Transversus abdominis plane block versus quadratus lumborum block type 2 for analgesia in renal transplantation: A randomised trial.

BACKGROUND: Several studies have shown an analgesic efficacy of a transversus abdominis plane block (TAPB) in reducing opioid requirements during and after cadaveric renal transplantation surgery, but the effect of a quadratus lumborum block (QLB) in this type of surgery is unclear. OBJECTIVES: The main objective of this prospective, randomised, double-centre clinical study was to compare the analgesic efficacy of a one-sided lateral approach TAPB with a unilateral QLB type 2 in cadaveric renal transplantation surgery. DESIGN: Randomised, single-blinded trial. SETTING: Two University-affiliated tertiary care hospitals between April 2016 and May 2017. PATIENTS: A total of 101 patients aged more than 18 years, scheduled for cadaveric renal transplantation. INTERVENTIONS: On receiving ethical board approval and individual informed consent, consecutive patients were allocated randomly to receive either an ultrasound-guided single-shot lateral TAPB or an ultrasound-guided single-shot QLB type 2 on the surgical side using 20 ml of bupivacaine 0.25% with adrenaline after a standardised induction of general anaesthesia. All patients on surgical completion and recovery from general anaesthesia were admitted to the postanaesthesia care unit for 24 h. They received standardised intravenous patient-controlled analgesia with fentanyl, and their pain scores were noted at regular intervals. MAIN OUTCOME MEASURES: The primary endpoint was total cumulative fentanyl dose used per kg body mass in the first 24 h after surgery. Secondary outcomes were the need to start a continuous infusion of fentanyl in addition to patient-controlled analgesia boluses during the stay in post-anaesthesia care unit, postoperative pain severity measured using a numerical rating scale, patient satisfaction with analgesic treatment, evidence of postoperative nausea and vomiting, pruritus and sedation level. RESULTS: The 49 patients allocated to the QLB type 2 group used significantly less fentanyl per kg in the first 24 h after surgery than the 52 patients who received a TAPB (median [IQR] 4.2 [2.3 to 8.0] µg kg versus 6.7 [3.5 to 10.7] µg kg, P = 0.042). No statistically significant differences were noted in the secondary endpoints within the study, including the frequency of adverse effects of opioids. CONCLUSION: The reduction of fentanyl consumption in the first 24 h after renal transplantation with no difference in pain intensity and patient satisfaction shows a beneficial effect of one-sided QLB type 2 over a one-sided TAPB in regards to postoperative analgesia. However, the reduction in opioid consumption did not affect the frequency of opioid-related adverse effects. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT02783586.

Pain relief during labor - what do we know and what should we know? research based on the student population in Warsaw.

OBJECTIVE: The aim: Women of reproductive age often think of motherhood and labor with fear of intense labor pain. The anxiety they experience can lead to their postponing pregnancy. There are not many studies in the literature that research the knowledge young women have about the analgesia of labor. The aim of the present work was to evaluate the state of awareness about the possible methods of labor analgesia among women of childbearing age. PATIENTS AND METHODS: Material and methods: An Internet survey was conducted among 160 women. It consisted of questions on the pharmacological and non-pharmacological methods of labor analgesia. Most of the respondents were not medical university students (96.2%). Correct answers ranged between 11.3% and 97.5% of the total responses. RESULTS: Results: The greatest number of incorrect answers were given to the question regarding contraindications to labor anesthesia (only 11.3% of answers were correct). There was also a low percentage of correct answers to questions about the risk of spinal cord injury during the procedure of inducing anesthesia (18.8% of correct answers), the motor activity of a woman after analgesia (22.5%) and the reimbursement of anesthesia (29.4%). Nearly 40% of the respondents did not know the correct answer to the question about the possibility of breastfeeding after anesthesia. The problem of aalgesia during twin delivery also posed a challenge. Over half of the respondents (54.1%) incorrectly answered the question about the occurrence of complications among women who want to become pregnant again after the procedure of labor anesthesia. Moreover, 70.6% of the women surveyed considered non-pharmacological methods of labor anesthesia to be safer compared to pharmacological analgesia. The most commonly mentioned methods of non-pharmacological labor pain relief included breathing techniques and water birth. CONCLUSION: Conclusions: The study shows that women of childbearing potential have an unsatisfactory level of knowledge about labor anesthesia. There is a need to improve the level of health education on this topic.

Opioid-Free Anesthesia in Bariatric Surgery: Is It the One and Only? A Comprehensive Review of the Current Literature.

Opioid-free anesthesia (OFA) is a heterogeneous group of general anesthesia techniques in which the intraoperative use of opioids is eliminated. This strategy aims to decrease the risk of complications and improve the patient's safety and comfort. Such potential advantages are particularly beneficial for selected groups of patients, among them obese patients undergoing laparoscopic bariatric surgery. Opioids have been traditionally used as an element of balanced anesthesia, and replacing them requires using a combination of coanalgesics and various types of local and regional anesthesia, which also have their side effects, limitations, and potential disadvantages. Moreover, despite the growing amount of evidence, the empirical data on the superiority of OFA compared to standard anesthesia with multimodal analgesia are contradictory, and potential benefits in many studies are being questioned. Additionally, little is known about the long-term sequelae of such a strategy. Considering the above-mentioned issues, this study aims to present the potential benefits, risks, and difficulties of implementing OFA in bariatric surgery, considering the current state of knowledge and literature.

The Safety of Peripheral Nerve Blocks: The Role of Triple Monitoring in Regional Anaesthesia, a Comprehensive Review.

Regional anaesthesia, referred to as regional blocks, is one of the most frequently used methods of anaesthesia for surgery and for pain management. Local anaesthetic drug should be administered as close to the nerve as possible. If administered too far away, this may result in insufficient block. If it is administrated too close, severe nerve damage can occur. Neurostimulation techniques and ultrasound imaging have improved the effectiveness and safety of blockade, but the risk of nerve injury with permanent nerve disfunction has not been eliminated. Intraneural administration of a local anaesthetic damages the nerve mechanically by the needle and the high pressure generated by the drug inside the nerve. In many studies, injection pressure is described as significantly higher for unintended intraneural injections than for perineural ones. In recent years, the concept of combining techniques (neurostimulation + USG imaging + injection pressure monitoring) has emerged as a method increasing safety and efficiency in regional anaesthesia. This study focuses on the contribution of nerve identification methods to improve the safety of peripheral nerve blocks by reducing the risk of neural damage.

The First Use of a Midline Catheter in Outpatient Pain Management.

Midline catheters (MCs) are used to deliver intravenous therapy lasting over 5 days to patients in hospitals. However, the constant development of home and outpatient care is challenging medical teams to provide effective and safe planned therapy to patients under such conditions. We describe the first time an MC was used in outpatient pain management in Poland. A 60-year-old man presented to the Pain Management Clinic with a history of RCC of the left kidney and lumbar back pain radiating to the left knee joint. The person whose case is described below had poor peripheral veins. He intravenously received lidocaine for 10 days via a midline catheter with a good response.

Analysis of Antidepressant, Benzodiazepine Anxiolytic, and Hypnotic Use When Treating Depression, Anxiety, and Aggression in Pain Clinic Patients Treated for Neuropathic Pain.

Depression, anxiety, and aggression accompany neuropathic pain. Effective treatment of these comorbidities enhances the outcomes of pain management. Therefore, the study was designed to analyze the relationship between the intensity of depression, anxiety, and aggression and the pharmacotherapy applied in the daily practice of treating neuropathic pain. The aim of the study was to evaluate the frequency of using antidepressants (ADs), benzodiazepine anxiolytics (BDAs), and hypnotics, and the influence of administering these on the intensity of depression, anxiety, and aggression in patients diagnosed with neuropathic pain. A multi-center survey was conducted among 421 patients. An evaluation of the severity of depression, anxiety, and aggression was made using the Hospital Anxiety and Depression Scale-Modified Version (HADS-M). Among the patients treated due to neuropathic pain, ADs are used much more often than BDAs and hypnotics. Depression was well controlled, while anxiety was identified as a possible uncontrolled therapeutic problem in these patients, despite the correlation between the frequency of AD and hypnotics usage and the severity of anxiety. We also found that women show a higher level of intensity in both anxiety and depression, but this does not influence the frequency of their being administered ADs, BDAs, and hypnotics.

The Effect of the Treatment at a Pain Clinic on the Patients' Assessment of Their Pain Intensity and the Incidence of Mental Disorders in the form of Anxiety, Depression, and Aggression.

The aim of the study was to analyze the effect of the treatment given to patients in a pain clinic on their assessment of pain intensity and the incidence of emotional disturbances in the form of anxiety, depression, and aggression. The study was conducted from January 2014 to April 2018 among patients under the care of two Warsaw pain clinics. The study tools were the Hospital Anxiety and Depression Scale-Modified Version (HADS-M) and the Numerical Rating Scale (NRS). The project enrolled 325 patients, with women comprising 60.62% of patients, and the age bracked of 65⁻79 years comprising 39.38% of patient. The major reasons for attending the pain clinic were osteoarticular pain (44.92%) and neuropathic pain (42.77%). The therapy applied lowered the patients' pain intensity (4.98 vs. 3.83), anxiety (8.71 vs. 8.12), aggression (3.30 vs. 3.08), and the overall HADS-M score (18.93 vs. 17.90), which shows that the treatment of both the pain symptoms and the associated emotional disturbances in the form of anxiety and aggression was effective. Sex is a factor affecting pain intensity. The level of mental disorders was influenced by the sex and age of the patients and how long they had been treated in the pain clinics.

Non-invasive evaluation of cardiac index by impedance cardiography in patients undergoing percutaneous nephrolithotomy.

INTRODUCTION: Percutaneous nephrolithotomy (PNL) is an endoscopic treatment of renal lithiasis. It is usually two-staged: it begins in the lithotomy position for ureteral catheter placement and retrograde pyelography, and subsequently an optimal renal access is obtained in the prone position. Some patients under epidural anesthesia do not tolerate the prone position and the PNL cannot be continued. This may be related to changes occurring within the circulatory system. The aim of this prospective randomized double-blind study was to evaluate the changes of the cardiac index (CI) during PNL. MATERIAL AND METHODS: In a group of 50 patients, with ASA physical status grade 1-2, epidural anesthesia with either 0.2% ropivacaine or 0.25% bupivacaine was performed and then the CI was evaluated by impedance cardiography. RESULTS: Forty-five patients were included in the analysis; all tolerated the PNL well. After turning prone, a decrease in the CI was always recorded, a maximum after 10-15 min - 22.58 ±11.47%. There was significant variability of recorded values. The average CI dropped from 2.96 ±0.42 l/min/m2 to 2.28 ±0.39 l/min/m2. In 7 patients the decrease in the CI was greater than 35%. No correlation was observed with the arterial blood pressure or the heart rate. The decrease in the CI occurred irrespective of the type of local anesthetic used (p = 0.91). CONCLUSIONS: A decrease in the CI was observed in every case, and it should be taken into consideration during qualification for PNL in the prone position.

Perioperative analgesia after intrathecal fentanyl and morphine or morphine alone for cesarean section: A randomized controlled study.

OBJECTIVES: Intrathecal morphine is used in the postoperative management of pain after caesarean section (CS), but might not be optimal for intraoperative analgesia. We hypothesized that intrathecal fentanyl could supplement intraoperative analgesia when added to a local anesthetic and morphine without affecting management of postoperative pain. METHODS: This prospective, randomized, double-blind, parallel-group study included 60 parturients scheduled for elective CS. Spinal anesthesia consisted of bupivacaine with either morphine 100 µg (M group), or fentanyl 25 µg and morphine 100 µg (FM group). The frequency of intraoperative pain and pethidine consumption in the 24 hours postoperatively was recorded. RESULTS: Fewer patients in the FM group required additional intraoperative analgesia (P < .01, relative risk 0.06, 95% confidence interval [CI] 0.004-1.04). The FM group was noninferior to the M group for 24-hour opioid consumption (95% CI -10.0 mg to 45.7 mg, which was below the prespecified boundary of 50 mg). Pethidine consumption in postoperative hours 1 to 12 was significantly higher in the FM group (P = .02). Postoperative nausea and vomiting (PONV) were more common in the FM group (P = .01). Visual analog scale scores, effective analgesia, Apgar scores, and rates of pruritus and respiratory depression were similar between the groups. CONCLUSIONS: Intrathecal combination of fentanyl and morphine may provide better perioperative analgesia than morphine alone in CS and could be useful when the time from anesthesia to skin incision is short. However, an increase in PONV and possible acute spinal opioid tolerance after addition of intrathecal fentanyl warrants further investigation using lower doses of fentanyl.

Analgesic efficacy of intrathecal fentanyl during the period of highest analgesic demand after cesarean section: A randomized controlled study.

Cesarean section (CS) is one of the most common surgical procedures in female patients. We aimed to evaluate the postoperative analgesic efficacy of intrathecal fentanyl during the period of greatest postoperative analgesic demand after CS. This period was defined by detailed analysis of patient-controlled analgesia (PCA) usage.This double-blind, placebo-controlled, parallel-group randomized trial included 60 parturients who were scheduled for elective CS. Participants received spinal anesthesia with bupivacaine supplemented with normal saline (control group) or with fentanyl 25 µg (fentanyl group). To evaluate primary endpoints, we measured total pethidine consumption over the period of greatest PCA pethidine requirement. For verification of secondary endpoints, we recorded intravenous PCA requirement in other time windows, duration of effective analgesia, pain scores assessed by visual analog scale, opioid side effects, hemodynamic changes, neonatal Apgar scores, and intraoperative pain.Detailed analysis of hour-by-hour PCA opioid requirements showed that the greatest demand for analgesics among patients in the control group occurred during the first 12 hours after surgery. Patients in the fentanyl group had significantly reduced opioid consumption compared with the controls during this period and had a prolonged duration of effective analgesia. The groups were similar in visual analog scale, incidence of analgesia-related side effects (nausea/vomiting, pruritus, oversedation, and respiratory depression), and neonatal Apgar scores. Mild respiratory depression occurred in 1 patient in each group. Fewer patients experienced intraoperative pain in the fentanyl group (3% vs 23%; relative risk 6.8, 95% confidence interval 0.9-51.6).The requirement for postoperative analgesics is greatest during the first 12 hours after induction of anesthesia in patients undergoing CS. The addition of intrathecal fentanyl to spinal anesthesia is effective for intraoperative analgesia and decreases opioid consumption during the period of the highest analgesic demand after CS, without an increase in maternal or neonatal side effects. We recommend using intrathecal fentanyl for CS in medical centers not using morphine or other opioids intrathecally at present.

Preoperative Local Administration of Morphine as an Add-on Therapy in Patients Undergoing Surgical Removal of an Odontogenic Maxillary Cyst. A Randomized, Double-Blind Pilot Study.

AIMS: To evaluate whether a combination of locally administered morphine (1 mg) and lidocaine as part of a multimodal analgesic approach is safe, and whether it improves pain control during the first 24 hours after odontogenic maxillary cyst removal under general anesthesia compared to local lidocaine alone. METHODS: In a double-blind, sham-controlled, single-center trial, patients scheduled for surgical removal of an odontogenic maxillary cyst under general anesthesia were randomly assigned to receive a local injection of lidocaine solution with either 1 mg of morphine (MLA group) or with no morphine (LA group). Pain management included intravenous acetaminophen (1 g every 6 hours) in all patients. Upon request, the patients could additionally receive ketoprofen (first-line additional analgesia) or tramadol (second-line additional analgesia). Pain intensity was assessed using a numeric rating scale. Primary outcome measures were (1) no need for any additional analgesic therapy and (2) time to the first rescue analgesic therapy during the first 24 hours after the surgery. RESULTS: Of 48 eligible patients, 24 were allocated to the MLA group and 24 to the LA group. The necessity of additional ketoprofen therapy did not differ significantly between the groups (25.0% vs 50.0%, P=.074). According to the Kaplan-Meier analysis, the probability of remaining without additional analgesic intervention was significantly higher in the MLA group (log-rank test, P=.040), but there were no significant (P>.05) differences in overall and maximum pain severity between the two groups. No adverse effects of morphine were recorded. CONCLUSION: Within the limitations of this study, local administration of 1 mg of morphine prior to the surgical removal of an odontogenic maxillary cyst was safe, but it did not prove to be very effective as an add-on therapy for postoperative pain control.

Is Hydroxyethyl Starch Irrelevant to Hemostasis in Patients Undergoing Liver Transplantation?--In vitro Analysis Based on Thromboelastometry.

BACKGROUND: Liver transplantation may be associated with severe bleeding that requires intensive fluid management. Aggressive fluid administration could result in hemodilution, triggering dilutional coagulopathy that intensifies bleeding. Colloids are plasma expanders used in daily practice. Fibrinogen, malfunctioning in liver cirrhosis, is the earliest decreasing clotting factor while bleeding. Fibrinogen supplementation is recommended as the first-choice therapy in such cases. Therefore, the influence of hemodilution on fibrin clot formation among patients with liver cirrhosis was analyzed, followed by the assessment of fibrinogen supplementation in clot restitution. MATERIAL AND METHODS: Blood collected from 22 patients with post-inflammatory liver cirrhosis was diluted up to 30% and 60% with crystalloid (0.9% NaCl) or colloid (6% hydroxyethyl starch 130/0.4), followed by fibrinogen supplementation corresponding to an overall dose of 4 g. The influence of hemodilution on plasma fibrinogen concentration and on thromboelastometry FIBTEM test was analyzed, as well as the influence of fibrinogen supplementation. RESULTS: Hemodilution lowers fibrinogen concentration and decreases fibrin clot formation. The higher the grade of dilution, the more profound the disturbances observed; 6% hydroxyethyl starch 130/0.4 cause more intense effect on fibrin clot formation than 0.9% NaCl. Fibrinogen supplementation improves fibrin clot formation as assessed in FIBTEM. CONCLUSIONS: Fibrinogen supplementation among patients with liver cirrhosis might improve fibrin clot formation during hemodilution. Fibrinogen supplementation might by considered as a possible treatment of coagulopathy during liver transplantation, but further clinical studies need to be performed.

Thoracic epidural analgesia in anaesthesia for liver transplantation: the 10-year experience of a single centre.

BACKGROUND: Improvements in operating techniques, methods of anaesthesia and postoperative care in liver transplantation (LT) contribute to better outcomes. In order to restrict postoperative mechanical ventilation, a thoracic epidural analgesia (TEA) has been performed in our centre since 2000. In this report we present our 10-year experience of using TEA as a component of LT anaesthesia. MATERIAL/METHODS: TEA was performed, by anaesthetists experienced in this method, on patients qualified for LT, who consented and met inclusion criteria: INR<1.5, APTT<45s and platelets >70 G/L. Since 2008 the decision to insert an epidural catheter has been additionally supported by thromboelastometry. We assessed extubation time, frequency of complications of TEA and undesired accidents. RESULTS: From 279 patients undergoing LT, TEA was performed on 67 (24%), and from these 56 (84%) were extubated in the operating theatre. There were 5 cases of unsatisfactory thoracic epidural analgesia. Only 1 epidural catheter was removed accidentally, on the 2nd postoperative day. None of the complications of TEA were observed in the TEA group. CONCLUSIONS: Based on our observations, it can be assumed that TEA done by experienced an anaesthetist is a safe component of anaesthesia in selected groups of patients undergoing LT, and allows for early extubation.

The use of thromboelastometry in the assessment of hemostasis during orthotopic liver transplantation reduces the demand for blood products.

BACKGROUND: Bleeding due to fibrinolysis is a serious intraoperative complication during orthotopic liver transplantation (OLT). For a number of years aprotinin was used to minimize risk of this complication. This drug was however banned in 2007 and substituted with other antifibrinolytics. The aim of the study was to assess the potential of intraoperative thromboelastometry to evaluate hemostasis and channelize antifibrinolytic therapy. MATERIAL/METHODS: Since ban on aprotinin, 39 patients underwent OLT in our center with no monitoring of fibrinolysis (NMF). Severe disturbances of hemostasis assessed clinically only as a need for blood and blood products transfusion and were treated with transfusion of fresh frozen plasma only. In 2008 we started to use thromboelastometry (ROTEM group, n=39), which allowed for targeted treatment of hyperfibrinolysis with tranexamic acid. RESULTS: The need for blood transfusion in ROTEM group was insignificantly a lower than in NMF group (4.1±4.76 vs 5.53±4.89 units, p=0.2). Patients from ROTEM group required also less plasma transfusions (10.01±7.47 vs 13.15±6.62, p=0.06). Severe fibrinolysis was found in 3 patients from ROTEM group (7.7%) and was treated with tranexamic acid. CONCLUSIONS: Thromboelastometry provides an immediate diagnosis of fibrinolysis, justifies implementation of targeted treatment and confirms effectiveness of the therapy. In a larger study group it can also result in significant minimization of blood products transfusion during OLT.