Interfascial plane blocks

Anatomical Relationships of the Proximal Attachment of the Hamstring Muscles with Neighboring Structures: From Ultrasound, Anatomical and Histological Findings to Clinical Implications

BACKGROUND

Injuries of the proximal attachment of the hamstring muscles are common. The present study aimed to investigate the relationship of the proximal attachment of the hamstring muscles with neighboring structures comprehensively.

METHODS

A total of 97 hemipelvis from 66 cryopreserved specimens were evaluated via ultrasound, anatomical and histological samples.

RESULTS

The proximal attachment of the hamstring muscles presents a hyperechogenic line surrounding the origin of the semimembranosus and the long head of the biceps femoris muscles, as well as another hyperechogenic line covering the sciatic nerve. The anatomical and histological study confirms the ultrasound results and shows different layers forming the sacrotuberous ligament. Furthermore, it shows that the proximal attachment of the semimembranosus muscle has a more proximal origin than the rest of the hamstring muscles. Moreover, this muscle shares fibers with the long head of the biceps femoris muscle and expands to the adductor magnus muscle. The histological analysis also shows the dense connective tissue of the retinaculum covering the long head of the biceps femoris and semimembranosus muscles, as well as the expansion covering the sciatic nerve.

CONCLUSIONS

These anatomical relationships could explain injuries at the origin of the hamstring muscles.

Day-surgery adult patients with obesity and obstructive sleep apnea: Current controversies and concerns

Obesity and obstructive sleep apnea are considered independent risk factors that can adversely affect perioperative outcomes. A combination of these two conditions in the ambulatory surgery patient can pose significant challenges for the anesthesiologist. Nevertheless, these patients should not routinely be denied access to ambulatory surgery. Instead, patients should be appropriately optimized. Anesthesiologists and surgeons must work together to implement fast-track anesthetic and surgical techniques that will ensure successful ambulatory outcomes.

Ultrasound-Guided Dorsolateral Approach for Quadratus Lumborum Block in Rabbits (Oryctolagus cuniculus): A Prospective, Randomized, Blinded, Cadaveric Study Comparing Four Different Injectate Volumes

Ultrasound-guided (US-guided) loco-regional anesthesia can provide significant analgesia and anesthetic-sparing effects when used in rabbits. The aims of this study were to investigate the thoraco-lumbar anatomy of the rabbits, particularly the quadratus lumborum (QL) muscle, to design an appropriate US-guided quadratus lumborum block (QLB) specific for rabbits, and to define the most adequate volume of injectate required to consistently cover the ventral branches of T11 to L3 without affecting the pelvic limb innervation (L4, L5 and L6). Sixteen adult rabbit cadavers were included in the study. After randomization, four different volumes of injectate (0.1 mL/kg, 0.2 mL/kg, 0.3 mL/kg and 0.4 mL/kg) were tested, with these volumes additionally randomized to two sites of injection (right or left QL fascia). An ultrasound-guided QLB was performed with a solution of lidocaine, iodinated contrast and tissue dye (in a proportion of 3:1:1 volume, respectively), with subsequent computed tomography (CT) and anatomical dissection, to evaluate the spread of the injectate. In all but one case, the US-guided QLB performed with a dorsolateral approach using 0.3 mL/kg was adequate, while a dose of 0.4 mL/kg consistently reached the targeted nerves but also extended to L4 and caudally. This may suggest that an injectate volume of 0.3 mL/kg may be the most appropriate to produce adequate spread while not affecting pelvic limb innervation.

Effect of interfascial pressure on block success during anterior quadratus lumborum block application: a prospective observational study

BACKGROUND

The quadratus lumborum block (QLB) has recently been used frequently for postoperative analgesia after abdominal surgery. The aim of this study was to investigate the effect of pressure changes between the middle thoracolumbar fascia layers to which the anterior QLB (aQLB) is applied at the level of the sensory block.

METHODS

A total of 67 patients planned to undergo laparoscopic cholecystectomy were evaluated in the context of this prospective study. Bilateral aQLBs were administered to all patients, and a peripheral nerve block catheter was placed between the psoas and quadratus lumborum muscles. The correlation of interfascial pressures (IFPs) during block application, 30 min intraoperatively, and 30 min postoperatively with the sensory block level was determined as the primary outcome measure. Secondary outcome measures were the sensory block levels 30 min after block application and 30 min postoperatively; visual analog scale scores 30 min and 6, 12, and 24 h postoperatively; and 24 h tramadol consumption.

RESULTS

The preoperatively and intraoperatively measured IFPs differed significantly between the right and left sides (P < 0.05). The preoperative and postoperative block levels also differed significantly between the right and left sides (P < 0.05). The preoperative and postoperative block levels and preoperatively measured IFPs showed a weakly negative correlation (right: r = 0.374; left: r = 0.470).

CONCLUSIONS

The results of this study show that pressure changes between the fasciae may be effective in aQLB application.

Thoracic Interfascial Plane Blocks and Outcomes After Minithoracotomy for Valve Surgery

Introduction. Thoracic interfascial plane blocks are increasingly used for pain management after minimally invasive thoracotomy for valve repair and replacement procedures. We hypothesized that the addition of these blocks to the intercostal nerve block injected by the surgeon would further reduce pain scores and opioid utilization. Methods. In this retrospective cohort study, 400 consecutive patients who underwent minimally invasive thoracotomy for mitral or aortic valve replacement and were extubated within 2 hours of surgery were enrolled. The maximum pain score and opioid utilization on the day of surgery and other outcome variables were compared between patients who received interfascial plane blocks and those who did not. Results.193 (48%) received at least one interfascial plane block while 207 (52%) received no interfascial plane block. Patients who received a thoracic interfascial plane block had a maximum VAS score on the day of surgery (mean 7.4 ± 2.5) after the block was administered which was significantly lower than patients in the control group who did not receive the block (mean 7.9 ± 2.2) (P = .02). Opioid consumption in the interfascial plane block group on the day of surgery was not significantly different from the control group. Conclusion. Compared to intercostal blocks alone, the addition of thoracic interfascial plane blocks was associated with a modest reduction in maximum VAS score on the day of surgery. However, no difference in opioid consumption was noted. Patients who received interfascial plane blocks also had decreased blood transfusion requirements and a shorter hospital length of stay.

Pain Management After Open Liver Resection: Epidural Analgesia Versus Ultrasound-Guided Erector Spinae Plane Block

Background: Multimodal analgesia techniques, including regional analgesia, have been shown to provide effective analgesia and minimize opioid consumption after liver resection surgery. While thoracic epidural analgesia (TEA) is considered the gold standard, its role in the current era of enhanced recovery after surgery (ERAS) has been questioned. Erector spinae plane blocks (ESPBs) have the potential to provide effective postoperative analgesia without the risks associated with epidural analgesia. The primary aim of this quality improvement project was to evaluate the analgesic efficacy of ultrasound-guided ESPB in comparison with TEA in patients undergoing open liver resection.

Methods: Fifty patients who underwent open liver resection and received TEA (n=25) or ESPB (n=25) as part of an ERAS pathway were retrospectively identified. The primary outcome measure was cumulative postoperative opioid consumption at 24 hours. Secondary outcomes included opioid consumption, pain scores, the incidence of nausea and vomiting requiring antiemetics, lower extremity muscle weakness, and occurrence of hypotension requiring treatment on arrival to the post-anesthesia care unit and at 2, 6, 12, 24 hours, and daily through postoperative day 7. 

Results: Opioid requirements were significantly lower in the TEA group compared to the ESPB group. Postoperative pain scores at rest and with deep inspiration were significantly lower in the TEA group through postoperative day 5. There were no differences in other outcome measures.

Conclusions: These findings suggest that compared with ESPB, TEA provides superior pain relief after open liver resection.

Efficacy of PECS block in addition to multimodal analgesia for postoperative pain management in patients undergoing outpatient elective breast surgery: A retrospective study

Background

Pectoralis nerve blocks (PECS) have been shown in numerous studies to be a safe and effective method to treat postoperative pain and reduce postoperative opioid consumption after breast surgery. However, there are few publications evaluating the PECS block effectiveness in conjunction with multimodal analgesia (MMA) in outpatient breast surgery. This retrospective study aims to evaluate the efficacy of PECS's blocks on perioperative pain management and opioid consumption.

Methods

We conducted a retrospective study to assess the efficacy of preoperative PECS block in addition to preoperative MMA (oral acetaminophen and/or gabapentin) in reducing opioid consumption in adult female subjects undergoing outpatient elective breast surgery between 2015 and 2020. A total of 228 subjects were included in the study and divided in two groups: PECS block group (received PECS block + MMA) and control Group (received only MMA). The primary outcome was to compare postoperative opioid consumption between both groups. The secondary outcome was intergroup comparisons of the following: postoperative nausea and vomiting (PONV), incidence of rescue antiemetic medication, PACU non-opioid analgesic medication required, length of PACU stay and the incidence of 30-day postoperative complications between both groups.

Results

Two hundred and twenty-eight subjects (n = 228) were included in the study. A total of 174 subjects were allocated in the control group and 54 subjects were allocated in the PECS block group. Breast reduction and mastectomy/lumpectomy surgeries were the most commonly performed procedures (48% and 28%, respectively). The total amount of perioperative (intraoperative and PACU) MME was 27 [19, 38] in the control group and 28.5 [22, 38] in the PECS groups (p = 0.21). PACU opioid consumption was 14.3 [7, 24.5] MME for the control group and 17 [8, 23] MME (p = 0.732) for the PECS group. Lastly, the mean overall incidence of postsurgical complications at 30 days was 3% (N = 5), being wound infection, the only complication observed in the PECS groups (N = 2), and hematoma (N = 2) and wound dehiscence (N = 1) in the control group.

Conclusion

PECS block combined with MMA may not reduce intraoperative and/or PACU opioid consumption in patients undergoing outpatient elective breast surgery.

Ultrasound-guided erector spinae plane block for pain management after gastrectomy: a randomized, single-blinded, controlled trial

Background

Open gastrectomy causes severe postoperative pain. Therefore, we investigated the opioid-sparing effect of the ultrasound-guided bilateral erector spinae plane block (ESPB) after open gastrectomy.

Methods

Adult patients undergoing open gastrectomy were randomly assigned to either the ESPB group (ESPB + fentanyl based intravenous patient-controlled analgesia [IV-PCA]) or a control group (fentanyl based IV-PCA only). The primary outcome was total fentanyl equivalent consumption during the first 24 hour postoperatively. Secondary outcomes were pain intensities using a numeric rating scale at the postanesthesia care unit (PACU) and at 3, 6, 12, and 24 hour postoperatively, and the amount of fentanyl equivalent consumption during the PACU stay and at 3, 6, and 12 hour postoperatively, and the time to the first request for rescue analgesia.

Results

Fifty-eight patients were included in the analysis. There was no significant difference in total fentanyl equivalent consumption during the first 24 hour postoperatively between the two groups (P = 0.471). Pain intensities were not significantly different between the groups except during the PACU stay and 3 hour postoperatively (P < 0.001, for both). Time to the first rescue analgesia in the ward was longer in the ESPB group than the control group (P = 0.045).

Conclusions

Ultrasound-guided ESPB did not decrease total fentanyl equivalent consumption during the first 24 hour after open gastrectomy. It only reduced postoperative pain intensity until 3 hour postoperatively compared with the control group. Ultrasound-guided single-shot ESPB cannot provide an efficient opioid-sparing effect after open gastrectomy.

Optimizing Nonopioid Analgesia and Different Pain Management Options following Abdominoplasty: A Systematic Literature Review

Introduction

Postoperative pain remains a significant challenge with the growing number of abdominoplasties every year. Opioids are currently considered the mainstay modality for controlling postoperative pain. However, opioid-related side effects raise the need for a safer and more effective approach. In this study, we aimed to investigate these alternative evidence-based postoperative pain relief modalities following abdominoplasty.

Methods

This systematic review was designed and conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The literature was systematically searched in December 2021 using the following databases: MEDLINE, Cochrane, and EMBASE. The MeSH terms used to aid the search were the following: abdominoplasty, postoperative pain management, postoperative analgesia, pain control, analgesia, and pain.

Results

Reviewing the literature resulted in a total of 851 publications. After implementing our criteria, only 13 articles were included in this study, with 990 patients. A continuous infusion pump was the most commonly used method of analgesia (n = 3), followed by a transversus abdominis plane block (n = 2). The postoperative pain assessment scale was mentioned in nine out of the 13. Compared to controls, all interventions resulted in considerably lower pain levels in all the patients. Patient satisfaction was reported in three studies, and all studies reported higher satisfaction rates than the control groups.

Conclusions

The authors performed a systematic review of the existing database of high-quality research on pain management after cosmetic abdominoplasty to determine the best pain management options currently available. However, future studies are recommended to assess the optimum dosing and administration methods.

Multimodal Analgesia in the Aesthetic Plastic Surgery: Concepts and Strategies

Postoperative pain management is crucial for aesthetic plastic surgery procedures. Poorly controlled postoperative pain results in negative physiologic effects and can affect length of stay and patient satisfaction. In light of the growing opioid epidemic, plastic surgeons must be keenly familiar with opioid-sparing multimodal analgesia regimens to optimize postoperative pain control.

Methods

A review study based on multimodal analgesia was conducted.

Results

We present an overview of pain management strategies pertaining to aesthetic plastic surgery and offer a multimodal analgesia model for outpatient aesthetic surgery practices.

Conclusion

This review article presents an evidence-based approach to multimodal pain management for aesthetic plastic surgery.

Enhanced recovery after surgery: Current status and future progress

Enhanced Recovery After Surgery (ERAS) pathways were first introduced almost a quarter of a century ago and represent a paradigm shift in perioperative care that reduced postoperative complications and hospital length of stay, improved postoperative quality of life, and reduced overall healthcare costs. Gradual recognition of the generalizability of the interventions and transferable improvements in postoperative outcomes, led them to become standard of care for several surgical procedures. In this article, we critically review the current status of ERAS pathways, address related controversies, and propose measures for future progress.

Comparison of Two Ultrasound-guided Plane Blocks for Pain and Postoperative Opioid Requirement in Lumbar Spine Fusion Surgery: A Prospective, Randomized, and Controlled Clinical Trial

INTRODUCTION

The erector spinae plane (ESP) block and thoracolumbar interfascial plane (TLIP) block were two novel plane blocks. The purpose of this study was to investigate TLIP block and ESP block on the effect of analgesic and opioid consumption in lumbar spine fusion surgery in the perioperative period.

METHODS

Three hundred and four patients who suffered lumbar spine fusion were included and randomly divided into three groups: a control group (n = 102), an ESP block group (n = 100), and a TLIP block group (n = 102). We recorded the numerical rating scale (NRS) pain at movement and static during the postoperative 48 h, opioid consumption, additional analgesic requirement, frequency of patient-controlled analgesia (PCA) compressions, Bruggemann Comfort Scale (BCS) score, side effects, duration of hospital stay, and the life quality score (LQS) after operation at 6 months.

RESULTS

The patients in the ESP block group have better analgesia during 12-48 h postoperative time at static state, a lower frequency of PCA compressions at 24-48 h after surgery, and the opioid consumption in the PCA (sufentanil) were less than those in the TLIP block group (P < 0.05). However, the BCS and LQS scores were no different between the two plane block groups after surgery at 6 months. There was no difference in hospital stay and the incidence of side effect among the three groups.

CONCLUSIONS

Our results found that patients who suffered ESP block have better analgesic effects and less pain scores in static states and less frequency of PCA compression and opioid analgesic consumption compared with those that suffered TLIP block.

TRIAL REGISTRATION

ChiCTR1800019639.

General anesthetic techniques for enhanced recovery after surgery: Current controversies

General anesthesia technique can influence not only immediate postoperative outcomes, but also long-term outcomes beyond hospital stay (e.g., readmission after discharge from hospital). There is lack of evidence regarding superiority of total intravenous anesthesia over inhalation anesthesia with regards to postoperative outcomes even in high-risk population including cancer patients. Optimal balanced general anesthetic technique for enhance recovery after elective surgery in adults includes avoidance of routine use preoperative midazolam, avoidance of deep anesthesia, use of opioid-sparing approach, and minimization of neuromuscular blocking agents and appropriate reversal of residual paralysis. Given that the residual effects of drugs used during anesthesia can increase postoperative morbidity and delay recovery, it is prudent to use a minimal number of drug combinations, and the drugs used are shorter-acting and administered at the lowest possible dose. It is imperative that the discerning anesthesiologist consider whether each drug used is really necessary for accomplishing perioperative goals.

Erector spinae plane block versus thoracic paravertebral block for pain management after total bilateral mastectomies

This prospectively designed, clinical quality improvement project compared pain scores and opioid consumption between ultrasound-guided, erector spinae plane blocks (ESPB) and thoracic paravertebral blocks (PVB) in patients undergoing total bilateral mastectomies without reconstruction. Twenty-five patients were included in an enhanced recovery pathway and received an ESPB on one side and a PVB on the contralateral side. Numeric rating scores at rest and with movement for each side were recorded in the recovery room at 2, 6, 12, 24, and 48 hours and on days 3 to 7. There were no significant differences in the resting or movement-evoked pain scores between sides receiving ESPB or PVB at any time point up to day 7 after surgery. Both ESPB and PVB confer equal analgesic effects in patients undergoing mastectomies. ESPB provides an alternative to PVB in reducing postoperative pain in patients undergoing mastectomy as part of an enhanced recovery pathway.

Respiratory depression in the post-anesthesia care unit: Mayo Clinic experience

The anesthesia recovery is a complex physiologic process as systems recover from the effects of surgery and anesthesia. Inadequate recovery of respiratory physiology can lead to severe hypoxemia-induced end-organ damage and even death. Emerging evidence suggests that signs of respiratory depression during early anesthesia recovery may portend increased risk for future severe adverse events. This article briefly reviews the Mayo Clinic research experience and advances in clinical practice. From the implementation of a step-down model of discharge criteria in the post-anesthesia care unit (PACU), consisting of PACU nurses monitoring patients in predetermined periods for signs of respiratory depression, and delaying PACU discharge for patients who exhibit signs of respiratory depression, and early intervention in high-risk patients. Subsequent studies found that even a single episode of respiratory depression in the PACU was strongly associated with subsequent respiratory complications. Further, patient baseline characteristics found to be associated with respiratory depression included obstructive sleep apnea and low body weight, and surgical factors associated with increased risk included the use of preoperative sustained-release opioids, perioperative gabapentinoid use, higher intraoperative opioids, isoflurane as the volatile anesthetic, and longer surgical duration. Based in part of Mayo Clinic research, the FDA issued a warning in 2019 on gabapentinoids use and respiratory complications, increasing the recommended level of respiratory vigilance in patients using this medication. Understanding the complex nature of postoperative respiratory events requires a range of translational and clinical research and constant update of practice.

Comparison of Ultrasound-Guided Type-II Pectoral Nerve Block and Rhomboid Intercostal Block for Pain Management Following Breast Cancer Surgery: A Randomized, Controlled Trial

PURPOSE

Although breast-conserving surgery-axillary dissection (BCS-AD) is a minimally invasive surgery, patients may suffer from moderate-to-severe pain. Several regional techniques can be used for pain control. The type II pectoral nerve block (PECS II) and the rhomboid intercostal block (RIB) are interfascial plane blocks that have been reported to provide effective analgesia after breast surgery. This study aims to compare the analgesic efficacy of the PECS II block and the RIB after breast surgery.

PATIENTS AND METHODS

Ninety female patients aged 18 to 65 years with American Society of Anesthesiologists (ASA) classes I and II physical status who underwent unilateral BCS-AD surgery were included. Patients were divided into three groups (n = 30 in each): the PECS II group, the RIB group, or the control group. PECS II block and RIB were performed with 30 mL 0.25% bupivacaine. Ibuprofen 400 mg IV 3 × 1 was given in the postoperative period. A patient control analgesia device included a dose of 10 µg/mL fentanyl, which was prepared and connected to the patients.

RESULTS

There were no statistical differences between groups in terms of demographical data. Postoperative fentanyl consumption was significantly lower in the PECS II and RIB groups than the control group. The need for rescue analgesia use was significantly higher in the control group than the other groups. At all times, visual analog scale scores were significantly lower in the PECS II and RIB groups than the control group.

CONCLUSIONS

The PECS II block and the RIB provide similar effective analgesia after BCS-AD.

Pain management after open liver resection: Procedure-Specific Postoperative Pain Management (PROSPECT) recommendations

Background and objectives

Effective pain control improves postoperative rehabilitation and enhances recovery. The aim of this review was to evaluate the available evidence and to develop recommendations for optimal pain management after open liver resection using Procedure-Specific Postoperative Pain Management (PROSPECT) methodology.

Strategy and selection criteria

Randomized controlled trials (RCTs) published in the English language from January 2010 to October 2019 assessing pain after liver resection using analgesic, anesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane databases.

Results

Of 121 eligible studies identified, 31 RCTs and 3 systematic reviews met the inclusion criteria. Preoperative and intraoperative interventions that improved postoperative pain relief were non-steroidal anti-inflammatory drugs, continuous thoracic epidural analgesia, and subcostal transversus abdominis plane (TAP) blocks. Limited procedure-specific evidence was found for intravenous dexmedetomidine, intravenous magnesium, intrathecal morphine, quadratus lumborum blocks, paravertebral nerve blocks, continuous local anesthetic wound infiltration and postoperative interpleural local anesthesia. No evidence was found for intravenous lidocaine, ketamine, dexamethasone and gabapentinoids.

Conclusions

Based on the results of this review, we suggest an analgesic strategy for open liver resection, including acetaminophen and non-steroidal anti-inflammatory drugs, combined with thoracic epidural analgesia or bilateral oblique subcostal TAP blocks. Systemic opioids should be considered as rescue analgesics. Further high-quality RCTs are needed to confirm and clarify the efficacy of the recommended analgesic regimen in the context of an enhanced recovery program.

The Role of Interfascial Plane Blocks in Paediatric Regional Anaesthesia: A Narrative Review of Current Perspectives and Updates

Regional anaesthesia has been increasingly used for analgesia in the perioperative period in paediatric anaesthesia for better pain control and improved patient outcomes. Interfascial plane blocks are considered as a subgroup of peripheral nerve blocks. The advent of ultrasound in modern regional anaesthesia practice has led to the evolution of various interfascial plane blocks. The ease of their performance and the low complication rates, compared with neuraxial anaesthesia, have led to their increased use in the perioperative period. Interfascial plane blocks are often incorporated in the multimodal analgesia regimen in the early recovery and ambulation after surgery protocols for various chest wall and abdominal surgeries. This achieves better pain control and decreases the requirements of opioids in the perioperative period, thereby facilitating early mobilization and discharge. This narrative review focuses on the relevant anatomic considerations, technique for the performance of each block along with its current applications and limitations, and includes a review of the current literature on various interfascial plane blocks in paediatric regional anaesthesia.

Practical Review of Abdominal and Breast Regional Analgesia for Plastic Surgeons: Evidence and Techniques

Regional analgesia has been increasing in popularity due to its opioid- sparing analgesic effects and utility in multimodal analgesia strategies. Several regional techniques have been used in plastic surgery; however, there is a lack of consensus on the indications and the comparative efficacy of these blocks. The goal of this review is to provide evidence-based recommendations on the most relevant types of interfascial plane blocks for abdominal and breast surgery. A systematic search of the PUBMED, EMBASE, and Cochrane databases was performed to identify the evidence associated with the different interfascial plane blocks used in plastic surgery. The search included all studies from inception to March 2020. A total of 126 studies were included and used in the synthesis of the information presented in this review. There is strong evidence for using the transversus abdominis plane blocks in both abdominoplasties as well as abdominally-based microvascular breast reconstruction as evidenced by a significant reduction in post-operative pain and opioid consumption. Pectoralis (I and II), serratus anterior, and erector spinae plane blocks all provide good pain control in breast surgeries. Finally, the serratus anterior plane block can be used as primary block or an adjunct to the pectoralis blocks for a wider analgesia coverage of the breast. All the reviewed blocks are safe and easy to administer. Interfascial plane blocks are effective and safe modalities used to reduce pain and opioid consumption after abdominal and breast plastic surgery.

Enhanced recovery pathways for ambulatory surgery

PURPOSE OF REVIEW

Implementation of enhanced recovery pathways have allowed migration of complex surgical procedures from inpatient setting to the outpatient setting. These programs improve patient safety and patient-reported outcomes. The present article discusses the principles of enhanced recovery pathways in adults undergoing ambulatory surgery with an aim of improving patient safety and postoperative outcomes.

RECENT FINDINGS

Procedure and patient selection is one of the key elements that influences perioperative outcomes after ambulatory surgery. Other elements include optimization of comorbid conditions, patient and family education, minimal preoperative fasting and adequate hydration during the fasting period, use of fast-track anesthesia technique, lung-protective mechanical ventilation, maintenance of fluid balance, and multimodal pain, nausea, and vomiting prophylaxis.

SUMMARY

Implementation of enhanced recovery pathways requires a multidisciplinary approach in which the anesthesiologist should take a lead in collaborating with surgeons and perioperative nurses. Measuring compliance with enhanced recovery pathways through an audit program is essential to evaluate success and need for protocol modification. The metrics to assess the impact of enhanced recovery pathways include complication rates, patient reported outcomes, duration of postoperative stay in the surgical facility, unplanned hospital admission rate, and 7-day and 30-day readmission rates.

Procedure-specific and patient-specific pain management for ambulatory surgery with emphasis on the opioid crisis

PURPOSE OF REVIEW

Postoperative pain is frequent while, on the other hand, there is a grooving general concern on using effective opioid pain killers in view of the opioid crisis and significant incidence of opioid abuse. The present review aims at describing nonopioid measures in order to optimize and tailor perioperative pain management in ambulatory surgery.

RECENT FINDINGS

Postoperative pain should be addressed both preoperatively, intraoperatively and postoperatively. The management should basically be multimodal, nonopioid and procedure-specific. Opioids should only be used when needed on top of multimodal nonopioid prophylaxis, and then limited to a few days at maximum, unless strict control is applied. The individual patient should be screened preoperatively for any risk factors for severe postoperative pain and/or any abuse potential.

SUMMARY

Basic multimodal analgesia should start preoperatively or peroperatively and include paracetamol, cyclo-oxygenase (COX)-2 specific inhibitor or conventional nonsteroidal anti-inflammatory drug (NSAID) and in most cases dexamethasone and local anaesthetic wound infiltration. If any of these basic analgesics are contraindicated or there is an extra risk of severe postoperative pain, further measures may be considered: nerve-blocks or interfascial plane blocks, gabapentinnoids, clonidine, intravenous lidocaine infusion or ketamine infusion. In the abuse-prone patient, a preferably nonopioid perioperative approach should be aimed at.

A novel ultrasound-guided lateral quadratus lumborum block in dogs: a comparative cadaveric study of two approaches

OBJECTIVE

To describe an ultrasound-guided lateral quadratus lumborum (LQL) block technique and the spread characteristics of lidocaine-dye injected in the LQL plane using a transversal (LQL-T) or a longitudinal (LQL-L) approach.

STUDY DESIGN

Experimental anatomic study.

ANIMALS

A total of eight canine cadavers.

METHODS

Bilateral ultrasound-guided injections in the fascial plane lateral to the quadratus lumborum muscle and medial to the thoracolumbar fascia (LQL plane) with the needle directed at the first lumbar (L1) transverse process were performed using lidocaine-dye (0.3 mL kg^-1). Anatomical dissection determined the dye distribution, sympathetic trunk staining and number of spinal nerves stained circumferentially >1 cm.

RESULTS

The LQL fascial plane was ultrasonographically recognized in all cadavers and filled with lidocaine-dye in all eight cadavers with the LQL-T approach and in six with LQL-L. The injectate spread ventral to the lumbar transverse processes, around the quadratus lumborum muscle and dorsal to the transversalis fascia, affecting the ventral branches of the spinal nerves and the sympathetic trunk. A median (range) of 4 (3-5) and 3 (0-4) ventral branches of the thoracolumbar nerves were dyed with LQL-T and LQL-L approaches, respectively (p = 0.04). The most cranial nerve stained was the twelfth thoracic (T12) with the LQL-T approach and T13 with LQL-L, and the most caudal was L3 with both approaches. The incidence of sympathetic trunk staining was significantly higher using LQL-T (six injections) compared with LQL-L (one injection; p = 0.04). Dye was not observed in the lumbar plexus, epidural space or abdominal cavity.

CONCLUSIONS AND CLINICAL RELEVANCE

Ultrasound-guided LQL-T approach resulted in a more consistent spread toward the spinal nerves and sympathetic trunk compared with LQL-L approach. Further studies are necessary to assess the LQL block effectiveness and success rate in live dogs.

Basics and Best Practices of Multimodal Pain Management for the Plastic Surgeon

Pain management is a central focus for the plastic surgeon’s perioperative planning, and it no longer represents a postoperative afterthought. Protocols that rely on opioid-only pain therapy are outdated and discouraged, as they do not achieve optimal pain relief, increase postoperative morbidity, and contribute to the growing opioid epidemic. A multimodal approach to pain management using non-opioid analgesic techniques is an integral component of enhanced recovery after surgery protocols. Careful perioperative planning for optimal pain management must be achieved in multidisciplinary collaboration with the perioperative care team including anesthesiology. This allows pain management interventions to occur at 3 critical opportunities—preoperative, intraoperative, and postoperative settings.