Ultrasound-guided distal glossopharyngeal nerve block for post-tonsillectomy pain relief in adults: a prospective randomized study

BACKGROUND

We aimed to evaluate the safety and efficacy of the novel distal approach of ultrasound (US)-guided glossopharyngeal nerve (GPN) block at the pharyngeal wall for enhancing the quality of analgesia in patients undergoing tonsillectomy.

METHODS

Fifty patients, both male and female, between the ages of 21 and 65, categorized as ASA I-II by the American Society of Anesthesiologists (ASA) and who were scheduled for tonsillectomy, were enrolled in the study. Patients were randomly assigned to receive general anesthesia with either bilateral US-guided distal GPN block (GPN group) or no block (control group). The time for first request of analgesics, postoperative pain scores, the total amount of rescue analgesic medication consumed within a 24-hour period, and the occurrence of any adverse events were all noted.

RESULTS

The onset of first analgesic request was significantly prolonged in GPN group than the control group (P=0.013). Pain scores at 30 min, 2 and 6 hours postoperative were found to be significantly lower in GPN group than the control group both at rest (adjusted P=0.005, 0.000, and 0.020 respectively) and during swallowing (adjusted P=0.002, 0.000, and 0.015 respectively), with significantly less morphine consumption at 24 hours postoperative in GPN group compared with the control group (P=0.002). No significant postoperative block-related complications were observed.

CONCLUSIONS

In patients having tonsillectomy, pre-emptive application of US-guided distal GPN block at the pharyngeal wall enhanced the quality of analgesia and decreased the need for rescue analgesics with no major adverse effects.

Comparison of ultrasound-guided genicular nerve block and knee periarticular infiltration for postoperative pain and functional outcomes in knee arthroplasty - A randomised trial

Background and Aims

Optimal analgesia after total knee arthroplasty (TKA) enhances patients' and surgical outcomes. The study investigated the ultrasound-guided genicular nerve block versus the periarticular infiltration in TKA.

Methods

Eighty-eight patients aged above 50 years scheduled for unilateral TKA were randomised as: Group 1 received intraoperative periarticular infiltration (0.5 mL adrenaline [4.5 µg/mL], 20 mL bupivacaine 0.5% with 89.5 mL saline) and Group 2 received immediate postoperative genicular nerve block (15 mL bupivacaine 0.25% with 2.5 g/mL adrenaline). The postoperative morphine consumption was during the first two postoperative days the primary outcome. The secondary outcomes were time to rescue analgesia, pain scores and functional outcomes. The comparison between groups was performed using the Chi-square test, the Student's t-test and the Mann-Whitney U test, as appropriate.

Results

The postoperative morphine consumption during the first two postoperative days and pain scores at rest at 12 h postoperatively were less in Group 1 than in Group 2 (P < 0.001). Pain scores during movement on the first postoperative day were lower in the periarticular group than the genicular group at 6, 12 and 24 h (P < 0.001). At 18 h, pain scores were higher in the periarticular group than in the genicular group at rest and movement (P < 0.001). Quadriceps motor strength scores were comparable between groups (P > 0.05). The knee range of motion and time up and go test during both days showed a statistically significant difference in the periarticular group compared to the genicular group (P < 0.05).

Conclusion

Periarticular infiltration and genicular nerve block yield effective postoperative analgesia and functional outcomes after TKA without motor affection.

Ultrasound guided erector spinae plane block versus thoracic epidural analgesia in traumatic flail chest, a prospective randomized trial

Background and Aims

Pain contributes to flail chest morbidities. The aim of this study was to compare the analgesic effects of ultrasound-guided erector spinae plane block (ESPB) with thoracic epidural analgesia (TEA) in patients with traumatic flail chest.

Material and Methods

Sixty patients aged 18 - 60 years, ASA I-II, with unilateral flail chest were allocated into TEA group with a loading dose of 6 ml bupivacaine 0.25% and 2 μg/ml fentanyl and ESPB group with a loading dose of 20 ml bupivacaine 0.25% and 2 μg/ml fentanyl. This was followed by continuous infusion of 6 ml/hour bupivacaine 0.125% and 2 μg/ml fentanyl in both groups for 4 days. Pain scores at rest and on coughing, rescue analgesic consumption, PaO2/FIO2 ratio, PaCO2, pulmonary functions and adverse events were recorded.

Results

In both groups, Visual Analog Scale (VAS) scores at rest and on coughing were significantly decreased after block initiation as compared to pre-block value. At all-time points, VAS scores at rest and on coughing were insignificantly different between both groups. PaO2/FIO2 ratio, forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) were significantly increased and respiratory rate, PaCO2, were significantly decreased as compared to pre-block values of the same group without significant difference between both groups. The incidence of hypotension was significantly higher in TEA group than ESPB group.

Conclusions

ESPB can achieve adequate analgesia in traumatic flail chest equivalent to that of TEA with significant improvement of arterial oxygenation and pulmonary functions and without serious adverse effects.

Dexmedetomidine induced hypotension and hemostatic markers

Background and Aims

The hemostatic system undergoes extensive alterations following surgical trauma leading to a hypercoagulable state. We assessed and compared the changes in platelet aggregation, coagulation, and fibrinolysis status during normotensive and dexmedetomidine-induced hypotensive anesthesia in patients undergoing spine surgery.

Material and Methods

Sixty patients undergoing spine surgery were randomly allocated into two groups: normotensive and dexmedetomidine-induced hypotensive groups. Platelet aggregation was assessed preoperatively, 15 min after induction, 60 min, and 120 min after skin incision, at the end of surgery, 2 h and 24 h postoperatively. Prothrombin time (PT), activated partial thromboplastin time (aPTT), platelet count, antithrombin III, fibrinogen, and D-dimer levels were measured preoperatively, 2 h and 24 h postoperatively.

Results

Preoperative platelet aggregation (%) was comparable between both groups. Platelet aggregation significantly increased intraoperative at 120 min after skin incision and postoperatively in the normotensive group compared to the preoperative value (P < 0.05) but it was insignificantly decreased during the intraoperative induced hypotensive period in the dexmedetomidine-induced hypotensive group (P > 0.05). Postoperative PT, aPTT significantly increased and platelet count, and antithrombin III significantly decreased in the normotensive group compared to the preoperative value (P < 0.05) but they were not significantly changed in the hypotensive group (P > 0.05). Postoperative D-dimer significantly increased in the two groups compared to the preoperative value (P < 0.05).

Conclusion

Intraoperative and postoperative platelet aggregation significantly increased in the normotensive group with significant alterations of the coagulation markers. Dexmedetomidine-induced hypotensive anesthesia prevented the increased platelet aggregation that occurred in the normotensive group with better preservation of platelet and coagulation factors.

Inter-semispinal plane (ISP) block for postoperative analgesia following cervical spine surgery: A prospective randomized controlled trial

STUDY OBJECTIVE

We evaluated the perioperative analgesic effects of the inter-semispinal plane (ISP) block in patients undergoing posterior cervical spine surgery.

DESIGN

Prospective, randomized, controlled, double-blinded trial.

SETTING

Operating room and surgical ward.

PATIENTS

60 patients aged 18-60 years of either gender, ASA I-II, undergoing elective posterior cervical spine surgery.

INTERVENTIONS

Patients were randomly assigned into a control group (general anesthesia only), ISP group received bilateral ultrasound guided ISP block at the level of C5 using 20 ml bupivacaine 0.25% on each side.

MEASUREMENTS

Visual analog scale (VAS), intraoperative fentanyl and 24 h postoperative pethidine consumptions and time to first rescue analgesic request were documented.

MAIN RESULTS

The median (quartiles) of 24 h postoperative rescue pethidine consumption was significantly lower in the ISP group [0 (0-46.25) mg] compared to that of the control group [143 (116.75-169.00) mg]; P < 0.001). VAS was significantly lower in the ISP group at 30 min, 1 h, 2 h,4 h, 6 h, 8 h and 12 h postoperative compared to control group (P < 0.05). At 18 and 24 h, VAS was not significantly different between groups. The median (quartiles) of intraoperative fentanyl consumption in the ISP group [0 (0-40.75) μg] was significantly lower compared to that of the control group [63.5 (39.5-90.25) μg]; P < 0.001]. The time to first rescue analgesic administration was significantly longer in the ISP group compared to the control group (P < 0.001).

CONCLUSION

Bilateral ultrasound-guided ISP block can provide decreased 24 h postoperative analgesic consumption as well as lower pain scores in the first 12 postoperative hours in patients undergoing posterior cervical spine surgery.

The effect of ultrasound-guided transversus abdominis plane (TAP) block on postoperative analgesia and neuroendocrine stress response in pediatric patients undergoing elective open inguinal hernia repair

BACKGROUND

Transversus abdominis plane block (TAP) is a compartmental block of the anterior abdominal wall. Surgical trauma produces multisystem reactions. Anesthetic techniques can modify the neuroendocrine surgical stress response.

AIM

The aim of this study was to evaluate the effect of TAP block on the modification of the surgical neuroendocrine stress response as well as its analgesia effect in children undergoing open inguinal hernia repair.

METHOD

Sixty children aged 3-10 years undergoing elective unilateral open inguinal hernia repair were randomized into group I (general anesthesia) or group II (received TAP block after induction of general anesthesia). Serum cortisol, blood glucose, quality of analgesia, postoperative need for rescue analgesia, and complications and degree of satisfaction of the patients and their parents were assessed.

RESULTS

Serum cortisol level was significantly lower in group II as compared to group I intraoperatively (17.73 ± 1.51 vs 21.80 ± 2.22 μg·dl^-1 ) and 30 min postoperatively (15.03 ± 1.56 vs 18.30 ± 1.53 μg·dl^-1 ). Blood glucose level was significantly lower in group II as compared to group I intraoperatively (107.57 ± 3.77 vs 115.40 ± 6.30 mg·dl^-1 ) and 30 min postoperatively (104.13 ± 3.78 vs 110.73 ± 4.83 mg·dl^-1 ). The quality of analgesia as indicated by CHEOPS and OPS scales was significantly better in group II. The consumption of postoperative rescue analgesia was significantly higher in group I as compared to group II (27.00 ± 9.97 vs 13.00 ± 9.43 mg·kg^-1 ).

CONCLUSION

TAP block is effective as a part of multimodal analgesia for children undergoing open inguinal hernia repair with significant attenuation in the neuroendocrine stress response induced by surgery.

Bariatric surgery improves cardiac function in morbidly obese patients with severe cardiomyopathy

BACKGROUND

Longstanding morbid obesity can be associated with severe cardiomyopathy. However, the safety and efficacy of bariatric surgery in patients with severe cardiomyopathy has not been studied, and the effect of surgical weight loss on postoperative cardiac function is also unknown. In addition, morbidly obese patients have significantly increased mortality associated with cardiac transplantation, often precluding them from becoming recipients.

METHODS

A retrospective study of patients with a left ventricular ejection fraction < or =35% who underwent bariatric surgery (1998-2005) was performed. Short-term morbidity/mortality, length of stay, excess weight loss, pre- and postoperative left ventricular ejection fraction, and New York Heart Association (NYHA) functional class were assessed.

RESULTS

A total of 14 patients (10 men and 4 women) with a mean preoperative body mass index of 50.8 +/- 2.04 kg/m(2) underwent bariatric surgery (10 underwent laparoscopic Roux-en-Y gastric bypass, 1 open Roux-en-Y gastric bypass, 2 sleeve gastrectomy, and 1 laparoscopic gastric banding). The complications were pulmonary edema in 1, hypotension in 1, and transient renal insufficiency in 2. The median length of stay was 3.0 days (range 2-9). The mean excess weight loss at 6 months was 50.4%, with a decrease in the mean body mass index from 50.8 +/- 2.04 kg/m(2) to 36.8 +/- 1.72 kg/m(2). The mean left ventricular ejection fraction at 6 months had significantly improved from 23% +/- 2% to 32% +/- 4% (P = .04), correlating with improved functional capacity, as measured by the NYHA classification. Preoperatively, 2 patients (14%) had an NYHA classification of IV, 6 (43%) a classification of III, and 6 (43%) a classification of II. At 6 months postoperatively, no patient had an NYHA classification of IV, 2 (14%) had a classification of III, and 12 (86%) an NYHA classification of II. Two patients had undergone cardiac transplant evaluations preoperatively and underwent successful transplantation after weight loss.

CONCLUSION

The results of our study have shown that bariatric surgery for patients with cardiomyopathy is feasible and effective. Surgically induced weight loss results in both subjective and objective improvement in cardiac function. In addition, surgical weight loss can provide a bridge to transplantation in patients who were prohibited secondary to their morbid obesity.

The impact of laparoscopic bariatric workshops on the practice patterns of surgeons

BACKGROUND

This study was designed to evaluate the impact of a 2-day laparoscopic bariatric workshop on the practice patterns of participating surgeons.

METHODS

From October 1998 to June 2002, 18 laparoscopic bariatric workshops were attended by 300 surgeons. Questionnaires were mailed to all participants.

RESULTS

Responses were received from 124 surgeons (41%), among whom were 56 bariatric surgeons (open) (45%), 30 advanced laparoscopic surgeons (24%), and 38 surgeons who performed neither bariatric nor advanced laparoscopic surgery (31%). The questionnaire responses showed that 46 surgeons (37%) currently are performing laparoscopic gastric bypass (LGB), 38 (31%) are performing open gastric bypass, and 39 (32%) are not performing bariatric surgery. Since completion of the course, 46 surgeons have performed 8,893 LGBs (mean, 193 cases/surgeon). Overall, 87 of the surgeons (70%) thought that a limited preceptorship was necessary before performance of LGB, yet only 25% underwent this additional training. According to a poll, the respondents thought that, on the average, 50 cases (range, 10-150 cases) are needed for a claim of proficiency.

CONCLUSION

Laparoscopic bariatric workshops are effective educational tools for surgeons wishing to adopt bariatric surgery. Open bariatric surgeons have the highest rates of adopting laparoscopic techniques and tend to participate in more adjunctive training before performing LGB. There was consensus that the learning curve is steep, and that additional training often is necessary. The authors propose a mechanism for post-residency skill acquisition for advanced laparoscopic surgery.

A novel technique for fascial fixation of laparoscopic adjustable gastric band ports

Access port dislodgement after laparoscopic adjustable gastric banding is a recurring problem that often requires operative revision. Securing the port to the abdominal wall fascia in the traditional way with standard instruments is challenging in obese patients due to a thick abdominal wall. Therefore, we have devised a novel and simple technique for access port fixation using the EndoStitch device.

The impact of laparoscopy on bariatric surgery

The rising popularity of bariatric surgery over the past several years is attributable in part to the development of laparoscopic bariatric surgery. Morbidly obese patients have associated comorbid conditions that may predispose them to postoperative morbidity. The laparoscopic approach to bariatric surgery offers a minimally invasive option that reduces the physiologic stress and provides clinical benefits, as compared with the open approach. This review summarizes the impact of laparoscopic surgery on bariatric surgery, the various risk factors that could potentially predispose morbidly obese patients to postoperative morbidity, the fundamental differences between laparoscopic and open bariatric surgery, and the physiology of reduced tissue injury associated with laparoscopic bariatric surgery.

Repair of ventral hernias in morbidly obese patients undergoing laparoscopic gastric bypass should not be deferred

BACKGROUND

There is no consensus regarding the optimal treatment of ventral hernias in patients who present for weight loss surgery.

METHODS

Medical records of consecutive morbidly obese patients who underwent laparoscopic Roux-en-Y (LRYGB) gastric bypass with a secondary diagnosis of ventral hernia were reviewed. Only patients who were beyond 6 months of follow-up were included.

RESULTS

The study population was 85 patients. There were three groups of patients according to the method of repair: primary repair (59), small intestine submucosa (SIS) (12), and deferred treatment (14). Average follow-up was 26 months. There was a 22% recurrence in the primary repair group. There were no recurrences in the SIS group. Five of the patients in the deferred treatment group (37.5%) presented with small bowel obstruction due to incarceration.

CONCLUSION

Biomaterial mesh (SIS) repair of ventral hernias concomitant with LRYGB resulted in the most favorable outcome albeit having short follow-up. Concomitant primary repair is associated with a high rate of recurrence. All incarcerated ventral hernias should be repaired concomitant with LRYGB, as deferment may result in small bowel obstruction.

Contralateral internal jugular vein interposition for salvage of a functioning arteriovenous fistula

Outflow obstruction in patients with hemodialysis access can cause venous hypertension and jeopardize the patency of the access site. Numerous surgical procedures have been described to decompress an occluded subclavian vein. In this report, we describe the use of the contralateral internal jugular vein as a bypass conduit to decompress an occluded brachiocephalic vein in a patient whose dialysis was dependent on this vein access.