Long-term Outcomes with Spinal versus General Anesthesia for Hip Fracture Surgery: A Randomized Trial.

BACKGROUND: The effects of spinal versus general anesthesia on long-term outcomes have not been well studied. This study tested the hypothesis that spinal anesthesia is associated with better long-term survival and functional recovery than general anesthesia. METHODS: A prespecified analysis was conducted of long-term outcomes of a completed randomized superiority trial that compared spinal anesthesia versus general anesthesia for hip fracture repair. Participants included previously ambulatory patients 50 yr of age or older at 46 U.S. and Canadian hospitals. Patients were randomized 1:1 to spinal or general anesthesia, stratified by sex, fracture type, and study site. Outcome assessors and investigators involved in the data analysis were masked to the treatment arm. Outcomes included survival at up to 365 days after randomization (primary); recovery of ambulation among 365-day survivors; and composite endpoints for death or new inability to ambulate and death or new nursing home residence at 365 days. Patients were included in the analysis as randomized. RESULTS: A total of 1,600 patients were enrolled between February 12, 2016, and February 18, 2021; 795 were assigned to spinal anesthesia, and 805 were assigned to general anesthesia. Among 1,599 patients who underwent surgery, vital status information at or beyond the final study interview (conducted at approximately 365 days after randomization) was available for 1,427 (89.2%). Survival did not differ by treatment arm; at 365 days after randomization, there were 98 deaths in patients assigned to spinal anesthesia versus 92 deaths in patients assigned to general anesthesia (hazard ratio, 1.08; 95% CI, 0.81 to 1.44, P = 0.59). Recovery of ambulation among patients who survived a year did not differ by type of anesthesia (adjusted odds ratio for spinal vs. general, 0.87; 95% CI, 0.67 to 1.14; P = 0.31). Other outcomes did not differ by treatment arm. CONCLUSIONS: Long-term outcomes were similar with spinal versus general anesthesia.

Application of Hip Pericapsular Nerve Block Combined With Spinal Anesthesia in the Treatment of Elderly Patients With Femoral Intertrochanteric Fracture.

OBJECTIVE: To investigate the effect of pericapsular nerve group (PENG) block combined with spinal anesthesia in the treatment of elderly patients with intertrochanteric fractures through "rapid diagnosis and treatment channel" PFNA internal fixation. METHODS: 52 elderly patients were randomly divided into the observation group (26 patients, PENG block combined with spinal anesthesia) and the control group (26 patients, spinal anesthesia alone). The general health, mean arterial pressure (MAP), and heart rate (HR) of both groups were compared at various stages: immediately before the administration of pain analgesia, during the positioning of spinal epidural anesthesia, at the beginning and end of the surgery, and 2 hours after surgery. Additionally, VAS scores at rest and during passive straight leg elevation by 15° were evaluated at 12 hours, 24 hours, 48 hours, 72 hours, and 7 days after surgery. RESULTS: The MAP and HR in the observation group under spinal anesthesia in the lateral position were lower than those in the control group (P < 0.05). Additionally, the VAS scores of the observation group during positioning and at 12 hours and 24 hours after surgery were lower than those in the control group under spinal epidural anesthesia (both P < 0.05). CONCLUSION: The application of ultrasound-guided PENG block combined with lumbar anesthesia can reduce pain when in lateral position, stabilize perioperative vital signs, and result in high satisfaction.

Efficacy and Safety of Pericapsular Nerve Group Block for Hip Fracture Surgery under Spinal Anesthesia: A Meta-Analysis.

Objective: To evaluate the effectiveness and safety of pericapsular nerve group (PENG) block for hip fracture surgery under spinal anesthesia. Methods: This meta-analysis was registered on INPLASY (INPLASY202270005). PubMed, Embase, Cochrane, CNKI, and Wanfang databases were searched to collect the randomized controlled trials of the PENG block applied to hip fracture surgery in the setting of spinal anesthesia, with the search period from inception to 1 May 2023. Two independent researchers gradually screened the literature, evaluated the quality, extracted the data, and eventually pooled data using RevMan 5.4. Results: Fifteen articles with 890 patients were enrolled. The combined results showed that the PENG block reduced pain scores during position placement (SMD = -0.35; 95% CI [-0.67, 0.02]; P=0.04; I2 = 0%). Subgroup analyses showed that compared to the unblocked group, the PENG block reduced pain scores at 12 h, 24 h, and 48 h postoperatively. The incidence of postoperative hypokinesia was reduced (RR = 0.11; 95% CI [0.01, 0.86]; P=0.04; I2 = 0.00%). The time to first walking was advanced (SMD = -0.90; 95% CI [-1.17, 0.63]; P < 0.00001; I2 = 0%). Conclusion: The PENG block can reduce postoperative pain and pain during spinal anesthesia positioning, which is helpful to improve the operability and comfort of spinal anesthesia and facilitate postoperative muscle strength recovery and early activity.

Effect of phenylephrine rescue injection on hypotension after spinal anaesthesia for caesarean delivery when guided by both heart rate and SBP during an early warning window: A randomised controlled trial.

BACKGROUND: Spinal anaesthesia is now the most common technique for caesarean delivery. However, because of the intermittent nature of noninvasive blood pressure (NIBP) measurements, maternal blood pressure may become hypotensive between the measurements. There is thus an inbuilt delay before the anaesthesiologist can intervene to counteract the hypotension. Based on the principle that changes in blood pressure can induce compensatory changes in the heart rate (HR), combining the NIBP with real-time HR, we designed two warning windows to predict hypotension and hypertension. OBJECTIVE: To evaluate whether phenylephrine administration guided by these warning windows would help maintain haemodynamic stability. SETTING: A teaching hospital. DESIGN: A randomised controlled trial. PATIENTS: One hundred and ten pregnant women scheduled for elective caesarean delivery were enrolled, from which, after exclusions, 86 were eligible for the study. INTERVENTIONS: All eligible patients received a continuous intravenous infusion of phenylephrine as soon as spinal anaesthesia was initiated. Thereafter, patients were randomly assigned to two groups. In the test group (Win-Group): rescue phenylephrine administration was triggered by an early warning window of HR above 100 beats per minute (bpm) and SBP 90 to 110 mmHg; pausing the infusion phenylephrine was triggered by a HR lower than 60 bpm and SBP greater than 90 mmHg. In the control group, phenylephrine was guided by BP only when it appeared on the monitor: SBP less than 90 mmHg was the trigger for administering rescue phenylephrine; SBP greater than 110 mmHg was the trigger for pausing the phenylephrine infusion. MAIN OUTCOME MEASURES: The primary outcome was incidence of hypotension. Secondary outcomes were the incidence of hypertension and other adverse haemodynamic events. RESULTS: The incidence of hypotension was significantly lower in the Win-Group than in the BP-Group (27.8 vs. 66.7%, P  = 0.001). The minimum SBP was significantly higher in Win-Group than in BP-Group (93.9 ±â€Š9.49 vs. 86.7 ±â€Š11.16 mmHg, P   =  0.004). There was no significant difference in the incidence of hypertension between groups. CONCLUSION: After spinal anaesthesia for caesarean delivery, when phenylephrine infusion is guided by HR along with BP from a warning window it effectively reduces the incidence of hypotension without any significant effect on incidence of hypertension. TRIAL REGISTRATION: Chictr.org.cn; Identifier: ChiCTR 2100041812.

Less Induction Time and Postoperative Pain Using Spinal Anesthesia Versus General Anesthesia With or Without the Use of Peripheral Nerve Blocks in Total Knee Arthroplasty.

BACKGROUND: Our aim was to analyze anesthetic induction time and postoperative pain using spinal anesthesia versus general anesthesia with or without the use of peripheral nerve blocks (PNBs) in total knee arthroplasty. The hypothesis was that spinal anesthesia would be beneficial with respect to induction time and postoperative pain and that PNBs would complement this effect. METHODS: Patients were stratified according to demographics, American Society of Anesthesiologists physical status classification system (ASA), and opioid intake and divided into: (A) general anesthesia without PNB; (B) general anesthesia with PNB; (C) spinal anesthesia without PNB; and (D) spinal anesthesia with PNB. Endpoints were anesthetic induction time, opioid consumption, and pain. Of 559 patients, 348 (62.3%) received general anesthesia (consisting of group A with 46 and group B with 302 patients), and 211 (37.7%) spinal anesthesia (consisting of group C with 117 and group D with 94 patients). RESULTS: We observed significantly lower total opioid intake 48 hours postoperative when applying spinal anesthesia by 2.08 mg (P < .05) of intravenous morphine-equivalent, and a reduction of 7.0 minutes (P < .05) until skin incision. The application of a PNB achieved a reduction of piritramide intake of 3.59 mg (P < .05) 48 hours postoperative and lengthened induction time by 8.5 minutes (P < .05). CONCLUSIONS: Statistically shorter anesthetic induction times without clinical relevance, but lower postoperative opioid dosages with clinical relevance were observed for patients undergoing total knee arthroplasty with spinal anesthesia. The additional application of PNBs led to a lower need for opioids and lower pain levels in the early postoperative phase.

The Effect of Warmed Serum on Shivering and Recovery Period of Patients Under General and Spinal Anesthesia: A Randomized Clinical Trial.

PURPOSE: Postoperative hypothermia followed by shivering is a common phenomenon in patients undergoing surgery under anesthesia, and should be prevented and treated in postoperative patient care units. This study was conducted to investigate the effect of warmed serum injection on postoperative shivering and recovery period of patients operated under general and spinal anesthesia. DESIGN: In this clinical trial, patients to be operated on under general and spinal anesthesia were randomly assigned into two groups of test and control. In the test group, patients received warmed intravenous fluids and blood products. All patients were monitored to record vital signs, incidences of hypothermia and shivering, and recovery period. METHODS: The collected data were analyzed with repeated measures analysis of variance to detect significant differences between groups and significant changes within groups over time. FINDINGS: The incidence of nausea, vomiting, and shivering in the intervention and control groups was (4.7%, 42%), (2.8%, 16.8%), and (6.6%, 43%), respectively. Patients in the intervention group had higher body temperature than the control group (<0.001). Also, patients under spinal anesthesia had higher body temperature than patients under general anesthesia (<0.001). Blood pressure reduction was also significantly higher in the control group than in the intervention group. The patients who received warm intravenous serum, and especially those who had received spinal anesthesia spent less time in the recovery room (<0.001). CONCLUSIONS: The use of warmed intravenous serum increased the patients' core temperature, reduced their postoperative shivering, and shortened their recovery period. Considering the potential risks associated with hypothermia, using such methods for hypothermia prevention can be highly effective in preventing shivering and prolongation of the recovery period and other potential complications. Anesthesia specialists and technicians are therefore encouraged to use this method as a preventive measure.

Effect of general and spinal anaesthesia on post-operative wound healing during laparoscopic totally extraperitoneal inguinal hernia repair: A meta-analysis.

Totally extraperitoneal prosthetic (TEP) is a surgical technique for the treatment of hernia. The purpose of this research is to compare the efficacy of both general anaesthesia and spine anaesthesia for TEP herniorrhaphy. The number of patients who received TEP operations related to the injury from 2008 to 2022 was counted in this study. Patients with TEP operation were classified into general anaesthesia and spine anaesthesia. In this research, 186 related articles were found in the data base, and in the end, 8 were analysed. This study involved 2452 cases of hernia. The data of the operation time, the infection of the wound and the bleeding of the wound were analysed. The analysis of the data was done with RevMan 5.3. Results indicated that there was no significant difference between general anaesthesia and spinal anaesthesia in post-surgical rates for post-operative wound infection (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.49-1.83; p = 0.86); In general anaesthesia, there was no difference in the risk of post-operative wound haematoma when compared with those treated with spinal anaesthesia (OR, 2.96; 95% CI, 0.37-23.69; p = 0.31). In the seven trials, there was no difference in the duration of the surgery between the general anaesthetic and the spinal anaesthesia group (mean difference, -1.44; 95% CI, -4.11 to 1.22; p = 0.29). Data from the available meta-analysis indicate that there is no difference in the risk of post-operative wound infection or wound haematoma when treated with TEP.

There is (probably) no (meaningful) difference in (most) outcomes between 'spinal' and 'general' anaesthesia for hip fracture surgery: time to move forward.

A meta-analysis influenced by two recent large randomised controlled trials (REGAIN and RAGA) concluded that little, if any, difference in commonly measured outcomes exists between patients administered spinal or general anaesthesia for their hip fracture surgery. We explore whether there is genuinely no difference, or what the methodological problems in research might be that prevent any real difference from being observed. We also discuss the need for greater nuance in future research to determine how anaesthetists might deliver perioperative care towards improving postoperative recovery trajectories in patients following hip fracture.

Quality of recovery after pericapsular nerve group (PENG) block for primary total hip arthroplasty under spinal anaesthesia: a randomised controlled observer-blinded trial.

BACKGROUND: The pericapsular nerve group (PENG) block is a novel regional anaesthesia technique that has been proposed as an effective motor-sparing block for total hip arthroplasty. Recent randomised studies show conflicting results regarding the analgesic efficacy of the PENG block for total hip arthroplasty. METHODS: We conducted a randomised controlled observer-blinded single-centre superiority trial comparing the efficacy of the PENG block with no block for patients undergoing primary total hip arthroplasty under spinal anaesthesia. All subjects received multimodal analgesia consisting of paracetamol and celecoxib. The primary outcome was quality of recovery (QoR) at 24 h as measured by the QoR-15 questionnaire. RESULTS: A total of 112 participants (56 in each group) were included in the analysis. The median (inter-quartile range [IQR]) 24-h QoR-15 scores were higher in subjects who received a PENG block (132 [116-138]) compared with subjects who did not (103 [97-112]) with a median difference of 26 (95% confidence interval, 18-31; P<0.001). Similarly, QoR-15 at 48 h was higher in the PENG group, and opioid use at 24 and 48 h postoperatively was significantly lower in the PENG group. However, we did not find significant differences in pain score, distance to ambulation, or anti-emetic use at any time point. We did not observe any PENG block-related complications. CONCLUSION: Adding a PENG block to a multimodal analgesia regimen that includes paracetamol and celecoxib improves the quality of recovery and reduces opioid requirements for patients undergoing primary total hip arthroplasty under spinal anaesthesia. CLINICAL TRIAL REGISTRATION: NCT04591353.

Subclavian vein ultrasound-guided fluid management to prevent post-spinal anesthetic hypotension during cesarean delivery: a randomized controlled trial.

BACKGROUND: Hypotension frequently occurs after spinal anesthesia during cesarean delivery, and fluid loading is recommended for its prevention. We evaluated the efficacy of subclavian vein (SCV) ultrasound (US)-guided volume optimization in preventing hypotension after spinal anesthesia during cesarean delivery. METHODS: This randomized controlled study included 80 consecutive full-term parturients scheduled for cesarean delivery under spinal anesthesia. The women were randomly divided into the SCVUS group, with SCVUS analysis before spinal anesthesia with SCVUS-guided volume management, and the control group without SCVUS assessment. The SCVUS group received 3 mL/kg crystalloid fluid challenges repeatedly within 3 min with a 1-min interval based on the SCV collapsibility index (SCVCI), while the control group received a fixed dose (10 mL/kg). Incidence of post-spinal anesthetic hypotension was the primary outcome. Total fluid volume, vasopressor dosage, changes in hemodynamic parameters, maternal adverse effects, and neonatal status were secondary outcomes. RESULTS: The total fluid volume was significantly higher in the control group than in the SCVUS group (690 [650-757.5] vs. 160 [80-360] mL, p < 0.001), while the phenylephrine dose (0 [0-40] vs. 0 [0-30] µg, p = 0.276) and incidence of post-spinal anesthetic hypotension (65% vs. 60%, p = 0.950) were comparable between both the groups. The incidence of maternal adverse effects, including nausea/vomiting and bradycardia (12.5% vs. 17.5%, p = 0.531 and 7.5% vs. 5%, p = 1.00, respectively), and neonatal outcomes (Apgar scores) were comparable between the groups. SCVCI correlated with the amount of fluid administered (R = 0.885, p < 0.001). CONCLUSIONS: SCVUS-guided volume management did not ameliorate post-spinal anesthetic hypotension but reduced the volume of the preload required before spinal anesthesia. Reducing preload volume did not increase the incidence of maternal and neonatal adverse effects nor did it increase the total vasopressor dose. Moreover, reducing preload volume could relieve the heart burden of parturients, which has high clinical significance. CLINICAL TRIAL REGISTRATION: The trial was registered with the Chinese Clinical Trial Registry at chictr.org.cn (registration number, ChiCTR2100055050) on December 31, 2021.

Tranexamic acid-associated intrathecal toxicity during spinal anaesthesia: A narrative review of 22 recent reports.

Therapeutic use of tranexamic acid (TXA) to minimise blood loss is common during a wide range of surgical procedures. This review aims to explore the clinical features of the accidental intrathecal administration of TXA and to identify contributory factors that might prevent future incidents. The author searched published reports of accidental intrathecal administration of TXA using Medline and Google Scholar databases from July 2018 to September 2022, including error reports in any language but excluding errors via nonintrathecal routes. The human factors analysis classification system (HFACS) framework was used to examine and classify the human and systemic factors that contributed to the errors. Twenty-two errors of accidental intrathecal administration were reported during the search period. The analysis showed that the outcome was death in eight patients (36%) and permanent harm in four (19%). The fatality rate was higher among female individuals (6/13 versus 2/8 male individuals). Two-thirds of errors (15/22) occurred during orthopaedic surgery (10) and lower segment caesarean sections (5). Nineteen of 21 patients developed refractory or super refractory status epilepticus, requiring mechanical ventilation and intensive care for 3 days to 3 weeks for those who survived the initial few hours. Severe sympathetic stimulation resulting in refractory ventricular arrhythmias was the final event in some patients, with death within a few hours. Lack of familiarity with clinical characteristics caused delayed diagnosis or confusion with other clinical conditions. A proposed plan to manage intrathecal TXA toxicity is presented, including immediate cerebrospinal fluid lavage; however, there is no specific approach. The HFACS suggested mistaking look-alike TXA ampoules for local anaesthetic was the predominant cause. The author concludes that inadvertent intrathecal TXA is associated with mortality or permanent harm in more than 50% of patients. The HFACS demonstrates that all errors are preventable.

Integrative review of non-pharmacological intervention and multidimensional evaluation for intraoperative anxiety under spinal anaesthesia.

INTRODUCTION: Patients under spinal anaesthesia experience high levels of anxiety during surgery. Clinical nurses tried to manage patient's anxiety under spinal anaesthesia using non-pharmacological interventions for its benefit. Thus, it is required to identify comprehensive evidences of various non-pharmacological interventions and of how to measure anxiety under spinal anaesthesia. AIMS: This study aims to review current research on the non-pharmacological interventions to relieve intraoperative anxiety under spinal anaesthesia and to identify subjective and objective measures of intraoperative anxiety under spinal anaesthesia. METHODS: Wittemore and Knafl's integrative review methodology was used. Researchers conducted five scientific rigor steps; problem identification, searching literature, evaluation of literature, analysis of literature and presentation of results. The PRISMA checklist was used. To evaluate the level of evidence, critical appraisal tools of Joanna Briggs Institute were used. RESULTS: Eleven studies were included in this integrative review. Delivering music is the most frequently used as non-pharmacological intervention by researchers. They tried to manage intraoperative anxiety under spinal anaesthesia with using diverse genre and application of music. In addition, dry cupping method, progressive muscle relaxation (PMR) exercise and virtual reality (VR) goggles were used in included studies. Researchers measured intraoperative anxiety under spinal anaesthesia with objective or subjective way. The State-Trait Anxiety Inventory and visual analogue scale were used as subjective method to approach intraoperative anxiety. In contrary, researchers tried to obtain objective evidence of intraoperative anxiety with vital signs, cortisol, blood glucose, alpha-amylase and adrenocorticotropic hormone. CONCLUSION: Various types of non-pharmacological interventions are effective to manage patient's intraoperative anxiety under spinal anaesthesia. It is recommended to measure intraoperative anxiety under spinal anaesthesia with using both objective and subjective methods. RELEVANCE TO CLINICAL PRACTICE: Clinical nurses can use non-pharmacological interventions to manage intraoperative anxiety under spinal anaesthesia by comprehensive monitoring with diverse measures.

Efficacy of intravenous dexamethasone on postoperative pain after caesarean delivery under spinal anaesthesia with an intrathecal long-acting opioid: a systematic review and meta-analysis.

PURPOSE: Intravenous dexamethasone is recommended in elective caesarean delivery to decrease postoperative pain. However, the efficacy of spinal anaesthesia with an intrathecal long-acting opioid such as morphine or diamorphine for caesarean delivery has not been systematically investigated. METHODS: We searched all randomized controlled trials (RCTs) of pregnant women undergoing caesarean delivery under spinal anaesthesia with an intrathecal morphine or diamorphine via MEDLINE, CENTRAL, EMBASE, ICTRP, and ClinicalTrials.gov on May 18, 2022. Primary outcomes were time to first rescue analgesia, consumption of oral morphine equivalents, and incidence of drug-related adverse reactions. We evaluated the risk of bias for each outcome using the Risk of Bias 2. We conducted a meta-analysis using a random effects model. We evaluated the certainty of evidence with the GRADE approach. RESULTS: Five RCTs (455 patients) were included. The results of intravenous dexamethasone were as follows: time to first rescue analgesia (mean difference [MD] 0.99 h, 95% confidence interval [CI] - 0.86 to 2.84; very low certainty) and consumption of oral morphine equivalents (MD - 6.55 mg, 95% CI - 17.13 to 4.02; moderate certainty). No incidence of drug-related adverse reactions was reported (very low certainty). CONCLUSION: The evidence was very uncertain about the efficacy of intravenous dexamethasone on time to first rescue analgesia and the incidence of drug-related adverse reactions. Intravenous dexamethasone probably reduces the consumption of oral morphine equivalents. Anaesthesiologists might want to consider intravenous dexamethasone for postoperative pain after caesarean delivery under spinal anaesthesia with an intrathecal long-acting opioid.

Comparison of the Effect of Forced-air Warming and Warmed Intravenous Fluid on the Comfort and Prevention of Shivering After Spinal Anesthesia in Patients Undergoing Orthopedic Surgery.

PURPOSE: This study aimed to compare the effect of forced-air warming and warmed intravenous fluid on the comfort and prevention of shivering after spinal anesthesia in patients undergoing orthopaedic surgery. DESIGN: Randomized controlled clinical trial. METHODS: A total of 120 patients were randomly divided into three groups: forced-air warming (38°C), warmed intravenous fluid (37°C), and the control group. Patients' comfort and severity of shivering were measured and recorded five times (immediately and 15 minutes after spinal anesthesia, end of the surgery, time of entrance to the recovery room, and 15 minutes after entering the recovery room), and compared with each other. FINDINGS: There was a significant difference between the three groups in terms of comfort at all points of evaluation times (P < .001). The comfort score in the control group was significantly higher than the two intervention groups (P < .001). Moreover, the comfort score in the warmed intravenous fluid group was significantly higher than the forced-air warming group (P < .001). In addition, there was a significant difference in shivering severity between the three groups at the end of the surgery, entrance to the recovery room, and 15 minutes after surgery (P < .001). The majority of patients in the forced-air warming group (90%) had no shivering at all three times, while the warmed IV fluid and control groups was 65% and 30% respectively. CONCLUSIONS: Non-pharmacological methods such as forced-air warming and warmed intravenous fluid can provide comfort and prevent shivering in orthopaedic patients undergoing spinal anesthesia. However, the use of forced-air warming is more effective than warmed intravenous fluid in providing comfort and preventing shivering in these patients. It is recommended that these methods be used in the operating room to provide comfort and prevent shivering in these patients.

THE COMPARATIVE EFFECTIVENESS OF ERECTOR SPINE PLANE BLOCK AND PARAVERTEBRAL BLOCK FOR EARLY REHABILITATION AFTER TOTAL HIP ARTHROPLASTY.

OBJECTIVE: The aim: To evaluate the effectiveness of erector spine plane block vs lumbar paravertebral block for early rehabilitation after total hip arthroplasty. PATIENTS AND METHODS: Materials and methods: The study included 60 ASA ІΙ-ΙΙΙ patients (female/male = 35/25) aged 41-82 years, undergone total hip arthroplasty under spinal anesthesia. The patients randomly divided into two groups (n=30 in each) according to postoperative regional analgesia technique: paravertebral block (PVB) and erector spine plane block (ESPB). The time interval to meet three criteria: adequate analgesia (<4 points of VAS), opioid-free period longer than 12 h, and possibility to cover walking 30 m distance without time restriction was analyzed. We also analyzed opioid requirement postoperatively. RESULTS: Results: The time interval to meet the three criteria after surgery was shorter to 9.4 h for patients in PVB group 36.3 h 95% CI 31.8 to 40.8 h than for patients in ESPB group 45.7 h 95% CI 40.1 to 51.3 h, (p = 0.016). During the first 24 h after surgery the total dose of nalbuphine per patient was significantly higher in ESPB group (10.7 95% CI 7.0 to 14.3) compared to PVB group (6.3 95% CI 3.7 to 9.0). CONCLUSION: Conclusions: The paravertebral block and erector spine plane block provide quite effective pain relieve in patients undergone total hip arthroplasty (<4 points of VAS). PVB has more opioid-preserving effect than ESPB. The paravertebral block is superior to erector spine plane block for early rehabilitation after total hip arthroplasty (the time required for patients to meet the three criteria was shorter PVB than ESPB).

Postoperative Analgesic Effectiveness of Quadratus Lumborum Block for Cesarean Delivery under Spinal Anesthesia.

BACKGROUND: Spinal morphine is the mainstay of postcesarean analgesia. Quadratus lumborum block has recently been proposed as an adjunct or alternative to spinal morphine. The authors evaluated the analgesic effectiveness of quadratus lumborum block in cesarean delivery with and without spinal morphine. METHODS: Randomized trials evaluating quadratus lumborum block benefits in elective cesarean delivery under spinal anesthesia were sought. Three comparisons were considered: spinal morphine versus spinal morphine and quadratus lumborum block; spinal morphine versus quadratus lumborum block; and no block or spinal morphine versus quadratus lumborum block. The two coprimary outcomes were postoperative (1) 24-h cumulative oral morphine equivalent consumption and (2) pain at 4 to 6 h. Secondary outcomes included area under the curve pain, time to analgesic request, block complications, and opioid-related side effects. RESULTS: Twelve trials (924 patients) were analyzed. The mean differences (95% CIs) in 24-h morphine consumption and pain at 4 to 6 h for spinal morphine versus spinal morphine and quadratus lumborum block comparison were 0 mg (-2 to 1) and -0.1 cm (-0.7 to 0.4), respectively, indicating no benefit. For spinal morphine versus quadratus lumborum block, these differences were 7 mg (-2 to 15) and 0.6 cm (-0.7 to 1.8), respectively, also indicating no benefit. In contrast, for no block or spinal morphine versus quadratus lumborum block, improvements of -18 mg (-28 to -7) and -1.5 cm (-2.4 to -0.6) were observed, respectively, with quadratus lumborum block. Finally, for no block or spinal morphine versus quadratus lumborum block, quadratus lumborum block improved area under the 48-h pain curve by -4.4 cm · h (-5.0 to -3.8), exceeding the clinically important threshold (3.96 cm · h), but no differences were observed in the other comparisons. CONCLUSIONS: Moderate quality evidence suggests that quadratus lumborum block does not enhance analgesic outcomes when combined with or compared with spinal morphine. However, the block improves postcesarean analgesia in the absence of spinal morphine. The clinical utility of this block seems limited to situations in which spinal morphine is not used.

Changes in electroencephalographic power and bicoherence spectra according to depth of dexmedetomidine sedation in patients undergoing spinal anesthesia.

Background: Assessment the depth of dexmedetomidine sedation using electroencephalographic (EEG) features can improve the quality of procedural sedation. Previous volunteer studies of dexmedetomidine-induced EEG changes need to be validated, and changes in bicoherence spectra during dexmedetomidine sedation has not been revealed yet. We aimed to investigate the dexmedetomidine-induced EEG change using power spectral and bicoherence analyses in the clinical setting. Patients and Methods: Thirty-six patients undergoing orthopedic surgery under spinal anesthesia were enrolled in this study. Dexmedetomidine sedation was conducted by the stepwise increase in target effect site concentration (Ce) while assessing sedation levels. Bispectral index (BIS) and frontal electroencephalography were recorded continuously, and the performance of BIS and changes in power and bicoherence spectra were analyzed with the data from the F3 electrode. Results: The prediction probability values for detecting different sedation levels were 0.847, 0.841, and 0.844 in BIS, 95% spectral edge frequency, and dexmedetomidine Ce, respectively. As the depth of sedation increased, δ power increased, but high ß and γ power decreased significantly (P <0.001). α and spindle power increased significantly under light and moderate sedation (P <0.001 in light vs baseline and deep sedation; P = 0.002 and P <0.001 in moderate sedation vs baseline and deep sedation, respectively). The bicoherence peaks of the δ and α-spindle regions along the diagonal line of the bicoherence matrix emerged during moderate and deep sedation. Peak bicoherence in the δ area showed sedation-dependent increases (29.93%±7.38%, 36.72%±9.70%, 44.88%±12.90%; light, moderate, and deep sedation; P = 0.008 and P <0.001 in light sedation vs moderate and deep sedation, respectively; P = 0.007 in moderate sedation vs deep sedation), whereas peak bicoherence in the α-spindle area did not change (22.92%±4.90%, 24.72%±4.96%, and 26.96%±8.42%, respectively; P=0.053). Conclusions: The increase of δ power and the decrease of high-frequency power were associated with the gradual deepening of dexmedetomidine sedation. The δ bicoherence peak increased with increasing sedation level and can serve as an indicator reflecting dexmedetomidine sedation levels.

Psoas compartment block efficacy and safety for perioperative analgesia in the elderly with proximal femur fractures: a randomized controlled study.

BACKGROUND: Proximal femur fractures are most common fractures in the elderly and associated with significant mortality and morbidity, with high economic and social impact. Perioperative pain management influence outcomes and mortality after surgery with early mobilization being possible. The goal of the study was to compare the efficacy and safety of the psoas compartment block (PCB) with spinal and general anesthesia. METHODS: We included 90 patients in this randomized controlled study and divided them into three groups. For patients in group 1 ultrasound-guided PCB with bupivacaine 0.125% 6-8 ml / h was performed. Intraoperative anesthesia was provided with PCB and a sciatic nerve block. Postoperative analgesia include prolonged CPB with bupivacaine 0.125% 6-8 ml / h. In group 2 intraoperative spinal anaesthesia were performed. Group 3 patients underwent general sevoflurane inhalation anaesthesia with fentanyl infusion for analgesia. All patients received paracetamol 3 g/day and dexketoprofen 75 mg/day during hospitalization. On-demand, nalbuphine 5 mg SC was used for analgesia. Efficacy outcomes were the ICU length of stay and the total duration of hospitalization, number of patients who had severe pain after surgery, incidence of on-demand analgesia, sleep quality, postoperative mobilization time. Safety outcomes include complication incidence. RESULTS: There were no differences in the duration of ICU stay - gr.1 72 [70-75], gr.2 74 [72-76], gr.3 72 [70-75] hours respectively (p = 0.29), and the total duration of hospitalization - gr.1144 [170-184], gr.2170 [148-188], gr.3178 [144-200] hours respectively. Patients in gr.1 had significantly lower nalbuphine consumption in the first 24 h after surgery and total during hospitalization (0 [0-5] mg versus 15 [10-20] and 20 [15-25] mg in the first 24 h in groups 2 and 3, respectively (p < 0.001). Gr. 1 had lower number of patients with severe pain (10% vs. 47 and 60% in groups 2 and 3, respectively, p < 0.05), lower number of on demand analgesia (0 [0-1] vs. 3 [2-4] and 4 [3, 4] in groups 2 and 3, respectively), better sleep quality (8 [7-9] vs. 6 [5-7] and 4 [3, 4] in groups 2 and 3, respectively, p < 0.001), significantly faster mobilization after surgery - sitting in bed and getting to his feet. MINS was diagnosed significantly more often in gr. 2 and 3 compared with gr. 1 (OR 9 95 CI 1,01-77, p = 0,048 for gr. 2 and OR 11 95 CI 1,2-91, p = 0, 03 for gr. 3). However, none of the patients had symptoms of myocardial ischemia and was not diagnosed with myocardial infarction. There were no difference in the incidence of nosocomial pneumonia and delirium. CONCLUSION: Perioperative PCB in elderly patients with a proximal femur fracture could be an effective analgesia technique, as it decrease the number of patients with severe pain, need for on demand analgesia and opioid consumption. PCB also decrease the incidence of opioid-associated nausea and vomiting, comparing to general anesthesia, and increase the number of patients, who was mobilized in the 1st day (sitting) and 2nd day (getting up) after surgery. PCB may reduce the incidence of MINS, although to assess this outcome more studies are needed. TRIAL REGISTRATION: Clinicaltrials.gov: NCT04648332 , first registration date 1/12/2020.

Spinal arachnoid sleeves and their possible causative role in cauda equina syndrome and transient radicular irritation syndrome.

INTRODUCTION: We have previously described arachnoid sleeves around cauda equina nerve roots, but at that time we did not determine whether injections could be performed within those sleeves. The purpose of this observational study was to establish whether the entire distal orifice of a spinal needle can be accommodated within an arachnoid sleeve. MATERIALS AND METHODS: We carefully dissected the entire dural sacs off four fresh cadavers, opened them by longitudinal incision, and immersed them in saline. Under direct vision, we penetrated the cauda equina roots nerves traveling almost vertically downward at 30 locations each with a 27- and a 25-G pencil-point needle (60 punctures total). We captured the images with a stereoscopic camera. RESULTS: The nerve root offered no noticeable resistance to needle entry. Although the arachnoid sleeves could not be identified with the naked eye, they were translucent but visible under microscopy. In 21 of 30 attempts with a 27-gauge needle, and in 20 of 30 attempts with a 25-gauge needle, the distal orifice of the spinal needle was completely within the arachnoid sleeve. CONCLUSION: It seems possible to accommodate the distal orifice of a 25- or a 27-gauge pencil-point spinal needle completely within the space of the arachnoid sleeve. An injection within this sleeve could potentially lead to a neurological syndrome, as we have previously proposed.

Effects of acupressure, gum chewing and coffee consumption on the gastrointestinal system after caesarean section under spinal anaesthesia.

This study evaluated the efficacy and safety of postoperative acupressure in the recovery of the gastrointestinal system (GIS) after caesarean section. A total of 160 primipara pregnant women delivered by caesarean section under spinal anaesthesia were randomised into four groups: group 1 (those who received acupressure), group 2 (coffee was provided three times a day), group 3 (chewed sugar-free gum for 15 min with an interval of 4 h from the second postoperative hour), and group 4 (control group). The first gas outflow and defaecation times of the women were compared among the groups. The first flatus and defaecation exit times of the women in the acupressure group were statistically earlier than those of the other groups. No difference was found among the gum-chewing, coffee, and control groups. Acupressure is effective in reducing the flatus and defaecation exit times due to GIS inactivity after abdominal surgery including caesarean section.Impact statementWhat is already known about the topic. The slowing of gastrointestinal system (GIS) motility also occurs after caesarean section aside from other surgical operations. If normal GIS movements do not occur, then several problems, such as the negative increase in the duration of breastfeeding and the mother-baby attachment during the postpartum period, may arise. Therefore, the early onset of bowel functions is important in women who give birth by caesarean section.What do the results of this study add. In the postoperative period, spontaneous GIS motility can be achieved by applying acupressure. The effective use of acupressure in the postoperative period prevents the need for pharmacological methods to eliminate the discomfort caused by the decreased motility of the GIS in women in the postpartum period.What are the implications of these findings for clinical practice and further research. Acupressure, a non-invasive, easy-to-use, and cost-effective method, plays a role in preventing GIS immotility. Midwives or obstetricians should receive training on acupuncture or acupressure and should ensure that acupuncture or acupressure practices are converted into a protocol to be implemented in the postoperative period. With this transformation, the treatment methods to increase GIS motility and the reduced medication use can decrease the mother's and the newborn's duration of hospital stay and the cost of hospitalisation.