Ultrasound-guided transversalis fascia plane block or transversus abdominis plane block for recovery after caesarean section: A randomised clinical trial.

BACKGROUND: Caesarean section is a widely performed surgical procedure that often results in moderate-to-severe postoperative pain. If left untreated, this pain can lead to short-term and long-term consequences. Transversalis fascia plane (TFP) block and transversus abdominis plane (TAP) block are among the regional anaesthesia techniques employed for managing pain after a caesarean section. OBJECTIVE: We aimed to compare the impact of these two blocks on the quality of recovery in patients undergoing elective caesarean section under spinal anaesthesia. DESIGN: A single-centre, double-blind, randomised trial. SETTINGS: Operating room, postanaesthesia recovery unit, and ward in a tertiary hospital. PARTICIPANTS: Ninety-three patients (ASA 2 to 3) were recruited. After exclusion, 79 patients were included in the final analysis: 40 in the TFP block group and 39 in the TAP block group. INTERVENTIONS: After surgery, participants received either TFP block (20 ml 0.25% bupivacaine for each side) or TAP block (20 ml 0.25% bupivacaine for each side). MAIN OUTCOME MEASURES: The primary outcome was the difference in obstetric quality of recovery 11-Turkish (ObsQoR-11T) scores between groups. Secondary outcomes included pain scores, opioid consumption and incidence of opioid-related complications. RESULTS: The mean ObsQoR-11T score was higher in the TFP block group compared with the TAP block group (97.13 ±â€Š6.67 points vs. 87.10 ±â€Š9.84 points, respectively; P  < 0.001). The pain scores in the TFP block group were slightly lower between postoperative 4 and 24 h. The mean total morphine consumption was 15.08 ±â€Š2.21 mg in the TFP block group and 22.21 ±â€Š3.04 mg in the TAP block group ( P  < 0.001). More patients required rescue analgesia between 4 and 8 h in the TAP block group [2.00 (5.00%) vs. 9.00 (23.08%), P  = 0.02]. No significant differences were observed between groups in terms of opioid-related side effects. CONCLUSION: TFP block used for analgesic purposes yielded a better quality recovery period than TAP block and also reduced opioid consumption. TRIAL REGISTRATION: Clinicaltrials.gov (NCT05999981). VISUAL ABSTRACT: http://links.lww.com/EJA/B6 .

Obturator Nerve Block Performed Blinded Versus by Ultrasound-guidence for Transurethral Resection of Bladder Tumors: A Randomized Controlled Trial.

PURPOSE: The primary outcome of this study is to compare the success rates of ONB techniques performed either with ultrasound guidance or with the blind technique. The second outcome is to compare the incidences of perioperative bleeding and the presence of recurrent tumors in the control cystoscopy performed in the 3rd postoperative month in both groups. MATERIALS AND METHODS:  The study was conducted in the urology operating room of Mugla Sitki Kocman Training and Research Hospital between December 2019 and March 2023. A total of 122 patients were included in the study: 22 females with a mean age of 56.63 ± 12.99 years and 100 males with a mean age of 63.18 ± 8.00 years. In one group (group 1), ONB was performed under ultrasound guidance by the same anesthesiologist, and in another group (group 2), ONB was performed blindly based on anatomical signs by the same urologist. RESULTS: Adductor muscle contraction was not observed in 53 patients (91.4%) in group 1 and in 49 patients (76.6%) in group 2 (p = 0.027). CONCLUSION: The success rate of ONB was higher when using an ultrasound-guided technique than when using a blind technique.

Comparison of the genotoxicity of propofol and desflurane using the comet assay in the lymphocytes of patients who underwent lumbar discectomy: A randomized trial.

OBJECTIVES: To compare the genotoxic effects of desflurane and propofol using comet assay in patients undergoing elective discectomy surgery. METHODS: This was a randomized controlled study. Patients who underwent elective lumbar discectomy under general anesthesia with propofol or desflurane were included in the study. Venous blood samples were obtained at 4 different time points: 5 minutes before anesthesia induction (T1), 2 hours after the start of anesthesia (T2), the first day after surgery (T3), and the fifth day following surgery (T4). Deoxyribonucleic acid damage in lymphocytes was assessed via the comet assay. RESULTS: A total of 30 patients, 15 in each group, were included in the analysis. The groups were similar in terms of age and gender distribution. There were no significant differences in demographics, duration of surgery, total remifentanil consumption, and total rocuronium bromide consumption. The comet assay revealed that head length, head intensity, tail intensity, tail moment at T1 were similar in the desflurane and propofol groups. Head length, tail length and tail moment measured in the desflurane group at T4 were significantly higher compared to the propofol group. Tail lengths of the desflurane group at T1, T2 and T3 were significantly higher than the corresponding values in the propofol group. CONCLUSION: Propofol and desflurane do not appear to induce DNA damage in lymphocytes. However, when the quantitative data were compared, it was determined that propofol had relatively lower genotoxic potential than desflurane.ClinicalTrials.gov Reg. No.: NCT05185167.

Standardizing nomenclature in regional anesthesia: an ASRA-ESRA Delphi consensus study of upper and lower limb nerve blocks.

BACKGROUND: Inconsistent nomenclature and anatomical descriptions of regional anesthetic techniques hinder scientific communication and engender confusion; this in turn has implications for research, education and clinical implementation of regional anesthesia. Having produced standardized nomenclature for abdominal wall, paraspinal and chest wall regional anesthetic techniques, we aimed to similarly do so for upper and lower limb peripheral nerve blocks. METHODS: We performed a three-round Delphi international consensus study to generate standardized names and anatomical descriptions of upper and lower limb regional anesthetic techniques. A long list of names and anatomical description of blocks of upper and lower extremities was produced by the members of the steering committee. Subsequently, two rounds of anonymized voting and commenting were followed by a third virtual round table to secure consensus for items that remained outstanding after the first and second rounds. As with previous methodology, strong consensus was defined as ≥75% agreement and weak consensus as 50%-74% agreement. RESULTS: A total of 94, 91 and 65 collaborators participated in the first, second and third rounds, respectively. We achieved strong consensus for 38 names and 33 anatomical descriptions, and weak consensus for five anatomical descriptions. We agreed on a template for naming peripheral nerve blocks based on the name of the nerve and the anatomical location of the blockade and identified several areas for future research. CONCLUSIONS: We achieved consensus on nomenclature and anatomical descriptions of regional anesthetic techniques for upper and lower limb nerve blocks, and recommend using this framework in clinical and academic practice. This should improve research, teaching and learning of regional anesthesia to eventually improve patient care.

Rider sitting position widens lumbar intervertebral distance: a prospective observational study

Abstract Background: Reduced lumbar lordosis may make the process of identifying the intervertebral distance easier. The primary aim of this study was to measure the L3-L4 intervertebral space in the same patients undergoing spinal anesthesia in three different sitting positions, including the classic sitting position (CSP), hamstring stretch position (HSP) and rider sitting position (RSP). The secondary aim was to compare ultrasonographic measurements of the depth of the ligamentum flavum and intrathecal space in these three defined positions. Methods: This study is a single-blinded, prospective, randomized study. Ninety patients were included in final analysis. the patients were positioned on the operating table in three different positions to perform ultrasonographic measurements of the spinal canal. The intervertebral distance (IVD), the distance between the skin and the ligamentum flavum (DBSLF) and the intrathecal space (IS) were measured in the L3 -L4 intervertebral space in three different positions. Results: The RSP produced the largest mean distance between the spinous processes. The RSP yielded a significantly larger IVD than did the CSP (p < 0.001) and HSP (p < 0.001). The DBSP was larger in the CSP than in the HSP (p = 0.001). The DBSLF was significantly larger in the RSP than in the HSP (p = 0.009). Conclusions: Positioning the patient in the RSP significantly increased the intervertebral distance between L3 -L4 vertebrae compared to the CSP and HSP, suggesting easier performance of lumbar neuraxial block.

The Shining Star of the Last Decade in Regional Anesthesia Part-II: Interfascial Plane Blocks for Cardiac, Abdominal, and Spine Surgery.

The sine qua non of enhanced recovery after surgery protocols designed to improve the perioperative experiences and outcomes of patients is to determine the most appropriate analgesia management. Although many regional techniques have been tried over the years in this purpose, interfacial plane blocks have become more popular with the introduction of ultrasound technology into daily practice and they have great potential to support effective postoperative pain management in many surgeries. The current article focuses on the benefits, techniques, indications, and complications of interfascial plane blocks applied in cardiac, abdominal, and spine surgeries.

Comparing ultrasound-guided modified thoracoabdominal nerves block through perichondrial approach with oblique subcostal transversus abdominis plane block for patients undergoing laparoscopic cholecystectomy: a randomized, controlled trial.

BACKGROUND: Laparoscopic cholecystectomy(LC) causes significant postoperative pain. Oblique subcostal transversus abdominis plane(OSTAP) block was described for postoperative analgesia, especially for upper abdominal surgeries. Modified thoracoabdominal nerves block through perichondrial approach(M-TAPA) block is a new technique defined by the modification of the thoracoabdominal nerves through perichondrial approach (TAPA) block, in which local anesthetics are delivered only to the underside of the perichondral surface. The primary aim of this study was to evaluate the effect of M-TAPA and OSTAP blocks as part of multimodal analgesia on postoperative opioid consumption in patients undergoing LC. METHOD: The present study was designed as a randomized, controlled, prospective study. Seventy-six adult patients undergoing LC were randomly assigned to receive either bilaterally M-TAPA or OSTAP block after the induction of anesthesia and before surgery using bupivacaine 0.25%, 25 ml. The primary outcome was assessed as postoperative 24 h opioid consumption, between groups were compared. Secondary outcomes were Numerical Rational scale(NRS) scores, time to first opioid analgesia, patient recovery, using the Quality of Recovery-15 (QoR-15) scale, nausea and vomiting, sedation score, metoclopramide consumption, and evaluating the analgesic range of dermatome. RESULTS: The mean tramadol consumption at the postoperative 24th hour was higher in the group OSTAP than in group M-TAPA (P = 0.047). NRS movement score at 12th hour was statistically significantly lower in group M-TAPA than in group OSTAP (P = 0.044). Dermatomes showed intense sensory analgesia between T7-11 in both groups, and it was determined that there was proportionally more involvement in the group M-TAPA. There were no differences between the groups in terms of other results. CONCLUSIONS: After the LC surgery, ultrasound-guided M-TAPA block effectively reduced opioid consumption, postoperative pain, and QoR-15 scores similar to OSTAP block. CLINICAL TRIAL REGISTRATION: The study was registered prospectively at clinicaltrials.gov (trial ID: NCT05108129 on 4/11/2021).

Rider sitting position widens lumbar intervertebral distance: a prospective observational study.

BACKGROUND: Reduced lumbar lordosis may make the process of identifying the intervertebral distance easier. The primary aim of this study was to measure the L3...L4 intervertebral space in the same patients undergoing spinal anesthesia in three different sitting positions, including the classic sitting position (CSP), hamstring stretch position (HSP) and rider sitting position (RSP). The secondary aim was to compare ultrasonographic measurements of the depth of the ligamentum flavum and intrathecal space in these three defined positions. METHODS: This study is a single-blinded, prospective, randomized study. Ninety patients were included in final analysis. the patients were positioned on the operating table in three different positions to perform ultrasonographic measurements of the spinal canal. The intervertebral distance (IVD), the distance between the skin and the ligamentum flavum (DBSLF) and the intrathecal space (IS) were measured in the L3...L4 intervertebral space in three different positions. RESULTS: The RSP produced the largest mean distance between the spinous processes. The RSP yielded a significantly larger IVD than did the CSP (p < 0.001) and HSP (p < 0.001). The DBSP was larger in the CSP than in the HSP (p = 0.001). The DBSLF was significantly larger in the RSP than in the HSP (p = 0.009). CONCLUSIONS: Positioning the patient in the RSP significantly increased the intervertebral distance between L3...L4 vertebrae compared to the CSP and HSP, suggesting easier performance of lumbar neuraxial block.

Comparison of orexin-A and neurofilament light chain levels in patients with relapsing-remitting multiple sclerosis: a pilot study.

Background and purpose: Multiple sclerosis is an autoimmune disease of the central nervous system, with myelin degeneration and Relapsing-Remitting Multiple Sclerosis (RRMS) as the most common type. The aim of this study was to determine the levels of Neurofilament Light Chain (NFL) and Orexin-A (OXA) in patients with RRMS and compare it with healthy control subjects' data. Methods: In this case-control study of 61 subjects, serum and cerebrospinal fluid samples were collected from 23 RRMS patients and 38 healthy control subjects. NFL and OXA levels were determined in cerebrospinal fluid and serum samples using enzyme-linked immunosorbent assay kits. Self-reported questionnaires were also administered to evaluate fatigue severity and impact. Receiver operating characteristic curve analysis was used to determine the optimal cut-off value of NFL and OXA. Results: The NFL and OXA concentrations in cerebro-spinal fluid of RRMS patients were significantly higher than those of the control group (p < 0.001), but no sig-nificant difference was found in the serum concentrations (p = 0.842, p = 0.597, respectively). The cut-off values were found to be 1.194 ng/ml for NFL and 77.81 pg/ml for OXA in cerebrospinal fluid. A positive correlation was found between the Expanded Disability Status Scale and Epworth Sleepiness Scale in RRMS patients (ρ = 0.49, p = 0.045). Conclusion: These results suggest that increased levels of both NFL and OXA in cerebrospinal fluid reflect neuronal destruction in RRMS. Further research of neurodegeneration should focus on neuropeptides to determine the possible roles in RRMS pathogenesis.

Erector Spinae Plane Block for anesthesia of open ventral hernia repair in severe Ankylosing Spondylitis.

Ankylosing spondylitis is a challenging disease for anesthesiologist due its airway and axial skeleton involvement. A 55 years old male patient suffering from severe ankylosing spondylitis, admitted to Anesthesiology Clinic. He was planned to receive a midline open ventral hernia repair. We decided to perform bilateral ultrasound-guided erector spinae plane (ESP) block at the level of T8 with 0.4 mcg kg-1 hour-1 dexmedetomidine sedation for complete anesthesia of the surgery. We performed ESP block with 25 mL of 0.25% bupivacaine and repeated the same procedure at the contralateral side. Twenty minutes later, the skin incision was started. We didn't need to apply an additive anesthetic or analgesic drug throughout the surgery. ESP block provides analgesia for different dermatomes by effecting ventral rami and rami communicantes of spinal nerves depending on the level of injection site. When performed between T7-T9 levels, it has been reported to effectively attenuate postoperative pain after different types of surgeries.

Standardizing nomenclature in regional anesthesia: an ASRA-ESRA Delphi consensus study of abdominal wall, paraspinal, and chest wall blocks.

BACKGROUND: There is heterogeneity in the names and anatomical descriptions of regional anesthetic techniques. This may have adverse consequences on education, research, and implementation into clinical practice. We aimed to produce standardized nomenclature for abdominal wall, paraspinal, and chest wall regional anesthetic techniques. METHODS: We conducted an international consensus study involving experts using a three-round Delphi method to produce a list of names and corresponding descriptions of anatomical targets. After long-list formulation by a Steering Committee, the first and second rounds involved anonymous electronic voting and commenting, with the third round involving a virtual round table discussion aiming to achieve consensus on items that had yet to achieve it. Novel names were presented where required for anatomical clarity and harmonization. Strong consensus was defined as ≥75% agreement and weak consensus as 50% to 74% agreement. RESULTS: Sixty expert Collaborators participated in this study. After three rounds and clarification, harmonization, and introduction of novel nomenclature, strong consensus was achieved for the names of 16 block names and weak consensus for four names. For anatomical descriptions, strong consensus was achieved for 19 blocks and weak consensus was achieved for one approach. Several areas requiring further research were identified. CONCLUSIONS: Harmonization and standardization of nomenclature may improve education, research, and ultimately patient care. We present the first international consensus on nomenclature and anatomical descriptions of blocks of the abdominal wall, chest wall, and paraspinal blocks. We recommend using the consensus results in academic and clinical practice.

Rhomboid Intercostal Block for Analgesia of Multiple Rib Fractures in an Infant.

Rhomboid intercostal block (RIB) is a novel plane block, which is thought to provide analgesia for both the anterior and the posterior hemithorax. Herein, we represent the successful usage of ultrasound-guided RIB on an infant patient to provide analgesia for multiple rib fractures and insertion of a chest tube. A 10-month-old, 8 kg, male infant was scheduled for insertion of a chest tube. The patient had right sided pneumothorax and multiple rib fractures from T4 to T8 after a car crush. Following induction of anaesthesia, he was placed in lateral decubitis position and RIB was performed with 8mL 0.125% bupivacaine. A paediatric epidural catheter was placed into the interfacial plane for post-operative intermittent local anaesthetic injection as a part of multimodal analgesia with administration of intravenous paracetamol 60 mg. The postoperative pain assessment was conducted with FLACC scale at the post-operative 10th minute, 30th minute, 1st, 2nd, 6th, 12th and 24th hours, and the Face, Legs, Activity, Cry, Consolability scale score was 2 at all time-points. Ultrasound-guided RIB provided effective analgesia for insertion of a chest tube and attenuation of pain due to multiple rib-fractures in our infant patient.

Early and late blood flow changes in the brachial artery following brachial plexus block.

BACKGROUND: A nerve block causes various hemodynamic changes in the vessel system. The primary objective of the present study is to examine the volume flow values in the brachial artery in the early and late period following an infraclavicular brachial plexus block. The secondary objective is to evaluate arterial diameter, forearm temperature and other Doppler ultrasound measurements in the late period. METHODS: An infraclavicular brachial plexus block was performed in ASA class I-II patients aged 18-65 years who were to undergo upper extremity surgery. Hemodynamic measurements and the measurement of the Doppler ultrasound parameters at five minutes before and five, 15, 30 minutes, 24, 48 hours after the block. RESULTS: Volume flow was increased at the 30th min after nerve block. A 47.17% decrease in the collected volume flow data was noted between the 30th min and 24th hour, and this change was found to be statistically significant. It is also worth highlighting the decrease in volume flow at 24 hours and 48 hours, which became closer to the volume flow value at time 0, but was still relatively higher than the value at time 0. CONCLUSIONS: The increase in volume flow following a change in the flow morphology after an infraclavicular nerve block persists for at least 24 hours. This may be the explanation for clinical advantage in all types of surgery and in particular after fractures, graft and reimplantation surgery.