Comparison of PECS II and erector spinae plane block for postoperative analgesia following modified radical mastectomy: Bayesian network meta-analysis using a control group.

The present study compared the effects of pectoral nerve block II (PECS II) and erector spinae plane (ESP) block for postoperative analgesia in patients who underwent modified radical mastectomy by performing a network meta-analysis (NMA) using indirect comparison with systemic analgesia. Studies comparing the analgesic effects of PECS II and ESP block were searched on MEDLINE, PubMed, EMBASE and the Cochrane Library. The primary outcome of this study was cumulative opioid consumption for 24 h postoperatively. Pain score during this period was also assessed. NMA was performed to compare the postoperative analgesic effects of plane blocks and systemic analgesia. A search of databases identified 17 studies, with a total of 1069 patients, comparing the analgesic efficacies of PECS II block, ESP block, and systemic analgesia. Compared with systemic analgesia, mean difference of opioid consumption was - 10 mg (95% credible interval [CrI] - 15.0 to - 5.6 mg) with PECS II block and - 5.7 mg (95% CrI - 11.0 to - 0.7 mg) with ESP block. Relative to systemic analgesia, PECS II block showed lower pain scores over the first postoperative 24 h, whereas ESP block did not. PECS II block showed the highest surface under the cumulative ranking curves for both opioid consumption and pain score. Both PECS II and ESP blocks were shown to be more effective than systemic analgesia regarding postoperative analgesia following modified radical mastectomy, and between the two blocks, PECS II appeared to have favorable analgesic effects compared to ESP block.

Intraoperative severe hypoglycemia indicative of post-hepatectomy liver failure.

We present the first reported case of a patient with intraoperative hypoglycemia, with no predisposing factors, that was indicative of post-hepatectomy liver failure due to liver injury. A 56-year-old man was hospitalized to undergo left lateral segmentectomy, cholecystectomy and T-tube choledocholithotripsy due to calculi in the intrahepatic and common bile ducts. His medical history was unremarkable. Three hours after surgery initiation, his glucose level decreased from 84 mg/dL to below detectable levels. We infused 20 % dextrose repeatedly until his glucose level returned to within normal limits. His aspartate aminotransferase and alanine aminotransferase levels increased to over 10,000 IU/L, and his blood urea nitrogen and creatinine levels increased postoperatively. Thus, we diagnosed post-hepatectomy liver failure and hepatorenal syndrome and treated the patient conservatively. This case illustrates that, if no other causative factors for severe hypoglycemia occurring during liver resection are present, the anesthesiologist should predict post-hepatectomy liver failure due to liver injury and inform the surgeon in order to enable rapid evaluation and treatment.

Patient-specific depth of endotracheal intubation-from anthropometry to the Touch and Read Method.

OBJECTIVE: Knowledge of accurate airway length (AL) enables safer placement of the endotracheal tube (ETT) in the trachea. Our objective was to check the safety of a new formula (Touch and Read method) to determine ETT depth. METHODS: AL was measured in 176 patients. Patients were divided into a normal group (AL >25 cm in men, >23 cm in women) and a risk group (AL ≤25 cm in men, ≤23cm in women). A control test (Conventional method) was performed in which the ETT was secured at a depth of 23 cm from the central incisor in men and 21 cm in women. In the experimental test (Touch and Read method), the ETT was secured at a depth equal to the distance from the angle of the mouth to the epiglottis tip plus 12.5 cm in men and 11.5 cm in women. The mean distance from the tube tip to the carina and that from the vocal cords to tube cuff were compared between the control and experimental tests in each group. RESULTS: The two distances were similar between control and experimental tests in the normal group, but differed in the risk group (Women: mean distance from tube tip to carina, 1.2 cm and from vocal cords to cuff, 2.7 cm [control test]; 1.9 and 2.0 cm, respectively [experimental test]. Men: 0.7 and 3.5 cm, respectively [control test]; 2.0 and 2.3 cm, respectively [experimental test]). CONCLUSION: Touch and Read method enables safer placement of the ETT in the trachea than the conventional method in the risk group.

Retro superior costotransverse ligament space block as an effective analgesia after laparoscopic gastrectomy -a case report.

BACKGROUND: The retro superior costotransverse ligament space (RSS) block, reported as a novel target in paraspinal block, involves the spreading of local anesthetics into the thoracic paravertebral space through slits around the superior costotransverse ligament . This blocks not only the dorsal rami but also the ventral rami, achieving a reliable complete sensory blockade. CASE: We performed an RSS block at the T5, T7, and T9 levels on both sides for postoperative analgesia in two patients who underwent laparoscopic gastrectomy. Both patients showed complete sensory blockade from T4 to L1 on the anterior, lateral, and posterior chest walls in the recovery room. The resting and dynamic pain scores were 0 at 30 min and 6 h postoperatively. The pain score consistently remained below 3 throughout postoperative period. CONCLUSIONS: The RSS block provided effective postoperative analgesia in laparoscopic gastrectomy through definitive complete sensory blockade.

Prevalence of common causes of neuropathic pain in Korea: population-based observational study.

OBJECTIVE: To investigate the prevalence of complex regional pain syndrome (CRPS), post-herpetic neuralgia (PHN), trigeminal neuralgia (TN), and diabetic neuropathy (DN), common causes of neuropathic pain encountered in pain clinics. METHODS: We investigated the period prevalence rate of CRPS, PHN, TN, and DN using data from a Korean national electronic database from 2009 to 2013. RESULTS: The prevalence of CRPS decreased slightly throughout the study period, while the prevalence of PHN increased from 2009 to 2013. The prevalence of TN was reduced over the same period. The prevalence of DN increased from 2009 to 2012 but decreased in 2013. All four neuropathic diseases were more prevalent in individuals aged over 70 years. The prevalence of CRPS, PHN, and TN were more common in women than in men, but DN showed no gender difference. CONCLUSION: While the prevalence of CRPS and TN has decreased in Korea, that of PHN and DN has increased. With the exception of DN, the neuropathic diseases were more prevalent in women. Further studies are necessary to investigate the risk factors and socioeconomic burden for each disease, and national efforts are essential to limit the development of these preventable neuropathic diseases.

Continuous quadratus lumborum block as part of multimodal analgesia after total hip arthroplasty: a case report.

BACKGROUND: Commonly used epidural or systemic analgesics for pain control after hip surgery carry risk for potential adverse effects. In contrast, the quadratus lumborum block (QLB) utilizes a simple and easy fascial plane technique and provides a wide area of sensory blockade. Thus, the QLB may be beneficial as analgesia after total hip arthroplasty. CASE: Here, we report the case of an 83-year-old man who received a continuous transmuscular QLB as part of a multimodal analgesia after hardware removal and total hip arthroplasty. The patient received a continuous infusion of 0.2% ropivacaine at 8 ml/h through an indwelling catheter in addition to patient-controlled analgesia with intravenous fentanyl and oral celecoxib. The patient's pain scores did not exceed 4, and no additional analgesics were required until postoperative day 5. CONCLUSIONS: Transmuscular QLB may be a suitable option for multimodal analgesia after total hip arthroplasty.

Multimodal analgesia with multiple intermittent doses of erector spinae plane block through a catheter after total mastectomy: a retrospective observational study.

BACKGROUND: Although case reports have suggested that the erector spinae plane block (ESPB) may help analgesia for patients after breast surgery, no study to date has assessed its effectiveness. This retrospective observational study analyzed the analgesic effects of the ESPB after total mastectomy. METHODS: Forty-eight patients were divided into an ESPB group (n = 20) and a control group (n = 28). Twenty patients in the control group were selected by their propensity score matching the twenty patients in the ESPB group. Patients in the ESPB group were injected with 30 mL 0.375% ropivacaine, followed by catheter insertion for further injections of local anesthetics every 12 hours. Primarily, total fentanyl consumption was compared between the two groups during the first 24 hours postoperatively. Secondary outcomes included pain intensity levels (visual analogue scale) and incidence of postoperative nausea and vomiting (PONV). RESULTS: Median cumulative fentanyl consumption during the first 24 hours was significantly lower in the ESPB (33.0µg; interquartile range [IQR], 27.0-69.5µg) than in the control group (92.8µg; IQR, 40.0-155.0µg) (P = 0.004). Pain level in the early postoperative stage (<3 hr) and incidence of PONV (0% vs. 55%) were also significantly lower in the ESPB group compared to the control (P = 0.001). CONCLUSIONS: Intermittent ESPB after total mastectomy reduces fentanyl consumption and early postoperative pain. ESPB is a good option for multimodal analgesia after breast surgery.

Erector spinae plane block for multimodal analgesia after wide midline laparotomy: A case report.

RATIONALE: The most commonly used regional techniques for analgesia following laparotomy thoracic epidural analgesia and paravertebral blocks are technically difficult to perform and carry a risk of severe complications. Recently, the erector spinae plane block (ESPB) has been reported to effectively treat neuropathic pain. The ultrasound-guided ESPB is an easily performed fascial plane block that can provide sensory blockade from T2-4 to T12-L1. Moreover, the ESPB reportedly blocks both the ventral rami of spinal nerves and the rami communicants, which contain sympathetic nerve fibres, through spread into the thoracic paravertebral space. PATIENT CONCERNS: We report the case of a 35-year-old female patient who underwent excision of a larger ovarian mass via laparotomy with a wide, midline incision from the xiphoid process to the pubic tubercle. DIAGNOSES: They were diagnosed with mucinous cystadenoma originated from the right ovary and fallopian tube, and a right oophorectomy and salpingectomy were performed. INTERVENTIONS: The ESPB was performed for postoperative pain control at the level of the T8 transverse process. Postoperative multimodal analgesia was provided according to the acute pain service protocol of our hospital. The patient was prescribed oral acetaminophen 175 mg every 6 hours and intravenous patient-controlled analgesia (PCA) with fentanyl 7 µg/mL. A 1:1 mixture of 0.75% ropivacaine (20 mL) and saline (20 mL) with epinephrine (1: 200,000) was manually injected through the indwelling catheter every 8 hours (20 mL per side). OUTCOMES: The first demand dose of fentanyl was administered at 9 hours and 39 minutes after the surgery. There were no reported resting pain scores >4, nor were any rescue analgesics needed during the first 5 postoperative days. LESSONS: The ESPB provided highly effective analgesia as a part of multimodal analgesia after laparotomy with a wide midline incision.

The erector spinae plane block for effective analgesia after lung lobectomy: Three cases report.

RATIONALE: The thoracic epidural block and thoracic paravertebral block are widely used techniques for multimodal analgesia after thoracic surgery. However, they have several adverse effects, and are not technically easy. Recently, the erector spinae plane block (ESPB), an injected local anesthetic deep to the erector spinae muscle, is a relatively simple and safe technique. PATIENT CONCERNS: Three patients were scheduled for video assisted thoracoscopic lobectomy with mediastinal lymph node dissection. All the patients denied any past medical history to be noted. DIAGNOSES: They were diagnosed with primary adenocarcinoma requiring lobectomy of lung. INTERVENTIONS: The continuous ESPB was performed at the level of the T5 transverse process. The patient was received the multimodal analgesia consisted of oral celecoxib 200 mg twice daily, intravenous patient-controlled analgesia (Fentanyl 700 mcg, ketorolac 180 mg, total volume 100 ml), and local anesthetic (0.375% ropivacaine 30 ml with epinephrine 1:200000) injection via indwelling catheter every 12 hours for 5 days. Additionally, we injected a mixture of ropivacaine and contrast through the indwelling catheter for verifying effect of ESPB and performed Computed tomography 30 minutes later. OUTCOMES: The pain score was maintained below 3 points for postoperative 5 days, and no additional rescue analgesics were administered during this period. In the computed tomography, the contrast spread laterally from T2-T12 deep to the erector spinae muscle. On coronal view, the contrast spread to the costotransverse ligament connecting the rib and the transverse process. In the 3D reconstruction, the contrast spread from T6-T10 to the costotransverse foramen. LESSONS: Our contrast imaging data provides valuable information about mechanism of ESPB from a living patient, and our report shows that ESPB can be a good option as a multimodal analgesia after lung lobectomy.

Cervical plexus block.

Cervical plexus blocks (CPBs) have been used in various head and neck surgeries to provide adequate anesthesia and/or analgesia; however, the block is performed in a narrow space in the region of the neck that contains many sensitive structures, multiple fascial layers, and complicated innervation. Since the intermediate CPB was introduced in addition to superficial and deep CPBs in 2004, there has been some confusion regarding the nomenclature and definition of CPBs, particularly the intermediate CPB. Additionally, as the role of ultrasound in the head and neck region has expanded, CPBs can be performed more safely and accurately under ultrasound guidance. In this review, the authors will describe the methods, including ultrasound-guided techniques, and clinical applications of conventional deep and superficial CPBs; in addition, the authors will discuss the controversial issues regarding intermediate CPBs, including nomenclature and associated potential adverse effects that may often be neglected, focusing on the anatomy of the cervical fascial layers and cervical plexus. Finally, the authors will attempt to refine the classification of CPB methods based on the target compartments, which can be easily identified under ultrasound guidance, with consideration of the effects of each method of CPB.

Alternative way to find sacral hiatus for blind caudal block - Based on 3D pelvis CT anthropometry: A retrospective study.

The aim of this study is to develop an alternative way to locate the sacral hiatus for blind caudal block from the anthropometrical data measured on 3D pelvic CT. The intersection of the line connecting two sacral cornua and the midline is considered the ideal point (IP) for caudal block. The mean length from the coccyx tip to the IP was measured using 3D pelvic CT images in 30 men and 30 women and was 6.5 cm and 6.0 cm, respectively. For the conventional method group, we used the conventional equilateral triangle method to find the sacral hiatus, which was named conventional method group needling point (CNP). For the experimental method group, the point 6.5 cm or 6.0 cm (mean length from the coccyx tip to the IP) away from the coccyx tip was called the experimental method group needling point (ENP). Drawing the three points of the IP, CNP, and ENP on the same patient's 3D pelvic CT, we compared the distance from the IP to the CNP with the distance from the IP to the ENP. We propose that the experimental method is comparable to the conventional method in locating the sacral hiatus, which is crucial for a successful caudal block procedure. Anthropometric measurements and virtual comparative test between two methods were done on the 3D pelvis CT. In men, the distance from the CNP to the IP was 0.8 ±â€¯0.5 cm in the conventional method group, while the distance from the ENP to the IP was 0.5 ±â€¯0.4 cm in the experimental method group (p < 0.05). In women, the same distances were 1.5 ±â€¯0.8 cm and 0.7 ±â€¯0.3 cm, respectively (p < 0.05). In conclusion, finding a point of 6.5 cm from the coccyx tip in men and 6.0 cm in women could be an alternative way to find the sacral hiatus for blind caudal block.

Abdominal peripheral nerve block as the only anesthetic technique for totally extraperitoneal endoscopic inguinal hernia repair: Two case reports.

RATIONALE: Laparoscopic totally extraperitoneal (TEP) inguinal hernia repair is a rapidly evolving, minimally invasive treatment modality for inguinal hernia. Compared with open hernia repair, this method requires a smaller incision, has cosmetic advantages, and facilitates rapid recovery and early return to daily activities because of less postoperative pain. Because general anesthesia is essential for TEP hernia repair, it cannot be performed on patients who have an increased risk of developing complications when placed under general anesthesia. PATIENT CONCERNS: We report 2 cases of single-port laparoscopic TEP (SP TEP) that were performed using only an abdominal peripheral nerve block (PNB) at our institute. General anesthesia and neuraxial block were dangerous for both patients owing to severe heart failure and severe chronic obstructive pulmonary disease (COPD). DIAGNOSES: They were diagnosed with an inguinal hernia requiring surgery. INTERVENTIONS: Hence, the anesthesiologist and surgeon decided to attempt a PNB to avoid complications from general anesthesia and allow faster recovery. An ipsilateral transversus abdominis plane block as well as a rectus sheath block and inguinal canal block were administered via ultrasound guidance. OUTCOMES: The patients did not report any pain, and no rescue drug was administrated. The operation times were 65 and 62minutes in patients 1 and 2, respectively. No intraoperative complications were noted. Patient 1 was discharged the day after the surgery, whereas patient 2 was discharged on the same day as the surgery. LESSONS: TEP hernia repair using abdominal PNB anesthesia seemed to be a safe and feasible technique without causing any additional complications. However, the use of abdominal PNB anesthesia alone for TEP hernia repair as an alternative to general anesthesia requires further investigation using a larger cohort.

Intraoperative dexmedetomidine sedation reduces the postoperative agitated behavior in elderly patients undergoing orthopedic surgery compared to the propofol sedation.

BACKGROUND: Postoperative agitation or confusion is one of the symptoms of hyperactive delirium in elderly patients. We retrospectively evaluated the incidence of postoperative abnormal psychomotor behavior in elderly surgical patients according to the use of different intraoperative sedative agents: dexmedetomidine vs. propofol. METHODS: The medical records of 855 elderly patients, who underwent orthopedic surgery with regional anesthesia between July 2012 and September 2015, were divided into two groups, the dexmedetomidine group (N.=263) and the propofol group (N.=592), and then evaluated. Agitated behavior was evaluated as the primary outcome, and patient-, surgery-, and anesthesia-related factors, as well as other postoperative complications, were investigated as secondary outcomes. To reduce the risk of confounder effects between the two groups, 263 patients were selected from the propofol group by propensity score matching. RESULTS: In the propensity-score-matched groups, the incidence of agitated behavior was lower in the dexmedetomidine group compared with the propofol group (6 [2.3%] vs. 17 [6.5%], P=0.027). All pre- and postoperative laboratory values were comparable between the two groups, including hemoglobin, hematocrit, platelet count, C-reactive protein, electrolytes, creatinine, glomerular filtration rate, and albumin. Moreover, intraoperative propofol sedation, older age, higher Charlson comorbidity index, and hip surgery were found to be significant factors for the occurrence of agitation. CONCLUSIONS: This study suggests that intraoperative dexmedetomidine sedation, as compared with propofol sedation, may have a greater beneficial effect in reducing agitated behavior in elderly patients undergoing orthopedic surgery with regional anesthesia.

Anti-allodynic effect of theoesberiven F in a vincristine-induced neuropathy model.

Allodynia is a main symptom of the peripheral neuropathy induced by vincristine treatment. Theoesberiven F, a combination of Melilotus extract and proxyphylline, is currently used for the treatment of inflammatory conditions due to its potent anti-inflammatory and analgesic properties. The anti-allodynic effect of theoesberiven F on mechanical and cold allodynia in a rat model of vincristine-induced neuropathy was investigated in the present study. Intraperitoneal vincristine injections were administered to male Sprague-Dawley rats at a dose of 0.1 mg/kg/day over 12 days (5 days of injection, a 2-day cessation and 5 days of injection). Rats that were allodynic following the vincristine injections were randomly allocated into four groups. Normal saline was injected into rats in the control group. Theoesberiven F (0.1, 0.25 and 0.5 mg/kg) was administered to rats in the three experimental groups, respectively. Mechanical and cold allodynia were measured at preadministration and at 15, 30, 60, 90, 120, 150 and 180 min following the intraperitoneal administration of normal saline or theoesberiven F. The decreased paw withdrawal threshold induced by vincristine injection was increased by theoesberiven F administration. The increased withdrawal frequency to cold stimuli developed by vincristine was reduced by theoesberiven F administration. The results of this study suggest that the administration of theoesberiven F may be beneficial in reducing the mechanical and cold allodynia developed during vincristine treatment.

Efficacy of ultrasound-guided fascia iliaca compartment block after hip hemiarthroplasty: A prospective, randomized trial.

BACKGROUND: The fascia iliaca compartment block (FICB) provides an analgesic effect in patients with femur fractures. However, the postoperative pain after hip surgery is different from that after femur fracture, because of the difference in the degree and location of tissue trauma. Whether FICB provides effective postoperative analgesia in patients undergoing total hip arthroplasty is not well understood. Moreover, there is no prospective randomized study to evaluate FICB as a postoperative analgesia in hemiarthroplasty. Therefore, we performed a randomized and prospective study to determine the effect of FICB after hemiarthroplasty. The objective of this study was to compare the opioid consumption between patients who received intravenous patient-controlled analgesia (PCA) with and without FICB. METHODS: Twenty-two patients aged 70 to 90 years who underwent bipolar hemiarthroplasty for femoral neck fracture were recruited and allocated randomly into 2 groups: FICB group (n = 11) and Non-FICB group (n = 11). All patients received spinal anesthesia with 10 mg of 0.5% hyperbaric bupivacaine. After surgery, the FICB was conducted using a modified technique with 0.2% ropivacaine (40 mL) under ultrasonographic guidance, and the intravenous PCA was administered to patients in both groups in the separate block room. The PCA was set up in the only bolus mode with no continuous infusion. The visual analog scale (VAS) and the opioid consumption were noted at 4, 8, 12, 24, and 48 hours postoperatively. RESULTS: The VAS was similar in both groups. The fentanyl requirement at 4, 8, and 12 hours was low in the FICB group. The total amount of fentanyl required in the first 24 hours was 246.3 µg in the FICB group and 351.4 µg in the Non-FICB group. No patient developed any residual sensory-motor deficit during the postoperative period. Patients in the Non-FICB group had nausea (n = 2), and pruritus (n = 1), and 1 patient had nausea in the FICB group during postoperative 2 days. CONCLUSION: The FICB has a significant opioid-sparing effect in first 24 hours after hemiarthroplasty. This suggests that FICB is an effective way for multimodal analgesia in hip surgery.