Transversus abdominis plane block with general anesthesia blunts the perioperative stress response in patients undergoing radical gastrectomy

Combination of dexamethasone and dexmedetomidine as adjuvants of transversus abdominis plane block for postoperative analgesia in gastric cancer patients: A double-blinded randomized controlled trial

STUDY OBJECTIVE

We conducted this double-blinded randomized controlled trial to examine whether the combination of dexamethasone and dexmedetomidine as adjuvants of transversus abdominis plane (TAP) block could improve analgesia efficacy and duration for gastric cancer patients.

DESIGN

Randomized controlled trial.

SETTING

The preoperative area, operating room, postanesthesia recovery room and bed ward.

PATIENTS

A total of 312 adult patients (104 per group) with gastric cancer were included.

INTERVENTIONS

Patients received bilateral subcostal TAP block with three different anesthetics (60 ml 0.25% ropivacaine added with 10 mg dexamethasone and 1 μg·kg-1 dexmedetomidine [A] or 10 mg dexamethasone [B] or 1 μg·kg-1 dexmedetomidine [C]).

MEASUREMENTS

The primary outcome was the incidence of moderate-to-severe pain 24 h on movement. Secondary outcomes included incidence of moderate-to-severe pain, pain score, opioids use, recovery quality and adverse events.

MAIN RESULTS

The incidence of moderate-to-severe pain on movement 24 h postoperatively of group A was significantly lower than group B (45.19% vs 63.46%; RR 0.71; 95% CI, 0.55 to 0.92) and group C (45.19% vs 73.08%, RR 0.62; 95% CI, 0.49 to 0.79). The median moving pain scores decreased significantly at 24 h (3.00 [3.00,5.00] vs 4.00 [3.00,6.00] vs 4.00 [3.00,5.00]; P < 0.001). There were significant differences in the opioids consumption within the first 24 h (27.5 [17.0,37.2] vs 30.0 [20.0,42.0] vs 32.0 [25.0,44.0] mg; P = 0.01) and the duration to first rescue analgesia (65.5 ± 26.7 vs 45.9 ± 34.5 vs 49.2 ± 27.2 h; P = 0.04).

CONCLUSIONS

The combination with dexamethasone and dexmedetomidine as adjuvants for TAP block reduced the incidence of moderate-to-severe pain and pain score both on movement and at rest at 24 h with prolonged duration to first rescue analgesia after gastric cancer surgery.

TRIAL REGISTRATION NUMBER

ChiCTR2000037981.

Dysregulation of systemic immunity and its clinical application in gastric cancer

Immunotherapy has profoundly changed the treatment of gastric cancer, but only a minority of patients benefit from immunotherapy. Therefore, numerous studies have been devoted to clarifying the mechanisms underlying resistance to immunotherapy or developing biomarkers for patient stratification. However, previous studies have focused mainly on the tumor microenvironment. Systemic immune perturbations have long been observed in patients with gastric cancer, and the involvement of the peripheral immune system in effective anticancer responses has attracted much attention in recent years. Therefore, understanding the distinct types of systemic immune organization in gastric cancer will aid personalized treatment designed to pair with traditional therapies to alleviate their detrimental effects on systemic immunity or to directly activate the anticancer response of systemic immunity. Herein, this review aims to comprehensively summarize systemic immunity in gastric cancer, including perturbations in systemic immunity induced by cancer and traditional therapies, and the potential clinical applications of systemic immunity in the detection, prediction, prognosis and therapy of gastric cancer.

Perioperative pain management with regional analgesia techniques for visceral cancer surgery: A systematic review and meta-analysis

STUDY OBJECTIVE

Regional analgesia following visceral cancer surgery might provide an advantage but evidence for best treatment options related to risk-benefit is unclear.

DESIGN

Systematic review of randomized controlled trials (RCT) with meta-analysis and GRADE assessment.

SETTING

Postoperative pain treatment.

PATIENTS

Adult patients undergoing visceral cancer surgery.

INTERVENTIONS

Any kind of peripheral (PRA) or epidural analgesia (EA) with/without systemic analgesia (SA) was compared to SA with or without placebo treatment or any other regional anaesthetic techniques.

MEASUREMENTS

Primary outcome measures were postoperative acute pain intensity at rest and during activity 24 h after surgery, the number of patients with block-related adverse events and postoperative paralytic ileus.

MAIN RESULTS

59 RCTs (4345 participants) were included. EA may reduce pain intensity at rest (mean difference (MD) -1.05; 95% confidence interval (CI): -1.35 to -0.75, low certainty evidence) and during activity 24 h after surgery (MD -1.83; 95% CI: -2.34 to -1.33, very low certainty evidence). PRA likely results in little difference in pain intensity at rest (MD -0.75; 95% CI: -1.20 to -0.31, moderate certainty evidence) and pain during activity (MD -0.93; 95% CI: -1.34 to -0.53, moderate certainty evidence) 24 h after surgery compared to SA. There may be no difference in block-related adverse events (very low certainty evidence) and development of paralytic ileus (very low certainty of evidence) between EA, respectively PRA and SA.

CONCLUSIONS

Following visceral cancer surgery EA may reduce pain intensity. In contrast, PRA had only limited effects on pain intensity at rest and during activity. However, we are uncertain regarding the effect of both techniques on block-related adverse events and paralytic ileus. Further research is required focusing on regional analgesia techniques especially following laparoscopic visceral cancer surgery.

The addition of peripheral nerve blocks to routine spinal or general anesthesia was associated with decreased risks of major adverse events after total hip or knee arthroplasty: A retrospective, propensity score-matched cohort study

Background

Although total joint arthroplasty is the most effective procedures for end-stage arthritis, the incidence of postoperative death and complications remains high. The association of additional peripheral nerve blocks (PNBs) to routine spinal or general anesthesia with major adverse events (including mortality and complication rates) in elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) has been subject to inconclusive findings.

Methods

This retrospective observational single institution study included all patients ≧ 18 years undergoing their first elective THA or TKA from January 1, 2012 to December 31, 2021. A 1:2 propensity score matching (PSM) was performed to account for the baseline differences between two groups that were accepted to PNB or not. Kaplan-Meier curves were employed to estimate the effects of PNB on mortality. The associations of PNB and the complications were assessed by logistic regression models.

Results

We identified 1328 patients, among whom 197 had PNB and 1131 had not. The 90-day all-cause mortality was significantly reduced in patients with PNBs (0 % vs 2.79 %, P = 0.041) after THA or TKA, when compared to the non-PNB group. PNB was also associated with a lower risk of pulmonary complications (odds ratio [OR], 0.430; 95%confidence interval [CI],0.216-0.857) and deep vein thrombosis (OR, 0.103; 95%CI, 0.011-0.954).

Interpretation

The results of this observational, propensity score-matched cohort study suggested a strong association between the addition of PNBs to routine spinal or general anesthesia and decreased risks of major adverse events.

Effect of thoracic paravertebral nerve block on delirium in patients after video-assisted thoracoscopic surgery: a systematic review and meta-analysis of randomized controlled trials

Background

Nerve blocks are widely used in various surgeries to alleviate postoperative pain and promote recovery. However, the impact of nerve block on delirium remains contentious. This study aims to systematically evaluate the influence of Thoracic Paravertebral Nerve Block (TPVB) on the incidence of delirium in patients post Video-Assisted Thoracoscopic Surgery (VATS).

Methods

We conducted a systematic search of PubMed, Embase, Web of Science, Cochrane Library, and Scopus databases in June 2023. The search strategy combined free-text and Medical Subject Headings (MeSH) terms, including perioperative cognitive dysfunction, delirium, postoperative cognitive dysfunction, paravertebral nerve block, thoracic surgery, lung surgery, pulmonary surgery, and esophageal/esophagus surgery. We utilized a random effects model for the analysis and synthesis of effect sizes.

Results

We included a total of 9 RCTs involving 1,123 participants in our study. In VATS, TPVB significantly reduced the incidence of delirium on postoperative day three (log(OR): -0.62, 95% CI [-1.05, -0.18], p = 0.01, I2 = 0.00%) and postoperative day seven (log(OR): -0.94, 95% CI [-1.39, -0.49], p < 0.001, I2 = 0.00%). Additionally, our study indicates the effectiveness of TPVB in postoperative pain relief (g: -0.82, 95% CI [-1.15, -0.49], p < 0.001, I2 = 72.60%).

Conclusion

The comprehensive results suggest that in patients undergoing VATS, TPVB significantly reduces the incidence of delirium and notably diminishes pain scores.

Systematic review registration

CRD42023435528. https://www.crd.york.ac.uk/PROSPERO.

The impact of the transversus abdominis plane block (TAP) on stress response measured through the complete blood- derived inflammatory markers

This study aims to evaluate the effect of the transversus abdominis plane (TAP) block on the blood cells and the inflammatory markers neutrophil- to- lymphocyte ratio (NLR), platelet- to- lymphocyte ratio (PLR), and systemic immune- inflammation index (SII) after the laparoscopic ovariectomy (LapOV) in dogs. 72 healthy bitches undergoing LapOV were randomly allocated to the no- TAP group of dogs under inhaled anesthesia (IA), the TAP- S group (IA and TAP with saline), and the TAP- B group (IA and TAP with bupivacaine). The NLR, PLR, and SII were calculated 1 h before ovariectomy (T0) and at 2-3 h (T1), 6-8 h (T2), and 20-24 h (T3) post- surgery. The number of dogs requiring postoperative analgesic rescue with buprenorphine and the doses administered in each group were recorded. Significant changes were observed in all groups' postoperative NLR, PLR, and SII over time. Between groups, no differences were observed in any of the ratios at any control point (NLR at T0-T3: p = 0.17, 0.36, 0.80, and 0.95; PLR at T0-T3: p = 0.70, 0.62, 0.21, 0.87; SII at T0-T3: p = 0.29, 0.65, 0.09, and 0.34). A significantly lower number of dogs required analgesic rescue in the TAP-B group (p = 0.0001) and a lower number of doses were administered (p = 0.001). There is no difference in the inflammatory response measured through the complete blood- derived inflammatory markers after the LapOV in dogs when the postoperative pain is managed entirely with opioids or with the TAP block with bupivacaine. The hydrodissection associated with the TAP block technique does not increase the inflammatory response.

Prediction model of stress ulcer after laparoscopic surgery for colorectal cancer established by machine learning algorithm

BACKGROUND

Patients with colorectal cancer (CRC) are prone to stress ulcer after laparoscopic surgery. The analysis of risk factors for stress ulcer (SU) in patients with CRC is important to reduce mortality and improve patient prognosis.

AIM

To identify risk factors for SU after laparoscopic surgery for CRC, and develop a nomogram model to predict the risk of SU in these patients.

METHODSThe clinical data of 135 patients with CRC who underwent laparoscopic surgery between November 2021 and June 2022 were reviewed retrospectively. They were divided into two categories depending on the presence of SUs: The SU group (n = 23) and the non-SU group (n = 112). Univariate analysis and multivariate logistic regression analysis were used to screen for factors associated with postoperative SU in patients undergoing laparoscopic surgery, and a risk factor-based nomogram model was built based on these risk factors. By plotting the model's receiver operating characteristic (ROC) curve and calibration curve, a Hosmer-Lemeshow goodness of fit test was performed.

RESULTS

Among the 135 patients with CRC, 23 patients had postoperative SU, with an incidence of 17.04%. The SU group had higher levels of heat shock protein (HSP) 70, HSP90, and gastrin (GAS) than the non-SU group. Age, lymph node metastasis, HSP70, HSP90, and GAS levels were statistically different between the two groups, but other indicators were not statistically different. Logistic regression analysis showed that age ≥ 65 years, lymph node metastasis, and increased levels of HSP70, HSP90 and GAS were all risk factors for postoperative SU in patients with CRC (P < 0.05). According to these five risk factors, the area under the ROC curve for the nomogram model was 0.988 (95%CI: 0.971-1.0); the calibration curve demonstrated excellent agreement between predicted and actual probabilities, and the Hosmer-Lemeshow goodness of fit test revealed that the difference was not statistically significant (χ2 = 0.753, P = 0.999), suggesting that the nomogram model had good discrimination, calibration, and stability.

CONCLUSION

Patients with CRC aged ≥ 65 years, with lymph node metastasis and elevated HSP70, HSP90, GAS levels, are prone to post-laparoscopic surgery SU. Our nomogram model shows good predictive value.

Propofol suppresses hormones levels more obviously than sevoflurane in pediatric patients with craniopharyngioma: A prospective randomized controlled clinical trial

OBJECTIVE

General anesthesia can disturb the hormone levels in surgical patients. Hormone deficiency is one of the major symptoms of craniopharyngioma (CP) in pediatric patients. The aim of this prospective randomized controlled clinical study is to evaluate whether propofol and sevoflurane influence the perioperative hormone levels in these patients and to determine which anesthesia technique causes less impact on hormone levels.

MATERIALS

Sixty-four ASA I and II pediatric patients with CP undergoing elective neurosurgery were randomly divided into the sevoflurane group (S group, n = 32) and the propofol group (P group, n = 32). Anesthesia was maintained with sevoflurane and propofol until the end of the operation. Demographic information, operation information and hemodynamic variables were recorded. The levels of hormones were evaluated preoperatively as the baseline (T0), 1h after the beginning of the operation (T1), immediately at the end of the operation (T2) and 72 h postoperatively (T3).

RESULTS

There were no significant differences in the two groups in terms of patients' demographics and intraoperative information, such as operation duration, blood loss and transfusion volumes, and fluid infusion volume (P>0.05). In both groups, compared to those at T0, the levels of TSH, FT3, TT3 and ACTH at T1, T2 and T3 were significantly lower. The levels of FSH, PRL and GH at T3 were also significantly lower (P<0.05). The FT3 and TT3 levels of both groups at T2 and T3 were significantly lower than those at T1, but the ACTH level was significantly increased (P<0.05). Compared to the levels at T2, the TSH, FT3, FT4 and ACTH levels of the two groups at T3 were significantly reduced (P<0.05). The baseline hormone levels of both groups were similar (P>0.05). At T1, the FT3, TT3, FT4, TT4 and ACTH levels in the P group were significantly lower than those in the S group (P<0.05). At T2, the TT3 and ACTH levels of the P group were significantly lower than those of the S group (P<0.05) At T3, the TT4 level in the P group was significantly lower than that of the S group (P<0.05).

CONCLUSION

Propofol and sevoflurane could reduce the levels of hormones intraoperatively and postoperatively in pediatric patients with craniopharyngioma. However, propofol reduced hormone levels more intensively, mainly intraoperatively. Postoperatively, propofol and sevoflurane had similar inhibition effects on the shift in hormone levels. Therefore, in pediatric patients with craniopharyngioma undergoing neurosurgery, sevoflurane might be the preferred anesthetic because it causes less interruption of hormone levels. However, because of their similar postoperative effects, which long-term effects of sevoflurane or propofol could produce optimal clinical situations? Thus more extensive clinical studies are needed.

TRIAL REGISTRATION

Clinical trial registration. This trail was registered at Chinese Clinical Trial Registry (http://www.chictr.org.cn, Jun Xiong) on 28/12/2021, registration number was ChiCTR2100054885.

Effects of pecto-intercostal fascial block combined with rectus sheath block for postoperative pain management after cardiac surgery: a randomized controlled trial

Background

Pecto-intercostal fascial block (PIFB) provides analgesia for cardiac median sternotomy, but many patients complain of severe drainage pain that cannot be covered by PIFB. Rectus sheath block (RSB) has been attempted to solve this problem, but whether PIFB combined with RSB can achieve better analgesia is uncertain.

Methods

This was a single-center randomized controlled trial at Peking University People’s Hospital from September 22, 2022 to December 21, 2022. Patients undergoing elective cardiac surgery with a median sternotomy were randomized at a 1:1 ratio to receive either bilateral PIFB and RSB (PIFB + RSB group) or PIFB (PIFB group). The primary outcome was intravenous opioid consumption within 24 h after surgery. Secondary outcomes included opioid consumption within 48 h, postoperative pain scores, time to extubation, and length of stay in the hospital. Interleukin (IL)-6, IL-10, and tumor necrosis factor (TNF)-α before and the first 24 h after surgery were measured.

Results

A total of 54 patients were analyzed (27 in each group). Intravenous opioid consumption within 24 h after surgery was 2.33 ± 1.77 mg in the PIFB + RSB group vs 3.81 ± 2.24 mg in the PIFB group (p = 0.010). Opioid consumption within 48 h after surgery was also reduced in the PIFB + RSB group (4.71 ± 2.71 mg vs 7.25 ± 3.76 mg, p = 0.006). There was no significant difference in pain scores, time to extubation, length of stay in hospital, or the levels of IL-6, IL-10 and TNF-α between the two groups.

Conclusions

The combination of PIFB and RSB reduced postoperative intravenous opioid consumption until 48 h after cardiac surgery.

Trial registration

This trial is registered at the Chinese Clinical Trial Registry (www.chictr.org.cn, ChiCTR2200062017) on 19/07/2022.

Analgesic efficacy of an ultrasound-guided transversus abdominis plane block with bupivacaine in cats: a randomised, prospective, masked, placebo-controlled clinical trial

OBJECTIVES

This randomised, prospective, masked clinical trial evaluated the postoperative analgesic efficacy of an ultrasound-guided transversus abdominis plane block (TAPB) with bupivacaine in cats undergoing ovariohysterectomy.

METHODS

Thirty-two healthy adult female cats undergoing elective ovariohysterectomy were randomised to undergo TAPB with bupivacaine (treatment group [TG], n = 16) vs placebo (control group [CG], n = 16) in addition to preoperative analgesia with buprenorphine (0.02 mg/kg IM). All patients received a general anaesthetic and, before surgical incision, a bilateral two-point (subcostal and lateral-longitudinal) TAPB was performed using 1 ml/kg bupivacaine 0.25% (0.25 ml/kg/point) or saline. Each cat was assessed by a blinded investigator before premedication (0 h) and at 1, 2, 3, 4, 8, 10 and 24 h postoperatively using the UNESP-Botucatu Feline Pain Scale - short form. Buprenorphine (0.02 mg/kg IV) and meloxicam (0.2 mg/kg SC) were administered when pain scores were ⩾4/12. Ten hours postoperatively, meloxicam was administered to cats that did not receive rescue analgesia. Statistical analysis included Student's t-tests, Wilcoxon tests and χ2 tests, and a linear mixed model with Bonferroni corrections (P <0.05).

RESULTS

Of the 32 cats enrolled, three in the CG were excluded from the analysis. The prevalence of rescue analgesia was significantly higher in the CG (n = 13/13) than in the TG (n = 3/16; P <0.001). Only one cat in the CG required rescue analgesia twice. Pain scores were significantly higher in the CG compared with the TG at 2, 4 and 8 h postoperatively. Mean ± SD pain scores were significantly higher in the CG, but not in the TG, at 2 (2.1 ± 1.9), 3 (1.9 ± 1.6), 4 (3.0 ± 1.4) and 8 h postoperatively (4.7 ± 0.6) than at 0 h (0.1 ± 0.3).

CONCLUSIONS AND RELEVANCE

A bilateral ultrasound-guided two-point TAPB with bupivacaine in combination with systemic buprenorphine provided superior postoperative analgesia than buprenorphine alone in cats undergoing ovariohysterectomy.

Non-diabetic euglycaemic ketoacidosis and rapid weight loss in a post-traumatic surgical patient: is the outré preventable?

To highlight the implications of the metabolic stress response and the role of anaesthesia in attenuating its deleterious effects, we present this extremely rare case of non-diabetic euglycaemic ketoacidosis with rapid weight loss in a post-traumatic surgical patient. Ketoacidosis is the accumulation of ketone bodies in blood and is generally associated with relative or absolute insulin deficiency secondary to diabetes mellitus, sodium-glucose cotransporter 2 inhibitors and extensive fasting. The stress of systemic disease, trauma or surgery in such predisposed patients could precipitate ketoacidosis. Our patient developed high anion gap metabolic acidosis intraoperatively due to ketosis, a potentially life-threatening complication, without any predisposing factors as a result of metabolic stress of major trauma and surgery. Aiding the interpretation, he lost 15 kg weight perioperatively, suggesting his body was in a hypercatabolic state. This report emphasises the value of anaesthetic techniques to prevent such rare complications.

Ultrasound Image-Guided Nerve Block Combined with General Anesthesia under an Artificial Intelligence Algorithm on Patients Undergoing Radical Gastrectomy for Gastric Cancer during and after Operation

This study was aimed at investigating the location of gastric cancer by using a gastroscope image based on an artificial intelligence algorithm for gastric cancer and the effect of ultrasonic-guided nerve block combined with general anesthesia on patients undergoing gastric cancer surgery. A total of 160 patients who were undergoing gastric cancer surgery from March 2019 to March 2021 were collected as the research objects, and the convolutional neural network (CNN) algorithm was used to segment the gastroscope image of gastric cancer. The patients were randomly divided into a simple general anesthesia group of 80 cases and a transversus abdominis plane block combined with rectus abdominis sheath block combined with the general anesthesia group of 80 cases. Then, compare the systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) at the four time points T0, T1, T2, and T3. The times of analgesic drug use within 48 hours after operation and postoperative adverse reactions were recorded. The visual analog scale (VAS) scores were also recorded at 4 h, 12 h, 24 h, and 48 h. The results show that the image quality after segmentation is good: the accuracy of tumor location is 75.67%, which is similar to that of professional endoscopists. Compared with the general anesthesia group, the transversus abdominis plane block combined with the rectus sheath block combined with the general anesthesia group had fewer anesthetics, and the difference was statistically significant (P < 0.05). Compared with the general anesthesia group, SBP, DBP, and HR were significantly reduced at T1, T2, and T3 in the transverse abdominis plane block combined with rectus sheath block and general anesthesia group (P < 0.05). Compared with the simple general anesthesia group, the VAS scores of the transversus abdominis plane block combined with rectus sheath block combined with the general anesthesia group decreased at 4 h, 12 h, and 24 h after surgery, and the difference was statistically significant (P < 0.05). The number of analgesics used in transversus abdominis plane block combined with the rectus sheath block combined with the general anesthesia group within 48 hours after operation was significantly less than that in the general anesthesia group, and the difference was statistically significant (P < 0.05). The average incidence of adverse reactions in the nerve block combined with the general anesthesia group was 2.5%, which was lower than the average incidence of 3.75% in the general anesthesia group. In summary, the CNN algorithm can accurately segment the lesions in the ultrasonic images of gastric cancer, which was convenient for doctors to make a more accurate judgment on the lesions, and provided a basis for the preoperative examination of radical gastrectomy for gastric cancer. Ultrasonic-guided nerve block combined with general anesthesia can effectively improve the analgesic effect of radical gastrectomy for gastric cancer, reduced intraoperative and postoperative adverse reactions and analgesic drug dosage, and had a good effect on postoperative recovery of patients. The combined application of these two methods can further improve the precision treatment of gastric cancer patients and accelerate postoperative recovery.

Efficacy of ultrasound-guided Transversus Abdominis Plane (TAP) block in inguinal hernia surgery and the immunomodulatory effects of proinflammatory cytokines: prospective, randomized, placebo-controlled study

Background

Tumor Necrosis Factor-α (TNF-α) and Interleukin-1β (IL-1β) are among the cytokines released secondary to the surgical stress response. The objective of this study was to investigate the effect of a Transversus Abdominis Plane (TAP) block on postoperative pain and its immunomodulatory activity through proinflammatory cytokines.

Methods

TAP (study group; n = 40) or p-TAP (placebo group; n = 40). Patients in the TAP group underwent an Ultrasound (US) guided unilateral TAP block using 20-cc 0.5% bupivacaine solution. Patients in the p-TAP group underwent a sham block using 20-cc isotonic solution. The TNF-α and IL-1β levels were measured three times at preoperative hour-0 and postoperative hours 4 and 24. Visual Analog Scale (VAS) scores were recorded at 0-hours, 30-minutes, 4-hours, and 24-hours. Analgesic use within the first 24-hours following surgery was monitored.

Results

The postoperative VAS score was decreased in the TAP group at all time points (0, 4, and 24 hours), and the differences between groups were statistically significant (p <  0.001 for all comparisons). In the TAP group, the TNF-α and IL-1β levels at 4 and 24 hours post operation were significantly lower than the preoperative levels (p <  0.001 for all comparisons).

Conclusion

The TAP block for pre-emptive analgesia enabled effective hemodynamic control during the intraoperative period, provided effective pain control in the postoperative period, and decreased inflammation and surgical stress due to the decreased levels of the proinflammatory cytokines TNF-α and IL-1β in the first postoperative 24 hours, indicating immunomodulatory effect.

Mid-axillary transversus abdominis plane block and stress response after abdominal hysterectomy: A randomised controlled placebo trial

BACKGROUND

The hormonal response to surgical trauma can have detrimental effects on patients. Transversus abdominis plane (TAP) block, which can improve analgesia after total abdominal hysterectomy (TAH) might attenuate the peri-operative stress response.

OBJECTIVE

To evaluate the ability of the TAP block to reduce stress response, opioid consumption and pain following TAH and multimodal analgesia.

DESIGN

Randomised, placebo-controlled double-blind study.

SETTING

The current study was conducted at a university hospital from July 2016 to September 2017.

PATIENTS

Fifty patients scheduled for TAH were included. Anaesthesia and postoperative analgesia were standardised.

INTERVENTION

After induction of anaesthesia, patients were allocated into two groups: ultrasound-guided bilateral mid-axillary TAP block with 20 ml of bupivacaine 0.25% (Group T) or 0.9% saline (Group C).

MAIN OUTCOME MEASURES

Levels of free serum cortisol, metanephrine and normetanephrine at 60 min and 6, 12 and 24 h after surgical incision. Pain scores and opioid consumption during the first 24 h after surgery.

RESULTS

There was no statistically significant difference between the median [IQR] peri-operative levels of stress hormones and pain scores between groups. Compared with baseline value 9.90 [4.2 to 23.1], free serum median cortisol levels were significantly high at 6 h in Group T, 23.6 [10.1 to 42.9] P = 0.015 and Group C 23.6 [9.9 to 46.3] P = 0.014. Only Group C showed significant elevation from the baseline median levels of plasma metanephrine at 60 min, 52.8 [33.4 to 193.2] P = 0.001, 6 h, 92.70 [2.4 to 202.6] P = 0.005 and normetanephrine at 60 min 83.44 [28.98 to 114.86] P = 0.004, 6 h 78.62 [36.6 to 162.31] P = 0.0005 and 24 h 80.96 [8.6 to 110.5] P = 0.025. Mean ± SD opioid consumption was similar in both groups: 39.60 ± 14.87 in Group T vs. 43.68 ± 14.93 in Group C (P = 0.338).

CONCLUSION

Mid-axillary TAP block does not improve stress response and analgesia in patients undergoing TAH receiving multimodal analgesia.

TRAIL REGISTRATION

ClinicalTrial.gov identifier: NCT03443271.

Comparing remifentanil and sufentanil in stress reduction during neurosurgery: a randomised controlled trial

Background In most scenarios, anaesthesiologists titrate opioids to control nociceptive surgical stress based on intraoperative haemodynamic changes. Remifentanil was reported to cause more profound cardiovascular depression than sufentanil. A concern is that this direct cardiovascular depression might counteract the hypertension and tachycardia caused by surgical manipulation and mask inadequate analgesia. Objective To compare remifentanil and sufentanil, titrated to maintain a comparable haemodynamic range (within 20% of baseline) and combined with the same propofol regimen, in stress reduction measured as plasma levels of putative mediators of surgical stress. Setting Huashan Hospital of Fudan University, Shanghai, China. Method Forty-five patients undergoing supratentorial glioma resection were randomised to the remifentanil group or the sufentanil group. Main outcome measures Plasma concentrations of cortisol, epinephrine, norepinephrine, interleukin-6, interleukin-10 and lymphocyte counts were analysed before anaesthesia, 1 h after incision, at the end of surgery and 24 h after incision using enzyme-linked immunosorbent assay and an automatic haematology analyser. Recovery profiles during emergence from anaesthesia were also compared. Results Except for a lower epinephrine concentration in the remifentanil group 24 h after incision (median [interquartile range], 4.2 [3.4-6.1] vs. 8.4 [4.8-12.5] ng/ml; P = 0.003), stress biomarkers were not significantly different between the two groups. Patients in the sufentanil group had lower grades in coughing, restlessness (P = 0.001 and < 0.001, respectively) and a lower incidence of postoperative shivering (P = 0.007). Conclusion Compared to that of sufentanil, the direct cardiovascular depression of remifentanil does not mask the clinical manifestation of inadequate analgesia when both drugs are titrated according to haemodynamic variables in neurosurgery.