Advances in regional anaesthesia and acute pain management: a narrative review

A review of local anesthetic-induced heart toxicity using human induced pluripotent stem cell-derived cardiomyocytes

Local anesthetic (LA) cardiotoxicity is one of the main health problems in anesthesiology and pain management. This study reviewed the reported LA-induced cardiac toxicity types, risk factors, management, and mechanisms, with attention to the use of human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) in heart toxicity research. Important scientific databases were searched to find relevant articles. We briefly assessed the reported cardiotoxic effects of different types of LA drugs, including ester- and amide-linked LA agents. Furthermore, cardiotoxic effects and clinical manifestations, strategies for preventing and managing LA-induced cardiotoxic effects, pharmacokinetics, pharmacodynamics, and sodium channel dynamics regarding individual variability and genetic influences were discussed in this review. The applications and importance of hiPSC-CMs cellular model for evaluating the cardiotoxic effects of LA drugs were discussed in detail. This review also explored hiPSC-CMs' potential in risk assessment, drug screening, and developing targeted therapies. The main mechanisms underlying LA-induced cardiotoxicity included perturbation in sodium channels, ROS production, and disorders in the immune system response due to the presence of LA drugs. Furthermore, drug-specific characteristics including pharmacokinetics and pharmacodynamics are important determinants after LA drug injection. In addition, individual patient factors such as age, comorbidities, and genetic variability emphasize the need for a personalized approach to mitigate risks and enhance patient safety. The strategies outlined for the prevention and management of LA cardiotoxicity underscore the importance of careful dosing, continuous monitoring, and the immediate availability of resuscitation equipment. This comprehensive review can be used to guide future investigations into better understanding LA cardiac toxicities and improving patient safety.

Erector Spinae Plane Block Versus Thoracolumbar Interfascial Plane Block in Lumbar Spine Surgery: A Meta-Analysis of Randomized Controlled Trials

STUDY DESIGN

Meta-analysis.

OBJECTIVE

To compare the effectiveness of postoperative pain control between erector spinae plane block (ESPB) and thoracolumbar interfascial plane (TLIP) block in lumbar spine surgery.

METHODS

PubMed, Embase, and MEDLINE electronic databases were searched for articles containing randomized controlled trials (RCTs) published between January 1900 and January 2024. We extracted the postoperative mean pain score, the first 24-h postoperative morphine consumption, and their standard deviation from the included studies. Meta-analysis was performed using the functions available in the metafor package in R software. We pooled continuous variables using an inverse variance method with a random-effects model and summarized them as standardized mean differences.

RESULTS

Five RCTs that directly compared the ESPB and TLIP block in lumbar spine surgery were included, enrolling 432 participants randomly into the two groups with 216 participants in each group. The pooled analyses showed that there was no significant difference between the ESPB and TLIP groups in terms of lower pain scores during the early (1 h) (standardized mean difference [SMD] -1.49, 95% confidence interval [CI], -3.10; 0.11), middle (12 h) (SMD -3.12, 95% CI, -6.86; 0.61), and late (24 h) (SMD -1.38, 95% CI, -3.01; 0.24) postoperative periods. There was also no significant difference in the first 24-h postoperative morphine equivalent consumption between the ESPB and TLIP groups (SMD -0.46 mg, 95% CI -1.23; 0.31).

CONCLUSION

No significant difference was observed between the ESPB and TLIP block in terms of postoperative pain control and 24-h morphine equivalent consumption for lumbar spine surgery.

Efficacy and safety of intrathecal diamorphine: a systematic review and meta-analysis with meta-regression and trial sequential analysis

BACKGROUND

Intrathecal diamorphine is believed to provide postoperative analgesia but is associated with adverse effects such as nausea and vomiting. There is little evidence of synthesis regarding intrathecal diamorphine in the contemporary literature. We performed a systematic review, meta-analysis with meta-regression and trial sequential analysis to determine the magnitude of intrathecal diamorphine efficacy and safety.

METHODS

We systematically searched the literature for trials comparing intrathecal diamorphine with a control group in patients undergoing all types of surgery. The primary efficacy and safety outcomes were intravenous morphine consumption and incidence of postoperative nausea and vomiting at 24 h following surgery, respectively.

RESULTS

Twelve trials were identified, which included data for 712 patients. Intrathecal doses of diamorphine ranged from 100 μg to 2500 μg. Intravenous morphine consumption at 24 h postoperatively was significantly reduced in the intrathecal diamorphine group, with a mean difference (95%CI) of -8 mg (-11 to -6), I2 = 93%, p < 0.001. There was a significant difference between three intrathecal diamorphine dosing subgroups but without correlation: mean differences (95%CI) -1 mg (-3-0), -26 mg (-40 to -11) and -6 mg (-15-4) in patients receiving doses of 0-200 μg, 201-400 μg and > 400 μg, respectively (p = 0.003). Intrathecal diamorphine increased postoperative nausea and vomiting with a risk ratio (95%CI) of 1.37 (1.19-1.58), I2 = 7%, p < 0.001. There were no differences in postoperative nausea and vomiting between the three intrathecal diamorphine dosing subgroups. There was no correlation observed with meta-regression of the primary efficacy and safety outcomes. The quality of evidence for all outcomes was very low.

CONCLUSION

There is very low level of evidence that intrathecal diamorphine provides effective analgesia after surgery, while increasing postoperative nausea and vomiting with doses > 200 μg.

Optimizing accrual to a large-scale, clinically integrated randomized trial in anesthesiology: A 2-year analysis of recruitment

BACKGROUND

Performing large randomized trials in anesthesiology is often challenging and costly. The clinically integrated randomized trial is characterized by simplified logistics embedded into routine clinical practice, enabling ease and efficiency of recruitment, offering an opportunity for clinicians to conduct large, high-quality randomized trials under low cost. Our aims were to (1) demonstrate the feasibility of the clinically integrated trial design in a high-volume anesthesiology practice and (2) assess whether trial quality improvement interventions led to more balanced accrual among study arms and improved trial compliance over time.

METHODS

This is an interim analysis of recruitment to a cluster-randomized trial investigating three nerve block approaches for mastectomy with immediate implant-based reconstruction: paravertebral block (arm 1), paravertebral plus interpectoral plane blocks (arm 2), and serratus anterior plane plus interpectoral plane blocks (arm 3). We monitored accrual and consent rates, clinician compliance with the randomized treatment, and availability of outcome data. Assessment after the initial year of implementation showed a slight imbalance in study arms suggesting areas for improvement in trial compliance. Specific improvement interventions included increasing the frequency of communication with the consenting staff and providing direct feedback to clinician investigators about their individual recruitment patterns. We assessed overall accrual rates and tested for differences in accrual, consent, and compliance rates pre- and post-improvement interventions.

RESULTS

Overall recruitment was extremely high, accruing close to 90% of the eligible population. In the pre-intervention period, there was evidence of bias in the proportion of patients being accrued and receiving the monthly block, with higher rates in arm 3 (90%) compared to arms 1 (81%) and 2 (79%, p = 0.021). In contrast, in the post-intervention period, there was no statistically significant difference between groups (p = 0.8). Eligible for randomization rate increased from 89% in the pre-intervention period to 95% in the post-intervention period (difference 5.7%; 95% confidence interval = 2.2%-9.4%, p = 0.002). Consent rate increased from 95% to 98% (difference of 3.7%; 95% confidence interval = 1.1%-6.3%; p = 0.004). Compliance with the randomized nerve block approach was maintained at close to 100% and availability of primary outcome data was 100%.

CONCLUSION

The clinically integrated randomized trial design enables rapid trial accrual with a high participant compliance rate in a high-volume anesthesiology practice. Continuous monitoring of accrual, consent, and compliance rates is necessary to maintain and improve trial conduct and reduce potential biases. This trial methodology serves as a template for the implementation of other large, low-cost randomized trials in anesthesiology.

Gynecological Laparoscopic Surgeries under Spinal Anesthesia: Benefits and Challenges

OBJECTIVE

This prospective study investigated the feasibility of performing laparoscopic pelvic surgery under spinal anesthesia and analyzed the intraoperative side effects, like pain, nausea, and vomitus, of 915 patients.

METHODS

The implementation and performance of laparoscopic surgery under local anesthesia on 915 patients (out of a total of 3212 who underwent laparoscopic pelvic surgery under spinal anesthesia) were analyzed in relation to BMI (body mass index), obesity, pain during surgery, amount of intraperitoneal mmHg CO2 gas pressure, and surgical complications.

RESULTS

BMI > 30, intra-abdominal adhesions, increased duration of the operation, bleeding, and increased intraperitoneal CO2 pressure were statistically significant as the main causes of pain during laparoscopic surgery under spinal anesthesia. Underweight patients, on the other hand, had less pain when intra-abdominal pressure increased compared to those of normal weight. The appearance of pain, nausea, and vomitus occurred in 10.3% of patients, and these events were easy to manage and treat. They did not affect the surgeon's work or the course of the operation.

CONCLUSIONS

In light of these observations, we are proposing spinal anesthesia for laparoscopic surgery as the first choice in patients who have no contraindications. To the best of our knowledge, this clinical study constitutes the largest clinical observation and dataset concerning spinal anesthesia in laparoscopic pelvic surgery.

TRIAL REGISTRATION

ISRCTN38987, 10 December 2019.

Latest Advances in Regional Anaesthesia

Training and expertise in regional anaesthesia have increased significantly in tandem with increased interest over the past two decades. This review outlines the most recent advances in regional anaesthesia and focuses on novel areas of interest including fascial plane blocks. Pharmacological advances in the form of the prolongation of drug duration with liposomal bupivacaine are considered. Neuromodulation in the context of regional anaesthesia is outlined as a potential future direction. The growing use of regional anaesthesia outside of the theatre environment and current thinking on managing the rebound plane after regional block regression are also discussed. Recent relevant evidence is summarised, unanswered questions are outlined, and priorities for ongoing investigation are suggested.

Quadratus lumborum block versus transversus abdominis plane block for inguinal hernia repair: A systematic review and meta-analysis with trial sequential analysis

INTRODUCTION

Postoperative pain management is crucial for patient recovery with Quadratus Lumborum Block (QLB) and Transversus Abdominis Plane Block (TAPB) emerging as potential techniques. We aimed to compare the analgesic efficacy of QLB and TAPB in patients undergoing inguinal hernia repair.

METHODS

We performed a systematic review of Cochrane, EMBASE, and MEDLINE databases to identify randomized controlled trials comparing QLB and TAPB in patients undergoing inguinal hernia repair. Outcomes included postoperative pain and opioid consumption. Statistical analysis was performed using RevMan 5.4. The review protocol was registered at PROSPERO (CRD42023445513).

RESULTS

We included five RCTs encompassing 255 patients. QLB was associated with a significant decrease in postoperative pain (MD -0.45; 95% CI -0.75 to -0.14; and p = 0.004; I2  = 94%). However, we found no difference in 24-h opioid consumption between QLB and TAPB groups.

CONCLUSION

QLB may offer superior pain reduction. However, its effect on opioid consumption remains unclear.

Adhesive polydopamine-based photothermal hybrid hydrogel for on-demand lidocaine delivery, effective anti-bacteria, and prolonged local long-lasting analgesia

Considering the astonishing prevalence of localized pain affecting billions of patients worldwide, the development of advanced analgesic formulations or delivery systems to achieve clinical applicability is of great significance. In this study, an integrated PDA-based LiH@PDA@Ag@PAA@Gelatin system was designed for sustained delivery of lidocaine hydrochloride (LiH). By optimizing the preparation process and formulation of the hydrogel, the hydrogel exhibited superior mechanical properties, reversibility, adhesion strength, and self-healing attributes. Moreover, PDA@Ag nanoparticles were evenly dispersed within the hydrogel, and the optimized PDA@Ag@PAA@Gelatin showed a higher photothermal conversion efficiency than that of pure PDA. Importantly, LiH@PDA@Ag@PAA@Gelatin could effectively capture and eradicate bacteria through the synergistic interaction between near-infrared (NIR), PDA, Ag and LiH. In vitro and in vivo tests demonstrated that LiH@PDA@Ag@PAA@Gelatin exhibited higher drug delivery efficiency compared to commercial lidocaine patches. By evaluating the mechanical pain withdrawal threshold of the spared nerve injury (SNI) model in rats, it was proven that LiH@PDA@Ag@PAA@Gelatin enhanced and prolonged the analgesic effect of LiH. Furthermore, LiH@PDA@Ag@PAA@Gelatin induced by NIR possessed excellent on-demand photothermal analgesic ability. Therefore, this study develops a convenient method for preparing localized analgesic hydrogel patches, providing an important step towards advancing PDA-based on-demand pain relief applications.

Utility of Artificial Intelligence for Real-Time Anatomical Landmark Identification in Ultrasound-Guided Thoracic Paravertebral Block

Thoracic paravertebral block (TPVB) is a common method of inducing perioperative analgesia in thoracic and abdominal surgery. Identifying anatomical structures in ultrasound images is very important especially for inexperienced anesthesiologists who are unfamiliar with the anatomy. Therefore, our aim was to develop an artificial neural network (ANN) to automatically identify (in real-time) anatomical structures in ultrasound images of TPVB. This study is a retrospective study using ultrasound scans (both video and standard still images) that we acquired. We marked the contours of the paravertebral space (PVS), lung, and bone in the TPVB ultrasound image. Based on the labeled ultrasound images, we used the U-net framework to train and create an ANN that enabled real-time identification of important anatomical structures in ultrasound images. A total of 742 ultrasound images were acquired and labeled in this study. In this ANN, the Intersection over Union (IoU) and Dice similarity coefficient (DSC or Dice coefficient) of the paravertebral space (PVS) were 0.75 and 0.86, respectively, the IoU and DSC of the lung were 0.85 and 0.92, respectively, and the IoU and DSC of the bone were 0.69 and 0.83, respectively. The accuracies of the PVS, lung, and bone were 91.7%, 95.4%, and 74.3%, respectively. For tenfold cross validation, the median interquartile range for PVS IoU and DSC was 0.773 and 0.87, respectively. There was no significant difference in the scores for the PVS, lung, and bone between the two anesthesiologists. We developed an ANN for the real-time automatic identification of thoracic paravertebral anatomy. The performance of the ANN was highly satisfactory. We conclude that AI has good prospects for use in TPVB. Clinical registration number: ChiCTR2200058470 (URL: http://www.chictr.org.cn/showproj.aspx?proj=152839 ; registration date: 2022-04-09).

Chest Wall and Abdominal Blocks for Thoracic and Abdominal Surgeries: A Review

PURPOSE OF REVIEW

The purpose of this review is to provide an up-to-date description and overview of the rapidly growing literature pertaining to techniques and clinical applications of chest wall and abdominal fascial plane blocks in managing perioperative pain.

RECENT FINDINGS

Clinical evidence suggests that regional anesthesia blocks, including fascial plane blocks, such as pectoralis, serratus, erector spinae, transversus abdominis, and quadratus lumborum blocks, are effective in providing analgesia for various surgical procedures and have more desirable side effect profile when compared to traditional neuraxial techniques. They offer advantages such as reduced opioid consumption, improved pain control, and decreased opioid-related side effects. Further research is needed to establish optimal techniques and indications for these blocks. Presently, they are a vital instrument in a gamut of multimodal analgesia options, especially when there are contraindications to neuraxial or para-neuraxial procedures. Ultimately, clinical judgment and provider skill set determine which blocks-alone or in combination-should be offered to any patient.

Ultrasound-Guided Block of the Sciatic and the Femoral Nerves in Rabbits-A Descriptive Anatomical Study

The rabbit is a popular animal model for human biomechanical research involving surgery on the hind limb. Mortality is higher in rabbits when undergoing general anesthesia compared to dogs and cats. Moreover, due to their nature as prey animals, rabbits have a tendency to hide signs of pain, making it challenging to detect discomfort at an early stage. Incorporating regional anesthesia into an anesthetic protocol can greatly reduce the requirements for systemic anesthetic and analgesic drugs, thereby minimizing associated side effects. In other species, a block of the sciatic (ScN) and the femoral nerves (FN) is usually applied in patients undergoing hind limb surgery. In phase 1 of this study, the ScN and the FN have been localized and an appropriate approach has been evaluated under sonographic guidance. In phase 2, a mixture of new methylene blue and lidocaine have been administered to the ScN and the FN in 10 cadavers (20 hind limbs). Staining of the nerves was evaluated by dissection. Ultrasonographically, the ScN appeared as a binocular structure surrounded by a hyperechoic rim. The FN appeared as a hypoechoic structure in the dorsal part of the iliopsoas muscle (IPM), becoming hyperechoic/honey-comb-like in the ventral part. Both nerves could be successfully stained in all animals over a median length of 2.3 cm which was considered effective. This technique allows feasible and accurate access to block the ScN and the FN and may lead to successful analgesia in rabbits undergoing hind limb surgery.

Comparison of regional anesthetic techniques for postoperative analgesia after adult cardiac surgery: bayesian network meta-analysis

Background

Patients usually suffer acute pain after cardiac surgery. Numerous regional anesthetic techniques have been used for those patients under general anesthesia. The most effective regional anesthetic technique was still unclear.

Methods

Five databases were searched, including PubMed, MEDLINE, Embase, ClinicalTrials.gov, and Cochrane Library. The efficiency outcomes were pain scores, cumulative morphine consumption, and the need for rescue analgesia in this Bayesian analysis. Postoperative nausea, vomiting and pruritus were safety outcomes. Functional outcomes included the time to tracheal extubation, ICU stay, hospital stay, and mortality.

Results

This meta-analysis included 65 randomized controlled trials involving 5,013 patients. Eight regional anesthetic techniques were involved, including thoracic epidural analgesia (TEA), erector spinae plane block, and transversus thoracic muscle plane block. Compared to controls (who have not received regional anesthetic techniques), TEA reduced the pain scores at 6, 12, 24 and 48 h both at rest and cough, decreased the rate of need for rescue analgesia (OR = 0.10, 95% CI: 0.016-0.55), shortened the time to tracheal extubation (MD = -181.55, 95% CI: -243.05 to -121.33) and the duration of hospital stay (MD = -0.73, 95% CI: -1.22 to -0.24). Erector spinae plane block reduced the pain score 6 h at rest and the risk of pruritus, shortened the duration of ICU stay compared to controls. Transversus thoracic muscle plane block reduced the pain scores 6 and 12 h at rest compared to controls. The cumulative morphine consumption of each technique was similar at 24, 48 h. Other outcomes were also similar among these regional anesthetic techniques.

Conclusions

TEA seems the most effective regional postoperative anesthesia for patients after cardiac surgery by reducing the pain scores and decreasing the rate of need for rescue analgesia.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, ID: CRD42021276645.

External Oblique Intercostal Block for Living Kidney Donor Open Nephrectomy: A Case Series

The external oblique intercostal (EOI) block is a novel regional technique that provides analgesia for upper abdominal incisions. We performed single-injection and continuous EOI blocks in living kidney donors who underwent open nephrectomy. In this case series, we report our experience with pain management using this technique in five patients at our centre. EOI block resulted in good pain relief in our patients. The median (IQR) numerical rating scale score was 3 (1-6) at rest immediately after the end of the surgery, predominantly visceral. We want to highlight the benefits regarding pain management of the association of EOI block with conventional therapy.

Benefits of PECS Block as Part of the Enhanced Recovery After Surgery (ERAS) Protocol for Breast Cancer Surgery in an Asian Institution: A Retrospective Cohort Study

INTRODUCTION

Regional analgesia techniques have been increasingly used for post-operative pain management following mastectomy. We aim to evaluate analgesic benefits of pectoral nerve (PECS2) block incorporated as part of the enhanced recovery after surgery (ERAS) protocol in patients undergoing mastectomy in University Malaya Medical Centre, Malaysia.

MATERIAL AND METHODS

A single centre, cohort study evaluating 335 women who have undergone unilateral mastectomy between January 2017 and March 2020 in Malaysia. Regional anaesthesia were given pre-operatively via ultrasound guided pectoral and intercostal nerves block (PECSII).

RESULTS

Utilization of regional anaesthesia increased from 11% in 2017 to 43% in 2020. Types and duration of surgeries were comparable. Opiod consumption was 3 mg lower in those who had PECS2 block ((27 [24-30] mg), in comparison with those who received general anaesthesia only (30 [26-34] mg), p < 0.001, and length of stay was half a day shorter in the regional anaesthesia group and these were statistically significant. However, pain score (2 [1-3]; 2 [1-3], p=0.719) and post-operative nausea and vomiting (PONV) (32.6-32.5%, p = 0.996) were similar.

CONCLUSION

This study highlights the importance of PECS2 block as a component of ERAS protocol for mastectomy in an Asian hospital. This study also inferred that patients may be safely discharged within 24 h of surgery and therefore, same day surgery may be feasible in selected group of patients undergoing mastectomy and this could imply overall cost benefits.

Extended Release of Bupivacaine from Temperature-responsive Hydrogels Provides Multi-day Analgesia for Postoperative Pain

OBJECTIVE

A local anesthetic that provides analgesia lasting at least three days could significantly improve postoperative pain management. This study evaluated the analgesic efficacy and safety of an extended-release formulation of bupivacaine based on the injectable hydrogel carrier poly(N-isopropylacrylamide-co-dimethylbutyrolactone acrylamide-co-Jeffamine M-1000 acrylamide) (PNDJ).

METHODS

The efficacy of PNDJ containing 4% bupivacaine (SBG004) given by peri-incisional subcutaneous injection (SBG004 SC) or wound filling instillation (SBG004 WF) was evaluated compared to saline, liposomal bupivacaine, bupivacaine collagen sponge, bupivacaine-meloxicam polyorthoester, and bupivacaine HCl in a porcine skin and muscle incision model. Mechanical allodynia was assessed by withdrawal from application of von Frey filaments, and local tolerance was evaluated by histology. Bupivacaine pharmacokinetics for SBG004 SC were measured in rabbits (16.5 mg bupivacaine/kg).

RESULTS

Animals demonstrated less mechanical allodynia at incisions receiving SBG004 SC for up to 96 hours postoperatively. Incisions treated with SBG004 SC tolerated more force without a withdrawal indicative of pain compared to saline for 96 hours, and compared to SBG004 WF and all active controls at 24, 48, and 72 hours except bupivacaine-meloxicam polyorthoester at 72 hours. By 49 days, SBG004 was histologically absent and was replaced with granulation tissue infiltrated with immune cells in some areas. In rabbits, Cmax was 41.6 ± 9.7 ng/mL with t1/2 82.0 ± 35.8 hours (mean ± SD).

CONCLUSIONS

Peri-incisional SBG004 SC provided extended release of bupivacaine sufficient to reduce sensation of incisional pain for 96 hours, in vivo bupivacaine delivery for at least 7 days, and a favorable local and systemic toxicity profile.

Acute Pain Management Pearls: A Focused Review for the Hospital Clinician

Acute pain management is a challenging area encountered by inpatient clinicians every day. While patient care is increasingly complex and costly in this realm, the availability of applicable specialists is waning. This narrative review seeks to support diverse hospital-based healthcare providers in refining and updating their acute pain management knowledge base through clinical pearls and point-of-care resources. Practical guidance is provided for the design and adjustment of inpatient multimodal analgesic regimens, including conventional and burgeoning non-opioid and opioid therapies. The importance of customized care plans for patients with preexisting opioid tolerance, chronic pain, or opioid use disorder is emphasized, and current recommendations for inpatient management of associated chronic therapies are discussed. References to best available guidelines and literature are offered for further exploration. Improved clinician attention and more developed skill sets related to acute pain management could significantly benefit hospitalized patient outcomes and healthcare resource utilization.

Pericapsular nervegroup (PENG) block—a scoping review

The obturator nerve and its accessory branch supplying the hip region, unlike the femoral nerve, are not adequately anaesthetized by conventional regional anaesthetic techniques targeting the hip region. With advancements in ultrasound-guided regional anaesthetic techniques, interests are revived in the field and efforts are being made to block them together. One such successful attempt is the novel peri-capsular nerve group (PENG) block. Consequently, further research on the PENG block began to explore its versatilities. The present study undertakes a scoping review of research on the PENG block in humans for any indication to determine the extent of the research done, the methodologies used, and other practical issues addressed in the research. This will help to identify potential research gaps that should be addressed in the future. PubMed, Google Scholar, Cochrane Library, KoreaMed, Latin American and Caribbean Health Science Literature, and the directory of open access journals were searched with the keyword “PENG block” and “pericapsular nerve group”. Manual search of electronically retrieved papers was also carried out. Among the 67 articles selected in our review, eighteen are case series; twenty-nine are case reports; two are randomized studies; one each of prospective cohort study, review, and cadaveric study; and 15 are editorials. However, only 64 articles were included later due to the retraction of three case reports. Data is insufficient to provide firm recommendations for or against different aspects of the block. The review encourages future work addressing different aspects of the PENG block.

Dynamics of Acute Postsurgical Pain over the Last Decade: A Bibliometric Analysis

OBJECTIVE

Minimizing acute postsurgical pain (APSP) remains a challenge, despite extensive research about it. This study comprehensively analyzed the literature on APSP to assess how the field has developed and where it may go in the future.

METHODS

Studies on APSP indexed in the Web of Science Core Collection and published from 2012 to 2021 were assessed for eligibility. Data from included studies were analyzed using CiteSpace, Python, and Microsoft.

RESULTS

Analysis of 5,236 publications on APSP showed that the number of articles per year has increased linearly. The United States leads other countries in terms of the number and centrality of publications. Cocitation analysis suggests that the field focused earlier on the incidence and risk factors of APSP, shifting later to a focus on the reduction and management of adverse outcomes due to APSP. The top-ranked keyword cluster during the study period was "short-term outcomes" (#0), followed by "risk factors" (#1). The strongest burst occurred for the keyword "combination," followed by "multimodal analgesia." The most recent burst occurred for the keywords "regional analgesia," "opioid use," "erector spinae plane block," and "infiltration."

CONCLUSIONS

Hotspots in APSP research since 2012 have been incidence, risk factors, and control of negative outcomes. Future research is likely to concentrate on the use of opioids and technological innovations in regional anesthesia. Our findings may help APSP researchers and clinicians understand their field, optimize clinical practice, and plan future research.

Regional Anesthetic and Analgesic Techniques for Clavicle Fractures and Clavicle Surgeries: Part 1—A Scoping Review

Objective. Clavicle fractures are common injuries potentially associated with significant perioperative pain. However, this region’s complex sensory innervation poses a challenge for regional anesthetic or analgesic (RA) techniques. We conducted this scoping review to summarize the current literature, particularly with regards to motor-sparing techniques. Methods. A scoping review was carried out in accordance with the Joanna Briggs Institute’s framework. All articles describing the use of RA for clavicle fractures or surgery were included. PubMed^®, Ovid MEDLINE^®, EMBASE^®, Scopus^®, CINAHL^®, and the Cochrane database were searched without language restrictions. Results. Database searches identified 845 articles, 44 of which were included in this review, with a combined patient total of 3161. We included all peer-reviewed publications containing clinical data and summarized the findings. Conclusions. Current evidence of RA techniques in clavicle surgery is heterogeneous, with different approaches used to overcome the overlapping sensory innervation. The literature largely comprises case reports/series, with several randomized controlled trials. Intermediate cervical plexus block is the regional technique of choice for clavicle surgery, and can provide reliable surgical anesthesia when combined with an interscalene block. Cervical plexus block can provide motor-sparing analgesia following clavicle surgery. Promising alternatives include the clavipectoral block, which is a novel motor-sparing regional technique. Further studies are required to determine the efficacy and safety of various techniques.

Minimally invasive anesthesia for laparoscopic hysterectomy: a case series

PURPOSE

Regional anesthesia (RA) is considered as a "minimally invasive technique" to achieve anesthesia. To assess the feasibility and the perioperative outcomes of laparoscopic hysterectomy in regional anesthesia from the point of view of the surgeon, anesthesiologist and patient.

METHODS

A retrospective search was performed to identify patients who underwent laparoscopic hysterectomy under RA from April 2020 to September 2021. Five patients affected by benign gynecological disease (atypical endometrial hyperplasia or uterine leiomyomas) were included.

RESULTS

The postoperative pain, nausea, and vomiting (PONV) and the antiemetic/analgesic intake were evaluated. Postoperative surgical and anesthesiological variables were recorded. Duration of surgery was 84 ± 4.18 and no conversion to GA was required. According to VAS score, the postoperative pain during the whole observation time was less than 4 (median). A faster resumption of bowel motility (≤ 9 h) and patient's mobilization (≤ 4 h) were observed as well as a low incidence of post-operative nausea and vomit. Early discharge and greater patient's satisfaction were recorded. Intraoperatively pain score was assessed on Likert scale during all the stages of laparoscopy in RA, with only 2 patients complaining scarce pain (= 2) at pneumoperitoneum.

CONCLUSION

RA showed to have a great impact on surgical stress and to guarantee a quicker recovery without compromising surgical results. RA technique could be a viable option for patients undergoing laparoscopic hysterectomy.

Use of Ultrasound-Guided Interfascial Plane Blocks in Anterior and Lateral Thoracic Wall Region as Safe Method for Patient Anesthesia and Analgesia: Review of Techniques and Approaches during COVID-19 Pandemic

Ultrasound-guided interfascial plane blocks performed on the anterior and lateral thoracic wall have become an important adjuvant method to general anesthesia and an independent method of local anesthesia and pain management. These procedures diminish the harmful effects of anesthesia on respiratory function and reduce the risk of phrenic nerve paralysis or iatrogenic pneumothorax. In postoperative pain management, interfascial plane blocks decrease the dosage of intravenous drugs, including opioids. They can also eliminate the complications associated with general anesthesia when used as the sole method of anesthesia for surgical procedures. The following procedures are classified as interfascial plane blocks of the anterior and lateral thoracic wall: pectoral nerve plane block (PECS), serratus anterior plane block (SAP), transversus thoracic muscle plane block (TTP), pectoral interfascial plane block (PIF), and intercostal nerve block (ICNB). These blocks are widely used in emergency medicine, oncologic surgery, general surgery, thoracic surgery, cardiac surgery, orthopedics, cardiology, nephrology, oncology, palliative medicine, and pain medicine. Regional blocks are effective for analgesic treatment, both as an anesthesia procedure for surgery on the anterior and lateral thoracic wall and as an analgesic therapy after trauma or other conditions that induce pain in this area. In the era of the COVID-19 pandemic, ultrasound-guided interfascial plane blocks are safe alternatives for anesthesia in patients with symptoms of respiratory distress related to SARS-CoV-2 and appear to reduce the risk of COVID-19 infection among medical personnel.

GENETIC INFLUENCES ON PAIN MECHANISMS

OBJECTIVE

The aim: To review the available results for genetic influences on pain syndrome development.

PATIENTS AND METHODS

Materials and methods: In the period from 2009 to 2020, a total of 45 research papers describing the key points of genetic influences on pain mechanisms in both adults and children were published in Ukrainian and English and they are now included in the PubMed, EMBASE, Cochrane, and Google Scholar research databases.

CONCLUSION

Conclusions: Pain is a comprehensive characteristic of a person; therefore, it is inevitable that several genes with little individual effect interact with each other and environmental factors, influencing pain susceptibility and chronic pain syndrome manifestation. This requires searching for biomarkers for diagnosing and predicting the development of acute and chronic pain syndromes, especially in pediatric practice.

An Observational Survey Study on the Use of Locoregional Anaesthesia in Non-Conventional Species: Current Practice and Potential Future Developments

The objectives of this study were to investigate the current attitudes of veterinarians towards the use of locoregional anaesthesia in non-conventional animal species and to identify areas for future useful research on this topic. A questionnaire was circulated online. A total of 417 veterinarians, including American and European specialists/specialists-in-training in both zoological medicine and anaesthesia/analgesia (ACZM/ECZM and ACVAA/ECVAA), participated in the study. Fifty-nine percent of respondents performed locoregional anaesthesia in rabbits, with intratesticular injections and local infiltration being the most commonly-reported techniques. ACZM/ECZM specialists reportedly performed dental blocks in rabbits more frequently than ACVAA/ECVAA specialists (p = 0.030). Forty percent of respondents performed locoregional anaesthesia in rodents, with intratesticular injections, topical/splash blocks and local infiltration being the most commonly reported techniques. The proportions of respondents who reportedly used locoregional anaesthesia in ferrets, birds and reptiles were 37.9%, 34.5% and 31.2%, respectively. The use of Tuohy (p < 0.001) and spinal needles (p < 0.001), as well as of ultrasonography (p = 0.009) and nerve-stimulators (p < 0.001), was more common among ACVAA/ECVAA compared to ACZM/ECZM specialists. Major topic areas for future research were identified as dental block techniques for rabbits and rodents and blocks for the wings of birds.

Simulation-Based Medical Education and Training Enhance Anesthesia Residents' Proficiency in Erector Spinae Plane Block

Background

Advances in regional anesthesia and pain management led to the advent of ultrasound-guided fascial plane blocks, which represent a new and promising route for the administration of local anesthetics. Both practical and theoretical knowledge of locoregional anesthesia are therefore becoming fundamental, requiring specific training programs for residents. Simulation-based medical education and training (SBET) has been recently applied to ultrasound-guided regional anesthesia (UGRA) with remarkable results. With this in mind, the anesthesia and intensive care residency program of the University of Milano-Bicocca organized a 4-h regional anesthesia training workshop with the BlockSim^® (Accurate Srl, Cesena) simulator. Our study aimed to measure the residents' improvement in terms of reduction in time required to achieve an erector spinae plane (ESP) block.

Methods

Fifty-two first-year anesthesia residents were exposed to a 4-h training workshop focused on peripheral blocks. The course included an introductory theoretical session held by a locoregional anesthetist expert, a practical training on human models and mannequins using Onvision^® (B. Braun, Milano) technologies, and two test performances on the BlockSim simulator. Residents were asked to perform two ESP blocks on the BlockSim: the first without previous practice on the simulator, the second at the end of the course. Trainees were also also asked to complete a self-assessment questionnaire.

Results

The time needed to achieve the block during the second attempt was significantly shorter (131 [83, 198] vs. 68 [27, 91] s, p < 0.001). We also observed a reduction in the number of needle insertions from 3 [2, 7] to 2 [1, 4] (p = 0.002), and an improvement aiming correctly at the ESP from 30 (58%) to 46 (88%) (p < 0.001). Forty-nine (94%) of the residents reported to have improved their regional anesthesia knowledge, 38 (73%) perceived an improvement in their technical skills and 46 (88%) of the trainees declared to be “satisfied/very satisfied” with the course.

Conclusions

A 4-h hands-on course based on SBET may enhance first-year residents' UGRA ability, decrease the number of punctures and time needed to perform the ESP block, and improve the correct aim of the fascia.

Considerations for Better Management of Postoperative Pain in Light of Chronic Postoperative Pain: A Narrative Review

Chronic postoperative pain (CPOP) is prevalent, with particularly high rates in breast surgery, thoracotomy, and amputation. As the world emerges from the coronavirus disease 2019 (COVID-19) lockdowns, it is expected that there will be an increase in surgical procedures, elevating the importance of preventing CPOP in the coming years. Risk factors are emerging to better stratify patients at high risk for CPOP. Perioperative analgesia plays an important role in managing acute postoperative pain and in some cases may limit its transition to CPOP. Acute postoperative pain is adaptive, normal, expected, and has a well-defined trajectory, while CPOP is maladaptive and, as a form of chronic pain, is challenging to treat. Good analgesia, early ambulation, and rehabilitation efforts may be helpful in preventing CPOP following certain surgeries. Enhanced Recovery After Surgery (ERAS) protocols present guidance to help promote recovery and prevent CPOP.

Comparison Between Ultrasound-Guided Suprainguinal Fascia Iliaca Block and Anterior Quadratus Lumborum Block for Total Hip Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Trial

BACKGROUND

Nerve block is a key technique in postoperative analgesia for total hip arthroplasty (THA). This study aimed to compare ultrasound-guided suprainguinal fascia iliaca block (SFIB) and anterior quadratus lumborum block (AQLB) in patients undergoing primary THA.

METHODS

In this prospective, double-blind, randomized controlled trial, 100 patients undergoing primary THA under general anesthesia were randomly allocated to receive an ultrasound-guided SFIB + sham AQLB (SFIB group), or an ultrasound-guided AQLB + sham SFIB (AQLB group). Before wound suture, all patients received periarticular infiltration analgesia which the local anesthetic was injected into joint capsule, exposed gluteal and abductor muscles, peritrochanteric zone, and subcutaneous tissue under the incision as multiple sites. The primary outcome was postoperative morphine consumption within 24 hours after surgery. Secondary outcomes were the time to first rescue analgesia, postoperative pain assessed on the visual analog scale, postoperative quadriceps strength, the time to hospital discharge, and the incidence of postoperative complications.

RESULTS

There were no significant differences between the 2 groups concerning morphine consumption within 24 hours after surgery (P = .774), the time to first rescue analgesia (P = .890), the time to hospital discharge (P = .532), and the incidence of postoperative complications (P > .05). The visual analog scale pain scores at rest and during motion also were similar at all time points (P > .05). Significantly more patients in the SFIB group experienced quadriceps muscle weakness at 2 hours (P = .008) and 6 hours (P = .009) after surgery.

CONCLUSION

Under the circumstances of this study, when combined with periarticular infiltration analgesia, the SFIB provided similar pain relief compared with AQLB in patients undergoing THA, but was associated with muscle weakness within 6 hours after surgery.

Can Acute Postoperative Pain Management After Tumour Resection Surgery Modulate Risk of Later Recurrence or Metastasis?

Background

Cancer is a leading cause of mortality worldwide, but death is rarely from the primary tumour: Rather it is multi-organ dysfunction from metastatic disease that is responsible for up to 90% of cancer-related deaths. Surgical resection of the primary tumour is indicated in 70% of cases. The perioperative stress response, tissue hypoxia at the site of surgery, and acute pain contribute to immunosuppression and neo-angiogenesis, potentially promoting tumour survival, proliferation, and metastasis. Poorly controlled acute postoperative pain decreases Natural Killer (NK) immune cell activity, which could potentially facilitate circulating tumour cells from evading immune detection. This consequently promotes tumour growth and distal metastasis.

Methods

We conducted a comprehensive literature search for links between acute pain and cancer outcomes using multiple online databases. Relevant articles from January 1st, 2010 to September 1st, 2021 were analysed and appraised on whether postoperative pain control can modulate the risk of recurrence, metastasis, and overall cancer survival.

Results

Although experimental and retrospective clinical data suggest a plausible role for regional anaesthesia in cancer outcome modulation, this has not been supported by the single, largest prospective trial to date concerning breast cancer. While there are mixed results on anaesthesiology drug-related interventions, the most plausible data relates to total intravenous anaesthesia with propofol, and to systemic administration of lidocaine.

Conclusion

The hypothesis that anaesthetic and analgesic technique during cancer surgery could influence risk of subsequent recurrence or metastasis has been prevalent for >15 years. The first, large-scale definitive trial among women with breast cancer found robust equivalent findings between volatile anaesthesia with opioid analgesia and regional anaesthesia. Therefore, while regional anaesthesia during tumour resection does not seem to have any effect on cancer outcomes, it remains plausible that other anaesthetic techniques (e.g. total intravenous anaesthesia and systemic lidocaine infusion) might influence oncologic outcome in other major tumour resection surgery (e.g. colorectal and lung). Therefore, another large trial is needed to definitively answer these specific research questions. Until such evidence is available, perioperative analgesia for cancer surgery of curative intent should be based on patient co-morbidity and non-cancer endpoints, such as optimising analgesia and minimising postoperative complications.

Pharmacological and clinical implications of local anaesthetic mixtures: a narrative review

Various techniques have been explored to prolong the duration and improve the efficacy of local anaesthetic nerve blocks. Some of these involve mixing local anaesthetics or adding adjuncts. We did a literature review of studies published between 01 May 2011 and 01 May 2021 that studied specific combinations of local anaesthetics and adjuncts. The rationale behind mixing long- and short-acting local anaesthetics to hasten onset and extend duration is flawed on pharmacokinetic principles. Most local anaesthetic adjuncts are not licensed for use in this manner and the consequences of untested admixtures and adjuncts range from making the solution ineffective to potential harm. Pharmaceutical compatibility needs to be established before administration. The compatibility of drugs from the same class cannot be inferred and each admixture requires individual review. Precipitation on mixing (steroids, non-steroidal anti-inflammatory drugs) and subsequent embolisation can lead to serious adverse events, although these are rare. The additive itself or its preservative can have neurotoxic (adrenaline, midazolam) and/or chondrotoxic properties (non-steroidal anti-inflammatory drugs). The prolongation of block may occur at the expense of motor block quality (ketamine) or block onset (magnesium). Adverse effects for some adjuncts appear to be dose-dependent and recommendations concerning optimal dosing are lacking. An important confounding factor is whether studies used systemic administration of the adjunct as a control to accurately identify an additional benefit of perineural administration. The challenge of how best to prolong block duration while minimising adverse events remains a topic of interest with further research required.

Laparoscopy in Gynecologic and Abdominal Surgery in Regional (Spinal, Peridural) Anesthesia, the Utility of the Technique during COVID-19 Pandemic

BACKGROUND

laparoscopic surgery is mainly performed in general anesthesia. Symptomatic patients infected with COVID-19 needing surgery are however at higher risk for COVID-19 complications in general anesthesia than in regional anesthesia. Even so, Covid transfection is a hazard to medical personnel during the intubation procedure and treatment drugs may be in shortage during a pandemic. Recovery and hospital stay are also shorter after laparoscopy. Laparoscopy performed in regional anesthesia may have several advantages in limiting Covid.

METHODS

international literature on the risk of COVID-19 complications development was searched. 3 topics concerning laparoscopic surgery were reviewed: (1) Achievements in laparoscopy; (2) Advantages of regional anesthesia compared to general anesthesia; (3) Feasibility to perform laparoscopy in regional anesthesia in COVID-19 pandemic. The authors reviewed abstracts and full-text articles concerning laparoscopic surgery, gynecology, anesthesia and COVID-19. Studies published in PubMed, Embase, Cochrane Library and found in Google Scholar before 1st FEB, 2021 were retrieved and analyzed.

RESULTS

a total of 83 studies were found, all of them written in English. 17 studies could be found in gynecology and in general surgery about laparoscopy with regional anesthesia. In Covid time only one study compared laparoscopic surgery in general anesthesia to laparotomy and another study laparotomy in general anesthesia to regional anesthesia. Laparoscopy showed no disadvantage compared to laparotomy in Covid pandemic and in another study laparotomy in general anesthesia was associated with higher mortality and more pulmonary complications. Trendelenburg position can be a threat if used by inexperienced personnel and can induce unintended anesthesia of breathing organs. On the other hand Trendelenburg position has advantages for cardiovascular and pulmonary functions. Pneumoperitoneum of low CO2 pressure is well tolerated by patients.

CONCLUSIONS

elective surgery should be postponed in symptomatic Covid patients. In inevitable emergency surgery intubation anesthesia in COVID-19 pandemic is as far as possible to be avoided. In COVID-19 pandemic, regional anesthesia is the preferred choice. The optimum may be the combination of laparoscopic surgery with regional anesthesia. Reducing the pneumoperitoneum is a good compromise for the comfort of patients and surgeons. A special case is gynecology, which needs to be performed in Trendelenburg position to free pelvic organs.

e-Learning in regional anesthesia

PURPOSE OF REVIEW

To explore the role and impact of e-learning technologies on regional anesthesia.

RECENT FINDINGS

21st century technologies, such as 'smart' medical appliances, personal computers, sophisticated apps, the ubiquitous Internet, and online 'e-learning' curricula, are having a powerful impact on anesthesia training: when we learn, what we learn, and how we learn. But is 'new' necessarily 'better'? The answer will result from the application of developments in IT technology through the current vision of architects of future anesthesia training programs. This narrative review aims to summarize the recent developments in anesthesia e-learning, and to forecast trends using regional anesthesia as an example.

SUMMARY

The review offers some recommendations to ensure that the blessings promised to human learning by this 'Brave New Cyberworld' do not become its nemesis.

Developing an enhanced recovery after surgery program for oncology patients who undergo hip or knee reconstruction surgery

Enhanced recovery after surgery (ERAS) protocols are applied in orthopedic surgery and are intended to reduce perioperative stress by implementing combined evidence-based practices with the cooperation of various health professionals as an interdisciplinary team. ERAS pathways include pre-operative patient counselling, regional anesthesia and analgesia techniques, post-operative pain management, early mobilization and early feeding. Studies have shown improvement in the recovery of patients who followed an ERAS program after hip or knee arthroplasty, compared with those who followed a traditional care approach. ERAS protocols reduce post-operative stress, contribute to rapid recovery, shorten length of stay (LOS) without increasing the complications or readmissions, improve patient satisfaction and decrease the hospital costs. We suggest that the ERAS pathway could reduce the LOS in hospital for patients undergoing total hip replacement or total knee replacement. These programs require good organization and handling by the multidisciplinary team. ERAS programs increase patient's satisfaction due to their active participation which they experience as personalized treatment. The aim of the study was to develop an ERAS protocol for oncology patients who undergo bone reconstruction surgeries using massive endoprosthesis, with a view to improving the surgical outcomes.

Determination of bupivacaine tissue concentration in human biopsy samples using high-performance liquid chromatography with mass spectrometry

In the present study, we developed a simple and rapid analytical method for the quantification of bupivacaine hydrochloride in human biopsy samples of adipose, muscle, neural, connective and cartilage tissue using liquid chromatography-mass spectrometry. Anesthetics were extracted from the tissue samples using 0.1% formic acid in acetonitrile for protein denaturation and hexane for removal of lipophilic impurities. Analytes were separated adequately on Phenomenex Luna Omega polar C18 column using a gradient mobile phase 0.1% formic acid in water and 0.1% formic acid in acetonitrile. The lower limits of quantification were ≤ 97 ng g^-1 tissue for all studied tissues. Intra-day recoveries were between 48.2% and 82.1% with relative standard deviations (RSDs) between 1.47% and 14.28%, whereas inter-day recoveries were between 52.2% and 77.6% with RSDs between 2.98% and 14.79%. The calibration curve showed a linear fit with R² higher than 0.99 in the concentration range from 0.16 to 100 μg g^-1 . Lidocaine hydrochloride was tested as internal standard because its recoveries and matrix effects were comparable to bupivacaine hydrochloride. Post-analytical corrections of measured bupivacaine tissue concentrations can accordingly be made based on recovery of lidocaine as internal standard, with recoveries between 51.2% and 86.9% and RSDs between 1.99% and 16.88%. The developed method could be used to study time-dependent spread of bupivacaine locally or to more distant locations across tissue barriers.

Proximal Perineural Femoral Nerve Injection in Pigs Using an Ultrasound-Guided Lateral Subiliac Approach-A Cadaveric Study

Simple Summary

Desensitizing the femoral nerve improves pain control in several species undergoing pelvic limb surgeries. Despite possible advantages, this method has not yet been described in pigs, although they make an accepted surgical animal model. We developed an approach for femoral nerve blockade using ultrasound guidance in pigs which could be useful for pain control in pigs undergoing pelvic limb surgery.

Abstract

Desensitizing the femoral nerve (FN) improves pain control in several species undergoing pelvic limb surgeries. Despite its advantages, this method has not yet been described in pigs, although they make an accepted surgical animal model. Based on anatomical dissections, first performed in two pig cadavers, an ultrasound-guided access for localization and perineural infiltration of the FN trunk at the iliopsoas compartment level was specified. The FN was found running between the psoas major and medial portion of iliac muscle. Ultrasonographically, the FN appeared as a hypoechogenic round–oval structure surrounded by a hyperechogenic rim. Technical feasibility and accuracy were assessed in six additional pig cadavers by injecting 0.15 mL kg⁻¹ methylene blue dye bilaterally in direct proximity to the nerve. The needle was inserted caudoventral to the coxal tuber, traversing the ultrasound plane as it progressed towards the FN in dorsomedial direction. Staining of the nerve was evaluated by dissection. The injection was considered effective if the nerve was stained in its entire circumference over a length of 2 cm. FNs of all investigated individuals could be successfully stained. This ultrasound-guided subiliac approach allows feasible and accurate access to the FN and may be useful in producing a successful blockade in vivo.

Efficacy of transmuscular quadratus lumborum block in the multimodal regimen for postoperative analgesia after total laparoscopic hysterectomy: A prospective randomised double-blinded study

Background and Aims

Transmuscular Quadratus Lumborum Block (TQLB) is a novel regional anaesthesia technique, however, its analgesic efficacy as a component of multimodal analgesia (MMA) in Total Laparoscopic Hysterectomy (TLH) is not well studied. The aim of the study was to evaluate the analgesic efficacy of TQLB as a component of MMA for postoperative pain in TLH.

Methods

A prospective double-blind randomised controlled study was done after approval from the ethical committee and informed patient consent. After randomisation, 37 patients in Group-Q received 20 ml 0.375% ropivacaine and in Group-C, 37 patients received saline in TQLB bilaterally after TLH surgery. All patients received intravenous patient controlled analgesia (IV-PCA) with fentanyl along with diclofenac 75 mg every 12 h. All the patients were assessed at 2, 4, 6, 8, 12, 18, and 24 hours. The primary outcome was the time to first analgesic request. The secondary outcome measures were total fentanyl consumption in 24 hrs, pain scores during rest and movement, postoperative nausea-vomiting, sedation and complications related to local anaesthetic and TQLB procedure.

Results

The mean [standard deviation (SD)] time to first analgesic request was 7.8 (1.5) hours in Group-Q and 3.2 (1.0) hours in Group-C (P < 0.0001). The mean (SD) dose of fentanyl used in 24 hours was 167.3 (44) μg in Group-Q and 226.5 (41.9) μg in Group-C (P < 0.0001).

Conclusion

The ultrasound-guided TQLB provides effective postoperative analgesia after TLH surgery in a multimodal analgesia approach. It reduces the fentanyl consumption and improves the visual analogue scale (VAS) score.

Improvement of Superficial and Deep Cutaneous Microcirculation Due to Axillary Plexus Anesthesia Impaired by Smoking

Background: Understanding microvascular physiology is key to any reconstructive procedure. Current concepts in anesthesia increasingly involve regional peripheral nerve blockade during microvascular reconstructive procedures. Whereas favorable effects on perfusion due to these techniques have been reported earlier, little evidence focusing on its effects in most peripheral vascular compartments is available. Methods: A total of 30 patients who were to receive axillary plexus blockade (APB) were included. Microcirculatory assessment of the dependent extremity was conducted utilizing combined laser-Doppler flowmetry and white light spectroscopy. Two probes (1–2 and 7–8 mm penetration depth) were used to assess changes in microcirculation. Results: APB resulted in significant changes to both superficial and deep cutaneous microcirculation. Changes in blood flow were most prominent in superficial layers with a maximum increase of +617% compared to baseline values. Significantly lower values of +292% were observed in deep measurements. Consecutively, a significant enhancement in tissue oxygen saturation was observed. Further analysis revealed a significant impairment of perfusion characteristics due to reported nicotine consumption (max Bf: +936% vs. +176%). Conclusion: Cutaneous microcirculation is strongly affected by APB, with significant differences regarding microvascular anatomy and vascular physiology. Smoking significantly diminishes the elicited improvements in perfusion. Our findings could influence reconstructive strategies as well as dependent perioperative anesthetic management.

Transmuscular Quadratus Lumborum Block versus Suprainguinal Fascia Iliaca Block for Hip Arthroplasty: A Randomized, Controlled Pilot Study

Background

This study aimed to investigate the analgesic efficacy and motor block profile of single-shot transmuscular quadratus lumborum block (QLB) in comparison with those of suprainguinal fascia iliaca block (FIB) in patients undergoing hip arthroplasty.

Methods

This randomized, double-blinded, controlled trial included adult patients undergoing hip arthroplasty under spinal anesthesia. Patients were allocated to one of two groups according to the regional block received: FIB group (n=19) or QLB group (n=17). Both study groups were compared with regard to the duration of analgesia (primary outcome), block performance time, pain during positioning for spinal anesthesia, total morphine consumption in the first postoperative 24-h period, quadriceps muscle power, and static and dynamic visual analog scale.

Results

Thirty-six patients were included in the final analysis. Both study groups had comparable durations of analgesia. Postoperative visual analog scale (static and dynamic) values were comparable between the two groups in most readings. The block performance time was shorter in the FIB group. The number of patients with pain during positioning for the subarachnoid block was lower in the QLB group. The total morphine requirement during the first 24 h was marginally lower in the FIB group, whereas the quadriceps motor grade was higher in the FIB group than in the QLB group at 4 h and 6 h after surgery.

Conclusion

Both single-shot blocks, namely the suprainguinal FIB and transmuscular QLB, provide effective postoperative analgesia after hip arthroplasty. FIB showed slightly lower 24-h morphine consumption, while QLB showed better quadriceps motor power.

Clinical Trial Registration

The study was registered at clinical trials registry system before enrollment of the first participant (NCT04005326; initial release date, 2 July 2019; https://clinicaltrials.gov/ct2/show/NCT04005326).

Comparison of local and regional anesthesia modalities in breast surgery: A systematic review and network meta-analysis

STUDY OBJECTIVE

Moderate to severe postoperative pain occurs in up to 60% of women following breast operations. Our aim was to perform a network meta-analysis and systematic review to compare the efficacy and side effects of different analgesic strategies in breast surgery.

DESIGN

Systematic review and network meta-analysis.

SETTING

Operating room, postoperative recovery room and ward.

PATIENTS

Patients scheduled for breast surgery under general anesthesia.

INTERVENTIONS

Following an extensive search of electronic databases, those who received any of the following interventions, control, local anesthetic (LA) infiltration, erector spinae plane (ESP) block, pectoralis nerve (PECS) block, paravertebral block (PVB) or serratus plane block (SPB), were included. Exclusion criteria were met if the regional anesthesia modality was not ultrasound-guided. Network plots were constructed and network league tables were produced.

MEASUREMENTS

Co-primary outcomes were the pain at rest at 0-2 h and 8-12 h. Secondary outcomes were those related to analgesia, side effects and functional status.

MAIN RESULTS

In all, 66 trials met our inclusion criteria. No differences were demonstrated between control and LA infiltration in regard to the co-primary outcomes, pain at rest at 0-2 and 8-12 h. The quality of evidence was moderate in view of the serious imprecision. With respect to pain at rest at 8-12 h, ESP block, PECS block and PVB were found to be superior to control or LA infiltration. No differences were revealed between control and LA infiltration for outcomes related to analgesia and side effects, and few differences were shown between the various regional anesthesia techniques.

CONCLUSIONS

In breast surgery, regional anesthesia modalities were preferable from an analgesic perspective to control or LA infiltration, with a clinically significant decrease in pain score and cumulative opioid consumption, and limited differences were present between regional anesthetic techniques themselves.

Earlier Is Better? Timing of Adductor Canal Block for Arthroscopic Knee Surgery under General Anesthesia: A Retrospective Cohort Study

The adductor canal block (ACB) is effective for treating postoperative pain during arthroscopic knee surgery, but its impact on anesthesia course and the optimal administration timing are unknown. This retrospective study addressed these questions. The aim of this study was to compare the effects of preoperative ACB and postoperative ACB on anesthesia course and postoperative recovery. We allocated 215 adult patients who underwent arthroscopic knee surgery under sevoflurane anesthesia between January 2019 and December 2019 to three groups. Group A received general anesthesia without ACB, Group B received ACB before general anesthesia induction, and Group C received ACB in the post-anesthesia recovery unit (PACU). Group B consumed significantly less sevoflurane (0.19 mL/kg/h) and milligram morphine equivalents (0.08 MME) intraoperatively than Groups A (0.22 mL/kg/h; 0.10 MME, respectively) and C (0.22 mL/kg/h; 0.09 MME, respectively). Groups B and C had lower visual analogue scale (VAS) scores upon PACU discharge than Group A. Dynamic, but not at-rest VAS scores, were significantly higher in Group A. Opioid consumption was similar in the ward, but Group A requested more intravenous parecoxib for pain relief. Length of hospital stay was similar. Thus, preoperative ACB reduced the amount of volatile anesthetic required and maintained stable hemodynamics intraoperatively. Preoperative or postoperative ACB improved postoperative pain control. Consequently, preoperative ACB is optimal for intraoperative stress suppression and postoperative pain control.

Comparison of mastectomy and breast reconstruction outcomes using low thermal dissection versus traditional electrocautery: a blinded randomized trial

INTRODUCTION

PlasmaBlade® is a thermal dissection device that may allow for improved perfusion of the mastectomy flap by limiting thermal injury. In this study we aim to compare the mastectomy flap perfusion using PlasmaBlade® versus traditional electrocautery.

METHODS

Patients undergoing bilateral mastectomy with immediate breast reconstruction were recruited. The right and left breasts of each patient were randomized to dissection with PlasmaBlade® or standard electrocautery. Randomization was performed using random sequences on the day of surgery and was blinded to the plastic surgeon. Mastectomy flap perfusion was assessed following completion of the mastectomy using intra-operative fluoroscopy and plastic surgeon review. Surgical site drainage and pain score were measured. Sign tests were employed to assess differences in perfusion and Wilcoxon paired test for the secondary outcomes.

RESULTS

Twenty patients were enrolled in the study with median age of 40.5 years and median BMI of 26 kg/m². In 18 patients (90%), perfusion was assessed to be better on the side of the PlasmaBlade® dissection. Median daily drainage over a 7-day period was 51 cc (IQR 35-61) on the PlasmaBlade® side and 44 cc (IQR 31-61) on the control side. Median pain score on the PlasmaBlade® side was 4.0 (IQR 2.3-5.9) and 4.4 (IQR 2.9-6) on the control side. No skin necrosis was noted in either groups.

CONCLUSION

Use of PlasmaBlade® appears to be a safe and reliable technique to perform mastectomy and breast reconstruction with equivalent outcomes to traditional electrocautery. Although, mastectomy skin flap perfusion was rated better intra-operatively for the PlasmaBlade® group, both cohorts had comparable outcomes. ClinicalTrials.gov Identifier: NCT03711916 Level of Evidence: I (Randomized trial).

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.

Practice Variation in Regional Anesthesia Utilization by Current and Former U.S. Military Anesthesiology Residents

Introduction

Per Joint Trauma System guidelines, military anesthesiologists are expected to be ready to lead an Acute Pain Service with regional anesthesia in combat casualty care. However, regional anesthesia practice volume has not been assessed in the military. The objective of this study was to assess regional anesthesia utilization among current residents and graduates of U.S. military anesthesiology residency programs.

Materials and Methods

All current and former active duty military anesthesiology program residents, trained at any of the four military anesthesiology residency programs between 2013 and 2019, were anonymously surveyed about their regional anesthesia practice. Bivariate statistics described the total single-injection and catheter block techniques utilized in the last month. Cluster analysis assessed for the presence of distinct practice groups within the sample. Follow-up analyses explored potential associations between cluster membership and other variables (e.g., residency training site, residency graduation year, overall confidence in performing regional anesthesia, etc.). This protocol received exemption determination separately from each site’s institutional review board.

Results

Current and former residents reported broad variation in regional anesthesia practice and clustered into four distinct practice groups. Less than half of respondents utilized a moderate to high number of different single-injection and catheter blocks.

Conclusions

These findings highlight the need for creative solutions to increase regional anesthesia training in military anesthesiology programs and continued ability to implement skills, such that all military anesthesiologists have adequate practice for deployed responsibilities.