The effect of preoperative erector spinae plane vs. paravertebral blocks on patient-controlled oxycodone consumption after video-assisted thoracic surgery: A prospective randomized,blinded, non-inferiority study

Study objectiveTo investigate the effective analgesia for video-assisted thoracic surgery.DesignIn this prospective non-inferiority study, we evaluated the postoperative analgesic effect of preoperative ultrasound-guided Erector Spinae Plane blocks (ESPB) on T4 and T6 levels in patients undergoing video-assisted thoracic surgery in comparison with paravertebral block (PVB) at the same intervertebral spaces.SettingA university hospital.Patients66 patients scheduled to undergo video-assisted thoracic surgery under general anesthesia were included.InterventionsPatients were randomly allocated to receive ultrasound-guided ESP blocks on T4 and T6 levels (Group ESPB, n = 33) or PVB (Group PVB, n = 33) with 30 mL 0.4% ropivacaine 30 min before anesthesia induction. A continuous flurbiprofen (8 mg/h) was infused postoperatively through a single-use infusion device and intravenous oxycodone supplied as analgesic rescue if needed, with bolus of oxycodone (1 mg) and lockout time being 10 min.MeasurementsThe primary outcome was the postoperative oxycodone consumption at 48 h.Main resultsIntraoperative use of sufentanil and remifentanil were comparable between these two groups. Pain scores, oxycodone rescue and Quality of Recovery (QoR) 15 on postoperative day 1 and 2 were equivalent between these two groups. Postoperative oxycodone consumption was 7.9 ± 8.7 boluses in ESPB group and 6.9 ± 6.3 boluses in PVB group at 48 h. The cumulative 48 h difference i.e. Oxycodone boluses_{with ESPB} minus Oxycodone boluses_{with PVB} was 2 (95% CI -1, 5.6). The lower limit of the 95% CI for this difference was −1, which was within the predefined non-inferiority margin of −10 (Δ).ConclusionsUltrasound-guided ESPB applied before video assisted thoracic surgery was non-inferior in analgesic effect compared with PVB in terms of pain score, analgesic rescue consumption and quality of recovery.Brief summary statementPreoperative Erector spinae plane blocks (ESPB), when in combination with round-the-clock NSAIDs, offered equivalent analgesia and quality of recovery after video assisted thoracic lung surgery compared with paravertebral blocks. Patients who received ESP blocks had similar consumption of oxycodone and length of hospital stay.     

Bilateral ultrasound-guided erector spinae plane block in patients undergoing lumbar spinal fusion: A randomized controlled trial

Study objectiveSpinal fusion surgery is associated with severe postoperative pain. We examined whether bilateral ultrasound-guided erector spinae plane block could alleviate postoperative pain in patients undergoing lumbar spinal fusion.DesignBlinded, randomized, controlled study.SettingTertiary university hospital, operating room, postoperative recovery room and ward.PatientsSixty patients with American Society of Anesthesiologists grade I or II scheduled for lumbar spinal fusion surgery were randomized into the erector spinae plane block group (ESPB group) and the control group in a 1:1 ratio.InterventionsPre-operative ultrasound-guided bilateral erector spinae plane block was performed in the ESPB group, while sham subcutaneous infiltration was performed in the control group.MeasurementsThe primary outcome was pain intensity at rest within 12 h postoperatively using the Numeric Rating Scale (NRS). Secondary outcomes included NRS pain scores at rest and on movement, postoperative opioid consumption and proportions of patients requiring opioid during the first 48 h after surgery.Main resultsThe ESPB group (n = 30) showed significantly lower pain scores at rest at 4 h after surgery (estimated mean difference − 1.6, 95% confidence interval [CI] -2.4 to −0.8, p < 0.001), at 8 h (−1.3, 95% CI -1.9 to −0.6, p < 0.001), and at 12 h (−0.7, 95% CI -1.3 to −0.1, p = 0.023). The two groups showed similar pain scores at rest at 24 h after surgery (estimated mean difference − 0.2, 95% CI -0.8 to 0.5) and 48 h (−0.3, 95% CI -0.8 to 0.2). The ESPB group also showed significantly lower pain score on movement at 4 h after surgery (−1.5, 95% CI -2.5 to −0.6). The ESPB group showed a significantly smaller proportion of patients requiring sufentanil within 12 h after surgery (p = 0.020), and the group consumed significantly less sufentanil during that period (p = 0.042).ConclusionsBilateral ultrasound-guided erector spinae plane block improves postoperative analgesia in patients undergoing lumbar spinal fusion.     

Analgesic efficacy of erector spinae plane block in lumbar spine surgery: A systematic review and meta-analysis

Study objectiveErector spinae plane block (ESPB) has gained popularity for perioperative analgesia in various surgeries. However, its efficacy in lumbar surgery remains unclear. This review aimed to determine whether ESPB could improve analgesic efficacy in lumbar spine surgery.DesignA meta-analysis of randomized controlled trials.SettingPerioperative setting.PatientsPatients undergoing lumbar spine surgery under general anesthesia.InterventionsWe searched the databases including PubMed, Cochrane Library, EMBASE, Web of Science etc. for published eligible controlled trials comparing ESPB with control (no block/sham block) in lumbar spine surgery.MeasurementsThe primary outcome was opioid consumption in the first 24 h after surgery.Main resultsTwelve studies comprising 665 participants were included. Compared to the control, ESPB reduced the opioid (morphine milligram equivalents) consumption significantly 24 h after surgery [mean difference (MD) = −14.55; 95% confidence interval (CI), −21.03 to −8.07; P < 0.0001] and lowered the pain scores at various time points (at rest or during movement) for 48 h after surgery. ESPB increased the patient satisfaction score (0−10) (MD = 2.38; 95% CI, 2.10 to 2.66; P < 0.0001), decreased the postoperative nausea and vomiting [risk ratio (RR) = 0.36; 95% CI, 0.20 to 0.67; P = 0.001], and minimized the length of hospital stay (MD = −1.24 days; 95% CI, −2.31 to −0.18; P = 0.02). Furthermore, subgroup analysis revealed additional reduction in opioid consumption by the block approach at the vertebral level of incision/operation than that at the fixed thoracic/lumbar level. However, considerable heterogeneity and low-grade quality of evidence were observed.ConclusionsESPB provided effective postoperative analgesia resulting in better patient satisfaction and recovery with decreased postoperative nausea and vomiting in patients undergoing lumbar surgery compared to the control. However, the low-grade quality of evidence compromised the findings, therefore further high-quality of evidence is required.PROSPERO registration number: CRD42021233362.     

Erector spinae plane block for postoperative analgesia in breast and thoracic surgery: A systematic review and meta-analysis

Study objectiveThe erector spinae plane block (ESPB) is a newly defined regional anesthesia technique first introduced in 2016. The aim of this study is to determine its analgesic efficacy compared with non-block care and thoracic paravertebral block (TPVB).DesignWe systematically searched PubMed, Web of Science citation index, Embase, the Cochrane Library, Google Scholar, and ClinicalTrials.gov register searched up to March 2020. We conducted a meta-analysis of randomized controlled trials (RCTs) that compared an ESPB to non-block care or TPVB for postoperative analgesia in breast and thoracic surgery patients. Primary outcome was 24-hour postoperative opioid consumption. Risk of bias was assessed using Cochrane methodology.Results14 RCTs that comprised 1018 patients were included. Seven trials involved thoracic surgery patients and seven included breast surgery patients. Meta-analysis revealed that ESPB significantly reduced 24-hour opioid consumption compared with the non-block groups (−10.5 mg; 95% CI: −16.49 to −3.81; p = 0.002; I² = 99%). Similarly, the finding was consistent in subgroup analysis between the breast surgery (−7.75 mg; 95%CI −13.98 to −1.51; p = 0.01; I² = 97%) and thoracic surgery (−14.81 mg; 95%CI −21.18 to −8.44; p < 0.001; I² = 96%) subgroups. The ESPB significantly reduced pain scores at rest or movement at various time points postoperatively compared with non-block group, and reduced the rate of postoperative nausea and vomiting (OR 0.48; 95%CI 0.27 to 0.86; p = 0.01; I² = 0%). In contrast, there were no significative differences reported in any of the outcomes for ESPB versus TPVB strata.ConclusionsESPB improved analgesic efficacy in breast and thoracic surgery patients compared with non-block care. Furthermore, current literature supported the ESPB offered comparable analgesic efficacy to a TPVB.     

Impact of ultrasound-guided erector spinae plane block on postoperative quality of recovery in video-assisted thoracic surgery: A prospective,randomized, controlled trial

Study objectiveRegional anesthesia improves postoperative analgesia and enhances the quality of recovery (QoR) after surgery. We examine the efficacy of ultrasound-guided erector spinae plane block (ESPB) on QoR after video-assisted thoracic surgery (VATS).DesignProspective, randomized, double-blinded, placebo-controlled trial.SettingSingle institution, tertiary university hospital.PatientsAdult patients who scheduled for VATS under general anesthesia were enrolled in the study.InterventionsWe randomly allocated patients to receive preoperative ultrasound-guided ESPB with 25 ml of either 0.5% ropivacaine (ESPB group) or normal saline (Control group).MeasurementsThe primary outcome was QoR as measured by the 40-item QoR questionnaire (QoR-40) score at postoperative day 1. Secondary results were post-anesthesia care unit (PACU) discharge time, acute postoperative pain, cumulative opioid consumption, the incidence of postoperative nausea or vomiting (PONV), and patient satisfaction.Main resultsThe global QoR-40 score at postoperative day 1 (median, interquartile range) was significantly higher in the ESPB group (174, 170 to 177) than the control group (161.5, 160 to 165), estimated median difference 11 (95% CI 9 to 13, P < 0.001). Compared with the control group, single-injection of ESPB reduced PACU discharge time, acute postoperative pain, and cumulative opioid consumption. Correspondingly, the median patient satisfaction scores were higher in the ESPB group than the control group (9 versus 7, P < 0.001).ConclusionPreoperative single-injection thoracic ESPB with ropivacaine improves QoR, postoperative analgesia, and patient satisfaction after VATS.     

Bilateral erector spinae plane blocks in children undergoing cardiac surgery: A randomized,controlled study

Study objectiveWe aimed to test the hypothesis that erector spinae plane block (ESPB) provides efficient analgesia and reduces postoperative morphine consumption in children undergoing cardiac surgery with median sternotomy.DesignA prospective, blinded, randomized, controlled study.SettingA tertiary university hospital, operating room and intensive care unit.PatientsForty children aged 2–10 years, who underwent cardiac surgery with median sternotomy. The patients were randomly divided into the block group (Group B) and the control group (Group C).InterventionsGroup B (n = 20) were treated with ultrasound-guided bilateral ESPB at the level of the T4-T5 transverse process, whereas no block was administered in Group C (n = 20). In all children, intravenous morphine at 0.05 mg/kg was used whenever the modified objective pain score (MOPS) ≥4 for postoperative analgesia.MeasurementsThe MOPS and Ramsay sedation score (RSS) were assessed at 0, 1, 2, 4, 6, 8, 10, 12, 16, 20 and 24 h postoperatively. Total morphine consumption at 24 h, extubation time and length of intensive care unit (ICU) stay was also evaluated and recorded.Main resultsBilateral ESPB significantly decreased the consumption of morphine in the first 24 h, postoperatively. During the postoperative 24-h follow-up, 11 children in Group C requested morphine and the cumulative dose of morphine was 0.83 ± 0.91 mg, while 4 children in Group B requested morphine and the cumulative dose of morphine was 0.26 ± 0.59 mg (p = 0.043). There was no significant difference between Groups B and C in terms of MOPS and RSS values, extubation time or length of ICU stay.ConclusionUltrasound-guided bilateral ESPB with bupivacaine provides efficient postoperative analgesia and reduces postoperative morphine consumption at 24 h in children undergoing cardiac surgery.     

The use of phenylephrine to obtund oxytocin-induced hypotension and tachycardia during caesarean section

BackgroundOxytocin causes clinically significant hypotension and tachycardia. This study examined whether prior administration of phenylephrine obtunds these unwanted haemodynamic effects.MethodsForty pregnant women undergoing elective caesarean section under spinal anaesthesia were randomised to receive either an intravenous 50 μg bolus of phenylephrine (Group P) or saline (Group S) immediately before oxytocin (3 U over 15 s). Systolic blood pressure, diastolic blood pressure, mean arterial pressure and heart rate were recorded using a continuous non-invasive arterial pressure device. Baseline values were averaged for 20 s post-delivery. Between-group comparisons were made of the mean peak changes in blood pressure and heart rate, and the mean percentage changes from baseline, during the 150 s after oxytocin administration.ResultsThe mean ± SD peak percentage change in systolic blood pressure was −16.9 ± 2% in Group P, and −19.0 ± 1.9% in Group S and the estimated mean difference was 2.1% (95% CI −3.5% to 7.8%; P=0.44); corresponding changes in heart rate were 13.5 ± 2.3% and 14.0 ± 1.5% and the mean estimated difference was 0.5% (95% CI −6.0% to 5%; P=0.87). The mean percentage change from the baseline measurements during the 150 s period of measurement was greater for Group S than Group P: systolic blood pressure −5.9% vs −3.4% (P=0.149); diastolic blood pressure −7.2% vs −1.5% (P=0.014); mean arterial pressure −6.8% vs −1.5% (P=0.007); heart rate 2.1% vs −2.4% (P=0.033).ConclusionIntravenous phenylephrine 50 μg immediately before 3 U oxytocin during elective caesarean section does not prevent maternal hypotension and tachycardia.     

Efficacy of erector spinae plane block for minimally invasive mitral valve surgery: Results of a double-blind,prospective randomized placebo-controlled trial

Study objectiveTo investigate if an erector spinae plane (ESP) block decreases postoperative opioid consumption, pain and postoperative nausea and vomiting in patients undergoing minimally invasive mitral valve surgery (MIMVS).DesignA single-center, double-blind, prospective, randomized, placebo-controlled trial.SettingPostoperative period; operating room, post-anesthesia care unit (PACU) and hospital ward in a university hospital.PatientsSeventy-two patients undergoing video-assisted thoracoscopic MIMVS via right-sided mini-thoracotomy and enrolled in the institutional enhanced recovery after cardiac surgery program.InterventionsAt the end of surgery, all patients received an ESP catheter at vertebra T5 under ultrasound guidance and were randomized to the administration of either ropivacaine 0.5% (loading of dose 30 ml and three additional doses of 20 ml with a 6 h interval) or normal saline 0.9% (with an identical administration scheme). In addition, patients received multimodal postoperative analgesia including dexamethasone, acetaminophen and patient-controlled intravenous analgesia with morphine. Following the final ESP bolus and before catheter removal, the position of the catheter was re-evaluated by ultrasound. Patients, investigators and medical personnel were blinded for the group allocation during the entire trial.MeasurementsPrimary outcome was cumulative morphine consumption during the first 24 h after extubation. Secondary outcomes included severity of pain, presence/extent of sensory block, duration of postoperative ventilation and hospital length of stay. Safety outcomes comprised the incidence of adverse events.Main resultsMedian (IQR) 24-h morphine consumption was not different between the intervention- and control-group, 41 mg (30–55) versus 37 mg (29–50) (p = 0.70), respectively. Likewise, no differences were detected for secondary and safety endpoints.ConclusionsFollowing MIMVS, adding an ESP block to a standard multimodal analgesia regimen did not reduce opioid consumption and pain scores.     

Ultrasound-guided erector spinae plane block versus thoracic epidural analgesia: Postoperative pain management after Nuss repair for pectus excavatum

Aim of the StudyPostoperative pain management is a significant challenge in patients undergoing Nuss repair for pectus excavatum chest wall deformity. Therapeutic anesthetic options primarily include patient-controlled intravenous analgesia, thoracic epidural analgesia (TEA), and cryoanalgesia. However, TEA is limited to inpatient use and both TEA and cryoanalgesia can result in neurologic injury. The novel technique of ultrasound-guided erector spinae plane regional analgesia has been used recently in our patients undergoing the Nuss repair and has shown impressive pain relief, but without the potential complications of other modalities. Erector spinae plane block (ESPB) postoperative pain management outcomes were studied as compared to TEA.MethodsThirty consecutive patients with severe pectus excavatum undergoing Nuss repair and placement of ultrasound-guided ESPB were each paired to a historical cohort control patient with TEA postoperative pain management. The cohort patient match was defined by age (± 2 years), gender, and CT pectus index (± 15%). Study variables included hospital length of stay (LOS), pain scores, and pain medication usage.ResultsPain scores as measured by area under the curve per hour (Day 1: 2.72 (SD = 1.37) vs. 3.90 (SD = 1.81), P = 0.006; Day 2: 2.83 (SD = 1.32) vs. 3.97 (SD = 1.82), P = 0.007) and oral morphine equivalent (OME) pain medication usage (Day 1: 11.9 (SD = 4.9) vs 56.0 (SD = 32.2), P < 0.001; Day 2: 14.7 (SD = 7.1) vs. 38.0 (SD = 21.7), P < 0.001) were higher for the first two postoperative days in the ESPB group. However, mean hospital LOS was nearly one day shorter for ESPB patients (3.78 (SD = 0.82) vs. 2.90 (SD = 0.87), P < 0.001) who were discharged home with the catheter in place until removal, typically at 5–7 days postoperatively.ConclusionUltrasound-guided ESPB is thus a feasible, safe, and effective alternative to TEA in postoperative pain management after Nuss repair and results in decreased hospital stay.Level of evidenceIII     

Erector spinae plane block for postoperative analgesia in robotically-assisted coronary artery bypass surgery: Results of a randomized placebo-controlled trial

Study objectiveTo investigate if an erector spinae plane (ESP) block decreases postoperative opioid consumption, pain and postoperative nausea and vomiting in patients undergoing robotically-assisted minimally invasive direct coronary artery bypass surgery (RAMIDCAB).DesignA single-center, double-blind, prospective, randomized, placebo-controlled trial.SettingPostoperative period; operating room, post-anesthesia care unit (PACU) and hospital ward in a university hospital.PatientsSixty-four patients undergoing RAMIDCAB surgery via left-sided mini-thoracotomy and enrolled in the institutional enhanced recovery after cardiac surgery program.InterventionsAt the end of surgery, patients received an ESP catheter at vertebra T5 under ultrasound guidance and were randomized to the administration of either ropivacaine 0.5% (loading dose of 30 ml and three additional doses of 20 ml each, interspersed with a 6 h interval) or normal saline 0.9% (with an identical administration scheme). In addition, patients received multimodal analgesia including acetaminophen, dexamethasone and patient-controlled analgesia with morphine. Following the final ESP bolus and before catheter removal, the position of the catheter was re-evaluated by ultrasound. Patients, investigators and medical personnel were blinded for the group allocation during the entire trial.MeasurementsPrimary outcome was cumulative morphine consumption during the first 24 h after extubation. Secondary outcomes included location and severity of pain, presence/extent of sensory block, duration of postoperative ventilation and hospital length of stay. Safety outcomes comprised the incidence of adverse events.Main resultsMedian (IQR) 24-h morphine consumption was not different between the intervention- and control-groups, 67 mg (35–84) versus 71 mg (52–90) (p = 0.25), respectively. Likewise, no differences were detected in secondary and safety endpoints.ConclusionsFollowing RAMIDCAB surgery, adding an ESP block to a standard multimodal analgesia regimen did not reduce opioid consumption and pain scores.     

Perioperative analgesic efficacy and safety of erector spinae plane block in posterior cervical spine surgery—a double blinded,randomized controlled study

Background contentPosterior cervical spine surgery (PCSS) are typically open surgeries and entail significant postoperative pain. Current perioperative pain management in PCSS is reliant on multimodal analgesia. While perioperative epidural anesthetic infusion can be used in lumbar surgeries, this is not an option in the cervical spine. Pre-emptive regional analgesia through erector spinae plane block (ESPB) has shown significant perioperative analgesic benefits in lumbar spine surgeries. There are no such clinical studies in PCSS.PurposeTo assess the safety and efficacy of ultrasound-guided ESPB for perioperative analgesia in PCSS.Study designProspective, randomized controlled, double-blinded study.Patient sampleEighty-six patients requiring sub-axial PCSS with or without instrumentation were randomized into two groups, those who underwent ESPB with multimodal analgesia (case) and those with only multimodal analgesia (control).Outcome measuresDemographic and surgical data (blood loss, duration of surgery, perioperative total opioid consumption, muscle relaxants used) were assessed. Postoperatively, the surgical site pain, alertness scale, satisfaction score, time to mobilization and complications were recorded.MethodsAfter anesthesia and prone position, case patients received ultrasound-guided ESPB at the T1 level using 15 ml of 0.25% bupivacaine and 8 mg Dexamethasone bilaterally while the control patients received only standard postoperative multimodal analgesia.ResultsThere were 43 patients in each group; the two groups were identical in demographic and surgical profile. The intraoperative opioid consumption (119.53±40.35 vs. 308.6±189.78; p<.001) in mcg), muscle relaxant usage (50.00±0.00 mg vs. 59.53±3.75 mg, p<.001), surgical duration (124.77±26.63/ 156.74±37.01 min; p<.01) and intraoperative blood loss (310.47±130.73 ml vs. 429.77±148.50 ml; p<.05) were significantly less in the ESPB group. In the postoperative period, the control group's pain score was significantly higher (p<.001). The Modified Observer Alertness/Sedation Score (MOASS) score and satisfaction scores also showed significant differences between the case and control groups (p<.001). The mean time required to ambulate (sitting/walking) was statistically less in cases (15.81±6.15/20.72±4.02 h) when compared to controls (16.86±6.18/ 23.05±8.88 h; p<.001).ConclusionIn patients undergoing PCSS, ESPB is a safe and effective technique with better outcomes than standard multimodal analgesia alone, in terms of reduced intraoperative opioid requirements and blood loss, better postoperative analgesia and early mobilization.     

The effect of ultrasound-guided intercostal nerve block,single-injection erector spinae plane block and multiple-injection paravertebral block on postoperative analgesia in thoracoscopic surgery: A randomized,double-blinded,clinical trial

Study objectiveThe study was to determine the analgesic effect of ultrasound-guided intercostal nerve block (ICNB) and single-injection erector spinae plane block (ESPB) in comparison with multiple-injection paravertebral block (PVB) after thoracoscopic surgery.DesignRandomized, controlled, double- blinded study.SettingOperating room, postoperative recovery room and ward.PatientsSeventy-five patients, aged 18–75 years, ASA I–II and scheduled for elective thoracoscopic partial pulmonary resection surgery were enrolled in the study. Seventy-two patients were left for final analysis.InterventionsPatients were randomly assigned into the three groups (PVB group, ICNB group or ESPB group). After anesthesia induction, a single anesthesiologist performed PVB at T5-T7 levels or ICNB at T4-T9 levels or ESPB at T5 level under ultrasound guidance using 20 ml of 0.375% ropivacaine. Patients were connected to the patient-controlled morphine analgesia device after surgery.MeasurementsCumulative morphine consumption at 24 h postoperatively as primary outcome was compared. Visual analog scale pain scores at rest and while coughing at 0, 2, 4, 8, 24 and 48 h postoperatively, cumulative morphine consumption at other observed time and rescue analgesia requirement were also recorded.Main resultsThere was a significant difference in median [interquartile range, IQR] morphine consumption at 24 h postoperatively among the three groups (PVB, 10.5 [9–15] mg; ICNB, 18 [13.5–22.1] mg; ESPB, 22 [15–25.1] mg; p = 0.000). This difference was statistically significant for PVB group vs ESPB group (median difference, −7.5; 95% confidence interval [CI], −12 to −4.5; p = 0.000) and PVB group vs ICNB group (median difference, −6; 95% CI, −9 to −3; p = 0.001), but not for ICNB vs ESPB (median difference, −3; 95% CI, −6 to 1.5; p = 0.192). PVB group had significantly lower VAS scores at rest and while coughing than ESPB group at 0, 2, 4, 8 h postoperatively and than ICNB group at 8 h postoperatively. There was no significant difference in the VAS scores between ICNB group and ESPB group at all time. Median VAS scores at rest and while coughing at all time were low (<4) in all groups. More rescue analgesia was needed in ESPB group during 48 postoperative hours (PVB vs ICNB vs ESPB; 13% vs 29% vs 46%; p < 0.05).ConclusionsUltrasound-guided multiple-injection PVB provided superior analgesia to ICNB and single-injection ESPB, while ICNB and single-injection ESPB were equally effective in reducing pain after thoracoscopic surgery.     

The effect of lidocaine patch for postoperative pain: A meta-analysis of randomized controlled trials

Study objectiveThe role of lidocaine patch (LP) in reducing postoperative pain by local anesthetic absorption has been evaluated in several studies; however, these trials have shown inconsistent results. This meta-analysis aimed to identify the benefits of LP, focusing on its pain-reducing and morphine-sparing effect in patients after surgery.DesignMeta-analysis.SettingPublished randomized controlled trials (RCTs) comparing the analgesic effects of LP after surgery to those of placebo or no patch.PatientsEleven RCTs including 539 patients.InterventionsWe searched electronic databases to identify relevant RCTs.MeasurementsThe primary outcome was postoperative pain score up to 48 h assessed using a numerical rating or visual analog scale, and the secondary outcomes were postoperative morphine consumption and side effects. The effect size was estimated by calculating the mean difference (MD) or risk ratio (RR), with 95% confidence interval (CI).Main resultsLP significantly decreased postoperative pain score at 6 h (MD, −1.85; 95% CI, −2.98 to −0.72; p = 0.001), 12 h (MD, −1.48; 95% CI, −2.07 to −0.88; p < 0.001), 24 h (MD, −1.18; 95% CI, −1.65 to −0.7; p < 0.001), and 48 h (MD, −1.33; 95% CI, −2.46 to −0.19; p = 0.022). In contrast, no significant effect on postoperative morphine consumption was observed at 24 h (MD, −3.48 mg; 95% CI, −7.94 to 0.98 mg; p = 0.127) or 48 h (MD, −5.29 mg; 95% CI, −13.28 to 2.71; p = 0.195). LP was unrelated to local (RR, 1.00, 95% CI, 0.67 to 1.49; p = 0.987) or systemic side effects (RR, 0.76, 95% CI, 0.52 to 1.11, p = 0.151).ConclusionsLP can lower postoperative pain without side effects, compared to placebo or no patch. However, its morphine-sparing effect remains unclear.     

Use of high-resolution thermography as a validation measure to confirm epidural anesthesia in mice: a cross-over study

BackgroundEffective epidural anesthesia is confirmed in humans by sensory assessments but these tests are not feasible in mice. We hypothesized that, in mice, infrared thermography would demonstrate selective segmental warming of lower extremities following epidural anesthesia.MethodsWe anesthetized 10 C57BL/6 mice with isoflurane and then inserted a PU-10 epidural catheter under direct surgical microscopy at T11-12. A thermal camera (thermal sensitivity ±0.05°C, pixel resolution 320x240 pixels, and spatial resolution 200 μm) recorded baseline temperature of front and rear paws, tail and ears. Thermography was assessed at baseline and 2, 5, 10, and 15 min after an epidural bolus dose of 50 μL bupivacaine 0.25% or 50 μL saline (control) using a cross-over design with dose order randomized and investigators blinded to study drug. Thermal images were recorded from video and analyzed using FLIR software. Effect over time and maximal effect (E_max) were assessed by repeated measures ANOVA and paired t-tests. Comparisons were between bupivacaine and control, and between lower vs upper extremities.ResultsEpidural bupivacaine caused progressive warming of lower compared with upper extremities (P <0.001), typically returning to baseline by 15 min after administration. Mean (±SD) E_max was +3.73 (±1.56) °C for lower extremities compared with 0.56 (±0.68) °C (P=0.03) for upper extremities. Following epidural saline, there was no effect over time (E_max for lower extremities −0.88 (±0.28) °C compared with the upper extremities −0.88 (±0.19) °C (P >0.99).ConclusionsThermography is a useful tool to confirm epidural catheter placement in animals for which subjective, non-noxious, sensory measures are impossible.     

Effectiveness of pigtail catheter crushing combined with AngioJet mechanical aspiration for treatment of acute left iliofemoral vein thrombosis

Background/objectiveWe investigated the efficacy of combined pigtail catheter crushing and AngioJet mechanical aspiration of thrombi in the treatment of acute iliofemoral deep venous thrombosis (DVT).MethodsEighty-two patients with acute iliofemoral DVT were retrospectively divided into a pigtail catheter + AngioJet group (group A, 42 cases) and an AngioJet-only group (group B, 40 cases). The difference in the circumference of the healthy limbs before and after treatment, immediate thrombus clearance rate in the lower limbs, recannalization percentage of venous lumen, and duration of postoperative hematuria were compared to evaluate the safety and effectiveness of the combination method.ResultsThe technical success rate was 100%, no serious bleeding complications occurred, lower extremity symptoms were effectively alleviated, and post-treatment recannalization percentage of venous lumen were similarly high in both groups. Group A fared significantly better than group B in immediate thrombus clearance (P < 0.05), intraoperative aspiration time (199.38 ± 68.55 vs. 295.30 ± 76.02 s), postoperative CDT urokinase dosage (2.10 ± 0.94 vs. 3.07 ± 0.94 million units), and duration of postoperative hematuria (13.23 ± 2.96 vs. 16.75 ± 3.11 h) (all P < 0.001). At 6 months, the recannalization percentage of venous lumen of group A and group B was 89.71 ± 16.02% and 88.64 ± 16.68%, respectively.ConclusionThe combination of pigtail catheter crushing and AngioJet mechanical aspiration of thrombi for acute left iliofemoral vein thrombosis is safe, easy, and effective, with a satisfactory short-term outcome.     

The effects of a resistive warming mattress during caesarean section: a randomised,controlled trial

BackgroundThe adverse effects of inadvertent perioperative hypothermia in the surgical population are well established. The aim of this study was to investigate whether a resistive warming mattress would reduce the incidence of inadvertent perioperative hypothermia in patients undergoing elective caesarean section.MethodsA total of 116 pregnant women booked for elective caesarean section were randomised to either intraoperative warming with a mattress or control. The primary outcome was the incidence of inadvertent perioperative hypothermia, defined as a temperature <36.0°C on admission to the recovery room. Shivering in the perioperative period, severity of shivering and the need for treatment, total blood loss, fall in haemoglobin, incidence of blood transfusion, immediate health of baby, and length of hospital stay were also recorded.ResultsThe incidence of inadvertent perioperative hypothermia in the mattress-warmed group was significantly lower than in the control group (5.2% vs. 19.0%, P = 0.043); mean temperatures differed between the two groups, 36.5°C and 36.3°C, respectively (P = 0.046). There was also a significantly lower mean (± SD) haemoglobin change in the mattress-warmed group at −1.1 ± 0.9 g/dL versus −1.6 ± 0.9 g/dL in the control group (P = 0.007). There was no difference in shivering (P = 0.798).ConclusionsA resistive warming mattress reduced the incidence of inadvertent perioperative hypothermia and attenuated the fall in haemoglobin. The use of resistive mattress warming should be considered during caesarean section.     

Comparison of sliding distance of lag screw and nonunion rate according to anteromedial cortical support in intertrochanteric fracture fixation: A systematic review and meta-analysis

IntroductionWe compared the sliding distance of the lag screw, change in neck-shaft angle (NSA), and nonunion rates according to the anteromedial cortical support on anteroposterior (AP) and lateral view radiographs post intertrochanteric fracture reduction.Material and MethodsIn this systematic review and meta-analysis, MEDLINE, Embase, and Cochrane Library databases were searched systematically for studies published before September 26, 2020. We performed synthetic analyses of the amount of lag screw sliding, change in NSA, and incidence of nonunion following reduction of intertrochanteric fractures by extramedullary reduction (EMR), neutral reduction (NR), and intramedullary reduction (IMR). The combined data of EMR and NR comprised the non-IMR group.ResultsOur study enrolled eight studies, representing 1,363 patients who underwent surgery for intertrochanteric fractures. A pooled analysis showed a larger sliding distance in the IMR group than in the non-IMR group (standard mean difference [SMD] = 1.47, 95% confidence interval [CI]: 0.73–2.20; P < 0.0001 and SMD = 1.27, 95% CI: 0.56–1.99; P = 0.0005, respectively) in both AP and lateral views. The pooled mean difference of change in NSA in the IMR group was −3.11° and differed significantly from that of the non-IMR group (95% CI: −4.07 to −2.16; P < 0.0001). In the lateral view, the nonunion rate was significantly higher in the IMR group than in the non-IMR group (odds ratio [OR] = 11.61; 95% CI, 3.32–40.62; P = 0.0001). In the subgroup analysis, the NR group showed a larger sliding distance than that of the EMR group in the AP view (SMD = 0.40, 95% CI: 0.04–0.76; P = 0.03); however, the reverse was true in the lateral view (SMD = 0.68, 95% CI: 0.38–0.97; P < 0.00001).ConclusionIn the current meta-analysis, larger sliding distances, more varus in NSA, and higher nonunion rates were observed in the IMR group than the non-IMR group, in both AP and lateral views. However, in the comparison between EMR and NR, it was difficult to conclude which of them was the ideal reduction method because of inconsistent results.     

Laparoscopic versus ultrasound-guided visualization of transversus abdominis plane blocks

BackgroundUltrasound-guided (US) transversus abdominis plane (TAP) block is commonly utilized as part of a multi-modal approach for postoperative pain management. This study seeks to determine whether laparoscopic-guided TAP blocks are as effective as US-guided TAP blocks among pediatric patients.MethodIn this prospective, randomized controlled trial, pediatric patients undergoing laparoscopic procedures were randomly assigned to one of two treatment arms: US-guided TAP block (US-arm) or laparoscopic-guided TAP block (LAP-arm). Primary outcome was PACU pain scores. Secondary outcomes included PACU opioid consumption, block completion time and block accuracy.ResultsTwenty-five patients were enrolled in each arm. In the LAP-arm, 59% of blocks were in the transversus abdominis plane compared to 74% of TAP blocks in the US-arm (p = 0.18). Blocks were completed faster in the LAP-arm (2.1 ± 1.9 vs. 7.9 ± 3.4 min, p<0.001). The average highest PACU pain score was 3.4 ± 3.1 for the LAP-arm and 4.3 ± 3.8 for the US-arm (p = 0.37). Overall PACU pain scores and opioid consumption were similar between the groups (1.2 ± 1.3 vs. 1.6 ± 1.6, p = 0.24; 2.2 ± 5.8 vs. 0.9 ± 1.4MME, p = 0.26).ConclusionLaparoscopic TAP blocks have equivalent efficacy in post-operative pain scores, narcotic use, and tissue plane accuracy as compared to US-guided TAP blocks. They are also completed faster and may result in less operating room and general anesthetic time for the pediatric patient.     

Effects of topical tranexamic acid during open reduction and internal fixation of acetabular fractures: A retrospective study

ObjectiveThe aim of this study was to assess the effect of topical tranexamic acid on blood loss and transfusion rates in acetabular fracture surgery.MethodsThe medical records of 61 patients who underwent open reduction and internal fixation for acetabular fracture between 2012 and 2015 were retrospectively reviewed. The patients were divided into two groups: Group I consisted of 31 patients (19 men and 12 women, mean age: 52 ± 19 years) who received intraoperatively a topical tranexamic acid solution of 3 g and Group 2 consisted of 30 control patients (17 men and 13 women, mean age: 48 ± 24 years) who received only 0.9% saline solution. The groups were compared based on their intraoperative blood loss, Postoperative drain output at 24 and 48 h, and postoperative hemoglobin levels, and transfusion rates.ResultsThe mean intraoperative blood loss was 410 ± 100 ml in Group 1, compared to 570 ml ± 160 ml of the control group (p < 0.05). The postoperative drain output after 24 h was 210 ± 70 ml in Group 1 compared to 330 ± 90 ml of the control group (p < 0.05). The drain output at 48 h was (50 ± 20 ml) in group 1 compared to 90 ± 40 ml of the control group (p < 0.05). The transfusion rate was significantly low group 1 (42%) than the control group (97%). Hemoglobin drop was again significantly less in tranexamic acid group (2.1 ± 1.1) than the control group (3.2 ± 1.3). The nadir postoperative hemoglobin was higher in the Group 1 (10.4 ± 1.5) than the control group (9.2 ± 1.3).ConclusionTopical administration of tranexamic acid reduces intraoperative and postoperative blood loss in acetabular fracture surgery, decreasing transfusion rates.Level of EvidenceLevel III, Therapeutic Study.