Racial and ethnic disparities in regional anesthesia in the United States: A narrative review

BACKGROUND

Racial and ethnic disparities exist in the delivery of regional anesthesia in the United States. Anesthesiologists have ethical and economic obligations to address existing disparities in regional anesthesia care.

OBJECTIVES

Current evidence of racial and ethnic disparities in regional anesthesia utilization in adult patients in the United States is presented. Potential contributors and solutions to racial disparities are also discussed.

EVIDENCE REVIEW

Literature search was performed for studies examining racial and ethnic disparities in utilization of regional anesthesia, including neuraxial anesthesia and/or peripheral nerve blocks.

FINDINGS

While minoritized patients are generally less likely to receive regional anesthesia than white patients, the pattern of disparities for different racial/ethnic groups and for types of regional anesthetics can be complex and varied. Contributors to racial/ethnic disparities in regional anesthesia span hospital, provider, and patient-level factors. Potential solutions include standardization of regional anesthetic practices via Enhanced Recovery After Surgery (ERAS) pathways, increasing patient education, health literacy, language translation services, and improving diversity and cultural competency in the anesthesiology workforce.

CONCLUSION

Racial and ethnic disparities in regional anesthesia exist. Contributors and solutions to these disparities are multifaceted. Much work remains within the subspecialty of regional anesthesia to identify and address such disparities.

Efficacy and safety of ketamine as an adjuvant to regional anesthesia: A systematic review and meta-analysis of randomized controlled trials

STUDY OBJECTIVE

To identify whether adding ketamine to the local anesthetics (LA) in the regional anesthesia could prolong the duration of analgesia.

DESIGN

A Systematic review and meta-analysis of randomized controlled trials.

SETTING

The major dates were obtained in the operating room and the postoperative recovery ward.

PATIENTS

A total of 1011 patients at ASA physical status I and II were included in the analysis. Procedure performed including cesarean section, orthopedic, radical mastectomy, urological or lower abdominal surgery and intracavitary brachytherapy implants insertion.

INTERVENTIONS

After an extensive search of the electronic database, patients received regional anesthesia combined or not combined general anesthesia and with or without adding ketamine to LA were included in the analysis. The regional anesthesia includes spinal anesthesia, brachial plexus block, pectoral nerve block, transversus abdominis plane block and femoral and sciatic nerve block.

MEASUREMENT

The primary outcome was the duration of analgesia. Secondary outcomes were the duration and onset time of motor and sensory block as well as the ketamine-related adverse effect. Data are expressed in mean differences in continuous data and odds ratios (OR) for dichotomous data with 95% confidence intervals. The risk of bias of the included studies was evaluated using the revised Cochrane risk of bias tool for randomized trials. The quality of evidence for each outcome was rated according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Working Group system.

MAIN RESULT

Twenty randomized controlled trials were included in the analysis. When ketamine was used as an adjuvant to LA, the duration of analgesia could be prolonged(172.21 min, 95% CI, 118.20 to 226.22; P<0.00001, I2 = 98%), especially in the peripheral nerve block(366.96 min, 95% CI, 154.19 to 579.74; P = 0.0007, I2 = 98%). Secondary outcomes showed ketamine could prolong the duration of sensory block(29.12 min, 95% CI, 10.22 to 48.01; P = 0.003, I2 = 96%) but no effect on the motor block(6.94 min, 95% CI,-2.65 to 16.53;P = 0.16, I2 = 84%), the onset time of motor and sensory block (motor onset time, -1.17 min, 95% CI, -2.67 to 0.34; P = 0.13, I2 = 100%; sensory onset time, -0.33 min, 95% CI,-0.87 to 0.20; P = 0.23, I2 = 96%) as well as the ketamine-related adverse effect(OR, 1.97, 95% CI,0.93 to 4.17;P = 0.08, I2 = 57%).

CONCLUSION

This study indicates that ketamine could be an ideal adjuvant to local anesthetics regardless of the types of anesthesia. Overall, the quality of the evidence is low.

Ultrasound-guided sphenopalatine ganglion block for effective analgesia during awake fiberoptic nasotracheal intubation: A case report

BACKGROUND

Awake fiberoptic nasotracheal intubation (AFNI) is the preferred airway management strategy for patients with difficult airways. However, this procedure can cause significant physical and psychological distress. This case report explores the application of a sphenopalatine ganglion (SPG) block as an alternative analgesic modality to mitigate the discomfort associated with AFNI.

CASE SUMMARY

A 63-year-old female with a history of right maxillary osteosarcoma underwent craniotomy for a suspected malignant brain lesion. The patient’s medical history included prior surgery, chemotherapy, and radiation therapy, resulting in significant jaw impairment and limited neck mobility. Considering the anticipated airway challenges, AFNI was planned. A SPG block was performed under real-time ultrasound guidance, providing effective analgesia during nasotracheal intubation.

CONCLUSION

The SPG block represents a promising analgesic approach in AFNI, offering potential benefits in alleviating pain involving the nasal and nasopharyngeal regions as well as improving patient cooperation.

Usefulness of ultrasound-guided serratus-anterior block in prevention of postoperative pain after breast surgery. A cohort study

OBJECTIVE

To evaluate superficial serratus anterior plane block's efficacy and side effects in preventing postoperative pain after breast cancer surgery.

METHODOLOGY

A prospective cohort study was conducted on 195 adult patients undergoing breast oncological surgery under general anesthesia (Group G, n = 96) or combined general anesthesia with superficial serratus anterior plane block (Group L, n = 99). Validated preoperative data, which are predictors of chronic postoperative pain of patients, were recorded (type of surgery, age, pain in the area of the intervention and the other regions; anesthetic-surgical data, analgesic doses used, duration of surgery; pain intensity (EVN scale) at immediate postoperative period, 24 h, seven days and one month after the surgery, and complications.

RESULTS

Pain intensity, measured by the EVN scale, had a mean of 1.02 +/- 1.656 in the Postoperative Unit; 1.20 +/- 1.448 at 24 h; 0.76 +/- 1208 seven days; and 0.34 +/- 0.757 one month after surgery. Patients were operated under general anesthesia (n = 96) or general anesthesia combined with the interfascial block (n = 99). Significant differences (p < 0.05) were found in age, height, and VAS scale in PACU. Ten complications were recorded, six in Group L and four in Group G. There were no differences between groups in complications.

CONCLUSIONS

Superficial serratus anterior plane blocks are effective and safe in pain control in the immediate postoperative period for breast cancer surgery as a part of the multimodal approach. No significant differences were found one week and one month after surgery.

Clavipectoral fascia plane block in midshaft clavicle fractures: A cadaveric study

STUDY OBJECTIVE

The objective of this anatomical study was to investigate the distribution of a solution administered using the Clavipectoral Fascia Plane Block (CPB) technique in a series of cadaveric models with midshaft clavicular fractures. The study aimed to address the knowledge gap regarding the impact of clavicular fractures on the distribution pattern of the CPB-administered solution.

DESIGN

Observational cadaveric study.

SETTING

The research was conducted in the laboratory setting of the University of Barcelona, adhering to the institution's ethical guidelines and standards.

PATIENTS

Five unembalmed human cadavers were used, generating ten clavicle samples.

INTERVENTIONS

A postmortem fracture was induced in the middle third of the clavicle using a blunt-edged hammer, simulating a midshaft clavicular fracture.

MEASUREMENTS

Anatomical dissection was performed in three layers: the superficial muscle plane, deep muscle plane, and clavicular periosteum plane. Dye staining with methylene blue was utilized to assess the distribution pattern.

MAIN RESULTS

In the superficial muscular plane, methylene blue was observed in the deltoid (100%), pectoralis major (100%), sternocleidomastoid (SCM) (70%), and trapezius muscles (100%). Conversely, the deep muscular plane, including the subclavius muscle, pectoralis minor, and Clavipectoral Fascia (CPF), exhibited no staining. At the clavicular periosteum plane, methylene blue distributed predominantly to the antero-superior region (57.3%), with a minimal impact on the postero-inferior area (6.5%).

CONCLUSIONS

The study reveals that the presence of a midshaft clavicular fracture does not significantly alter the diffusion pattern of the CPB-administered solution, maintaining a consistent distribution in both intact and fractured clavicle models.

Erector spinae plane block did not improve postoperative pain-related outcomes and recovery after video-assisted thoracoscopic surgery : a randomised controlled double-blinded multi-center trial

INTRODUCTION

There is a sizable niche for a minimally invasive analgesic technique that could facilitate ambulatory video-assisted thoracoscopic surgery (VATS). Our study aimed to determine the analgesic potential of a single-shot erector spinae plane (ESP) block for VATS. The primary objective was the total hydromorphone consumption with patient-controlled analgesia (PCA) 24 h after surgery.

METHODS

We conducted a randomized, controlled, double-blind study with patients scheduled for VATS in two major university-affiliated hospital centres. We randomized 52 patients into two groups: a single-shot ESP block using bupivacaine or an ESP block with normal saline (control). We administered a preoperative and postoperative (24 h) quality of recovery (QoR-15) questionnaire and assessed postoperative pain using a verbal numerical rating scale (VNRS) score. We evaluated the total standardized intraoperative fentanyl administration, total postoperative hydromorphone consumption (PCA; primary endpoint), and the incidence of adverse effects.

RESULTS

There was no difference in the primary objective, hydromorphone consumption at 24 h (7.6 (4.4) mg for the Bupivacaine group versus 8.1 (4.2) mg for the Control group). Secondary objectives and incidence of adverse events were not different between the two groups at any time during the first 24 h following surgery.

CONCLUSION

Our multi-centre randomized, controlled, double-blinded study found no advantage of an ESP block over placebo for VATS for opioid consumption, pain, or QoR-15 scores. Further studies are ongoing to establish the benefits of using a denser block (single-shot paravertebral with a continuous ESP block), which may provide a better quality of analgesia.

Diaphyseal forearm fracture management in adolescent patients from 2011 to 2020: A multicenter study of surgery and regional anesthesia trends

BACKGROUND

Diaphyseal forearm fractures are common traumatic injuries among children. There has been much debate on the use of intramedullary nailing (IMN) or plate fixation in the adolescent population (10-16 years of age). Furthermore, as ultrasound technology has advanced, the safety and efficacy of ultrasound-guided axillary brachial plexus block for children has dramatically improved. Therefore, anesthesia options for adolescent patients have increased in recent years. This study aimed to investigate recent surgical and regional anesthesia trends of diaphyseal forearm fractures in patients 10 to 16 years of age in Japan through a multicenter epidemiological survey from 2011 to 2020.

METHODS

This retrospective, multicenter study included 226 pediatric patients with diaphyseal forearm fracture aged 10-16 years treated from January 2011 to December 2020. We divided the patients into four groups according to the period in which they were treated: early (2011-2013), middle (2014-2016), late (2017-2019), and COVID-19 (2020). Information from medical records was used to investigate the number of surgeries, types of anesthesia administered, and internal fixation methods used for diaphyseal forearm fracture in adolescent patients during each period.

RESULTS

The number of surgeries was generally constant in each period but decreased during the COVID-19 period. In the early, middle, late, and COVID-19 periods, the percentages of surgeries performed under regional anesthesia were 67.7, 85.5, 87.0, and 100% respectively (p = 0.003). During the same periods, the percentages of patients receiving IMN were 41.5, 49.3, 58.0, and 66.7%, respectively (p = 0.033).

CONCLUSION

The use of IMN and regional anesthesia to treat diaphyseal forearm fracture in patients 10 to 16 years of age steadily increased during the study period from 2011 to 2020. These results indicate that regional anesthesia is safe, effective, and well-tolerated by adolescent patients. The treatment strategy for diaphyseal forearm fractures in adolescents using regional anesthesia in combination with IMN worked well and was effective during COVID-19. Our evidence suggests this trend will continue. We anticipate that our findings can be extrapolated for upper extremity fractures in adolescent patients beyond the Tokai region of Japan where the study was based.

Association of anesthetic modality and other variables on 1-year functional patency of cephalic-based arteriovenous fistulae

OBJECTIVE

Some studies suggest that regional anesthesia provides better patency for arteriovenous fistula (AVF) for hemodialysis access as compared to local and general anesthesia. This study evaluates the impact of anesthetic modality on long term fistula function at 12 months.

METHODS

A retrospective review of patients undergoing cephalic vein-based hemodialysis access in consecutive cases between 2014 and 2019 was conducted from five safety net hospitals. The primary endpoint was functional patency at 12 months. Subset analysis individually evaluated cephalic-based lower forearm and wrist vs upper arm AVFs. Bivariate and multivariate logistic regression models evaluated the relationship between anesthetic modality and fistula function at 12 months.

RESULTS

There were 818 cephalic-based fistulas created during the study period. The overall 12-month functional patency rate was 78.7%, including an 81.3% patency for upper arm AVF and 73.3% for wrist AVF (P = .009). There was no statistically significant difference among patients with functional and nonfunctional AVFs at 12 months with respect to anesthetic modality when comparing regional, local, and general anesthesia (P = .343). Multivariate regression analysis identified that history of AVF/arteriovenous graft (odds ratio [OR], 0.24; P = .007), receiving intraoperative systemic anticoagulation (OR, 2.49; P < .001), and vein diameter (OR, 1.85; P = .039) as independently associated with AVF functional patency at 12 months.

CONCLUSIONS

There was no association between anesthetic modality and functional patency of cephalic-based AVFs at 12 months. Further studies are needed to better define which patients may benefit from regional anesthesia.

Comparison of the analgesic efficacy of the ultrasound-guided transversalis fascia plane block and erector spinae plane block in patients undergoing open inguinal hernia repair under spinal anesthesia

BACKGROUND

Open inguinal hernia repair (OIHR) surgery is a common surgical procedure, and ultrasound guided interfascial plane blocks can also be included in current approaches to postoperative multimodal analgesia regimens. This study aimed to compare the postoperative analgesic efficacy of the erector spinae plane block (ESPB) and transversalis fascia plane block (TFPB) in patients undergoing OIHR.

METHODS

This prospective, randomized, assessor-blinded comparative study was conducted in the postoperative recovery room and ward of a tertiary hospital. A total of 80 patients with American Society of Anesthesiologists physical status I-III were enrolled and allocated equally to either the ESPB or TFPB group. The patients received standard multimodal analgesia in addition to an ultrasound-guided ESPB or TFPB. During the first 24 h postoperatively, tramadol consumption was assessed and pain levels at rest and during movement were compared using numeric rating scale (NRS) scores at 1, 3, 6, 9, 12, 18, and 24 h postoperatively.

RESULTS

The results showed no difference in NRS scores at any time point between the groups, except for NRS at rest in the third hour. However, tramadol consumption was lower in the TFPB group than in the ESPB group overall (88 ± 75.2 vs. 131 ± 93.7 mg, respectively; P = 0.027, mean difference: -43, 95% CI [-80.82, -5.18]).

CONCLUSIONS

The TFPB leads to lower tramadol requirements in the first 24 h postoperatively than the ESPB in patients undergoing OIHR.

Cadaveric study of the ultrasound-guided erector spinae plane block over the transverse process of the twelfth thoracic vertebra in dogs: Transversal vs longitudinal approach

This study describes a transversal (TV) ultrasound-guided erector spinae plane (ESP) block technique over the transverse process of T12. And evaluates the distribution of the dye and affected nerves branches compared to a longitudinal (LNG) approach over the transverse process of T12 in canine cadavers. Secondly, it also compares de anatomy and dimensions of the transverse processes of T12 with T9 and T5. For this double-masked, cadaveric experimental study, 12 adult Beagle cadavers were injected with 0.6 mL/kg of dye/contrast. Spread was evaluated by computed tomography (CT) and dissection. Mean bodyweight was 9.76 (±0.59) kg. The TV and LNG approaches stained a median (range) of four (2-6) and three (1-6) medial branches of the dorsal rami of the spinal nerves, three (2-6) and three (2-5) lateral branches, and one (0-3) and one (0-4) ventral branches, respectively. Dye was detected in the epidural space in 55.6% and 66.7% of cases for the TV and LNG approaches, respectively (P=0.63). And in the ventral paravertebral compartment in 22.2% and lymphatics in 88.8% in both approaches. There were no statistical differences for the spread. The dorsolateral edge of the transverse process (TP) was not visible with CT at T12. The mean (±SD) length of the TP was significantly shorter at T12 [3.34 (±0.22)] mm, compared to T9 [6.08 (±0.47)] mm and T5 [5.93 (±0.62)] mm (P <0.001). This study showed similar distribution whether using a TV or LNG approach and differences in the anatomy and length of the T12 TP.

Ultrasound-guided nerve blocks in emergency medicine practice: 2022 updates

OBJECTIVES

In the Emergency Department (ED), ultrasound-guided nerve blocks (UGNBs) have become a cornerstone of multimodal pain regimens. We investigated current national practices of UGNBs across academic medical center EDs, and how these trends have changed over time.

METHODS

We conducted a cross-sectional electronic survey of academic EDs with ultrasound fellowships across the United States. Twenty-item questionnaires exploring UGNB practice patterns, training, and complications were distributed between November 2021-June 2022. Data was manually curated, and descriptive statistics were performed. The survey results were then compared to results from Amini et al. 2016 UGNB survey to identify trends.

RESULTS

The response rate was 80.5% (87 of 108 programs). One hundred percent of responding programs perform UGNB at their institutions, with 29% (95% confidence interval (CI), 20%-39%) performing at least 5 blocks monthly. Forearm UGNB are most commonly performed (96% of programs (95% CI, 93%-100%)). Pain control for fractures is the most common indication (84%; 95% CI, 76%-91%). Eighty-five percent (95% CI, 77%-92%) of programs report at least 80% of UGNB performed are effective. Eighty-five percent (95% CI, 66%-85%) of programs have had no reported complications from UGNB performed by emergency providers at their institution. The remaining 15% (95% CI, 8%-23%) report an average of 1 complication annually.

CONCLUSIONS

All programs participating in our study report performing UGNB in their ED, which is a 16% increase over the last 5 years. UGNB's are currently performed safely and effectively in the ED, however practice improvements can still be made. Creating multi-disciplinary committees at local and national levels can standardize guidelines and practice policies to optimize patient safety and outcomes.

S erratus anterior plane block alone, paravertebral block alone and their combination in video-assisted thoracoscopic surgery: the THORACOSOPIC double-blind, randomized trial

OBJECTIVES

Serratus anterior plane block (SAPB) and paravertebral block (PVB) are well known to reduce pain levels after video-assisted thoracoscopic surgery (VATS). However, the relative efficacies of each block and a combination of the 2 have not been fully characterized. The objective of the present study was to assess the efficacy of PVB alone, SAPB alone and the combination of PVB and SAPB with regard to the occurrence and intensity of pain after VATS.

METHODS

We conducted the THORACOSOPIC single-centre, double-blind, randomized trial in adult patients due to undergo elective VATS lung resection. The participants were randomized to PVB only, SAPB only and PVB + SAPB groups. The primary end-point was pain on coughing on admission to the postanaesthesia care unit. The secondary end-points were postoperative pain at rest and on coughing at other time points and the cumulative opioid consumption. Pain was scored on a visual analogue scale.

RESULTS

One-hundred and fifty-six patients (52 in each group) were included. On admission to the postanaesthesia care unit, the 3 groups did not differ significantly with regard to the pain on coughing: the visual analogue scale score was 3 (0-6), 4 (0-8) and 2 (0-6) in the PVB, SAPB and PVB + SAPB groups, respectively (P = 0.204). During postoperative care, the overall pain score was significantly lower in the SABP + PVP group at rest and on cough.

CONCLUSIONS

The combination of SABP + PVB could be beneficial for pain management in VATS in comparison to SABP or PVB alone.

Fascia iliaca catheters for donor site pain after split-thickness skin grafting for acute burn injury: a retrospective review

The management of acute burn pain poses significant challenges. Regional techniques have become increasingly popular in perioperative burn pain management. Continuous nerve block catheters are particularly useful for split thickness skin grafts where donor site pain can exceed that of the burn-injured site. Donor skin is frequently harvested from the anterolateral thigh. The fascia iliaca (FI) compartment block provides blockade of both the lateral femoral cutaneous nerve and the femoral nerve and thus, it is a useful modality for burn donor pain. Our institution initiated a protocol in which continuous fascia iliaca catheters were placed in patients undergoing split-thickness skin grafting of the anterolateral thigh. This retrospective review seeks to assess the impact of this modality on post-operative pain scores and opioid requirements. Oral morphine equivalent administration was significantly lower in the FI group than the control group starting with POD 0, which is the day of the FI catheter insertion (188 vs 327mg, p<0.001). Over the next 4 postoperative days, OME administration remained lower in the FI group compared to control patients, although not statistically significant on POD 3-4. There was a significant difference in OME administered between the FI group and the control group on POD 5 (159.5 vs 209.2mg, p<0.05). Our retrospective study evaluating the role of fascia iliaca catheters in burn patients undergoing split thickness skin grafting surgery showed significantly lower opioid consumption on postoperative days 1-5 compared to patients without a fascia iliaca catheter.

Updates From the Other Side of the Drape: Recent Advances in Multimodal Pain Management and Opioid Reduction Among Pediatric Surgical Patients

As the management of acute pain for children undergoing surgical procedures as well as recognition of the short and long term risks of exposure to opioids has evolved, multimodal and multidisciplinary approaches using organized pathways has resulted in improved perioperative outcomes and patient satisfaction. In this 2023 symposium held at the American Academy of Pediatrics on Surgery meeting, a multidisciplinary discussion on current enhanced recovery after surgery pathways, alternate methods of effective pain control and education and advocacy efforts for opioid reduction were discussed, and highlights are included in this article.

Nerve Blocks for Craniotomy

PURPOSE OF REVIEW

Postcraniotomy headache (PCH) is a common adverse event and can lead to various complications and decreased quality of life.

RECENT FINDINGS

To reduce postcraniotomy pain and associated complications, a multimodal pain therapy including analgesics, analgesic adjuncts, and regional anesthesia is essential. The use of opioids should be minimized to facilitate prompt postoperative neurosurgical assessment. Here, we provide an update on the latest evidence regarding the role of scalp nerve blocks in the pain management of patients undergoing craniotomy procedure. Nerve blocks are effective in alleviating postoperative pain after craniotomy. Scalp blocks contribute to lower pain levels and less opioid consumption in the first 48 h following surgery. Moreover, there is a significant decrease in patients suffering from PONV among patients who receive scalp block.

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.

Outcomes of cell infusion for the treatment of neurological sequelae induced by spinal anesthesia-associated subdural hematoma: A case report

Background

Subdural hematoma following spinal anesthesia for cesarean delivery is a rare complication. Surgical removal of the hematoma is the standard treatment. However, there are still many patients who suffer permanent nerve damage of varying degrees after surgery. Cell therapy has recently shown great potential for treating nerve damage.

Case presentation

This report described a case of paraplegia due to an epidural hematoma occurring after spinal anesthesia for cesarean section. The patient underwent surgery to remove the hematoma and rehabilitation afterward. However, no improvement was noted. Paralysis of the lower extremities associated with urinary retention and constipation persisted. The patient received three administrations of cell infusion: the first time with autologous bone marrow-derived mononuclear cells and the following two with autologous adipose mesenchymal/stromal cells. After three cell infusions, the patient was able to walk and could urinate and defecate voluntarily. Sensory and motor function were improved and MRI showed a decrease in adherence of the nerve roots and spinal cord.

Conclusions

Our results demonstrated that cell therapy may ameliorate paralysis of the lower extremities as well as fecal and urinary function following spinal hematoma associated with spinal anesthesia.

Dislodgment of continuous suprascapular nerve block catheters after physiotherapy: A cadaver study

BACKGROUND

Continuous peripheral nerve blocks are commonly used for pain management. However, the incidence of catheter dislodgement or migration is unclear, and may be underestimated and underreported. Our objective was to assess suprascapular catheter tip positioning before and after routine simulated shoulder physiotherapy manipulation in an anatomical cadaver model.

METHOD

Eight ultrasound-guided continuous suprascapular nerve block catheters were placed in cryopreserved fresh cadavers. Computed tomography (CT) confirmed the location of the catheter tip after injection of 1 ml of contrast medium. We performed a series of standardized shoulder movements during a simulated shoulder physiotherapy session in cadavers. Following this, we administered 1 ml of methylene blue through the catheters, and then performed anatomical dissections to accurately identify the location of the catheter tips and compare them to their placement prior to the 'physiotherapy'.

RESULT

CT imaging confirmed the location of the catheter tips at the suprascapular notch in all cases. However, following physiotherapy, 2 catheters (25%) were found to have migrated - specifically, 1 was located in the supraspinatus muscle, and the other was located in the trapezius muscle.

CONCLUSION

Our findings suggest that catheter dislodgement may occur in approximately 25% of cases following simulated physiotherapy manipulation. However, further research is needed to determine the read incidence of catheter dislodgement in clinical practice.

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.

Analgesic efficacy of an opioid-free postoperative pain management strategy versus a conventional opioid-based strategy following laparoscopic radical gastrectomy: an open-label, randomized, controlled, non-inferiority trial

OBJECTIVE

In patients undergoing laparoscopic radical gastrectomy, the use of subcostal transversus abdominis plane block (STAPB) for completely opioid-free postoperative pain management lacks convincing clinical evidence.

METHODS

This study included 112 patients who underwent laparoscopic radical gastrectomy at the 900TH Hospital of the Joint Logistics Support Force from October 2020 to March 2022. Patients were randomly divided into (1:1) continuous opioid-free STAPB (C-STAPB) group and conventional group. In the C-STAPB group, 0.2% ropivacaine (bilateral, 20 ml per side) was injected intermittently every 12 h through a catheter placed on the transverse abdominis plane for postoperative pain management. The conventional group was treated with a conventional intravenous opioid pump (2.5 μg/kg sufentanil and 10 mg tropisetron, diluted to 100 ml with 0.9% NS). The primary outcomes were the accumulative area under the curve of the numeric rating scale (NRS) score at 24 and 48 h postoperatively at rest and during movement. The secondary outcomes were postoperative recovery outcomes, postoperative daily food intake, and postoperative complications.

RESULTS

After exclusion (n = 16), a total of 96 patients (C-STAPB group, n = 46; conventional group, n = 49) were included. We found there were no significant differences in the cumulative AUC of NRS score PACU-24 h and PACU-48 h between the C-STAPB group and conventional group at rest [(mean difference, 1.38; 95% CI, - 2.21 to 4.98, P = 0.447), (mean difference, 1.22; 95% CI, - 6.20 to 8.65, P = 0.744)] and at movement [(mean difference, 2.90; 95% CI, - 3.65 to 9.46; P = 0.382), (mean difference, 4.32; 95% CI, - 4.46 to 13.1; P = 0.331)]. The 95% CI upper bound of the difference between rest and movement in the C-STAPB group was less than the inferior margin value (9.5 and 14 points), indicating the non-inferiority of the analgesic effect of C-STPAB. The C-STAPB group had faster postoperative recovery profiles including earlier bowel movement, defecation, more volume of food intake postoperative, and lower postoperative nausea and vomiting compared to conventional groups (P < 0.001).

CONCLUSIONS

After laparoscopic radical gastrectomy, the analgesic effect of C-STAPBP is not inferior to the traditional opioid-based pain management model.

TRIAL REGISTRATION

ChiCTR2100051784.

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.

A Single Center's Experience With Spinal Anesthesia for Pediatric Patients Undergoing Surgical Procedures

PURPOSE

To perform a single institution review of spinal instead of general anesthesia for pediatric patients undergoing surgical procedures. Spinal success rate, intraoperative complications, and postoperative outcomes including unplanned hospital admission and emergency department visits within seven days are reported.

METHODS

Retrospective chart review of pediatric patients who underwent spinal anesthesia for surgical procedures from 2016 until 2022. Data collected included patient demographics, procedure and anesthetic characteristics, intraoperative complications, unplanned admissions, and emergency department returns.

RESULTS

The study cohort included 1221 patients. Ninety-two percent of the patients tolerated their surgical procedure without requiring conversion to general anesthesia, and 78% of patients that had spinals placed successfully did not receive any sedation following lumbar puncture. The most common intraoperative event was systolic blood pressure below 60 mm Hg (14%), but no cases required administration of vasoactive agents, and no serious intraoperative adverse events were observed. Post-Anesthesia Care Unit Phase I was bypassed in 72% of cases with a median postoperative length of stay of 84 min. Forty-six patients returned to the emergency department following hospital discharge, but no returns were due to anesthetic concerns.

CONCLUSIONS

Spinal anesthesia is a viable and versatile option for a diversity of pediatric surgical procedures. We noted a low incidence of intraoperative and postoperative complications. There remain numerous potential advantages of spinal anesthesia over general anesthesia in young pediatric patients particularly in the ambulatory setting.

LEVEL OF EVIDENCE

IV.

TYPE OF STUDY

Retrospective cohort treatment study.

Erector spinae plane block as an anesthesia technique for an emergent thoracotomy; a case report

BACKGROUND

The erector spinae plane block (ESPB) is a novel regional block technique for pain management following thoracic surgeries. However, there are minimal cases in which the technique was used as the main anesthesia technique during surgery.

CASE PRESENTATION

Here, we report the successful use of ESBP for applying anesthesia in a case during an emergent thoracotomy for performing pericardiotomy and loculated tamponade evacuation.

CONCLUSIONS

Using ESPB with a higher concentration of local anesthetics, in this case, prepared appropriate anesthesia for performing an emergent thoracotomy while avoiding multiple needle insertions and the risk of further hemodynamic instability.

Liposomal bupivacaine interscalene blocks demonstrate a greater proportion of total shoulder arthroplasty patients with clinically tolerable pain: a retrospective quality improvement study of 491 patients

OBJECTIVE

To evaluate the effects of liposomal bupivacaine use for interscalene blocks on postoperative analgesia in total shoulder arthroplasty patients.

METHODS

De-identified total or reverse total shoulder arthroplasty patients between 2018 and 2021 were analyzed. Patients were grouped into single shot interscalene block with liposomal bupivacaine (LB) with plain bupivacaine, other block (OB) with other local anesthetics (mepivacaine, ropivacaine, or plain bupivacaine), or no block (NB). The primary outcome was the proportion of patients with clinically tolerable pain scores (mean VAS ≤4) from 0 to 24 ​h in each group. Secondary outcomes included averaged visual analog pain scores (VAS) and opioid consumption measured in morphine milligram equivalents (MMEs) from 0 to 24 ​h. We also analyzed the proportion of patients with clinically tolerable pain, mean VAS, and opioid consumption from 0 to 72 ​h in those patients with at least a 3-day hospital length of stay.

RESULTS

A total of 491 de-identified total shoulder arthroplasty patients, 285 liposomal bupivacaine group (LB), 178 other block group (OB), and 28 no block group (NB), were analyzed. The primary outcome showed a statistically significant different proportion of patients with clinically tolerable pain from 0 to 24 ​h in the LB group (69 ​%) vs. OB group (39 ​%) vs. NB group (11 ​%) (<0.001). Secondary outcomes included statistically significant differences in VAS (LB median ​= ​3.35, OB median ​= ​4.38, NB median ​= ​5.25 (p ​< ​0.001, <0.001)) and total MME opioid consumption (LB median ​= ​40, OB median ​= ​60, NB median ​= ​88 (p ​< ​0.001, 0.001)) between groups from 0 to 24 ​h. For patients who had hospital stays of at least 3 days, a significant association was found with having achieved clinically tolerable pain 0-72 ​h and the LB group (51 ​%) vs. OB group (21 ​%) vs. NB group (11 ​%) (P ​= ​0.006). However, there was no statistical difference in mean VAS or opioid consumption between these groups.

CONCLUSION

A greater proportion of total shoulder arthroplasty patients that received liposomal bupivacaine in interscalene block have clinically tolerable pain scores from 0 to 24 ​h, lower VAS, and lower MME consumption in patients following total shoulder arthroplasty.

LEVEL OF EVIDENCE

Level III - Clinical Study.

Effect of local anesthetic volume (20 vs. 40 ml) on the analgesic efficacy of costoclavicular block in arthroscopic shoulder surgery: a randomized controlled trial

BACKGROUND

Among the various diaphragm-sparing alternatives to interscalene block, costoclavicular block (CCB) demonstrated a low hemidiaphragmatic paresis (HDP) occurrence but an inconsistent analgesic effect in arthroscopic shoulder surgery. We hypothesized that a larger volume of local anesthetic for CCB could provide sufficient analgesia by achieving sufficient supraclavicular spreading.

METHODS

Sixty patients scheduled for arthroscopic rotator cuff repair were randomly assigned to receive CCB using one of two volumes of local anesthetic (CCB20, 0.75% ropivacaine 20 ml; CCB40, 0.375% ropivacaine 40 ml). The primary outcome was the rate of complete analgesia (0 on the numeric rating scale of pain) at 1 h postoperatively. The secondary outcomes included a sonographic assessment of local anesthetic spread, diaphragmatic function, pulmonary function, postoperative opioid use, and other pain-related experiences within 24 h postoperatively.

RESULTS

The rates of complete analgesia were not significantly different (23.3% [7/30] and 33.3% [10/30] in the CCB20 and CCB40 groups, respectively; risk difference 10%, 95% CI [-13, 32], P = 0.567). There were no significant differences in other pain-related outcomes. Among the clinical factors considered, the only factor significantly associated with postoperative pain was the sonographic observation of supraclavicular spreading. There were no significant differences in the incidence of HDP and the change in pulmonary function between the two groups.

CONCLUSIONS

Using 40 ml of local anesthetic does not guarantee supraclavicular spread during CCB. Moreover, it does not result in a higher rate of complete analgesia compared to using 20 ml of local anesthetic in arthroscopic shoulder surgery.

Pain management for hospitalized patients with rib fractures: A systematic review of randomized clinical trials

STUDY OBJECTIVE

Rib fractures (RF) are common injuries. Multiple analgesia strategies are available for treatment of pain associated with RF. However, the optimal multimodal technique for pain management is not known. The primary aim of this review was to evaluate the status of evidence derived from randomized clinical trials (RCTs) on the effectiveness of pain management modalities for rib fracture pain. Other patient-centered outcomes were secondary objectives.

METHODS

Searches were conducted in MEDLINE, Embase, Scopus, and Cochrane Library. The screening process involved two phases, two researchers independently screened the title and abstract and subsequently screened full text. RCT data were extracted independently by two research team members. Consensus was achieved by comparison and discussion when needed. Risk of bias assessment was performed using the Cochrane Risk of Bias 2 tool.

RESULTS

A total of 1344 citations were identified. Title and abstract screening excluded 1128 citations, and full text review excluded 177 articles. A total of 32 RCTs were included in the full review. Multiple analgesia techniques and medications were identified and their effect on pain score and need for rescue opioid analgesia. None of the included studies were judged to have a high risk of bias, while only 10 studies were assessed as having a low risk of bias.

CONCLUSIONS

This systematic review found that studies are of low quality with diverse methodologies and outcomes. A reduction in pain scores was found for epidural analgesia when compared with other modalities. However, the low quality of the evidence necessitates cautious interpretation of this finding. PROSPERO registration: CRD42022376298 (Nov, 16, 2022).

Combined Single-Shot Infiltration Between the Popliteal Artery and Capsule of the Knee and Adductor Canal Block With Bupivacaine, Dexmedetomidine, and Dexamethasone for Total Knee Arthroplasty: A Propensity-Matched Analysis

Background

To investigate if combined single-shot adductor canal blockade (ACB) and infiltration between the popliteal artery and capsule of the knee (IPACK) provide better postoperative pain management compared to ACB alone for patients undergoing unilateral total knee arthroplasty (TKA).

Methods

This retrospective cohort study included adult patients who underwent primary, unilateral TKA. Patients were separated into 2 cohorts: single-shot ACB alone (performed with bupivacaine 0.25%) and combined single-shot ACB + IPACK (performed with bupivacaine 0.25%, dexmedetomidine 1 mg/kg, and dexamethasone 4 mg). Patients were propensity-matched 1:1. The primary study outcome was total opioid consumption converted to morphine milligram equivalents (MME) per eight-hour interval and postoperative day. Secondary outcomes included pain scores, length of stay, ambulation distance, return to emergency department, hospital readmission, and 30-day adverse events.

Results

One hundred eighty patients were identified, of which propensity matching used 71% to yield 64 patients receiving ACB alone and 64 receiving combined ACB + IPACK. Combined ACB + IPACK had significantly lower total summative MME throughout the entire postoperative stay (P = .002) and cumulatively after the first 24 hours (P < .001). Combined ACB + IPACK also had lower mean pain scores for 0-8 hours (P = .005) and 8-16 hours (P = .009) postoperatively. There were no significant differences in secondary outcomes.

Conclusions

Combined single-shot ACB + IPACK block was associated with lower total narcotic intake and mean pain scores during most of the immediate postoperative period following primary, unilateral TKA compared to ACB alone. Implementing longer-acting, single-shot ACB + IPACK for TKA can balance effective and more selective pain management with early rehabilitation.

Comparison of the median and intermediate approaches to the ultrasound-guided sacral erector spinae plane block: a cadaveric and radiologic study

BACKGROUND

Erector spinae plane block (ESPB) is a well-established method for managing postoperative and chronic pain. ESPB applications for the sacral area procedures are called sacral ESPBs (SESPBs). This cadaveric study aimed to determine the distribution of local anesthesia using the median and intermediate approaches to the SESPB.

METHODS

Four cadavers were categorized into the median and intermediate approach groups. Ultrasound-guided SESPBs were performed using a mixture of radiopaque agents and dye. Following confirmation of the solution distribution through computed tomography (CT), the cadavers were dissected to observe the solution distribution.

RESULTS

CT images of the median group demonstrated subcutaneous pooling of the radiopaque solution between the S1 and S5 horizontal planes. Radiopaque solution also passed from the sacral foramina to the anterior sacrum via the spinal nerves between S2 and S5. In the intermediate group, the solution distribution was observed along the bilateral erector spinae muscle between the L2 and S3 horizontal planes; no anterior transition was detected. Dissection in the median group revealed blue solution distribution in subcutaneous tissue between horizontal planes S1 and S5, but no distribution in superficial fascia or muscle. In the intermediate group, red solution was detected in the erector spinae muscle between the L2 and S3 intervertebral levels.

CONCLUSIONS

Radiologic and anatomic findings revealed the presence of radiopaque dye in the superficial and erector spinae compartments in both the median and intermediate groups. However, anterior transition of the radiopaque dye was detected only in the median group.

Intercostal spinal nerve cryoablation for analgesia following pectus excavatum repair

Pectus excavatum is a common chest wall deformity, most often treated during adolescence, that presents a significant postoperative pain control challenge for pediatric surgeons following surgical correction. The purpose of this article is to review the technique and outcomes of intercostal spinal nerve cryoablation for postoperative analgesia following surgical correction of pectus excavatum. Contemporary and historic literature were reviewed. Findings are summarized to provide a concise synopsis of the benefits of intercostal spinal nerve cryoablation relative to alternative analgesic modalities, as well as advocate for more widespread inclusion of this technique into multimodal pain regimens.

A prospective, randomized trial of liposomal bupivacaine compared to conventional bupivacaine on pain control and postoperative opioid use in adults receiving adductor canal blocks for total knee arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) is a commonly performed procedure to alleviate pain and improve functional limitations caused by end-stage joint damage. Effective management of postoperative pain following TKA is crucial to the prevention of complications and enhancement of recovery. Adductor canal blocks (ACB) with conventional bupivacaine (CB) provide adequate analgesia after TKA, but carry a risk of rebound pain following block resolution. Liposomal bupivacaine (LB) is an extended-release local anesthetic that can provide up to 72 h of pain relief. The objective of this study was to compare postoperative outcomes between ACBs using LB and CB after TKA.

METHODS

This single institution, prospective, randomized, clinical trial enrolled patients scheduled for TKA. Participants were randomized to receive ACB with either LB or CB. Pain scores up to 72 h postoperatively were assessed as the primary outcome. Opioid consumption and length of stay were evaluated as secondary outcomes.

RESULTS

A total of 80 patients were enrolled. Demographic and clinical characteristics were similar between the two groups. LB group showed significantly lower cumulative opioid use during the 72 h evaluated (P = 0.016). There were no differences in pain scores or length of stay between the groups.

CONCLUSION

The study demonstrated that LB ACBs led to significantly lower opioid consumption in the days following TKA without affecting pain scores or length of stay. This finding has important implications for improving postoperative outcomes and reducing opioid use in TKA patients. Previous studies have reported inconsistent results regarding the benefits of LB, highlighting the need for further research.

TRIAL REGISTRATION

This project was retrospectively registered with clinicaltrials.gov ( NCT05635916 ) on 2 December 2022.

Analgesic efficacy and safety of erector spinae versus serratus anterior plane block in thoracic surgery: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Erector spinae plane block (ESPB) and serratus anterior plane block (SAPB) are regional anesthesia techniques that have shown favorable results in pain management following thoracic surgeries; however, their relative superiority is unclear. This review (PROSPERO: CRD42023443018) aims to compare the analgesic efficacy of ESPB and SAPB in patients undergoing thoracic surgeries through the pooled analysis of co-primary outcomes: postoperative oral-morphine-equivalent (mg) consumption in 24 h and pain scores (static) at 24 h.

METHODS

A literature search was conducted across PubMed, Cochrane Library, and Google Scholar to identify randomized controlled trials (RCTs) from inception to May 2023, comparing ESPB and SAPB in thoracic surgeries. Statistical pooling was done using Review Manager 5.4.1. Bias assessment employed the Cochrane Collaboration Risk-of-Bias 2.0 tool. The strength of evidence was assessed using the guidelines from the GRADE working group.

RESULTS

Nine RCTs (485 patients) were included in the study. Postoperative pain scores (static) at 24 h (mean difference (MD) =  - 0.31 [- 0.57, 0.05], p = 0.02) and postoperative oral-morphine-equivalent (mg) consumption in 24 h (MD =  - 19.73 [- 25.65, - 13.80], p < 0.00001) were significantly lower in the ESBP group. However, the MDs did not exceed the set threshold for clinical importance. No significant differences were observed in the opioid-related adverse effects and block-related complications.

CONCLUSION

Our statistically significant results imply that ESPB has superior analgesic efficacy compared to SAPB; however, this difference is clinically unimportant. The safety profile of the two blocks is comparable; hence, current evidence cannot define the relative superiority of one block over the other. Our findings warrant further research with standardized methodologies and a longer duration of analgesic efficacy assessment to yield robust evidence for better clinical applications.

Regional anesthesia might reduce recurrence and metastasis rates in adult patients with cancers after surgery: a meta-analysis

BACKGROUND

The influence of anesthesia techniques on cancer recurrence and metastasis following oncological surgery is a topic of growing interest. This meta-analysis investigates the potential effects of regional anesthesia (RA), either independently or combined with general anesthesia (GA), on these outcomes.

METHODS

We performed an extensive search across PubMed, Embase, and the Cochrane Library databases. The primary outcome was cancer recurrence, while the secondary outcomes were local recurrence and distant metastasis. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated by utilizing random-effects models. The Newcastle-Ottawa Scale (NOS) was used for quality assessment of observational studies, the Cochrane Risk of Bias Tool for Randomized Trials (Rob 2.0) was used for randomized controlled trials, and all the outcomes were assessed by using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE).

RESULTS

This study included 32 studies comprising 24,724 cancer patients. RA, either alone or in combination with GA, was significantly associated with reduced cancer recurrence compared to GA alone (OR = 0.82; 95% CI = 0.72 to 0.94; p < 0.01). This association remained significant for prostate cancer patients in subgroup analyses (OR = 0.71; 95% CI = 0.51 to 0.98; p = 0.04) and in the context of epidural anesthesia combined with GA. However, there were no significant associations noted for local recurrence or distant metastasis.

CONCLUSIONS

This meta-analysis provides evidence that RA, used alone or adjunctively with GA, is associated with a lower risk of cancer recurrence, particularly in patients with prostate cancer. However, no significant effects were observed on local recurrence or distant metastasis. Further prospective studies should be conducted to clarify this important issue.

Ultrasound-guided pericapsular nerve group and obturator nerve phenol neurolysis for refractory inpatient hip cancer metastasis pain: a case report

INTRODUCTION

Bone cancer metastasis may produce severe and refractory pain. It is often difficult to manage with systemic analgesics. Chemical neurolysis may be an effective alternative in terminally ill patients.

CASE REPORT

Female terminally ill patient with hip metastasis of gastric cancer in severe pain. Neurolytic ultrasound-guided blocks of the pericapsular nerve group and obturator nerve were performed with 5% phenol. This led to satisfactory pain relief for 10 days, until the patient's death.

DISCUSSION

This approach may be effective and safe as an analgesic option for refractory hip pain due to metastasis or pathologic fracture in terminally ill patients.

Ultrasound-guided rhomboid intercostal block (RIB) for acute scapula fracture in the emergency department

INTRODUCTION

Proper pain in acute scapular fractures can be challenging to achieve due to their anatomy and location. While the current mainstay of treatment relies on opioids, the Rhomboid Intercostal Block (RIB) has been utilized for anesthesia to effectively treat pain for scapular fractures. However, it has not yet been utilized in the emergency department (ED).

CASE REPORT

In this case report, we present the first documented use of RIB to treat pain safely and effectively in a 69-year-old male with a scapula fracture following a ground-level fall in the ED. The RIB was performed under ultrasound guidance, providing precise localization and administration of the nerve block.

CONCLUSION

The RIB demonstrated successful pain management in the ED. Although hopeful, further research is needed to understand limitations, potential side effects, length of pain control, and overall clinical outcomes of the RIB in the ED.

Intraoperative ultrasound-guided pectoral nerve blocks for cardiac implantable device procedures

BACKGROUND

Pectoral nerve (PECs) blocks are established regional anesthesia techniques that can provide analgesia to the anterior chest wall. Although commonly performed preoperatively by anesthesiologists, the feasibility of electrophysiologist-performed PECs blocks from within cardiac implantable electronic device (CIED) pockets at the time of implantation has not been established. The objective of this study is to assess the feasibility of routine PECs blocks performed by the electrophysiologist from within the exposed device pocket at the time of CIED procedures.

METHODS

Patients undergoing CIED procedures underwent a PECs I block (15 cc of 1% lidocaine/0.25% bupivacaine) injected between the pectoralis major and minor muscles guided by ultrasound placed in the device pocket, or PECs II block, which included a second injection (15 cc) between pectoralis minor and serratus anterior muscles. Postoperatively, pain was assessed on a numeric scale (0-10) at 1, 2, 4, and 24 h, and 2 weeks after the procedure.

RESULTS

Among 20 patients (age 65 ± 16 years, 70% male, 55% with history of chronic pain), PECs I (75%) and PECs II (25%) blocks were performed. The procedures were de novo implantation (n = 17) or device revision (n = 3). The average pain score in the first 4 h was 0.4 ± 0.8 and 0.3 ± 0.6 at 24 h after the procedure. During the 24-h postoperative period, 4 patients received opioids. Two patients were discharged with opioids for pain unrelated to the procedure.

CONCLUSIONS

Intraoperative PECs blocks can be feasibly performed from within an exposed pocket at the time of CIED procedures with minimal postoperative pain.

Examining gender bias in regional anesthesia academic publishing: a 50-year bibliometric analysis

BACKGROUND

The connection between academic career advancement and publishing research articles is important, as it can impact promotion and compensation decisions. Gender bias in academic publishing is a known issue, with studies showing low numbers in key roles in female representation. This article aims to analyze the ratio of women to men as first and last authors in the Regional Anesthesia & Pain Medicine (RAPM) journal and explore other factors such as the mentorship effect and representation in regional anesthesia associations.

MAIN BODY

We examined the RAPM articles from 1976 to 2023 evaluating the gender of first and last authors. We analyzed the trend over the years and also analyze the subset of original articles. A further analysis was conducted to analyze the relationship between the first and last author's gender. Additionally, regional anesthesia societies were contacted to gather data on the gender of their members. We included 5650 articles; most of them were first authored by men (72.9-87.7%). There was a positive trend over time for female first authorship but not for last authorship. The analysis also revealed a mentorship effect in recent years for both overall articles and the subgroup of original articles. The representation of women within regional anesthesia societies contrasted with the representation of women as last authors in original articles.

CONCLUSIONS

Our findings raise important questions about gender bias in academic publishing highlighting the need for increased representation and opportunities for women in the field of regional anesthesia.

Clavipectoral plane block performed in the emergency department for analgesia after clavicular fractures

Clavicle fractures are common injuries in the Emergency Department (ED). Adequate pain control with oral or intravenous medications is the central aspect of treatment. The ultrasound-guided clavipectoral plane block (CPB), previously described in anesthesia literature, offers complete analgesia of the clavicle with a low adverse effect profile. In this case series, we describe the first reported utilization of the CPB for analgesia for acute clavicular fractures in the ED. We performed the CPB for distal and midshaft clavicular fractures on patients who suffered from a variety of traumatic accidents including bicycle accidents, motorcycle accidents, and motor vehicle accidents. All patients experienced significant reductions in their reported pain without any reported complications. Given the need to provide patients with appropriate pain control in the ED, the CPB offers an effective, simple method for providing analgesia without known significant risks, including without the risks associated with high-dose systemic analgesia.

Perioperative considerations for patients undergoing surgical stabilization of rib fractures: A narrative review

Surgical stabilization of rib fractures (SSRF) has become an increasingly common management strategy for traumatic rib fractures. Although historically managed with supportive care, patients with multiple rib fractures and flail chest increasingly undergo SSRF, and so the anesthesiologist must be well-versed in the perioperative management and pain control for these patients, as controlling pain in this population is associated with decreased length of stay and improved outcomes. There are multiple modalities that can be used for both pain control and as part of the anesthetic plan in patients undergoing SSRF. This narrative review provides a comprehensive summary of anesthetic considerations for surgical rib fracture patients, covering the preoperative, intraoperative, and postoperative periods. We describe an approach to the assessment of high-risk patients, analgesic and anesthetic techniques including emerging techniques within locoregional anesthesia, ventilation strategies, and potential complications. This review also identifies areas where additional research is needed to ensure optimal anesthetic management for patients undergoing SSRF.

The effects of intrathecal morphine on urinary bladder function and recovery in patients having a cesarean delivery - A randomized clinical trial

INTRODUCTION

Spinal anesthesia with intrathecal morphine (ITM) is a common anesthesia technique for cesarean delivery. The hypothesis was that the addition of ITM will delay micturition in women undergoing cesarean delivery.

METHODS

Fifty-six ASA physical status I and II women scheduled to undergo elective cesarean delivery under spinal anesthesia were randomized to the PSM group (50 mg prilocaine + 2.5 mcg sufentanil + 100 mcg morphine; n = 30) or PS group (50 mg prilocaine + 2.5 mcg sufentanil; n = 24). The patients in the PS group received a bilateral transverse abdominal plane (TAP) block. The primary outcome was the effect of ITM on the time to micturition and the secondary outcome was the need for bladder re-catheterization.

RESULTS

The time to first urge to urinate (8 [6-10] hours in the PSM group versus 6 [4-6] hours in the PS group) and the time to first micturition (10 [8-12] hours in the PSM group versus 6 [6-8] hours in the PS group) were significantly (p < 0.001) prolonged in the PSM group. Two patients in the PSM group met the 800 mL criterium for urinary catheterization after 6 and 8 h respectively.

CONCLUSION

This study is the first randomized trial to demonstrate that the addition of ITM to the standardized mixture of prilocaine and sufentanil significantly delayed micturition.

Combined multiple regional anesthesia for microwave ablation of liver Tumors: Initial experience

OBJECTIVE

This study aims to assess the feasibility and safety of combined multiple regional anesthesia (CMRA) as a potential strategy to decrease pain and reliance on intravenous analgesics during and after ultrasound-guided microwave ablation (US-guided-MWA) of liver tumors.

METHODS

A cohort of 75 patients with a total of 99 liver tumors who underwent US-guided-MWA of liver tumors were enrolled. These patients were randomly allocated into three groups: A, B, and C. Prior to the ablation procedure, Group A patients received a combination of hepatic hilar block (HHB), Transversus abdominis plane block (TAPB), and local anesthesia (LA). Patients in Group B were administered HHB in conjunction with LA, while those in Group C received TAPB and LA. Evaluative parameters included the Numerical Rating Scale (NRS) scores, consumption of morphine, incidence of complications, and factors influencing perioperative pain.

RESULTS

All patients successfully underwent US-guided-MWA. The peak NRS scores for pain during ablation across the three groups were 2.36 ± 1.19, 3.28 ± 1.59, and 4.24 ± 1.42 respectively (P < 0.01), while the count of patients requiring morphine were 4/25, 8/25, and 13/25 respectively (P < 0.01). Postoperative NRS scores for the three groups at 4, 8, 12, 24, and 36-hour intervals demonstrated a pattern of initial increase followed by a decrease, with the order at each interval being: Group A < Group C < Group B. Factors associated with increased pain included larger tumor size, greater number of tumors, and longer procedure and ablation time (P < 0.05). No major complications were recorded across the three groups.

CONCLUSION

CMRA offers an effective and safe modality to manage pain during and after US-guided-MWA of liver tumors.

A Prospective Cohort Study to Evaluate Needle Passes Using a Portable Ultrasound Device versus Traditional Landmark Approach for Epidural Anesthesia in a Busy Obstetric Tertiary Care Center

Despite its many cited benefits, ultrasound guidance for neuraxial procedures is not widespread in anesthesiology. Some cited limitations include device cost and accessibility. We test the hypothesis that a handheld and relatively inexpensive ultrasound can improve neuraxial proficiency (e.g., decreased needle manipulations and block time). This prospective study compared the number of needle passes, redirections, and procedural time between epidural placed with a handheld ultrasound versus landmarks. Needle passes and attempts were defined as the number of times the Tuhoy needle was redirected, and the times skin was punctured (re-insertion). Procedural time was defined as the time from local anesthetic infiltration until loss of resistance was obtained. The impact of level of training and accuracy of the device were also analyzed. 302 patients receiving labor epidural were included in the study. No difference in body mass index (BMI) nor distribution of level of training was noted between the groups. Regression analysis adjusted for BMI demonstrated a decrease in needle passes (-1.75 (95% CI -2.62, -0.89), p < 0.001), needle attempts (-0.51 (95% CI -0.97, -0.04), p = 0.032) and procedural time (-154.67s 95% CI -303.49s, -5.85s), p = 0.042) when a handheld ultrasound was utilized. The mean (95% Confidence interval) difference between needle depth and ultrasound depth was 0.39 cm (0.32, 0.46), p < 0.001. The use of a handheld device resulted in statistically significant decrease of needle manipulations and block time. More research is needed to evaluate the impact of and increase in accessibility of ultrasound technology.

Analgesic Techniques for Rib Fractures-A Comprehensive Review Article

PURPOSE OF REVIEW

Rib fractures are a common traumatic injury that has been traditionally treated with systemic opioids and non-opioid analgesics. Due to the adverse effects of opioid analgesics, regional anesthesia techniques have become an increasingly promising alternative. This review article aims to explore the efficacy, safety, and constraints of medical management and regional anesthesia techniques in alleviating pain related to rib fractures.

RECENT FINDINGS

Recently, opioid analgesia, thoracic epidural analgesia (TEA), and paravertebral block (PVB) have been favored options in the pain management of rib fractures. TEA has positive analgesic effects, and many studies vouch for its efficacy; however, it is contraindicated for many patients. PVB is a viable alternative to those with contraindications to TEA and exhibits promising outcomes compared to other regional anesthesia techniques; however, a failure rate of up to 10% and adverse complications challenge its administration in trauma settings. Serratus anterior plane blocks (SAPB) and erector spinae blocks (ESPB) serve as practical alternatives to TEA or PVB with lower incidences of adverse effects while exhibiting similar levels of analgesia. ESPB can be performed by trained emergency physicians, making it a feasible procedure to perform that is low-risk and efficient in pain management. Compared to the other techniques, intercostal nerve block (ICNB) had less analgesic impact and required concurrent intravenous medication to achieve comparable outcomes to the other blocks. The regional anesthesia techniques showed great success in improving pain scores and expediting recovery in many patients. However, choosing the optimal technique may not be so clear and will depend on the patient's case and the team's preferences. The peripheral nerve blocks have impressive potential in the future and may very well surpass neuraxial techniques; however, further research is needed to prove their efficacy and weaknesses.

Quadratus Lumborum block as primary anesthetic technique for colostomy procedure: a case report

An elderly patient was admitted to the hospital due to an enterovesical fistula and a terminal colostomy was proposed. The patient had a high anesthetic risk and thus a quadratus lumborum block was chosen as the sole anesthetic technique. This block has been described to provide both somatic and visceral analgesia to the abdomen. In fact, it yielded good anesthetic conditions to perform the procedure and allowed the patient to be hemodynamically stable and comfortable throughout the case. The postoperative period was uneventful.

Transversus abdominis plane block vs quadratus lumborum block for postoperative analgesia in inguinal hernia repair: A systematic review and meta-analysis

PURPOSE

The present review was designed to differentiate between the analgesic value of transversus abdominis plane block (TAP) vs the quadratus lumborum block (QLB) for patients undergoing inguinal hernia surgery.

METHODS

PubMed, CENTRAL, Scopus, Embase, Google Scholar, Open gray, and a clinical trial registry were searched up to 18th February 2023 for randomized controlled trials (RCTs) comparing TAP and QLB for inguinal hernia repair.

RESULTS

Six RCTs from India, Turkey, and Norway published between the years 2019 to 2023 were included. Anesthetic agents and dosages were similar for TAP and QLB groups in each study. On meta-analysis, pain scores were not statistically significant different between TAP and QLB at 3-6 h (MD: 0.46 95% CI: -0.11, 1.03 I2 = 86%), 12 h (MD: 1.34 95% CI: -0.12, 2.80 I2 = 97%), and 24 h (MD: 0.38 95% CI: -0.77, 1.53 I2 = 97%). Meta-analysis of total analgesic consumption showed a tendency of reduced analgesic consumption with QLB as compared to TAP but the difference was not significant (SMD: 0.69 95% CI: 0.00, 1.37 I2 = 83%). Data on complications was scarcely available. GRADE assessment of the evidence was low to moderate.

CONCLUSION

Low to moderate-quality preliminary evidence suggests no difference in the analgesic efficacy of TAP and QLB for adult patients undergoing inguinal hernia repair. While there was a tendency for lower postoperative analgesic consumption with QLB, it needs to be verified by future studies.

Regional anesthesia improves inpatient but not outpatient opioid demand in tibial shaft fracture surgery

BACKGROUND

Patients undergoing operative treatment of tibial shaft fractures have considerable pain largely managed with opioids. Regional anesthesia (RA) has been increasingly used to reduce perioperative opioid use.

METHODS

This was a retrospective study of 426 patients that underwent operative treatment of tibial shaft fractures with and without RA. Inpatient opioid consumption and 90-day outpatient opioid demand were measured.

RESULTS

RA significantly decreased inpatient opioid consumption for 48 h post-operatively (p = 0.008). Neither inpatient use after 48 h nor outpatient opioid demand differed in patients with RA (p > 0.05).

CONCLUSIONS

RA may help with inpatient pain control and reduce opioid use in tibial shaft fracture.

LEVEL OF EVIDENCE

Level III, retrospective, therapeutic cohort study.

Perioperative Analgesia in Spine Surgery: A Review of Current Data Supporting Future Direction

This Clinical Research discusses the diverse nature of spine surgery procedures and the use of multimodal analgesia within enhanced recovery after surgery (ERAS) protocols to improve patient outcomes. Spine surgeries range from minor decompressions to extensive tumor resections, performed by neurosurgeons or orthopedic spine surgeons on adults and children. To manage perioperative pain effectively, various methods have been employed, including multimodal analgesia within ERAS protocols. Incorporating ERAS protocols into spine surgery has shown benefits such as reduced pain scores, decreased opioid use, shorter hospital stays, and improved functionality. ERAS protocols help to enhance patient outcomes, focusing on deconstructing these protocols for surgeons and anesthesiologists.

Spinal Anesthesia Prior to Laparoscopic Hysterectomy Resulted in Decreased Postoperative Pain and Opioid Use

Study Objective

To determine if a pre-operative morphine/bupivacaine spinal injection prior to laparoscopic hysterectomy reduced postoperative pain and resulted in less opioid consumption during the hospital stay.

Methods

A retrospective cohort study (Canadian Task Force Classification II-2) was conducted at a single institution regional referral center (community hospital) in North Carolina. Three hundred nineteen patients met criteria for inclusion: 192 received spinal anesthesia and 127 did not. Baseline demographics were similar between the two groups. Median pain scores were significantly lower in the treatment than the control group on day of surgery (DOS) (2 vs. 6; P < 0.001) and postoperative day 1 (POD1) (2 vs. 4; P < 0.001).

Results

Primary outcomes were pain scores on DOS and POD1 and inpatient opioid use. Pain scores were obtained using the 0 to 10 Numerical Rating Scale. Opioids were converted to oral morphine milliequivalents (OME). Median opioid use was also significantly lower in the treatment than the control group on DOS (0 vs. 15.00 OME; P < 0.001) and POD1 (0 vs. 7.5 OME; P < 0.001). Median length of stay between the groups was not significantly different.

Conclusion

Pre-operative morphine spinal injection for laparoscopic hysterectomy led to significantly lower pain scores and inpatient opioid consumption. Pre-operative spinal anesthesia for benign laparoscopic hysterectomy appears helpful for enhancing the postoperative experience.

Evaluation of the effectiveness of artificial intelligence for ultrasound guided peripheral nerve and plane blocks in recognizing anatomical structures

BACKGROUND

We aimed to assess the accuracy of artificial intelligence (AI) based real-time anatomy identification for ultrasound-guided peripheral nerve and plane block in eight regions in this prospective observational study.

METHODS

After obtaining ethics committee approval and written informed consent from 40 healthy volunteers (20 men and 20 women, between 18 and 72 years old), an ultrasound device installed with AI software (Nerveblox, SmartAlfa, Turkey) were used to scan regions of the cervical plexus, brachial plexus, pectoralis (PECS), rectus sheet, femoralis, canalis adductorius, popliteal, and ESP by three anesthesiology trainees. During scanning by a trainee, once software indicates 100 % scan success of associated anatomic landmarks, both raw and labeled ultrasound images were saved, assessed, and validated using a 6-point scale between 0 and 5 by two expert validators. Evaluation scores of the validators for each block were compared according to demographics (gender, age, and BMI) and block type exists.

RESULTS

The scores were not different except ESP, femoralis, and cervical plexus regions between the experts. The mean scores of the experts for the PECS, popliteal and rectus sheath were significant between males and females (p < 0.05). In terms of BMI, significant differences in the scores were observed only in the canalis adductorius, brachial plexus, and ESP regions (p < 0.05).

CONCLUSIONS

Ultrasound guided AI-based anatomy identification was performed in commonly used eight block regions by the trainees where AI technology can successfully interpret the anatomical structures in real-time sonography which would be valuable in assisting anesthesiologists.

Lower Extremity Peripheral Nerve Blocks for Patients at Risk for Acute Compartment Syndrome

A delayed acute compartment syndrome (ACS) diagnosis often results in devastating complications; however, the sensitivity of the classic signs and symptoms is very low. All analgesic modalities have been implicated in delaying the diagnosis, but there is very little evidence linking peripheral nerve blocks (PNBs) with delays in diagnosis. In fact, there is evidence that PNBs may facilitate an early diagnosis; this may be in part due to differences in how ischemic and inflammatory pain is transmitted through unique nociceptive pathways. Collaboration is required to optimize care for patients at risk for ACS.