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BACKGROUND: The nociception level (NOL) index is a quantitative parameter derived from physiological signals to measure intraoperative nociception. The aim of this systematic review and meta-analysis was to evaluate if NOL monitoring reduces intraoperative opioid use compared to conventional therapy (opioid administered at clinician discretion). METHODS: This meta-analysis comprises randomized clinical trials comparing NOL-guided opioid administration to conventional therapy in adult patients undergoing any type of surgery. A systematic search of PubMed, Scopus, and CENTRAL databases was conducted. The primary outcome was intraoperative opioid consumption and the effect estimate of the NOL index was measured using the standardized mean difference (SMD) where 0.20 is considered a small and 0.80 a large effect size. A random-effects model with Hartung-Knapp-Sidik-Jonkman adjustment was applied to estimate the treatment effect. Heterogeneity was explored clinically and statistically (using the inconsistency I² statistic, prediction intervals, and influence analysis). The quality (certainty) of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) guidelines methodology. RESULTS: This review comprised 9 trials (519 patients). The intraoperative opioid SMD (NOL monitoring versus conventional therapy) was -0.26 (95% confidence interval [CI], -0.82 to 0.30; P = .31; low certainty of evidence). We observed substantial clinical (intraoperative opioid regimens) and statistical heterogeneity with the I² statistic being 86% (95% CI, 75%-92%). The prediction interval was between -1.95 and 1.42 indicating where the SMD between NOL and conventional therapy would lie if a similar study were conducted in the future. CONCLUSIONS: This meta-analysis does not provide evidence supporting the role of NOL monitoring in reducing intraoperative opioid consumption.
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The Greater Auricular Nerve (GAN), a branch of the cervical plexus, is used to provide anesthesia or pain relief in the ear and neck region. This case report details the use of a GAN block in a 71-year-old male patient with basal cell carcinoma on his right auricular helix. Due to multiple comorbidities (myocardial infarction resulting in a cardiac stent, hypertension), regional anesthesia was preferred. We aim to share our experience with the GAN block for ear surgery.
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Anestesia de Conducción , Bloqueo Nervioso , Masculino , Humanos , Anciano , Oído Externo/cirugía , Oído Externo/inervación , Ultrasonografía , Ultrasonografía Intervencional/métodosRESUMEN
Objective: For patient safety, maintaining hemodynamic stability during surgical procedures is critical. Dynamic indices [such as systolic pressure variation (SPV) and pulse pressure variation (PPV)], have recently seen an increase in use. Given the risks associated with such invasive techniques, there is growing interest in non-invasive monitoring methods-and plethysmographic waveform analysis. However, many such non-invasive methods involve intricate calculations or brand-specific monitors. This study introduces the simple systolic ratio (SSR), derived from pulse oximetry tracings, as a non-invasive method to assess fluid responsiveness. Methods: This prospective observational study included 25 adult patients whose SPV, PPV, and SSR values were collected at 30-min intervals during open abdominal surgery. The SSR was defined as the ratio of the tallest waveform to the shortest waveform within pulse tracings. The correlations among SSR, SPV, and PPV were analyzed. Additionally, anaesthesia specialists visually assessed pulse oximetry tracings to determine fluid responsiveness using the SSR method. Results: Strong correlations were observed between SSR and both SPV (r = 0.715, P < 0.001) and PPV (r = 0.702, P < 0.001). Receiver operator curve analysis identified optimal SSR thresholds for predicting fluid responsiveness at 1.47 for SPV and 1.50 for PPV. A survey of anaesthesia specialists using the SSR method to visually assess fluid responsiveness produced an accuracy rate of 83%. Conclusion: Based on the strong correlations it exhibits with traditional markers, SSR has great potential as a clinical tool, especially in resource-limited settings. However, further research is needed to establish its role, especially as it pertains to its universal applicability across monitoring devices.
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Facioscapulohumeral muscular dystrophy (FSHD) is a muscular dystrophy that can affect individuals of all age groups. Its prevalence is reported to be 0.4-1 in 10,000 people. Because of the low occurrence of FSHD, anaesthetic management is primarily based on expert opinions, case reviews, or brief series. Here, we present the case of a 72-year-old woman with FSHD who underwent hip fracture (HF) surgery. To prevent respiratory compromise due to FSHD, we opted for lumbar-sacral plexus block. To the best of our knowledge, there is no information in the literature regarding the use of combined lumbar-sacral plexus block in patients with FSHD undergoing HF surgery.
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Scapulothoracic arthrodesis (STA) surgery is performed to stabilize the scapula in patients with facioscapulohumeral dystrophy (FSHD). Postoperative pain could be a major problem even while using erector spinae plane block (ESPB). We performed a preoperative ESPB with an intraoperative ESPB catheter, but rescue analgesia was needed for pain in the periscapular area in the postoperative period. The patient's pain score was reduced by applying an ultrasound-guided dorsal scapular nerve (DSN) and long thoracic nerve (LTN) block. Selective DSN and LTN blocks can be effective in enhancing postoperative analgesia in STA surgery.
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Analgesia , Nervios Torácicos , Humanos , Manejo del Dolor , Dolor Postoperatorio/tratamiento farmacológico , ArtrodesisRESUMEN
Objective: Peroral endoscopic myotomy (POEM) has proven to be a successful treatment method for achalasia in both adult and pediatric patients. Yet, there is a lack of evidence for anaesthetic management of pediatric patients who underwent POEM procedure. In this study, we aim to present perioperative and postoperative management strategies for pediatric patients with achalasia from in anaesthesia aspect. Methods: Medical records were reviewed for 16 pediatric patients at a single center who underwent POEM procedure for achalasia between 2017 and 2020. Patients' data regarding demographics, preoperative diet, body mass index, perioperative monitoring and vitals, airway management, anaesthesia maintenance, mechanical ventilation settings duration of recovery, length of stay, pain management and adverse events were evaluated. Results: The study cohort included 7 female and 9 male patients with a mean age of 5.5 years. Anaesthesia maintenance was provided with 0.8-1.2 minimum alveolar concentration sevoflurane in a 40-60% O2-air mixture, Remifentanil infusion and bolus doses of Rocuronium. The median age was 3 years for patients ventilated in pressure controlled ventilation mode and 10 years in volume controlled ventilation mode. Respiration rate and minute ventilation were adjusted to maintain end tidal carbon dioxide (ETCO2) below 45 mmHg. Needle decompression was applied for 14 patients (87.5%) for treatment of capnoperitoneum. The mean procedure duration and recovery room duration were 66 (±22.9) minutes and 62 (±21) minutes, respectively. Postoperative pain management is provided with paracetamol and tramadol in total 8 patients (50%). There was no adverse event during postoperative period and all patients discharged in a mean time of 3 days. Conclusion: POEM has demonstrated encouraging outcomes in terms of safety and effectiveness in pediatric patients. Due to challenging nature of the pediatric patients, it is important to acknowledge that the procedure requires specialized anaesthesia management. Management of perioperative complications of increased ETCO2 requires understanding the physiologic results of pneumo-mediastinum and pneumo-peritoneum. Beside the known anaesthetic management strategies, a tailored approach should be adopted for each patient. Further investigations should be conducted to develop standardized management.
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BACKGROUND: This study aims to compare the effects of 8 mmHg and 12 mmHg pneumoperitoneum (PNP) pressures on operative, postoperative, and anesthesiological parameters in robot-assisted laparoscopic radical prostatectomy (RARP). METHODS: In this prospective study, 43 patients undergoing RARP performed by a single experienced surgeon were randomly assigned to either the low-pressure group (8 mmHg - Group I) or the standard-pressure group (12 mmHg - Group II). We evaluated the operative and postoperative parameters from both urological and anesthesiological perspectives. All patients were treated using the AirSeal® insufflation system. RESULTS: No statistically significant differences were observed between the groups in terms of console time, estimated blood loss, time to first flatus, or hospital length of stay. PNP was increased due to bleeding in six patients in the 8 mmHg group and two patients in the 12 mmHg group. Except for the heart rate measured five minutes after the initial incision, there were no observed differences between the groups in terms of blood pressure, ventilation, and administered medications. The heart rate was significantly lower in Group I (54.4 vs. 68.8, p=0.006). Additionally, during the surgery, the number of manipulations performed by the anesthesiologists, including drug administrations and ventilator management, was significantly lower in Group I (6.1 vs. 9.6, p=0.041). CONCLUSION: In RARP, while the 8 mmHg PNP pressure does not demonstrate differences in operative parameters compared to the 12 mmHg pressure, it offers the advantage of requiring fewer anesthetic interventions, thus minimizing the impact on cardiovascular and respiratory systems.
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Neumoperitoneo Artificial , Prostatectomía , Procedimientos Quirúrgicos Robotizados , Humanos , Prostatectomía/métodos , Masculino , Estudios Prospectivos , Persona de Mediana Edad , Neumoperitoneo Artificial/métodos , Procedimientos Quirúrgicos Robotizados/métodos , Anciano , Laparoscopía/métodos , Presión , Neoplasias de la Próstata/cirugíaRESUMEN
BACKGROUND: Postoperative pain continues to represent an important problem even after minimally invasive robotic-assisted laparoscopic radical prostatectomy, which results in discomfort in the postoperative period and sometimes prolongs hospital stays. Regional anesthesia and analgesia techniques are used in addition to systemic analgesics with the multimodal approach in postoperative pain management. Ultrasound-guided fascial plane blocks are becoming increasingly important, especially in minimally invasive surgeries. Another important cause of discomfort is urinary catheter pain. The present randomized controlled study investigated the effect of rectus sheath block on postoperative pain and catheter-related bladder discomfort in robotic prostatectomy operations. METHODS: This randomized controlled trial was conducted from March to August 2022. Written informed consent was obtained from all participants. Approval for the study was granted by the Clinical Research Ethics Committee. All individuals provided written informed consent, and adults with American Society of Anesthesiologists Physical Condition classification I to III planned for robotic prostatectomy operations under general anesthesia were enrolled. Following computer-assisted randomization, patients were divided into 2 groups, and general anesthesia was induced in all cases. Rectus sheath block was performed under general anesthesia and at the end of the surgery. No fascial plane block was applied to the patients in the non-rectus sheath block (RSB) group.Postoperative pain and urinary catheter pain were assessed using a numerical rating scale. Fentanyl was planned as rescue analgesia in the recovery room. In case of numerical rating scale scores of 4 or more, patients were given 50 µg fentanyl IV, repeated if necessary. The total fentanyl dose administered was recorded in the recovery room. IV morphine patient-controlled analgesia was planned for all patients. All patients' pain (postoperative pain at surgical site and urethral catheter discomfort) scores and total morphine consumption in the recovery unit and during follow-ups on the ward (3, 6, 12, and 24 hours) in the postoperative period were recorded. RESULTS: Sixty-one patients were evaluated. Total tramadol consumption during follow-up on the ward was significantly higher in the non-RSB group. Fentanyl consumption in the postanesthesia care unit was significantly higher in the non-RSB group. Total morphine consumption was significantly lower in the RSB group at 0 to 12 hours and 12 to 24 hours. Total opioid consumption was 8.81 mg in the RSB group and 19.87 mg in the non-RSB group. A statistically significant decrease in urethral catheter pain was noted in the RSB group at all time points. CONCLUSION: RSB exhibits effective analgesia by significantly reducing postoperative opioid consumption in robotic prostatectomy operations.
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Bloqueo Nervioso , Dolor Postoperatorio , Prostatectomía , Procedimientos Quirúrgicos Robotizados , Ultrasonografía Intervencional , Humanos , Prostatectomía/métodos , Prostatectomía/efectos adversos , Dolor Postoperatorio/prevención & control , Dolor Postoperatorio/tratamiento farmacológico , Masculino , Procedimientos Quirúrgicos Robotizados/efectos adversos , Procedimientos Quirúrgicos Robotizados/métodos , Bloqueo Nervioso/métodos , Persona de Mediana Edad , Ultrasonografía Intervencional/métodos , Anciano , Dimensión del Dolor , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/uso terapéutico , Recto del Abdomen/inervaciónRESUMEN
Editöre mektup.
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Neoplasias , Bloqueo Nervioso , Humanos , Fémur/cirugía , Extremidad Inferior , Fascia , Dolor PostoperatorioRESUMEN
Awake breast surgeries under nerve blocks have been a challenge for anaesthesiologists, and different block combinations have been used for surgery under sedation. Thoracic paravertebral block (TPVB) was thought to be sufficient alone for surgical anaesthesia of the breast. We performed a combination of TPVB, pectoralis nerve I block, and serratus anterior plane block for awake breast surgery in an elderly patient with serious comorbidities. Surgical anaesthesia was achieved, excluding skin incision. Any regional anaesthesia technique alone is not sufficient; rather, multiple thoracic wall blocks are needed for surgical anaesthesia of the breast.
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Diaphragmatic paralysis is one of the most important complications of upper extremity blocks and therefore limits the use of these blocks in patients with impaired respiratory functions. The appropriate block type should be selected by evaluating the location of the surgery and the risks of diaphragmatic paralysis of various blocks. In this case report, we aimed to evaluate the peripheral nerve blocks associated with diaphragmatic paralysis by presenting the anesthesia management of a patient with pneumonectomy planned for elbow arthroplasty due to elbow luxation.
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Anestesia de Conducción , Parálisis Respiratoria , Humanos , Codo/cirugía , Neumonectomía , Parálisis Respiratoria/cirugía , Extremidad Superior , Anestésicos LocalesRESUMEN
Facioscapulohumeral dystrophy (FSHD) typically affects the periscapular muscles, resulting in scapular winging. Scapulothoracic arthrodesis (STA) stabilizes the scapula to provide better movement for these patients. Analgesia regimen for FSHD patients who received a single-shot erector spinae plane block (ESPB) and a catheter at the area were retrospectively analyzed in this study. Patients were asked to rate their pain postoperatively and only 5 of 10 patients needed rescue analgesic. No complications occurred. Our experience suggests that continuous ESPB may be helpful for providing analgesia in FSHD patients undergoing STA.
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Distrofia Muscular Facioescapulohumeral , Bloqueo Nervioso , Humanos , Distrofia Muscular Facioescapulohumeral/cirugía , Estudios Retrospectivos , Rango del Movimiento Articular , Artrodesis/métodos , Dolor , Bloqueo Nervioso/métodosRESUMEN
BACKGROUND: Myofascial pain syndrome (MPS) is a condition characterized by trigger points in the taut bands of skeletal muscles, commonly affecting the trapezius, rhomboid, and supraspinatus muscles. Rhomboid intercostal block (RIB), an interfascial plane block used to assist perioperative analgesia might be a potential treatment option in MPS. OBJECTIVES: To investigate the short and long-term effects of ultrasound-guided RIB in reducing the severity of pain, disability, and improving quality of life in MPS patients with trigger points in the rhomboid muscle. STUDY DESIGN: Retrospective study. SETTING: Physical medicine and rehabilitation outpatient clinic in a university hospital. METHODS: Patients with a diagnosis of MPS who received ultrasound (US)-guided RIB between November 2021 and January 2022 were enrolled in this study. All patients reported pain lasting >= 3 months and severity >= 4/10 on numeric rating scale (NRS), without any comorbidities affecting the neuromuscular system. Trigger points in the rhomboid muscle were treated with US-guided RIB. Pain intensity was evaluated using a NRS at pre-treatment and one week, one month and one year after the injection. At pre-treatment, one month, and one year after treatment, self-administered neck pain and disability scale and Nottingham Health Profile were evaluated. RESULTS: A total of 23 patients were included in this study (5 men and 18 women, with an average age of 45). Pain severity was statistically significantly reduced in approximately 90%, 60-70%, and 50% of the chronic MPS patients at the first week, first month, and first year following injection, respectively. Disability scores improved significantly in 70% and 56% of those patients at the first month and first-year follow-up. Improvement in the quality of life was observed at the first month and maintained at the first-year follow-up. LIMITATIONS: The retrospective design of this study is a limitation. Due to the lack of a control group, this treatment option could not be compared with other treatments. CONCLUSIONS: Our study demonstrated that RIB might be an effective long-term treatment option for MPS in the reduction of pain and disability, improvement of quality of life and overall patient satisfaction.
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Fibromialgia , Síndromes del Dolor Miofascial , Masculino , Humanos , Femenino , Persona de Mediana Edad , Dimensión del Dolor , Estudios Retrospectivos , Estudios de Seguimiento , Calidad de Vida , Síndromes del Dolor Miofascial/terapia , Dolor , Ultrasonografía IntervencionalRESUMEN
COVID-19 pandemic has changed clinical practice significantly. Trying to avoid airway manipulation to reduce viral transmission favoured regional anaesthesia techniques over general anaesthesia when feasible. In this case report, we share the anaesthetic care of a 45-year-old male with a history of intensive care unit admission due to COVID, positive pressure ventilation, and ECMO support. The patient was diagnosed with cubital tunnel syndrome, and his treatment was successfully applied as surgical release under infraclavicular block. This case is discussed in relation to recent trends in anaesthesiology, regarding patients with COVID-19 history.
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INTRODUCTION: Maternal anti-SARS-CoV-2 Spike antibodies can cross the placenta during pregnancy, and neonates born to infected mothers have acquired antibodies at birth. Few studies reported data on the histopathological changes of the placenta during infection and placental infection. SARS-CoV-2 infection may cause impaired development of the placenta, thus predisposing maternal and fetal unfavorable outcomes. The prospective study aims to evaluate the risk of vertical transmission of SARS-CoV-2 and placental passage of anti-Spike antibodies as well as the impact of clinical severity on placental structures. METHODS: This is a prospective cohort study on 30 pregnant women infected by SARS-CoV-2 with their neonates. The demographic features and pregnancy outcomes were collected. Gross and microscopic examinations of the placentas were done. Maternal and umbilical cord sera were obtained at the time of delivery. Nasopharyngeal swabs were collected from neonates immediately after birth. RESULTS: The concentrations of total anti-SARS-CoV-2 Spike antibodies were higher in pregnant women with moderate to severe/critical disease. The maternal total anti-SARS-CoV-2 Spike levels were correlated with those of neonatal levels. The rate of placental abnormalities is high in the mothers with severe disease, and those with positive anti-SARS-CoV-2 IgM. All neonates had negative nasopharyngeal swabs for SARS- CoV-2 infections and all placentas were negative in immunohistochemical staining for Spike protein. DISCUSSION: The maternally derived anti-SARS-CoV-2 Spike antibody can transmit to neonates born to infected mothers regardless of gestational age. Our results indicated that the disease severity is associated with ischemic placental pathology which may result in adverse pregnancy outcomes.
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COVID-19/complicaciones , Enfermedades Placentarias/virología , Complicaciones Infecciosas del Embarazo/virología , SARS-CoV-2 , Adulto , Anticuerpos Antivirales/sangre , Anticuerpos Antivirales/inmunología , COVID-19/transmisión , Estudios de Cohortes , Femenino , Sangre Fetal/inmunología , Humanos , Inmunidad Materno-Adquirida/inmunología , Recién Nacido , Transmisión Vertical de Enfermedad Infecciosa , Placenta/química , Placenta/patología , Placenta/virología , Enfermedades Placentarias/patología , Embarazo , Complicaciones Infecciosas del Embarazo/patología , Resultado del Embarazo , Nacimiento Prematuro , Estudios Prospectivos , SARS-CoV-2/aislamiento & purificación , Índice de Severidad de la Enfermedad , Glicoproteína de la Espiga del Coronavirus/análisis , Glicoproteína de la Espiga del Coronavirus/inmunologíaRESUMEN
Epidural anesthesia and thoracic paravertebral blocks have been the mainstay of regional anesthesia for thoracic surgery for many years. Following introduction of ultrasound use during regional anesthesia practices, new blocks named interfascial plane blocks have been introduced into clinical practice. Although interfascial plane blocks fail to provide surgical anesthesia their contribution to providing analgesia is clinically important. In this review we mention the most commonly accepted blocks namely pectoral blocks, serratus anterior plane block, erector spinae plane block and rhomboid blocks.