The effect of transversus abdominis plane block application on postoperative analgesia quality and patient satisfaction after varicocele surgery: a randomized clinical trial.

Background: Postoperative pain management is an important aspect of anesthesia care and multimodal analgesic techniques are generally recommended. Objective: To compare the effect of spinal anesthesia + transversus abdominis plane (TAP) block application on postoperative analgesia quality and patient satisfaction with spinal anesthesia + intrathecal morphine (ITM) application. Methods: A total of 70 patients were randomly separated into 2 groups as spinal anesthesia + TAP block (TAP block group, n = 34) and spinal anesthesia + ITM group (ITM group, n = 36). The groups were compared in respect of age, body mass index values, and visual analog scale (VAS) values at 0 h, 2 h, 6 h, 12 h, and 18 h, and patient satisfaction was scored by Quality Improvement in Postoperative Pain Management at 24 h. Results: The mean age of the patients was 32.52 ± 6.50 years in the TAP block group and 30.11 ± 5.62 years in the ITM group, with no statistically significant difference determined. There was no statistically significant difference in terms of VAS values at 0 h, 2 h, 6 h, 12 h, and 18 h. When the factors affecting postoperative patient satisfaction were evaluated, feeling fatigue after the surgery (r = -0.811, P = 0.001) and postoperative complications such as nausea, vomiting, and itching (r = -0.831, P = 0.001) were found to have a negative effect on patient satisfaction. Conclusion: Due to low complication rates, TAP block is an effective application for postoperative analgesia management in varicocele operations that increases patient satisfaction postoperatively.

Are high fresh gas flow rates necessary during the wash-in period in low-flow anesthesia?

In low-flow anesthesia (LFA), there is a wash-in period in which usually high fresh gas flow (FGF) rates are used to achieve the required initial concentration of anesthetic agent in the alveoli. The aim of this study was to compare the efficiency, safety and the consumption of desflurane in LFA using constant FGF (1 L/min) and conventional LFA using high FGF (4 L/min) during the wash-in period. Eighty patients, who were scheduled for elective surgery under general anesthesia with endotracheal intubation, were enrolled in the study. Wash-in was accomplished with 1 L/min FGF (50% O2, 50% air) and 18% desflurane in group 1; and by 4 L/min FGF (50% O2, 50% air) and 6% desflurane in group 2. Throughout the surgery, the vaporizer was adjusted to maintain 0.6 to 0.8 minimum alveolar concentration (MAC). The time required to reach 0.7 MAC was shorter in group 1 (160 seconds [135-181] vs 288 seconds [240-500], P < .001). In 6 patients in group 1 and 13 in group 2, vaporizer settings were adjusted to maintain 0.6 to 0.8 MAC (P = .048). Desflurane consumption in the first hour and total desflurane consumption were higher in group 2 (P < .001 and P = .012, respectively). The efficiency of anesthesia in both the first hour and in total was higher in group 1 (P < .001). It is safe, more efficient, and economical to use 1 L/min FGF during the wash-in period in LFA.

Low-flow anaesthesia with a fixed fresh gas flow rate.

During the wash-in period in low flow anaesthesia (LFA), high fresh gas flow is used to achieve the desired agent concentration. In this study, we aimed to evaluate the safety of fixed 1 L/min fresh gas flow desflurane anaesthesia in both the wash-in and maintenance periods in patients including the obese ones. 104 patients undergoing surgery under general anaesthesia were included. After endotracheal intubation, fresh gas flow was reduced to 1 L/min and the desflurane vaporizer was set at 18%. The time from opening the vaporizer to end-tidal desflurane concentration reaching 0.7 MAC was recorded (MAC 0.7 time). Throughout the surgery, hemodynamic variables, FIO2, MAC and BIS values were observed. MAC 0.7 time, BIS and MAC values at the start of surgery, number of adjustments in vaporizer settings, desflurane consumption were recorded. The average MAC 0.7 time was 2.9 ± 0.5 min. MAC and BIS values at the start of the surgery were 0.7 (0.6-0.8) and 39 ± 8.5 respectively. No individual patient had a BIS value above 60 throughout the surgery. Hemodynamic variables were stable and FIO2 did not fall below 30% in any patient. The number of adjustments in vaporizer settings was 56. Average desflurane consumption was 0.33 ± 0.05 mL/min. We demonstrated that LFA without use of initial high fresh gas flow during the wash-in period is an effective, safe and economic method which is easy to perform.

Ultrasound-Guided Bilateral Erector Spinae Block Versus Tumescent Anesthesia for Postoperative Analgesia in Patients Undergoing Reduction Mammoplasty: A Randomized Controlled Study.

PURPOSE: The aim of this prospective, randomized, double-blind study was to compare the tumescent anesthesia method and erector spinae block with respect to postoperative analgesia consumption, pain scores and patient satisfaction, in patients receiving breast reduction surgery under general anesthesia. METHODS: The study included 44 females, aged 20-65 years, who were to undergo breast reduction surgery, without adjunctive liposuction on the breast. Using the closed envelope method, the patients were randomly separated into two groups to receive tumescent anesthesia or erector spinae block (ESB). Patients in the ESB group received the block before general anesthesia by a single anesthetist (G.Ö.). RESULTS: The 24-h tramadol consumption with PCA, which was the primary outcome of the study, was determined to be statistically significantly less in the ESB group (p < 0.001). The NRS scores were compared at 30 min postoperatively and then at 1, 2, 4, 6, 12 and 24 h. At all the measured time points, the pain scores of the ESB group were statistically significantly lower (p < 0.001). Additional analgesia was required by one patient in the ESB group and by seven patients in the tumescent group and was applied as 1 g paracetamol. The requirement for additional analgesia was statistically significantly lower in the ESB group (p < 0.024). Patient satisfaction was statistically significantly better in the ESB group (p < 0.001). CONCLUSIONS: According to the results of this study, bilateral ESB performed under ultrasound guidance in breast reduction surgery was more effective than tumescent anesthesia concerning postoperative analgesia consumption and pain scores. ESB could be an appropriate, effective and safe postoperative analgesia method for patients undergoing reduction mammoplasty surgery. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Anesthesia Procedure for Congenital Insensitivity to Pain in a Child with Anhidrosis Syndrome: A Rare Case.

Congenital insensitivity to pain with anhidrosis (CIPA) syndrome is a neuropathy characterized by insensitivity to pain, impaired thermoregulation, anhidrosis, and mental retardation. A 9-year old boy with CIPA syndrome, underwent 2 operations for a calcaneal ulcer. During the first operation standard monitorization was performed. In the second operation, Bispectral Index (BIS) monitoring was added and temperature was monitored with an esophageal probe. In the first operation, in which anesthesia induction was applied with ketamine and midazolam, extremity movements with surgical stimuli were seen. Despite pain insensitivity, as extremity movements were seen with surgical stimuli, propofol was administered in the second operation. Throughout the operation, the BIS values varied from 19-58 and body temperature was measured as 36.1°C-36.9°C. In conclusion, despite the absence of pain sensitivity in CIPA syndrome cases, there is an absolute need for the administration of anesthesia in surgical procedures because of tactile hyperesthesia.

Ultrasound-guided versus surgical transversus abdominis plane block in obese patients following cesarean section: a prospective randomised study / Bloqueio cirúrgico do plano transverso abdominal versus guiado por ultrassom em pacientes obesas após cesárea: estudo prospectivo e randomizado

Abstract Background and objectives Ultrasound-guided transversus abdominis plane block demonstrated efficacy in providing post-operative analgesia by prolonging the time to first analgesic requirement and reducing the total analgesic consumption. The surgical transversus abdominis plane block, a novel technique, can be performed safely in obese patients in whom muscle layers cannot be sufficiently exposed. Here, we compared applicability, efficacy and complications of surgical transversus abdominis plane and ultrasound-guided transversus abdominis plane blocks in obese pregnant women following cesarean section under general anesthesia. Methods Seventy-five pregnant women with pre- and post-pregnancy body mass index > 30 were randomized and allocated into two groups: Ultrasound-guided transversus abdominis plane block (UT group; n = 38) and surgical TAP block (ST group; n = 37). Visual analogue scale scores at post-operative 0, 2, 6, 12 and 24 hours (h), time to first analgesic requirement, total analgesic consumption amount in 24 h, post-operative side effects, complications and patient satisfaction were recorded. Results and conclusions Age, American Society of Anesthesiologist score, operative duration, body mass index, mean time to first analgesic requirement and total analgesic consumption in 24 h were similar between groups, while significant differences in pre- and post-pregnancy body mass index were observed between groups. Block procedure durations were 7 and 10 minutes in ST and UT groups, respectively. No significant differences in visual analogue scale scores were observed between the groups at all times; itching and nausea was observed in one (UT group) and four (UT and ST groups) patients, respectively. Surgical transversus abdominis plane block was safe in obese pregnant patients and provided similar post-operative analgesia to ultrasound-guided transversus abdominis plane block.

Resumo Justificativa e objetivos O bloqueio do plano transverso abdominal (TAP) guiado por ultrassom (US) demonstrou eficácia no fornecimento de analgesia no pós-operatório ao prolongar o tempo até a primeira necessidade de analgésico e reduzir o consumo total de analgésico. O bloqueio TAP cirúrgico (uma nova técnica) pode ser realizado com segurança em pacientes obesas nas quais as camadas musculares não podem ser suficientemente expostas. Comparamos a aplicabilidade, a eficácia e as complicações do bloqueio TAP cirúrgico e do bloqueio TAP-US em gestantes obesas submetidas à cesárea sob anestesia geral. Método Setenta e cinco mulheres grávidas com índice de massa corporal (IMC) pré e pós-gravidez > 30 foram randomicamente alocadas em dois grupos: bloqueio TAP-US (Grupo TAP-US, n = 38) e bloqueio TAP cirúrgico (Grupo TAP-C, n = 37). Os escores da escala visual analógica (VAS) nos tempos 0, 2, 6, 12 e 24 horas de pós-operatório, o tempo até a primeira necessidade de analgésico, o consumo total de analgésico em 24 horas, os efeitos colaterais no pós-operatório, as complicações e a satisfação do paciente foram registrados. Resultados e conclusões Idade, estado físico ASA, tempo cirúrgico, IMC, média de tempo até a primeira necessidade de analgésico e consumo total de analgésico em 24 horas foram semelhantes entre os grupos, enquanto diferenças significativas foram observadas entre os grupos em relação ao IMC pré- e pós-gravidez. As durações dos procedimentos de bloqueio foram de 7 e 10 minutos nos grupos TAP-US e TAP-C, respectivamente. Não houve diferença significativa nos escores VAS entre os grupos em todos os momentos; prurido e náusea foram observados em um paciente (Grupo TAP-US) e em quatro (Grupo TAP-C), respectivamente. O bloqueio TAP cirúrgico foi seguro nas pacientes grávidas obesas e forneceu analgesia similar à do bloqueio TAP-US no pós-operatório.

Quadratus Lumborum Block Versus Transversus Abdominis Plane Block in Children Undergoing Low Abdominal Surgery: A Randomized Controlled Trial.

BACKGROUND AND OBJECTIVES: Truncal blocks have a place within multimodal analgesia techniques in abdominal surgery. The quadratus lumborum block is a new abdominal truncal block used for somatic analgesia of both the upper and lower abdomen. In this prospective, double-blind, randomized study, we aimed to compare quadratus lumborum block and transversus abdominis plane block in pediatric patients undergoing lower abdominal surgery. METHODS: Fifty-three children undergoing unilateral inguinal hernia repair or orchiopexy surgery were randomized into 2 groups: transversus abdominis plane block and quadratus lumborum block. All blocks were performed under general anesthesia before surgery. Pain levels were assessed using an FLACC (Face, Legs, Activity, Cry, Consolability) scale. RESULTS: The study included 50 patients, after excluding 3 patients who were not eligible. The number of patients who required analgesia in the first 24 hours postoperatively was significantly lower in the quadratus lumborum block group (P < 0.05). In the quadratus lumborum block group, the postoperative 30-minute and 1-, 2-, 4-, 6-, 12-, and 24-hour FLACC scores were lower compared with those of the transversus abdominis plane block group (P < 0.05). Parent satisfaction scores were higher in the quadratus lumborum block group (P < 0.05). CONCLUSIONS: The results of this study showed that in pediatric patients undergoing unilateral inguinal hernia repair or orchiopexy the quadratus lumborum block provided longer and more effective postoperative analgesia compared with the transversus abdominis plane block. CLINICAL TRIALS REGISTRATION: The trial was registered prospectively at clinicaltrials.gov (NCT02715999).

Anti-inflammatory and Anti-nociceptive Actions of Systemically or Locally Treated Adipose-Derived Mesenchymal Stem Cells in Experimental Inflammatory Model.

Cell-based therapies using mesenchymal stem cells provide hopeful results. Therefore, in this present study, possible anti-inflammatory and anti-nociceptive actions of locally or systemically treated adipose-derived mesenchymal stem cells (ADMSCs) investigated in experimental inflammation model. ADMSCs were isolated from a male Wistar rat under anesthesia, and then they were cultured and expanded for transplantation in all the experimental animals. Effects of intraperitoneal or intraplantar ADMSC treatments on the hallmarks of the inflammatory nociception, such as hyperalgesia, allodynia, edema, and several biochemical parameters were investigated using a well-established carrageenan (CG)-induced hindpaw inflammation model in male rats. Both local and systemic ADMSC treatment increased the latencies, thresholds, and the development of edema in a time-dependent manner. In addition, administration of ADMSC suppressed the increased level of interleukin (IL)-1ß, IL-6, and nitric oxide (NO), but further enhanced that of IL-10. Locally treated ADMSC at inflammatory sites effectively suppressed the CG-induced inflammatory responses when compared to the intraperitoneal route of administration. Findings suggest that therapeutic potential of ADMSC can change depending on its route of administration. Local ADMSC treatments may suppress the development of inflammatory-nociception and edema by decreasing the production of pro-inflammatory cytokines and NO level and increasing the anti-inflammatory cytokine production at inflammatory sites.

Efeitos da inclinação de agulha peridural e diferentes velocidades de injeção na distribuição de anestesia peridural / Effects of epidural needle rotation and different speeds of injection on the distribution of epidural block / Efectos de la inclinación de la aguja epidural y diferentes velocidades en la distribución de la anestesia epidural

JUSTIFICATIVA E OBJETIVOS: Este estudo prospectivo e randomizado avaliou o efeito das velocidades da injeção na anestesia peridural unilateral sobre as características do bloqueio, parâmetros hemodinâmicos e critérios de alta hospitalar em 60 pacientes. Levobupivacaína a 5% foi administrada nos pacientes (n = 30) do Grupo F durante 1 minuto (rápido) e durante 3 minutos nos pacientes (n = 30) do Grupo S (lento), com agulha em ângulo de 5º-10º a partir da linha média. O sucesso da anestesia peridural unilateral foi mais significante no Grupo S do que no Grupo F (70,3% vs 16%, p < 0,001). Nos pacientes do Grupo S, o tempo necessário para o nível máximo de bloqueio sensitivo nos lados não operados foi mais curto e o tempo de regressão para dois segmentos, mais longo (p < 0,05). O tempo para walk-out foi mais longo no Grupo F (p < 0,05). Consideramos que a administração lenta de anestésico local em anestesia peridural unilateral é mais eficaz do que a administração rápida.

BACKGROUND AND OBJECTIVES: This prospective, randomised study examined the effect of injection speeds for unilateral epidural anesthesia on block characteristics, hemodynamic parameters, and discharge criteria in 60 patients. Levobupivacaine 5% was administered to Group F over 1 min (fast) and to Group S over 3 min (slow) (n = 30 each) with the needle angulated at 5º-10º from the midline. Unilateral epidural block was significantly more successful in Group S than in Group F (70.3% vs. 16%; p < 0.001). On the non-operated sides in group S, the maximal sensorial block time was shorter and the regression time for 2 segments was longer (p < 0.05). And the walk-out time was longer in group F (p < 0.05). We consider that the slow administration of local anesthetic in unilateral epidural anesthesia is more effective than rapid administration.

JUSTIFICATIVA Y OBJETIVOS: Este estudio prospectivo y aleatorio ha evaluado el efecto de las velocidades de la inyección para la anestesia epidural unilateral sobre las características del bloqueo, parámetros hemodinámicos y criterios del alta hospitalaria en 60 pacientes. La levobupivacaína al 5% se administró en los pacientes (n = 30) del Grupo F durante 1 minuto (rápido) y durante 3 minutos en los pacientes (n = 30) del grupo S (lento), con una aguja en ángulo de 5º-10º a partir de la línea media. El éxito de la anestesia epidural unilateral fue más significativo en el Grupo S que en el Grupo F (70,3% vs 16%, p < 0,001). En los pacientes del Grupo S, el tiempo necesario para el nivel máximo de bloqueo sensitivo en los lados no operados fue más corto y el tiempo de regresión para los dos segmentos, más largo (p < 0,05). El tiempo para walk-out fue más largo en el Grupo F (p < 0,05). Consideramos que la administración lenta de anestésico local en la anestesia epidural unilateral es más eficaz que la administración rápida.

Selective spinal anaesthesia with low-dose bupivacaine and bupivacaine + fentanyl in ambulatory arthroscopic knee surgery.

OBJECTIVE: To investigate the effects of selective spinal anaesthesia with low-dose bupivacaine alone and in combination with various doses of fentanyl, on blockage, haemodynamics, quality of anaesthesia, perioperative complications, and hospital release criteria. METHODS: This prospective study included 45 ASA I-II patients (age range: 20-77 years). The cases were randomised into 3 groups: Group 1 (n = 15) 0.8 ml of 4 mg 0.5% hyperbaric bupivacaine; Group 2 (n = 14) 1.3-ml solution of 4 mg 0.5% hyperbaric bupivacaine + 25 microg of fentanyl; and Group 3 (n = 14) 1.1-ml solution of 3 mg 0.5% hyperbaric bupivacaine + 25 microg of fentanyl. A double-blind design was employed and all patients were injected through L3-4 or L4-5 using a 25G point spinal needle. Sensory-motor blockage starting and ending time, maximum level of sensory-motor blockage, and grade and quality of anaesthesia were recorded. Haemodynamics, and respiration rates, and side effects were evaluated. Times for ability to pass to the stretcher without aid, walking, micturition, release from the hospital, and the first time an analgesic was needed were recorded. RESULTS: The time when an analgesic was first required was longer in the groups in which an opioid was added, and the shortest release time from the hospital was observed in Group 3. Other parameters remained similar across all groups. CONCLUSION: Low-dose bupivacaine, with or without fentanyl, can be used safely in lower extremity surgery and can provide rapid and safe release criteria.

Regional intravenous anesthesia in knee arthroscopy.

OBJECTIVE: The goal of the study was to investigate the regional intravenous anesthesia procedure in knee arthroscopy and to evaluate the effects of adding ketamine over the anesthesia block charactery and tourniquet pain. MATERIAL/METHOD: Forty American Society of Anesthesiologists (ASA) II patients who received knee arthroscopy were enrolled. After monitoring, a peripheral IV line was inserted.The venous blood in the lower extremity was evacuated with a bandage, and the proximal cuff of the double-cuff tourniquet was inflated. The patients were randomly split into two groups. While Group P received 80 ml 0.5% prilocaine, Group PK received 0.15 mg/kg ketamine (80 ml in total) via the dorsum of the foot. We recorded onset time of the sensory block, end time of the sensory block, presence of the motor block, the time when the patient verbally reported tourniquet pain and surgical pain, duration of tourniquet tolerance, fentanyl consumption during the operation, time to first analgesic requirement, methemoglobin values at 60 minutes, operative conditions, 24-hour analgesic consumption, discharge time, and hemodynamic parameters. RESULTS: The body mass index (BMI) of the patients who required general anesthesia was significantly higher than the BMI of other patients. The onset time of the sensory block was shorter for those in Group PK, but the time to first analgesic requirement was longer. CONCLUSION: Regional intravenous anesthesia using the doses and volumes commonly used in knee arthroscopy may be an inadequate block among patients with high BMI values. Moreover, the addition of ketamine to the local anesthetic solution may produce a partial solution by shortening the onset of sensory block and prolonging the time until the first analgesic is required.

Regional intravenous anesthesia in knee arthroscopy

OBJECTIVE: The goal of the study was to investigate the regional intravenous anesthesia procedure in knee arthroscopy and to evaluate the effects of adding ketamine over the anesthesia block charactery and tourniquet pain. MATERIAL/METHOD: Forty American Society of Anesthesiologists (ASA) II patients who received knee arthroscopy were enrolled. After monitoring, a peripheral IV line was inserted.The venous blood in the lower extremity was evacuated with a bandage, and the proximal cuff of the double-cuff tourniquet was inflated. The patients were randomly split into two groups. While Group P received 80 ml 0.5 percent prilocaine, Group PK received 0.15 mg/kg ketamine (80 ml in total) via the dorsum of the foot. We recorded onset time of the sensory block, end time of the sensory block, presence of the motor block, the time when the patient verbally reported tourniquet pain and surgical pain, duration of tourniquet tolerance, fentanyl consumption during the operation, time to first analgesic requirement, methemoglobin values at 60 minutes, operative conditions, 24-hour analgesic consumption, discharge time, and hemodynamic parameters. RESULTS: The body mass index (BMI) of the patients who required general anesthesia was significantly higher than the BMI of other patients. The onset time of the sensory block was shorter for those in Group PK, but the time to first analgesic requirement was longer. CONCLUSION: Regional intravenous anesthesia using the doses and volumes commonly used in knee arthroscopy may be an inadequate block among patients with high BMI values. Moreover, the addition of ketamine to the local anesthetic solution may produce a partial solution by shortening the onset of sensory block and prolonging the time until the first analgesic is required.

Single voxel proton MR spectroscopy findings of typical and atypical intracranial meningiomas.

PURPOSE: To prospectively define proton magnetic resonance spectroscopy (MRS) findings of meningiomas, and describe the ability or inability of short- and long-echo MRS to differentiate typical and atypical meningiomas in vivo. MATERIAL AND METHODS: Seventeen patients with pathologically confirmed typical meningiomas and six with atypical meningiomas were evaluated with conventional MR imaging and MRS before resection. MRS studies using point-resolved spectroscopy (PRESS) localisation, at short- and long-echo time (TR 2000 ms, TE: 30 and 144 ms, 64-96 acquisition) were acquired on a 1.5 T scanner. MRS data obtained from these patients were compared with histopathological findings. Mean cellular proliferation (MIB-1) antibody staining against the Ki-67 antigen was also determined in all meningiomas. RESULTS: Prominent choline (Cho) was present in all meningiomas. Alanine (Ala) was observed in 21 cases of the 23 meningiomas. Acetylaspartate (NAA) and creatine (Cr) were either not observed or detected in minimal amounts in at all both groups of meningiomas on long TE (144 ms) spectra. The mean Cho/Cr values in the four atypical meningiomas were 4.44+/-0.30 (mean+/-standard deviation) and 3.39+/-0.52 in the 12 typical meningiomas on short TE spectra. Cho/Cr ratio could not be determined in the other seven cases because of a lack of creatine peak. Of the five meningiomas in which a lactate peak was detected, four were in typical cases and only one was in atypical meningioma. Mean MIB-1 proliferation index was 3.7% in typical meningiomas and 10% in atypical meningiomas. CONCLUSION: Prominent Cho, absence or low amount of NAA and Cr, and presence of Ala were common characteristics of spectral pattern of both atypical and typical meningiomas on MRS. MRS cannot reliably differentiate typical intracranial meningiomas from atypical meningiomas preoperatively. Mean MIB-1 proliferation index was well correlated with histopathology findings.

Intradiploic epidermoid cysts of the skull: a report of four cases.

Epidermoid cysts are uncommon, benign and slow-growing lesions. They may often reach an enormous size without producing neurological symptoms. Intradiploic epidermoid cysts are nearly 25% of all epidermoids. They are derived from ectodermal remnants that stay within the cranial bones during embryonic development. Intradiploic epidermoid cysts can be located in any part of the skull. Two of our four cases were located in left occipital bone and the others were in the frontal bone. These tumours can occur at any age from the first to the seventh decade of life. Our cases had a mean age of 38.75 years (19-55 years). They may reach great sizes before the initial diagnosis and may produce major neurological signs. For good long-term prognosis, correct radiological assessment and complete removal of the tumour with its capsule are essential. We report four cases of intradiploic epidermoid cysts of the skull and analyse the clinical, radiological features and treatment of these lesions in the light of relevant literature.