgesia (PCA) with Fentanyl. The primary end point was a post-operative pain score utilising a verbal Numerical Rating Score (NRS, 0–10) on rest and coughing in the post anaesthetic care unit (PACU) and in the first 24 h. Secondary outcomes measured were: opioid usage, length of stay and any clinical adverse events.ResultsThere was no significant treatment difference in PACU NRS at rest and coughing (p-values 0. 382 and 0.595respectively). Similarly, there were no significant differences in first 24 h NRS at rest and coughing (p-values 0.285 and 0.431 respectively). There was no significant difference in Fentanyl use in PACU or in the first 24 h (p- values 0.900 and 0.783 respectively). Neither was there a significant difference found in mean total Fentanyl use between ESPB and WI groups (p-value 0.787).ConclusionOur observations found both interventions had an overall similar efficacy.Trial registrationThe study was registered with the Australian New Zealand Clinical Trial Registry (ACTRN: 12619000113156).

Comparison of analgesic efficacy of transversus abdominis plane block with local wound infiltration using 0.25% levobupivacaine for post cesarean analgesia: A randomized controlled trial

The key component of Enhanced recovery after cesarian section (ERAC) is to improve maternal and child outcome and enhance recovery by dint of effective non opioid based pain control. We aim to compare the efficacy of Transverse abdominis plane (TAP) block with local wound infiltration for postoperative analgesia in cesarian section (CS).Eighty-two patients undergoing caesarean section under spinal anaesthesia were randomized to undergo local wound infiltration(Group I) (n=41) versus landmark guided bilateral TAP plane block (Group T) with 20ml of 0.25% levobupivacaine postoperatively Each patient was assessed post-operatively by a blinded investigator at regular intervals up to 24 h for visual analogue score (VAS). Requirement of analgesia, patient satisfaction, time for the first and second rescue analgesia, and the incidence of side effects was also noted. The median VAS was more in the group I compared to group II and was statistically significant (p=0.0032). The mean time to first rescue analgesia was prolonged in group I (4.060 ± 0.682 hrs) compared to group T (3.302 ± 0.519 hrs)(P< 0.001). The mean total analgesic requirement in 24 hours was reduced in group T (89.63 ± 41.82) as compared to group I (137.2 ± 33.13) (P<0.001. Group (T) compared to group I patient had a higher mean patient satisfaction score (1.487 ± 0.589) (2.097 ± 0.430) respectably (P < 0.001).TAP block provides better quality of analgesia and can be safely incorporated as a part of multi-model analgesic regimen postoperative pain over local infiltration in cesarian section.

Updates on Wound Infiltration Use for Postoperative Pain Management: A Narrative Review.

Local anesthetic wound infiltration (WI) provides anesthesia for minor surgical procedures and improves postoperative analgesia as part of multimodal analgesia after general or regional anesthesia. Although pre-incisional block is preferable, in practice WI is usually done at the end of surgery. WI performed as a continuous modality reduces analgesics, prolongs the duration of analgesia, and enhances the patient’s mobilization in some cases. WI benefits are documented in open abdominal surgeries (Caesarean section, colorectal surgery, abdominal hysterectomy, herniorrhaphy), laparoscopic cholecystectomy, oncological breast surgeries, laminectomy, hallux valgus surgery, and radical prostatectomy. Surgical site infiltration requires knowledge of anatomy and the pain origin for a procedure, systematic extensive infiltration of local anesthetic in various tissue planes under direct visualization before wound closure or subcutaneously along the incision. Because the incidence of local anesthetic systemic toxicity is 11% after subcutaneous WI, appropriate local anesthetic dosing is crucial. The risk of wound infection is related to the infection incidence after each particular surgery. For WI to fully meet patient and physician expectations, mastery of the technique, patient education, appropriate local anesthetic dosing and management of the surgical wound with “aseptic, non-touch” technique are needed.

To Compare the Analgesic Efficacy Of Wound Infiltration with Bupivacaine and Mixture of Bupivacaine and Tramadol for Postoperative Pain Relief in Cesarean Section Under Spinal Anesthesia

Background: The cesarean section is one of the common obstetrical surgery. Multimodal techniques can provide the mother with the best pain alleviation. One of the simplest and safest procedure is wound infiltration. The study is to compare the analgesic efficacy of bupivacaine wound infiltration and a mixture of tramadol and bupivacaine for postoperative pain relief. Materials and Methods: After receiving approval from the institutional ethics committee, 60 pregnant women aged 18–35 years who had undergone elective cesarean section under spinal anesthesia were included in the study. The patients were randomized into two groups of 30 each. Group B patients received 0.25% bupivacaine 0.7 mg/kg (diluted to 20 ml with normal saline), while group BT patients received 2 mg/kg tramadol mixed with 0.25% bupivacaine 0.7 mg/kg (diluted to 20 ml with normal saline). Time to first analgesia request, pain score by visual analogue scale, and diclofenac consumption in 24 h were compared. Adverse effects such as nausea, vomiting, and shivering were also noted. Results: The time to the first request for analgesia in Group T was 386.17 ± 233.84 min compared to Group B which was 192.50 ± 134.77 (P < 0.0002). Total diclofenac consumption in the first 24 h was significantly reduced in Group T compared to Group B (P < 0.0068). Conclusions: Subcutaneous infiltration of the wound with tramadol and bupivacaine prolongs the absence of pain and the consumption of analgesics after cesarean section and at the same time increases patient satisfaction.

Comparative Study between Ultrasound Guided Oblique Subcostal Transversus Abdominis Plane Block and Local Wound Infiltration as Postoperative Analgesia in Hepatectomy

Abstract Background Poorly controlled acute pain after hepatectomy is related to somatic pain signals derived from the abdominal wall and is associated with a variety of unwanted post-operative consequences, including patient suffering, distress, respiratory complications, delirium, myocardial ischemia, prolonged hospital stay, an increased likelihood of chronic pain, increased consumption of analgesics, delayed bowel function and increase the requirement for rescue analgesics. Appropriate pain treatment protocols to reduce postoperative morbidity, improve the results of the surgery and decrease hospital costs. Objective to assess the postoperative analgesic efficacy of transversus abdominis plane (TAP) block compared local wound infiltration after hepatectomy regarding the pain relief, effect on hemodynamics, requirement of first supplemental doses of analgesia and total number of doses received. Patients and Methods All patients were informed with the procedure US guided TAP block and were trained to use the visual analogue scale (VAS). The study was conducted on 60 randomly chosen patients aged 18 to 60 years, American Society of Anesthesiologists (ASA) class I ,II and III scheduled for hepatectomy in Ain Shams University Hospitals after approval of the medical ethical committee. They were allocated in two groups of 30 patients each: Results The results of the study revealed that there is Patients receiving TAP block had significantly lower pain scores for 12 h after operation and decrease total need of analgesic in first 24 h post operative compared with patients who received wound infiltration. Conclusion oblique subcostal TAP block was effective in reducing postoperative pain scores at rest and movement for 12-24 hours and lower total 24-h postoperative opioid and analgesic consumption after hepatectomy under general anesthesia, compared to local wound infiltration.

A comparative study between bupivacaine-dexmedetomidine mixture versus bupivacaine-magnesium mixture in Pre-incision skin infiltration for para-umbilical hernia repair regarding their intraoperative and postoperative analgesic effect

Abstract Background Poorly controlled acute pain after abdominal surgery is related to somatic pain signals derived from the abdominal wall and is associated with a variety of unwanted post-operative consequences, including patient suffering, distress, respiratory complications, delirium, myocardial ischemia, prolonged hospital stay, an increased likelihood of chronic pain, increased consumption of analgesics, delayed bowel function and increase the requirement for rescue analgesics. Appropriate pain treatment protocols to reduce postoperative morbidity, improve the results of the surgery and decrease hospital costs. Aim of the Work to compare skin infiltration with bupivacaine-dexmedetomidine mixture versus bupivacainemagnesium mixture for analgesia in patients undergoing para-umbilical hernia repair under general anesthesia. magnesium. Results This study demonstrated that the addition of dexmedetomidine to wound infiltration with local anesthetics improves postoperative pain and reduces the need for analgesics which can be explained by different mechanisms: inhibition of painconduction in C -fibers, decreased in the production of inflammatory cytokines, the vasoconstrictive effect of 2 on vascular smooth muscle prolongs the time of analgesia, inhibition of tetrodotoxin-sensitive Na+ channels, and the absorption of dexmedetomidine to systemic circulation resulting in supraspinal analgesia. Patients and Methods A prospective randomized clinical trial study was conducted in Ain Shams university hospital on 44 adult patients undergoing para umbilical hernia or infra umbilical incisional hernia repair. The patients were randomly divided into two groups using their computer-generated random numbers will be enrolled in group D for bupivacaine-dexmedetomidine and group M for bupivacaine- Conclusion Pre-skin incision wound infiltration with dexmedetomidine–bupivacaine mixture provides prolonged local anesthetic effect, decreases the need for rescue analgesics, and provides better sedation than bupivacaine–magnesium sulfate mixture or bupivacaine alone in patients undergoing surgeries for hernia repair.

Comparative Study Between Caudal Block And Local Wound Infiltration In Inguinal Hernia Repair In Pediatric Patients

Abstract Background Postoperative analgesia can be provided by a multimodal approach includes opioids, nonsteroidal anti-inflammatory drugs, paracetamol infusion and regional anesthetic techniques such as local infiltration or nerve blocks. In contrast to opioids, local anesthetics can be administered safely and in recent guidelines regional anesthesia is accepted as the cornerstone of postoperative pain relief in the pediatric patients. Objective Compare the postoperative analgesic effectiveness of local wound infiltration of bupivacaine against bupivacaine administered caudally in pediatric patients undergoing unilateral inguinal hernia repair. Patients and methods This study was carried out in Ain Shams University hospitals on 40 pediatric patients of both sexes aged from 6 months to 7 years belonging to ASA I or II undergoing elective unilateral inguinal hernia repair. They were randomly allocated into two groups: group C receiving caudal block, group L receiving local wound infiltration. Hemodynamic changes, postoperative pain score using FLACC pain score, postoperative analgesia and complications were recorded. Results There was no significant difference between the two groups as regard demographic data or hemodynamic variables. Pain score shows no statically significant differences between two groups in the first hour. But statistically significant decrease in FLACC score after (1, 2 and 3 hours) in group C in comparison with group L.decreased significantly in group C after 1 hour postoperative. Duration of analgesia longer in group C with no significant difference in total amount of postoperative analgesia. There was significant increase in incidence in complications in group C than group L Conclusion Caudal block provides better and longer analgesia but requires experience and may lead to complications. In contrast, wound infiltration is simple without significant side effects. Therefore, local wound infiltration may be a preferred technique for producing postoperative analgesia in pediatric inguinal hernia repair.

Diabetic ferroptosis plays an important role in triggering on inflammation in diabetic wound.

Impaired wound healing is a major complication of diabetes and involves sustained inflammation and oxidative stress at the wound site. Here, we investigated the potential involvement of ferroptosis, a newly discovered form of cell death characterized by iron-dependent accumulation of lipid peroxides in the pathogenesis of diabetic wound healing. Fibroblasts and vascular endothelial cells exposed to high glucose concentrations in vitro contained elevated levels of reactive oxygen species (ROS), lipid peroxidation products, and ferroptosis-associated proteins and displayed reduced survival and migration. These effects of high glucose were all significantly reduced by treatment with the ferroptosis inhibitor ferrostatin-1 (Fer-1). Similarly, in a rat model of diabetes, direct application of Fer-1 to the wound site reduced the expression of oxidative stress and inflammation markers and accelerated wound healing via activation of the anti-inflammatory phosphoinositide 3-kinase (PI3K)/protein kinase B (AKT) pathway. Our results implicate ferroptosis in wound healing and identify a potential new therapeutic target for difficult-to-treat diabetic wounds.NEW & NOTEWORTHY Ferroptosis-related characteristic changes were found in diabetic wound models. Inhibition of ferroptosis improved inflammatory infiltration of diabetic wounds. PI3K/AKT signal pathway was rescued by restraining of ferroptosis. Mitigation of ferroptosis in diabetic wound promoted the wound healing.

Comparative Study between Bupivacaine-Dexmedetomidine versus Bupivacaine-Dexamethasone in Skin Infiltration as Post-Operative Analgesia for Patients undergoing Abdominoplasty Surgeries

Abstract Background Poorly controlled acute pain after abdominal surgery is related to somatic pain signals derived from the abdominal wall and is associated with a variety of unwanted postoperative consequences, including patient suffering, distress, respiratory complications, delirium, myocardial ischemia, prolonged hospital stay, an increased likelihood of chronic pain, increased consumption of analgesics, delayed bowel function and increase the requirement for rescue analgesics. Appropriate pain treatment protocols to reduce postoperative morbidity, improve the results of the surgery and decrease hospital costs. Aim of the Work To compare skin infiltration with bupivacaine-dexmedetomidine mixture versus bupivacaine-dexamethasone mixture for analgesia in abdominoplasty under general anesthesia. Patients and Methods A prospective randomized clinical trial study was conducted in Ain Shams university hospital on 40 adult patients undergoing Abdominoplasty surgeries. The patients were randomly divided into two groups using their computer-generated random numbers will be enrolled in group I for bupivacaine-dexmedetomidine and group II for bupivacaine-dexamethasone. Results This study demonstrated that the addition of dexmedetomidine to wound infiltration with local anesthetics improves postoperative pain and reduces the need for analgesics. Conclusion Wound infiltration with bupivacaine -dexmedetomidine mixture provides prolonged local anesthetic effect, decreases the need for rescue analgesics, and provides better sedation than bupivacaine–dexamethasone mixture in patients undergoing Abdominoplasty surgeries.

INVESTIGATION OF CCL2/MCP-1 LEVEL IN BLOOD SERUM OF SURGICAL PAEDIATRIC PATIENTS AS MARKER OF ADEQUACY OF PERIOPERATIVE PAIN MANAGEMENT

BACKGROUND. Surgical treatment leads to the development of postoperative pain in 80% of cases. Therefore, prompt and effective pain management is among the key priorities for healthcare professionals. The aim of the study is to determine the CCL2 / MCP-1 level in the blood serum of patients in the postoperative period under different analgesic methods and to assess the relationship between the inflammatory response and the pain response using the Visual Analog Scale (VAS). Materials and methods. We studied 30 pediatric patients with acute surgical abdominal pathologies, aged 8 to 15 years for urgent surgical procedures requiring general anesthesia. The patients were divided into 3 groups according to selected methods of intraoperative anesthesia: the 1 group included 12 patients, who received standard general anesthesia, the 2 group involved 10 patients, who received general anesthesia and infiltration anesthesia of the wound with 0.5% bupivacaine, a local anesthetic, and the 3 group included 8 children, who received general anesthesia and wound infiltration with 0.5% bupivacaine plus adjuvant (dexamethasone – 4 mg). One hour before surgery and in the postoperative period (3 and 12 hours after surgery), the patients were asked to fill in a pain diary assessing the intensity of pain syndrome and its dynamic characteristics using a visual analogue scale (VAS). Investigation to the rate of inflammatory response was assessed by monocytechemoattractant protein-1 (MCP-1). RESULTS. We found out that the plasma CCL2 / MCP-1 level in the patients prior surgery averaged 17.25 ± 7.8 pg / ml; (p <0.05), the baseline plasma CCL2 / MCP-1 levels in the patients of all groups were nearly the same. In patients of the 1st group there was an increase in the level of CCL2 / MCP-1 in the blood plasma (2.3 times) 3 hours after surgery, p <0.05, and 12 hours after surgery, the level of the studied chemokine increased by 6.7 times compared with the results obtained before surgery (p <0,05). Patients in the second group had no increase in inflammatory markers after 3 hours, but after 12 hours after surgery, plasma CCL2 / MCP-1 level significantly increased in 2.2 times compared with the values of the chemokine before surgery (p <0,05). In patients of group 3, the level of CCL2 / MCP-1 in blood plasma did not change statistically at 3 hours and 12 hours after surgery, although on average it decreased quantitatively. In the preoperative period the pain intensity ranked by the VAS scale averaged 7.8 scores and almost did not differ in the all study groups, but in the postoperative period, the degree of pain intensity was quantitatively the lowest in group 3 compared with 1 and 2 study groups. CONCLUSION. The dynamics of plasma CCL2 / MCP-1 levels in the patients reflects the development of the general adaptation syndrome in response to trauma. The CCL2 / MCP-1 level is significantly influenced by the type of anesthesia. The multimodal approach to the pain management is considered as the most effective and optimal method in perioperative care of patients

Small Volume of Rabies Immunoglobulin (RIG) is Effective for Local Wound Infiltration in Rabies Post-Exposure Prophylaxis whereas Intramuscular RIG is just a Wastage

Rabies is a zoonosis that is 100% fatal once symptoms of the disease appear. However, it is almost 100% preventable if the prophylactic measures with proper wound wash, vaccines and immunoglobulins are taken soon after exposure to the animal bite. A general tendency has been noticed among clinicians all over the world to inject Rabies Immunoglobulins (RIG) intramuscularly, mostly in the gluteal muscle, despite the guidelines that suggest infiltrating it into the wounds. This has resulted in failures of Post Exposure Prophylaxis in many countries leading to the death of patients due to rabies. Here we discuss how giving any amount or even large amount of RIG intramuscularly (IM) is not going to neutralise rabies virus at the wound site especially during the window period, exposing the patients to the risk of rabies, whereas a small volume of RIG injected into the wound(s) is a lifesaving intervention as it neutralises the virus there and then in the wound(s) especially during the initial window period when the exposed person is unprotected, as the response to concurrent vaccination may take 10-14 days after exposure/ bite.

Transversus Abdominis Plane Block Versus Local Wound Infiltration for Postoperative Pain After Laparoscopic Colorectal Cancer Resection: a Randomized, Double-Blinded Study

BackgroundDespite the extensive administration of the enhanced recovery after surgery (ERAS) program, postoperative pain remains a major concern for patients. Transversus abdominis plane (TAP) block and local wound infiltration (LWI) are two techniques that have been widely applied in abdominal surgery. However, these two techniques have rarely been compared in terms of their analgesic effects on patients that undergo laparoscopic colorectal surgery with the ERAS program. MethodsA randomized, double-blinded study was conducted in this study. Briefly, 174 patients that underwent colorectal surgery with the ERAS program were randomly allocated to TAP block treatment (TAP group) or local wound infiltration (LWI group). All patients were assessed for their pain scores at rest and in motion at 6, 24, 48, and 72 h after surgery. The administration frequency of bolus for PCIA and the use amount of rescue analgesics (parecoxib) were recorded. Finally, the patients were monitored with follow-up surveys on their postoperative function recovery, complications, lengths of stay, treatment cost, and satisfaction. ResultsIn terms of the pain scores at rest and in motion, the two groups revealed no significant difference throughout the study sessions, and no difference was found in the administration frequency of bolus and the use amount of parecoxib. Moreover, the two groups demonstrated similar results in their postoperative recovery, and no significant differences were found in terms of postoperative complications. ConclusionsCompared with local wound infiltration, transversus abdominis plane block is not significantly advantageous for postoperative pain control and recovery in patients undergoing laparoscopic colorectal surgery with the ERAS program. However, local wound infiltration might be preferred since it is available with less technical difficulties.

Postoperative pain after cesarean section: an audit of practice after implementation of the PROSPECT recommendations

Cesarean section (CS) is the most frequently performed surgical intervention worldwide. Post- cesarean pain is often underestimated and undertreated and can impair rapid maternal recovery, mother and child bonding and breastfeeding. Recently, PROSPECT recommendations on postoperative pain for CS were published and they include systematic paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs), intravenous dexamethasone, neuraxial morphine/dia- morphine or an abdominal wall block or wound infiltration, abdominal wall binders, non-closure of the peritoneum and a Joel-Cohen incision. Opioids are administered as rescue. In UZ Leuven, these PROSPECT recommendations were implemented at the end of 2020. To evaluate the efficacy of these PROSPECT recommendations, a prospective audit was performed from January 1 st , 2021 till April 30 th , 2021. All patients with a CS were prospectively followed for correct implementation of the pain protocol and for pain scores in rest and at mobilization. Rescue opioid consumption as well as patient satisfaction were recorded. 185 consecutive patients that had undergone a CS were included in the audit. In 55 patients the pain protocol was not followed mostly due to no or reduced administration of NSAIDs. Patient satisfaction was high, especially in patients in which the protocol was followed. Pain scores at rest and at mobilization were low and the percentage of patients having pain scores above 30 mm VAS remained low. Rescue opioid consumption was low. We conclude that the implementation of the PROSPECT based pain protocol after CS was effective in controlling pain, reducing opioid consumption and resulted in high patient satisfaction especially if the protocol was correctly followed. Omission of NSAIDs is occurring relatively frequent, but mostly because of valid medical reasons to omit NSAIDs.

The role of antimicrobial defense factors in the pathogenesis of immune disorders in deviated septum. Part 2

The article presents the data from Russian and foreign researchers on the state of humoral and cellular factors of antimicrobial protection of the mucous membrane of the nasal cavity and paranasal sinuses in the pathogenesis of immune disorders in deviated septum. One of the factors affecting the intensity of the inflammatory reaction and the rate of epithelialization of the mucous membrane is a decrease in IL-10 receptor expression, and, as a consequence, a decrease in its endogenous production. In vivo experiments have shown that the reduced expression of genes responsible for the synthesis of interleukin-10 inhibits infiltration of the wound postoperative surface of phagocytes, reducing the expression of CC-chemokines (MCP-1, MIP-1α), their receptors, cytokines, and interleukin-1α. The role of cellular and humoral factors, interreceptor interactions of cells of the respiratory, glandular epithelium, phagocytes, and lymphocytes in pathological conditions of the nasal mucosa and paranasal sinuses was analyzed. The role of immune mechanisms in the development of pathological reactions in deviated septum is shown. The presented review will expand the understanding of the role of antimicrobial factors in the pathogenesis of immune disorders in deviated septum.

Efficacy of postoperative pain management using patient-controlled wound infusion method after laparotomy in children: Three cases

For many years the impact of pain on children has been underestimated. Nowadays it is known to cause a wide spectrum of negative consequences. Therefore, this article aimed to report the effectiveness and success of the patient-controlled wound infiltration (PCWI) – one of the most recent postoperative pain management approaches. We carried out three cases of the PCWI technique for patients aged nine-to-ten years in the Hospital of Lithuanian University of Health Sciences Kaunas Clinics. During surgery, the leading surgeon placed a multi-holed catheter preperitoneally, which was then connected to patient-controlled analgesia (PCA) device containing a pump with the analgesic solution filled beforehand. After the surgery, the patients evaluated their pain scores using a visual analogical scale every 3 h up until the removal of the catheter. The average pain score of all three patients did not exceed more than 3.5 points with an overall pain score tendency to decrease over time when PCWI was applied. Moreover, no analgesia nor catheter-related complications were observed. PCWI showed to be a good pain-relieving, easily used, and applied method with no incidence of complications and no adverse effects of medications when applied for no longer than 48 hours.

Results of simultaneous operations for nodular goiter

In recent years, there has been an increase in patients with thyroid pathology around the world, which is associated with iodine deficiency and often these diseases are combined with other pathologies that require surgical treatment. The aim of our work was to evaluate the effectiveness of simultaneous operations in nodular goiter. Material and methods . The article presents the results of simultaneous operations that were performed in 19 patients with nodular goiter. Echinococcosis of the liver was found in 8 of them, cholelithiasis in 11 (chronic calculous cholecystitis – 7 and recurrent choledocholithiasis – 4). All operations were performed under endotracheal anesthesia from two approaches, and thyroidectomy and resection of the thyroid gland in combination with cholecystectomy (choledochotomy) were performed in 11 and in 8 with echinococcectomy. In addition to conventional examination methods, a fine-needle aspiration biopsy of the thyroid gland was performed in all patients with nodular goiter to exclude proliferative growth and identify the contents of the cyst. Postoperative complications and long-term results were studied (from 3 months to 3.5 years). Results . In the immediate postoperative period, complications arose in 3 cases each (wound suppuration, infiltration and pleurisy). 18 patients were examined up to 3 and 6 months, 15 patients – from one to 2 years, 13 patients – from 2 to 3.5 years; recurrence of goiter and associated diseases (gallstone disease and echinococcosis of the liver) were not found. Conclusion . Simultaneous operations can be performed in cases of nodular goiter combination with echinococcosis and gallstone disease, but under the condition of strict adherence to the rules of the principle of aparasiticity and antiparasiticity in echinococcectomy. When performing simultaneous operations, it is necessary to fully examine the patient, determine the indications and contraindications, the volume of the planned operation, and also pay attention to the preoperative preparation and management of the postoperative period.