Rationale and Design for the BLOCK-SAH Study (Pterygopalatine Fossa Block as an Opioid-Sparing Treatment for Acute Headache in Aneurysmal Subarachnoid Hemorrhage): A Phase II, Multicenter, Randomized, Double-Blinded, Placebo-Controlled Clinical Trial with a Sequential Parallel Comparison Design

BACKGROUND

Acute post-subarachnoid hemorrhage (SAH) headaches are common and severe. Management strategies for post-SAH headaches are limited, with heavy reliance on opioids, and pain control is overall poor. Pterygopalatine fossa (PPF) nerve blocks have shown promising results in treatment of acute headache, including our preliminary and published experience with PPF-blocks for refractory post-SAH headache during hospitalization. The BLOCK-SAH trial was designed to assess the efficacy and safety of bilateral PPF-blocks in awake patients with severe headaches from aneurysmal SAH who require opioids for pain control and are able to verbalize pain scores.

METHODS

BLOCK-SAH is a phase II, multicenter, randomized, double-blinded, placebo-controlled clinical trial using the sequential parallel comparison design (SPCD), followed by an open-label phase.

RESULTS

Across 12 sites in the United States, 195 eligible study participants will be randomized into three groups to receive bilateral active or placebo PPF-injections for 2 consecutive days with periprocedural monitoring of intracranial arterial mean flow velocities with transcranial Doppler, according to SPCD (group 1: active block followed by placebo; group 2: placebo followed by active block; group 3: placebo followed by placebo). PPF-injections will be delivered under ultrasound guidance and will comprise 5-mL injectates of 20 mg of ropivacaine plus 4 mg of dexamethasone (active PPF-block) or saline solution (placebo PPF-injection).

CONCLUSIONS

The trial has a primary efficacy end point (oral morphine equivalent/day use within 24 h after each PPF-injection), a primary safety end point (incidence of radiographic vasospasm at 48 h from first PPF-injection), and a primary tolerability end point (rate of acceptance of second PPF-injection following the first PPF-injection). BLOCK-SAH will inform the design of a phase III trial to establish the efficacy of PPF-block, accounting for different headache phenotypes.

Evaluation of ultrasound-guided suprazygomatic maxillary nerve block in functional endoscopic sinus surgery for postoperative pain relief: A randomised controlled trial

Background and Aims

Postoperative pain can impede functional recovery and delay hospital discharge after functional endoscopic sinus surgery (FESS). The study aimed to assess the efficacy of ultrasound (USG)-guided suprazygomatic maxillary nerve block (SZMNB) for postoperative pain in FESS.

Methods

Forty-eight adult patients between 18 and 65 years of age with American Society of Anesthesiologists physical status I and II and scheduled to undergo FESS were enroled in this randomised controlled study. Patients were randomly allocated to either receive USG-guided SZMNB with general anaesthesia (n = 24) or general anaesthesia alone (n = 24). The numerical rating scale (NRS) pain score in the immediate postoperative period was recorded as the primary outcome. A total of 24 h postoperative rescue analgesic consumption, surgeon satisfaction score, postoperative haemodynamics, and postoperative complications were noted as secondary outcomes.

Results

The median (interquartile range) of the NRS pain score in the immediate postoperative period was 0 (0-0.25)[95% confidence interval (CI): 0, 0.08] in the block group compared to 2 (1.75-3) [95% CI: 1.60, 2.40] in the control group, P < 0.001]. Pain scores were significantly reduced at all time intervals till 24 h after surgery (P < 0.001). None of the patients required rescue analgesia in the block group. In contrast, eight patients required diclofenac 75 mg intravenous as rescue analgesia within 1 h of surgery and ten patients within 1-6 h of surgery in the control group. Other secondary outcomes were comparable between groups (P > 0.05).

Conclusion

The USG-guided SZMNB provides excellent postoperative analgesia for patients undergoing FESS without significant side effects.

Analysis of endonasal sinus surgery in a private outpatient setting in a tropical environment: A STROBE analysis

OBJECTIVES

To evaluate results and failure factors in endonasal surgery in a private outpatient setting in a tropical environment.

MATERIAL AND METHOD

A single-center observational study included 337 patients consecutively undergoing endonasal surgery in a private hospital on Réunion Island, a French overseas administrative Département in the Indian Ocean between 2019 and 2021. The main objective was to assess the success rate of the outpatient pathway. Secondary objectives comprised analysis of complications and identification and management of factors for failure of outpatient management. The study was conducted according to the STROBE editorial guideline.

RESULTS

The 337 surgeries notably comprised 112 septoplasties (37.5%), 104 meatotomies (30.3%), 15 unilateral total ethmoidectomies (4.6%), 48 bilateral total ethmoidectomies with sphenoidotomy (14.3%), and 18 Draf procedures (5.5%). Seventy-five percent of patients (252/337) were operated on as outpatients, with a success rate of 90% (227/252 patients). The rate of severe intraoperative complications was 1.5% (5/337). On multivariate analysis, 3 variables were identified as influencing risk of failure of the outpatient pathway: emergency analgesia in the operating room [odds ratio (OR): 91.61; 95% confidence interval (CI): 22.8-540.3], operating time (OR: 1.05; 95% CI: 1.01-1.09), and recovery room time (OR: 1.02; 95% CI: 1.01-1.03).

CONCLUSION

Our study in a tropical environment found eligibility and success rates for outpatient endonasal surgery similar to those in metropolitan France. This makes surgical and anesthesiological training a key factor in the success of outpatient care, while the location of the care structure and the climate seem to have little impact.

Postoperative Nausea and Vomiting following Endoscopic Sinus Surgery under the Guidance of Adequacy of Anesthesia or Pupillometry with Intravenous Propofol/Remifentanil

Postoperative nausea and vomiting (PONV) constitutes an adverse event after endoscopic sinus surgery (ESS) under general anesthesia (GA) with intravenous opioids, such as remifentanil (RMF). Monitoring the nociception/antinociception balance using the surgical pleth index (SPI) or pupillary dilatation reflex (PRD) helps guide intravenous RMF infusion. We aimed to investigate whether their employment could help reduce the incidence of PONV in patients undergoing ESS. The data of 30 patients from the GA group, 31 from the SPI group, and 28 from the PRD group were analyzed. The initial RMF infusion rate of 0.25 µg/kg body weight/minute was increased by 50% when the SPI, PRD, or Boezaart Bleeding Scale (BBS) were elevated by >15, >5%, or >2 points, respectively, until they normalized. PONV was present in 7/89 patients (7.9%): 2/31 patients (6.5%) of the SPI group, 1/30 patients (3.3%) of the GA group, and 4/28 patients (14.3%) of the PRD group. Neither PRD nor SPI guidance for RMF administration reduced the incidence of PONV compared to standard practice. Further studies are required in order to investigate the possibility of PONV eradication in patients undergoing ESS under GA when it is possibly combined with paracetamol/metamizole preventive analgesia, as well as those using antiemetic prophylaxis based on the Apfel Score and premedication with midazolam.

The effect of opioid-free anaesthesia on the quality of recovery after endoscopic sinus surgery: A multicentre randomised controlled trial

BACKGROUND

It remains to be determined whether opioid-free anaesthesia (OFA) is consistently effective for different types of surgery.

OBJECTIVES

The current study hypothesised that OFA could effectively inhibit intraoperative nociceptive responses, reduce side effects associated with opioid use, and improve the quality of recovery (QoR) in endoscopic sinus surgery (ESS).

DESIGN

A multicentre randomised controlled study.

SETTING

Seven hospitals participated in this multicentre trial from May 2021 to December 2021.

PATIENTS

Of the 978 screened patients who were scheduled for elective ESS, 800 patients underwent randomisation, and 773 patients were included in the analysis; 388 patients in the OFA group and 385 patients in the opioid anaesthesia group.

INTERVENTIONS

The OFA group received balanced anaesthesia with dexmedetomidine, lidocaine, propofol and sevoflurane; the opioid anaesthesia group received opioid-based balanced anaesthesia using sufentanil, remifentanil, propofol and sevoflurane.

OUTCOME MEASURES

The primary outcome was 24-h postoperative QoR as evaluated by the Quality of Recovery-40 questionnaire. The key secondary outcomes were episodes of postoperative pain and postoperative nausea and vomiting (PONV).

RESULTS

A significant difference (P = 0.0014) in the total score of 24-h postoperative Quality of Recovery-40 was found between the OFA group, median [interquartile range], 191 [185 to 196] and the opioid anaesthesia group (194 [187 to 197]). There were significant differences between the opioid anaesthesia group and the OFA group in the numerical rating scale score for pain after surgery at 30 min (P  = 0.0017), 1 h (P  = 0.0052), 2 h (P  = 0.0079) and 24 h (P = 0.0303). The difference in the area under the curve of pain scale scores between the OFA group (24.2 [3.0 to 47.5]) and the opioid anaesthesia group (11.5 [1.0 to 39.0]) was significant (P = 0.0042). PONV occurred in 58 of 385 patients (15.1%) in the opioid anaesthesia group compared with 27 of 388 patients (7.0%) in the OFA group, suggesting the incidence of PONV in the OFA group was significantly lower than in the opioid anaesthesia group (P  = 0.0021).

CONCLUSION

OFA can provide good intraoperative analgesia and postoperative recovery quality as effectively as conventional opioid anaesthesia in patients undergoing ESS. OFA can be an alternative option in the pain management of ESS.

TRIAL REGISTRATION

The study was registered at the Chinese Clinical Trial Registry (ChiCTR2100046158; registry URL: http://www.chictr.org.cn/enIndex.aspx.).

Transnasal sphenopalatine ganglion block for pain relief during panretinal photocoagulation laser for diabetic retinopathy: a pre and post interventional study

This study was performed to utilize transnasal Sphenopalatine Ganglion (SPG) block for pain reliving during panretinal photocoagulation (PRP) in diabetic patients with diabetic retinopathy. This pre and post interventional study was performed on 20 patients with proliferative diabetic retinopathy. The first PRP treatment session of all the patients is performed with no transnasal SPG block, but before holding the second session, all the patients underwent transnasal SPG block and pain levels during and after PRP were compared to each other. Before the transnasal SPG block, each nostril of all the cases was inspected for finding any obstruction in each PRP session. Transnasal SPG block was also performed in with 2% lidocaine. The mean age of the included cases was 52.84 ± 8.62 years old (from 36 to 72 years old). All the cases underwent two PRP lasers treatment sessions with the same characteristic (spot size, power and duration) for each patient. In the first and second PRP treatment sessions, the mean NRS scores were obtained immediately after the PRP laser (8.4 vs. 4.2), 15 min (8.2 vs. 4.2), 1 h (8.0 vs. 4.1), and 24 h (5.4 vs. 3.6) after the PRP respectively. The mean NRS scores significantly reduced during the second PRP treatment session compared to the first session (p < 0.001). Transnasal SPG block is a safe and effective strategy used for relieving pain caused by the PRP laser treatment in patients with diabetic retinopathy.

Bilateral Sphenopalatine Ganglion Block With Liposomal Bupivacaine Followed by Severe Hypertension: A Case Report

We reviewed a case of bilateral sphenopalatine ganglion (SPG) blockade with liposomal bupivacaine for sinus surgery. The case was complicated by severe postoperative hypertension refractory to antihypertensives and needing intensive care unit (ICU) admission. While SPG blockade has been used to treat headaches and provide perioperative analgesia, this complication and a possible mechanism have not been described. We discuss how local anesthetic spread beyond the SPG may have caused prolonged parasympathetic blockade and hypertension. Before approved indications are established, we recommend avoiding the use of liposomal bupivacaine in off-label settings when the function of bilateral autonomic structures could be affected.

The Effect of Sphenopalatine Ganglion Block on the Postoperative Pain in Patients Undergoing Septorhinoplasty

OBJECTIVES

This study aimed to evaluate the effect of preoperative sphenopalatine ganglion block (SPBG) on the postoperative pain (POP) in patients undergoing septorhinoplasty (SRP).

METHODS

A retrospective cohort study was performed. A total of 42 patients that had received septorhinoplasty included in the study. The patients that had received SPBG before the surgery included in the Block group (n:20) and the patients that had not received SPBG before the surgery included in the Control group (n:22). POP was questioned with a numeric rating scale (NRS) at the 30th minute (t1), 1st hour (t2), 4th hour (t3), 12th hour (t4), and 24th hour (t5) and noted. The intraoperative details and the dose of the postoperative rescue analgesics were also noted.

RESULTS

The average dose of Paracetamol that was used in the postoperative first 24 hours was 500 mg in the Block group and 1363 mg in the Control group, and the difference was statistically significant (P = .001). The average dose of Tramadol was 0 mg in the Block group and 45 mg in the Control group, and the difference was statistically significant (P = .001). There was a statistically significant difference among the groups with respect to NRS in the first 24 hours postoperatively (P < .05). The number of the patients requiring rescue analgesics was lower in the Block group than the Control group. The difference was statistically significant at the t1, t2, and t5 time intervals (P > .05).

CONCLUSIONS

Preoperative SPGB is an effective option to reduce POP and the need for rescue analgesics for patients undergoing SRP.

CLINICAL TRIAL NUMBER

NCT04020393.

Multicenter study on the effect of nonsteroidal anti-inflammatory drugs on postoperative pain after endoscopic sinus and nasal surgery

BACKGROUND

The taboo of avoiding nonsteroidal anti-inflammatory drugs (NSAIDs) after functional endoscopic sinus surgery (FESS) has been waning. The impetus to reduce opioid prescriptions in view of the opioid epidemic led the authors to change their practices to include NSAIDs after sinus surgery. This study's aim was to analyze the differences between patients before and after we began recommending NSAIDs after FESS.

METHODS

A prospective cohort study was performed on patients undergoing FESS or other endoscopic nasal surgeries at 3 institutions, by 5 rhinologists and 1 facial plastic surgeon. Before introducing NSAIDs, all patients were given a prescription for hydrocodone-acetaminophen 5/325 mg and also recommended preferentially to use acetaminophen 325 mg. After the addition of NSAIDs, ibuprofen 200 mg and acetaminophen 325 mg were recommended preferentially, using the narcotic as a rescue medication. Patients kept a pain diary and medication log, and gave a visual analog scale (VAS) score for overall pain. Demographics, surgical variables, and comorbidities were also analyzed.

RESULTS

One hundred sixty-six total patients were recruited and had data that could be analyzed (65 without NSAIDs, 101 with NSAIDs). Overall, mean pain VAS score was 3.12 ± 1.95 for the non-NSAID group and 2.33 ± 2.30 for the NSAID group (p value = 0.006). The day with the highest mean pain was the first postoperative day. The mean number of total opioid pills taken was 6.94 ± 6.85 without NSAIDs vs 3.77 ± 4.56 with NSAIDs (p = 0.018). Age and gender were found to be the only consistently significant patient variables to affect pain. There were no bleeding complications.

CONCLUSION

NSAID use was introduced into the practices of 5 practicing rhinologists and 1 facial plastic surgeon. No bleeding complications were seen. Both pain and overall opioid usage were reduced significantly.