Effects of peribulbar bupivacaine as an adjunct to general anaesthesia on peri-operative outcome following retinal detachment surgery

Sixty premedicated, ASA physical status I or II patients weighing > 25 kg scheduled for elective retinal detachment repair were randomly assigned to receive either peribulbar block with 10 ml of 0.25% bupivacaine (block group) or intravenous morphine 150 microg.kg-1 (morphine group), prior to the induction of general anaesthesia (n = 30 in each group). Patients were evaluated for intra-operative oculocardiac reflex, peri-operative pain relief, recovery from anaesthesia and postoperative nausea and vomiting. Apart from significantly reducing the incidence of oculocardiac reflex (30% vs. 70%, p = 0.0019), peribulbar bupivacaine also attenuated the severity of the reflex. Postoperative pain relief was superior in the block group. More block group patients had the maximum recovery score in the immediate postoperative period (80% vs. 27%, p < 0. 0001) and they achieved complete recovery significantly faster than the morphine group (17.3 (14.7) min vs. 66.7 (29.7) min, p < 0.0001). The incidence (40% vs. 77%, p = 0.004) and severity of postoperative nausea and vomiting were significantly less in the block group. In summary, peribulbar bupivacaine, when administered together with general anaesthesia, attenuated oculocardiac reflex, provided comparable intra-operative and superior postoperative analgesia, resulted in significantly earlier and better recovery from anaesthesia, and significantly reduced the incidence and severity of postoperative nausea and vomiting.     

Midazolam sedation and local anaesthesia compared with general anaesthesia for paediatric outpatient dental surgery

Midazolam sedation may offer an alternative to general anaesthesia for dental treatment in children. This study evaluated the efficacy and safety of i.v. midazolam with local anaesthesia in uncooperative paediatric dental patients. Thirty children (aged 2–10 years, physical status ASA 1 or 2) were randomized into two groups to receive general anaesthesia (group G) or local anaesthesia during sedation with i.v. midazolam (group M). Incremental doses of midazolam 0.05 mgkg^-1 were given to a sedative endpoint of 2 on a Sedation Scale of 5–0 (hyperactive–asleep), or 0.4 mgkg^-1 maximum, then as needed to maintain the same level of sedation. Amnesia was tested at the sedative endpoint by showing the child a tinkling ball and checking recall 1 h after surgery. Recovery was assessed by the Post-Anesthetic Recovery Scale at 3 h (0–10) with 10 representing readiness for discharge. Questionnaires were completed by the dentist and anaesthetist during recovery and by telephone to the parents 1–2 weeks later. Dental treatment was completed according to protocol in 11 of the 15 patients in group M (sedative doses: 0.27 0.09 mgkg^-1, mean SD) and all patients in group G. Recovery was similar in both groups, with discharge criteria met after 1 h 30 min in all but one group M patient. None had recall for intra-operative events. However, the variability of responsiveness makes midazolam unreliable when used alone to facilitate dental treatment, and the high dose requirements make close monitoring of paediatric patients mandatory.     

Brainstem anesthesia presenting as contralateral third nerve palsy following peribulbar anesthesia for cataract surgery

Brainstem anesthesia is a serious complication that has been reported to occur more commonly with retrobulbar anesthesia compared to peribulbar anesthesia. We herein report a case of contralateral third nerve palsy following administration of peribulbar anesthesia for cataract surgery. Two hours after the surgery, the patient recovered completely without any residual neurological deficit. The importance of immediate recognition of clinical signs and symptoms of central spread of the local anesthetic and the mechanical factors of the block that could have contributed to this complication are discussed in this report.     

Analgesic efficacy of ketorolac 0.5% ophthalmic solution (Accular) in paediatric strabismus surgery

This prospective double-blind study was designed to assess the analgesic efficacy of ketorolac 0.5% ophthalmic solution compared with placebo in 30 healthy children undergoing extraocular muscle recession for correction of strabismus. After paracetamol 20 mg.kg-1 preoperatively, a standard anaesthetic was given. There were no significant differences in Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) and faces pain scale (FPS) scores, requirement for supplementary analgesia or in postoperative vomiting between the two groups over the following 24 h. This study did not demonstrate improved postoperative analgesia when topical ketorolac eye drops were given in addition to paracetamol. This observed lack of efficacy may reflect difficulties in the use of CHEOPS and FPS in this age group with this pain model.     

The analgesic efficacy of sciatic nerve block in addition to femoral nerve block in patients undergoing total knee arthroplasty: a systematic review and meta‐analysis

The aim of this meta‐analysis was to assess the postoperative analgesic efficacy of sciatic nerve block when combined with femoral nerve block after total knee arthroplasty. Outcomes included resting pain scores (analogue scale, 0–100), intravenous morphine consumption at 12 h, 24 h and 48 h postoperatively, and functional outcomes comprising knee flexion, distance walked, and length of stay. Twelve randomised controlled trials were included, with a total of 600 patients. When combined with femoral nerve block, sciatic nerve block significantly reduced resting pain scores at 12 h postoperatively with a mean difference of 10 (95% CI: ?15 to ?5; p < 0.00001). Resting pain scores at 24 h, and intravenous morphine consumption at 12 h, 24 h and 48 h postoperatively were also significantly reduced, but without clinical significance beyond 12 h and without affecting functional outcomes. In conclusion, sciatic nerve block confers additional postoperative analgesia within the first 12 postoperative hours compared with femoral nerve block alone for patients undergoing total knee arthroplasty.     

Postoperative oxygenation in the elderly following general or local anaesthesia for ophthalmic surgery

Peripheral oxygen saturation was recorded on the pre-operative night (between 2400 and 0600 h), the immediate postoperative period (first 60 min) and the first postoperative night (2400 to 0600 h) in 18 elderly patients aged 70 years or over presenting for elective ophthalmic surgery. Nine patients had surgery performed under general anaesthesia employing muscle relaxants and controlled ventilation and nine under local anaesthesia using a peribulbar block. The median (interquartile range) percentage of time during which the patients had an oxygen saturation of less than 90% was 0 (0-0.2) and 0.04 (0-0.4) on the pre-operative night, 0.7 (0-1.4) and 0.3 (0-1.2) in the immediate postoperative period, and 0.05 (0-0.16) and 0 (0-0.3) on the postoperative night in the general and local anaesthesia patients respectively. There were no significant differences between general and local anaesthesia in respect of these data and the overall incidence of significant desaturation was low. The present study could not demonstrate any adverse effect of general anaesthesia on oxygen saturation in patients undergoing minimally invasive surgery.     

Effect of preincisional ilioinguinal and iliohypogastric nerve block on postoperative analgesic requirement in day-surgery patients undergoing herniorrhaphy under spinal anaesthesia

BACKGROUND: By choosing spinal anaesthesia instead of general anaesthesia, and by infiltrating the wound area with local anaesthetic the need for postoperative analgesics may be reduced. An ilioinguinal and iliohypogastric nerve block (IINB) in inguinal herniorrhaphy was, therefore, studied in a day surgery setting in combination with a spinal block. METHODS: One hundred ASA I-II adult patients scheduled for inguinal herniorrhaphy were given spinal anaesthesia with hyperbaric 0.5% bupivacaine. In a randomized and blinded fashion half of them received an IINB 5 min before the surgical incision with 10 ml of 0.5% bupivacaine (B-IINB) and the other half with saline (S-IINB). All patients received ketoprofen 100 mg i.v. during surgery and another 100 mg 2-3 h postoperatively. The patients were observed for about 6 h in the day surgery unit before discharge. RESULTS: The results showed that in comparison with the S-IINB group, significantly fewer patients in the B-IINB group needed analgesics (P<0.01) and the amount required was also significantly less postoperatively, before discharge (about 6 h postoperatively) (P<0.05). The latency to the need for the first postoperative analgesic was shorter in the S-IINB patients (P<0.01). At home the VAS scores and the need for analgesics (oral ketoprofen 100 mg) were low with no differences between the groups. No complications occurred. CONCLUSION: It is concluded that no long-term analgesia could be demonstrated by a preincisional IINB performed during spinal anaesthesia in day-surgery inguinal herniorrhaphy patients. Thus, reduced analgesic requirement was seen only for about 6 h postoperatively.     

Randomised controlled trial of dexmedetomidine sedation vs general anaesthesia for inguinal hernia surgery on perioperative outcomes in infants

Background

Neonates and infants undergoing general anaesthesia for hernia surgery are at risk of perioperative cardiorespiratory adverse events. The use of regional anaesthesia with dexmedetomidine preserves airway tone and may potentially avoid these complications. This study compares the perioperative conditions and adverse events between dexmedetomidine sedation with caudal block and general anaesthesia with caudal block for inguinal hernia surgery in infants.

Analgesia and discharge following preincisional ilioinguinal and iliohypogastric nerve block combined with general or spinal anaesthesia for inguinal herniorrhaphy

BACKGROUND: Preincisional ilioinguinal and iliohypogastric nerve block (IINB) reduces postoperative analgesics after inguinal herniorrhaphy. The effect of an IINB on postoperative pain and discharge profile was therefore studied in day-surgery patients undergoing inguinal herniorrhaphy with general or spinal anaesthesia. METHODS: Seventy ASA I-II adult patients scheduled for inguinal herniorrhaphy received an IINB before the surgical incision with 15 ml of 0.5% bupivacaine. In a randomized fashion half of them received general anaesthesia with spontaneous breathing via a laryngeal mask (GA-group) and the other half received spinal anaesthesia with 5 mg of bupivacaine diluted with sterile water to 2.5-ml volume (SPIN-group). In the postanaesthesia care unit (PACU), pain was assessed on a scale from 0 to 10 (VAS) and ketorolac 30 mg i.v. (VAS < 5), or fentanyl 0.05 mg i.v. (VAS > or = 5) was administered as scheduled. In the day surgery unit and at home the analgesic was a tablet of ibuprofen 200 mg + codeine 30 mg (VAS > or = 3). RESULTS: Patients in the SPIN-group reported lower postoperative pain scores at 30, 60 min (P < 0.0001) and 120 min (P < 0.05) after surgery, and longer time to first analgesic use (P < 0.0001). Patients in the GA-group had a shorter time to discharge without voiding (P < 0.001) and with voiding (P < 0.05). After discharge, there were no significant differences between the groups regarding pain scores at rest and at walking, or the doses of analgesic. Adverse events were rare in both groups. CONCLUSION: Only a relatively short immediate analgesic benefit could be demonstrated by a combination of IINB with spinal anaesthesia compared with IINB combined with general anaesthesia. The use of general anaesthesia facilitated an earlier postoperative discharge than spinal anaesthesia.     

A comparison between ilioinguinal-iliohypogastric nerve block performed by anaesthetist or surgeon for postoperative analgesia following groin surgery in children

A study was performed to compare postoperative analgesia in children undergoing groin surgery. Patients were randomly allocated to receive ilioinguinal-iliohypogastric (I-I) nerve blocks using 0.25% plain bupivicaine (0.5 ml·kg^?1) performed either percutaneously by the anaesthetist after the induction of general anaesthesia, before surgery commenced, or intraoperatively, under direct vision, by the surgeon. Analgesia was assessed by pain scoring in the recovery room and at hourly intervals for eight h postoperatively. Analgesic requirement was also noted. Statistical analysis of the results revealed no difference in pain score between groups treated either by anaesthetist or surgeon. However, children under two years of age had significantly higher pain scores than those over two.     

Analgesic efficacy of bilateral superficial cervical plexus block for thyroid surgery: meta-analysis and systematic review

Background

Thyroid surgery is moderately painful, but is increasingly being considered as a day-case procedure. Bilateral superficial cervical plexus block (BSCPB) provides an adjuvant technique to facilitate this approach, but there is great evidential heterogeneity in randomised controlled trials (RCTs) about its use.

Single-injection thoracic paravertebral block for postoperative pain treatment after thoracoscopic surgery

Background. Thoracoscopic surgery can be associated with considerablepostoperative pain. While the benefits of paravertebral blockon pain after thoracotomy have been demonstrated, no investigationson the effects of paravertebral block on pain after thoracoscopyhave been conducted. We tested the hypothesis that a single-injectionthoracic paravertebral block, performed preoperatively, reducespain scores after thoracoscopic surgery. Methods. Of 45 patients recruited, 40 completed the study. Theywere randomly allocated to two groups: the paravertebral groupreceived i.v. patient-controlled analgesia (PCA) with morphineplus single-injection thoracic paravertebral block with bupivacaine0.375% and adrenaline 1:200 000 0.4 ml kg^–1 (n=20). Thecontrol group was treated with a back puncture without injectionand morphine PCA (n=20). Results. The main outcomes recorded during 48 h after surgerywere pain scores using the visual analogue scale (VAS, 0–100).Secondary outcomes were cumulative morphine consumption andpeak expiratory flow rate (PEFR). Half an hour and 24 h aftersurgery, median (25th–75th percentiles) VAS on coughingin the paravertebral group was 31.0 (20.0–55.0) and 30.5(17.5–40.0) respectively and in the control group it was70.0 (30.0–100.0) and 50.0 (25.0–75.0) respectively.The difference between the groups over the whole observationperiod was statistically significant (P<0.05). Twenty-fourand 48 h after surgery, median (25th–75th percentiles)cumulative morphine consumption (mg) was 49.0 (38.3–87.0)and 69.3 (38.8–118.5) respectively in the paravertebralgroup and 51.2 (36.0–84.1) and 78.1 (38.4–93.1)in the control group (statistically not significant). No differenceswere found in PEFR or the incidence of any side-effects betweengroups. Conclusion. We conclude that single-shot preoperative paravertebralblock improves post-operative pain treatment after thoracoscopicsurgery in a clinically significant fashion.      

A comparison of 1% ropivacaine with a mixture of 0.75% bupivacaine and 2% lignocaine for peribulbar anaesthesia

In a single centre, randomised, double-blind study, 54 patients underwent intraocular surgery under peribulbar anaesthesia with either ropivacaine 1% or a mixture of bupivacaine 0.75% and lignocaine 2%, both with hyaluronidase 7.5 iu.ml-1. There were no significant differences in volume of anaesthetic required, time to onset of block, peri-operative pain scores or frequency of adverse events between the ropivacaine group and the lignocaine and bupivacaine group.     

General anaesthesia versus thoracic paravertebral block for breast surgery: A meta-analysis

Background

Thoracic paravertebral block (TPVB) offers an attractive alternative to general anaesthesia (GA) for ambulatory breast surgery. The aim of this meta-analysis was first to evaluate the safety and efficacy of TPVB for breast surgery, and second to compare TPVB with GA with regard to postoperative pain, nausea and vomiting, opioid consumption and length of hospital stay.

Methods

An electronic and manual search of English- and French-language articles on TPVB in breast surgery (published from January 1980 to June 2010) yielded 41 citations. Two levels of screening identified 11 relevant studies. The Mantel–Haenszel method (fixed effect) was used to perform the meta-analysis.

Results

Eleven studies were retained for analysis. When TPVB was used instead of GA, pain scores were significantly decreased at 1 and 6 h postoperatively (mean difference of 2.48 (95%confidence interval (CI): 2.20–2.75) and 1.71 (95%CI: 1.64–1.78), respectively). Furthermore, postoperative analgesic consumption was significantly lower in patients who received TPVB compared with GA (relative risk (RR) 0.23, (95%CI: 0.15–0.37)). TPVB was also associated with significantly less postoperative nausea and vomiting (RR 0.27 (95%CI: 0.12–0.61)). Increased patient satisfaction and a shorter hospital stay also favoured TPVB over GA.

Conclusions

TPVB provides effective anaesthesia for ambulatory breast surgery and can result in significant benefits over GA. However, further studies are required to determine whether these advantages would still be present if an optimal technique for outpatient GA is employed. Adjunctive ultrasonography may contribute to improve the safety of TPVB in breast surgery and requires further investigation.     

A randomised controlled trial of intravenous dexmedetomidine added to dexamethasone for arthroscopic rotator cuff repair and duration of interscalene block

Prolongation of peripheral nerve blockade by intravenous dexamethasone may be extended by intravenous dexmedetomidine. We randomly allocated 122 participants who had intravenous dexamethasone 0.15 mg.kg⁻¹ before interscalene brachial plexus block for day-case arthroscopic rotator cuff repair to intravenous saline (62 participants) or intravenous dexmedetomidine 1 μg.kg⁻¹ (60 participants). The primary outcome was time from block to first oral morphine intake during the first 48 postoperative hours. Fifty-nine participants reported taking oral morphine, 25/62 after placebo and 34/60 after dexmedetomidine, p = 0.10. The time to morphine intake was shorter after dexmedetomidine, hazard ratio (95%CI) 1.68 (1.00–2.82), p = 0.049. Median (IQR [range]) morphine doses were 0 (0–12.5 [0–50]) mg after control vs. 10 (0–30 [0–50]) after dexmedetomidine, a difference (95%CI) of 7 (0–10) mg, p = 0.056. There was no effect of dexmedetomidine on pain at rest or on movement. Intra-operative hypotension was recorded for 27/62 and 50/60 participants after placebo vs. dexmedetomidine, respectively, p < 0.001. Other outcomes were similar, including durations of sensory and motor block. In conclusion, dexmedetomidine shortened the time to oral morphine consumption after interscalene block combined with dexamethasone and caused intra-operative hypotension.     

Comparison of articaine and bupivacaine/lidocaine for single medial canthus peribulbar anaesthesia

In a single-centre, randomized, double-blind study, we comparedthe efficacy of 2% articaine with that of a mixture of 0.5%bupivacaine and 2% lidocaine for peribulbar anaesthesia in cataractsurgery, using a single medial canthus injection technique.Eighty-two patients were allocated randomly to receive 7–9 mlof a mixture of 0.5% bupivacaine and 2% lidocaine or an equalvolume of 2% articaine with 1:200 000 epinephrine. Hyaluronidase30 iu ml^–1 was added to both solutions. Thedegree of akinesia was scored 1, 5 and 10 min after theblock, at the end of surgery and at discharge from the day caseunit. Primary outcome measures were the difference in ocularmovement scores 5 min after block and the need for supplementaryinferolateral injections. There was greater akinesia in thearticaine group at 5 min (P=0.01). Ten patients (24%) inthe articaine group and 21 patients (51%) in the bupivacaine/lidocainegroup required a supplementary injection (P=0.02). The mean(SD) volume of local anaesthetic required to achieve adequateblock for surgery was 9.7 (2.1) ml in the articaine group and11.0 (2.2) ml in the bupivacaine/lidocaine group (P=0.01). Therewas a faster offset of akinesia after surgery in the articainegroup (P=0.01). There were no differences between groups inthe incidence of reported pain or of minor complications. Inour study, 2% articaine with 1:200 000 epinephrine wassafe and efficacious for single medial canthus peribulbar anaesthesia. Br J Anaesth 2001; 87: 584–7     

A randomised trial of serratus anterior plane block for analgesia after thoracoscopic surgery

We evaluated the effect of pre‐operative serratus anterior plane block on postoperative pain and opioid consumption after thoracoscopic surgery. We randomly allocated 89 participants to block with 30 ml ropivacaine 0.375% (n = 44), or no block without placebo or sham procedure (n = 45). We analysed results from 42 participants in each group. Serratus anterior plane block reduced mean (SD) remifentanil dose during surgery, 0.12 (0.06) mg.h^?1 vs. 0.16 (0.06) mg.h^?1, p = 0.016, and reduced mean (SD) fentanyl consumption in the first 24 postoperative hours, 3.8 (1.9) μg.kg^?1 vs. 5.7 (1.6) μg.kg^?1, p = 0.000004. Block also reduced the worst median (IQR [range]) pain scores reported in the first 24 postoperative hours: 6 (5–7 [3–10]) vs. 7 (6–7 [3–10]), p = 0.027. Block decreased dissatisfaction with pain management, categorised as ‘highly unsatisfactory’, ‘unsatisfactory’, ‘neutral’, ‘satisfactory’ or ‘highly satisfactory’: 1/2/21/18/0 vs. 1/14/15/11/1, p = 0.0038. There were no differences in the rates of nausea, vomiting, dizziness or length of hospital stay. Serratus anterior plane block may be used to reduce pain and opioid use after thoracoscopic lung surgery.     

Efficacy of erector spinae plane block for analgesia in breast surgery: a systematic review and meta-analysis

The erector spinae plane block is a new regional anaesthesia technique that provides truncal anaesthesia for breast surgery. This systematic review and meta-analysis was undertaken to determine if the erector spinae plane block is effective at reducing pain scores and opioid consumption after breast surgery. This study also evaluated the outcomes of erector spinae plane blocks compared with other regional blocks. PubMed, Embase, Scopus, the Cochrane Central Register of Controlled Trials and ClinicalTrials.gov were searched. We included randomised controlled trials reporting the use of the erector spinae plane block in adult breast surgery. Risk of bias was assessed with the revised Cochrane risk-of-bias tool. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework was used to assess trial quality. Thirteen randomised controlled trials (861 patients; 418 erector spinae plane block, 215 no blocks, 228 other blocks) were included. Erector spinae plane block reduced postoperative pain compared with no block: at 0-2 hours (mean difference (95% CI) −1.63 (−2.97 to −0.29), 6 studies, 329 patients, high-quality evidence, I² = 98%, p = 0.02); at 6 hours (mean difference (95% CI) −0.90 (−1.49 to −0.30), 5 studies, 250 patients, high-quality evidence, I² = 91%, p = 0.003); at 12 hours (mean difference (95% CI) −0.46 (−0.67 to −0.25), 5 studies, 250 patients, high-quality evidence, I² = 58%, p < 0.0001); and at 24 hours (mean difference (95% CI) −0.50 (−0.70 to −0.30), 6 studies, 329 patients, high-quality evidence, I² = 76%, p < 0.00001). Compared with no block, erector spinae plane block also showed significantly lower postoperative oral morphine equivalent requirements (mean difference (95% CI) −21.55mg (−32.57 to −10.52), 7 studies, 429 patients, high-quality evidence, I² = 99%, p = 0.0001). Separate analysis of studies comparing erector spinae plane block with pectoralis nerve block and paravertebral block showed that its analgesic efficacy was inferior to pectoralis nerve block and similar to paravertebral block. The incidence of pneumothorax was 2.6% in the paravertebral block group; there were no reports of complications of the other blocks. This review has shown that the erector spinae plane block is more effective at reducing postoperative opioid consumption and pain scores up to 24 hours compared with general anaesthesia alone. However, it was inferior to the pectoralis nerve block and its efficacy was similar to paravertebral block. Further evidence, preferably from properly blinded trials, is required to confirm these findings.     

Para-umbilical block: a new concept for regional anaesthesia in children

This preliminary study describes a new technique to provide analgesia in children undergoing umbilical hernia repair. The para-umbilical block consists of infiltrating the anterior cutaneous branches of the two tenth spinal roots over and under the rectus sheath far from the operative field. Intra and postoperative analgesia as well as operative conditions were assessed in 11 children 16.7±31 months old, weighing 8421±6941 g, the block being performed before surgery under light general anaesthesia. Intraoperative analgesia, operative conditions and recovery were good in all patients. Analgesia was adequate one h after surgery in ten patients, six h after surgery in eight. The block proved to be safe and on the whole effective in this short series. The study should proceed on a multi-centre basis if possible. Indications can be extended.