The Effect of Preprocedural Low-Dose Ketamine for Pain and Anxiety in Patients during Thoracic Epidural Catheterization.

Background and Objectives: Thoracic epidural catheterization (TEC) can be both uncomfortable and fearful for patients when performed awake with the thought that the procedure may be painful. The aim of this study was to assess the effect of low-dose intravenous ketamine administration on pain and anxiety during the TEC procedure. Materials and Methods: Sixty patients were randomly divided into two groups to receive intravenous (IV) placebo (Group P) and IV low-dose (0.15 mg/kg) ketamine (LDK) (Group K) 3 min before the procedure in a double-blind manner. A visual analog scale (VAS) was used to measure anxiety (VAS-A) and pain (VAS-P) scores. Vital parameters were monitored before premedication (T1), 20 min after premedication (T2), during skin anesthesia (T3), during TEC (T4), and 5 min after TEC (T5). VAS-A values were recorded at T1, T3, T4, and T5 periods, and VAS-P levels were noted at T3, T4, and T5 periods. Results: During TEC (T4), both VAS-P and VAS-A were significantly lower in Group K (p < 0.001). The mean VAS-A value was 10.6 mm lower, and the mean VAS-P value was 9 mm lower in Group K than in Group P at the T4 time point. Additionally, the mean VAS-P value was 7.7 mm lower in Group K compared to Group P at the T3 time point (p < 0.001). Both groups showed a statistically significant difference in VAS-A measurements when compared at their respective time points (p < 0.001). However, only Group P demonstrated a statistically significant difference in VAS-P measurements (p < 0.001). VAS-P values remained stable in Group K. The number of patients who did not recall the procedure was significantly higher in Group K (p < 0.001). Furthermore, the number of patients who would consent to the same procedure in the future was significantly higher in Group K (p = 0.007). Conclusions: A preprocedural LDK (0.15 mg/kg) can effectively prevent anxiety and pain experienced by patients during the TEC procedure. Administration of LDK may provide a more comfortable procedure process without causing ketamine-induced side effects (hemodynamic, respiratory, and psychological).

Comparison of combined deep and superficial serratus anterior block with thoracic paravertebral block for postoperative pain in patients undergoing video-assisted thoracoscopic surgery.

Background/aim: Thoracic paravertebral block (TPVB) is a well-established procedure for the management of postoperative pain in patients undergoing video-assisted thoracic surgery (VATS). In recent years, there have been studies suggesting that fascial plane blocks may be an alternative to TPVB. The objective of our study was to determine the efficacy of combined deep and superficial serratus anterior block (C-SAPB) as an alternative to TPVB in the management of postoperative analgesia in VATS. Materials and methods: The patients were divided into two groups: the TPVB group and the C-SAPB group. Both groups were administered the same dose of local anesthetics. Multimodal analgesia was achieved for the groups. The primary outcome measure was visual analog scale (VAS) pain scores recorded within the first 48 h of the postoperative period in each group. The secondary outcomes were analgesic requirement, rescue analgesics, complications rate, and postoperative patient satisfaction. Results: Thirty patients with C-SAPB and 30 patients with TPVB were analysed. VAS rest and VAS coughing scores were similar between the groups (p > 0.05). Demographic and side effect conditions, total morphine use, additional analgesic needs, vital parameters, block procedure time, and patient satisfaction were also similar between the groups (p > 0.05). Additionally, although block application times were comparable, the time was slightly shorter in C-SAPB. Conclusion: Similar analgesic efficacy was observed between C-SAPB and TPVB. TPVB maintains its place among the first choices in VATS. The efficacy of C-SAPB is comparable to that of TPVB. While the duration of C-SAPB application is not a significant factor, the brief nature of the procedure and its straightforward administration suggest that it may be an effective method.

Comparison of the effects of one-level and bi-level pre-incisional erector spinae plane block on postoperative acute pain in video-assisted thoracoscopic surgery; a prospective, randomized, double-blind trial.

BACKGROUND: This prospective, randomized, double-blind trial aimed to compare the postoperative analgesic efficacy of One-Level pre-incisional erector spinae plane block (ESPB) and Bi-Level pre-incisional ESPB in patients undergoing video-assisted thoracic surgery (VATS). METHODS: This pilot trial was conducted between April 2022 and February 2023 with sixty patients. The patients were randomly divided into two groups. In One-Level ESPB Group (n = 30) block was performed at the thoracal(T)5 level with the 30 ml 0.25% bupivacaine. In the Bi-Level ESPB Group (n = 30) block was performed at T4 and T6 levels by using 15 ml of 0.25% bupivacaine for each level. In the postoperative period, 50 mg dexketoprofen every 12 h and 1 g paracetamol every 8 h were given intravenously (IV). Patient-controlled analgesia (PCA) prepared with morphine was applied to the patients. 0.5 mg/kg of tramadol was administered via IV for rescue analgesia. Visual analog scale (VAS) scores were recorded in the postoperative 1st, 2nd, 4th, 12th, 24th, and 48th -hours. The need for additional analgesics and side effects were recorded. In two groups, patients' demographics and postoperative hemodynamic data were recorded. RESULTS: VAS scores at resting were statistically significantly higher at the 1st (p: 0.002) and 4th -hour (p: 0.001) in the One-Level ESPB. When the groups were evaluated in terms of VAS coughing scores, the 4th -hour (p: 0.001) VAS coughing scores results were found to be statistically significantly higher in the One-Level ESPB group. In terms of VAS values evaluated during follow-up, the rates of VAS coughing score > 3 values were found to be statistically significantly lower in the Bi-Level ESPB group (p: 0.011). There was no statistically significant difference between the groups in terms of side effects, morphine consumption, and additional analgesic use (p > 0.05). CONCLUSIONS: Adequate analgesia was achieved in the early postoperative period in the group treated with Bi-Level ESPB with similar morphine consumption and side effects. This may be an advantage, especially in the early postoperative period when the pain is quite intense.

The effect of body mass index on thoracic paravertebral block analgesia after video-assisted thoracoscopic surgery; a prospective interventional study.

BACKGROUND: To investigate the effects of body mass index (BMI) on intensity postoperative pain in patients who underwent thoracic paravertebral block (TPVB) for postoperative analgesia after video-assissted thoracoscopic surgery (VATS). METHODS: Patients aged 18-80 years, ASA I-III, and BMI 18-40 kg/m2 who underwent elective VATS were included in the study. The patients were divided into 3 groups according to their BMI levels. TPVB was performed under ultrasound-guidance at the fifth thoracic vertebrae, and 30 ml of 0.25% bupivacaine was injected. The patient-controlled analgesia (PCA) was performed by using morphine and multimodal analgesia was performed. As a rescue analgesic agent, 0.5 mg/kg tramadol was given to patients intravenously when a score of visual analog scale (VAS) at rest was ≥ 4. The primary outcome was determined as VAS scores at rest and cough. Secondary outcomes were determined as postoperative morphine consumption, additional analgesic requirement, and side effects. RESULTS: The post-hoc test revealed that the VAS resting scores at the 4th hour (p: 0.007), 12th hour (p: 0.014), and 48th hour (p: 0.002) were statistically significantly lower in Group I compared to Group II. Additionally, VAS resting scores were also statistically significantly lower in Group I compared to Group III at all time points (p < 0.05). Similarly, the post-hoc test indicated that the VAS coughing scores at the 4th hour (p: 0.023), 12th hour (p: 0.011), and 48th hour (p: 0.019) were statistically significantly lower in Group I compared to Group II. Moreover, VAS coughing scores were statistically significantly lower in Group I compared to Group III at all time points (p < 0.001). Furthermore, there were statistically significant differences in terms of additional analgesic use between the groups (p: 0.001). Additionally, there was a statistically significant difference in terms of morphine consumption via PCA and morphine milligram equivalent consumption between the groups (p < 0.001). CONCLUSIONS: Higher postoperative VAS scores with TPVB applied in obese patients and the consequent increase in additional analgesics and complications require more specific postoperative management in this patient group.

Comparison of analgesic efficacy of different local anesthetic volumes for erector spinae plane block in thoracotomy patients; a prospective randomized trial.

BACKGROUND: Erector spinae plane block (ESPB) is a thoracic wall block that has been used frequently in recent years. It was aimed to compare the analgesic efficacy of bupivacaine in different volumes for ESPB in patients undergoing thoracotomy. METHODS: Patients who were in the age range of 18 to 65 years, ASA I-III, had a body mass index (BMI) of 18-30 kg/m2 and were undergoing thoracotomy were included in the study. Patients were assigned to ESPB with 30 ml 0.25% bupivacaine (Group-1) or ESPB with 20 ml 0.25% bupivacaine (Group-2) groups according to the analgesia protocol. In the postoperative care unit, intravenous morphine was administered via a patient-controlled analgesia pump for 24 h. A paracetamol dose of 1 g every 8 h and a dexketoprofen dose of 50 mg twice daily were administered iv for multimodal analgesia. RESULTS: Visual analog scale (VAS) resting scores, the 1st (p = 0.001), 2nd (< 0.001), 4th (< 0.001), 8th (< 0.001), 16th (< 0.010), 24th (< 0.044), and 48th (< 0.005)-hour VAS resting results were found to be statistically significantly higher in the 20 ml group than the 30 ml group. VAS cough scores were statistically significantly higher in the 20 ml group at the 1st (< 0.003), 2nd (< 0.001), 4th (< 0.001), 8th (< 0.001), 16th (< 0.004), 24th (< 0.031), and 48th (< 0.009)-hour. Morphine consumption, and additional analgesic use were found to be statistically significantly higher in the 20 ml group than in the 30 ml group (p < 0.001, p = 0.001, respectively). There was no statistically significant difference between the groups in terms of side effects (p > 0.05). CONCLUSIONS: The results of ESPB applied with 20 ml and 30 ml of local anesthetic before the surgical incision in thoracotomy patients showed that the use of 30 ml of local anesthetic provided more effective analgesia. In addition, similar side-effect rates show that 30 ml of local anesthetic can be used safely.

Non-intubated video-assisted thoracoscopic surgery under combination of erector spinae plane block and thoracic paravertebral block.

BACKGROUND: The use of anesthetics and analgesic drugs and techniques in combination yields a multimodal effect with increased efficiency. In this case series, we aimed to evaluate the anesthetic effect of the thoracic paravertebral block (TPVB) and erector spinae plane block (ESPB) combination in patients, who underwent non-intubated video-assisted thoracoscopic surgery (NIVATS). METHODS: Medical records of 16 patients, who underwent NIVATS for wedge resection under the combination of ESPB and TPVB were reviewed retrospectively. Demographic data of patients, duration of the sensory block, amount of the anesthetic agent used for premedication and sedo-analgesia, any presence of perioperative cough, operative times, postoperative visual analog scale (VAS) scores in the postoperative follow-up period, the need for additional analgesia, and patient satisfaction were reviewed. RESULTS: Of the patients included in the study, 12 were men and 4 were women. The mean age was 48.6 years and the mean BMI was 24.7 kg/m2. The mean time needed for the achievement of the sensorial block was 14 min and the mean skin-to-skin operative time was 21.4 min. During the procedure, patients received 81.5 ± 27.7 mg of propofol and 30 ± 13.6 micrograms of remifentanil infusions, respectively. The mean dose of ketamine administered in total was 58.1 ± 12.2 mg. Only 2 patients needed an extra dose of remifentanil because of recurrent cough. No patients developed postoperative nausea vomiting. During the first 24 h, the VAS static scores of the patients were 3 and below, while VAS dynamic scores were 4 and below. Morphine consumption in the first postoperative 24 h was 13.2 mg. CONCLUSIONS: In conclusion, combined ESPB and TPVB with added intravenous sedo-analgesia in the presence of good cooperation between the surgical team and the anesthesiologist in the perioperative period can provide optimal surgical conditions including the prevention of cough in NIVATS. It is not sufficient to state that this combination is superior to alone ESPB or alone TPVB, as it is a preliminary study with a limited number of cases.

The Effect of Erector Spinae Plane Block and Combined Deep and Superficial Serratus Anterior Plane Block on Acute Pain After Video-Assisted Thoracoscopic Surgery: A Randomized Controlled Study.

OBJECTIVE: The study aimed to compare the analgesic effects of erector spinae plane block (ESPB) and a combination of the deep and superficial serratus anterior plane block (C-SAPB) methods in patients who underwent video-assisted thoracoscopic surgery (VATS). DESIGN: A prospective, randomized study. SETTING: At a single-center, high-volume, tertiary thoracic surgery center. PARTICIPANTS: Adult patients undergoing VATS. INTERVENTIONS: Ultrasound-guided ESPB and C-SAPB. MEASUREMENTS AND MAIN RESULTS: Patients were assigned to ESPB (group 1) or C-SAPB (group 2) groups according to the analgesia protocol. All interventions were performed with single-needle insertion. Multimodal analgesia was achieved via paracetamol, dexketoprofen, and intravenous morphine for both study groups. Pain scores were assessed by the visual analog scale (VAS). Morphine consumption, rescue analgesic requirements, and side effects were recorded postoperatively for 24 hours. The primary outcome was determined as VAS scores at rest and coughing. The secondary outcomes of this study were postoperative morphine consumption and the requirement of rescue analgesics. There was no statistically significant difference between the groups in terms of VAS scores (p > 0.05). The groups also were similar in terms of demographic characteristics, side effects, morphine consumption, additional analgesic use, and duration of block procedures (p > 0.05). There also were comparable results in terms of hemodynamic variables (p > 0.05). CONCLUSIONS: Patients who underwent VATS receiving ESPB or C-SAPB had similar pain scores, opioid consumption, and side effects during the first postoperative 24 hours. At the same time, the fact that the duration of the block procedure was similar in both groups showed that multisite serratus anterior plane block can be an effective alternative method in analgesic treatment after VATS, considering that it easily can be applied. The authors here think that C-SAPB can be a good alternative to ESPB because the outcomes of both applications are similar, and C-SAPB easily can be seen and applied with ultrasound.

Do not invade, just support.

BACKGROUND: Since the first attempts for ventilation, there have been significant changes in terms of the size of devices, ventilation techniques, and technology. In time, invasive methods and huge devices were replaced by non-invasive methods and small and portable devices. Increased use of non-invasive methods was followed by enrichment of literature on the topic. This study aimed to determine the evolution of non-invasive ventilation (NIV) literature and predict future trends. MATERIALS AND METHODS: We used the Web of Science database for search. To include all papers, we searched multiple keywords, including "non-invasive ventilation, non-invasive positive pressure, continuous positive airway pressure, CPAP, NIV." All articles that meet the criteria published in the respiratory system, critical care medicine, anesthesiology, and emergency medicine fields during 1975-2020 were determined. RESULTS: We made bibliometric analyses of 2847 original articles. However, the limited number of articles in the first years, published by year, exceeded a hundred with the new millennium and continues to increase. We predict that 233 and 334 papers will be published in 2021-2025, respectively. Most active countries were United States of America (576, 20.2 %), France (395, 13.8 %), Italy (293, 10.2 %). The most used keywords in NIV papers are non-invasive ventilation, continuous positive airway pressure and obstructive sleep apnea. CONCLUSION: NIV technology and new devices are developing day by day. In addition, new areas of use have been defined by doctors. All these bring about new and different studies on NIV. We believe the present study that summarized the history and development of NIV literature will guide the authors who want to study this area (Tab. 4, Fig. 8, Ref. 19).

Serratus Posterior Superior Intercostal Plane Block for Rescue Analgesia After Clavicle Fracture Surgery: A Case Report.

Clavicle fractures are the most common fractures of the shoulder girdle. Due to the complex sensory innervation of the clavicle, patients' pain scores are high in the postoperative period. Therefore, multimodal regional analgesia techniques provided by the combination of cervical plexus and/or brachial plexus have been successfully applied in the literature. Serratus posterior superior intercostal plane block (SPSIPB) is a plane block that provides anterolateral chest wall analgesia. It provides analgesia between C3 and T10. In this case report, our experience with SPSIPB, which we applied for rescue analgesia in a patient who underwent surgery for a clavicle fracture, is described.

Comparison of efficacy of erector spinae plane block, thoracic paravertebral block, and erector spinae plane block and thoracic paravertebral block combination for acute pain after video-assisted thoracoscopic surgery: a randomized controlled study.

BACKGROUND: The aim of this study was to compare the efficacy of ultrasound-guided erector spinae plane block (ESPB), thoracic paravertebral block (TPVB), and ESPB and TPVB combination on acute pain after video-assisted thoracoscopic surgery (VATS). METHODS: Seventy-five patients were evaluated (three groups: ESPB, TPVB, or combined ESPB-TPVB [comb-group], each 25 patients). All interventions were performed with the same volume of bupivacaine (20 mL). Primary outcome was VAS (Visual Analog Scale) during the first 24 hours. Secondary outcomes were postoperative morphine consumption and rescue analgesic requirements. RESULTS: VAS during rest and coughing of TPVB was significantly higher compared to other groups (in all measurements compared to comb-group; and in all but 24 hours measurement to ESPB) ESPB and comb-group had similar VAS in all measurements (e.g., median VAS in ESPB, TPVB and comb-group at 8th hour: 3-4-2 [P=0.014] during coughing and 2-3-1 in rest [P<0.001], respectively). Morphine consumption was statistically significantly higher in TPVB than comb-group (ESPB: 15.28 mg; TPVB: 19.30 mg; ESPB+TPVB: 10.00 mg) (P=0.003). Rescue analgesic requirement was statistically significantly higher in the TPVB group than comb-group (P=0.009). CONCLUSIONS: ESPB alone and the combination of ESPB and TPVB provided superior primary outcomes compared to TPVB alone. Morphine and rescue analgesic consumptions were higher in TPVB than comb-group. ESPB and comb-group were statistically similar in terms of primary and secondary outcomes. This study is one of the first studies using the combination of ESBP and TPVB for pain after VATS, and shows the efficacy of this approach.

Is there a correlation between preoperative neutrophil-to-lymphocyte, platelet-to-lymphocyte, and lymphocyte-to-monocyte ratios and postoperative pain in video-assisted thoracoscopic surgery?

ABSTRACT: Many thoracic surgery procedures are now performed with video-assisted thoracoscopic surgery (VATS). Postoperative pain is a common condition in patients undergoing VATS. In this study, we aimed to investigate whether neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR) are effective in evaluating postoperative pain in patients undergoing VATS.This prospective observational study was performed between March 2021 and September 2021 at a tertiary thoracic surgery center. The study included patients who had undergone elective VATS. Preoperative and postoperative NLR, PLR, LMR, hemogram values and postoperative visual analog scale (VAS) were recorded.A total of 105 patients were analyzed. A positive correlation was observed between postoperative monocyte, neutrophils and VAS resting and VAS cough levels in the early postoperative period. No significant correlation was found between preoperative and postoperative NLR, PLR, and LMR values and VAS rest and VAS cough values. When compared to the preoperative period, a negative correlation was found between the change in the postoperative LMR value and the VAS rest and VAS cough values in the early postoperative period.When compared to the preoperative period, the change in postoperative neutrophil, postoperative monocytes, and postoperative LMR values in patients undergoing VATS in thoracic surgery can be used as a guide in the objective evaluation of postoperative acute pain. It is the belief of the researchers that comprehensive new studies on this subject will contribute significantly to the determination of objective criteria in postoperative pain evaluation.

Effects of hydrodissection on anesthesia characteristics in ultrasound guided infraclavicular brachial plexus blockade.

BACKGROUND: The development of ultrasonography technology and its widespread application have increased peripheral nerve block applications, especially in limb surgeries, since it reduces complication rates and increases success rates in peripheral nerve block applications. However, even experienced physicians need to direct a large number of needles and injections for adequate local anesthetic spread, which can cause accidental vascular puncture and local anesthetic systemic toxicity. Such complications can be prevented by hydrodissection and a safer and successful anesthesia can be provided to patients in this study, it was aimed to investigate the effects of hydrodissection on anesthesia characteristics in the infraclavicular brachial plexus blockade. MATERIALS AND METHODS: Ninety patients were included in our study after approval by the Ethics Committee. These patients were randomly divided into 2 groups (Group I: Infraclavicular brachial plexus blockade with normal method and Group II: infraclavicular brachial plexus blockade with hydrodissection). After obtaining patient consent, monitoring and vascular access were provided. Group I patients were mixed with 30 mL of local anesthetic mixture (15 mL of distilled water and 15 mL of 0.5% bupivacaine), and Group II patients were treated with 15 mL of distilled water by hydrodissection and 15 mL of 0.5% bupivacaine anesthesia resident. Block characteristics were evaluated and recorded every 5 minutes for the first 30 minutes by a blinded observer. The sensory block score was 7, the total score was 14 or above, and the block was considered successful, and the patient was ready for surgery. Postoperative block removal times, analgesia, and complications were evaluated and recorded. RESULTS: A significant difference was found between the sensory and motor block onset times and postoperative VAS scores between the normal and hydrodissection groups (P < .05). There were no significant differences in terms of block application times, postoperative block removal times, and complications between the groups. CONCLUSION: In this study, it has been shown that hydrodissection in peripheral nerve blocks does not lag in terms of block success and characteristics compared to normal methods, whereas anesthetists with less experience in peripheral nerve block experience obtain safer and more successful results in practice.

The Incidence of Itching in Thoracic Epidural Morphine Applications: Can Laboratory Parameters Be Effective in Predicting Itching?

Background Epidural morphine, a powerful analgesic, also causes significant itching in patients. This study aimed to determine the incidence of thoracic epidural morphine-induced pruritus (EMIP) after thoracotomy and to investigate preoperative laboratory parameters for predicting itching in patients who received thoracic epidural morphine (TEM). Methods The patients were divided into two groups. The itching (+) group consists of patients who developed itching (n=31). The no-itching (-) / control group (n=31) was selected among patients who did not develop itching after TEM. Preoperative hemogram values, neutrophil/lymphocyte rate (NLR), platelet/lymphocyte rate (PLR), lymphocyte/monocytes rate (LMR), preoperative and postoperative alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase (ALP), gamma-glutamyl transferase values, and whether there was itching in the first 48 hours after surgery were determined. Results The incidence of thoracic EMIP after thoracotomy was 7.9%. While preoperative and postoperative ALP was found to be lower in patients with itching compared to those without itching. The cut-off value for preoperative/postoperative ALP was 84.5/53. Decreased white blood cell (WBC) could predict pruritus with a borderline statistical significance. Conclusions The incidence of EMIP after thoracotomy was lower compared to other literature data. Infusion of morphine only into the epidural area may cause a low incidence of EMIP. Laboratory parameters ALP and WBC can predict EMIP, but other hemogram parameters, NLR, LMR, and PLR cannot predict EMIP.

The effectiveness of ARISCAT Risk Index, other scoring systems, and parameters in predicting pulmonary complications after thoracic surgery.

The Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) risk index, which is frequently used in nonthoracic surgery, may not be sufficient to predict postoperative pulmonary complications (PPCs). We aimed to evaluate the effectiveness of the ARISCAT risk index, ASA, preoperative albumin level, neutrophil/lymphocyte ratio (NLR), and other parameters in predicting PPCs after thoracic surgery. Patients undergoing elective thoracic surgery with 1-lung ventilation (OLV) were prospectively analyzed. Demographic data, ARISCAT score, ASA, Nutritional Risk Score-2002, NLR, white blood cell counts, albumin, hemoglobin levels, intraoperative complications, postoperative average visual analogue scale (VAS) score for pain at the 24th-hour, the length of stay in the postoperative intensive care unit, chest tube removal time, postoperative complications, and discharge time were recorded. Patients were assessed for morbidity and mortality on the 90th-day. 120 patients' data were analyzed. PPCs developed in 26 patients. The development of PPCs was statistically significant in patients with high ARISCAT scores (P = .002), high ARISCAT grades (P = .009), and ASA III (P = .002). The albumin level was statistically significantly lower in patients who had mortality within 3 months (P = .007). When scoring systems and laboratory parameters were evaluated together, patients with high ARISCAT grade, Albumin < 35g/L, and ASA III had significantly higher development of PPCs (P = .004). ARISCAT risk index and ASA were found to be significant in predicting PPCs after thoracic surgery. They were also valuable when evaluated in combination with preoperative albumin levels. Additionally; age, male gender, duration of surgery, and duration of OLV were also found to be associated with PPCs.

Comparison of Thoracic Epidural Analgesia and Thoracic Paravertebral Block Applications in the Treatment of Acute Pain After Thoracotomy in Geriatric Patients.

Background Thoracic epidural analgesia (TEA) and thoracic paravertebral block (TPVB) are commonly used in geriatric patients for pain management after thoracotomy. In this study, we aimed to investigate the effect of TEA and TPVB on postoperative analgesia in geriatric patients who underwent thoracotomy. Methodology Postoperative analgesia follow-up files of patients over 65 years of age who underwent thoracotomy were analyzed retrospectively. Patient's demographic data, diagnosis, type of surgery, postoperative 24-hour mean arterial pressure (MAP), heart rate, respiratory rate, peripheral oxygen saturation, static/dynamic visual analog scale (VAS) scores, need for additional analgesics, global pain assessment, and side effects such as nausea, vomiting, hypotension, bradycardia, and respiratory depression were examined. The patients were divided into two groups: those treated with TEA (Group 1) and those treated with TPVB (Group 2). Results There was no statistically significant difference between the groups in terms of demographic data (p > 0.05). MAP in the TEA group was statistically significantly lower than in the second and sixth-hour TPVB group (p = 0.008, p < 0.001). VAS static scores in the TEA group were statistically significantly lower at 30 minutes (p = 0.001), and at one, two, six, twelve, and twenty-four hours compared to the TPVB group (p < 0.001, except at 30 minutes). VAS dynamic scores were statistically significantly lower in the TEA group at 30 minutes, and at one, two, six, twelve, and twenty-four hours compared to the TPVB group (p < 0.001). There was no statistically significant difference between the groups in terms of nausea, vomiting, hypotension, and bradycardia (p > 0.05). The use of additional analgesics in the TEA group was statistically significantly lower than in the TPVB group (p < 0.001). Conclusions More effective postoperative analgesia results with stable hemodynamic conditions were observed in geriatric patients who underwent TEA for thoracotomy compared to TPVB. Regarding side effects, although there was a lower incidence in TPVB, this was not statistically significant when compared to TEA. TEA, as a component of the multimodal analgesia approach, can be accepted as a safe and effective method in the elderly patient group who underwent thoracotomy.

Postoperative Analgesic Efficacy of Thoracic Paravertebral Block and Erector Spinae Plane Block Combination in Video-Assisted Thoracic Surgery.

Background The combination of a thoracic paravertebral block (TPVB) and erector spinae plane block (ESPB) has not been investigated. We aimed to evaluate the effects of the combination of TPVB and ESPB particularly on postoperative pain scores in patients undergoing video-assisted thoracic surgery (VATS). Methods From January 1, 2021, to March 1, 2021, 13 patients older than 18 years who underwent combined ESPB and TPVB for analgesic treatment after elective VATS were included in the study. Standard anesthesia induction was performed for all patients, and the block was performed in the lateral decubitis position before surgery. Using the in-plane technique, an ultrasound (US)-compatible 22-gauge, 8-mm nerve block needle was introduced 2-3 cm lateral to the spinous process of the T6 vertebra and advanced in the caudocranial direction. Fifteen (15) ml of 0.25% bupivacaine was administered and pleural depression was observed. The same needle was withdrawn from the paravertebral space and advanced into the interfascial plane above the transverse process and below the erector spinae muscle at the T5 level. Then, 15 ml of 0.25% bupivacaine was injected. Results The combination of TPVB and ESPB was performed in 13 patients. The mean age was 44.3 (21-68) years. The mean body mass index (BMI) was 23.21 (16.9-35.9) kg/m2. Postoperative 24 hours morphine consumption was 24.5 (16-42) mg. In three cases, visual analog scale (VAS) scores at rest were ≥4; therefore, tramadol (25 mg, IV) was given as an additional analgesic. Nausea and vomiting were observed in only one case in the early postoperative period. Conclusions As a new technique, the combination of TPVB and ESPB in this preliminary study provided effective postoperative pain management along with the use of morphine in acceptable quantities. Large-scale, randomized-controlled, and comparative studies are needed to demonstrate the efficacy of the combination of TPVB and ESPB.

The Effect of Different Types of Laryngeal Mask Airways on Sound Quality: A Prospective Randomized Study.

Background Although the deterioration in sound quality is not as much as endotracheal intubation, it can also be seen after the use of laryngeal mask airway (LMA). The aim of this study is to investigate the effects of different LMA types on voice performance. Methods This study included 88 patients aged 18-80 years, whose surgical procedure was not planned to take longer than 120 minutes. In the acoustic voice analysis, F0, jitter%, and shimmer% were examined. In addition, the Voice Handicap Index (VHI)-30 questionnaire has completed an evaluation of voice quality. The patients were randomly divided into two groups (I-gel LMA [n=44]; Classic LMA [n=44]) according to the closed envelope method. Results A total of 88 patients were included in the study. Demographic data of the patients were statistically similar between the groups (p > 0.05). The changes in the preoperative and postoperative F0, jitter, and VHI-30 values in the I-gel group were statistically significant (p: 0.002, p: 0.001, p < 0.001). Shimmer values were not significantly different (p: 0.762). In the classical LMA group, preoperative and postoperative F0, jitter, shimmer, and VHI-30 values were statistically significantly different (p: 0.001, p: 0.012, p: 0.036, p < 0.001). Conclusion I-gel LMA and classic LMA negatively affect voice performance in the preoperative and postoperative periods. This situation was also observed in the VHI-30 index test. However, when this situation was evaluated in terms of shimmer analysis, the decrease in voice quality in the early postoperative period was more limited in the I-gel group.

Is there a relationship between body mass index and postoperative pain scores in thoracotomy patients with thoracic epidural analgesia?

ABSTRACT: Postoperative efficacy of thoracic epidural analgesia (TEA) following thoracic surgery may vary in patients with different body mass index (BMI) values, regardless of the success of the method. This study aimed to investigate the effects of BMI on postoperative pain scores in patients who underwent thoracotomy with TEA.After obtaining the ethical committee approval (Date: May 11, 2021, Number: 2012-KEAK-15/2305) the data of 1326 patients, who underwent elective thoracic surgery in high volume tertiary thoracic surgery center between January 2017 and January 2021, were analyzed retrospectively. Patients between the age of 18 and 80 years, who underwent thoracotomy and thoracic epidural catheterization (TEC), and who were assigned American Society of Anesthesiologists I to III physical status were included to the study. Of the 406 patients, who underwent a successful TEC, 378 received postoperative analgesia for 72 hours. Visual analog scale (VAS) scores of these patients were evaluated statistically. Based on BMI, patients were categorized into the following 5 groups: Group I: BMI < 20 kg/m2, Group II: BMI = 20 to 24.9 kg/m2, Group III: BMI = 25 to 29.9 kg/m2, Group IV: BMI = 30 to 34.9 kg/m2, and Group V: BMI ≥ 35 kg/m2.There were no statistically significant differences in TEC success across different BMI groups (P > .05). Catheter problems and VAS scores significantly increased with higher BMI values in the postoperative 72-hours period (P < .05). Rates of rescue analgesic use were higher in BMI groups of 30 toto 34.9 kg/m2 and ≥35 kg/m2 compared to the other BMI groups.This study revealed that higher BMI in patients may increase VAS scores, who administered TEA for pain management following thoracotomy. This correlation was supported by the increased need for additional analgesics in patients with high BMI. Therefore, patients with high BMI values would require close monitoring and follow-up.

What Is the Minimum Effective Volume of Local Anaesthetic Applied in Brachial Plexus Blockage With an Axillary Approach Under Ultrasonography Guidance?

Peripheral nerve blocks with the use of ultrasonography (USG) allow visualisation of both the structures and nerves and make the block administrations safe, quick, and comfortable. However, few publications concerning the minimum local anesthetic (LA) volume are capable of providing blocks. This study aimed to find the minimum effective LA volume in brachial plexus blockage administrations with an axillary approach accompanied by ultrasonography in hand, elbow, and forehand operations. Materials and Method The study included a total of 55 patients (classified as American Society of Anesthesiologists (ASA) I-II) who underwent hand surgery by administering USG-guided axillary brachial plexus blockage. The ulnar, median, and radial nerves were located, and the minimum effective LA volume was investigated starting with a total of 21 ml of bupivacaine 0.5%. After accomplishing the blockage, the volume was decreased by 0.5 ml for each nerve. Block administration time, block onset times, anesthesia times, and time to first analgesic requirement were recorded. Results The minimum effective LA volume for each nerve was 2.5 ml for a total of 7.5 ml. In comparing block administration times, there were no differences between high or low volume groups. It was found that sensory block onset time was 17 minutes for 7.5 ml and 11 minutes for 21 ml; sensory block regression time was six hours for 7.5 ml and 10.4 hours for 21 ml, respectively. This regression was statistically significant. The first analgesic requirement was 5.8 - 16.6 hours, respectively, for each group. Conclusion In the administration of an USG-guided axillary block, sufficient anesthesia can be achieved by administering 2.5 ml of bupivacaine 0.5% for each nerve. However, it might be kept in mind that motor and sensory block onset time will be extended and regression time and time to the first analgesic requirement will be shorter with this volume. In addition, more advanced studies must be done for the determination of the optimum volume which can be used.