Efficacy of Two Unique Combinations of Nerve Blocks on Postoperative Pain and Functional Outcome After Total Knee Arthroplasty: A Prospective,Double-Blind,Randomized Controlled Study

BackgroundThis study aimed to explore the efficacy of two unique combinations of nerve blocks on postoperative pain and functional outcome after total knee arthroplasty (TKA).MethodsPatients scheduled for TKA were randomized to receive a combination of adductor canal block (ACB) + infiltration between the popliteal artery and capsule of the posterior knee block (IPACK) + sham obturator nerve block (ONB) + sham lateral femoral cutaneous nerve block (LFCNB) (control group), or a combination of ACB + IPACK + ONB + sham LFCNB (triple nerve block group), or a combination of ACB + IPACK + ONB + LFCNB (quadruple nerve block group). All patients received local infiltration analgesia. Primary outcome was postoperative morphine consumption. Secondary outcomes were the time until first rescue analgesia, postoperative pain assessed on the visual analog scale (VAS), QoR-15 score, functional recovery of knee, and postoperative complications.ResultsCompared with the control group, the triple and quadruple nerve block groups showed significantly lower postoperative morphine consumption (17.2 ± 9.7 mg vs. 11.2 ± 7.0 mg vs. 11.4 ± 6.4 mg, P = .001). These two groups also showed significantly longer time until first rescue analgesia (P = .007 and .010, respectively, analyzed with Kaplan-Meier method), significantly lower VAS scores on postoperative day 1 (P < .01), significantly better QoR-15 scores on postoperative days 1 and 2 (P < .001), and significantly better functional recovery of knee including range of motion (P = .002 and .001 on postoperative days 1 and 2), and daily ambulation distance (P < .001 and P = .004 on postoperative days 1 and 2). However, the absolute change in morphine consumption, VAS scores, and QoR-15 scores did not exceed the reported minimal clinically important differences (MCIDs) (morphine consumption: 10 mg; VAS scores: 1.5 at rest and 1.8 during movement; QoR-15 scores: 8.0). The MCIDs of other outcomes have not been reported in literature. The triple and quadruple nerve block groups showed no significant differences in these outcomes between each other. The three groups did not show a significant difference in complication rates.ConclusionAdding ONB or ONB + LFCNB to ACB + IPACK can statistically reduce morphine consumption, improve early pain relief, and functional recovery. However, the absolute change in morphine consumption, VAS scores, and QoR-15 scores did not exceed the MCIDs. Based on our findings and considering the sample size of this study, there is not enough clinical evidence to support the triple or quadruple nerve block use within a multimodal analgesic pathway after TKA.     

Transversus abdominis plane block versus local anesthetic wound infiltration for optimal analgesia after laparoscopic cholecystectomy: A systematic review and meta-analysis with trial sequential analysis

BackgroundBoth transversus abdominis plane (TAP) block and local anesthetic wound infiltration have been used to relieve pain after laparoscopic cholecystectomy. We undertook this systematic review and meta-analysis with trial sequential analysis to determine the best analgesic technique.MethodsWe systematically searched the literature for trials comparing TAP block with wound infiltration after laparoscopic cholecystectomy. The primary outcome was pain score during rest (analogue scale, 0–10) at 2 postoperative hours. Secondary pain-related outcomes included pain scores during rest at 12 and 24 h, pain scores during movement and intravenous morphine consumption at 2, 12 and 24 h, and postoperative nausea and vomiting. Other secondary outcomes sought were block-related complications such as rates of postoperative infection, hematoma, visceral injury and local anesthetic systemic toxicity.ResultsTen trials including 668 patients were identified. There was a significant difference in pain score during rest at 2 postoperative hours in favour of TAP block when compared with wound infiltration (mean difference [95%CI]: −0.7 [−1.2, −0.2]; I2 = 71%; p = 0.008). Pain scores during rest at 12 and 24 h and pain scores during movement at 24 h were also significantly lower with TAP block than wound infiltration. Postoperative morphine consumption and the incidence of postoperative nausea and vomiting were significantly lower in patients who received a TAP block. Data were insufficient to compare block-related complications. The overall quality of evidence was moderate-to-high.ConclusionsThere is moderate-to-high level evidence that the TAP block provides superior analgesia when compared with wound infiltration in patients undergoing laparoscopic cholecystectomy.Trial registry number: PROSPERO CRD42020208057.     

Better timing of ultrasound-guided transversus abdominis plane block for early recovery after open inguinal herniorrhaphy: A prospective randomised controlled study

BackgroundThis study investigated the optimal timing of analgesic transversus abdominis plane (TAP) block in the operating room for better recovery quality using the Korean version of the Quality of Recovery-40 (QoR-40K) questionnaire in patients who had undergone open inguinal herniorrhaphy.MethodsThis single-centre, prospective randomised controlled study included adult male patients who had an ASA physical status of I–II. A total of 80 patients were analysed. The patients were randomly assigned and classified into pre-incisional TAP (pre-TAP) block (n = 40) and post-incisional TAP (post-TAP) block (n = 40) groups. The quality of postoperative functional recovery and complications were compared between the two groups during 24 h postoperatively.ResultsPreoperative findings of the two groups were comparable. The global QoR-40K score was higher in the pre-TAP group than in the post-TAP group. Among sub-dimensions, scores of physical comfort and pain were higher in the pre-TAP group than in the post-TAP group. In the post-anaesthesia care unit, the pre-TAP group showed lower pain scores than the post-TAP block group. There was no severe pain in the pre-TAP group, but two patients (5.0%) in the post-TAP block group suffered severe pain. The pre-TAP group required lower doses of IV rescue opioid in the PACU than the post-TAP group. All patients were discharged from hospital on postoperative day 1 without surgical complications.ConclusionsThe timing of analgesic TAP block may be of clinical importance to prevent postoperative pain and to improve the quality of early patient recovery following open inguinal herniorrhaphy.     

Intraoperative multimodal analgesic bundle containing dexmedetomidine and ketorolac may improve analgesia after robot-assisted prostatectomy in patients receiving rectus sheath blocks

BackgroundMinimally invasive robot-assisted laparoscopic radical prostatectomy (RALP) has replaced open prostatectomy. However, RALP does not reduce postoperative pain compared to the open approach. We explored whether bundled intraoperative intravenous infusion of dexmedetomidine and ketorolac reduced opioid requirements during the 24 h after RALP.MethodsEighty patients (two parallel groups) were enrolled in this prospective non-randomized study from September 2020 to November 2020. All received preoperative rectus sheath blocks for analgesia after RALP. A multimodal analgesic bundle (dexmedetomidine and ketorolac) was administered intraoperatively in the study group (n = 39) but not in the control group (n = 40). The total postoperative opioid requirements (expressed in milligrams of intravenous morphine) and pain scores (derived using a visual analog scale) were compared between the two groups up to 24 h after surgery.ResultsThe two groups were demographically similar. During surgery, patients in the study group received less remifentanil and more ephedrine than controls. The study group required significantly less opioids during the 24 h after surgery (28.3 vs. 40.0 mg, p = 0.006). The between-group pain scores differed significantly at 1 and 6 h after surgery. All other postoperative characteristics were comparable between the two groups.ConclusionsThe intraoperative multimodal analgesic bundle (intravenous dexmedetomidine and ketorolac) improved postoperative analgesia after RALP in patients with rectus sheath blocks, as evidenced by the opioid-sparing effect after surgery.     

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.     

Effect of total intravenous anesthesia or inhalation anesthesia on postoperative quality of recovery in patients undergoing total laparoscopic hysterectomy: A randomized controlled trial

Study objectiveTo investigate the effect of propofol-based total intravenous anesthesia (TIVA) or sevoflurane-based inhalation anesthesia on postoperative quality of recovery in patients undergoing total laparoscopic hysterectomy.DesignA prospective randomized controlled trial.SettingAn operating room, a postoperative recovery area, and a hospital ward.PatientsA total of 102 female patients scheduled for elective total laparoscopic hysterectomy were randomly divided into two groups: the propofol group (group P) or sevoflurane group (group S).InterventionsAnesthesia in group P was induced by propofol, fentanyl and rocuronium, and maintained by intravenous infusion of propofol and remifentanil. Anesthesia in group S was induced by a tidal volume inhalation technique with sevoflurane and rocuronium and maintained with sevoflurane and remifentanil. Patients in group P did not receive any volatile drugs.MeasurementsQuality of Recovery-40 (QoR-40), Pittsburgh Sleep Quality Index (PSQI) and Numerical Rating Scale (NRS) scores were assessed at 8, 24, 48, 72 h, 7 days and 30 days after surgery. Intraoperative hemodynamics, postoperative inflammatory indicators and adverse reactions were also recorded.Main resultsThe QoR-40 score and its 5 dimensions were similar in the two groups at each point in time (P > 0.05). Group S had less consumption of remifentanil (P < 0.001) but increased use of phenylephrine (P = 0.001) intraoperatively. PSQI scores were also comparable between groups at each point in time (P > 0.05). NRS scores at 72 h (P = 0.023) and 7 days (P = 0.017) after surgery, postoperative NLR (P = 0.024) and hs-CRP (P = 0.042), and the incidence of abdominal distension (P = 0.017) were significantly lower in group P than in group S. Multiple linear regression analyses demonstrated that duration of pneumoperitoneum and sleep quality were associated with postoperative recovery.ConclusionsThe choice of intravenous or inhalation maintenance anesthesia did not affect overall postoperative recovery as measured by the QoR-40 in patients undergoing total laparoscopic hysterectomy. Reducing the duration of pneumoperitoneum and improving sleep quality were conducive to postoperative recovery.     

Topical Cannabidiol (CBD) After Total Knee Arthroplasty Does Not Decrease Pain or Opioid Use: A Prospective Randomized Double-Blinded Placebo-Controlled Trial

BackgroundMultimodal analgesia has become the standard of care for pain management following total knee arthroplasty (TKA). Cannabidiol (CBD) is increasingly utilized in the postoperative period. The purpose of this study was to analyze the analgesic benefits of topical CBD following primary TKA.MethodsIn this randomized double-blinded placebo-controlled trial, 80 patients undergoing primary unilateral TKA applied topical CBD (CBD; n = 19), essential oil (EO; n = 21), CBD and essential oil (CBD + EO; n = 21), or placebo (PLA; n = 19) thrice daily around the knee for two weeks postoperatively. This supplemented a standardized multimodal analgesic protocol. Outcomes included visual analog scale (VAS) pain and numeric rating scale (NRS) sleep scores (collected on postoperative day [POD] 0, 1, 2, 7, 14, 42), and cumulative postoperative opioid use (42 days).ResultsDemographic characteristics were similar among the four cohorts. Preoperative VAS and NRS scores were similar among groups. The CBD cohort had a higher mean VAS pain score on POD 2 compared to the EO cohort (CBD: 69.9 ± 19.3 versus. EO: 51.0 ± 18.2; P = .013). No statistically significant differences existed for VAS scores at other times, and no statistically significant differences were observed for postoperative NRS sleep scores or postoperative opioid use at any time point.ConclusionUtilization of topical CBD in supplement to multimodal analgesia did not reduce pain or opioid consumption, or improve sleep scores following TKA. These results suggest that the local effects of topical CBD are not beneficial for providing additional pain relief after TKA.     

Posteromedial quadratus lumborum block versus transversus abdominal plane block for postoperative analgesia following laparoscopic colorectal surgery: A randomized controlled trial

Study objectiveOur hypothesis was that a pre-operative posteromedial quadratus lumborum (QL) block would reduce postoperative morphine consumption and provide superior analgesia in the setting of multimodal analgesia compared with a lateral transversus abdominis plane (TAP) block for laparoscopic colorectal surgery.DesignA randomized controlled study.SettingA single tertiary hospital. March to August 2018.Patients80 ASA I–II colorectal cancer patients undergoing laparoscopic radical resection were enrolled. 77 patients (group QL 38, group TAP 39) were included in the analysis.InterventionPre-operatively, patients were randomized to receive either a QL or TAP block (0.375% ropivacaine 20 ml bilaterally for each group).MeasurementsThe primary outcome was cumulative morphine consumption 24 h postoperatively. Secondary outcomes included postoperative pain scores, clinical recovery, and side-effect profiles of the blocks.Main resultsFor the primary outcome measure, morphine consumption 24 h postoperatively was significantly lower in the QL group than in the TAP group (estimated median difference −8 mg, adjusted 95% confidential interval −12 to −6 mg, P < 0.001). The pain visual analogue scores at rest and during movement were found to be statistically significantly lower in the QL group than in the TAP group 8, 12, and 24 h postoperatively (P < 0.006). The QL group reported higher overall satisfaction scores regarding postoperative analgesia than the TAP group (P = 0.014). One patient in the QL group experienced moderate back pain close to the needle entry site postoperatively. There was no statistically significant difference in postoperative nausea and vomiting, bowel recovery or length of hospital stay between the groups.ConclusionsThe pre-operative bilateral, ultrasound-guided posteromedial QL block reduces morphine consumption and improves analgesia in the setting of multimodal analgesia compared with the lateral TAP block after laparoscopic colorectal surgery.     

Multimodal analgesia reduces narcotic requirements and antiemetic rescue medication in laparoscopic Roux-en-Y gastric bypass surgery

BackgroundAfter bariatric surgery, patients are at risk for narcotic-related side effects [1]. Multimodal pain management strategies should be used when possible to reduce the consumption of narcotic medication [2]. The purpose of this study was to investigate whether multimodal analgesia reduces narcotic consumption and may have an influence on opioid-related side effects in patients undergoing laparoscopic Roux-en-Y gastric bypass surgery (LRYGB).MethodsIn this retrospective data analysis, we examined the data of a total of 181 consecutive patients undergoing LRYGB. In January 2011, IV acetaminophen became clinically available. Hydromorphone patient controlled analgesia (PCA) was replaced by IV acetaminophen and IV ketorolac (TNT—Tylenol and Toradol). The first 89 patients received postoperative hydromorphone PCA (PCA group). The next 92 patients received IV acetaminophen and IV ketorolac every 6 hours for the first 24 hours (TNT group). In the TNT group, 8 patients were excluded in the analysis.ResultsThere were no differences in clinical characteristics between the groups except for smoking history. Patients treated with PCA required 4.2 mg hydromorphone in the postoperative period. Patients in the TNT group required 1.1 mg hydromorphone. This was a statistically significant reduction of opioids by 73.8%. After discharge from postanesthesia care unit, 34.8% of patients required antiemetic rescue medication (AERM) compared with 20.2% in the TNT group (P<.001). The relative risk (AERM/no AERM) in the postoperative period after postanesthesia care unit discharge is 1.75 (95% CI, 1.05–2.92).ConclusionThis study suggests that a multimodal analgesic regimen (TNT) can reduce postoperative narcotic consumption, which may lead to a reduction in the number of patients requiring AERM.     

Comparison of remimazolam-based and propofol-based total intravenous anesthesia on postoperative quality of recovery: A randomized non-inferiority trial

Study objectiveThe quality of recovery (QoR) of remimazolam-based and propofol-based total intravenous anesthesia was compared as measured by QoR-15 scores.DesignA prospective, double-blind, randomized controlled, non-inferiority trial.SettingAn operating room, a post-anesthesia care unit (PACU), and a hospital ward.PatientsFemale patients (n = 140; 20–65 years) scheduled for open thyroidectomy were enrolled and randomly assigned to the remimazolam or propofol group.InterventionsThe remimazolam group received continuous remimazolam infusions and effect-site target-controlled remifentanil infusions. The propofol group received effect-site target-controlled infusions of propofol and remifentanil.MeasurementsThe primary outcome was QoR-15 on postoperative day 1 (POD1). The mean difference between the groups was compared against a non-inferiority margin of −8. Secondary outcomes were QoR-15 on POD2, hemodynamic data, time to lose and recover consciousness, sedation score upon PACU admission, pain, and postoperative nausea and vomiting profiles at the PACU and ward. Group-time interaction effects in hemodynamic data and QoR-15 were analyzed using a linear mixed model.Main resultsThe total QoR-15 score on POD1 in the remimazolam group was non-inferior to that in the propofol group (mean [SD] 111.2 [18.8] vs. 109.1 [18.9]; mean difference [95% CI] 2.1 [−4.2, 8.5]; p = 0.002 for non-inferiority). The QoR-15 score on POD2 was comparable between the groups, and no group-time interaction was observed. At the end of anesthesia, after extubation, and upon arrival at the PACU, mean arterial pressure was significantly higher in the remimazolam group. Remimazolam group was more sedated at the time of admission to PACU. Pain intensity and the requirement for analgesics were lower in the remimazolam group than in the propofol group.ConclusionsRemimazolam-based total intravenous anesthesia provided a similar QoR to propofol. Remimazolam and propofol can be used interchangeably for general anesthesia in female patients undergoing thyroid surgery.     

Rectus sheath block for acute pain management after robot-assisted prostatectomy

BackgroundRobot-assisted laparoscopic prostatectomy (RALP) is a favored surgical approach for treating prostate cancer. However, RALP does not decrease postoperative pain significantly despite its minimal invasiveness. The pain associated with robot-assisted surgery is most severe during the immediate postoperative period. We aimed to demonstrate that preoperative rectus sheath block (RSB) can reduce acute pain after RALP.MethodsA prospective non-randomized study with two parallel groups was performed from June 2020 to August 2020. A total of 100 patients undergoing RALP were divided into two groups: the RSB group (n = 50) and the non-RSB group (n = 50). Ultrasound-guided RSB was performed preoperatively only in the RSB group. The primary outcome of the study was the visual analog scale (VAS) pain score during coughing (VAS-C) 1 h after surgery. In addition, the VAS pain score at rest (VAS-R) and the VAS-C were assessed up to 24 h after surgery. The doses of postoperative opioids consumed were also recorded.ResultsThe RSB group had a significantly lower VAS-C 1 h after RALP (58 [47–73] vs. 74 [63–83] mm, p = 0.001). In addition, the RSB group had significantly lower VAS-R and VAS-C scores, and postoperative opioid requirement, up to 6 h after surgery compared to the non-RSB group. Moreover, the VAS-R was significantly lower in the RSB group than in the non-RSB group 24 h after surgery.ConclusionPreoperative RSB significantly improved analgesia during the early period after RALP. The long-term analgesic efficacy of RSB needs further study.     

Ultrasound-guided bilateral superficial cervical plexus blocks enhance the quality of recovery in patients undergoing thyroid cancer surgery: A randomized controlled trial

Study objectiveRegional anesthesia can improve postoperative analgesia and enhance the quality of recovery (QoR) after surgery. This trial evaluates the effects of ultrasound-guided bilateral superficial cervical plexus block (SCPB) on QoR in patients undergoing thyroid cancer surgery.DesignProspective, randomized, double-blinded, placebo-controlled trial.SettingOperating room.PatientsSeventy-four ASA I–II female patients scheduled for thyroid cancer surgery were included to the study.InterventionsPatients were randomly allocated to receive pre-operative ultrasound-guided bilateral SCPB with 10 ml of ropivacaine 0.5% or normal saline on each side.MeasurementsThe primary endpoint was the quality of recovery, which was assessed using the 15-item quality of recovery questionnaire (QoR-15). Secondary endpoints were acute postoperative pain, time to first rescue analgesia, the number of patients requiring rescue analgesia, length of post-anesthesia care unit (PACU) stay, the incidence of postoperative nausea or vomiting (PONV) and dizziness, and patient satisfaction.Main resultsThe global QoR-15 score at 24 h postoperatively was significantly higher in the SCPB group (Median [IQR], 118 [115–120]) than the control group (110 [106–112]) with a median difference of 8 (95% CI: 6 to 10, P < .001). Compared with the control group, pre-operative ultrasound-guided bilateral SCPB reduced postoperative pain up to 24 h and the incidence of PONV, as well as the length of PACU stay. Additionally, the patient satisfaction scores were improved in the SCPB group (P = .024).ConclusionPre-operative ultrasound-guided bilateral SCPB with ropivacaine enhances the quality of recovery, postoperative analgesia and patient satisfaction, alleviates the incidence of PONV, and accelerates the PACU discharge following thyroid cancer surgery.     

Effects of epidural combined with general anesthesia versus general anesthesia on quality of recovery of elderly patients undergoing laparoscopic radical resection of colorectal cancer: A prospective randomized trial

Study objectivesThe aim of the present study was to assess the quality of recovery from anesthesia on patients subjected to laparoscopic radical resection of colorectal cancer under epidural block combined with general anesthesia or general anesthesia by means of Quality of Recovery-15 (QoR-15) questionnaire.DesignProspective randomized trial.SettingThe setting is at an operating room, a post-anesthesia care unit, and a hospital ward.PatientsSeventy patients, aging from 65 to 79 years with an American Society of Anesthesiologists physical status II or III, were scheduled to undergo laparoscopic radical resection of colorectal cancer.InterventionsEpidural block combined with general anesthesia or general anesthesia.MeasurementsThe QoR-15 was administered by an investigator blind to group allocation before surgery (T₀), at 24 and 72h after surgery (T₁ and T₂), and on postoperative day 7 (T₃). The quality of recovery, as assessed by the score on the QoR-15, was compared between the groups. Besides, the consumption of anesthetics, respiratory recovery time, response time, extubation time, flatus time, the incidence of nausea or vomiting, the consumption of antiemetic and analgesic agents, and the duration of the hospital stay were also recorded.Main resultsThe QoR-15 scores at T₁ and T₂ were significantly higher in the E + G group compared with the G group (P < 0.05). Among the five dimensions of the QoR-15, physiological comfort, physiological independence, pain, and emotional dimension were significantly better at T₁ in the E + G group, and physiological comfort and pain were significantly better at T₂ in the E + G group.ConclusionThis study demonstrates that epidural block combined with general anesthesia can improve the early recovery of elderly patients after laparoscopic radical resection of colorectal cancer from the perspective of patients.     

Anterior quadratus lumborum block at the lateral supra-arcuate ligament versus transmuscular quadratus lumborum block for postoperative analgesia in patients undergoing laparoscopic nephrectomy: A randomized controlled trial

Study objectiveThe analgesic efficacy of transmuscular quadratus lumborum block (TQLB) to decrease the need for opioid consumption after laparoscopic nephrectomy has been demonstrated in several studies. However, the effect of an anterior QLB approach at the lateral supra-arcuate ligament (QLB-LSAL) in this surgical context is unclear. Here, we aimed to compare postoperative analgesic effects of the two block approaches in laparoscopic nephrectomy.DesignA single-center, randomized controlled trial.SettingUniversity-affiliated tertiary care hospital.PatientsA total of 106 patients with American Society of Anesthesiologists (ASA) physical status of I–III scheduled to undergo elective laparoscopic nephrectomy under general anesthesia.InterventionsPatients were randomly allocated to receive preoperative TQLB or QLB-LSAL with 0.5% ropivacaine (25 mL). Postoperatively, patient-controlled analgesia with intravenous sufentanil was administered.MeasurementsThe primary outcome was postoperative intravenous morphine equivalent consumption within the first 24 h postoperatively. Secondary outcomes included pain scores, satisfaction scores, levels of sedation, and incidence of nausea or vomiting.Main resultsPatients who underwent preoperative QLB-LSAL used a significantly lower intravenous morphine equivalent dose than those who underwent preoperative TQLB within the initial 24 h after surgery (34.3 ± 6.3 mg vs 23.5 ± 3.2 mg, P < 0.001). No significant differences were observed in pain scores, satisfaction scores, sedation scores, or incidence of nausea or vomiting between the groups.ConclusionsThe results indicate that, compared to TQLB, QLB-LSAL is a beneficial nerve block that can reduce postoperative opioid consumption, making it a potentially superior approach to achieve multimodal analgesia after laparoscopic nephrectomy.     

多模式镇痛与静脉自控镇痛对类风湿关节炎全膝关节置换术围手术期镇痛效果的病例对照研究

目的 :比较多模式镇痛与静脉自控镇痛对类风湿关节炎患者全膝关节置换围手术期的镇痛效果。方法 :自2015年6月至2016年6月对40例类风湿关节炎患者行单侧全膝关节置换术治疗,分为2组。静脉自控镇痛组20例,男3例,女17例,平均年龄(59.6±2.3)岁;多模式镇痛组20例,男2例,女18例,平均年龄(56.3±1.3)岁。静脉自控镇痛组采用静脉镇痛泵控制性滴入舒芬太尼镇痛,多模式镇痛组采用连续股神经阻滞、膝关节局部注射及丁丙诺啡贴剂联合镇痛方案,比较两组患者全膝关节置换术后48 h内VAS评分及不良反应发生率,术后1周HSS评分,评价两种镇痛模式的优劣。结果:术后6、24 h,多模式镇痛组患者VAS评分低于静脉自控镇痛组;术后48 h在运动和静止状态下,多模式镇痛组患者VAS评分均低于静脉自控镇痛组。术后1周多模式镇痛组HSS评分高于静脉自控镇痛组,HSS评分中的功能、疼痛及活动度评分,多模式镇痛组优于静脉自控镇痛组,但肌力评分两组差异无统计学意义。结论:多模式镇痛效果好,不良反应少,是类风湿关节炎患者全膝关节置换围手术期理想的镇痛方案。     

Clinical efficacy of ultrasound guided bilateral erector spinae block for single-level lumbar fusion surgery: a prospective,randomized, case-control study

BACKGROUND CONTEXTPostoperative experience plays a vital role in patient recovery and does not depend on the type and quality of the surgical procedure alone. Non-opioid therapies have become part of the multimodal analgesic regimen for better pain control and reduced opioid-related side effects. Most recently evolved among these are the regional anesthetic techniques, such as the thoracolumbar interfascial plane (TLIP) block and the erector spinae (ESP) block.PURPOSETo assess the efficacy of ultrasound-guided (US) ESP block for postoperative analgesia after a single level lumbar spine fusion surgery compared with conventional (opioid-based) multimodal postoperative analgesia.STUDY DESIGNA prospective, randomized, controlled, and double-blinded clinical trial.PATIENT SAMPLEA 100 consecutive patients requiring single-level lumbar spinal fusion procedure were randomized into two groups- block (multimodal analgesia with US-ESP) and control (only multimodal analgesia) groups.OUTCOME MEASURESDemographic and surgical data, intra-operative blood loss, duration of surgery, total opioid consumption (TOC) and amount of muscle relaxants used were assessed. Postoperatively, the Numeric pain Rating Scale(NRS), Modified Observer's assessment of Alertness and/or Sedation Scale (MOASS) and Patient satisfaction scores were recorded every 2 hours for the first 6 hours followed by every 6 hours for 24 hours. Continuous variables were analyzed using Student's t-test, and categorical variables were analyzed using either the Chi-square test or Fisher's exact test. p-value < .05 was considered statistically significant.METHODSPatients in both groups underwent the identical protocol for pre-emptive analgesia and induction of anesthesia. Patients in the block group received the US-ESP block after induction and positioning, followed by the multimodal analgesia, while the control group received only the multimodal analgesia.RESULTSBoth groups had identical demographic backgrounds and surgical profile. TOC for 24 hours following induction was significantly lower in the block group than the control group (105.0 ± 15.15 vs 158.00 ± 23.38mcg; p < .001). The total muscle relaxant consumption during surgery was also significantly less in the block group than the control group (51.90 ± 3.17 vs 57.70 ± 5.90; p < .001). The intra-operative blood loss was significantly less (p < .001) in the block group (303.00 ± 86.55 ml) than the control group (437.00 ± 116.85 ml). Compared to the block group, the control group's pain score (NRS) was significantly higher in the first 48 hours following surgery. The MOASS score was significantly lower in the control group (4.46 ± 0.50 vs 3.82 ± 0.82; p < .001) in the immediate postoperative period. The satisfaction score was significantly higher in the block group than the control group (9.52 ± 0.65 vs 8.22 ± 0.79; p < .001).CONCLUSIONThe employed US-ESP block for single-level lumbar fusion surgery is an effective component of multimodal analgesia for reducing blood loss, total opioid consumption, and related side effects with a significant reduction of postoperative pain and higher patient satisfaction.     

Analgesic efficacy of ketamine and magnesium after laparoscopic sleeve gastrectomy: A randomized,double-blind,placebo-controlled trial

BackgroundKetamine and magnesium are antagonists of the N-methyl-d-aspartate receptor, and are valuable adjuvants for multimodal analgesia and opioid sparing. Data are limited regarding the opioid sparing efficacy of the combined intraoperative application of these agents in laparoscopic bariatric surgery. The objective of this study was to compare the postoperative opioid sparing properties of a single intraoperative dose of ketamine versus a combination of single doses of ketamine and magnesium after laparoscopic gastric sleeve resection in bariatric patients.MethodsOne hundred and twenty- six patients were randomly assigned to receive single boluses of ketamine alone 0.5 mg kg⁻¹ IV (ketamine group); combined ketamine bolus of 0.5 mg kg⁻¹ IV and magnesium 2 g IV (ketamine and magnesium group); or placebo. Opioid consumption at 24 h (in morphine equivalents); pain at rest; postoperative nausea and vomiting impact score; sedation scores; and trends of transcutaneous carbon-di-oxide values were analysed.ResultsThe median (inter-quartile range [range]) morphine consumption at 24 h were 32 (24–47 [4.8–91]) mg in the ketamine group, 37 (18–53 [1–144]) mg in the ketamine and magnesium group, and 26 (21–36 [5–89]) mg in the control group and were not significantly different between the groups. There were no differences for all other outcomes examined.ConclusionCombined single intraoperative bolus doses of ketamine and magnesium did not result in postoperative opioid sparing after laparoscopic gastric sleeve resection.     

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.     

The value of pre-emptive analgesia in the treatment of postoperative pain after laparoscopic cholecystectomy

BACKGROUND AND AIM: Postoperative pain is an important surgical problem. Recent studies in pain pathophysiology have led to the hypothesis that with pre-operative administration of analgesics (pre-emptive analgesia) it may be possible to prevent or reduce postoperative pain. This study was planned to investigate the efficacy of pre-emptive analgesia on postoperative pain after laparoscopic cholecystectomy. METHODS: 45 patients undergoing laparoscopic cholecystectomy were randomized into three groups. Bupivacaine was injected into the area of skin incision before trocar entry and after trocar removal in group 1 and 2, respectively; however, this procedure was not applied to the control group. The pain score of the patients was evaluated by the visual analogue scale (VAS) at 1, 4, 12( )and 24 h after surgery. The daily analgesic requirement was evaluated in terms of diclophenac sodium (Diclomec, Abdi Ibrahim, 75 mg) intake/day. Analgesics were given to the patients whose VAS was 5 or higher. RESULTS: While there was no significant difference in VAS scores between group 1 and 2, the mean pain scores of these two groups were found to be significantly lower than of the control group although the analgesic requirement of the patients in each group was not statistically significant. CONCLUSION: Pre-emptive analgesia is as effective as postsurgical local anaesthesia in reducing postoperative pain.