Programmed intermittent bolus infusion vs. continuous infusion for erector spinae plane block in video-assisted thoracoscopic surgery: A double-blinded randomised controlled trial.

BACKGROUND: The optimal form of administration for erector spinae plane block has not been established. OBJECTIVE: To compare the efficacy of programmed intermittent bolus infusion (PIB) and continuous infusion for erector spinae plane block. DESIGN: A prospective, randomised, double-blind study. SETTING: A single centre between June 2019 and March 2020. PATIENTS: Included patients had an American Society of Anesthesiologists physical status 1 to 3 and were scheduled for video-assisted thoracic surgery. INTERVENTIONS: Patients were randomised to receive continuous infusion (0.2% ropivacaine 8 ml h-1; Group C) or PIB (0.2% ropivacaine 8 ml every 2 h; Group P). MAIN OUTCOME MEASURES: The primary outcome was the number of desensitised dermatomes in the midclavicular line, measured 21 h after first bolus injection. RESULTS: Fifty patients were randomly assigned to each group; finally, the data of 24 and 25 patients in Group C and P, respectively, were analysed. The mean difference in the number of desensitised dermatomes in the midclavicular line at 5 and 21 h after the initial bolus administration was 1.0 [95% confidence interval (CI) 0.5 to 1.5] and 1.6 (95% CI 1.1 to 2.0), respectively, which was significantly higher in Group P than in Group C (P < 0.001). The median difference in rescue morphine consumption in the early postoperative period (0 to 24 h) was 4 (95% CI 1 to 8) mg, which was significantly lower in Group P (P = 0.035). No significant difference in the postoperative numerical rating scale score was found between the groups. CONCLUSIONS: PIB for erector spinae plane block in video-assisted thoracic surgery resulted in a larger anaesthetised area and required a lower anaesthetic dose to maintain the analgesic effect. Therefore, it is more suitable for erector spinae plane block than continuous infusion. TRIAL REGISTRATION: UMIN Clinical Trials Registry (UMIN-CTR, ID: UMIN000036574, Principal investigator: Taro Fujitani, 04/22/2019, https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000041671).

Comparison of ultrasound-guided erector spinae plane block and thoracic paravertebral block for postoperative analgesia after video-assisted thoracic surgery: a randomized controlled non-inferiority clinical trial.

BACKGROUND AND OBJECTIVES: The anesthetic characteristics of ultrasound-guided erector spinae plane block (ESPB) remain unclear. We compared the analgesic efficacies of ESPB and thoracic paravertebral block (TPVB) for analgesia after video-assisted thoracic surgery (VATS). METHOD: In this prospective randomized non-inferiority trial, 88 patients undergoing VATS randomly received ESPB or TPVB. All patients received continuous infusion of 0.2% levobupivacaine (8 mL/hour) after injection of a 20 mL 0.2% levobupivacaine bolus. The primary outcome was median differences between the groups in postoperative numerical rating scale (NRS) scores at rest, 24 hours postoperatively. RESULTS: Eighty-one patients completed the study. The median difference in NRS scores at rest 24 hours postoperatively was 1 (range 0-1), demonstrating the non-inferiority of ESPB to TPVB. NRS scores at rest were significantly lower in the TPVB group at 1, 2 and 24 hours postoperatively (p=0.02, 0.01 and 0.006, respectively). NRS scores on movement were similar. More dermatomes in parasternal regions were anaesthetized in the TPVB group (p<0.0001). Total plasma levobupivacaine concentrations were significantly lower in the ESPB group within 20 hours postoperatively (p=0.036). CONCLUSIONS: The analgesic effect of ESPB after VATS was non-inferior to that of TPVB 24 hours postoperatively. TRIAL REGISTRATION NUMBER: UMIN000030658.

Programmed intermittent bolus infusion versus continuous infusion of 0.2% levobupivacaine after ultrasound-guided thoracic paravertebral block for video-assisted thoracoscopic surgery: A randomised controlled trial.

BACKGROUND: The analgesic benefits of programmed intermittent bolus infusion for thoracic paravertebral block remain unknown. OBJECTIVE: The aim of this study was to compare the analgesia from intermittent bolus infusion with that of a continuous infusion after thoracic paravertebral block. DESIGN: A randomised controlled study. SETTING: A single centre between December 2016 and November 2017. Seventy patients scheduled for video-assisted thoracoscopic surgery were included in the study. INTERVENTION(S): Patients were randomly assigned to receive 0.2% levobupivacaine via continuous infusion (5 ml h, continuous group) or programmed intermittent bolus infusion (15 ml every 3 h, bolus group) after an initial 15-ml bolus injection of 0.2% levobupivacaine. MAIN OUTCOME MEASURES: The main outcome was the amount of rescue fentanyl (per kg of body weight) consumed within 24 h after surgery. Secondary outcomes were postoperative pain scores, plasma levobupivacaine concentrations and the number of dermatomes anaesthetised. RESULTS: There was no significant difference between the continuous and bolus groups in the postoperative consumption of fentanyl (median [interquartile range] 5.5 [4 to 9.5] µg kg versus 6 [3.5 to 9] µg kg respectively, P = 0.45) and postoperative pain scores within 24 h. At 20 h after initiating the infusions, there was no statistically significant difference between the two groups in terms of the plasma levobupivacaine concentration. The number of dermatomes anaesthetised to pinprick and cold testing was significantly greater in the bolus group. CONCLUSION: Our findings suggest that postoperative pain and opioid usage are similar with either programmed intermittent bolus infusion or continuous infusion after thoracic paravertebral block. Programmed intermittent bolus infusion provides a wider sensory blockade and could benefit patients requiring a wider extent of anaesthesia. TRIAL REGISTRATION: UMIN Clinical Trials Registry (UMIN-CTR; URL: http://umin.ac.jp/ctr/, ID: UMIN000023378).

Comparison of analgesic efficacy between two approaches of paravertebral block for thoracotomy: A randomised trial.

BACKGROUND: Although several approaches for ultrasound-guided thoracic paravertebral block have been introduced, little is known regarding the differences in analgesic efficacy. We conducted this prospective randomised trial to examine whether the type of approach for ultrasound-guided thoracic paravertebral block could affect analgesic quality in thoracotomy. METHODS: Patients scheduled for video-assisted thoracotomy were randomly allocated into two groups by block technique: the intercostal approach (group IC) or the paralaminar approach (group PL). At the start and end of surgery, 20 mL of 0.5% ropivacaine was injected, followed by a continuous infusion of 0.2% ropivacaine at 5 mL h-1 . We also started intravenous fentanyl patient-controlled analgesia at 0.5 µg kg-1  h-1 and bolus dose of 15 µg. The main outcome was the number of rescue fentanyl use. We also evaluated postoperative pain scores and number of blocked dermatomes showing a reduced sensation. RESULTS: Enrolment was ceased because of implementation of a minimally invasive surgical method. Overall, 42 subjects completed the trial for analysis. The number of rescue fentanyl use in group PL was significantly less than that in group IC at 3, 6, 12 and 24 hour postoperatively. The numerical rating scale (NRS) at rest in group PL was significantly lower at 1, 3, 6, and 12 hour postoperatively. Patients in Group PL developed significantly wider sensory block level (median (IQR [range]); 4 (4-5 [2-7])) than those in Group IC (3 (3-3 [2-9])). CONCLUSIONS: We suggested that paralaminar approach provided superior analgesia for thoracotomy rather than the intercostal approach.

Ultrasound-guided thoracic paravertebral block by the paralaminar in-plane approach using a microconvex array transducer: methodological utility based on anatomical structures.

OBJECTIVE: We evaluated the analgesic feasibility of paralaminar in-plane (PL) approach for ultrasound-guided thoracic paravertebral block (USG-TPVB). As the needle trajectory was expected to be closely affected by the distance from the skin to the lamina-transverse process junction (LTPJ), we examined the correlativity between them on computed tomography (CT) or ultrasonography. METHODS: Thirty-two patients undergoing thoracotomy were recruited. We measured the distances between the skin and LTPJ using preoperative CT (S-L) and procedural ultrasonography (US-L). At the beginning and the end of the surgery, 20 ml of 0.5% ropivacaine was injected. The level of sensory block and postoperative numerical pain rating scale (NRS) was assessed. Relationships among the measured parameters and the agreement of the needle depth (ND) with S-L and US-L were evaluated using Pearson's correlation coefficient and Bland-Altman analysis. RESULTS: S-L and US-L were strongly correlated with ND (r = 0.72 and r = 0.81, respectively) but not with BMI. The Bland-Altman analysis showed that the mean percent differences between the ND and S-L or ND and US-L were -9.6 and 20.1%, respectively. Catheters were inserted 18.6 mm lateral from the midline on average. Analgesia extended to 3-5 dermatomes in 29 patients, and the median NRS was 2 at 1, 6, 12, and 24 h after surgery, respectively. CONCLUSIONS: We demonstrated that PL approach provided feasible analgesia for thoracotomy and the ND was significantly correlated with the morphometric values. This technique allowed for inner catheter insertion route targeting longer anteroposterior thoracic paravertebral space length; this may reduce potential risk of pleural puncture for USG-TPVB. Trial registry number This study was registered in the UMIN Clinical Trials Registry (UMIN-CTR). (URL: http://umin.ac.jp/ctr/ , ID:UMIN000014821).

[Comparison of Analgesic Efficacy between Posterior and Lateral Transversus Abdominis Plane Block Techniques for Laparoscopic Gynecological Surgery].

BACKGROUND: Posterior transversus abdominis plane (TAP) block has been considered as a useful technique for lower abdominal postoperative analgesia, but in ultrasound-guided block, its efficacy and usability are still unknown. We prospectively compared the analgesic efficacy among posterior and lateral TAP block and with control group in laparoscopic gynecological surgery. METHODS: 29 patients were randomly assigned to a study group. Ultrasound-guided TAP block was performed before the operation. In the posterior group (n =10), a needle was inserted from posterior to the middle axillary line, and its tip was centrally positioned at the origin of the transversus abdominis muscle. In the lateral group (n=10), a needle was inserted from the middle axillary line, and the tip was peripherally positioned at the surface of the transversus abdominis muscle. Visual analog scale (VAS), the use frequency of fentanyl rescue dose, and the period of time until initial rescue use after the operation were measured. RESULTS: In posterior group, pain scores both at rest and on movement were significantly lower than other groups at early phase (P<0.05). The number of uses of the fentanyl rescue dose was smaller in posterior group than in control group in the first 6 postoperative hours (1±1.2 vs 3±1.5, P<0.05). CONCLUSIONS: Ultrasound-guided posterior TAP block could become a more useful tool for postoperative analgesia. We presumed that its additional effect is caused from reduction of visceral pain related to sympathetic nerve block.

How does fortification affect the distribution of calcium and vitamin B1 intake at the school lunch for fifth-grade children?

The purpose of this study was to estimate the usual intake distribution of calcium and vitamin B(1) of fifth-grade children based on a 3-d dietary survey and to assess nutrient intake using Dietary Reference Intakes (DRIs 2010). A cross-sectional study was undertaken from October 2007 to February 2008 in schools located in Tokyo and Okayama, Japan. A total of 94 fifth-grade children attending 5 elementary schools participated in the study. The weighed plate waste method and observation were used to collect data on the school lunches and dietary records by children, accompanied by photographs used to collect data on meals at home. The study lasted 3 d, 2 non-consecutive days with school lunches and 1 d without. The estimated proportion of subjects below the Estimated Average Requirement (EAR) for calcium intake with milk in the school lunch decreased by 40% compared to the calcium intake without milk in the school lunch. Vitamin B1 intake from less than 0.45 mg/1,000 kcal fortified rice was estimated to be 0%. The intake distribution of calcium has increased by 150 mg by taking milk and the intake distribution of vitamin B1 has increased 0.20 mg by taking fortified rice in the school lunch. Calcium and vitamin B1 intake in the school lunch has changed the distribution of calcium and vitamin B1 intake upward, and decreased the number of estimated subjects that were below EAR. However, the distribution was not shifted across the board and the shape of the distribution has changed.

Amounts served and consumed of school lunch differed by gender in Japanese elementary schools.

School lunches serve to improve nutritional status and to promote the health of children. The purpose of this study was to investigate the portion sizes of school lunches served and consumed in Japanese elementary schools. In addition, gender difference in servings and consumption were also studied. A cross-sectional study was undertaken between October 2007 and February 2008 in schools located in Tokyo and Okayama, Japan. A total of 192 fifth-grade children attending four elementary schools participated in this study. Weighed plate waste methods and observation were used to collect dietary data for two non-consecutive days. The proportion of children who chose staple foods along with main dishes and/or side dishes for at least one day was higher in boys than in girls (respectively, for staple food: 42.1% vs. 9.3%, for main dish and/or side dish: 68.4% vs. 44.3%, P < 0.001). The ratio of initial amount served to amount offered was 0.88 ± 0.11 for boys and 0.84 ± 0.10 for girls (P < 0.05). The ratio of amount consumed to amount offered was 1.04 ± 0.19 for boys and 0.88 ± 0.12 for girls (P < 0.001). Weight was related to amount consumed both in boys (r = 0.222, P < 0.05) and in girls (r = 0.201, P < 0.05). These findings suggest that the nutritional standards of school lunch programs should take into account gender differences. Clearly, boys were more likely to consume more than the initial amounts served due to their higher propensity to take second helpings. Boys feel few reservations about taking second helpings to adjust their total intake. However, school lunch plans should take into consideration girls' reluctance to do so, by serving appropriate initial portion sizes.

Direct evidence for the ongoing brain activation by enhanced dynorphinergic system in the spinal cord under inflammatory noxious stimuli.

BACKGROUND: Dynorphin A in the spinal cord is considered to contribute to nociceptive stimuli. However, it has not yet been determined whether activation of the spinal dynorphinergic system under nociceptive stimuli plays a role in direct acceleration of the ascending nociceptive pathway. In this study, the authors investigated the role of spinal dynorphinergic transmission in ongoing brain activation under noxious stimuli in mice. METHODS: The changes in prodynorphin messenger RNA expression and dynorphin A (1-17)-like immunoreactivity in the mouse spinal cord were determined after the intraplantar injection of complete Freund's adjuvant in mice. The signal intensity in different brain regions after the intraplantar injection of complete Freund's adjuvant or intrathecal injection of dynorphin A (1-17) was measured by a pharmacological functional magnetic resonance imaging analysis. RESULTS: Complete Freund's adjuvant injection produced pain-associated behaviors and induced a dramatic increase in signal intensity in the mouse cingulate cortex, somatosensory cortex, insular cortex, and thalamic nuclei. These effects were not seen in prodynorphin knockout mice. Prodynorphin messenger RNA expression and dynorphin A (1-17)-like immunoreactivity on the ipsilateral side of the spinal cord were markedly increased in complete Freund's adjuvant-injected mice. Furthermore, intrathecal injection of dynorphin A (1-17) at relatively high doses caused pain-associated behaviors and a remarkable increase in the activities of the cingulate cortex, somatosensory cortex, insular cortex, and medial and lateral thalamic nuclei in mice. CONCLUSIONS: These findings indicate that spinally released dynorphin A (1-17) by noxious stimuli leads to the direct activation of ascending pain transmission.