NRFit connectors in regional anaesthesia: avoiding medication errors

The continuous development of medicine in most fields requires physicians to apply the latest methods and technology to ensure patients' safety. In the field of anesthesiology we are pioneers in the application of measures that guarantee the security of our patients, making possible the greatest reduction in mortality seen among all other specialties. This objective has been achieved thanks to the introduction of changes such as the one presented in this review article. The specific NRFit® connections for neuraxial and other regional anesthesia applications prevent wrong route medication errors to occur. These medication errors have been related to a high morbidity and mortality rate. This article reviews this new technology based in our own two-year experience at Hospital Universitario Príncipe de Asturias (Alcalá de Henares, Madrid) as well as a literature review using PubMed, UpToDate and ClinicalKey.

A comparative study between single injection (corner pocket approach) and double injection costoclavicular block: A randomized parallel arm, non-inferiority trial

BACKGROUND

Previous studies have shown that ultrasound guided costoclavicular block may require a double shot to provide adequate, rapid sensory and motor blockade. In this trial, we hypothesized that if the corner pocket approach (between axillary artery and median cord) is used instead of the central approach (at the midpoint of the 3 cords) when performing single-shot costoclavicular block, the onset of blockade would be non-inferior to the double-shot technique.

METHOD

Ninety patients undergoing upper limb surgery were randomized to 2 groups for ultrasound-guided costoclavicular block (CCB) at a tertiary hospital. One group received ultrasound guided single-shot CCB using the corner pocket approach and other received ultrasound guided double-shot - the first shot at the centre of the 3 cords and the second between the axillary artery and the median cord. An observer blinded to group assignment recorded blockade onset time (defined as the time required to achieve a minimal sensorimotor composite score of 14 out of 16 points).

RESULTS

Of the 101 patients assessed for eligibility, 90 were recruited over period of 1 year (February 2022 to January 2023), with 45 in each group. Onset time was 22.1 ± 3.1 min in the single-shot group and 22.4 ± 2.9 min in the double-shot group. This difference was insignificant (P = .3).

CONCLUSION

Time to onset of blockade and full anaesthesia are similar in single-shot corner pocket CCB vs double-shot CCB. Further studies are required to determine the minimum effective volume of local anaesthetic required for the described technique.

Short-term outcomes after selective shunt during carotid endarterectomy: a propensity score matching analysis

INTRODUCTION AND OBJECTIVES

Carotid cross-clamping during carotid endarterectomy might lead to intraoperative neurologic deficits, increasing stroke/death risk. If deficits are detected, carotid shunting has been recommended to reduce the risk of stroke. However, shunting may sustain a specific chance of embolic events and subsequently incurring harm. Current evidence is still questionable regarding its clear benefit. The aim is to determine whether a policy of selective shunt impacts the complication rate following an endarterectomy.

MATERIAL AND METHODS

From January 2013 to May 2021, all patients undergoing carotid endarterectomy under regional anesthesia with intraoperative neurologic alteration were retrieved. Patients submitted to selective shunt were compared to a non-shunt group. A 1:1 propensity score matching (PSM) was performed. Differences between the groups and clinical outcomes were calculated, resorting to univariate analysis.

RESULTS

Ninety-eight patients were selected, from which 23 were operated on using a shunt. After PSM, 22 non-shunt patients were compared to 22 matched shunted patients. Concerning demographics and comorbidities, both groups were comparable to pre and post-PSM, except for chronic heart failure, which was more prevalent in shunted patients (26.1%, P=0.036) in pre-PSM analysis. Regarding 30-day stroke and score Clavien-Dindo ≥2, no significant association was found (P=0.730, P=0.635 and P=0.942, P=0.472, correspondingly, for pre and post-PSM).

CONCLUSIONS

In this cohort, resorting to shunting did not demonstrate an advantage regarding 30-day stroke or a Clavien-Dindo ≥ 2 rates. Nevertheless, additional more extensive studies are mandatory to achieve precise results concerning the accurate utility of carotid shunting in this subset of patients under regional anesthesia.

Continuous PENG block in an oncologic patient with bilateral femoral avascular necrosis

The PENG block (pericapsular nerve group) is a recently described technique to address the innervation of the hip, one of the most complex anatomical regions to treat at the locoregional level. We present the case of a patient with acute lymphoblastic leukaemia complicated by avascular necrosis of the bilateral femoral head and previous history of severe chronic pain with probable central sensitization to opioids and a severe thrombocytopenia due to myelotoxicity from chemotherapy treatment. Given the need for orthopaedic surgery to manage femoral necrosis and in anticipation of complex perioperative pain management, a multimodal strategy was planned including bilateral ultrasound-guided continuous PENG blocks to achieve proper pain control in the perioperative period and promote early recovery. The operation and initial recovery were uneventful and the patient was discharged to the ward within 24 h and started early rehabilitation as planned. The patient had a successful recovery with good functionality.

Retrospective analysis of regional anaesthesia in hip surgery: A clinical audit

INTRODUCTION

Total hip arthroplasty is one of the most frequent surgical interventions in the hospital setting. Nonetheless, the ideal method to manage post-operative pain is still unknown. Multimodal analgesia techniques based on regional anaesthesia are amongst the most promising solutions.

OBJECTIVES

The aim of this study was to evaluate postoperative pain after total hip arthroplasty according to whether peripheral nerve block was performed (femoral block, fascia iliaca block and pericapsular nerve group block). Intravenous morphine consumption during the patient's stay in the post-anaesthesia care unit was measured, as well as the number of opioid rescues at 24 and 48 h post intervention. As secondary objectives, the prevalence of nerve injury, prolonged quadricipital block, and morphine consumption were established according to other variables of interest.

MATERIALS AND METHODS

In this observational retrospective study, data was collected from the electronic medical record of 656 traumatological surgery patients from April 2018 to August 2020, with the following inclusion criteria: over 18 years old, ASA I-III, primary total hip arthroplasty under general anaesthesia or subarachnoid anaesthesia (only with hyperbaric bupivacaine) and use of levobupivacaine for peripheral nerve block.

RESULTS

A total of 362 patients were selected. The main surgical indication was coxarthrosis (61.3%), followed by hip fracture (22.6%). Peripheral nerve blocks were performed on 169 patients (66.3% femoral, 27.7% PENG, and 6.0% fascia iliaca). Mean postoperative opioid consumption in PACU was lower in patients in who received a PENG (2.2 mg) or a femoral (3.27 mg) block, compared to those who received neither (6.69 mg). There were no differences in opioid rescues at 24 and 48 h after the procedure. Nerve injury incidence was low (.8%), and not associated with nerve blocks. The incidence of prolonged quadricipital paralysis was also low (1.3%), and was mainly associated with femoral nerve block (75% of cases).

CONCLUSIONS

This retrospective study supports the use of regional blocks as opioid-sparing techniques, highlighting their role in rapid functional recovery with no motor impairment.

Ultrasound-guided sciatic popliteal block performed at the Emergency Department in a patient with a scorpion bite and severe pain

We report the case of a paediatric patient who presented at the Emergency Department with severe pain in the right lower extremity caused by a scorpion sting. Analgesics were ineffective, so we decided to perform an ultrasound-guided popliteal block, which provided complete analgesia and allowed the patient to be followed up in the outpatient department, with no adverse effects. The sting of the species of scorpion found in Spain is not dangerous to human life; however, it causes self-limiting localised pain that lasts for 24-48h, and can be severe. The first-line treatment is effective analgesia. Regional anaesthesia techniques are useful in the control of acute pain, and are an example of effective collaboration between the Anaesthesiology and Emergency services.

Resistance to local anesthetics: Truth or myth?

The report of anesthetic technique failure is crucial and the etiology of the problem should be determined. We describe a case of locoregional anesthesia failure, in which, after excluding its most common causes, the resistance to local anesthetics was considered as the most probable clinical hypothesis. For this reason, a genetic test was performed, as well as the efficacy of other local anesthetics was evaluated, constituting a different approach in the cases of locoregional anesthesia failure. True resistance to local anesthetics is difficult to diagnose so information about this is scarce in the literature. One of the proposed causes is a mutation of sodium channels where local anesthetics bind. If not recognized, the application of locorregional anesthesia in this patient's condition can lead to unpleasant experiences and unnecessary risks, related to toxic levels of local anesthetics. For this reason, the resistance to local anesthetics should be always precluded in cases of strong clinical suspicion. This approach could be applied in similar cases.

Role of adjuvants in regional anesthesia: A systematic review

The combination of drugs and routes of administration produces a synergistic effect, and one of the most important components of multimodal analgesic strategies are, therefore, nerve blocks for pain management. The effect of a local anaesthetic can be prolonged by administering an adjuvant. In this systematic review, we included studies on adjuvants associated with local anaesthetics in peripheral nerve blocks published in the last 5 years in order to evaluate their effectiveness. The results were reported according to the PRISMA guidelines. The 79 studies selected using our criteria showed a clear prevalence of dexamethasone (n=24) and dexmedetomidine (n=33) over other adjuvants. Different meta-analyses comparing adjuvants suggest that dexamethasone administered perineurally achieves superior blockade with fewer side effects than dexmedetomidine. Based on the studies reviewed, we found moderate evidence to recommend the use of dexamethasone as an adjuvant to peripheral regional anaesthesia in surgeries that can cause moderate to severe pain.

Erector spinae plane block for surgery of esophageal atresia in a preterm neonate

Pain management during and after thoracotomy is challenging in premature neonates. Ultrasound-guided fascial plane block techniques, such as the erector spinae plane block are a relatively new regional anesthesia technique and have emerged as an alternative to thoracic epidural due to its clinical effectiveness, ease of administration and theoretically being safer to perform. The relative ease of identifying anatomical landmarks compared to the paravertebral block, as well as its safety profile compared to an epidural, may have contributed to the erector spinae plane Bs growing popularity. Currently, however, the published evidence for the efficacy of regional anesthesia techniques in low birth weight newborns undergoing this surgery is limited to few isolated case reports. Herein we describe the use of unilateral erector spinae plane block as part of anesthesia and postoperative analgesia management of surgical correction of esophageal atresia in a preterm neonate.

Ultrasound-guided sub-multifidus block for postoperative pain after lumbar spine surgery - a prospective case series

We describe this series of 15 cases who were scheduled for single level lumbar spine decompression with instrumentation. Here we describe ultrasound (US) guided sub-multifidus block (SMFB). Injections of local anesthetic deep to the multifidus muscle provided reliable block of dorsal rami of spinal nerves at multiple levels in this series. With US the multifidus muscle can be identified both in axial and parasagittal planes. Needle tip is easily visualized beneath the multifidus and medial to transverse process. A good quality analgesia was documented by pain scores. There were no adverse events. This block needs to be compared with routine multimodal analgesia or with the recently describe thoracolumbar interfascial plane block to compare safety and analgesic efficacy.

Lumbar plexus terminal branch block, a safe alternative for transfemoral aortic valve implantation. Case report

Transcatheter aortic valve implantation is an alternative treatment for patients with severe aortic stenosis, it is conventionally performed under general anaesthesia or local anaesthesia plus sedation. We present the first case of trans-femoral, trans-catheter aortic valve implantation, performed in our hospital in a patient with severe aortic stenosis, who was a high surgical risk. Anaesthesia consisted of a combination of bilateral selective blockade of the iliohypogastric, ilioinguinal and genitofemoral nerves with the patient awake without sedation, using an ultrasound-guided approach. Transcatheter aortic valve implantation was successful and passed without incident, the patient remained immobile, calm, did not report pain, and sedation or hypnotics were not necessary during dilation of the vascular accesses with the introducer. Standard monitoring demonstrated haemodynamic stability, without cardiovascular repercussions and did not necessitate vasopressor or inotropic drug support. After the intervention, the patient was sent to the Cardiac Intensive Care Unit, where he remained asymptomatic and stable. Subsequently, the patient was admitted to the cardiology ward from where he was discharged without complications.

Unintended intrapleural insertion of an epidural catheter in thoracic surgery: regional analgesia game over, or is there another way out?

In thoracic surgery, optimized pain control is crucial to prevent dysfunction in cardiorespiratory mechanics. Epidural anesthesia (EA) and paravertebral block (PVB) are the most popular techniques for analgesia. Unintended intrapleural insertion of an epidural catheter is a rare complication. Our report presents a case of a patient submitted to pulmonary tumor resection by video-assisted thoracoscopic surgery (VATS). There was difficulty in epidural insertion related to patient's obesity, but after general anesthesia induction, no additional intravenous analgesia was needed after epidural injection. Surgery required conversion to thoracotomy, with intrapleural identification of epidural catheter. At the end of surgery, surgeons reoriented catheter to paravertebral space, with leak absence confirmation after local anesthetic injection through the catheter. In postoperative period, pain control was efficient, with no complications. It was a successful case that shows that when we find unexpected complications, we can look for alternative solutions to give our patient the best treatment.

Childbirth with epidural analgesia in a pregnant woman with hypokalemic periodic paralysis

Familial hypokalaemic periodic paralysis (FHPP) is an uncommon genetic disease characterized by muscle weakness associated with hypokalaemia. Episodes are precipitated by drugs, stress, metabolic diseases, hypothermia or infection. We report the case of a 38-year-old pregnant women with FHPP who underwent epidural analgesia for labour. Pregnant women with FHPP require multidisciplinary management involving an anaesthesiologist, a gynaecologist and a paediatrician. It is important to maintain normothermia, prevent hyperventilation, monitor electrolytes, avoid glucose infusions and medications that cause hypokalaemia, and administer potassium supplements when required. Locoregional techniques should be preferred over general anaesthesia. Early epidural analgesia reduces the risk of pain that could trigger an episode of FHPP. In the case of general anaesthesia, drugs that can cause malignant hyperthermia should be avoided, and short-acting non-depolarizing neuromuscular blockers with blockade-depth monitoring should be used.

Immune response in breast cancer surgery. A comparative and prospective study of different anesthetic techniques

INTRODUCTION

The main reason for high mortality in breast cancer is local recurrence and metastasis, despite surgery as the first therapeutic option. The anesthesia used in the operation room can determine the immune response.

METHODS

A prospective, comparative and non- randomised study in patients undergoing breast cancer surgery was conducted in our hospital after obtaining approval from the Hospital's Institutional Review Board. Patients were divided in two groups: Group A received general anesthesia with propofol and opioids. Group B, in addition to general anesthesia, three interfascial blocks (Pec I, Pec II and BRILMA) were performed in all patients. Three blood samples were taken 1) previous anesthetic induction; 2) two hours after the end of the surgery and 3) 24-48 h after surgery. Leukocytes, CD3, CD4, CD8 and Natural Killer cells were determined at each time.

RESULTS

103 patients were included. 59 (group A) received general anesthesia and 54 (group B) general anesthesia and interfascial blocks. Regarding baseline characteristics, age was significantly higher in the group that received general anesthesia and mastectomy was more frequent in the group that received interfascial blocks. We observed after surgery an increase in leukocytes level that returns close to baseline levels. On the other hand, a reduction in the immune response was observed that also returns to the previous level 48 h after surgery. Group A and B get similar results and also subgroups of hormonal receptors (HER+, PR and/or ER+).

CONCLUSIONS

Interfascial blocks in chest wall added to general anesthesia in breast cancer surgery has not shown a significant difference in the inflammatory response or immunological depression compared to general anesthesia as the only anesthetic technique. It seems to trend less immunological depression in the interfascial block group.

S-ICD implantation under the serratus plane block and transversus thoracis muscle plane block. A clinical case

INTRODUCTION

The development of a subcutaneous implantable cardioverter-defibrillator (S-ICD) combined with the typical patient comorbidities creates new challenges for anaesthesia.

CLINICAL CASE

A young male, ASA II, was proposed for S-ICD placement, after recovery from a sudden CRP episode. We performed regional anaesthesia with a serratus plane block (SPB) and transversus thoracic muscle plane block (TTPB) with administration of Mepivacaine and Ropivacaine. S-ICD placement was achieved under regional anaesthesia. In the perioperative period, the patient remained hemodynamically stable, without any complications or pain.

DISCUSSION

The implantation of the ICD occurs in fragile patients, with high anaesthetic risk. In this case, the association of SPB and TTPB was an effective anaesthetic/analgesic approach, has advantages when compared with other techniques and has potential use in other procedures.

Analysis of bupivacaine and ropivacaine-related cardiac arrests in regional anesthesia: A systematic review of case reports

Regional anesthesia as a component of multimodal analgesia protocols has become more and more a part of modern perioperative pain management. The widespread adoption of ultrasound guidance in regional anesthesia has surely played an important role in that growth and it has significantly improved patient safety, decreased the incidence of block failure, cardiac arrest, and reduced complication rates. The objective of this systematic review is to extract, analyze, and synthesize clinical information about bupivacaine and ropivacaine related cardiac arrest that we might have a clearer picture of the clinical presentation. The literature search identified 268 potentially relevant publications and 22 relevant case reports were included in the review. Patients' demographics, types of regional anesthesia, hypotension, heart rhythm disorders, seizures, cardiac arrest, fatal outcome, recommendations and limitations on prevention and treatment of bupivacaine and ropivacaine related cardiac arrest are analyzed and discussed in the systematic review. Both bupivacaine and ropivacaine-induced local anesthetic toxicity can result in cardiac arrest. Lipid emulsion, telemetry, local anesthetic toxicity resuscitation training appears to be promising in improvement of survival but more research is needed. Improvement and encouragement of reporting the local anesthetic toxicity are warranted to improve the quality of information that can be analyzed in order to make more precise conclusion.

Childbirth with epidural analgesia in a pregnant woman with hypokalemic periodic paralysis

Familial hypokalaemic periodic paralysis (FHPP) is an uncommon genetic disease characterized by muscle weakness associated with hypokalaemia. Episodes are precipitated by drugs, stress, metabolic diseases, hypothermia or infection. We report the case of a 38-year-old pregnant women with FHPP who underwent epidural analgesia for labour. Pregnant women with FHPP require multidisciplinary management involving an anaesthesiologist, a gynaecologist and a paediatrician. It is important to maintain normothermia, prevent hyperventilation, monitor electrolytes, avoid glucose infusions and medications that cause hypokalaemia, and administer potassium supplements when required. Locoregional techniques should be preferred over general anaesthesia. Early epidural analgesia reduces the risk of pain that could trigger an episode of FHPP. In the case of general anaesthesia, drugs that can cause malignant hyperthermia should be avoided, and short-acting non-depolarizing neuromuscular blockers with blockade-depth monitoring should be used.

Erector spinae plane block for chronic low back pain analgesia: A case series

BACKGROUND

Chronic low back pain (CLBP) is a frequent condition, poorly managed with conventional treatments. The ultrasound-guided erector spinae plane block has increasingly been used in the management of acute and chronic pain. We aimed to determine this technique's analgesic efficacy in patients with moderate to severe CLBP.

METHODS

Ten consecutively selected patients: adults, regularly followed in our Pain Clinic with moderate/severe long-term CLBP refractory to pharmacological treatment, VAS > 4. Prospective data collection: before the intervention -demographical data, past medical history, current pain therapies, VAS pain level, Brief Pain Inventory- Short Form and Neuropathic Pain Questionnaire; 30 min after - VAS and satisfaction level; 24 and 72 h, 7 days and 1 month after - complications and pain level.

RESULTS

Majority of females (90%), mean age of 70.3 years-old. All had primary musculoskeletal CLBP. 90% experienced severe pain (VAS >= 7) in the last 24 h. Half presented neuropathic characteristics. Patients were very satisfied with the technique (mean: 8.75) with immediate pain relief (VAS mean: 2.3). 24 and 72 h, 7 days and 1 month after the treatment VAS means were 3.2, 3.1, 3.8 and 6.2. We report a 20.8 days duration mean. No short or long-term complications.

DISCUSSION AND CONCLUSIONS

Ultrasound-guided erector spinae plane block has preliminary advantages in CLBP: easily performed with low complications risk, immediate discharge home with absence of motor block, 100% efficacy at short and medium-terms. Even though pain's relief was shorter than a month, it is a useful tool allowing patients' well-being, physical rehabilitation and exercise during this period.

S-ICD implantation under the serratus plane block and transversus thoracis muscle plane block. A clinical case

INTRODUCTION

The development of a subcutaneous implantable cardioverter-defibrillator (S-ICD) combined with the typical patient comorbidities creates new challenges for anesthesia.

CLINICAL CASE

A young male, ASA II, was proposed for S-ICD placement, after recovery from a sudden CRP episode. We performed regional anesthesia with a serratus plane block and transversus thoracic muscle plane block with administration of mepivacaine and ropivacaine. S-ICD placement was achieved under regional anesthesia. In the perioperative period, the patient remained hemodynamically stable, without any complications or pain.

DISCUSSION

The implantation of the ICD occurs in fragile patients, with high anesthetic risk. In this case, the association of serratus plane block and transversus thoracic muscle plane block was an effective anesthetic/analgesic approach, has advantages when compared with other techniques and has potential use in other procedures.

[Erector spinae plane block in pediatric orthopedic surgery: two case reports]

The erector spinae plane block is a safe and effective regional anesthesia technique, which has earned new indications perioperatively since its description. We introduce two pediatric anesthesia cases in which we performed the erector spinae plane block during intermediate/major orthopedic surgeries. The first patient is a 2 year-old girl submitted to surgical treatment of developmental dysplasia of the hip. The second patient is a 14 year-old boy submitted to surgical treatment of bilateral clubfoot. This last patient is potentially the first published case in which the erector spinae plane block was performed for ankle and foot surgery. Both cases experienced excellent analgesia, avoiding opiate requirement completely.

[Antimicrobial effects of fentanyl and bupivacaine]

STUDY OBJECTIVE

In this study, we aimed to compare the antimicrobial effects of bupivacaine and fentanyl citrate and to reveal the impact on antimicrobial effect potential in the case of combined use.

DESIGN

In vitro prospective study.

SETTING

University Clinical Microbiology Laboratory.

MEASUREMENTS

In our study, in vitro antimicrobial effect of 0.05 mg.mL^-1 fentanyl citrate, 5 mg.mL^-1 bupivacaine were tested against Staphylococcus aureus American Type Culture Collection (ATCC) 29213, Pseudomonas aeruginosa ATCC 27853, Klebsiella pneumoniae ATCC 13883, Escherichia coli ATCC 25922 and Candida albicans ATCC 10231 as Group F (Fentanyl Citrate) and Group B (Bupivacaine), respectively. S. aureus ATCC 29213, P. aeruginosa ATCC 27853, Klebsiella pneumoniae ATCC 13883 and Escherichia coli ATCC 25922 were cultured onto Mueller Hinton agar (Oxoid, UK) plates and Candida albicans ATCC 10231 were cultured onto Sabouraud dextrose agar (Oxoid, UK) plates for 18-24 hours at 37°C.

MAIN RESULTS

In terms of inhibition zone diameters, S. Aureus ATCC 29213, P. aeruginosa ATCC 27853, and C. albicans ATCC10231 values obtained after 12 and 24 hours of incubation were significantly higher in Group F than Group B (p < 0.001). In terms of inhibition zone diameters, E. coli ATCC 25922, and K. pneumomiae ATCC 13883 values obtained after 12 and 24hours of incubation were significantly higher in Group B than Group F (p < 0.001, E. coli 12ª hour p = 0.005).

CONCLUSIONS

Addition of fentanyl to Local Anesthetics (LAs) is often preferred in regional anesthesia applications in today's practice owing especially to its effect on decreasing the local anesthetic dose and increasing analgesia quality and patient satisfaction. However, when the fact that fentanyl antagonized the antimicrobial effects of LAs in the studies is taken into account, it might be though that it contributes to an increase in infection complications. When the fact that fentanyl citrate, which was used in our study and included hydrochloric acid and sodium hydroxide as protective agents, broadened the antimicrobial effect spectrum of LAs, had no antagonistic effect and showed a synergistic antimicrobial effect against E. Coli is considered, we are of the opinion that the addition of fentanyl to LAs would contribute significantly in preventing the increasing regional anesthesia infection complications.

[PECS I block for postoperative analgesia in patients undergoing breast augmentation surgery: a randomized double-blind placebo-controlled study]

BACKGROUND AND OBJECTIVES

PECS I block was first described for surgery involving the pectoralis muscles. No randomized clinical trial has been conducted on surgeries that directly involve these muscles, such as subpectoral breast augmentation. We hypothesized that PECS I block would decrease pain in the postoperative period in this population.

METHODS

This was a randomized, double-blind, placebo-controlled trial in women undergoing subpectoral breast augmentation surgery. PECS I block was performed using 0.4 mL.kg^-1 of 0.9% saline on one side and bupivacaine (0.25%) on the other side, each patient being her own control. Numeric Rating Scale (NRS) pain scores (0-10) were measured at rest and during movement. The primary outcome was pain score at rest 30 minutes after arrival in the PACU. To detect a clinically significant difference of 50% in pain reduction, 14 volunteers were enrolled (power of 90% and alpha<0.05).

RESULTS

In the PACU, three patients had no difference in pain between sides, five had reduced pain on the placebo side, and six had reduced pain on the bupivacaine side. In the bupivacaine group, pain scores at rest at 5, 30 and 60 minutes and 24 hours were 4.89 (4.23-5.56; mean 95% CI), 3.75 (3.13-4.37), 3.79 (2.93-4.64), and 2.29 (1.56-3.01), respectively, whereas in the placebo group, they were 4.96 (4.32-5.60), 4.00 (3.50-4.49), 3.93 (3.12-4.73), and 2.29 (1.56-3.01), respectively.

CONCLUSIONS

PECS I block in patients undergoing breast augmentation surgery does not provide better pain relief than placebo. Therefore, the indications for PECS I block in breast augmentation surgery should be reconsidered.

[Articular and cutaneous nerve block at elbow: two cases report]

BACKGROUND AND OBJECTIVES

In patients with elbow fractures, when there is suspected injury to underlying nerves, it is imperative for surgeons to elicit the function in the immediate postoperative period. Brachial plexus blocks like interscalene, supraclavicular and infraclavicular approaches can be a hurdle in such situations. The block planned should allow assessment of integrity of the nerves immediately in the postoperative period.

CASE REPORT

We describe two cases in which we administered a block not yet described in literature. We blocked the cutaneous and articular branches innervating the elbow under ultrasound guidance. General anesthesia was administered in both cases. The block provided stable intraoperative hemodynamics, good postoperative analgesia and also allowed surgeons to test the viability of the nerve.

CONCLUSION

In situations where nerves are injured during elbow fractures, selective articular cutaneous block at elbow can be used as it provides good perioperative analgesia, besides allowing evaluation of motor and sensory components in the postoperative period.

[SBA 2020: Regional anesthesia guideline for using anticoagulants update]

The development of protocols to prevent perioperative Venous Thromboembolism (VTE) and the introduction of increasingly potent antithrombotic drugs have resulted in concerns of increased risk of neuraxial bleeding. Since the Brazilian Society of Anesthesiology (SBA) 2014 guideline, new oral anticoagulant drugs were approved by international regulating agencies, and by ANVISA. Societies and organizations that try to approach concerns through guidelines have presented conflicting perioperative management recommendations. As a response to these issues and to the need for a more rational approach, managements were updated in the present narrative revision, and guideline statements made. They were projected to encourage safe and quality patient care, but cannot assure specific results. Like any clinical guide recommendation, they are subject to review as knowledge grows, on specific complications, for example. The objective was to assess safety aspects of regional analgesia and anesthesia in patients using antithrombotic drugs, such as: possible technique-associated complications; spinal hematoma-associated risk factors, prevention strategies, diagnosis and treatment; safe interval for discontinuing and reinitiating medication after regional blockade.

[Recommendations for local-regional anesthesia during the COVID-19 pandemic]

Desde o início da pandemia de COVID‐19, muitas questões surgiram referentes à segurança do manejo anestésico de pacientes acometidos pela doença. A anestesia regional, seja esta periférica ou neuroaxial, é alternativa segura no manejo do paciente COVID‐19, desde que o emprego de modalidades que minimizam o comprometimento da função pulmonar seja escolhido. A adoção dessa técnica anestésica minimiza os efeitos adversos no pós‐operatório e oferece segurança para o paciente e equipe, desde que sejam respeitados os cuidados com proteção individual e de contágio interpessoal. Respeito às contraindicações e emprego criterioso das técnicas e normas de segurança são fundamentais. Este manuscrito tem por objetivo revisar as evidências disponíveis sobre anestesia regional em pacientes com COVID‐19 e oferecer recomendações práticas para sua realização segura e eficiente.

[Ultrasound-guided multiple peripheral nerve blocks, a way out for anesthesia in morbidly obese patients for bone marrow aspiration]

Morbid obesity is associated with various pathophysiological changes which affect the outcome of anesthesia and surgery. So it's challenging to give anesthesia to such patients. We present a 59-year-old adult morbidly obese, hypertensive, diabetic female with hypothyroidism operated for proximal humerus fracture and now presented with non-union of fracture, requiring percutaneous injection of bone marrow aspirate from the iliac crest to the site of non-union. The patient was extremely anxious and refused to undergo the procedure under local anesthesia or sedation and demanded anesthesia. Given her comorbidities general anesthesia (GA) was avoided and the procedure was accomplished using Ultrasound (USG) guided Transversus abdominis plane (TAP) block and Lateral Femoral Cutaneous Nerve (LFCN) block for the bone marrow aspirate from the iliac crest and Intercostobrachial nerve block (T2) was given to prevent pain while injecting the aspirate into the non-union site. Dexmedetomidine and ketamine were given for deep level sedation and analgesia. TAP block and LFCN block is generally used for post-op analgesia but can be also used for surgical anesthesia instead of General anesthesia in specific scenarios. Its perioperative application and its potential use instead of GA have been discussed.

[SBA 2020: Regional anesthesia safety recommendations update]

The purpose of the Brazilian Society of Anesthesiology's (SBA) Regional Anesthesia Safety Recommendations Update is to provide new guidelines based on the current relevant clinical aspects related to safety in regional anesthesia and analgesia. The goal of the present article is to provide a broad overview of the current knowledge regarding pre-procedure asepsis and antisepsis, risk factors, diagnosis and treatment of infectious complications resulting from anesthetic techniques. It also aims to shed light on the use of reprocessed materials in regional anesthesia practice to establish the effects of aseptic handling of vials and ampoules, and to show cost-effectiveness in the preparation of solutions to be administered continuously in regional blockades. Electronic databases were searched between January 2011 (final date of the literature search for the past SBA recommendations for safety in regional anesthesia) and September 2019. A total of 712 publications were found, 201 of which were included for further analysis, and 82 new publications were added into the review. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess the quality of each study and to classify the strength of evidence. The present review was prepared by members of the SBA Technical Standards Committee.

[The need for supplemental blocks in single versus triple injections in infraclavicular brachial plexus blocks with a medial approach: a clinical and anatomic study]

BACKGROUND AND OBJECTIVES

To evaluate the single-injection and triple-injection techniques in infraclavicular blocks with an ultrasound-guided medial approach in terms of block success and the need for supplementary blocks.

METHODS

This study comprised 139 patients who were scheduled for elective or emergency upper-limb surgery. Patients who received an infraclavicular blocks with a triple-injection technique were included in Group T (n=68). Patients who received an infraclavicular blocks with a single-injection technique were included in Group S (n=71). The number of patients who required supplementary blocks or had complete failure, the recovery time of sensory blocks and early and late complications were noted.

RESULTS

The block success rate was 84.5% in Group S, and 94.1% in Group T without any need for supplementary nerve blocks. The blocks were supplemented with distal peripheral nerve blocks in 8 patients in Group S and in 3 patients in Group T. Following supplementation, the block success rate was 95.8% in Group S and 98.5% in Group T. These results were not statistically significant. A septum preventing the proper distribution of local anesthetic was clearly visualized in 4 patients. The discomfort rate during the block was significantly higher in Group T (p <0.05).

CONCLUSION

In ultrasound-guided medial-approach infraclavicular blocks, single-injection and triple-injection techniques did not differ in terms of block success rates. The need for supplementary blocks was higher in single injections than with triple injections. The presence of a fascial layer could be the reason for improper distribution of local anesthetics around the cords.

Bilateral erector spinae plane block for scoliosis surgery: Case series

Spinal correction surgery is a very invasive surgical procedure and results in severe postoperative pain. We report six cases in which Bilateral Erector Spinae Plane Block was performed for scoliosis surgery. Our aim was to provide an effective perioperative pain management and to achieve intraoperative hemodynamic stability with no interference on neuromonitoring. The technical challenges are also highlighted. An ultrasound guided scout scan is necessarry to identify the bony prominences and determine the possible multiple injection points. Erector Spinae Plane Block in scoliosis surgery is an easier and safer technique compared to epidural anesthesia and can use instrumented complex spinal surgery. This block seems to have a role in perioperative pain pathway complementing the multimodal analgesic regimen and not have interference with evocated potentials in adults. However the diffusion mechanism of the this block is not well known hence it should be awake regarding local anesthetic toxicity.

[General anesthesia combined with erector spinae plane block for ductus arteriosus closure: two case reports]

BACKGROUND

Failure of ductus arteriosus closure in preterm neonates results in a left-to-right shunt that leads to variable severities of hemodynamic and respiratory distress. When medical therapy fails, surgical ligation via left lateral thoracotomy remains an alternative approach and can be performed in the operating room or at the bedside with a low mortality rate. Opioid-based anesthesia is a frequent choice among anesthesiologists who manage patent ductus arteriosus cases based on the suppression of the stress response and maintenance of hemodynamic stability. This rationale suggests that regional anesthesia may also be an advantageous technique and may benefit earlier weaning from ventilation. Blocking afferent signals before incision may also modulate the long-term consequences of altered sensory perception and pain responses.

CASE REPORT

We present two cases of general anesthesia combined with erector spinae plane block as part of multimodal anesthesia in premature twins undergoing patent ductus arteriosus closure.

DISCUSSION

In these cases, the use of erector spinae plane block combined with general anesthesia was efficient to minimize the negative impact of surgery and allowed a reduction in the amount of intraoperative opioid use for patent ductus arteriosus closure.

Comparison of peribulbar block and general anaesthesia in mechanical vitrectomy: a prospective observational study

INTRODUCTION

Vitrectomy surgery is a common procedure for the treatment of several types of ophthalmologic conditions. It can be performed under regional anaesthesia with peribulbar block (PB) or general anaesthesia (GA). There are no evidence-based recommendations on the optimal anaesthesia strategy for this procedure. The aim of this study was to compare the advantages of PB and GA for vitrectomy surgery.

MATERIALS AND METHODS

A prospective observational study was conducted on adults submitted for mechanical vitrectomy between January 2017 and December 2017. Demographic and perioperative data were collected, namely ASA physical status, median arterial pressure, heart rate, postoperative opioid consumption, postoperative nausea and vomiting, times of induction, surgery, recovery, and hospital stay and costs considering medication and material needed. Statistical analysis was performed using SPSS v.25, with chi-square, Fisher and Mann-Whitney U tests, according to the type of variables analysed.

RESULTS AND DISCUSSION

We included 179 patients submitted for mechanical vitrectomy: 91 (51%) with PB and 88 (49%) under GA. Patients submitted to PB were older (69.0 vs. 64.5 years, p=.006) and presented with higher ASA physical status (p=.001). For haemodynamic outcomes, patients submitted to PB presented with less variation of median arterial pressure (-3.0 vs. -13.5mmHg, p=.000) and with no significant differences in heart rate (-2.0 vs. -3.0 bpm, p=.825). In the postoperative period, the PB group presented with decreased need of postoperative analgesia (0.0 vs. 5.0, p=.026) and a lower incidence of nausea and vomiting (1.0 vs. 12.0, p=.001). Times related to anaesthesia and surgery were better in PB group, with shorter induction time (10.0 vs. 11.0min, p=.000), surgery time (56.5 vs. 62.0min, p=.001), recovery time (10.0 vs. 75.5min, p=.000), and hospital stay (2.0 vs. 3.0 days, p=.000). When analysing costs, PB was less expensive than GA (4.65 vs. 12.09 euros, p=.021) CONCLUSION: PB is a reliable and safe alternative to GA for patients undergoing mechanical vitrectomy, permitting good anaesthesia and akinesia conditions during surgery, better haemodynamic stability, and less postoperative complications, especially in older patients and those with more comorbidities.

[Hemidiaphragmatic paralysis after ultrasound-guided supraclavicular block: a prospective cohort study]

BACKGROUND AND OBJECTIVES

The frequent onset of hemidiaphragmatic paralysis during interscalene block restricts its use in patients with respiratory insufficiency. Supraclavicular block could be a safe and effective alternative. Our primary objective was to assess the incidence of hemidiaphragmatic paralysis following ultrasound-guided supraclavicular block and compare it to that of interscalene block.

METHODS

Adults warranting elective shoulder surgery under regional anesthesia (Toulouse University Hospital) were prospectively enrolled from May 2016 to May 2017 in this observational study. Twenty millilitres of 0.375% Ropivacaine were injected preferentially targeted to the "corner pocket". Diaphragmatic excursion was measured by ultrasonography before and 30 minutes after regional anesthesia. A reduction ≥ 25% in diaphragmatic excursion during a sniff test defined the hemidiaphragmatic paralysis. Dyspnoea and hypoxaemia were recorded in the recovery room. Predictive factors of hemidiaphragmatic paralysis (gender, age, weight, smoking, functional capacity) were explored. Postoperative pain was also analysed.

RESULTS

Forty-two and 43 patients from respectively the supraclavicular block and interscalene block groups were analysed. The incidence of hemidiaphragmatic paralysis was 59.5% in the supraclavicular block group compared to 95.3% in the interscalene block group (p < 0.0001). Paradoxical movement of the diaphragm was more common in the interscalene block group (RR = 2, 95% CI 1.4-3; p = 0.0001). A similar variation in oxygen saturation was recorded between patients with and without hemidiaphragmatic paralysis (p = 0.08). No predictive factor of hemidiaphragmatic paralysis could be identified. Morphine consumption and the highest numerical rating scale (NRS) at 24 hours did not differ between groups.

CONCLUSIONS

Given the frequent incidence of hemidiaphragmatic paralysis following supraclavicular block, this technique cannot be recommended for patients with an altered respiratory function.

Spinal Myoclonus: Is It An Anesthetic Mystery?

The goal is to present a descriptive study related an unprecedent case of spinal myoclonus (SM) following subarachnoid anesthesia (SA). SM are sudden, brief, involuntary non-generalized spasms that can be an adverse effect of drug administration via neuraxial routes. Female, 67y, ASA II, proposed for hip replacement surgery, with normal preoperative exams. 7min after SA with 10mg of bupivacaine 0,5%, no motor blockade observed, and patient complained of unbearable pain in legs and perineum and bilateral, asymmetrical and arrhythmic myoclonic movements in the lower limbs. The latter solved after 48h of general anesthesia and rocuronium perfusion, amongst other therapeutics. Accordingly, intrathecal bupivacaine appears to be the SM most likely cause, regarding the absence of neurologic and electrolyte disorders, spinal cord direct trauma, drug exchange and normal perioperative examination, imaging and laboratory testing.It is mandatory to always take the patients' anaesthetic histories and recognize, treat and report rare anaesthetic complications.

[Ultrasound-guided costoclavicular block as an alternative for upper limb anesthesia in obese patients]

BACKGROUND AND OBJECTIVES

Costoclavicular brachial plexus block is an anesthesia performed through the infraclavicular route described in the literature as a safe and effective route for upper limb anesthesia distal to the elbow. The following report describes the case of a patient whose traditional plexus blocking techniques presented ultrasound visualization difficulty, but the costoclavicular approach was easy to visualize for anesthetic blockade.

CASE REPORT

A grade 3 obese patient scheduled for repair of left elbow fracture and dislocation. Ultrasound examination revealed a distorted anatomy of the supraclavicular region and the axillary region with skin lesions, which made it impossible to perform the blockade in these regions. It was decided to perform an infraclavicular plexus block at the costoclavicular space, where the brachial plexus structures are more superficial and closer together, supported by a muscular structure, lateral to all adjacent vascular structures and with full view of the pleura. The anesthetic block was effective to perform the procedure with a single injection and uneventfully.

CONCLUSION

Costoclavicular brachial plexus block is a good alternative for upper limb anesthesia distal to the elbow, being a safe and effective option for patients who are obese or have other limitations to the use of other upper limb blocking techniques.

The erector spinae plane block (ESPB) in the management of chronic thoracic pain. Correlation of pain/analgesia areas and long term effect of the treatment in three cases

The erector spinae plane block (ESPB) is a technique that is used both as perioperative analgesia and in the management of chronic pain. This has been described recently and is being a resource increasingly used for its easy implementation and low rate of complications. However, the correlation between pain and analgesia, as well as its long-term effect on chronic pain, should be studied. We present a series of 3 cases in which the effectiveness of the ESPB in patients with chronic chest pain was evaluated. The block was performed in all cases by depositing 20ml of 0.2% Ropivacaine in the fascial plane of the erector spinae muscle. The pain was measured using a numerical scale prior to the block, at 30minutes and a month. The areas were marked on the skin with different colours for comparison.

Prospective, randomized comparative study of ultrasound-guided blocking of the lateral cutaneous branches of the intercostal nerves versus conventional analgesia in non-reconstructive breast surgery

OBJECTIVE

The objective of this study is to determine whether the accomplishment of an interfascial blockade, the blocking of the cutaneous branches of the intercostal nerves in the axillary line (BRILMA) associated with a multimodal analgesic regimen improves post-operative analgesia and allows saving opioids after non-reconstructive surgery of breast.

MATERIAL AND METHODS

A prospective, randomised and simple blind study was conducted on patients that underwent non-reconstructive breast surgery. The patients were randomly assigned to the blocking group, or to the standard post-operative analgesia group (paracetamol and dexketoprofen). The main variables analysed were the pain intensity assessed by the verbal numerical scale and the analgesic rescue needs with tramadol.

RESULTS

Statistically significant differences were observed in the consumption of tramadol during the study period (10.5mg in the BRILMA group, compared to 34.3 in the control group, P=.0001). There were also differences in the pain assessment, with lower values found in the BRILMA group.

CONCLUSIONS

In non-reconstructive breast surgery, performing a BRILMA block allows obtaining lower pain scores, which implies less need for rescue analgesics and a significant saving of tramadol in the study period.

Combination of thoracic blocks as a main anesthetic tecnique in modified radical mastectomy for patients with severe respiratory disease

The addition of ultrasound to locoregional anaesthesia in the last few years has led to the description of various fascial thoracic blocks with analgesic purposes: PECS 1 and 2 block, serratus plane block, serratus intercostal fascial block, blockade in the plane of the thoracic transverse muscle..., which have been added to other well-known nerve blocks, such as thoracic paravertebral block or intercostal block. In this sense, locoregional anaesthesia has been universally recommended in patients with severe respiratory processes in order to avoid ventilatory support and subsequent weaning that considerably increases postoperative morbidity and mortality rates. However, as regards thoracic wall and axillary hollow, there are very few references which detail the use of nerve or fascial blocks as a main anaesthetic method. Two extreme cases are presented of multi-pathological patients with serious respiratory disease who successfully underwent a modified radical mastectomy plus surgery in the axillary space using a combination of ultrasound-guided thoracic blocks that allowed surgery without general anaesthesia, avoiding mechanical ventilation, and maintaining spontaneous breathing throughout the surgical procedure. The main indications of the anaesthetic blocks used are described, focusing on the performance of the technique and underlining, in a novel way, the possibility of facing aggressive surgery at the level of the armpit with only locoregional anaesthesia.

General or regional? Exploring patients' anaesthetic preferences and perception of regional anaesthesia

INTRODUCTION AND OBJECTIVES

Regional anaesthesia (RA) has gained popularity due to its numerous benefits and increasing safety. Yet, often patients refuse this procedure and prefer general anaesthesia (GA). This study aimed to investigate variables (demographic factors, safety perception of GA and RA, patients' fears, anxiety, and knowledge) related to patients' anaesthetic preference.

MATERIAL AND METHODS

Participants were patients aged 18 years or more proposed to an anaesthesia appointment for preoperative assessment. Patients completed a written questionnaire before meeting the anaesthesiologist. The questionnaire asked about their preferences, fears and perceptions about RA.

RESULTS

One hundred and 2patients agreed to participate. Mean age was 52.6±13.5 years, 57.8% were female and 44.5% had at least 12 years of education. Given the choice, 54.0% would prefer GA and 20.7% said they would refuse RA if proposed by the anaesthesiologist. Among patients who already experienced neuroaxial anaesthesia, 40.0% said they did not wish to repeat it. Patients who preferred GA over RA perceived GA to be safer than RA and expressed more anxiety towards being awake during surgery and more fear of feeling pain during surgery, of having back pain, and of needle puncture. Results also suggested that patients are unaware of RA's real risks and benefits.

CONCLUSIONS

Knowing patients' fears is essential for the anaesthesiologist address their patients' needs. Anaesthesiologists should work on improving general population perspective and knowledge about RA.

Lumbar erector spinae plane block: Successful control of acute pain after lumbar spine surgery - A clinical report

We report the successful clinical case of a patient scheduled for lumbar spine surgery in which we performed a bilateral single-shot erector spinae plane block as part of a multimodal analgesic strategy for pain control. Performing the block preoperatively dismissed the need for extra intraoperative opioids other than those for intubation, and enabled the use of paracetamol for analgesia only. Further, there was no need for hypotensive techniques, as the block provided satisfactory sympathetic blockade and regional vasodilation with a clear surgical field. Postoperatively, the patient had minor opioid consumption and was able to freely move without any motor impairment or pain from early on in the Post Anaesthesia Care Unit. The use of single-shot erector spinae plane block at the lumbar level for lumbar spine surgery analgesia emphasises its wide application and analgesic efficacy.

Ultrasound guided erector spinae plane block as a cause of unintended motor block

Erector spinae plane block (ESPB) as postoperative analgesia method has been successfully carried out in several surgical interventions. Postoperative pain treatment for cesarean section is considered one of the important challenges for anesthesiologists due to the risk of chronic pain development and even pospartum depression. Regional anesthesia techniques were effectively used to prevent the pain together with multimodal analgesia regimes in cesarean section. Formerly, successful erector spinae plane block was documented as postoperative analgesia treatment for cesarean section; however, no motor weakness was recorded as a side effect. In this case report, we present an unexpected motor weakness as a side effect of the erector spinae plane block after cesarean delivery operation in a 29 year old patient. To our knowledge, this is the first report of motor weakness related to the ESPB.

Bilateral single shot erector spinae plane block for pectus excavatum and pectus carinatum surgery in 2 pediatric patients

Numerous publications have emerged on the application of erector spinae plane block in adult population. There are few reports of the use of this block in pediatric patients. The objective is to report 2 cases of adolescents, one diagnosed with pectus excavatum and the other one with pectus carinatum undergoing reconstructive surgery in which a bilateral single-shot erector spinae plane block was performed as an analgesic technique. The block was performed before surgery under general anesthesia in lateral decubitus position, guided by ultrasound using 20ml of 0.25% bupivacaine per side. After the surgery they were extubated and transferred to the Intensive Care Unit. During their postoperative period they had visual analogic scale values less than 4 and no long term narcotics were used during the intraoperative and postoperative period. Bilateral single shot erector spinae plane block was effective as an analgesic technique for the intraoperative and postoperative period in pectus excavatum and pectus carinatum surgery in adolescents.

Pectoral nerve block as a single anesthetic technique for breast surgery and sentinel lymph node investigation

Breast cancer surgery is usually performed under general anesthesia or, more recently, combined with conventional regional techniques. Pectoral nerves (PECs) block appears as an analgesic alternative in these procedures, but few studies refer to it as a single anesthetic technique^1-3. In this case report, we describe a 56-year-old female patient, BMI 31kg/m², ASA IV, admitted for elective tumorectomy of the left upper quadrant of the breast and sentinel node investigation. Given the multiple comorbidities and the high anesthetic and surgical risk, the anaesthetic plan consisted in ultrasound guided PECs II block as a single anesthetic technique. The authors report a successful anesthetic and pain management without complications in breast surgery. PECs block, as a single anesthetic technique, may be safe, advantageous and effective with haemodynamic stability and few side effects in high risk cardiac patients.

Radiological study to evaluate the spreading of two volumes (10 vs. 20ml) of radiological contrast in the block of cutaneous branches of intercostal nerves in medial axillary line (BRILMA) in a porcine experimental model

OBJECTIVE

Interfascial blocks of the thoracic wall are being developed as an alternative to central blocks in breast surgery. However, there are few studies that have evaluated the anatomical extension of the local anaesthetic. The objective of this study was to analyse, using fluoroscopy, the spreading of two volumes (10 vs. 20ml) of radiological contrast in the serratus-intercostal plane block in an experimental pig model.

MATERIAL AND METHODS

Ten Large-White breed pigs were selected to have a bilateral ultrasound serratus-intercostal plane block performed, with the administering of 10ml and 20ml of iopamidol in the right and left hemithorax, respectively. The spreading of contrast was analysed by fluoroscopy. The Spearman test correlation was used to evaluate the relationship between the administered volume and radiological spreading. A value of P<.05 was considered significant.

RESULTS

Twenty anaesthetic blocks were performed, being able to analyse 18 of them. The administration of 10ml of contrast was associated with a mean spreading of 2.28±0.31 (95% CI; 2.01-2.54) intercostal spaces, while the administration of 20ml showed a spreading of 3±0.25 (95% CI; 2.81-3.18) intercostal spaces. There was a significant correlation between the injected volume and the spreading of the contrast (Spearman correlation coefficient of 0.81; P=.0001).

CONCLUSION

The results showed a spreading of volume subject to the serratus-intercostal plane block, although not maintaining a 1:1 ratio. Doubling the volume increased the blocked segments by 31%. These findings, if corroborated in the clinical practice, would allow a more precise adjustment in the anaesthetic volume administered.

The usefulness of interpectoral block as an analgesic technique in breast cancer surgery

OBJECTIVE

To compare the analgesic efficacy of continuous interpectoral block (CIPB) compared to intravenous analgesia (IV) after breast surgery.

MATERIAL AND METHOD

A prospective, comparative and randomised study of women aged from 18-75years, ASAI-III, operated for breast cancer. In group1 (CIPB) after general anaesthetic, an ultrasound-guided interpectoral catheter was placed and 30mL of 0.5% ropivacaine was administered through it. In the event of an increase in heart rate and blood pressure >15% after the surgical incision, intravenous fentanyl 1μg·kg^-1 was administered, repeating the dose as necessary. In the postoperative period, perfusion of ropivacaine 0.2% 5mL·h^-1; with PCA bolus 5mL/30minutes was administered through the catheter for 24hours and rescue analgesia prescribed with 5mg subcutaneous morphine chloride. In group2 (IV), after induction of general anaesthesia, intravenous fentanyl was administered in the same way as in the other group. The patients received metamizole 2g with dexketoprofen 50mg and ondansetron 4mg postoperatively followed by perfusion of metamizole 4%, tramadol 0.2% and ondansetron 0.08% 2ml·h^-1; with PCA bolus 2mL/20min for 24hours. The same rescue analgesia was prescribed. The principal variables recorded were pain at rest and during movement, according to a simple verbal scale (VAS 0-10) and the rescue analgesia required on discharge from recovery, at 12 and at 24hours.

RESULTS

137 patients were included: 81 in group1 (59.12%) and 56 in group2 (40.87%). No significant differences were observed in the analgesia between either group, but differences were observed in the dose of intraoperative fentanyl (P<.05). Differences that were not significant were observed in the rescue analgesia required on recovery (10% fewer on group1).

CONCLUSIONS

Both techniques provided effective postoperative analgesia, but the CIPB group required significantly less intraoperative fentanyl.

Erector spinae plane block for radical mastectomy: A new indication?

The erector spinae plane block is a technique recently described by Forero et al. in September 2016. It has applications in the control of chronic pain with neuropathic component of the chest wall, and for pain control in thoracoscopic surgery. In this article, we describe the use of this technique as part of a multimodal analgesic approach in a 40-year-old woman, who underwent radical mastectomy due to breast cancer. By performing this block before anesthetic induction, we have achieved an opioid sparing effect, avoiding a possible immunomodulatory effect, although not yet proven in humans. During hospitalization, the patient reported no pain (0/10 in numeric scale), without resorting to rescue analgesia. The easy, fast and safe execution of erector spinae plane block makes it a promising technique in the context of surgical pain during radical mastectomy.

Erector spinae plane block for analgesia after lower segment caesarean section: Case report

Effective postoperative analgesia after emergency caesarean section is important because it provides early recovery, ambulation and breast-feeding. The ultrasound-guided erector spinae plane block has been orginally described for providing thoracic analgesia at the T5 transverse process by Forero et al. We performed post-operative bilateral erector spinae plane blocks with 20ml bupivacaine 0.25% at the level of the T9 transverse process in a pregnant woman after caesarean section. In this report, we described that bilateral erector spinae plane block at T9 level provides effective and long-lasting postoperative analgesia for lower abdominal surgery.

Continuous erector spinae plane block for analgesia in pediatric thoracic surgery: A case report

Erector spinae plane block has been recently described and it appears as a very promising regional analgesia technique. We report the first continuous erector spinae plane block performed in a pediatric patient for thoracic surgery. A 15-month-old boy, diagnosed with a paracardiac teratoma was scheduled for a tumor resection with a thoracotomy approach. After general anesthesia induction, a continuous erector spinae plane block at T5 level was performed with ropivacaine 0.2%. After surgery, a continuous thoracic interfascial infusion of ropivacaine 0.1% along with multimodal rescue analgesia was initiated. The patient tolerated the procedure well with no complications. It appears that this is a good alternative to thoracic epidural and paravertebral block, given the simple reproducibility and potential greater safety of this technique.

The PECS II block as a major analgesic component for clavicle operations: A description of 7 case reports

Clavicle fractures correspond to 35% of traumatic fractures of the shoulder girdle. Regional anaesthesia has shown better analgesic results than systemic treatment for perioperative management. Innervation of the clavicle is complex, at present its knowledge raises controversy. The lateral pectoral nerve through the innervating musculature predominantly participates in the lateral and anterior part of the clavicle. The following report of 7 cases describes the effective postoperative analgesia of modified PEC II block in patients with middle third clavicle fracture or acromioclavicular dislocation who underwent a modified PEC II block for postoperative pain management, in the context of a multimodal analgesia. The potential advantage of this management over other analgesic procedures should be evaluated in specific clinical trials.

[Superior gluteal nerve: a new block on the block?]

BACKGROUND AND OBJECTIVES

The superior gluteal nerve is responsible for innervating the gluteus medius, gluteus minimus and tensor fascia latae muscles, all of which can be injured during surgical procedures. We describe an ultrasound-guided approach to block the superior gluteal nerve which allowed us to provide efficient analgesia and anesthesia for two orthopedic procedures, in a patient who had significant risk factors for neuraxial techniques and deep peripheral nerve blocks.

CLINICAL REPORT

An 84-year-old female whose regular use of clopidogrel contraindicated neuraxial techniques or deep peripheral nerve blocks presented for urgent bipolar hemiarthroplasty in our hospital. Taking into consideration the surgical approach chosen by the orthopedic team, we set to use a combination of general anesthesia and superficial peripheral nerve blocks (femoral, lateral cutaneous of thigh and superior gluteal nerve) for the procedure. A month and a half post-discharge the patient was re-admitted for debriding and correction of suture dehiscence; we performed the same blocks and light sedation. She remained comfortable in both cases, and reported no pain in the post-operative period.

CONCLUSIONS

Deep understanding of anatomy and innervation empowers anesthesiologists to solve potentially complex cases with safer, albeit creative, approaches. The relevance of this block in this case arises from its innervation of the gluteus medius muscle and posterolateral portion of the hip joint. To the best of our knowledge, this is the first report of an ultrasound-guided superior gluteal nerve block with an analgesic and anesthetic goal, which was successfully achieved.

Efficacy of ultrasound-guided transversus abdominis plane block in laparoscopic hysterectomy. Clinical trial

OBJECTIVES

Transversus abdominis plane block is a regional anaesthesia technique that has proven to be effective for postoperative pain reduction in different abdominal surgical procedures. This study evaluated its efficacy on post laparoscopic hysterectomy pain intensity and analgesic consumption.

MATERIALS AND METHODS

Randomized controlled trial which included 40 patients scheduled for laparoscopic hysterectomy, enrolled in 2 groups: transversus abdominis plane block+systemic analgesia (Group 1; n=20), versus systemic analgesia (Group 2; n=20). Opioid consumption within the first 24 postoperative hours, pain intensity scores at 60min, 2, 8 and 24h after surgery, adverse events related to systemic analgesia and time to hospital discharge were evaluated and registered.

RESULTS

We found no differences between both groups in opioid consumption (10mg vs. 7mg; P=.2) and pain scores (NVS) within the first 24 postoperative hours, at 60min (3 vs. 5; P=.65), 120min (0 vs. 2; P=.15), 8 and 24h (0 vs. 0; P>.50) for the last 2 points in time analysed. Adverse events related to medication and time to hospital discharge showed similar results.

CONCLUSIONS

Adding a transversus abdominis plane block technique to opioid PCA does not seem to improve postoperative pain management in laparoscopic hysterectomy. Patient preparation time and costs could be incremented and complications (although rare) related to the technique could appear.