Rhomboid intercostal block combined with sub-serratus plane block versus rhomboid intercostal block for postoperative analgesia after video-assisted thoracoscopic surgery: a prospective randomized-controlled trial.

BACKGROUND: Rhomboid intercostal block (RIB) and Rhomboid intercostal block with sub-serratus plane block (RISS) are the two types of plane blocks used for postoperative analgesia after video-assisted thoracoscopic surgery (VATS). This prospective randomized controlled trial was performed to analyze the postoperative analgesic effects of ultrasound-guided RIB block and RISS block after video-assisted thoracoscopic surgery. METHODS: Ninety patients aged between 18 and 80 years, with American Society of Anesthesiologists physical status Classes I-II and scheduled for elective unilateral VATS were randomly allocated into three groups. In group C, no block intervention was performed. Patients in group RIB received ultrasound-guided RIB with 20-mL 0.375% ropivacaine and those in group RISS received ultrasound-guided RIB and serratus plane block using a total of 40-mL 0.375% ropivacaine. All patients received intravenous sufentanil patient-controlled analgesia upon arrival in the recovery room. Postoperative sufentanil consumption and pain scores were compared among the groups. RESULTS: The dosages of sufentanil consumption at 24 h after the surgery in the RIB and RISS groups were significantly lower than that in group C (p < 0.001 and p < 0.001 for all comparisons, respectively), the postoperative Numerical Rating Scale (NRS) scores in the RIB and RISS groups at 0.5, 1, 3, 6, 12, 18, and 24 h after surgery when patients were at rest or active were significantly lower than that in group C (p < 0.05 for all comparisons). The required dosage of sufentanil and time to first postoperative analgesic request in groupRISS were less than those in the group RIB at 24 h after the surgery (p < 0.001 and p < 0.001 for all comparisons, respectively). Similarly, the Numerical Rating Scale scores for group RISS at 12, 18, and 24 h after the surgery when the patients were active were significantly lower than those for group RIB (p < 0.05 for all comparisons). CONCLUSION: Both ultrasound-guided RIB block and RISS block can effectively reduce the demand for sufentanil within 24 h after VATS, and less sufentanil dosage is needed in patient with RISS block. Ultrasound-guided RIB block and RISS block can effectively relieve pain within 24 h after VATS, and RISS block is more effective.

Dexmedetomidine in the prevention of postoperative delirium in elderly patients following non-cardiac surgery: A systematic review and meta-analysis.

The efficacy of dexmedetomidine in the prevention of postoperative delirium (POD) remains ambiguous, however, it has been used to reduce the incidence of delirium in elderly patients. Here, we conducted a meta-analysis study for assessing the effects of dexmedetomidine on POD among elderly patients following non-cardiac surgery. A systematic literature search was performed against the PubMed, EMBASE, Cochrane Library, and Web of Science databases, and all relevant literature published till November 30, 2019, were considered. Our analysis included 16 randomised controlled trials conducted with 4534 patients for exploring the effects of dexmedetomidine on POD in elderly patients following non-cardiac surgery. It was observed that the overall incidence of POD was significantly lower in the dexmedetomidine group than in the control group (risk ratio [RR] 0.51, 95% confidence interval [CI] 0.43-0.61, P < .01). Similar results were obtained from subgroup analysis upon comparison of the placebo (RR 0.52, 95% CI 0.41-0.66, P < .01, moderate quality of evidence), propofol-treated (RR 0.55, 95% CI 0.38-0.78, P < .01, low quality of evidence), and midazolam-treated (RR 0.38, 95% CI 0.20-0.71, P < .01, low quality of evidence) groups. Trial sequential analysis revealed that the cumulative z-value superseded the monitoring boundary and reached the required information size. However, patients who received dexmedetomidine had a higher incidence of bradycardia and hypotension. In conclusion, the meta-analysis revealed that dexmedetomidine appears to decrease the risk of POD in elderly patients following non-cardiac surgery. However, as some of the studies were heterogeneous and of low quality, high-quality trials are necessary for drawing more definitive conclusions.

[Combined inflating lung and insufflating calf pulmonary surfactant under general anesthesia in the treatment of postoperative intractable atelectasis].

OBJECTIVE: To explore the efficacy and safety of combined inflating lung and insufflating calf pulmonary surfactant under general anesthesia for treating postoperative intractable atelectasis. METHODS: From August 2006 to January 2013, 15 patients with obstinate postoperative atelectasis receiving pressure control lung expansion were enrolled. The bronchial cannula was intubated into the affected side to assist the expanding of the lung, and the calf pulmonary surfactant was insufflated selectively. The chest auscultation and computed tomography (CT) scan was performed at 1 d and 5 d after the procedure respectively, to evaluation the effect. The airway pressure, mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR) and oxygen saturation (SpO2) were recorded before the treatment, during the treatment and after the treatment.Monitoring arterial blood gas before and after treatment. RESULTS: After the expansion of the lung and insufflation of calf pulmonary surfactants, the iconographic scan showed that collapsed alveolar was reinflated in 12 (80.0%) patients at 1 d after the treatment and in 14 patients(93.3%) at 5 d after the procedure.There were not notable vital sign change and complications during the treatment.At after the treatment, 1, 3, 5 and 7 d after the treatment, PaO2 was higher (P < 0.05), and there were not significantly difference in the PaCO2 and pH (P > 0.05) . CONCLUSION: Combined pressure control lung expansion with selectively insufflating calf pulmonary surfactant under general anesthesia may be an effective therapy for postoperative intractable atelectasis.

[Influence of P2Y12 receptor inhibitor on pain threshold and spinal p38MAPK in rat bone cancer pain model].

OBJECTIVE: To investigate the role of P2Y12 receptor in rat bone cancer pain model and its influence on p38MAPK (Mitogen-activated protein kinase). METHOD: A total of forty female SD rats, weighting 200 - 250 g, were randomly divided into 5 groups (n = 8): normal group (group N), sham group (group S), vehicle group (group DA), cancer group (group A), and analgesia group (group MA). Rats in group N were untreated, rats in group S were injected with Hank's solution 10 µl into the left tibial metaphysis; rats in group DA, group A and group MA were injected with Walker 256 cancer cells (10 µl, 2×107 cells/ml) into the left tibial metaphysic to establish the model of bone cancer pain. Catheterization was simultaneously made in four groups between L3 and L4 vertebra except group N. Saline (0.9%, 15 µl) was injected in group S and group A, DMSO (5%, 15 µl) was injected in group DA, and MRS2395 (400 pmol/µl, 15 µl) was injected in group MA on day 9 to 12 post-inoculation. Mechanical withdrawal thresholds were measured on left hind paw before and every 10 min after intrathecal injection. Rats were euthanized after measuring mechanical withdrawal threshold at day 12 post-inoculation. L4-6 sections of spinal cord were collected to determine the expression of p-p38MAPK by immunohistochemistry and immunofluorescent. RESULT: Compared to that in group N (36.1 g ± 4.0 g) and group S (38.9 g ± 5.2 g), mechanical withdrawal thresholds in group MA (19.8 g ± 5.0 g) were decreased on day 9 post-inoculation (P < 0.01), and the expression of p-p38MAPK in spinal cord was increased on day 12 (P < 0.01). Compared to that in group DA (17.7 g ± 3.0 g) and group A (19.1 g ± 2.5 g), mechanical withdrawal threshold in group MA was obviously increased after intrathecal injection, peaked at (26.5 g ± 4.7 g) (P < 0.05); compared with group DA (number 43.4 ± 3.8, IOD 569 ± 27) and group A(number 45.0 ± 2.6, IOD 594 ± 22), the expression level of p-p38MAPK in spinal cord in group MA at day 12 was significantly decreased (number 20.9 ± 2.2, IOD 246 ± 25) (P < 0.01); Mechanical withdrawal threshold in group MA was still lower than group N and group S, while the expression of p-p38MAPK was higher than group N (number 9.9 ± 2.4, IOD 82 ± 28) and group S (number 10.9 ± 2.2, IOD 109 ± 25) (P < 0.01). Immunofluorescent showed that p-p38MAPK was colocalized with microglia in spinal dorsal horn, but not with neurons and astrocytes. CONCLUSIONS: These results demonstrate rat bone cancer pain could partially relieved after intrathecal injection of P2Y12 receptor inhibitor MRS2395 through inhibiting the phosphorylation of p38MAPK in spinal dorsal horn.

[Therapeutic feasibility of percutaneous puncture and chemical neurolysis of thoracic sympathetic nerve block in palmar hyperhidrosis under the guidance of computed tomograph].

OBJECTIVE: To explore the therapeutic feasibility of percutaneous puncture and neurolytic thoracic sympathetic nerve block under the guidance of computed tomograph (CT). METHODS: From September 2009 to August 2010, 23 cases with primary palmar hyperhidrosis underwent percutaneous puncture and neurolytic thoracic sympathetic nerve block at our hospital. The puncture of thoracic sympathetic nerve was guided by CT through the gap of T3-4. The screen showed the direction of needle and the location of needle tip at the upper joint of costal head beside T3 body and outside of costal pleura. A mixed injection of 1% lidocaine and 30% iohexol was administered. On CT, lidocaine was found to cover the area where the thoracic sympathetic nerve was located. And after several minutes, the patient's palms turned warm and dry from cool and wet without the onset of Horner's syndrome. Then 2.5 ml of absolute alcohol was injected to block the thoracic sympathetic nerve. RESULTS: CT could guide the needle to the right position. And the injectate spreaded to the site of thoracic sympathetic nerve. At 5 min after anesthetic injection, the palmar temperature raised an average of 2.86°C and the amplitude of pulse rose over 55%. Palmar hyperhidrosis was cured in 19 patients by one attempt and 4 patients required a second block with absolute alcohol. No complication occurred and there were 2 patients with tendency of recurrence during a follow-up period of 8 - 18 months. CONCLUSION: The CT-guided therapy of percutaneous puncture and chemical neurolysis of thoracic sympathetic nerve block is both feasible and efficacious for palmar hyperhidrosis.

Analgesic effects of erector spinae plane block for patients after breast surgery: a systematic review and meta-analysis.

OBJECTIVE: This meta-analysis investigated the analgesic effects of erector spinae plane block (ESPB) in patients undergoing breast surgery. METHODS: PubMed, Embase, Web of Science, and the Cochrane Library were searched from database establishment to January 31, 2020. Two reviewers independently extracted the data. The primary outcomes were pain scores and opioid consumption during the first 24 hours after surgery. The risk of bias of the included studies was assessed according to the Cochrane Handbook. RESULTS: Six randomized controlled trials of 415 patients were included. Compared with the control value, the pain score was significantly lower in the ESPB group at different time points postoperatively. Patients who underwent ESPB required lower opioid consumption (standardized mean difference = -2.02, 95% confidence interval [CI] = -2.85 to -1.20, I2= 91%. The rates of postoperative nausea (risk ratio [RR] = 0.79, 95% CI = 0.48-1.30, I2 = 47%) and postoperative vomiting (RR = 0.76, 95% CI = 0.30-1.96, I2 = 33%) did not differ between the groups. The quality of evidence was low or very low. CONCLUSIONS: ESPB significantly alleviated pain and reduced opioid consumption after breast surgery. Further research is needed to expand its clinical application.PROSPERO registration number CRD42020167900.

Postoperative Analgesic Efficacy of Erector Spinae Plane Block in Patients Undergoing Lumbar Spinal Surgery: A Systematic Review and Meta-Analysis.

Lumbar spine surgery is one of the most widespread types of surgery for treating back and leg pain. However, the postoperative period always presents with severe pain due to the removal of skin, subcutaneous tissues, bones, and ligaments. Patients usually require high doses of opioids to relieve pain during the initial three days after operation, as well as experience drug-related complications and prolonged length of stay in hospital. We found that Erector spinae plane block significantly reduced postoperative opioid consumption and pain scores. The present systematic review revealed that ESPB was effective and safe for postoperative analgesia.

Application of controlled low central venous pressure during hepatectomy: A systematic review and meta-analysis.

STUDY OBJECTIVE: Previous studies reported that controlled low central venous pressure (CVP) can reduce blood loss during liver resection. This systematic review and meta-analysis sought to explore the efficacy and safety of low CVP in patients undergoing hepatectomy. DESIGN: A systematic review and meta-analysis of randomized controlled trials (RCTs). REVIEW METHODS: RCTs were searched in PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Chinese BioMedical database, Chinese Scientific Journals Database, and Wanfang database from inception to April 30, 2021. Subgroup analyses were performed based on different surgical methods (open hepatectomy vs laparoscopic hepatectomy) and published countries (China vs other countries). The quality of evidence was assessed by Grading of Recommendations, Assessment, Development, and Evaluation. MAIN RESULTS: Eighteen RCTs containing 1285 participants (626 patients in the low CVP group and 659 patients in the control group) were included in this study. The forest plot showed that low CVP effectively reduced blood loss during liver resection compared with the control group (MD = -311.92 mL, 95% CI [-429.03, -194.81]; P < 0.001, I2 = 96%). Furthermore, blood transfusion volume (MD = -158.85 mL, 95% CI [-218.30, -99.40]; P < 0.001, I2 = 55%) and the number of patients requiring transfusion (RR 0.41, 95% CI 0.27-0.65, P < 0.001, I2 = 0%) were decreased in the low CVP group. Subgroup analyses showed similar results. Notably, the alanine transaminase level was significantly lower in the low CVP group during the first five postoperative days. However, no significant differences were observed for other postoperative liver function indicators (aspartate aminotransferase, total bilirubin, serum albumin, and prothrombin time), renal function indicators (blood urea nitrogen and serum creatinine) and perfusion parameters (heart rate, mean arterial pressure, and urine volume). The incidence of complications was similar between the two groups. CONCLUSION: The findings of this study showed that low CVP is effective and safe during hepatectomy. Therefore, this technique is recommended to reduce blood loss during hepatectomy. PROSPERO registration number: CRD42021232829.

Dexmedetomidine as an adjuvant for single spinal anesthesia in patients undergoing cesarean section: a system review and meta-analysis.

OBJECTIVE: Previous studies reported the effect of dexmedetomidine on intrathecal anesthesia. In this review, we explored the impact of dexmedetomidine as an adjunct for lumbar anesthesia in patients undergoing cesarean section. METHODS: Two authors searched eligible random controlled trials in electronic databases, including PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, the Chinese BioMedical database, Chinese Scientific Journal Database, and the Wanfang database. RESULTS: Ten trials comprising 970 patients were included in this review. Intrathecal dexmedetomidine significantly reduced the onset time of sensory block (standardized mean difference (SMD), -1.50, 95% confidence interval (CI) -2.15, -0.85, I2 = 92%) and motor block (SMD -0.77, 95% CI -1.50, -0.49, I2 = 60%) and prolonged the block duration time (sensory block: SMD 2.02, 95% CI 1.29, 2.74, I2 = 93%; motor block: SMD 1.90, 95% CI 1.07, 2.74, I2 = 94%). Patients who received dexmedetomidine showed a lower incidence of shivering. No significant difference was reported for the neonatal Apgar score and other complications. CONCLUSION: The use of intrathecal dexmedetomidine during cesarean section can shorten the onset time of spinal anesthesia and enhance the effect of local anesthetic. It has no significant impact on neonates and there were no other adverse events.

[Clinical Characteristics and Karyotype Analysis of Myelodysplastic Syndrome Patients with TP53 mutation].

OBJECTIVE: To investigate the clinical characteristics of myelodysplastic syndrome (MDS) with TP53 mutant and the relationship between TP53 mutation and monosomal karyotype in MDS patients. METHODS: The TP53 mutations in 102 patients with de nove MDS were retrospectively analyzed, and the clinical features of the TP53 mutation group and the non-mutation group were compared. The relationship between TP53 mutation and karyotype, especially monosomal karyotype was analyzed. RESULTS: Fifty-two out of the 102 MDS patients were male and 50 were female, the median age was 59.5 (23-83) years old. The mutational frequency of TP53 was 12.7%, which mostly occurred in patients with MDS-EB. As compared with non-mutation group, the hemoglobin level and platelet count were lower (P=0.001, P=0.033), the LDH level and bone marrow blast ratio were higher in TP53 mutation group (P=0.002, P＜0.001), but the statistical difference of alsolute count of neutrophils and levels of serum ferritin and ß2-microglobulin between 2 groups was not found. The karyotype abnormality frequency of patients with TP53 mutation was 90.9%, among them 72.7% was monosomal karyotype. The incidence of monosomal karyotype in the TP53 mutation group was very significantly higher than that in the non-mutation group (P＜0.001). MDS with TP53 mutation and monosomal karyotype appeared in the groups with high and very high IPSS-R risk. CONCLUSION: MDS patients with TP53 mutation have unique clinical features and high incidence of monosomal karyotype, and their overall prognosis is poor.

[Selective percutaneous dorsal root ganglion radiofrequency thermocoagulation guided by CT scanning in treatment of post-herpetic neuralgia].

OBJECTIVE: To present the experience in a technique used to treat intractable postherpetic neuralgia (PHN)-percutaneous dorsal root ganglion (DGR) radiofrequency thermocoagulation guided by CT scanning. METHODS: Sixteen PHN patients underwent puncture of radiohealing needle into the superior 1/3 of the corresponding intervertebral foramen guided by CT. Electric stimulation test and impedance test were conducted to confirm the right spot. Radiofrequency heat coagulation therapy under the condition of 90 degrees C 90 s was performed for 3 cycles. Then mixture of betamethasone and lidocain was injected and the needle was pulled out. CT was conducted to observe if pneumothorax occurred. The patients were followed up for 2-16 months. RESULTS: Radiofrequency thermocoagulation was performed on 45 target dorsal root ganglia in 16 PHN patients with the effect of immediate disappearance of hyperalgesia. Remaining spontaneous pain was seen in 5 cases, however, with decreases of attack frequency and severity. The visual analogue pain scale score was decreased from 7-9 before the procedure to 2-3 after the procedure. No relapse was found during the follow-up. CONCLUSION: Selective percutaneous DRG radiofrequency thermocoagulation guided by CT scanning is effective in treatment of PHN.

False esophageal hiatus hernia caused by a foreign body: a fatal event.

Foreign body ingestion is a common complaint in gastrointestinal clinics. It is usually not difficult to diagnose because most of the patients report a definitive history of accidental foreign body ingestion. However, in rare cases, patients do not have a clear history. Thus, the actual condition of the patient is difficult to diagnosis or is misdiagnosed; consequently, treatment is delayed or the wrong treatment is administered, respectively. This report describes a fatal case of esophageal perforation caused by an unknowingly ingested fishbone, which resulted in lower esophageal necrosis, chest cavity infection, posterior mediastinum fester, and significant upper gastrointestinal accumulation of blood. However, his clinical symptoms and imaging data are very similar with esophageal hiatal hernia. Unfortunately, because the patient was too late in consulting a physician, he finally died of chest infection and hemorrhage caused by thoracic aortic rupture. First, this case report underlines the importance of immediate consultation with a physician as soon as symptoms are experienced so as not to delay diagnosis and treatment, and thus avoid a fatal outcome. Second, diagnostic imaging should be performed in the early stage, without interference by clinical judgment. Third, when computed tomography reveals esophageal hiatus hernia with stomach incarceration, posterior mediastinal hematoma, and pneumatosis caused by esophageal, a foreign body should be suspected. Finally, medical professionals are responsible for making people aware of the danger of foreign body ingestion, especially among children, those who abuse alcohol, and those who wear dentures, particularly among the elderly, whose discriminability of foreign bodies is decreased, to avoid dire consequences.