Role of regional anesthesia and analgesia in the opioid epidemic

Suprazygomatic Maxillary Nerve Blocks and Opioid Requirements in Pediatric Adenotonsillectomy: A Randomized Clinical Trial

Importance

Pain management following pediatric adenotonsillectomies is opioid-inclusive, leading to potential complications.

Objective

To investigate the use of suprazygomatic maxillary nerve (SZMN) blocks to reduce pain and opioid use after pediatric intracapsular adenotonsillectomy and to measure recovery duration and incidence of complications.

Design, Setting, and Participants

This was a randomized, blinded, prospective single-center tertiary pediatric hospital that included 60 pediatric patients (2-14 years old) scheduled for intracapsular adenotonsillectomy from November 2021 to March 2023. Patients were excluded for having combined surgical procedures, developmental delay, coagulopathy, chronic pain history, known or predicted difficult airway, or unrepaired congenital heart disease. Participants were randomized to receive bilateral SZMN blocks (block group) or not (control group).

Intervention

SZMN block administered bilaterally under general anesthesia for intracapsular adenotonsillectomy.

Primary Outcomes and Measures

Opioid consumption, FLACC (Face, Legs, Activity, Cry, Consolability) scores, and rates of opioid-free postanesthesia care unit (PACU) stay. Secondary outcomes were recovery duration and incidence of adverse effects, ie, nausea, vomiting, block site bleeding, and emergency delirium.

Results

The study population included 53 pediatric patients (mean [SD] age, 6.5 [3.6] years; 29 [55%] females; 24 [45%] males); 26 were randomly assigned to the SZMN block group and 27 to the control group. The mean (SD) opioid morphine equivalent consumption during PACU stay was 0.15 (0.14) mg/kg for the 27 patients in the control group compared with 0.07 (0.11) mg/kg for the 26 patients in the block group (mean difference, 0.08; 95% CI, 0.01-0.15; Cohen d, 0.64). The block group had a higher incidence of opioid-free PACU stays (n = 7 patients; 58%) compared with the control group (n = 15 patients; 26%) (mean difference, 32%; 95% CI, 5%-53%). Patients in the block group experienced lower FLACC scores (0.7 vs 1.6; mean difference, 0.9; 95% CI, 0.2-1.6; Cohen d, 0.7). The overall occurrence of adverse events was similar in the 2 groups, with no reported nerve block-related complications.

Conclusions and Relevance

The results of the randomized clinical trial indicate that SZMN blocks are a useful adjunct tool for managing postoperative pain in pediatric intracapsular adenotonsillectomy. Use of these blocks during adenotonsillectomy provided clinically meaningful reductions of postoperative opioid consumption with a low risk of complications.

Trial Registration

ClinicalTrials.gov Identifier: NCT04797559.

The Outcomes of an Opioid-Free Anaesthetic Plan in Fourteen Dogs Undergoing Enucleation Using an Ultrasound-Guided Supra-Temporal Retrobulbar Block: A Retrospective Case Series

The objective of this retrospective case series is to report the outcomes of an opioid-free anesthetic plan in dogs undergoing enucleation surgery. A total of 14 dogs were admitted for enucleation between March and December 2020. A multimodal approach to perioperative analgesia was used, with a focus on retrobulbar anesthesia. A combination of an ultrasound-guided retrobulbblock with a supratemporal approach in association with ketamine, dexmedetomidine and non-steroidal anti-inflammatory drugs was used in the reported cases. Intraoperative nociception was defined as an increase of 20% from the baseline in one or more of the following parameters: heart rate, respiratory rate or mean arterial pressure. An ultrasound-guided retrobulbar block in an opioid-free anesthesia regime was effective at managing the perioperative analgesia of 13 out of 14 dogs. In only one case, a bolus of fentanyl was administered to treat intraoperative nociception. Recovery was uneventful in all the dogs, and the postoperative pain scores remained below the intervention threshold at all time points. To the authors' knowledge, this is the first reported case series of opioid-free anesthesia for enucleation in dogs.

Localizing the Pain: Continuous Paravertebral Nerve Blockade in a Patient with Acute Pancreatitis

Patient: Female, 41-year-old

Final Diagnosis: Pancreatitis

Symptoms: Abdominal pain • nausea • vomiting

Medication: —

Clinical Procedure: —

Specialty: Anesthesiology

A guide to regional analgesia for Total Knee Arthroplasty

Regional analgesia has been introduced successfully into the postoperative pain management after total knee arthroplasty, reducing pain scores, opioid use and adverse effects.

Combination of regional analgesia techniques is associated with better pain management and lower side effects than single regional techniques.

Adductor canal block provides good analgesia and considerably lower detrimental effect in muscular strength than femoral nerve block, enhancing surgical recovery.

Infiltration techniques may have equivalent analgesic effect than epidural analgesia and peripheral nerve blocks, however there should be awareness of dose dependent toxicity.

Novel long-acting local anesthetics role for regional analgesia is still to be determined, and will require larger randomized trials to support its advantage over traditional local anesthetics.

Cite this article: EFORT Open Rev 2021;6:1181-1192. DOI: 10.1302/2058-5241.6.210045

Regional Anesthesia for Symptomatic Treatment of Stingray Envenomation

Stingray envenomation is common in coastal regions around the world and may result in intense pain that can be challenging to manage. Described therapies involve hot water immersion and potentially other options such as opioid and nonopioid analgesics, removal of the foreign body, wound debridement, antibiotics for secondary infection, and tetanus toxoid. However, for some patients, this may not be enough. Peripheral nerve blockade is a frequently used perioperative analgesic technique, but it has rarely been described in the management of stingray envenomation. Here, we report a case of stingray envenomation in an otherwise healthy 36-y-old male with pain refractory to traditional therapies. After admission for pain control, the patient received an ultrasound-guided sciatic popliteal nerve block. Upon completion of the peripheral nerve block, the patient reported rapid and complete resolution of the intense pain, which did not return thereafter.

Serratus intercostal interfascial plane block in supraumbilical surgery: a prospective randomized comparison

BACKGROUND

Upper abdominal wall surgical incisions may lead to a severe postoperative pain. Therefore, adequate analgesia is important. Here we investigate whether the low serratus-intercostal interfascial plane block (SIPB) achieves an effective analgesia, considering opioids consumption, pain control and recovery quality in upper abdominal surgeries.

METHODS

This blinded, randomized controlled study was conducted on 102 patients undergoing open upper abdominal wall surgery under general anesthesia. All patients who received serratus-intercostal plane block at the eighth rib as analgesic technique were included in SIPB group and in control group those who received continuous intravenous morphine analgesia. Pain scores in numeric verbal scale (NVS) and opioids consumption at 0, 6, 12, 24 and 48 hours postoperatively were assessed. The quality of the postoperative recovery was evaluated using the QoR-15 questionnaire at 24 hours.

RESULTS

This study showed lower postoperative opioid consumption at 24 hours (P<0.0001; 4.17 mg vs. 41.52 mg of morphine) and better pain control (P<0.005) with mean pain scores (NVS 1.8±1.5 vs. 4.8±1.6) in group 0 (SIPB). The global QoR-15 scores 24 hours postoperatively were higher (better quality) in the SIPB group (122 vs. 100).

CONCLUSIONS

The low serratus-intercostal interfascial plane block (SIPB) provides efficient analgesia leading to a saving of opioids and improvement of the recovery quality in patients undergoing upper abdominal wall surgeries.