1
|
Kavakli AS, Sahin T, Koc U, Karaveli A. Ultrasound-Guided External Oblique Intercostal Plane Block for Postoperative Analgesia in Laparoscopic Sleeve Gastrectomy: A Prospective, Randomized, Controlled, Patient and Observer-Blinded Study. Obes Surg 2024; 34:1505-1512. [PMID: 38499943 PMCID: PMC11031435 DOI: 10.1007/s11695-024-07174-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 03/12/2024] [Accepted: 03/13/2024] [Indexed: 03/20/2024]
Abstract
PURPOSE The external oblique intercostal plane (EOI) block is a novel block technique for anterolateral upper abdominal wall analgesia. The superficial nature of the external oblique intercostal plane allows it to be easily identified even in patients with obesity. The aim of this study was to test the hypothesis that EOI block would reduce IV morphine consumption within 24 h after laparoscopic sleeve gastrectomy. MATERIALS AND METHODS Patients were randomly assigned to one of two groups: EOI block group and control group. The patients in the EOI block group received ultrasound-guided bilateral EOI block with a total of 40 ml 0.25% bupivacaine after anesthesia induction. The patients in the control group received no intervention. Postoperatively, all the patients were connected to an intravenous patient controlled analgesia (PCA) device containing morphine. The primary outcome of the study was IV morphine consumption in the first postoperative 24 h. RESULTS The median [interquartile range] morphine consumption at 24 h postoperatively was significantly lower in the EOI block group than in the control group (7.5 [3.5 to 8.5] mg vs 14 [12 to 20] mg, p = 0.0001, respectively). Numerical rating scale (NRS) scores at rest and during movement were lower in the EOI block group than in the control group at 2, 6, and 12 h but were similar at 24 h. No block-related complications were observed in any patients. CONCLUSION The results of the current study demonstrated that bilateral EOI block reduced postoperative opioid consumption and postoperative pain in patients with obesity undergoing laparoscopic sleeve gastrectomy. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT05663658.
Collapse
Affiliation(s)
- Ali Sait Kavakli
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Istinye University, 34396, Istanbul, Turkey.
- Istinye Universite Hastanesi, Aşık Veysel Mah, Süleyman Demirel Cd. No:1, 34517, Esenyurt, Istanbul, Turkey.
| | - Taylan Sahin
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Istinye University, 34396, Istanbul, Turkey
| | - Umit Koc
- Department of General Surgery, Faculty of Medicine, Istinye University, 34396, Istanbul, Turkey
| | - Arzu Karaveli
- Department of Anesthesiology and Reanimation, University of Health Sciences, Antalya Training and Research Hospital, 07100, Antalya, Turkey
| |
Collapse
|
2
|
Antony KM, McDonald RC, Gaston L, Hetzel S, Li Z. Surgical transversus abdominis plane block with liposomal bupivacaine at cesarean: a pilot randomized trial. Am J Obstet Gynecol MFM 2024; 6:101273. [PMID: 38154599 PMCID: PMC10990562 DOI: 10.1016/j.ajogmf.2023.101273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 12/20/2023] [Accepted: 12/21/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Postcesarean pain control is challenging. In addition to intrathecal morphine, recent studies have shown that liposomal bupivacaine administered via conventional transversus abdominis plane block reduces postcesarean opioid use. However, whether the administration of liposomal bupivacaine via a surgical approach also reduces opioid use is unknown. OBJECTIVE This study aimed to investigate whether the administration of liposomal bupivacaine via surgical transversus abdominis plane block (TAP block) reduces the cumulative dose of opioids administered in the first 48 hours after cesarean delivery among participants who also receive intrathecal morphine. STUDY DESIGN This was a pilot single-blind randomized controlled trial of 60 parturients undergoing cesarean delivery at a community tertiary referral hospital staffed by academic physicians. Immediately before fascial closure during cesarean delivery, a total of 80 mL of dilute bupivacaine plus liposomal bupivacaine or dilute bupivacaine alone was administered via surgical transversus abdominis plane block (40 mL on each side). The primary outcome was a median cumulative opioid dose received within the first 48 hours after cesarean delivery measured in morphine milligram equivalents. In addition, opioid use at other time points, pain scores, and participant satisfaction were assessed. A sample size of 60 was determined to be adequate to inform a potential future adequately powered randomized trial. The primary outcome of morphine milligram equivalents and pain scores were compared using a Wilcoxon rank-sum test. RESULTS Between October 11, 2021, and August 29, 2022, 60 participants were randomized and analyzed: 31 were allocated to liposomal bupivacaine plus regular bupivacaine (intervention group), and 29 were allocated to regular bupivacaine alone (control group). Participants allocated to the intervention group used a median cumulative dose of 2 morphine milligram equivalents of opioids (interquartile range, 0-24) in the first 48 hours compared with 8 morphine milligram equivalents (interquartile range, 0-40) among participants allocated to the control group (P=.236). The percentage of participants who used ≤15 morphine milligram equivalents of opioids was 61% in the intervention arm and 41% in the control arm (P=.123), and the percentage who used zero opioids was 45% in the intervention arm and 34% in the control arm (P=.399). The total number of opioid pills prescribed at discharge was fewer in the intervention arm than in the control arm (P=.029). Patient satisfaction with the intervention group and control group was similar. CONCLUSION Our pilot study suggests that liposomal bupivacaine administered via surgical transversus abdominis plane block is worth critical evaluation as an adjunctive analgesic modality in an adequately powered randomized trial.
Collapse
Affiliation(s)
- Kathleen M Antony
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI (Dr Antony); Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI (Drs Antony, McDonald, and Gaston).
| | - Ryan C McDonald
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI (Drs Antony, McDonald, and Gaston); Division of Academic Specialists in Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI (Drs McDonald and Gaston)
| | - Luther Gaston
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI (Drs Antony, McDonald, and Gaston); Division of Academic Specialists in Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI (Drs McDonald and Gaston)
| | - Scott Hetzel
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI (Mr Hetzel and Dr Li)
| | - Zhanhai Li
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI (Mr Hetzel and Dr Li)
| |
Collapse
|
3
|
Boviatsis V, Triantopoulos A. Double-Edge, Single-Edge, and Intermediate-Edge Ultrasound Sign and Correlation With Fascial Plane Block Efficacy: An Experimental Study. Cureus 2024; 16:e51858. [PMID: 38205088 PMCID: PMC10781027 DOI: 10.7759/cureus.51858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2024] [Indexed: 01/12/2024] Open
Abstract
Introduction Ultrasound-guided fascial plane blocks are nowadays the gold standard technique for regional anesthesia and postoperative analgesia. Despite their high success rate, cases of partial or total failure of this method have been reported. This experimental study aims to address the corresponding ultrasound signs and their association with fascial plane block efficacy. Methods After capturing the appropriate sonographic image that included muscle layers and their fasciae, an 18-gauge epidural needle penetrated the cadaveric porcine tissue and was forwarded until the tip of the needle reached the target fascial plane. The infusion of methylthioninium chloride or methylene blue dye was performed, causing tissue hydro dissection. The documentation of the generated ultrasound images was followed by surgical exposure of the tip of the needle. Results The distribution of the dye into the plane of interest (double-edge sign) was equivalent to block success, whereas the single-edge sign (accumulation of the dye between fascia and epimysium) indicated total block failure. The intermediate-edge sign, a combination of the previous ultrasound signs, is related to partial failure of block performance. Conclusion The identification of the three novel sonographic signs is an accurate predictive factor of peripheral nerve block efficacy. The respective data are expected to aid the rapid improvement of interfascial plane block accuracy and techniques, leading to their more effective execution and simultaneously eliminating the failure rates. Thereby, the amelioration of intra and postoperative analgesia will be accomplished, expediting the patient's hospital discharge and reducing or even avoiding opioid consumption.
Collapse
|
4
|
Mongelli F, Marengo M, Bertoni MV, Volontè F, Ledingham NS, Garofalo F. Laparoscopic-Assisted Transversus Abdominis Plane (TAP) Block Versus Port-Site Infiltration with Local Anesthetics in Bariatric Surgery: a Double-Blind Randomized Controlled Trial. Obes Surg 2023; 33:3383-3390. [PMID: 37740830 DOI: 10.1007/s11695-023-06825-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 08/21/2023] [Accepted: 09/15/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND The transversus abdominis plane (TAP) block has shown great potential usefulness in the management of postoperative pain; however, there is lacking evidence regarding its use in bariatric surgery. This randomized double-blind trial was aimed at comparing the effectiveness of the TAP block and port-site infiltration (PSI) in patients undergoing bariatric surgery. METHODS We included patients ≥ 18 years old undergoing bariatric surgery. From July 2020 to July 2021, all eligible patients were randomized to receive either laparoscopic-assisted TAP block or PSI. Demographic and clinical data were collected and analyzed. RESULTS During the study period, we included 113 patients. Fifty-one were allocated to the TAP block group and 62 to the PSI group. The mean age was 47.9 ± 11.2 years, 88 (77.9%) patients were female, and mean BMI was 40.5 ± 5.9 kg/m2. Operative time was 110 ± 42 min vs. 114 ± 41 min in the TAP block and PSI groups (p = 0.658). At 24 h after surgery, pain on the VAS was 2.5 ± 2.6 vs. 2.3 ± 2.1 (p = 0.661). No significant difference between the groups was noted at 3, 6, 12, and 18 h. Also, opioid and antiemetic consumption, the length of stay (3.4 ± 1.5 days vs. 3.2 ± 1.1 days, p = 0.392), and satisfaction score (154 ± 10 pts vs. 154 ± 16 pts, p = 0.828) were similar in the two groups. CONCLUSIONS Patients undergoing bariatric surgery and receiving either the TAP block or the PSI had similar postoperative pain, nausea, length of stay, and satisfaction. As PSI is technically easier and more reproducible, it might be the first choice for postoperative multimodal analgesia in bariatric surgery.
Collapse
Affiliation(s)
- Francesco Mongelli
- Department of Surgery, Bellinzona e Valli Regional Hospital, EOC, Via Gallino 12, 6500, Bellinzona, Switzerland.
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana, 6500, Lugano, Switzerland.
| | - Michele Marengo
- Department of Surgery, Locarno Regional Hospital, EOC, 6600, Locarno, Switzerland
| | | | | | | | - Fabio Garofalo
- Department of Surgery, Lugano Regional Hospital, EOC, 6900, Lugano, Switzerland
| |
Collapse
|
5
|
Gungor I, Gunaydin B, Buyukgebiz Yeşil BM, Bagcaz S, Ozdemir MG, Inan G, Oktar SO. Evaluation of the effectiveness of artificial intelligence for ultrasound guided peripheral nerve and plane blocks in recognizing anatomical structures. Ann Anat 2023; 250:152143. [PMID: 37572764 DOI: 10.1016/j.aanat.2023.152143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND We aimed to assess the accuracy of artificial intelligence (AI) based real-time anatomy identification for ultrasound-guided peripheral nerve and plane block in eight regions in this prospective observational study. METHODS After obtaining ethics committee approval and written informed consent from 40 healthy volunteers (20 men and 20 women, between 18 and 72 years old), an ultrasound device installed with AI software (Nerveblox, SmartAlfa, Turkey) were used to scan regions of the cervical plexus, brachial plexus, pectoralis (PECS), rectus sheet, femoralis, canalis adductorius, popliteal, and ESP by three anesthesiology trainees. During scanning by a trainee, once software indicates 100 % scan success of associated anatomic landmarks, both raw and labeled ultrasound images were saved, assessed, and validated using a 6-point scale between 0 and 5 by two expert validators. Evaluation scores of the validators for each block were compared according to demographics (gender, age, and BMI) and block type exists. RESULTS The scores were not different except ESP, femoralis, and cervical plexus regions between the experts. The mean scores of the experts for the PECS, popliteal and rectus sheath were significant between males and females (p < 0.05). In terms of BMI, significant differences in the scores were observed only in the canalis adductorius, brachial plexus, and ESP regions (p < 0.05). CONCLUSIONS Ultrasound guided AI-based anatomy identification was performed in commonly used eight block regions by the trainees where AI technology can successfully interpret the anatomical structures in real-time sonography which would be valuable in assisting anesthesiologists.
Collapse
Affiliation(s)
- Irfan Gungor
- Gazi University Faculty of Medicine, Department of Anesthesiology & Reanimation, Ankara, Besevler 06500, Turkey
| | - Berrin Gunaydin
- Gazi University Faculty of Medicine, Department of Anesthesiology & Reanimation, Ankara, Besevler 06500, Turkey.
| | - Beyza M Buyukgebiz Yeşil
- Gazi University Faculty of Medicine, Department of Anesthesiology & Reanimation, Ankara, Besevler 06500, Turkey
| | - Selin Bagcaz
- Gazi University Faculty of Medicine, Department of Anesthesiology & Reanimation, Ankara, Besevler 06500, Turkey
| | - Miray Gozde Ozdemir
- Gazi University Faculty of Medicine, Department of Anesthesiology & Reanimation, Ankara, Besevler 06500, Turkey
| | - Gozde Inan
- Gazi University Faculty of Medicine, Department of Anesthesiology & Reanimation, Ankara, Besevler 06500, Turkey
| | - Suna O Oktar
- Gazi University Faculty of Medicine, Department of Radiology, Ankara, Besevler 06500, Turkey
| |
Collapse
|
6
|
Şalvız EA, Bingül ES, Güzel M, Savran Karadeniz M, Turhan Ö, Emre Demirel E, Saka E. Comparison of Performance Characteristics and Efficacy of Bilateral Thoracic Paravertebral Blocks in Obese and Non-Obese Patients Undergoing Reduction Mammaplasty Surgery: A Historical Cohort Study. Aesthetic Plast Surg 2023; 47:1343-1352. [PMID: 36763114 DOI: 10.1007/s00266-023-03270-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 01/19/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Although ultrasound (US)-guided regional anesthesia techniques are advantageous in the management of obese patients; the procedures can still be associated with technical difficulties and greater failure rates. The aim of this study is to compare the performance properties and analgesic efficacy of US-guided bilateral thoracic paravertebral blocks (TPVBs) in obese and non-obese patients. METHODS Data of 82 patients, who underwent bilateral reduction mammaplasty under general anesthesia with adjunctive TPVB analgesia between December 2016 and February 2020, were reviewed. Patients were allocated into two groups with respect to their BMI scores (Group NO: BMI < 30 and Group O: BMI ≥ 30). Demographics, ideal US visualization time, total bilateral TPVB procedure time, needle tip visualization and performance difficulties, number of needle maneuvers, surgical, anesthetic and analgesic follow-up parameters, incidence of postoperative nausea and vomiting (PONV), sleep duration, length of postanesthesia care unit (PACU) and hospital stay, and patient/surgeon satisfaction scores were investigated. RESULTS Seventy-nine patients' data were complete. Ideal US visualization and total TPVB performance times were shorter, number of needle maneuvers were fewer and length of PACU stay was shorter in Group NO (p < 0.05). Postoperative pain scores were generally similar within first 24 h (p > 0.05). Time to postoperative pain, total analgesic requirements, incidence of PONV, sleep duration, length of hospital stay were comparable (p > 0.05). Satisfaction was slightly higher in Group NO (p < 0.05). CONCLUSIONS US-guided TPVB performances in obese patients might be more challenging and take longer time. However, it is still successful providing good acute pain control in patients undergoing reduction mammaplasty surgeries. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 . TRIAL REGISTRATION NCT04596787.
Collapse
Affiliation(s)
- Emine A Şalvız
- Department of Anesthesiology and Reanimation, Istanbul Faculty of Medicine, Istanbul University, Millet caddesi Cerrahi monoblok, Giris kati, 34093, Fatih, Istanbul, Turkey
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Emre S Bingül
- Department of Anesthesiology and Reanimation, Istanbul Faculty of Medicine, Istanbul University, Millet caddesi Cerrahi monoblok, Giris kati, 34093, Fatih, Istanbul, Turkey
| | - Mehmet Güzel
- Department of Anesthesiology and Reanimation, Istanbul Faculty of Medicine, Istanbul University, Millet caddesi Cerrahi monoblok, Giris kati, 34093, Fatih, Istanbul, Turkey
| | - Meltem Savran Karadeniz
- Department of Anesthesiology and Reanimation, Istanbul Faculty of Medicine, Istanbul University, Millet caddesi Cerrahi monoblok, Giris kati, 34093, Fatih, Istanbul, Turkey.
| | - Özlem Turhan
- Department of Anesthesiology and Reanimation, Istanbul Faculty of Medicine, Istanbul University, Millet caddesi Cerrahi monoblok, Giris kati, 34093, Fatih, Istanbul, Turkey
| | - Ebru Emre Demirel
- Department of Anesthesiology and Reanimation, Istanbul Faculty of Medicine, Istanbul University, Millet caddesi Cerrahi monoblok, Giris kati, 34093, Fatih, Istanbul, Turkey
| | - Esra Saka
- Department of Anesthesiology and Reanimation, Istanbul Faculty of Medicine, Istanbul University, Millet caddesi Cerrahi monoblok, Giris kati, 34093, Fatih, Istanbul, Turkey
| |
Collapse
|
7
|
Schott N, Chamu J, Ahmed N, Ahmed BH. Perioperative truncal peripheral nerve blocks for bariatric surgery: an opioid reduction strategy. Surg Obes Relat Dis 2023; 19:851-857. [PMID: 36854643 DOI: 10.1016/j.soard.2023.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/14/2022] [Accepted: 01/14/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND Bariatric surgical patients are vulnerable to cardiopulmonary depressant effects of opioids. The enhanced recovery after surgery (ERAS) protocol to improve postoperative morbidity recommends regional anesthesia for postoperative pain management. However, there is limited evidence that peripheral nerve blocks (PNB) have added benefit. OBJECTIVE Study the effect of PNB on postoperative pain and opioid use following bariatric surgery. SETTING Academic medical center, United States. METHODS We conducted a cohort study of patients who underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) surgery. A total of 44 patients received the control ERAS protocol with preoperative oral extended-release morphine sulfate (MS), while 45 patients underwent a PNB with either intrathecal morphine (IM) or oral MS per local ERAS protocol. The PNB group either underwent preoperative bilateral T7 paravertebral (PVT) PNBs (27 patients) with IM or postoperative transversus abdominis plane (TAP) PNBs (18 patients) with oral MS. The primary outcome compared total opioid consumption between the ERAS control group and the PNB group up to 48 hours postoperatively. Secondary outcomes included comparison by block type and postoperative pain scores. RESULTS PVT or TAP PNB patients had a reduction in mean postoperative oral morphine equivalent (OME) requirements compared with the ERAS protocol cohort at 24 hours (93.9 versus 42.8 mg), P < .0001; at 48 hours (72.6 versus 40.5 mg); and in pain scores at 24 hours (5.64/10 versus 4.46/10), P = .02. OME and pain scores were higher in the SG cohort. CONCLUSION Addition of truncal PNB to standard ERAS protocol for bariatric surgical patients reduces postoperative total opioid consumption.
Collapse
Affiliation(s)
- Nicholas Schott
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jauhleene Chamu
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Noor Ahmed
- North Allegheny Senior High School, Pittsburgh, Pennsylvania
| | - Bestoun H Ahmed
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| |
Collapse
|
8
|
Garbin M, Ruel HLM, Watanabe R, Malo A, Monteiro BP, Steagall PV. Analgesic efficacy of an ultrasound-guided transversus abdominis plane block with bupivacaine in cats: a randomised, prospective, masked, placebo-controlled clinical trial. J Feline Med Surg 2023; 25:1098612X231154463. [PMID: 36848291 PMCID: PMC10812078 DOI: 10.1177/1098612x231154463] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
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.
Collapse
Affiliation(s)
- Marta Garbin
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Université de Montréal, Saint-Hyacinthe, QC, Canada
| | - Hélène LM Ruel
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Université de Montréal, Saint-Hyacinthe, QC, Canada
| | - Ryota Watanabe
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Université de Montréal, Saint-Hyacinthe, QC, Canada
| | - Annie Malo
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Université de Montréal, Saint-Hyacinthe, QC, Canada
| | - Beatriz P Monteiro
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Université de Montréal, Saint-Hyacinthe, QC, Canada
| | - Paulo V Steagall
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Université de Montréal, Saint-Hyacinthe, QC, Canada
- Department of Veterinary Clinical Sciences, Centre for Companion Animal Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Hong Kong, China
| |
Collapse
|
9
|
Owusu-Agyemang P, Feng L, Porche VH, Williams UU, Cata JP. Race, ethnicity, and the use of regional anesthesia in cancer patients undergoing open abdominal surgery: A single-center retrospective cohort study. Front Med (Lausanne) 2022; 9:950444. [PMID: 36059836 PMCID: PMC9433667 DOI: 10.3389/fmed.2022.950444] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/02/2022] [Indexed: 11/13/2022] Open
Abstract
Background Where applicable, regional anesthesia has been shown to be superior to opioid or non-opioid analgesic modalities alone. However, some studies have shown ethnic-based disparities in the use of regional anesthesia in patients undergoing surgical procedures. In this study of patients who had undergone major oncologic surgery, our main objective was to compare the use of regional anesthesia between patients of different ethnicities. Methods A retrospective review of adults who had undergone major open abdominal surgical procedures between 2016 and 2021 was performed. Logistic regression models were used to assess the association between baseline patient characteristics and the use of regional anesthesia. Results A total of 4,791 patients were included in the analysis. The median age was 60.5 years [interquartile range, 49, 69], the majority were female (65%), and of American Society of Anesthesiologists Physical Status Class (ASA) 3 (94.7%). Regional anesthesia was used in 2,652 patients (55.4%) and was not associated with race or ethnicity (p = 0.287). Compared to White patients, the odds of regional anesthesia use in other racial/ethnic groups were: Asian {odds ratio (OR) 0.851 [95% confidence interval (CI), 0.660–1.097]; p = 0.2125}, Black/African American [OR 0.807 (95% CI, 0.651–1.001); p = 0.0508], Hispanic/Latino [OR 0.957 (95% CI, 0.824–1.154); p = 0.7676], Other race [OR 0.957 (95% CI, 0.627–1.461); p = 0.8376]. In the multivariable analysis, age [OR 0.995 (95% CI, 0.991–1.000); p = 0.0309] and female gender [OR 1.231 (95% CI, 1.090–1.390); p = 0.0008] were associated with the use of regional anesthesia. Conclusion In this single-institution retrospective study of adults who had undergone major open abdominal surgery, the use of regional anesthesia was not associated with race or ethnicity. In the multivariable analysis, age and female gender were associated with the use of regional anesthesia.
Collapse
Affiliation(s)
- Pascal Owusu-Agyemang
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
- Anesthesiology and Surgical Oncology Research Group, Houston, TX, United States
- *Correspondence: Pascal Owusu-Agyemang
| | - Lei Feng
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Vivian H. Porche
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Uduak U. Williams
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Juan P. Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
- Anesthesiology and Surgical Oncology Research Group, Houston, TX, United States
| |
Collapse
|
10
|
Can Postoperative Pain Be Prevented in Bariatric Surgery? Efficacy and Usability of Fascial Plane Blocks: a Retrospective Clinical Study. Obes Surg 2022; 32:2921-2929. [PMID: 35776242 DOI: 10.1007/s11695-022-06184-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 06/18/2022] [Accepted: 06/22/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Providing analgesia after bariatric surgery might be challenging due to a high prevalence of obstructive sleep apnea syndrome and the increased sensitivity to respiratory depression triggered by opioid overuse after surgery. Various combination methods with paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), and other pain medications such as ketamine or gabapentin have been suggested for reduction of the opioid usage. Regional anesthetic techniques represent a valuable option as they improve patient comfort while reducing opioid-related side effects. In this study, we have evaluated the adjuvant benefits of these various techniques in reduction of the postoperative pain in bariatric surgery. METHODS After the approval of the IRB Ethics Committee, the records of the patients who had laparoscopic bariatric surgery between January 2019 and December 2021 were reviewed retrospectively. RESULTS Records of 120 patients who underwent laparoscopic bariatric surgery between January 2019 and December 2021 were reviewed. In total, 113 patients with full documentation were included in this study. Among these, 74 patients were administered regional analgesia. The main regional analgesia techniques were transversus abdominis plane and rectus sheath block. The pain scores of those receiving regional analgesia were statistically low. The opioid consumption after transversus abdominis plane and rectus sheath block was significantly lower than that of others. External oblique intercostal block alone provides a postoperative opioid consumption similar to those of transversus abdominis plane and rectus sheath block. CONCLUSION The use of fascial plane blocks in bariatric surgery significantly reduces opioid consumption. Transversus abdominis plane and rectus sheath block combination and external oblique intercostal block seem to be the most effective options. CLINICAL TRIALS NUMBER NCT05284695.
Collapse
|
11
|
Copperthwaite A, Sahebally SM, Raza ZM, Devane L, McCawley N, Kearney D, Burke J, McNamara D. A meta-analysis of laparoscopic versus ultrasound-guided transversus abdominis plane block in laparoscopic colorectal surgery. Ir J Med Sci 2022; 192:795-803. [PMID: 35499808 DOI: 10.1007/s11845-022-03017-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 04/22/2022] [Indexed: 12/18/2022]
Abstract
BACKGROUND Enhanced recovery programmes in laparoscopic colorectal surgery (LCS) employ combined approaches to achieve postoperative analgesia. Transversus abdominis plane (TAP) block is a locoregional anaesthetic technique that may reduce postoperative pain. AIMS To perform a systematic review and meta-analysis to compare the effectiveness of laparoscopic- versus ultrasound-guided TAP block in LCS. METHODS Databases were searched for relevant articles from inception until March 2022. All randomised controlled trials (RCTs) that compared laparoscopic (LTB) versus ultrasound-guided (UTB) TAP blocks in LCS were included. The primary outcome was narcotic consumption at 24 h postoperatively, whilst secondary outcomes included pain scores at 24 h postoperatively, operative time, postoperative nausea and vomiting (PONV) and complication rates. Random effects models were used to calculate pooled effect size estimates. RESULTS Three RCTs were included capturing 219 patients. Studies were clinically heterogenous. On random effects analysis, LTB was associated with significantly lower narcotic consumption (SMD - 0.30 mg, 95% CI = - 0.57 to - 0.03, p = 0.03) and pain scores (SMD - 0.29, 95% CI = - 0.56 to - 0.03, p = 0.03) at 24 h. However, there were no differences in operative time (SMD - 0.09 min, 95% CI = - 0.40 to 0.22, p = 0.56), PONV (OR = 0.97, 95% CI = 0.36 to 2.65, p = 0.96) or complication (OR = 1.30, 95% CI = 0.64 to 2.64, p = 0.47) rates. CONCLUSIONS LTB is associated with significantly less narcotic usage and pain at 24 h postoperatively but similar PONV, operative time and complication rates, compared to UTB. However, the data were inconsistent, and our findings require further investigation. LTB obviates the need for ultrasound devices whilst also decreasing procedure logistical complexity.
Collapse
Affiliation(s)
- Amy Copperthwaite
- Department of Colorectal Surgery, Beaumont Hospital, 9, Dublin, Ireland.
- Royal College of Surgeons, St Stephen's Green, Dublin 2, Dublin, Ireland.
- Department of Otolaryngology, Sligo University Hospital, Sligo, Ireland.
| | - Shaheel Mohammad Sahebally
- Department of Colorectal Surgery, Beaumont Hospital, 9, Dublin, Ireland
- Royal College of Surgeons, St Stephen's Green, Dublin 2, Dublin, Ireland
| | - Zeeshan Muhammad Raza
- Department of Colorectal Surgery, Beaumont Hospital, 9, Dublin, Ireland
- Royal College of Surgeons, St Stephen's Green, Dublin 2, Dublin, Ireland
| | - Liam Devane
- Department of Colorectal Surgery, Beaumont Hospital, 9, Dublin, Ireland
- Royal College of Surgeons, St Stephen's Green, Dublin 2, Dublin, Ireland
| | - Niamh McCawley
- Department of Colorectal Surgery, Beaumont Hospital, 9, Dublin, Ireland
- Royal College of Surgeons, St Stephen's Green, Dublin 2, Dublin, Ireland
| | - David Kearney
- Department of Colorectal Surgery, Beaumont Hospital, 9, Dublin, Ireland
- Royal College of Surgeons, St Stephen's Green, Dublin 2, Dublin, Ireland
| | - John Burke
- Department of Colorectal Surgery, Beaumont Hospital, 9, Dublin, Ireland
- Royal College of Surgeons, St Stephen's Green, Dublin 2, Dublin, Ireland
| | - Deborah McNamara
- Department of Colorectal Surgery, Beaumont Hospital, 9, Dublin, Ireland
- Royal College of Surgeons, St Stephen's Green, Dublin 2, Dublin, Ireland
| |
Collapse
|
12
|
Transversus Abdominis Plane Block Versus Intraperitoneal Local Anesthetics in Bariatric Surgery: A Systematic Review and Network Meta-analysis. Obes Surg 2021; 31:4305-4315. [PMID: 34282569 DOI: 10.1007/s11695-021-05564-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 06/24/2021] [Accepted: 06/30/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Transversus abdominis plane (TAP) block and intraperitoneal local anesthetics (IPLA) are widely investigated techniques that potentially improve analgesia after bariatric surgery. The analgesic efficacy of TAP block has been shown in previous studies, but the performance of TAP block can be difficult in patients with obesity. We performed a systematic review and meta-analysis to compare the analgesic efficacy of TAP block and IPLA. An alternative technique is useful in clinical setting when TAP block is not feasible. METHODS We searched PubMed, Embase, and CENTRAL from inception until August 2020 for randomized controlled trials comparing both techniques. The primary outcome was cumulative morphine consumption at 24 h. Secondary pain-related outcomes included pain score at rest and on movement at 2, 6, 12, and 24 h; postoperative nausea and vomiting; and length of hospital stay. RESULTS We included 23 studies with a total of 2,178 patients. TAP block is superior to control in reducing opioid consumption at 24 h, improving pain scores at all the time points and postoperative nausea and vomiting. The cumulative opioid consumption at 24 h for IPLA is less than control, while the indirect comparison between IPLA with PSI and control showed a significant reduction in pain scores at rest, at 2 h, and on movement at 12 h, and 24 h postoperatively. CONCLUSIONS Transversus abdominis plane block is effective for reducing pain intensity and has superior opioid-sparing effect compared to control. Current evidence is insufficient to show an equivalent analgesic benefit of IPLA to TAP block.
Collapse
|
13
|
Cavaliere F, Allegri M, Apan A, Calderini E, Carassiti M, Cohen E, Coluzzi F, Di Marco P, Langeron O, Rossi M, Spieth P, Turnbull D. A year in review in Minerva Anestesiologica 2019. Anesthesia, analgesia, and perioperative medicine. Minerva Anestesiol 2021; 86:225-239. [PMID: 32118384 DOI: 10.23736/s0375-9393.20.14424-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Franco Cavaliere
- Department of Cardiovascular and Thoracic Sciences, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy -
| | - Massimo Allegri
- Unità Operativa Terapia del Dolore della Colonna e dello Sportivo, Policlinic of Monza, Monza, Italy.,Italian Pain Group, Milan, Italy
| | - Alparslan Apan
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Giresun, Giresun, Turkey
| | - Edoardo Calderini
- Unit of Women-Child Anesthesia and Intensive Care, Maggiore Polyclinic Hospital, Ca' Granda IRCCS and Foundation, Milan, Italy
| | - Massimiliano Carassiti
- Unit of Anesthesia, Intensive Care and Pain Management, Campus Bio-Medico University Hospital, Rome, Italy
| | - Edmond Cohen
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Flaminia Coluzzi
- Unit of Anesthesia, Department of Medical and Surgical Sciences and Biotechnologies, Intensive Care and Pain Medicine, Sapienza University, Rome, Italy
| | - Pierangelo Di Marco
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiologic, and Geriatric Sciences, Sapienza University, Rome, Italy
| | - Olivier Langeron
- Department of Anesthesia and Intensive Care, Henri Mondor University Hospital, Sorbonne University, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Marco Rossi
- Institute of Anesthesia and Intensive Care, Sacred Heart Catholic University, Rome, Italy
| | - Peter Spieth
- Department of Anesthesiology and Critical Care Medicine, University Hospital of Dresden, Dresden, Germany
| | - David Turnbull
- Department of Anaesthetics and Neuro Critical Care, Royal Hallamshire Hospital, Sheffield, UK
| |
Collapse
|
14
|
Grape S, Kirkham KR, Albrecht E. The Analgesic Efficacy of Transversus Abdominis Plane Block After Bariatric Surgery: a Systematic Review and Meta-analysis with Trial Sequential Analysis. Obes Surg 2020; 30:4061-4070. [DOI: 10.1007/s11695-020-04768-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
15
|
Application of Vitamin E Acetate on Staple Lines and Anastomoses of Roux-en-Y Gastric Bypass: Impact on Postoperative Pain and Acute Phase Reactants. Obes Surg 2020; 30:2988-2993. [PMID: 32342266 DOI: 10.1007/s11695-020-04635-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE Postoperative pain after laparoscopic surgery has 3 components: parietal, visceral, and associated with pneumoperitoneum. Visceral pain accounts for around 30% of the total pain and is less amenable to be controlled by multimodal analgesia. The topical application of vitamin E ointment has demonstrated an anti-inflammatory effect in the local inflammatory response against surgical aggression. Vitamin E has been also associated with a reduction in postoperative pain of skin wounds. The aim of this study was to evaluate the effect of the topical application of vitamin E acetate on staple lines and anastomoses of Roux-en-Y gastric bypass, as part of a multimodal analgesia scheme within an Enhanced Recovery After Surgery (ERAS) program. METHODS A prospective randomized clinical trial was performed. Patients were divided into 2 groups: patients receiving a topical application of vitamin E on staple lines and anastomoses (G1) and patients not receiving it (G2). The primary endpoint was postoperative pain, as measured by VAS 24 h after surgery. Secondary outcomes include morphine rescue needs, acute phase reactants 24 h after surgery, and hospital stay. RESULTS One hundred forty patients were included, 70 in each group. Postoperative pain was 10 mm in G1 and 21.8 mm in G2 (p < 0.001). Morphine needs within the first 24 h were 2.9% in G1 and 13.2% in G2 (p = 0.026). C-reactive protein levels were significantly lower in G1 (8.7 mg/dL vs 11.9; p = 0.016). Mean hospital stay was 2.1 days in G1 and 2.9 in G2 (p = 0.019). CONCLUSION Topical application of vitamin E reduces postoperative pain and acute phase reactants, allowing an earlier discharge. TRIAL REGISTRATION NCT03765827, https://www.clinicaltrials.gov.
Collapse
|
16
|
Ruiz-Tovar J, Gonzalez G, Sarmiento A, Carbajo MA, Ortiz-de-Solorzano J, Castro MJ, Jimenez JM, Zubiaga L. Analgesic effect of postoperative laparoscopic-guided transversus abdominis plane (TAP) block, associated with preoperative port-site infiltration, within an enhanced recovery after surgery protocol in one-anastomosis gastric bypass: a randomized clinical trial. Surg Endosc 2020; 34:5455-5460. [PMID: 31932932 DOI: 10.1007/s00464-019-07341-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 12/24/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND The use of ultrasonography to assist needle placement during transverse abdominal plane (TAP) technique has provided direct visualization of surround anatomical musculature and facial planes. However, the increased girth in patients undergoing bariatric surgery is challenging to visualize via ultrasonography which may lead to poor postoperative analgesia. OBJECTIVE The aim of the study is to investigate whether the addition of postoperative laparoscopic-guided TAP block as part of a multimodal analgesic regimen within the ERAS protocol compared to no block provides better postoperative analgesia in patients undergoing one-anastomosis gastric bypass surgery. PATIENTS AND METHODS A prospective clinical trial was performed. Patients were randomized into two groups: patients undergoing postoperative laparoscopic-guided TAP (TAP-lap) and patients not receiving TAP-lap (Control). Multimodal analgesia included preoperative port-site infiltration with Bupivacaine 0.25% in both groups and systemic Acetaminophen. Pain quantification as measured by visual analogic scale (VAS) was assessed at 6 and 24 h after surgery, and 24-h postoperative opioid consumption. RESULTS One hundred and forty patients were included, 70 in each group. The mean operation time was 78.5 ± 14.4 min in TAP-lap and 75.9 ± 15.6 min in Control (NS). The mean postoperative pain, as measured by VAS, 6 h after surgery was 23.1 ± 11.3 mm in TAP-lap and 41.8 ± 16.2 mm in Control (p = 0.001). 24 h after surgery was 16.6 ± 11.4 mm in TAP-lap and 35.4 ± 12.7 mm in Control (p = 0.001). Morphine rescues were necessary in 14.2% in Control and 2.8% in TAP-lap (p = 0.035). CONCLUSION Laparoscopic-guided TAP block as part of a multimodal analgesia regimen can reduce postoperative pain and opioid consumption, without increasing operative time.
Collapse
Affiliation(s)
- Jaime Ruiz-Tovar
- Centre of Excellence for the Study and Treatment of Obesity and Diabetes, Valladolid, Spain. .,Rey Juan Carlos University Hospital, Madrid, Spain.
| | - Gilberto Gonzalez
- Centre of Excellence for the Study and Treatment of Obesity and Diabetes, Valladolid, Spain
| | - Andrei Sarmiento
- Centre of Excellence for the Study and Treatment of Obesity and Diabetes, Valladolid, Spain
| | - Miguel A Carbajo
- Centre of Excellence for the Study and Treatment of Obesity and Diabetes, Valladolid, Spain
| | | | - Maria Jose Castro
- Centre of Excellence for the Study and Treatment of Obesity and Diabetes, Valladolid, Spain
| | - Jose Maria Jimenez
- Centre of Excellence for the Study and Treatment of Obesity and Diabetes, Valladolid, Spain
| | - Lorea Zubiaga
- Centre of Excellence for the Study and Treatment of Obesity and Diabetes, Valladolid, Spain
| |
Collapse
|
17
|
Aikawa K, Tanaka N, Morimoto Y. Modified thoracoabdominal nerves block through perichondrial approach (M-TAPA) provides a sufficient postoperative analgesia for laparoscopic sleeve gastrectomy. J Clin Anesth 2019; 59:44-45. [PMID: 31212124 DOI: 10.1016/j.jclinane.2019.06.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 06/09/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Katsuhiro Aikawa
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo 060-8638, Japan.
| | - Nobuhiro Tanaka
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo 060-8638, Japan
| | - Yuji Morimoto
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo 060-8638, Japan.
| |
Collapse
|