Post-thoracotomy pain relief: Thoracic paravertebral block compared with systemic opioids

BackgroundWe evaluated the safety and efficacy of thoracic paravertebral block as a method of pain relief after thoracotomy in comparison with systemic opioids.Study designRandomized controlled trial.MethodsWe scheduled 40 patients divided into two groups to receive either 20 ml bupivacaine (0.5%) incremental injections for intra and postoperative analgesia via a catheter inserted in the thoracic paravertebral space. The other 20 patients received systemic morphine for postoperative analgesia. We recorded postoperative Visual Analog Scale pain score, total morphine consumption, time to first analgesic request, changes in pulmonary functions and side effects.ResultsVisual analogue scale (VAS) at rest was lower in the paravertebral group at all measurement points except at 16, 20 and 24 h postoperatively. Pain on coughing showed significant difference (P value < 0.05) at 8 and 16 h but not at 24 h. Post-operative consumption of morphine was 36 (22–42) mg in the control group versus 9 (2–22) mg in the paravertebral block group (PVB) (P value = 0.003). Total bupivacaine dose used in the PVB group in the first 24 h was 300–420 mg. For time to first analgesic request it was significantly longer in the morphine group than the paravertebral block group. VAS at first analgesic request was not statistically different between the two groups.There was no significant difference between the two groups as regards to peak expiratory flow rate (PEFR) preoperatively, after 12 h or 24 h.There was a significant reduction in the incidence of side effects in the TPVB group compared to morphine group concerning vomiting and pruritus.no local anesthetic toxicity was reported.ConclusionWe conclude that thoracic PVB provides effective post thoracotomy analgesia supported by lower VAS pain scores at rest and on coughing compared to intravenous morphine with significant less incidence of side effects.     

Anesthesia management with ultrasound-guided thoracic paravertebral block for donor nephrectomy: A prospective randomized study

Study objectiveTo determine the efficacy of ultrasound-guided thoracic paravertebral block intraoperatively and 24 hours postoperatively in patients undergoing donor nephrectomy.DesignProspective randomized controlled study.SettingPrivate foundation university hospital; November 2014 to June 2015.PatientsThirty-two patients undergoing donor nephrectomy (exclusion criteria: coagulation disorders, allergy to local anesthetics, and unwillingness to participate). The final study population comprised 30 patients (15 male, 15 female) randomly assigned to either Group P (paravertebral block, n = 14) or Group M (morphine, n = 16).InterventionsIn Group P, a unilateral paravertebral catheter was inserted 1 day preoperatively; on the day of surgery, a single-level unilateral paravertebral block was administered through the catheter before general anesthesia. Infusion of bupivacaine continued intraoperatively and postoperatively. Patients in Group M received only general anesthesia, and morphine patient-controlled analgesia was begun postoperatively.MeasurementsIntraoperative analgesic and anesthetic requirement, postoperative numerical rating scale pain scores, additional analgesic consumption during the postoperative period, and incidence of complications related to thoracic paravertebral block (TPVB) like pleural puncture, pneumothorax, epidural spread, injection into the subarachnoid space, intravascular injection, and Horner's syndrome and rate of opioid related adverse reactions like nausea and vomiting, itching, constipation, and respiratory depression.ResultsIntraoperative remifentanil consumption was significantly higher in Group M, and postoperative morphine consumption was significantly lower in Group P (P < .001). During the first 24 hours postoperatively, the mean numerical rating scale pain scores were similar and there were no significant differences between the 2 groups. There were no statistically significant differences in the additional analgesic consumption and rate of adverse reactions between the 2 groups. We didn't detect any complication related to TPVB in group P.ConclusionsContinuous thoracic paravertebral block provides good intraoperative stability with a low anesthetic requirement and reduces postoperative morphine consumption for up to 24 hours. Ultrasound guided technique enhanced the safety of TPVB and provides analgesia without major complications.     

Thoracic paravertebral block compared to thoracic paravertebral block plus pectoral nerve block in reconstructive breast surgery

IntroductionMajor breast surgery was usually performed under general anaesthesia until the first patient series with thoracic paravertebral block was published. This block was introduced into our Hospital, and with the purpose of obtaining a more comfortable perioperative period, it was combined with blocking the pectoral nerves. In this study, both anaesthetic techniques are compared, as regards control of postoperative pain, incidence of postoperative nausea and vomiting, and sedation requirements.Material and methodsAn observational study was conducted with 60 patients scheduled for breast surgery with subpectoral implants (augmentation and /or prosthesis). Two groups were studied. The first (Group I) was randomly selected from a patient records data base to have thoracic paravertebral block and sedation. In the second (Group II), a pectoral nerve block was performed combined with a thoracic paravertebral block.ResultsIn Group I, 33.3% of the patients had a score of ≤ 3 on the visual analogue scale (VAS) at 8 hours, and 66.7% had a VAS score of ≥ 4 at 24 h, compared to 80% of the Group II patients who had a VAS score of ≤ 3 at 8 hours and 20% with a VAS score ≥ 4 at 24 h. The mean difference in the VAS scores at 8 hours between the two groups was statistically significant: mean VAS score at 8 hours in Group I, 4.23±2.4 compared to 1.77±2.2 in Group II. There was no difference in the VAS scores at 24 hours. No statistically significant differences were found between the two groups in the incidence of postoperative nausea and vomiting. The need for intra-operative sedation supplements with propofol boluses was less in Group II, 40% compared to 90% in Group II.ConclusionsPectoral nerve block is a technique that improves the results obtained with thoracic paravertebral block in reconstructive breast surgery, with better post-operative analgesic control in the immediate post-operative period and a lower requirement for sedation.     

Eficacia del bloqueo paravertebral continuo como método analgésico en la toracotomía

IntroductionOpen thoracotomy is one of the surgical procedures that is still very painful in the postoperative period, which, in this type of surgery can have on respiratory function and subsequent recovery of the patient.Patients and methodThe aim of the study is to assess continuous paravertebral thoracic block as an analgesic technique in thoracotomy. A total of 139 patients undergoing pulmonary resection surgery by posterolateral thoracotomy received postoperative analgesia using a 1.5% lidocaine infusion (7–10 ml/h) through a thoracic paravertebral catheter for at least 48 h. Pain intensity measured on the visual analogue scale (VAS) both at rest (passive VAS) and during stimulated cough (active VAS) was recorded at time of discharge from the Recovery Unit, and on the second, third and fourth day post-surgery. Postoperative complications and the need for analgesic rescue were studied.ResultsOn discharge from recovery, 98.6% of the patients had mild pain (passive VAS <3), 1.4% had moderate pain (passive VAS 4–6) and none with severe pain (EVA >6); on the 2nd day post-surgery, 97.9% had mild pain, and 1.2% moderate pain; on the third day 98.6% had mild pain and 0.7% moderate pain; and on the 4th day 100% had mild pain. There were no complications arising from the analgesic technique.ConclusionsContinuous thoracic paravertebral analgesia is effective and safe in controlling post-thoracotomy pain.     

Transversus abdominis plane block: The analgesic efficacy of a new block catheter insertion method

BackgroundLocal anesthetic (LA) administration via a correctly placed block catheter could help optimum deposition in the transversus abdominis plane (TAP). The aim of the study is to assess the postoperative analgesic efficacy of TAP block achieved by initially injecting the LA through a catheter placed by ultrasound-guided Seldinger catheter insertion approach (USCIA).MethodsFifty patients scheduled for open inguinal hernia repair were randomized into two groups. Group USCIA: Patients received USCIA-TAP block. Group control: Patients did not receive TAP block. All patients received patient-controlled intravenous morphine postoperatively. The analgesic efficacy of USCIA-TAP block was assessed measuring the total amount of postoperative morphine requirements over the first 48 h postoperatively. Pain scores and level of patient satisfaction with pain relief after surgery were noted.ResultsThe mean cumulative morphine requirement over the first 48 postoperative hours was significantly lower in USCIA group in comparison with the Control group (18.1 ± 4.1 vs. 57.9 ± 5.3 mg). The success rate of USCIA-TAP block catheter placement was 88%. The pain score of USCIA group was significantly lower at 3, 6, 12, and 24 postoperative hours compared with the Control group. The USCIA group had a significantly higher rate of satisfaction with regard to pain control in comparison with the Control group at the 12th and 24th postoperative hours (9 {8–10} vs. 6 {5–7} and 9 {8–10} vs. 7 {6–8}, respectively).ConclusionThe use of a single dose of USCIA-TAP block reduced the total amount of morphine requirement over the first 48 postoperative hours for patients undergoing abdominal surgery.     

Thoracic paravertebral block versus pectoral nerve block for analgesia after breast surgery

BackgroundPectoral nerve block (Pecs) is a novel interfascial plane block which can provide analgesia after breast surgery while paravertebral block (PVB) is widely used for this purpose. We evaluated the difference between the two techniques in regard to morphine consumption and analgesic efficacy after modified radical mastectomy (MRM).MethodsSixty patients undergoing elective MRM were randomly allocated into either PVB with 15–20 ml of levobupivacaine 0.25% at the level of fourth thoracic vertebra or Pecs block with 10 ml of levobupivacaine 0.25% injected inbetween pectoralis major and pectoralis minor muscle and another 20 ml levobubivacaine 0.25% inbetween pectorlis minor and serratus anterior muscle. Primary outcome measure was morphine consumption in the first 24 h while secondary outcome measures included pain scores, intraoperative fentanyl consumption as well as postoperative nausea and vomiting (PONV).ResultsPostoperative morphine consumed at 24 h was significantly lower in Pecs group [21 (20–25) mg] than in PVB group [28 (22–31) mg], (p = 0.002). Time for first request of morphine was longer in Pecs group [175 (155–220) min] than in PVB group [137.5 (115–165) min], (p < 0.001). Numerical rating score (NRS) at rest was lower in Pecs group compared with PVB group at 1 h, 6 h and 12 h (p < 0.001) but at 18 h and 24 h it was lower in PVB group compared with Pecs group (p = 0.008 and <0.001 respectively). During movement, NRS was significantly lower at 1st hour in Pecs group (p < 0.001) while at 18 h and 24 h it was significantly lower in PVB group (p < 0.001). PONV was comparable between both groups.ConclusionPecs block reduced postoperative morphine consumption in the first 24 and pain scores in the first 12 h in comparison with PVB after mastectomy.     

Comparison of caudal epidural block and ultrasonography-guided transversus abdominis plane block for pain relief in children undergoing lower abdominal surgery

Study objectiveWe conducted this study to compare the efficacy of caudal epidural block (CEB) vs ultrasonography-guided transversus abdominis plane (TAP) block for providing postoperative pain relief in children scheduled for lower abdominal surgery. Whereas the primary objective was to compare the duration of postoperative analgesia, the secondary objectives included comparative assessment (TAP vs CEB) of quality of pain relief in the first 24 hours postoperatively and rescue analgesia requirements.DesignRandomized-control, prospective, observer-blinded, 2-arm, single-center comparison.SettingOperating room, postoperative recovery area.PatientsEighty-children, aged 2-6 years, of American Society of Anesthesiologists physical status I/II scheduled to undergo unilateral lower abdominal surgery under general anesthesia.InterventionsThe recruited children were randomly allocated to receive under general anesthesia either CEB (group C, 0.75 mL/kg of 0.25% bupivacaine) or ultrasonography-guided administration of TAP block (group T, 0.5 mL/kg of 0.25% bupivacaine).MeasurementsIntraoperative: heart rate and noninvasive blood pressure; postoperative: pain profile, including duration of postoperative analgesia, quality of pain relief, and rescue analgesia requirements.Main resultsThe median duration of postoperative analgesia was significantly greater in children who received CEB than those who were administered TAP block (group C: 362.5 minutes [172.5-693.75] vs group T: 210 minutes [108.75-362.5]; P < .05). No difference was found in the incidence of postoperative pain up to 6 hours from the point of initiation of assessment (group C: 47.2% vs group T: 55.9%; P > .05). The children who received CEB experienced greater incidence of pain in the 6- to 24-hour postoperative interval than those administered TAP block (group C: 75% vs group T: 44.1%; P < .05). Although there was no difference in the rescue analgesia requirements, the number of children not requiring any rescue analgesia in the first 24 hours postoperatively was significantly higher in the TAP group (group C: n = 2 vs group T: n = 8; P < .05).ConclusionsIn children undergoing lower abdominal surgery, CEB provides a significantly prolonged duration of postoperative analgesia when compared with ultrasonography-guided TAP block.     

Dexamethasone bupivacaine versus bupivacaine for peribulbar block in posterior segment eye surgery

AimThe study conducted aims to assess the efficacy, time to first analgesic request, and postoperative inflammatory response after adding dexamethasone to local anesthetic mixture for a peribulbar block in posterior segment eye surgery.Patients and methodsA double-blind randomized study was carried out on 50 ASA I and II patients scheduled for elective posterior segment surgery (vitreoretinal). Patients were allocated randomly into two groups, 25 patients in each group. Group I received equal volumes of 10 ml of a l:1 mixture of bupivacaine 0.5% and saline, supplemented with 4 mg dexamethasone in 1 ml saline and group II received the same local anesthetic mixture (total volume 10 ml) without adding dexamethasone. The duration and onset of motor block, time to first analgesic request, postoperative inflammatory response, and other side effects such as nausea and vomiting were assessed.ResultsPatients receiving peribulbar block were significantly pain free by end of surgery (0 h) (P < 0.05) and throughout the postoperative period in the dexamethasone group at 2 and 6 h postoperatively. The number of patients requiring rescue analgesics was significantly lower with dexamethasone bupivacaine block (P < 0.05). The incidence of postoperative nausea and vomiting was significantly less in the first group (I) in comparison to the other group (II) (P < 0.05) and lastly the level of C reactive protein postoperatively was found to be significantly less in the dexamethasone group than the other one (P < 0.0001).ConclusionAdding dexamethasone to bupivacaine in peribulbar block appears to be a safe and clinically superior adjuvant with less postoperative pain, inflammatory response in patients undergoing posterior segment eye surgery.     

Ultrasound guided transversus abdominis plane block in pediatric patients undergoing laparoscopic surgery

ObjectiveTo assess safety and effectiveness of ultrasound-guided TAP block in children undergoing laparoscopic surgery for undescended testis.Subjects and methodsThis randomized controlled trial involved 108 children, 3–7 years old, randomly allocated into one of two equal groups; TAP Group and Control Group. All children received general anesthesia using propofol 1.5–2.5 mg/kg, atracurium 0.5 mg/kg and fentanyl 2 μg/kg. TAP Group received 0.5 ml/kg of ropivacaine 0.375% bilaterally under ultrasound guidance and control group received regular analgesics. Quality of analgesia was assessed using Children’s Hospital Eastern Ontario Pain Scale (CHEOPS) and Objective behavioral pain score (OPS). The primary outcome measures were hemodynamic parameters and degree of pain. Secondary outcome measures were intraoperative fentanyl requirement, postoperative rescue analgesia (time and dose), complications, hospital stay and degree of satisfaction of patients and their parents.ResultsTAP block group had significantly lower intraoperative fentanyl dose (p < 0.001), significantly longer time to first postoperative request of analgesic (p < 0.001), lower analgesic dose during the first postoperative 24 h (p < 0.001) and lower pain scores along the whole 24 postoperative hours. Mean arterial pressure and heart rate were within the clinically accepted range in the two groups. Parents’ satisfaction was significantly higher (p < 0.001) in the TAP block group.ConclusionTAP block under ultrasound guidance was easy, safe, reliable and effective analgesic in children undergoing laparoscopic surgery for undescended testis.     

Ultrasound guided transversus abdominis plane block versus local wound infiltration in children undergoing appendectomy: A randomized controlled trial

BackgroundThe transversus abdominis plane block (TAP) has been described for pain management following abdominal surgery in adults, but there are only few reports on its use in pediatrics. The aim of this study was to evaluate the analgesic effect of ultrasound guided TAP block in patients scheduled for open appendectomy versus an active comparator (wound infiltration).MethodsForty-four children aged 4–16 years (ASA 1–2) were enrolled. Patients were randomized into two groups (22 in each). Patients in group (T) were assigned to receive ultrasound guided TAP block using 0.4 ml/kg of bupivacaine 0.25%, and those in group (L) were assigned to receive local infiltration by the surgeon. Maximum pain scores, the time to the first analgesic requirement and the number of analgesic requirements were recorded over 48 h.ResultsThe ultrasound guided TAP block increased the mean time to the first analgesic requirement (10.4 ± 1.5 h) in comparison with the local infiltration group (5.4 ± 1.5). The cumulative number of doses of analgesic was significantly lower in TAP group than in local infiltration group (3.7 ± 1.1 versus 5.3 ± 2.1) and the Pain Scale score was significantly lower in the TAP group over the study period. Besides, there were no complications attributable to the ultrasound guided TAP block.ConclusionUltrasound-guided TAP block with (0.4 ml/kg) 0.25% bupivacaine provides prolonged postoperative analgesia and reduced analgesic use without any clinical side-effects after appendectomy in children.     

The effect of multimodal balanced anaesthesia and long term gabapentin on neuropathic pain,nitric oxide and interleukin-1β following breast surgery

ObjectivesTo evaluate the effect of multimodal balanced anaesthesia and gabapentin (6 months) on neuropathic pain qualities, nitric oxide (NO) and interleukin 1-beta (IL-1β).MethodologyThis randomized study was conducted on 50 women scheduled for conservative breast surgery for cancer followed by chemotherapy and/or radiotherapy. Women enrolled into two groups; either to receive balanced general anaesthesia (GA) (control group) or ultrasound guided thoracic paravertebral with GA, multimodal balanced anaesthesia, (intervention group). Nociceptive pain was evaluated for 24 h. Neuropathic pain was evaluated using pain questionnaire 1 month postoperatively and neuropathic pain scale at 1, 3, 6 and 9 months. Gabapentin was prescribed to women reporting neuropathic pain 1 month postoperatively and for 6 months. NO and IL-1β were measured before operation, 1, 3, 6 & 9 months, postoperatively. Their relationship with neuropathic pain was assessed.ResultsNociceptive pain was less in intervention group than control group immediately post operative, 4 h after surgery at rest and 8 h with movement. Neuropathic pain started few days postoperatively, in both groups. Its onset, sites, duration and precipitating factors did not differ between the groups. Sensitive, hot pain and unpleasantness reduced significantly 1 month postoperatively, in intervention group. Two months later, itchy, dull and sharp pain was significantly less in intervention group. At 6 months, most of neuropathic pain items except sharp and deep pain lowered significantly in intervention group. At 9 months, hot and superficial pain was still less in intervention group. NO decreased significantly 1 and 3 months postoperatively, while IL-1β was significantly lower through different times, in intervention group. IL-1β correlated well with neuropathic pain intensity and unpleasantness.ConclusionBreast surgery for cancer was associated with neuropathic pain that continued for 9 months after surgery. Multimodal balanced GA had positive impact on acute nociceptive and neuropathic pain. Gabapentin reduced almost all neuropathic pain qualities.     

The effect of gabapentin premedication on pain and anxiety during cataract surgery under peribulbar block

BackgroundThe principal goal of sedation during eye surgery is to keep the patient calm and comfortable without depression of the protective airway reflexes or affecting the hemodynamics. The aim of the present study was to evaluate the effect of oral gabapentin premedication on anxiety and pain during cataract surgery done under peribulbar block.Material and methodsIn this double blinded placebo controlled study, 60 patients scheduled for cataract surgery under peribulbar block were randomly allocated into two groups. In the gabapentin group (n = 30), patients were premedicated 2 h before peribulbar block by 1200 mg oral gabapentin capsules. In the placebo group (n = 30), patients were premedicated 2 h before peribulbar block by oral placebo capsules. Verbal pain score (VPS), sedation score, verbal anxiety score (VAS), respiratory rate, oxygen saturation, heart rate, blood pressure and side effects were recorded.ResultsVPS was low in the gabapentin group versus the placebo group after the block till discharge (P < 0.01). VAS for anxiety was low in the gabapentin group versus the placebo group 1 h after premedication till discharge (P < 0.01). The heart rate and blood pressure were high in the placebo group versus the gabapentin group from arrival to the operating room till discharge. No side effects were recorded.ConclusionPremedication with 1200 mg oral gabapentin reduces anxiety and pain during cataract surgery done under peribulbar block without producing side effects.     

Postoperative continuous transversus abdominis plane block vs continuous wound infusion of levobupivacaine in females undergoing open gynecologic procedures

IntroductionTransversus abdominis plane (TAP) block is used as a part of multimodal analgesia in decreasing pain of lower abdominal wall incision. Local anesthetic instillation of wounds through subcutaneous or subfascial catheters is used to treat postoperative pain in different types of surgery. The aim of this randomized controlled trial was to study the opioid-sparing effect of these two techniques (if any) compared to placebo in women undergoing gynecologic procedures through transverse lower abdominal incisions.MethodsSeventy-eight ASA I–III patients planned to undergo gynecologic procedures through a transverse lower abdominal incision were randomly divided into three equal groups: Control (C) group (n = 26), Continuous Wound Infusion (CWI) group (n = 26), and continuous transversus abdominis plane block (TAP) group (n = 26). After standardized general anesthetic and before extubation, the patients were given the allocated treatment. A morphine patient-controlled analgesia (PCA) was started postoperatively alongside with the local anesthetic (or placebo) infusion. Cumulative dose of morphine PCA in the first postoperative 48 h was the primary outcome. Secondary outcomes included visual analog pain score (VAS) at rest and on movement and complications of morphine PCA.ResultsThe cumulative dose of morphine PCA in the first postoperative 48 h was higher in control group than in groups CWI and TAP (P < 0.001). However, no significant difference was found between groups CWI and TAP. No significant differences were found among the three groups regarding VAS during rest but TAP group showed less pain scores than groups C and CWI on movement. The three groups were similar regarding morphine side effects.ConclusionContinuous bilateral TAP block and CWI can decrease PCA morphine consumption in the first postoperative 48 h when compared to placebo in women undergoing gynecologic surgery through transverse lower abdominal incision. Continuous TAB block might give better analgesia with movement than CWI.     

Bloqueo del plano del músculo erector de la columna para analgesia de dolor lumbar crónico: serie de casos

BackgroundChronic 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.MethodsTen 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 minutes after – VAS and satisfaction level; 24 and 72 hours, 7 days and 1 month after - complications and pain level.ResultsMajority 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 hours. 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 hours, 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 conclusionsUltrasound-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.     

Bilateral sphenopalatine ganglion block as adjuvant to general anaesthesia during endoscopic trans-nasal resection of pituitary adenoma

BackgroundThis study was conducted to investigate the anaesthetic, vasodilator, and post-operative analgesic sparing effect of bilateral sphenopalatine ganglion block (SPGB) in patients undergoing endoscopic endo-nasal trans-sphenoidal surgery.MethodsThirty adult patients of ASA (I, II), aged 20–60 years, were randomly allocated to either the block group or the non-block group (n = 15, for each). After establishment of general anesthesia with sevoflurane and 100% oxygen, the patients received bilateral SPGB with 1.5 ml of either 0.5% bupivacaine (block group) or 0.9% NaCl (non-block group). Intra-operative mean arterial pressure (MAP) was maintained at 60–65 mmHg by using nitroglycerine. End-tidal sevoflurane concentration required to maintain bispectral index values (40–50) throughout the operation was recorded. Nitroglycerine and propranolol consumption, blood loss, recovery profile, perioperative catecholamines, post-operative pain and meperidine consumption were evaluated.ResultsBlock group showed significant decrease in sevoflurane and nitroglycerine consumption, blood loss, emergence time and time needed to achieve ?9 Aldrete score, P < 0.0001. All patients in non-blockade group (100%) were supplemented by nitroglycerine to achieve the target MAP versus 9 patients (60%) in the block group (P < 0.01). Propranolol administration was necessary in 9 patients (60%) in the non-block group versus 3 patients (20%) in the block group, P < 0.05. At PACU, visual analogue pain score and number of patients received meperidine analgesia were significantly less in the block group versus non-block group, P < 0.0001 and P < 0.001, respectively. Intra- and post-operative plasma epinephrine and nor-epinephrine levels were significantly higher in the non-block group than the block group, P < 0.05.ConclusionBilateral SPGB has anaesthetic, vasodilator and analgesic sparing effect when combined with general anaesthesia during endoscopic endo-nasal trans-sphenoidal resection of pituitary adenoma.     

Preoperative use of gabapentin decreases the anesthetic and analgesic requirements in patients undergoing radical mastectomy

Background/aimGabapentin is an anticonvulsant drug that is safe and effective for the treatment of neuropathic pain syndrome, as well as postoperative pain with good results. This prospective randomized study was done to evaluate the effects of preoperative administration of oral gabapentin (1200 mg) on the intraoperative fentanyl and isoflurane consumption, postoperative analgesic requirements and postoperative pain in patients undergoing radical mastectomy.MethodsSixty ASA I and II patients were randomly allocated into two equal groups to receive oral gabapentin 1200 mg, 2 h before surgery (G group) or control (C group). General anesthesia was induced and maintained at bispectral index value between 40 and 60. During surgery the end-tidal isoflurane concentrations required to maintain adequate depth of anesthesia and the required incremental doses of intraoperative fentanyl were recorded. Postoperative pain was assessed using visual analogue scale (VAS) at rest for 24 h. Postoperatively, whenever visual analogue scale (VAS) was more than 5 or on patients’ demand, analgesia in both groups was provided with diclofenac sodium (1 mg/kg IM) or tramadol hydrochloride (1 mg/kg IV) as needed. VAS, analgesics requirements, and side-effects were assessed for 24 h postoperatively.ResultsIntraoperative fentanyl and postoperative analgesic consumption were significantly lower in G group than C group (P < 0.001). Patients in the G group had significantly lower end-tidal concentrations of isoflurane required to maintain adequate depth of anesthesia (P < 0.05). VAS was significantly lower in G group than C group at the first three measurement times (P < 0.01). The incidence of postoperative nausea and vomiting was significantly lower in G group than C group (30% versus 60% of patients, respectively, P < 0.05). The incidence of dizziness was significantly higher in the G group than C group (26% versus 3.3% of patients, respectively, P < 0.05).ConclusionGabapentin (1200 mg) administered orally 2 h before surgery decreased the intraoperative fentanyl and isoflurane consumption, postoperative analgesic requirements, postoperative pain, and the incidence of postoperative nausea and vomiting, but increased dizziness.     

Chronic postoperative pain after general anesthesia with or without a single-dose preincisional paravertebral nerve block in radical breast cancer surgery

Background and objectiveOver 50% of patients still experience pain a year after mastectomy with or without lymphadenectomy. We aimed to determine the association between anesthetic technique, acute postoperative pain intensity, and the development of chronic postoperative pain.Patients and methodsForty patients were randomly assigned to receive general anesthesia with or without a paravertebral nerve block for modified radical mastectomy. Postoperative pain was assessed on a visual analog scale at 60 minutes and 24 hours; the patients were also asked to respond to a telephone questionnaire on chronic pain 4 to 5 months later.ResultsNo significant differences in acute pain were observed. Twenty-nine responded to the telephone questionnaire. Only 1 patient in the paravertebral block group reported chronic neuropathic pain and none had phantom breast pain. Only 1 patient (6.7%) in the paravertebral block group reported chronic neuropathic pain and none had phantom breast pain. In the group that received general anesthesia alone, 1 patient reported phantom breast pain and 6 patients had neuropathic pain, associated with phantom breast pain in 2 cases (incidence of chronic pain 50%; P = .01, Fischer exact test; relative risk, 7.5, 95% confidence interval, 1.0-53.5). The incidences of myofascial pain (neck muscle tightness) were similar in the 2 groups.ConclusionsFour to 5 months after mastectomy, fewer cases of chronic pain developed in the group operated under general anesthesia with a preincisional paravertebral block than in the group that received only general anesthesia, with postoperative morphine chloride for analgesia.     

Portal track infiltration versus Interscalene brachial plexus block for Pain control following shoulder arthroscopy

Arthroscopic shoulder surgery is often associated with severe postoperative pain that can be difficult to manage without large-dose opioids 1, 2.Local anaesthetics can also be injected into joint spaces to provide analgesia during and after arthroscopic surgery [3].The goal of the present study was to assess the efficacy of the portal track infiltration versus interscalene block on adequacy of pain control, and possible side effects.MethodsSixty patients of ASA I or II patients, presenting for arthroscopic subacromial decompression, were included in this comparative randomized study.Group I received preincisional 30 ml of bupivacaine 0.5% using spinal needle 22G at the site of insertion of the trocars, 10 ml at each trocars site. Group II received interscalene block using the same equal amount of 30 ml bupivacaine 0.5% at the start of the procedure before general anaesthesia using electric nerve stimulator. Visual analogue scale (VAS), time to first need of analgesia in each group, total amount of analgesia and the occurrence of side effects necessitating overnight hospital stay were recorded.ResultsThere was significant reduction of heart rate and mean blood pressure in group II compared to group I from 15 min onwards.VAS readings were insignificant between the two groups in the first 9 h postoperatively.As regards the timing of first requirement of analgesics and total amount of analgesia required in the first 24 h, and the complications necessitating overnight stay, the readings were insignificant in both groups.ConclusionThis denotes that pre-emptive analgesia offered using portal track infiltration not only gives equipotent analgesia to that of the interscalene, but lacks significant risks and can be easily to give by the surgeon.     

The analgesic efficacy of continuous fascia iliaca block vs. continuous psoas compartment block after hip surgery: A comparative study

BackgroundBoth psoas compartment block and fascia iliaca compartment block have been shown to be reliable blocks for postoperative pain relief for procedures involving the hip joint. This study evaluated the efficacy of continuous psoas compartment block with continuous fascia iliaca block for postoperative analgesia after hip surgery.MethodsIn randomized blinded study Forty, ASA I–III patients aged 30–75 years, with BMI less than 40, scheduled for hip surgery, were divided to one of two groups. Group P: continuous psoas compartment block (n = 18) and group F: continuous fascia iliaca block (n = 19). Standard general anesthesia was induced after finishing the block technique. After recovery 30 ml of 0.125% levobupivacaine was injected through the catheter to all patients. Postoperative 24 h meperidine consumption, patient satisfaction, visual analogue scale pain scores at (1, 6, 12, 18, and 24 h) postoperative, postoperative hemodynamics (HR and MAp), evidence of sensory and motor blockades, and incidence of adverse effects were recorded.ResultsThere was no significant difference between the two groups in 24 h postoperative meperidine requirements, postoperative VAS, patient satisfaction, postoperative hemodynamics, and distribution of sensory and motor block of (femoral, lateral femoral cutaneous, and obturator nerves). The epidural anesthesia occurred in two patients in psoas group (11%).ConclusionBoth continuous fascia iliaca block and continuous psoas compartment block were comparable in providing safe and effective analgesia after hip surgery.     

The efficacy of preoperative pregabalin on reduction of the incidence and severity of postdural puncture headache after spinal anesthesia

ObjectiveThe aim of this study was to evaluate the efficacy of prophylactic pregabalin on postdural puncture headache incidence and severity after spinal anesthesia.Method86 ASA I-II male and female patients age 20–50 years old, undergoing elective general surgeries below the umbilicus under spinal anesthesia with 3 ml heavy bupivacaine 0.5% (15 mg), patients were randomly allocated into one of two groups (Group C, n = 43) (control group) received a placebo capsule 2 h preoperatively (Group P, n = 43) received 150 mg pregabalin capsule 2 h preoperatively, number of attempts for spinal block, sensory level, motor block grade, postoperative time to first analgesic requirement, the incidence, onset and intensity of PDPH and adverse events were recorded for 72 h.ResultsThe peak sensory level in C group and P group showed no statistical significant difference, the time to peak sensory block was significantly earlier in P group than group C, the time to reach the modified Bromage motor block grade 3 was significantly earlier in P group than C group, time to two segment regression of sensory level to S1 and motor block regression to modified Bromage grade 0 were statistically insignificant between the studied groups. Group P had a significantly longer time to first analgesic requirements than group C, and there was no significant difference in VAS (visual analogue scale) of pain between the studied groups. There was significant increase in sedation score in P group compared to C group at 2 h and 6 h postoperatively, and there was statistically significant reduction in the incidence rate and severity of PDPH in P group compared to group C. There were no recorded cases of dizziness, visual disturbances, or PONV.Conclusionspreoperative oral pregabalin 150 mg reduced the incidence and severity of PDPH, beside the earlier onset of peak sensory and motor block with increase duration of analgesia in patients undergoing elective surgeries under spinal anesthesia.