Comparison of the effectiveness of circumferential versus non-circumferential spread in median and ulnar nerve blocks. A double-blind randomized clinical trial.

BACKGROUND AND OBJECTIVES: Circumferential (C) spread of local anesthetic around the nerve is recommended for a successful nerve block. We tested the hypothesis that C spread produces a more complete block than non-circumferential (NC) spread. METHODS: We randomized 124 patients undergoing open carpal tunnel syndrome surgery to receive C or NC spread ultrasound-guided median and ulnar nerve blocks. The primary outcome was the proportion of patients who developed complete sensory block measured at 5, 15 and 30 min. The loss of cold sensation was graded as: 0 (complete block), 1 (incomplete block), or 2 (no block). Secondary outcomes included motor block, nerve swelling and adverse events. RESULTS: In group C, complete sensory block at 5 min was 2.4 (95% CI 1.0 to 5.7; p=0.04) times more frequent in the median nerve and 3.0 (95% CI 1.2 to 7.2; p=0.01) times more frequent in the ulnar nerve compared with group C. However, at 15 and 30 min, it was similar between groups. Complete motor block was more frequent in group C than in group NC for both the median nerve: 1.5 (95% CI 1.1 to 2.2; p<0.01) at 15 min, 1.1 (95% CI 1.0 to 1.2; p=0.02) at 30 min, and the ulnar nerve: 1.7 (95% CI 1.2 to 2.6; p<0.01) at 15 min, 1.2 (95% CI 1.0 to 1.4; p<0.01) at 30 min. The incidence of nerve swelling and adverse effects was similar between groups. CONCLUSIONS: C spread around the median and ulnar nerves at the level of the antecubital fossa generates more complete sensory and motor blocks compared with NC spread. TRIAL REGISTRATION NUMBER: EudraCT 2011-002608-34 and NCT01603680.

Interfascial intercostal nerves block: alternative to epidural analgesia in open gastrectomy? Report on 4 clinical cases / Interfascial intercostal nerves block: alternative to epidural analgesia in open gastrectomy? Report on 4 clinical cases

Abstract The ultrasound-guided intercostal nerves (cutaneous branches) block in the mid-axillary line at the level of the 8th rib (modified BRILMA) is an analgesic technique described back in 2015. Four patients undergoing open gastrectomy (who are not candidates for epidural analgesia) are discussed. The patients underwent the above-mentioned bilateral block, with the administration of 15 mL of levobupivacaine 0.5% into the fascial plane, between the serratus anterior muscle and the external intercostal muscle, with the aim of blocking the intercostal nerves T6 to 11. Postoperative pain control was adequate, with low levels of opioids used. There were no complications associated with the technique.

Resumen El bloqueo ecoguiado de los nervios intercostales (ramas cutáneas) en la línea media axilar a nivel de la 8 costilla (BRILMA modificado) es una técnica analgésica descrita en 2015. Se presentan cuatro pacientes sometidos a gastrectomía abierta (sin posibilidad de administrar la analgesia epidural), a los que se realizó este bloqueo de manera bilateral. Se depositaron 15 ml de levobupivacaína 0,5% en el plano fascial entre el musculo serrato anterior y el intercostal externo, con el objetivo de bloquear los nervios intercostales T6-11. El control postoperatorio del dolor en los pacientes fue adecuado, con escaso consumo de opioides. No hubo complicaciones asociadas a la técnica.

Esmolol versus ketamine-remifentanil combination for early postoperative analgesia after laparoscopic cholecystectomy: a randomized controlled trial.

PURPOSE: Controversy surrounds the optimal technique to moderate pain after laparoscopic cholecystectomy (LC). Opioid analgesics, sympatholytic drugs, and adjuvants, such as ketamine, have all been used. We compared esmolol with a combination of remifentanil plus ketamine in patients undergoing LC to determine the impact of these drugs on morphine requirements and pain control. METHODS: Sixty American Society of Anesthesiologists physical status I-II patients undergoing LC and anesthetized with sevoflurane were randomized to one of two groups. Group E patients received a bolus of esmolol 0.5 mg·kg(-1) iv at induction followed by an infusion of 5-15 µg·kg(-1)·min(-1), and Group R-K patients received a bolus of ketamine 0.5 mg·kg(-1) iv and remifentanil 0.5 µg·kg(-1) iv at induction followed by a remifentanil infusion titrated over a range of 0.1-0.5 µg·kg(-1)·min(-1). All patients received paracetamol, dexketoprofen, and levobupivacaine via infiltration of laparoscopic port sites. After surgery, a predetermined bolus of morphine was administered according to a verbal numerical rating scale (VNRS) for pain intensity. The primary outcome of interest was postoperative morphine requirement. RESULTS: Median consumption of morphine was higher in Group R-K than in Group E (5 mg [4-6] vs 0 mg [0-2], respectively; P < 0.001). In the postanesthesia care unit, patients in Group R-K had higher pain scores than patients in Group E (difference in maximum VNRS, -11; 95% confidence interval (CI), -19 to -3). The concentration of sevoflurane to maintain a bispectral index~40 was higher in Group E than in Group R-K (between-group difference 0.3%; 95% CI, 0.15 to 0.40). The incidence of postoperative nausea and vomiting was similar between the two groups. CONCLUSION: Intraoperative esmolol infusion reduces morphine requirements and provides more effective analgesia compared with a combination of remifentanil-ketamine given by infusion in patients undergoing LC.