The impact of moderate versus deep neuromuscular blockade on the recovery characteristics following laparoscopic sleeve gastrectomy: A randomized double blind clinical trial.

Background: Anesthesia with deep neuromuscular block for laparoscopic surgery may result in less postoperative pain with lower intra-abdominal pressure. However, the results in the existing literature are controversial. This study aimed to evaluate the effect of deep versus moderate neuromuscular block (NMB) on the postoperative recovery characteristics after laparoscopic sleeve gastrectomy (LSG) for weight loss surgery. Methods: This is parallel-group, randomized clinical trial. The study was conducted at a tertiary care center. Patients undergoing LSG were included. Patients were randomly assigned to either deep (post-tetanic count 1-2) or moderate (train-of-four 1-2) NMB group. The primary outcomes were numeric rating scale scores of the postoperative pain at rest and postoperative shoulder pain. The secondary outcomes were the length of hospital stay (LOS) and postoperative complications. The statistics were performed using StatsDirect statistical software (Version 2.7.9). Results: Two groups were identified: Group D (deep NMB), 29 patients, and Group M (moderate NMB), 28 patients. The BMI mean values for groups D and M were 44 and 45 kg/m2 respectively (P > 0.05). The mean durations of surgery for were 46.7 min and 44.1 min for groups M and D, respectively (P > 0.05). The mean train-of-four (TOF) counts were 0.3 and 0 for groups M and D, respectively (P < 0.05). The mean times from giving reversal agent to tracheal extubation (minutes) were 6.5 and 6.58 min for groups M and D, respectively (P > 0.05). In the recovery room, the means of pain scores were 3 and 4 for groups M and D, respectively (P > 0.05). Upon admission to the surgical ward, the median values of the pain score were non-significant (P > 0.05) (95% CI: 0.4-0.7). The opioid consumption in the recovery room was non-significant between both groups (P > 0.05) (95% CI: 0.3-0.6). Postoperative shoulder pain was non-significant between both groups (P > 0.05) (95% CI: 0.4-0.7). The median values of surgeon opinion of both groups were non-significant (P > 0.05). Regarding the LOS, the mean values of groups D and M were 1.20 and 1.21 days, respectively (P > 0.05). Conclusions: There was no significant difference between moderate and deep NMB techniques in terms of duration of the surgical procedure, postoperative pain, shoulder pain, and length of hospital stay. Further studies on a larger sample size are required to investigate the long-term recovery characteristics of patients with obesity undergoing LSG.

Foot health and quality of life among adults in Riyadh, Saudi Arabia: a cross-sectional study.

BACKGROUND: Foot conditions are frequent among the Saudi population. However, little is known regarding the effects of foot health on quality of life among the general Saudi population. This study aimed to assess foot health status, general health, and quality of life among the population of Riyadh using the Foot Health Status Questionnaire (FHSQ). METHODS: In this cross-sectional study, out of the total number of participants approached, using a preset questionnaire, by trained medical students to participate in this study, 398 met the inclusion criteria. The questionnaire started with an informed consent followed by a set of questions regarding the sociodemographic and past medical characteristics of the participants. Foot health and overall health were assessed using a FHSQ. RESULTS: A statistically significant positive correlation was observed between all the FHSQ domains, except for footwear. The strongest correlation was observed between foot pain and foot function, foot pain and general foot health, and foot function and general foot health. A statistically significant positive correlation was observed between general foot health and general health, vitality, social function. Our results also showed that foot pain, general foot health, vitality, and social function scores were significantly lower in women as compared to men. CONCLUSION: Significant positive correlation was observed between poor foot health and declining quality of life; thus, it is crucial to increase society's awareness of the importance of medical foot care and continuous follow-up and consequences if left unrecognized and untreated. This is a major domain that can improve the well-being and quality of life of a population.

Immediate Dialysis After Simultaneous Laparoscopic Peritoneal Dialysis Catheter Placement and Laparoscopic Inguinal Hernia Repair.

Background and Objectives: Peritoneal dialysis (PD) is an accepted renal replacement therapy for end-stage renal disease (ESRD). Managing inguinal hernia in patients with PD is not standardized. Thus, this study reported the outcomes of simultaneous laparoscopic peritoneal dialysis catheter (PDC) placement and transabdominal preperitoneal (TAPP) repair of inguinal hernia. Methods: Thirteen patients with chronic renal disease and inguinal hernia attending a tertiary hospital between May 1, 2016 and June 30, 2021 were evaluated for laparoscopic PDC placement. Concurrent laparoscopic inguinal herniorrhaphy and laparoscopic PDC placement were performed. Dialysate fluid was measured intraoperatively to the level below the incised peritoneum by 1 inch. The inflow and outflow was smooth without leakage. The amount was increased gradually in the two weeks after regular PD was obtained. Results: Laparoscopic PDC was inserted for 13 patients. Ten patients had unilateral hernia and two had bilateral inguinal hernia. Associated paraumbilical hernia was discovered in two patients. The median follow-up was 30 months. The measured safe amount of dialysate fluid intraoperatively was 400 - 600 mL. There was no death, intraoperative complication, or dialysate leakage. Three PDCs were removed owing to noncompliance. No hernia recurrence was observed. Conclusion: Simultaneous laparoscopic PDC placement and laparoscopic repair of inguinal hernia with immediate dialysis is a safe and feasible surgical technique. Utilizing minimally invasive surgery affords PDC placement and inguinal hernia repair simultaneously.

Efficacy of interspace between the popliteal artery and the capsule of the posterior knee (iPACK) block versus periarticular local infiltration analgesia after unilateral total knee arthroplasty: Prospective randomized control trial.

OBJECTIVES: To compare the efficacy of interspace between the popliteal artery and the capsule of the posterior knee (iPACK) block with periarticular local infiltration analgesia (LIA) to assess postoperative pain control and enhanced recovery after total knee arthroplasty (TKA). METHODS: This research was carried out at King Saud University Medical City, Riyadh, Saudi Arabia, from September 2020 to March 2021. Eighty Patients scheduled for elective unilateral TKA were randomized to receive either iPACK or periarticular LIA along with adductor canal block under spinal anesthesia. The primary outcome was postoperative pain score, and secondary outcomes included physical rehabilitation, duration of surgery, length of post-anesthesia care unit stay, hemodynamics, and length of hospital stay. RESULTS: The pain score during activity in iPACK group was significantly lower compared to LIA group at 4 hours postoperatively, but no significant difference was observed at 24 or 48 hours. The timed up and go test took significantly longer for patients in LIA group at 4, 24, and 48 hours compared to those in iPACK group. No significant differences in knee range of motion were observed between the 2 groups at any point. CONCLUSION: Based on our findings, iPACK block is an effective technique in reducing pain in the immediate postoperative period without affecting motor function, resulting in enhanced recovery following primary TKA.

High-resolution ultrasound as an aid in the diagnosis and treatment of post-brachioplasty injury to the medial brachial and the medial antebrachial nerves - Two case reports.

INTRODUCTION: Injury to the medial brachial and the medial antebrachial nerves may occur after brachioplasty and may lead to severe pain. We report on two cases to demonstrate that high-resolution ultrasound may be used as an aid in the diagnosis and treatment of post-brachioplasty injury to these small cutaneous nerves. CASE REPORTS: We report on two cases. The first case was a 29-year old female with severe arm pain secondary to a neuroma of the right medial brachial nerve. The diagnosis of a neuroma was done using high-resolution ultrasound and proximal nerve block led to immediate complete relief of pain. Recurrent but milder pain occurred and this was treated with multiple nerve blocks. The second case was a 34-year-old female with severe arm/forearm pain secondary to entrapment of the left medial antebrachial cutaneous nerve by a suture in the middle arm. The diagnosis was reached using high-resolution ultrasound and proximal nerve block led to immediate complete relieve of pain. Recurrent but milder pain occurred and this was treated by surgical nerve decompression. DISCUSSION: Previous literature confirms that high-resolution ultrasound can accurately identify small sensory nerves of the arm and forearm. CONCLUSION: We demonstrate that high resolution ultrasound may be used as an aid in the diagnosis and treatment of post-brachioplasty injury to the medial brachial and the medial antebrachial nerves. Proximal nerve block is extremely effective to relief the severe pain in these patients. However, recurrence of pain is expected and further management may be done by a trial of repeated injections or by surgical exploration.

Combined PENG and LFCN blocks for postoperative analgesia in hip surgery-A case report.

Total hip arthroplasty (THA) is considered an extremely painful procedure. Postoperative analgesic technique especially in an elderly with significant comorbidities is even more challenging. Pericapsular nerve group (PENG) block is a novel technique that has been described recently as an effective analgesic method for hip surgery. We report a case of a successful PENG and lateral femoral cutaneous nerve blocks for postoperative analgesia in THA.

A technique to identify the axillary nerve and its cutaneous branch for triceps nerve-to-deltoid nerve transfer. A case report.

INTRODUCTION: Triceps nerve-to-deltoid nerve transfer requires the identification of the axillary nerve in the quadrilateral space. This may be difficult especially for residents-in-training. The senior author is a Professor of Hand Surgery at a teaching institution and has devised a new technique of identification of the axillary nerve and its cutaneous branch using surface land-marks and on-table ultrasonography. CASE REPORT: The axillary nerve and the quadrilateral space is first identified using anatomical landmarks. The ultrasound probe is the used to identify the quadrilateral space and the axillary nerve which appears as hyper-echoic oval-shaped structure. The ultrasound probe is then moved to scan the cutaneous branch of the axillary nerve as it branches-off the main nerve trunk. Finally, the cutaneous branch is traced superficially till it becomes subcutaneous. This point is marked and the skin incision is made along this marked point. During surgery, the cutaneous branch is followed retrograde to the axillary nerve in the quadrilateral space. DISCUSSION: Ultrasound guidance for localization of various nerves is now routinely done by anesthetists in the Operating Room. This localization is used for nerve blocks and in patients with brachial plexus injuries. Hence, the ultrasound machine and the expertise are already available in the operating room; and no special arrangements with the Radiology Department are needed. CONCLUSION: A technique of identification of the cutaneous branch of the axillary nerve using anatomical landmarks and ultrasonography is described. The localization is accurate and is of help in patients undergoing triceps nerve-to-deltoid nerve transfer.

Intraoperative Nerve Stimulation During Brachial Plexus Surgery: Comparison Between a Totally Disposable Nerve Stimulator and Nerve Stimulator Normally Used for Nerve Blocks.

BACKGROUND: Intraoperative nerve stimulation is done routinely in brachial plexus and peripheral nerve surgery as well as in selective neurectomy in spastic patients. OBJECTIVE: The current study compares the use of 2 different devices for nerve stimulation: a totally disposable nerve stimulator and a nerve stimulator used for nerve blocks by anesthetists. METHODS: A retrospective study of 60 patients who underwent brachial plexus surgery: In 30 patients, we used the totally disposable nerve stimulator (group 1) and in another 30 patients, we used the anesthesia device (group 2). The cost of disposable materials used for nerve stimulation was calculated in each group. The same surgeon performed all operations, and he was asked to give his subjective opinion regarding the convenience and ease of use of the device in each group. RESULTS: The main advantages of the totally disposable device are its placement totally within the sterile field, and it is operated by the surgeon without the need to communicate with the anesthetist. However, the totally disposable device had several major disadvantages when compared to the anesthesia device. Firstly, the disposable stimulator can only deliver 0.5, 1.0, and 2.0 mA stimuli, while the anesthesia device can deliver stimuli of 0.1 to 5 mA (in 0.1 mA increments). Secondly, the disposable stimulator frequently fails to operate during surgery, and this is not experienced with the anesthesia device. Finally, the cost of disposables is less using the anesthesia device. CONCLUSION: Our center has stopped using the disposable nerve stimulator in favour for the anesthesia device.

HISTORIQUE: La stimulation nerveuse intraopératoire est utilisée régulièrement lors d'opérations du plexus brachial et des nerfs périphériques, de même que lors de neurectomies sélectives chez les patients spastiques. OBJECTIF: La présente étude visait à comparer deux dispositifs différents pour la stimulation nerveuse, soit un stimulateur nerveux entièrement jetable et un stimulateur nerveux qu'utilisent les anesthésistes pour les blocages nerveux. MÉTHODOLOGIE: Les chercheurs ont effectué une étude rétrospective auprès de 60 patients qui avaient subi une opération du plexus brachial. Chez 30 patients, ils ont utilisé le stimulateur nerveux entièrement jetable (groupe I) et chez 30 autres, le dispositif d'anesthésie (groupe II). Les chercheurs ont calculé le coût des fournitures jetables utilisées pour la stimulation nerveuse dans chaque groupe. Le même chirurgien a effectué toutes les opérations et a été invité à donner son avis subjectif sur le caractère pratique et la facilité d'utilisation du dispositif dans chaque groupe. RÉSULTATS: Les dispositifs complètement jetables ont comme principaux avantages de se situer entièrement dans le champ stérile et d'être utilisés par le chirurgien sans qu'il communique avec l'anesthésiste. Cependant, ils comportent plusieurs désavantages par rapport au dispositif d'anesthésie. D'abord, ils peuvent seulement délivrer un stimulus de 0,5 mA, 1,0 mA et 2,0 mA, alors que les dispositifs d'anesthésie en délivrent de 0,1 mA à 5 mA (par incréments de 0,1 mA). Ensuite, le stimulateur jetable est souvent défaillant pendant la chirurgie, ce qui ne se produit pas avec le dispositif d'anesthésie. Enfin, le dispositif d'anesthésie réduit le coût des fournitures jetables. CONCLUSION: Le centre des chercheurs a cessé d'utiliser le stimulateur nerveux jetable au profit du dispositif d'anesthésie.

Ultrasound-guided rectus sheath block in children with umbilical hernia: Case series.

BACKGROUND: Umbilical hernia repair, a common day-case surgery procedure in children, is associated with a significant postoperative pain. The most popular peripheral nerve blocks used in umbilical hernia repair are rectus sheath infiltration and caudal block. The rectus sheath block may offer improved pain relief following umbilical hernia repair with no undesired effects such as lower limb motor weakness or urinary retention seen with caudal block which might delay discharge from the hospital. Ultrasound guidance of peripheral nerve blocks has reduced the number of complications and improved the quality of blocks. The aim of this case series is to assess the post rectus sheath block pain relief in pediatric patients coming for umbilical surgery. METHODS: Twenty two (22) children (age range: 1.5-8 years) scheduled for umbilical hernia repair were included in the study. Following the induction of general anesthesia, the ultrasonographic anatomy of the umbilical region was studied with a 5-16 MHz 50 mm linear probe. An ultrasound-guided posterior rectus sheath block of both rectus abdominis muscles (RMs) was performed (total of 44 punctures). An in-plain technique using Stimuplex A insulated facet tip needle 22G 50mm. Surgical conditions, intraoperative hemodynamic parameters, and postoperative analgesia by means of the modified CHEOPS scale were evaluated. RESULTS: ultrasonograghic visualization of the posterior sheath was possible in all patients. The ultrasound guided rectus sheath blockade provided sufficient analgesia in all children with no need for additional analgesia except for one patient who postoperatively required morphine 0.1 mg/kg intravenously. There were no complications. CONCLUSIONS: Ultrasound guidance enables performances of an effective rectus sheath block for umbilical hernia. Use of the Stimuplex A insulated facet tip needle 22G 50mm provides easy, less traumatic skin and rectus muscle penetration and satisfactory needle visualiza.

Efficacy of ultrasound-guided obturator nerve block in transurethral surgery.

BACKGROUND: During transurethral resection surgery (TUR), accidental stimulation of the obturator nerve can cause violent adductor contraction, leading to serious intraoperative complications. General anesthesia with muscle relaxation is currently the preferred technique for TUR surgery. Spinal anesthesia combined with obturator nerve block has also been used for TUR surgery in geriatric population. Blind, anatomical methods for identifying the obturator nerve are often unsatisfactory. Therefore, we conducted this prospective study to validate the efficacy of ultrasound-guided obturator nerve block (USONB) during TUR procedures. METHODS: Eighteen male patients undergoing TURP surgery under spinal anesthesia were included in the study. Bilateral USONB with maximum 20 ml of 1% lidocaine per patient was performed. An independent observer was present to monitor any adduction movements during the operation and to record patient and surgeon satisfactions. RESULTS: In all patients, obturator nerve was visualized from the first attempt, requiring an average of 4.3 min for blocking of each side. USONB was successful (97.2%) in preventing an adductor spasm in all except one patient. Patient's and surgeon's satisfaction were appropriate. In all patients, adductor muscle strength recovered fully within 2 h following the surgical procedure. CONCLUSIONS: USONB is safe and effective during TUR surgery. It provides optimal intra-and postoperative conditions.

Efficacy of ultrasound-guided transversus abdominis plane (TAP) block for postcesarean section delivery analgesia--a double-blind, placebo-controlled, randomized study.

BACKGROUND: Ultrasound-guided transversus abdominis plane (TAP) block has been used for intra-operative and postoperative analgesia. Here we evaluate the efficacy of TAP block for postoperative cesarean delivery analgesia. METHOD: A randomized, double-blind, placebo-controlled trial was performed at King Khalid University Hospital on 40 patients undergoing cesarean delivery under spinal anesthesia with bupivacaine and fentanyl. At the end of surgery they received bilateral ultrasound-guided TAP block either with bupivacaine 0.25% (B group) 20 patients, or saline (S group, or placebo group) 20 patients, followed by patient controlled analgesia with i.v. morphine only. Each patient was assessed 24 hours after delivery for pain, morphine consumption, nausea, vomiting, sedation, patient's satisfaction, and also pain relief during mobilization (24 hours post-cesarean section). RESULTS: All 40 participants completed the study. Total morphine consumption was reduced more than 60% in the bupivacaine group; the bupivacaine group also reported improved satisfaction with their pain relief over 24 hours after surgery, reduced morphine consumption, less nausea, vomiting, and better patient's satisfaction. CONCLUSION: Ultrasound-guided TAP block improved postoperative analgesia, reduced morphine consumption and improved patient's satisfaction regarding analgesia after cesarean delivery.