An Evaluation of the Adding Magnesium Sulfate to Ropivacaine on Ultrasound-Guided Transverse Abdominis Plane Block After Abdominal Hysterectomy

Transversus Abdominis Plane Block Following Cesarean Section: A Prospective Randomized Controlled Study Comparing the Effects on Pain Levels of Bupivacaine, Bupivacaine + Dexmedetomidine, and Bupivacaine + Dexamethasone

Background: The transversus abdominis plane (TAP) block is providing effective postoperative analgesia in patients undergoing cesarean section (CS). This study aims to evaluate and compare the effects on pain levels of bupivacaine alone versus bupivacaine combined with dexmedetomidine and bupivacaine combined with dexamethasone in ultrasound-guided TAP block for postoperative pain after CS. Material and Method: In this randomized controlled trial, 120 patients with American Society of Anesthesiologists (ASA) physical status I and II scheduled for elective cesarean section under spinal anesthesia were randomly divided into three groups. At the end of the surgery, an ultrasound-guided TAP block was performed on all patients: bupivacaine 0.5% (Group B), bupivacaine 0.5% + dexmedetomidine (1 µg/kg) (Group BD), and bupivacaine 0.5% + dexamethasone (4 mg) (Group BDx). Postoperatively, all patients were evaluated at 0, 1, 4, 8, 16, and 24 h for visual analog scores VASs, tramadol consumption, complications, and patient satisfaction. A p value of < 0.05 is statistically significant. Results: At 0 h, VASs in the sitting and supine positions were significantly higher in the BDx group (0.85 ± 1.61 and 0.85 ± 1.36, respectively) compared to the B group (0.05 ± 0.32 in both positions) and the BD group (0.15 ± 0.48 in both positions) (p = 0.005 and p = 0.001, respectively). At the 24th hour, VASs in the sitting and supine positions were significantly lower in the BDx group (1.7 ± 1.2 and 1.43 ± 1.05) compared to the B group (2.3 ± 0.68 and 2.2 ± 0.72) and the BD group (2.57 ± 1.01 and 2.28 ± 0.78) (p = 0.005 and p = 0.001, respectively). At 0 h, the tramadol requirement was highest in the BDx group at 12.5%, while it was not required in the B and BD groups (p = 0.005). At 0 h, the rate of nausea and vomiting was highest in the BDx group at 17.5%, compared to 2.5% in the BD group and 0% in the B group (p = 0.003). Patient satisfaction scores were higher in the dexamethasone group compared to the other groups. This was significant between Group B and Group BDx (p = 0.009 < 0.05). Conclusions: Adding dexmedetomidine or dexamethasone to bupivacaine in ultrasound-guided TAP blocks reduces postoperative pain and increases patient satisfaction after cesarean sections. Dexamethasone, due to its delayed onset but extended duration, achieves lower pain scores and higher satisfaction. Further research is necessary to confirm these findings.

To assess the analgesic efficacy of adjuvant magnesium sulfate added with ropivacaine over ropivacaine alone as a continuous infiltration in total abdominal hysterectomy wound: A randomized controlled trial

Background and Aims

Magnesium sulfate (MgSO4) has been demonstrated to have analgesic property in various clinical settings. This study explores if addition of MgSO4 to ropivacaine increases its analgesic efficacy when infiltrated continuously in the postsurgical wound following total abdominal hysterectomy.

Material and Methods

This randomized controlled trial was conducted at a tertiary care referral hospital in New Delhi, India. Fifty-two patients were randomized into two groups to receive the intervention of which 48 were able to complete the study. The first group (n = 26) received 0.25% ropivacaine infiltration and the second group (n = 26) received 0.25% ropivacaine with 5% MgSO4 at the incision site for 48 h postoperatively. Primary objective was to compare the total postoperative opioid (morphine) consumption by the study participants in both the groups and the secondary objectives were pain scores at rest and at movement, patient satisfaction score, and wound quality of life on the 7th postoperative day among the two groups.

Results

Both the groups were comparable in their demographic characteristics. The median morphine consumed at 48 h postoperatively was 16.5 [0-77] mg in the ropivacaine group and 13[1-45] mg in the ropivacaine with MgSO4 group and the difference was statistically insignificant (P = 0.788). There was no statistical difference between the groups with respect to the pain scores, patient satisfaction, or wound quality of life at 7 days.

Conclusion

The addition of MgSO4 to ropivacaine does not confer any additional postoperative analgesic benefits over ropivacaine alone in continuous wound infiltration following total abdominal hysterectomy.

Comparative evaluation of bupivacaine with magnesium sulphate and dexamethasone as adjuvants in ultrasound-guided transversus abdominis plane block for open unilateral inguinal hernia surgeries: A randomised controlled trial

Background and Aims

Inguinal hernia repair is associated with moderate to severe pain that is most extreme in the first 24 hours. The aim of this study was to compare the efficacy of dexamethasone versus magnesium sulphate (MgSO₄) with bupivacaine in ultrasound-guided transversus abdominis plane (TAP) block for patients undergoing unilateral inguinal hernioplasty.

Methods

Eighty patients were randomly allocated to two groups to receive ultrasound-guided TAP block postoperatively with either 20 ml of 0.25% bupivacaine with 8 mg of dexamethasone (Group BD) or 20 ml of 0.25% bupivacaine with 250 mg of MgSO₄ (Group BM). Patients were assessed for the first 24 hours after surgery for pain at rest and movement using a numerical rating scale (NRS). Two mg/kg of tramadol was administered as rescue analgesia. The time to first demand tramadol, total consumption of tramadol, patient satisfaction score and side effects were evaluated.

Results

The time to the first dose of rescue analgesia was significantly longer in BD group (596.13 ± 57.93 min) than in the BM group (422.50 ± 51.95 min). The NRS scores in the BD group were significantly lower compared to the BM group both at rest and on movement. The total requirement of tramadol was significantly less in the BD group (154.55 ± 59.11 mg) compared to the BM group (270.25 ± 105.72 mg). The incidence of side effects was lower and patient satisfaction was higher in BD group compared to BM group.

Conclusion

Bupivacaine with dexamethasone in TAP block after unilateral open inguinal hernioplasty provides increased duration of analgesia and decreased requirement for rescue analgesics compared to magnesium sulphate, with lesser side effects and better patient satisfaction.

The Effect of the Magnesium Sulfate in Ultrasound-Guided Quadratus Lumborum Block on Postoperative Analgesia: A Randomized Controlled Trial

INTRODUCTION

Quadratus lumborum block (QLB) has proven to be an effective analgesic technique in various abdominal surgeries. Magnesium sulfate as an adjuvant in different nerve blocks has been reported. The aim of this study was to assess the efficacy of magnesium sulfate as an adjuvant to ropivacaine in an ultrasound-guided QLB for postoperative analgesia in laparoscopic gynecologic surgery.

METHODS

Ninety patients belonging to American Society of Anesthesiologists (ASA) physical status I or II, aged between 40 and 60 years, scheduled for laparoscopic gynecologic surgery were enrolled. Patients were divided into three groups and received bilateral quadratus lumborum block: ropivacaine group (group N, 0.375% ropivacaine 40 ml + normal saline 4 ml), magnesium sulfate group (group M, 0.375% ropivacaine 40 ml + 10% magnesium sulfate 4 ml), and control group (group C, normal saline 44 ml). Visual analogue scale (VAS) at rest and during activity at 4, 6, 12, 24, and 48 h postoperatively, consumption of morphine, the time of first analgesic request, frequency of rescue analgesia, satisfaction with postoperative analgesia, and any side effects were recorded.

RESULTS

VAS scores in groups M and N were significantly lower than in group C at 4 and 6 h postoperatively (P < 0.001). VAS scores were lower in group M at 12 and 24 h postoperatively compared to groups N and C (P < 0.05). The mean total morphine consumption was significantly lower in group M than in groups N and C (P < 0.001). The mean time to the first patient-controlled analgesia (PCA) bolus was significantly prolonged in group M compared to group C (P < 0.05). The satisfaction with postoperative analgesia of group M was superior to that of groups N and C (P < 0.05). There was no significant difference in side effects among the three groups.

CONCLUSION

Magnesium sulfate as an adjuvant to ropivacaine in ultrasound-guided QLB prolongs the duration of analgesia, decreases analgesic requirements, and improves patient satisfaction without significant side effects.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR1900027066.

Current Strategies in Pain Regimens for Robotic Urologic Surgery: A Comprehensive Review

Context

Robotic surgery is becoming the most common approach in minimally invasive urologic procedures. Robotic surgery offers less pain to patients because of smaller keyhole incisions and less tissue retraction and stretching of fascia and muscular fibers. Tailored pain regimens have also evolved and allowed patients to feel minimal to no discomfort after robotic urologic surgery, allowing in parallel better surgical outcomes. This study aims to analyze the most current pain regimens in robotic urologic surgery and to evaluate the most current pain protocols and corresponding outcomes.

Evidence Acquisition

A literature review was performed of published manuscripts utilizing Pubmed and Google Scholar on pain protocols for patients undergoing robotic urologic surgery.

Results

Multimodal analgesia is gaining ground in robotic urologic surgery. Regional analgesia includes four major modalities: Neuroaxial analgesia, intercostal blocks, tranvsersus abdominis plane blocks, and paravertebral blocks. Each approach has a different injection site, region of analgesia coverage, and duration of coverage depending upon local anesthesia and/or adjuvant utilized with advantages and disadvantages that make each modality unique and efficacious.

Conclusions

Robotic urologic surgery has offered the advantage of smaller incisions, faster recovery, less postoperative opioid consumption, and better surgical outcomes. Neuraxial, intercostal, transversus abdominis plane, and quadratus lumborum blocks are the best and most adopted approaches which offer optimal outcomes to patients.

Effects of Ketamine and Lidocaine Infusion on Acute Pain after Elective Open Abdominal Surgery, a Randomized, Double-Blinded Study

Background: Most patients suffer from moderate to severe pain after elective laparotomy. They often require opioids to alleviate their pain. Opiates invariably induce certain side effects and, occasionally, dependence. Intraoperative infusion of lidocaine and low-dose ketamine reduces postoperative pain and analgesic requirements. This study aims to evaluate the effects of simultaneous infusion of lidocaine and ketamine during open abdominal surgery on the postoperative pain severity and analgesic consumption. Methods: In this randomized, double-blinded, single-center study that was performed in Iran, 80 patients scheduled for elective open abdominal surgery under general anesthesia were enrolled in two LK and P groups. Group LK (n=40) received lidocaine-ketamine infusion, and group P (n=40) received placebo (normal saline). Both infusions were started thirty minutes after initiation of surgery and were terminated once the surgery was completed. For postoperative pain management, patient-controlled analgesia (PCA), including fentanyl and paracetamol, was administered for both groups. All patients were evaluated for pain visual analogue scale (VAS) and total adjunctive analgesic (diclofenac suppository) consumption within the first 24 hours after the surgery. The data were analyzed using SPSS. P values <0.05 were considered significant. Results: Intraoperative infusion of Lidocaine and Ketamine resulted in desirable postoperative pain control. Patients of LK group demonstrated a significant reduction in the pain score at 1, 6, 12, 18, and 24 hours after termination of surgery (p<0.001). It also resulted in a decreased requirement for postoperative analgesics, as cumulative analgesic consumption was decreased meaningfully in the patients of LK group (p<0.001). Conclusion: Intravenous infusion of lidocaine and ketamine during elective open abdominal surgery reduces pain intensity and analgesic requirements in the first 24 hours postoperatively, without major additional side effects.

Ilioinguinal and Iliohypogastric Nerve Block for Acute and Chronic Pain Relief After Caesarean Section: A Randomized Controlled Trial

Background

There is an increasing cesarean section (CS) rate in Egypt. Multiple methods are used to manage pain after CS.

Objectives

This study aimed to assess the effect of ultrasound-guided bilateral ilioinguinal and iliohypogastric nerve block on pain reduction after CS.

Methods

We classified 64 cases of elective CS into two equal groups. The block group underwent the nerve block, and the control group did not. Postoperative pain, morphine consumption, time to analgesic request, and complications were compared between the two groups.

Results

No significant difference was detected between the two groups regarding patient characteristics or operation duration. However, pain scores during rest and movement were significantly lower in the block group than in controls, especially within the first 12 hours following the operation. Morphine consumption was significantly lower in the block group (4.53 ± 1.456) in group B vs. (8.87 ± 2.013) in group C with P-value < 0.001. Time to the first rescue analgesia was significantly longer in the intervention group than in the other group (12.25 vs. 3.81 hours). Pruritis and nausea incidence was significantly higher in controls than in the block group. The incidence of chronic postoperative pain was significantly lower in the block group.

Conclusions

The ilioinguinal and iliohypogastric nerve block is efficient and safe for managing postoperative pain following CS. It is associated with significant improvement of acute and chronic pain after such operations.

Evaluation of the Effects of Oral Magnesium Sachet on the Prevention of Spinal Anesthesia-Induced Headache After Cesarean Section: A Randomized Clinical Trial

Background: Post-dural puncture headache (PDPH) is a common complication of spinal anesthesia. It often goes away after a few days but may be more severe in some patients and persists for weeks. Objectives: This study aimed to evaluate the effect of oral magnesium on the prevention of PDPH after cesarean section for the first time. Methods: In this double-blind, randomized clinical trial, 100 candidates for elective cesarean section under spinal anesthesia were randomly divided into 2 groups: (i) the intervention group that received 300 mg of oral magnesium powder and (ii) the control group that received starch powder. The frequency and severity of headache and amount of analgesic consumption in both groups were measured 1, 2, and 3 days after cesarean section. Data were analyzed using SPSS version 22 at 95% CI. Results: The frequency of PDPH 1, 2, and 3 days after surgery was 8% vs 24% (P = 0.029), 10% vs 26% (P = 0.039), and 12% vs 18% (P = 0.401) in the intervention and control groups, respectively. The mean and SD of pain severity was 0.52 ± 1.83 vs 1.5 ± 2.84 (P = 0.03) on the first day, 0.70 ± 2.19 vs 1.58 ± 2.86 (P = 0.05) on the second day, and 0.82 ± 2.32 vs 1.18 ± 2.62 on the third day (P = 0.43) in the intervention and control groups, respectively. Although more patients in the control group received rescue analgesia, no significant difference was seen between the 2 study groups. Conclusions: In women candidates for cesarean section, oral administration of 300 mg magnesium 2 hours before surgery significantly reduces the frequency and severity of PDPH, but its impact on reducing analgesic consumption is not significant.

Anesthetic Conversion of Preexisting Labor Epidural Analgesia for Emergency Cesarean Section and Efficacy of Levobupivacaine with or Without Magnesium Sulphate: A Prospective Randomized Study

Background: For pregnant women who require an emergency cesarean section (CS), extending labor epidural analgesia as quickly as feasible to good quality anesthesia is a critical issue. This indicates the presence of functional labor epidural analgesia and reduces the need for general anesthesia. Addition of magnesium increases anesthetic and analgesic qualities of epidural anesthesia. Objectives: The purpose of this trial was to assess the role of adding magnesium sulfate (MgSO4) with levobupivacaine to speed up the conversion of labor epidural analgesia into enough anesthesia for emergency CS. Methods: Fifty parturients were randomly assigned to receive 19.5 mL of levobupivacaine 0.5% with either 0.5 mL of normal saline 0.9% (Group I) or 0.5 mL of MgSO4 10% (Group II) after receiving labor epidural analgesia. We documented the onset of block (loss of pinprick to T6), number of patients needing additional analgesia, the time needed for sensory and motor blockade to recover, and the adverse effects. Results: The frequency of patients receiving intraoperative supplements was comparable in the study groups (P = 0.491), although the onset of the block was faster in Group II than in Group I (P = 0.000*). Group II took substantially longer to recover from sensory and motor blockade than Group I (P = 0.001* and P = 0.001*, respectively). In both groups, the occurrence of adverse events was similar. Conclusions: Adding 50 mg of MgSO4 to levobupivacaine 0.5% accelerated the epidural top, and both sensory onset and motor blocks period were prolonged as compared to levobupivacaine alone when extending epidural analgesia for emergency CS.

Management of pain using magnesium sulphate: A narrative review

Pain is one of the most complex and unpleasant sensory and emotional human experiences. Pain relief continues to be a major medical challenge. The application of systemic opioid and regional analgesia techniques has facilitated a decrease in the occurrence and gravity of pain. Magnesium has an evolving role in pain management. Magnesium sulphate (MgSO4), the pharmacological form of magnesium, is a physiological voltage-dependent blocker of N-methyl-D-aspartate (NMDA)-coupled channels. In terms of its antinociceptive role, magnesium blocks calcium influx, which inhibits central sensitization and decreases preexisting pain hypersensitivity. These properties have encouraged the research of magnesium as an adjuvant agent for intra- and post-operative analgesia. Moreover, the mentioned magnesium impacts are also detected in patients with neuropathic pain. Intravenous magnesium sulphate, followed by a balanced analgesia, decreases opioid consumption. This review has focused on the existing evidence concerning the role of magnesium sulphate in pain management in situations including neuropathic pain, postherpetic neuralgia, trigeminal neuralgia, migraine, and post-operative pain. Additional studies are required to improve the use of magnesium sulphate for pain to increase the quality of life of patients.

The Effect of Pneumoperitoneum-induced Hypertension During Laparoscopic Cholecystectomy Under General Anesthesia on Postoperative Pain: A Randomized Clinical Trial

Background

Acute postoperative pain is a significant cause of morbidities. This study aimed to evaluate the effect of intraoperative blood pressure during laparoscopic cholecystectomy under general anesthesia on postoperative pain in patients without underlying disorders.

Methods

In this randomized clinical trial, 72 patients undergoing general anesthesia for elective laparoscopic cholecystectomy were randomly assigned into two groups: Group A with higher than baseline preoperative blood pressure (MAP allowed to increase up to 20% higher than baseline MAP by inducing pneumoperitoneum) and group B with normal to low blood pressure (MAP deliberately controlled at a tight limit from normal baseline MAP values to 20% less than baseline by titrating TNG infusion). The Visual Analog Scale (VAS) after 2, 8, 12, and 24 hours of surgery, and the total dose of meperidine used to manage postoperative pain were recorded and compared between the two groups.

Results

The pain scores in group A were significantly lower than group B (P = 0.001). The postoperative analgesia request time was different between the two groups (P = 0.53). During the first 24 hours, the total meperidine consumption dose in group A was significantly lower than in group B (P = 0.001).

Conclusions

High intraoperative blood pressure may affect the postoperative pain after laparoscopic cholecystectomy and lead to less postoperative pain score and analgesic requirements.

Comparison of Intraperitoneal Bupivacaine and Intravenous Ketorolac for Postoperative Pain Management Following Laparoscopic Cholecystectomy

Background

Postoperative pain following laparoscopic cholecystectomy (LC) arises from incision sites and residual intraperitoneal CO2 gas. Opioids as a class of pain-relieving drugs are broadly used to control pain after LC; however, these drugs can cause various side effects.

Objectives

The purpose of this study was to compare the efficacy of intraperitoneal injection of bupivacaine with that of intravenous ketorolac in managing postoperative pain in patients who had undergone LC.

Methods

This randomized, double-blind clinical trial was carried out on patients who had undergone LC. Ninety patients who had undergone elective LC were randomly divided into 3 groups (n = 30 for each group). Group A received 40 mL of 0.25% bupivacaine solution intraperitoneally at the end of the operation; group B received 30 mg of ketorolac intravenously 30 minutes before surgery and every 8 hours after surgery, and patients in group C received normal saline intraperitoneally and intravenous injection. The patients were postoperatively assessed for Visual Analog Scale (VAS) scores, postoperative opioid consumption, shoulder pain, side effects (sedation, nausea, and vomiting), and satisfaction. The data were analyzed using SPSS. P values < 0.05 were considered significant.

Results

The intraperitoneal injection of bupivacaine and intravenous injection of ketorolac were significantly effective in reducing postoperative abdominal pain, shoulder pain, and incidence of nausea and vomiting compared to the placebo group (P < 0.001). Although intraperitoneal bupivacaine and intravenous ketorolac had no significant difference in pain relief compared with each other, patients in both bupivacaine and ketorolac groups were significantly more satisfied with their analgesia compared to the control group (P < 0.001).

Conclusions

Intraperitoneal injection of bupivacaine and intravenous injection of ketorolac both are safe and effective methods to control pain, nausea, and vomiting after LC.

Comparison of Ultrasound-Guided Erector Spinae Plane Block and Oblique Subcostal Transverse Abdominis Plane Block for Postoperative Analgesia in Elderly Patients After Laparoscopic Colorectal Surgery: A Prospective Randomized Study

INTRODUCTION

Postoperative analgesia in elderly patients is still a thorny problem. Ultrasound-guided oblique subcostal transverse abdominis plane block (TAPB) has been demonstrated to provide postoperative analgesia after abdominal surgeries. However, recent studies have suggested that an alternative method, erector spinae plane block (ESPB), might also be effective. In this study, we compared the postoperative analgesic effects of ESPB and TAPB in elderly patients who had undergone laparoscopic colorectal surgery.

METHODS

Sixty-two elderly patients (≥ 65 years old) scheduled for elective laparoscopic colorectal surgery with general anesthesia were randomly allocated to two equally sized groups: ESPB group and TAPB group. The ESPB group had a bilateral erector spinae plane block, and the TAPB group had a bilateral oblique subcostal transverse abdominis plane block. The primary outcome was visual analogue scale (VAS) pain score during the first 24 postoperative hours at resting and active states. The secondary outcomes were postoperative consumption of sufentanil, satisfaction score, the number of patients who required antiemetics, incidence of block-related complications, and other side events.

RESULTS

There were no demographic differences between two groups. Compared to the TAPB group, the ESPB group had lower VAS pain scores and sufentanil consumption during the first 24 postoperative hours. Additionally, ESPB reduced the occurrence of postoperative nausea and vomiting. Furthermore, the satisfaction score was higher in the ESPB group. No other complications were reported between the two groups.

CONCLUSIONS

Compared with oblique subcostal TAPB, ESPB more effectively reduced postoperative pain and opioid consumption. Thus, ESPB is suitable for postoperative analgesia in elderly patients who have undergone laparoscopic colorectal surgery.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR2000033236.

The Effects of Intravenous Vitamin C on Stress Response Severity in Abdominal Hysterectomy Following Prolonged Fasting Time

Background

Inevitable prolonged fasting time before surgery leads to inflammatory reactions, surgery-related stress response, and consequently unfavorable outcomes; thus, developing strategies to mitigate these consequences is crucial.

Objectives

In this study, we evaluated the effect of ascorbic acid on stress response reduction in abdominal hysterectomy following prolonged fasting time.

Methods

Eligible women candidates for abdominal hysterectomy following prolonged fasting time were enrolled in the study and divided into 2 groups of vitamin C [group C; 1 g intravenously (IV) before surgery] and placebo (group P). Before induction of anesthesia, C-reactive protein (CRP), mean arterial pressure (MAP), heart rate (HR), and blood sugar (BS) were measured and compared between the 2 groups at 4-point times, 24 and 48 hours immediately after extubation.

Results

Finally, the data of 80 patients were included for the final analysis. A statistically significant difference was observed between the 2 groups in terms of CRP and BS values in T1 CRP serum levels; at the end of the study, CRP values were 0.5 ± 0.55 and 0.92 ± 0.69 in groups C and P, respectively (P = 0.012), and BS levels were 124.12 ± 18.11 and 152.0 ± 17.36 in groups C and P, respectively (P = 0.0001). However, this significant difference was not observed at T2 regarding CRP (P = 0.145) and BS (P = 0.135), as well as at T3 regarding CRP (P = 0.282) and BS (P = 0.213). However, according to both CRP and BS values, the trend of changes from T0 to T3 was significant in the 2 groups (P < 0.0001). Hemodynamic parameters were not significantly different between the 2 groups. No adverse event was reported in the 2 groups.

Conclusions

We found that ascorbic acid could induce short-term positive effects in abdominal hysterectomy following prolonged fasting time. Obviously, the optimal dosage, timing, and specific cases that benefit the most from this intervention should be investigated.

Effectiveness of Sublingual Buprenorphine and Fentanyl Pump in Controlling Pain After Open Cholecystectomy

Background

The proper management of postoperative pain improves patients’ quality of life, accelerates early postoperative recovery, shortens hospitalization period, and reduces medical costs. This study aimed to compare the effectiveness of intravenous fentanyl pump and sublingual buprenorphine tablet in controlling pain after open cholecystectomy.

Objectives

Evaluating the effectiveness of sublingual buprenorphine in reducing postoperative pain and complications after open cholecystectomy.

Methods

This study was a double-blind, randomized clinical trial. The study population encompassed those candidates undergoing open cholecystectomy, patients with ASA class I and II, individuals undergoing no other concomitant surgery, and patients in the age range of 20 - 50 years. The first group received sublingual buprenorphine 6, 12, and 18 hours after the first administration. The second group received fentanyl as patient-controlled analgesia (PCA) for 24 hours. Then nausea, vomiting, sedation, and Visual Analog Scale (VAS) scores were evaluated at the beginning, 2, 6, 12, 18, and 24 hours after surgery. The collected data were analyzed using SPSS software version 20.

Results

The mean age of the patients in the buprenorphine and fentanyl groups were 44.8 ± 5.5 and 42.8 ± 7.1 years, respectively. In this study, 22.5% of the patients in the buprenorphine group and 35.5% of the patients in the fentanyl group were male. During 6 and 24 hours after surgery, the pain level regarding the VAS scores was significantly lower in the buprenorphine group than in the fentanyl group; however, analgesic consumption was higher in the fentanyl group. In the early hours after surgery (2 and 6 hours), nausea and vomiting were lower in the buprenorphine group than in the fentanyl group even though the difference was not significant.

Conclusions

This study suggests buprenorphine as an effective drug for patients to reduce postoperative pain because of its limited complications, inexpensiveness, and more convenient administration method.

Novel Regional Nerve Blocks in Clinical Practice: Evolving Techniques for Pain Management

This review examines the use of novel US-guided nerve blocks in clinical practice. Erector spinae block is a regional anesthesia technique doing by injecting a local anesthetic among the erector spinae muscle group and transverse processes. The phrenic nerve is a branch of the cervical plexus, arising from the anterior rami of cervical nerves C3, C4, and C5. The quadratus lumborum muscle is located along the posterior abdominal wall. It originates from the transverse process of the L5 vertebral body, the iliolumbar ligament, and the iliac crest. US-guided peripheral nerve procedures have a considerable scope of use, including treating headaches and hiccups to abdominal surgical pain, cesarean sections, musculoskeletal pathologies. These nerve blocks have been an effective addition to clinical anesthesia practice. The use of peripheral nerve blocks has improved postoperative pain, lessened the use of opioids and their potential side effects, and decreased the incidence of sleep disturbance in patients. More research should be done to further delineate the potential benefits of these blocks.

Comparison of Dexmedetomidine and Dexamethasone as Adjuvants to Ultra-Sound Guided Interscalene Block in Arthroscopic Shoulder Surgery: A Double-Blinded Randomized Placebo-Controlled Study

BACKGROUND

Interscalene block is one of the popular methods for decreasing pain and analgesic consumption after shoulder arthroscopic surgeries.

OBJECTIVES

The objective is to compare the analgesic duration of effects of dexmedetomidine and dexamethasone as adjuvants to 0.5% ropivacaine in ultrasound-guided interscalene blocks for arthroscopic shoulder surgery in an ambulatory setting.

METHODS

In this randomized controlled trial, 117 adult patients candidate for ambulatory arthroscopic shoulder surgery under general anesthesia were divided into three groups to perform an ultra-sound guided interscalene block before the surgery. The ropivacaine (control) group received ropivacaine 0.5% 20 mL, group Dexamethasone received ropivacaine 0.5% 20 mL plus 4mg dexamethasone, and group dexmedetomidine received ropivacaine 0.5% 20 mL plus 75 mcg of dexmedetomidine. Time to return of sensory function, of motor function, of first pain sensation, amount of opioid medication consumed at 24 hours and 48 hours post-operatively were measured.

RESULTS

The 24-hour median (25th- 75th percentile) opioid consumption in morphine equivalents was similar between groups 22.5 mg (10 - 30), 15 mg (0 - 30), and 15 mg (0 - 20.6) in the ropivacaine, dexmedetomidine, and dexamethasone groups, respectively (P = 0.130). The median (25th- 75th percentile) 48 hours post-operatively, the median opioid consumption in morphine equivalents was 40 mg (25 - 67.5) in the ropivacaine group, 30 mg (22 - 50.6) in the dexamethasone group, and 52.5 mg (30 - 75) in the dexmedetomidine group (P = 0.278). The median 24-hour pain scores were 6 (5 - 8) in the ropivacaine control group, 7 (5.5 - 8) in the dexamethasone group, and 7 (4 - 9) in the dexmedetomidine group (P = 0.573).

CONCLUSIONS

There was no statistical difference in opioid consumption at 24 and 48 hours post-operatively when comparing dexmedetomidine, dexamethasone, and no adjuvant. However, intraoperative opioid use was significantly lower with dexmedetomidine compared to dexamethasone and plain 0.5% ropivacaine. The safe side effect profile of dexmedetomidine makes it a reasonable alternative as an adjuvant for peripheral nerve blockade when dexamethasone use may be contraindicated.

Comparison of Three Different Doses of Dexmedetomidine Added to Bupivacaine in Ultrasound-Guided Transversus Abdominis Plane Block; A Randomized Clinical Trial

Background

Adding dexmedetomidine to bupivacaine has been shown to prolong the analgesic effects of the transversus abdominis plane (TAP) block. However, the optimal dose of this adjuvant drug is unclear.

Objectives

Identifying optimal doses of dexmedetomidine added to bupivacaine in the TAP block.

Methods

In this randomized controlled trial, 86 patients candidate for elective open inguinal herniorrhaphy under spinal anesthesia were divided randomly into three groups; low (L), medium (M), and high (H) dose of dexmedetomidine, that finally 80 cases ended the study and were analyzed. At the end of the surgery, the patients underwent ultrasound-guided TAP block. In all patients of the three groups, the analgesic base of the block was 20 mL bupivacaine 0.125% that was supplemented with 0.5, 1, or 1.5 µ/kg of dexmedetomidine in groups L, M, and H, respectively.

Results

The maximum duration of the block was 4 hours in group L and 8 hours in groups M and H. None of the patients needed to receive analgesic at 0, 2, and 24 hours after the block. The dose of analgesic required in the first 8 hours of the block in groups M and H was less than in group L (P < 0.02). Patients in groups H and M were more satisfied with the block (P < 0.01) and experienced less pain compared with group L (P < 0.01). Drowsiness and sedation were observed in patients up to 4 hours after the TAP block, which was dependent on the dexmedetomidine dose (P < 0.01).

Conclusions

Based on our results, the optimal dose of supplemental dexmedetomidine could be 1 µ/kg in the TAP block.

Utilization of Magnesium for the Treatment of Chronic Pain

CONTEXT

The International Association for the Study of Pain (IASP) defines chronic pain as pain that persists or recurs for longer than 3 months. Chronic pain has a significant global disease burden with profound effects on health, quality of life, and socioeconomic costs.

EVIDENCE ACQUISITION

Narrative review.

RESULTS

There are several treatment options, including pharmacological therapy, physical rehabilitation, psychological therapies, and surgical interventions, for chronic pain management. Magnesium has been FDA-approved for several indications including hypomagnesemia, arrhythmia, prevention of seizures in eclampsia/preeclampsia, and constipation. Magnesium has been used for numerous off-label uses, notably for acute and chronic pain management. The mechanism of magnesium in pain management is primarily through its action as a voltage-gated antagonist of NMDA receptors, which are involved in pain transduction.

CONCLUSIONS

This narrative review will focus on the current evidence and data surrounding the utilization of magnesium as a treatment option for chronic pain.

The Impact of Optimal Dose of Ketamine on Shivering Following Elective Abdominal Hysterectomy: A Randomised Comparative Study

Background

Following surgery, patients frequently suffer from shivering, and this can lead to postoperative complications and discomfort.

Objectives

This study aimed to compare the effect of ketamine on patients’ shivering following an elective abdominal hysterectomy. Patients were given either Ketamine (0.25 mg or 0.5 mg/kg) or a placebo. The study and surgery took place in a subspecialty University Hospital for Gynecology and Obstetrics.

Methods

This study was an interventional, randomized, controlled clinical trial. Ninety-six women who underwent elective abdominal hysterectomy were randomly assigned to three groups. Ketamine was administered to all participants 20 min prior to the end of surgery. The first group received 0.25 mg/kg of intravenous ketamine. The second group received 0.5 mg/kg intravenous ketamine. The third group received a placebo of intravenous saline. Postoperative shivering, sedation grade, hallucination, nausea, vomiting, and nystagmus were measured for each patient up to 30 minutes.

Results

The study showed that patients suffered from less shivering in the two groups that received ketamine. The reduced shivering was seen 5, 10, and 20 min following surgery in the two groups that were given two doses of 0.25 and 0.5 mg/kg ketamine compared to the control group (P value < 0.05). There was a significant difference between patients receiving normal saline and those having 0.25 and 0.5 mg/kg of ketamine in the rate of sedation grade, nausea, vomiting, and nystagmus (P value < 0.05). The main differences in patients receiving ketamine were the sedation grade at zero time and postoperative hallucination experienced by those patients who received 0.5 mg/kg of ketamine.

Conclusions

Ketamine reduced shivering in all patients following elective abdominal hysterectomy. This was regardless of dose. Patients were less likely to suffer from hallucinations and sedation grade with a lower dose of ketamine (0.25 mg/kg compared to 0.50 mg/kg).

Effect of Preoperative Duloxetine on Opioid Consumption in Women Undergoing Abdominal Hysterectomy: A Randomized, Double-Blinded, Placebo-Controlled Trial

Background

Pain is one of the most challenging issues following surgery, and it is crucial to provide adequate and appropriate pain control measures.

Objectives

This study assessed the efficacy of preoperative duloxetine in controlling postoperative pain in women following an abdominal hysterectomy in Yas Hospital affiliated to Tehran University of Medical Sciences between December 2019 and April 2020.

Methods

The study involved 80 women who were candidates for elective abdominal hysterectomy. The participants were randomly assigned to one of two groups. Group 1 received a 60 mg duloxetine capsule two hours before surgery. Group 2 received placebo following the same schedule. The amount of administrated opioids and the time from surgery to the administration of opioids were recorded, along with the frequency of nausea and vomiting experienced.

Results

Two patients from each group withdrew before the study ended. In total, 38 women in each group were assessed. There were no significant differences in age, duration of surgery, and the amount of administrated opioids between the two groups. However, the number of patients who had nausea and vomiting differed significantly between the two groups (65% vs. 34%; P = 0.006).

Conclusions

Our findings showed that duloxetine was not effective in controlling pain after abdominal hysterectomy. In addition, patients who received duloxetine had a significantly higher rate of nausea/vomiting.

Comparing the Effect of Bupivacaine and Ropivacaine in Cesarean Delivery with Spinal Anesthesia

Background

Spinal anesthesia is the most common technique used for cesarean delivery due to some advantages compared to regional anesthesia. It is easily performed and provides a rapid onset of block. Though bupivacaine is a generally used long-acting amide type local anesthetic drug for spinal anesthesia, ropivacaine may sometimes be selected.

Objectives

This prospective, randomized, double-blinded study was aimed at comparing clinical efficacy and safety between ropivacaine and bupivacaine during cesarean section.

Methods

After getting ethical committee approval and written informed consent, 65 women who referred to Imam Khomeini Hospital of Ahvaz, Iran in 2018 were chosen for elective cesarean delivery under spinal anesthesia. They were randomly allocated to receive either ropivacaine 1% (n = 33) or bupivacaine 0.5% (n = 32). Afterwards, the differences in the anesthetic efficacy, vital signs, and hemodynamics of participants between the two groups were recorded.

Results

Duration of sensory block was shorter in the ropivacaine group than bupivacaine group (132.5 ± 21.6 min vs. 175.8 ± 26.2 min; P < 0.001). Ropivacaine also produced a shorter duration of motor blockade than bupivacaine (124.8 ± 20.2 min vs. 168.2 ± 21.7 min; P < 0.001). There is no difference between the two groups in terms of systolic and diastolic blood pressure, but the heart rate of patients in the bupivacaine group is significantly higher than the ropivacaine group.

Conclusions

The results suggest that ropivacaine and bupivacaine are two efficient drugs in anesthesia in the cesarean section, ropivacaine is a better choice due to little influence on the hemodynamics and shorter duration of sensory block and motor block which are useful for the recovery and also safe to the patients.

Appendectomy Pain Control by Transversus Abdominis Plane (TAP) Block in Children

Background

Pain control after surgery in children is very important. Despite having good analgesic effects, the use of opioids is, however, limited due to side effects.

Objectives

This study was aimed to investigate the effect of transverse abdominis plane (TAP) block on the intensity and frequency of pain after appendectomy in children.

Methods

In a single-blinded clinical trial, 40 children aged from 4 to 16 years, candidates for the appendectomy, were divided randomly to intervention and control groups. The intervention group received ultrasound-guided TAP block using 0.25 mL/kg of 0.25% bupivacaine in the Petit triangle after general anesthesia. Postoperative pain was assessed within the first 24 hours after surgery based on the Wong-Baker FACES Pain Rating Scale (WBFP).

Results

There was a reduction in WBFP scores at 2 hours after appendectomy in the intervention group compared with the control group (5.05 ± 2.83 vs 6.30 ± 2.2063). Also, the pain intensity within 24 hours after surgery in the intervention and control groups was 3.10 ± 1.33, and 3.60 ± 1.63 respectively according to WBFP scale (P > 0.05).

Conclusions

The TAP block was effective to reduce pain after appendectomy in children, however, there was no significant difference between intervention and control groups. Further studies with larger sample sizes are needed to be done in this area of research.

Comparison of the Post-Caesarean Analgesic Effect of Adding Dexmedetomidine to Paracetamol and Ketorolac: A Randomized Clinical Trial

Background

Paracetamol and non-steroidal anti-inflammatory drugs (e.g. ketorolac) can be considered for mild to moderate post-caesarean pain. As a selective α-2 agonist adrenergic receptor, dexmedetomidine has analgesic and sedative effects without causing respiratory depression.

Objectives

This study aimed to evaluate the effects of adding dexmedetomidine to paracetamol or ketorolac on post-caesarean pain and the associated complications thereof.

Methods

Sixty pregnant women, who were candidates for caesarean section with spinal anesthesia, were randomly assigned to either of two groups of 30 patients. For post-operative pain management, an intravenous patient-controlled analgesia (PCA) device was used for 24 hours. Dexmedetomidine (3 µg kg^-1) was added to paracetamol (35 mg kg^-1) in the group DP and to ketorolac (1 mg kg^-1) in the group DK. Visual analog scale (VAS), Ramsay sedation scale, hemodynamic changes, rescue analgesic (meperidine) consumption, patient satisfaction, and possible complications were recorded at 6, 12, and 24, hours after surgery, and compared afterward.

Results

The pain score was significantly lower in the DK group than in the DP group (P < 0.05). The hemodynamics and sedation scale were similar in both groups. The total meperidine consumption was higher in the DP group, but it was not significantly different. Maternal satisfaction was greater in the DK group (P < 0.05). Concerning complications, the two groups did not show statistically significant differences (P = 0.4).

Conclusions

The addition of dexmedetomidine to ketorolac, compared with its addition to paracetamol, causes further reduction in the post-operative pain score and provides more satisfaction.