Cervical erector spinae plane block: a cadaver study

Background

Cervical erector spinae plane (ESP) block has been described to anesthetize the brachial plexus (BP), however, the mechanism of its clinical effect remains unknown. As the prevertebral fascia encloses the phrenic nerves, BP and erector spinae muscles to form a prevertebral compartment, a local anesthetic injected in the cervical ESP could potentially spread throughout the prevertebral compartment. This study utilizes cadaveric models to evaluate the spread of ESP injections at the C6 and C7 levels to determine whether the injection can reach the BP and its surrounding structures.

Methods

For each of the five cadavers, an ESP injection posterior to the transverse process of C6 was performed on one side, and an ESP injection posterior to the transverse process of C7 was performed on the contralateral side. Injections were performed under ultrasound guidance and consisted of a 20 mL mixture of 18 mL water and 2 mL India ink. After cadaver dissection, craniocaudal and medial-lateral extent of the dye spread in relation to musculoskeletal anatomy as well as direct staining relevant nerves was recorded. The degree of dye staining was categorized as “deep,” “faint,” or “no.”

Results

The phrenic nerve was deeply stained in 1 injection and faintly stained in 2 injections. Caudally, variable staining of C8 (100%) and T1 (50%) roots were seen. Faintly staining at C4 root was only seen in one sample (10%). There was variable staining of the anterior scalene muscles (40%) anterior to the BP and the rhomboid intercostal plane caudally (30%).

Conclusions

Ultrasound-guided cervical (C6 and C7) ESP injections consistently stain the roots of the BP and dorsal rami. This study supports the notion that the cervical ESP block has the potential to provide analgesia for patients undergoing shoulder and cervical spine surgeries.

Comparing the Clinical Features and Trauma Scores of Trauma Patients Aged Under 65 Years with Those of Patients Aged over 65 Years in the Intensive Care Unit: A Retrospective Study for Last Ten Years

Objective

This retrospective study aimed to compare the clinical characteristics and trauma scores of Intensive Care Unit (ICU) trauma patients 65 years and older with the patients under 65 years old.

Materials and Methods

Trauma patients (n=161) who stayed at least 24 hours in ICU were included. Patients younger than 65 years were included into Group 1 (n=109) and patients aged ≥65 years (n=52) were included into Group 2. Patient characteristics and trauma index scores (GCS; APACHE II score, ISS; TRISS and RTS) at ICU admission were calculated.

Results

The patients in Group 2 had more comorbid disease compared with Group 1 (61.5%, 6.4%) (p=0.001). The Trauma-related Injury Severity Score score were higher in Group 1 (49.76±33.75) compared with Group 2 (35.38±34.93) (p=0.006). The APACHE II score were higher in Group 2 (20.08±7.60) compared with Group 1 (17.00±6.90) (p=0.007). The need for invasive mechanical ventilation and tracheostomy were more frequent in Group 2 trauma patients compared with those of patients in Group 1 (92.3%, 73.4%; p=0.003; 26.9%, 8.3%; p=0.002; respectively). The need for transfusion of packed red blood cell suspension (PRBC) was more frequent in Group 2 compared with Group 1 (92.3%, 55.0%; respectively) (p=0.001). The mortality rate was found to be higher in Group 2 compared with Group 1 (48.1%, 19.3%; respectively) (p=0.001).

Conclusion

The elderly trauma patients have more comorbid disease, higher scores for APACHE II and lower scores for TRISS, more mechanical ventilation and tracheostomy requirements and higher mortality rate compared with young trauma patients.

Effect of 6% hydroxyethyl starch 130/0.4 on kidney and haemostatic function in cardiac surgical patients: a randomised controlled trial

Whether third‐generation hydroxyethyl starch solutions provoke kidney injury or haemostatic abnormalities in patients having cardiac surgery remains unclear. We tested the hypotheses that intra‐operative administration of a third‐generation starch does not worsen postoperative kidney function or haemostasis in cardiac surgical patients compared with human albumin 5%. This triple‐blind, non‐inferiority, clinical trial randomly allocated patients aged 40–85 who underwent elective aortic valve replacement, with or without coronary artery bypass grafting, to plasma volume replacement with 6% starch 130/0.4 vs. 5% human albumin. Our primary outcome was postoperative urinary neutrophil gelatinase‐associated lipocalin concentrations, a sensitive and early marker of postoperative kidney injury. Secondarily, we evaluated urinary interleukin‐18; acute kidney injury using creatinine RIFLE criteria, coagulation measures, platelet count and function. Non‐inferiority (delta 15%) was assessed with correction for multiple comparisons. We enrolled 141 patients (69 starch, 72 albumin) as planned. Results of the primary analysis demonstrated that postoperative urine neutrophil gelatinase‐associated lipocalin (median (IQR [range])) was slightly lower with hydroxyethyl starch (5 (1–68 [0–996]) ng.ml⁻¹) vs. albumin (5 (2–74 [0–1604]) ng.ml⁻¹), although not non‐inferior [ratio of geometric means (95%CI) 0.91 (0.57, 1.44); p = 0.15] due to higher than expected variability. Urine interleukin‐18 concentrations were reduced, but interleukin‐18 and kidney injury were again not non‐inferior. Of 11 individual coagulation measures, platelet count and function, nine were non‐inferior to albumin. Two remaining measures, thromboelastographic R value and arachidonic acid‐induced platelet aggregation, were clinically similar but with wide confidence intervals. Starch administration during cardiac surgery produced similar observed effects on postoperative kidney function, coagulation, platelet count and platelet function compared with albumin, though greater than expected variability and wide confidence intervals precluded the conclusion of non‐inferiority. Long‐term mortality and kidney function appeared similar between starch and albumin.

The Effect of the Modified Thoracolumbar Interfacial Nerve Plane Block on Postoperative Analgesia and Healing Quality in Patients Undergoing Lumbar Disk Surgery: A Prospective, Randomized Study

Objective:

The purpose of this study was to investigate the effect of the modified thoracolumbar interfascial plane block (TLIP) on postoperative analgesia and quality of recovery in patients undergoing lumbar disk surgery.

Method:

Ninety patients scheduled for lumbar disk surgery were divided into a control group (Group C) and a modified TLIP block group (Group T). Controlled analgesia was administered to both groups. Pain evaluation was performed at 30 min and at 1., 2., 4., 8.,12., and 24. hrs using a VAS scale, with patients at rest and duringand patients completed the QoR-40 quality of recovery inventory.

Results:

Fentanyl used during postoperative 24 hours was 742.5±220.3 mcg in Group C and 446.0±241.98 in Group T. Postoperative fentanyl consumption was statistically significantly lower in Group T (p<0.001) with a statistically significant intergroup difference. The patient’s pain, physical independence, physical comfort, psychological support, and emotional support were compared using the QoR-40 questionnaire survey. Significant differences in favor of Group T were observed (p<0.001, p=0.017, p=0.002, p=0.001 and p<0.001, respectively). Static and dynamic pain scores in Group C and Group T were recorded at 30 min and at 1, 2, 4, 8, 12, and 24^h. Mean static scores were statistically significantly different in favor of Group T with the exception of 8^th and 12^h assessments (p<0.05). Dynamic scores were statistically significantly different in favor of Group T at all time points (p<0.05).

Conclusion:

Pain scores, opioid consumption and QoR-40 values after lumbar disk surgery were superior in the group undergoing TLIP. We think that the modified TLIP block may be an important method in terms of postoperative analgesia and patient recovery for lumbar spinal disk surgery.

Retained Perineural Catheter: A Sentinel Case Report

We report the rare complication of a retained peripheral nerve block catheter (PNBC). A 45-year-old man with intractable postamputation phantom limb pain was treated with continuous infusions via femoral and sciatic peripheral nerve catheters. The catheters were removed by an emergency department physician 2 days after placement. Five months later, the patient presented with a discharging sinus from the sciatic nerve catheter site. Magnetic resonance imaging (MRI) was inconclusive. Surgical exploration showed 15 cm of retained peripheral nerve catheter, which was removed.

Hypotension Prediction Index software for management of hypotension during moderate- to high-risk noncardiac surgery: protocol for a randomized trial

BACKGROUND

Hypotension is associated with serious complications, including myocardial infarction, acute kidney injury, and mortality. Consequently, predicting and preventing hypotension may improve outcomes. We will therefore determine if use of a novel hypotension prediction tool reduces the duration and severity of hypotension in patients having non-cardiac surgery.

METHODS/DESIGN

We will conduct a two-center, pragmatic, randomized controlled trial (N = 213) in noncardiac surgical patients > 45 years old who require intra-arterial blood pressure monitoring. All participating patients will be connected to a Flortrac IQ sensor and EV1000 platform (Edwards Lifesciences, Irvine). They will be randomly assigned to blinded or unblinded arms. The Hypotension Prediction Index (HPI) and advanced hemodynamic information will be universally recorded, but will only be available to clinicians when patients are assigned to unblinded monitoring. The primary outcome will be the effect of HPI software guidance on intraoperative time-weighted average mean arterial pressure under a threshold of 65 mmHg, which will be assessed with a Wilcoxon-Mann-Whitney 2-sample, two-tailed test.

DISCUSSION

Our trial will determine whether the Hypotension Prediction Index and associated hemodynamic information substantively reduces hypotension during non-cardiac surgery.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03610165 . Registered on 1 August 2018.

The Effect of Pre-emptive Dexketoprofen Administration on Postoperative Pain Management in Patients with Ultrasound Guided Interscalene Block in Arthroscopic Shoulder Surgery

Background: Postoperative pain is an important problem for patients undergoing shoulder surgery. Our study investigated analgesic efficacy, duration of analgesia, postoperative analgesic use and patient satisfaction with the use of preemptive intravenous dexketoprofen for interscalene block in addition to general anesthesia in arthroscopic shoulder surgery. Methods: 60 patients, scheduled for arthroscopic shoulder surgery were randomized (30 patients each) into either: - control group (Group1) or dexketoprofen group (Group 2). Patients were followed for 48 hours to compare both groups for; post-operative pain scores, effectiveness of postoperative analgesia, duration of analgesia, and analgesia consumption. Duration of postoperative sensory block of the shoulder joint was defined as time to onset of pain at the incision site. Duration of postoperative motor block of the shoulder joint was defined as time to onset of first shoulder movement. Results: While no significant difference was determined for motor block time, sensory block time was significantly longer in the dexketoprofen group (p < 0.05).VAS scores were significantly lower at all times in the dexketoprofen group (p < 0.05).Total PCA fentanyl consumption was 274.16 ± 314.89 (μg) in the dexketoprofen group, and 490.00 ± 408.98 (μg) in the control group, the difference was statistically significant (p < 0.05). No significant difference was observed between the groups' demographic and hemodynamic data. Conclusion: Pre-emptive IV dexketoprofen may be a good option for arthroscopic shoulder surgery and provides effective analgesia.

Preemptive intravenous ibuprofen application reduces pain and opioid consumption following thyroid surgery

OBJECTIVE

The primary aim of this study was to investigate the effects of preemptive a single dose IV ibuprofen on postoperative 48 h opioid consumption and postoperative pain in patients undergoing thyroidectomy.

METHODS

The study included 40 patients aged 18 to 65, scheduled for elective thyroidectomy. Patients were randomly divided into 2 groups. Control group (n = 20) received 100 mL saline solution 15 min before surgery, while study group (n = 20) received 800 mg IV ibuprofen in 100 mL saline. The same general anesthesia protocol was applied in both groups, and all operations were performed by the same surgical team using the same technique. Postoperative analgesia was assessed using a visual analogue scale (VAS) and the amount of consumption of 48 h postoperative fentanyl with patient-controlled analgesia (PCA) and additional analgesia requirements were recorded. When additional analgesia was required, 1000 mg IV paracetamol was used.

RESULTS

VAS scores in the ibuprofen group were found lower than the control group in the all-time points (p < 0.05). Opioid consumption in the 48 h was significantly higher in the control group than the ibuprofen group (p < 0.001). Using of rescue analgesia was significantly higher in the control group than the ibuprofen group, statistically (p < 0.05). A significant difference was observed between two groups in terms of side effects of fentanyl consumption (nausea and vomiting) (p < 0.001).

CONCLUSION

To use preemptive a single dose IV ibuprofen decreases pain scores and postoperative opioid consumption in patients following thyroidectomy. Additionally, this application increase the patient comfort reducing nausea and vomiting in early postoperative period.

Erector Spinae Plane Block Catheter Insertion under Ultrasound Guidance for Thoracic Surgery: Case Series of Three Patients

The erector spinae plane (ESP) block is a novel plane block first reported for thoracic analgesia. It affects the dorsal and ventral rami of the thoracic nerves. Owing to the ease of the technique and decreased risk of complication of the ESP block under ultrasound guidance, it can be a preferable procedure compared with other invasive techniques, such as neuraxial and nerve blocks. In this case report, we presented three patients who had thoracic surgery under general anesthesia. The ESP block and catheter placement was applied to the patients before operation. The catheter was inserted deep into the erector spinae muscle and was used successfully for postoperative pain management.

Does a single-dose preemptive intravenous ibuprofen have an effect on postoperative pain relief after septorhinoplasty?

PURPOSE

Septorhinoplasty is a surgical procedure widely employed by otolaryngologists and plastic surgeons. The purpose of this study was to investigate the effects of a single pre-emptive dose of iv ibuprofen on postoperative pain and opioid consumption in patients undergoing septorhinoplasty.

MATERIAL AND METHODS

50 patients scheduled for septorhinoplasty were included in this prospective, randomized, double-blinded study. Control group (n = 25) was administered 100 mL iv saline solution 30 min preoperatively, while Ibuprofen group (n = 26) received 800 mg ibuprofen iv. in 100 mL saline solution. Intravenous fentanyl was administered with a Patient Controlled Analgesia device after surgery for postoperative pain management. Postoperative pain was evaluated using a Visual Analogue Scale (VAS) with 0 representing no pain and 10 the worst pain possible.

RESULTS

VAS scores at 10, 20, and 30 min and at 1, 2, 4, 8, 12 and 24 h were lower in the ibuprofen group than in the control group (p < 0.05). Total fentanyl consumption was lower in the ibuprofen group compared to the placebo group (148.8 ± 86.4 mcq vs 338.00 ± 81.00 mcq), respectively.

CONCLUSION

We suggest that the pre-emptive use of iv ibuprofen at a dosage of 800 mg 30 min before septorhinoplasty will be beneficial in reducing opioid consumption and pain scores.

Lung Hydatid Cyst Treatment With Laparotomy: A New and Different Technique

This report presents the case of a patient with a pulmonary hydatid cyst. The patient underwent laparotomy for hepatic and splenic cysts, and cystotomy and capitonnage were perfomed using a transdiaphragmatic intervention. The pulmonary hydatid cyst was located at the base of the lung and near the diaphragm. The diaphragm was cut about 5 cm at the front, and the thorax was entered.The pulmonary cyst was treated intraabdominally. This technique is effective and safe, and it prevents the patient from undergoing a second operation. The suggestion is that this technique, which has not been defined before, can be applied safely in carefully selected patients.

Comparison of transverse short-axis classic and oblique long-axis “Syringe-Free” approaches for internal jugular venous catheterization under ultrasound guidance

Background and objectives

Methods

Results

Conclusion

The Effects of Positive End-Expiratory Pressure at Different Levels on Postoperative Respiration Parameters in Patients Undergoing Laparoscopic Cholecystectomy

Purpose/Aim of the study: We investigated the effects of different positive end-expiratory pressure (PEEP) levels on postoperative respiration parameters in patients undergoing laparoscopic cholecystectomy.

MATERIALS AND METHODS

One hundred and five consecutive patients were randomly divided to three groups (n = 35, for each group). Group I did not receive PEEP whereas group II received PEEP as 5 cmH₂O and group III received PEEP as 8 cm H₂O. Measurements with spirometer were taken 1 hour before the operation (T₁) and, 1 (T₂), 6 (T₃), and 24 hours (T₄) after extubation by an anesthetist. Forced expiratory volume (FEV₁), forced vital capacity (FVC), and peak expiratory flow (PEF) were recorded.

RESULTS

Group I had higher FVC values measured at T₂ time point compared with other groups (p < 0.05, for both groups). There was a statistically significant difference between group I and group III in terms of the FVC values measured at T₃ and T₄ time points (p = 0.05 and p < 0.05, retrospectively). A statistical difference was found between group I and group II in terms of FEV₁ measured at T₂ time point (p < 0.05). Group I had higher FEV₁ values measured at T₃ and T₄ time points compared to group III (p = 0.05, P<0.05; respectively). Group III had lower PEF values measured at T₄ time point compared to group I and II (p < 0.05).

CONCLUSIONS

We concluded that PEEP with 5 or 8 cmH₂O has negative effects on lung function tests measured with spirometer during postoperative 1^st, 6^th, and 24^th hours in patients underwent elective laparoscopic cholecystectomy.

Can We Perform Distal Nerve Block Instead of Brachial Plexus Nerve Block Under Ultrasound Guidance for Hand Surgery?

OBJECTIVE

Distal nerve blocks are used in the event of unsuccessful blocks as rescue techniques. The primary purpose of this study was to determine the sufficiency for anesthesia of distal nerve block without the need for deep sedation or general anesthesia. The secondary purpose was to compare block performance times, block onset times, and patient and surgeon satisfaction.

MATERIALS AND METHODS

Patients who underwent hand surgery associated with the innervation area of the radial and median nerves were included in the study. Thirty-four patients who were 18-65 years old and American Society of Anesthesiologists grade I-III and who were scheduled for elective hand surgery under conscious nerve block anesthesia were randomly included in an infraclavicular block group (Group I, n=17) or a radial plus median block group (Group RM, n=17). The block performance time, block onset time, satisfaction of the patient and surgeon, and number of fentanyl administrations were recorded.

RESULTS

The numbers of patients who needed fentanyl administration and conversion to general anesthesia were the same in Group I and Group RM and there was no statistically significant difference (p>0.05). The demographics, surgery times, tourniquet times, block perfomance times, and patient and surgeon satisfaction of the groups were similar and there were no statistically significant differences (p>0.05). There was a statistically significant difference in block onset times between the groups (p<0.05).

CONCLUSIONS

Conscious hand surgery can be performed under distal nerve block anesthesia safely and successfully.