Inadvertent Puncture of Dilated Right Ventricle During Transversus Thoracic Muscle Plane Block: Lessons Learnt.

ABSTRACT: The transversus thoracic muscle plane (TTP) block is gaining widespread recognition in cardiac surgery, particularly in facilitating fast-tracking. Here, we report a case of inadvertent puncture of the right ventricle (RV) during the administration of ultra sound-guided (USG) TTP block in a 3-year-old child posted for atrial septal defect (ASD) closure and mitral valve repair. We also discuss the care that should be taken to avoid such complications and such cases require extra caution during TTP block.

Regional Anesthesia Complications and Contraindications.

Regional anesthesia has a strong role in minimizing post-operative pain, decreasing narcotic use and PONV, and, therefore, speeding discharge times. However, as with any procedure, regional anesthesia has both benefits and risks. It is important to identify the complications and contraindications related to regional anesthesia, which patient populations are at highest risk, and how to mitigate those risks to the greatest extent possible. Overall, significant complications secondary to regional anesthesia remain low. While a variety of different regional anesthesia techniques exist, complications tend to fall within 4 broad categories: block failure, bleeding/hematoma, neurological injury, and local anesthetic toxicity.

[A prospective comparative study on effectiveness of single versus continuous adductor canal block combined with local infiltration anesthesia in unicompartmental knee arthroplasty].

Objective: To compare the early analgesic effects and the impact on knee joint function recovery after unicompartmental knee arthroplasty (UKA) between single adductor canal block (SACB) and continuous adductor canal block (CACB) combined with local infiltration anesthesia (LIA) using a prospective study. Methods: The patients with knee osteoarthritis admitted between April 2022 and December 2023 were enrolled as a subject. Among them, 60 patients met the selection criteria and were enrolled in the study. They were randomly assigned to the SACB group or CACB group in a ratio of 1:1 using a random number table method. There was no significant difference between the two groups ( P>0.05) in terms of age, gender, height, body mass, body mass index, affected side, and preoperative resting visual analogue scale (VAS) score and active VAS score, Oxford knee score (OKS), and American Hospital of Special Surgery (HSS) score. All patients received multimodal analgesia management using LIA combined with SACB or CACB. The operation time, pain related indicators (resting and activity VAS scores, number and timing of breakthrough pain, opioid consumption), joint function related indicators (quadriceps muscle strength, knee range of motion, OKS score, and HSS score), as well as postoperative block complications and adverse events were recorded and compared between the two groups. Results: There was no significant difference in the operation time between the two groups ( P<0.05). All patients in the two groups were followed up with a follow-up time of (9.70±4.93) months in the SACB group and (12.23±5.05) months in the CACB group, and the difference was not significant ( P>0.05). The CACB group had a significant lower resting VAS score at 24 hours after operation compared to the SACB group ( P<0.05). There was no significant difference in resting and active VAS scores between the two groups at other time points ( P>0.05). The CACB group had a significantly lower incidence of breakthrough pain compared to the SACB group [9 cases (30.00%) vs. 17 cases (56.67%); P<0.05). However, there was no significant difference in the timing of breakthrough pain occurrence and opioid consumption between the two groups ( P>0.05). Four cases in the SACB group and 7 cases in the CACB group experienced adverse events, with no significant difference in the incidence of adverse events between the two groups ( P>0.05). The CACB group had significantly better knee joint mobility than the SACB group at 1 and 2 days after operation ( P<0.05). There was no significant difference between the two groups in knee joint mobility on 0 day after operation and quadriceps muscle strength and OKS and HSS scores at different time points ( P>0.05). Conclusion: In UKA, the analgesic effects and knee joint function recovery are similar when compared between LIA combined with SACB and LIA combined with CACB. However, SACB is simpler to perform and can avoid adverse events such as catheter displacement and dislocation. Therefore, SACB may be a better choice.

Local Anesthetic Systemic Toxicity in Cardiac Surgery Patient with Erector Spinae Plane Catheter: A Case Report.

Regional anesthesia nerve blocks are increasingly used for patients undergoing cardiac surgery as part of multimodal pain management. Though rare, local anesthetic systemic toxicity (LAST) is a severe complication that requires vigilant monitoring. We present a case of a postcardiac surgery patient who developed LAST multiple days after surgery from lidocaine via an erector spinae plane catheter. This episode was determined to be a result of impaired lidocaine metabolism from liver shock caused by worsening pulmonary hypertension. Even under continuous monitoring, patients with cardiac or liver dysfunction are at increased risk of complications from local anesthetics.

Perioperative pain management with regional analgesia techniques for visceral cancer surgery: A systematic review and meta-analysis.

STUDY OBJECTIVE: Regional analgesia following visceral cancer surgery might provide an advantage but evidence for best treatment options related to risk-benefit is unclear. DESIGN: Systematic review of randomized controlled trials (RCT) with meta-analysis and GRADE assessment. SETTING: Postoperative pain treatment. PATIENTS: Adult patients undergoing visceral cancer surgery. INTERVENTIONS: Any kind of peripheral (PRA) or epidural analgesia (EA) with/without systemic analgesia (SA) was compared to SA with or without placebo treatment or any other regional anaesthetic techniques. MEASUREMENTS: Primary outcome measures were postoperative acute pain intensity at rest and during activity 24 h after surgery, the number of patients with block-related adverse events and postoperative paralytic ileus. MAIN RESULTS: 59 RCTs (4345 participants) were included. EA may reduce pain intensity at rest (mean difference (MD) -1.05; 95% confidence interval (CI): -1.35 to -0.75, low certainty evidence) and during activity 24 h after surgery (MD -1.83; 95% CI: -2.34 to -1.33, very low certainty evidence). PRA likely results in little difference in pain intensity at rest (MD -0.75; 95% CI: -1.20 to -0.31, moderate certainty evidence) and pain during activity (MD -0.93; 95% CI: -1.34 to -0.53, moderate certainty evidence) 24 h after surgery compared to SA. There may be no difference in block-related adverse events (very low certainty evidence) and development of paralytic ileus (very low certainty of evidence) between EA, respectively PRA and SA. CONCLUSIONS: Following visceral cancer surgery EA may reduce pain intensity. In contrast, PRA had only limited effects on pain intensity at rest and during activity. However, we are uncertain regarding the effect of both techniques on block-related adverse events and paralytic ileus. Further research is required focusing on regional analgesia techniques especially following laparoscopic visceral cancer surgery.

Lower extremity peripheral nerve block for total knee arthroplasty in a patient with chronic inflammatory demyelinating polyneuropathy: A case report.

RATIONALE: Chronic inflammatory demyelinating polyneuropathy (CIDP) is an autoimmune disorder that affects the peripheral nerves, leading to weakness and sensory symptoms. CIDP is a rare disease, and few studies have reported on anesthetic management in patients with this condition, especially the peripheral nerve block (PNB). Therefore, a safe and standardized anesthetic approach remains to be established. This case report aims to address this gap in evidence by documenting our experience with PNB in a patient with CIDP undergoing surgery. It contributes significantly to expanding the range of anesthetic options and enhancing perioperative outcomes for patients with CIDP. PATIENT CONCERNS: A 58-year-old woman diagnosed with CIDP was scheduled to undergo left total knee arthroplasty due to osteonecrosis. We anticipated postoperative pain and aggravation of neurological symptoms. DIAGNOSIS: CIDP. INTERVENTIONS: To manage the postoperative pain, we planned a combination of general anesthesia (GA) and lower extremity PNBs, viz. the tibial and femoral nerve blocks, supplemented with intravenous patient-controlled analgesia. An initial dose of fentanyl 50 µg was administered as analgesia. The tibial and femoral nerves were identified using a peripheral nerve stimulator in conjunction with an ultrasonic echo device while the patient was conscious, to minimize the risk of nerve injury. The tibial and femoral nerve blocks were performed with 20 mL of ropivacaine (0.25%) and dexamethasone 2.2 mg, respectively. Subsequently, we administered fentanyl and ketamine and initiated continuous infusion of remifentanil. Thereafter, propofol 120 mg was administered intravenously over a span of 1 minute, followed by continuous infusion at 4 mg/kg/h. Upon confirming loss of consciousness, we induced GA using a supraglottic airway device without using muscle relaxants. For postoperative analgesia, we administered acetaminophen 1000 mg. OUTCOMES: The patient experienced no pain immediately after surgery, and good analgesia was achieved subsequently without worsening of sensory symptoms during rehabilitation. LESSONS: We achieved effective anesthetic management in a patient with CIDP by combining GA with nerve stimulation and ultrasound-guided PNB. It is crucial to devise a personalized anesthesia plan that focuses on the patients' safety and comfort while minimizing risk in patients with CIDP.

Prophylactic dexamethasone for rebound pain after peripheral nerve block in adult surgical patients: systematic review, meta-analysis, and trial sequential analysis of randomised controlled trials.

BACKGROUND: Rebound pain occurs after the resolution of peripheral nerve block and hampers patient recovery in the postoperative period. We sought to synthesise available data from randomised controlled trials (RCTs) evaluating the efficacy of prophylactic dexamethasone for rebound pain in adult patients undergoing surgery with a peripheral nerve block. METHODS: In this systematic review and meta-analysis, RCTs reporting rebound pain and use of dexamethasone in the context of a peripheral nerve block were searched in various databases and updated in May 2023. The primary outcome was the incidence of rebound pain; secondary outcomes included the severity and time to onset of rebound pain, patient satisfaction with pain control, sleep disturbance because of pain, and adverse effects of dexamethasone. Subgroup analysis was conducted based on the effect of route of administration (intravenous or perineural) on the incidence of rebound pain. Trial sequential analysis was performed to rule out the possibility of a false positive result. RESULTS: Seven RCTs comprising 574 patients were included in this review. The dexamethasone group was associated with a reduction in the incidence of rebound pain with an odds ratio of 0.16 (95% confidence interval 0.10-0.27, P=0.00, I2=0%) compared with the control group. Trial sequential analysis confirmed the adequate information size for the beneficial effect of dexamethasone. Subgroup analysis showed that both intravenous and perineural administration were associated with a significant reduction in the incidence of rebound pain. CONCLUSIONS: Current evidence suggests that both intravenous and perineural dexamethasone reduce the incidence of rebound pain after a peripheral nerve block provided for postoperative analgesia. SYSTEMATIC REVIEW PROTOCOL: PROSPERO CRD42023424031.

Efficacy of Supplemental Ultrasound-Guided Pericapsular Nerve Group (PENG) Block Combined with Lateral Femoral Cutaneous Nerve Block in Patients Receiving Local Infiltration Analgesia after Hip Fracture Surgery: A Prospective Randomized Controlled Trial.

Background and Objectives: Local infiltration analgesia (LIA) represents a potential approach to reducing pain in patients undergoing total hip arthroplasty (THA). The pericapsular nerve group (PENG) block also provides adequate analgesia for fractures and THA. As most hip surgeries use a lateral incision, affecting the cutaneous supply by branches of the lateral femoral cutaneous nerve (LFCN), the LFCN block can contribute to postoperative analgesia. However, no studies have investigated the effectiveness of supplemental PENG block combined with LFCN block in patients undergoing LIA after hip fracture surgery. Our study aimed to assess the effectiveness of PENG combined with LFCN block following hip fracture surgery in patients who underwent LIA. Materials and Methods: Forty-six patients were randomly assigned to LIA or PENG + LFCN + LIA groups. The primary outcome was the pain score at rest and during movement at 2, 6, 12, 24, and 48 h postoperatively. The total opioid dose for postoperative analgesia was also measured at the same time points. Secondary outcomes included postoperative cognitive function assessment. Results: The median pain scores at rest and during movement were lower in the PENG + LFCN + LIA group throughout the study periods compared to the LIA group, except at 2 h (at rest) and 48 h (during movement) after surgery. The total fentanyl dose was lower in the PENG + LFCN + LIA group at all time points after surgery when compared to the LIA group. Postoperative delirium incidence and the median abbreviated mental test scores were not significantly different between the two groups. Conclusions: The combination of PENG and LFCN blocks may contribute to enhanced recovery for patients undergoing LIA after hip fracture surgery. However, further well-controlled research is necessary to determine the effectiveness of supplemental PENG combined with LFCN block in addressing cognitive deficits in these patients.

[Research progress on early postoperative pain management strategies after arthroscopic anterior cruciate ligament reconstruction].

Objective: To summarize the early postoperative pain management strategies for anterior cruciate ligament reconstruction (ACLR), and to select a reasonable and effective pain management plan to promote functional rehabilitation after ACLR. Methods: The literature about the early postoperative pain management strategies of ACLR both domestically and internationally in recent years was extensiverly reviewed, and the effects of improving postoperative pain were reviewed. Results: Currently, physical therapy and oral medication have advantages such as economy and simplicity, but the effect of improving postoperative pain is not satisfactory, often requires a combination of intravenous injection or intravenous pump, which is also a common way to relieve pain. However, in order to meet the analgesic needs of patients, the amount of analgesic drugs used is often large, which increases the incidence of various adverse reactions. Local infiltration analgesia (LIA), including periarticular or intra-articular injection of drugs, can significantly improve the early postoperative pain of ACLR, and achieve similar postoperative effectiveness as nerve block. LIA can be used as an analgesic technique instead of nerve block, and avoid the corresponding weakness of innervated muscles caused by nerve block, which increases the risk of postoperative falls. Many studies have confirmed that LIA can alleviate postoperative early pain in ACLR, especially the analgesic effects of periarticular injection are more satisfactory. It can also avoid the risk of cartilage damage caused by intra-articular injection. However, the postoperative analgesic effect and timeliness still need to be improved. It is possible to consider combining multimodal mixed drug LIA (combined with intra-articular and periarticular) with other pain intervention methods to exert a synergistic effect, in order to avoid the side effects and risks brought by single drugs or single administration route. LIA is expected to become one of the most common methods for relieving postoperative early pain in ACLR. Conclusion: Early pain after arthroscopic ACLR still affects the further functional activities of patients, and all kinds of analgesic methods can achieve certain effectiveness, but there is no unified standard at present, and the advantages and disadvantages of various analgesic methods need further research.

Comparison of the effects of transversus thoracic muscle plane block and pecto-intercostal fascial block on postoperative opioid consumption in patients undergoing open cardiac surgery: a prospective randomized study.

BACKGROUND: There is an association exists between cardiac surgery, performed through median sternotomy, and a considerable postoperative pain. OBJECTIVES: The aim of the current study is to compare the effects of transversus thoracic muscle plane block (TTMPB) and pecto-intercostal fascial plane block (PIFB) upon postoperative opioid consumption among the patients who underwent open cardiac surgery. METHODS: The present prospective, randomized, comparative study was conducted among 80 patients who underwent elective on-pump cardiac surgery with sternotomy. The subjects were randomly assigned to two groups with each group containing 40 individuals. For the TTMPB group, bilateral ultrasound-guided TTMPB was adopted in which 20 ml of 0.25% bupivacaine was used on each side. In case of PIFB group, bilateral ultrasound-guided PIFB was adopted with the application of 20 ml of 0.25% bupivacaine on each side. The researchers recorded the first time for rescue analgesia, the overall dosage of rescue analgesia administered in the first 24 h after the operation and the postoperative complications. RESULTS: The PIFB group took significantly longer time to raise the first request for rescue analgesia (7.8 ± 1.7 h) than the TTMPB group (6.7 ± 1.4 h). Likewise, the PIFB group subjects had a remarkably lower 'overall morphine usage' in the first 24 h after the operation (4.8 ± 1.0 mg) than TTMPB group (7.8 ± 2.0 mg). CONCLUSION: Bilateral ultrasound-guided PIFB provided a longer time for the first analgesic demand than bilateral ultrasound-guided TTMPB in patients undergoing open cardiac surgery. In addition to this, the PIFB reported less postoperative morphine usage than the TTMPB and increases satisfaction in these patients. TRIAL REGISTRATION: This study was registered at Clinical Trials.gov on 28/11/2022 (registration number: NCT05627869).

Safety and Complications of Landmark-based Paravertebral Blocks: A Retrospective Analysis of 979 Patients and 4983 Injections.

OBJECTIVE: This study aimed to determine the incidence of complications after landmark-based paravertebral blocks for breast surgery. METHODS: The medical records of patients who received a paravertebral block for breast surgery between 2019 and 2022 were reviewed. Patient age, sex, type of procedure, number of injections, volume of injected anesthetic, and possible complications were noted. A record was identified as a possible serious block-related complication if there was concern or treatment for local anesthetic systemic toxicity, pneumothorax, altered mental status, or intrathecal/epidural spread. Other complications recorded were immediate postblock hypotension and nausea/vomiting requiring treatment and unanticipated postsurgical admission. Patients receiving ultrasound-guided paravertebral blocks were excluded from this study. RESULTS: Over a 3-year period, 979 patients received paravertebral blocks using the landmark technique for breast surgery, totaling 4983 injections. Overall, 6 patients required assessment for postblock issues (0.61%), including hypotension (2 patients), nausea (3 patients), and hypotension + altered mental status (1 patient). This latter patient was identified as having a serious complication related to the paravertebral block (0.1%). This patient had unintentional intrathecal spread and altered mental status that required mechanical ventilation. The incidence of block-related hypotension and nausea requiring treatment was thus 0.31% and 0.31% respectively. Four patients required unanticipated admission, but none were for block-related reasons. No patients in this study were found to have local anesthetic systemic toxicity or pneumothorax. CONCLUSION: Our study suggests that landmark-based paravertebral blocks for breast surgery result in a very low complication rate and are a safe technique for postsurgical analgesia.

Thoracic paravertebral block for perioperative lung preservation during VATS pulmonary surgery: study protocol of a randomized clinical trial.

BACKGROUND: Postoperative pulmonary complications (PPCs) extend the length of stay of patients and increase the perioperative mortality rate after video-assisted thoracoscopic (VATS) pulmonary surgery. Thoracic paravertebral block (TPVB) provides effective analgesia after VATS surgery; however, little is known about the effect of TPVB on the incidence of PPCs. The aim of this study is to determine whether TPVB combined with GA causes fewer PPCs and provides better perioperative lung protection in patients undergoing VATS pulmonary surgery than simple general anaesthesia. METHODS: A total of 302 patients undergoing VATS pulmonary surgery will be randomly divided into two groups: the paravertebral block group (PV group) and the control group (C group). Patients in the PV group will receive TPVB: 15 ml of 0.5% ropivacaine will be administered to the T4 and T7 thoracic paravertebral spaces before general anaesthesia induction. Patients in the C group will not undergo the intervention. Both groups of patients will be subjected to a protective ventilation strategy during the operation. Perioperative protective mechanical ventilation and standard fluid management will be applied in both groups. Patient-controlled intravenous analgesia is used for postoperative analgesia. The primary endpoint is a composite outcome of PPCs within 7 days after surgery. Secondary endpoints include blood gas analysis, postoperative lung ultrasound score, NRS score, QoR-15 score, hospitalization-related indicators and long-term prognosis indicators. DISCUSSION: This study will better evaluate the impact of TPVB on the incidence of PPCs and the long-term prognosis in patients undergoing VATS lobectomy/segmentectomy. The results may provide clinical evidence for optimizing perioperative lung protection strategies. TRIAL REGISTRATION: ClinicalTrials.gov NCT05922449 . Registered on June 25, 2023.

Ultrasound-guided erector spinae plane block for perioperative analgesia in patients undergoing laparoscopic nephrectomies surgery: a randomized controlled trial.

BACKGROUND: Laparoscopic nephrectomy is a commonly utilized surgical approach for the management of renal cancer. Despite its widespread acceptance, postoperative pain management remains a significant challenge for many patients undergoing this procedure. Traditional pain management techniques, including opioid and nonsteroidal anti-inflammatory drug administration, may not provide adequate pain relief and may result in adverse effects. In recent years, erector spinae plane block (ESPB) has emerged as a promising regional anesthesia technique due to its simplicity, safety, and potential efficacy in reducing postoperative pain. ESPB has demonstrated effectiveness in reducing postoperative pain in various surgical procedures. However, the efficacy of ESPB in laparoscopic nephrectomy for renal cancer has not been extensively studied. As such, further investigation is necessary to determine the potential benefits of ESPB in this context. The addition of adjuvants such as dexmedetomidine and dexamethasone to nerve blocks has been shown to improve both the duration and quality of the block. Multiple studies have demonstrated the safety and efficacy of these adjuvants in reducing postoperative pain and opioid consumption and improving patient satisfaction. The use of dexmedetomidine and dexamethasone as adjuvants for nerve blocks represents a promising approach for enhancing regional anesthesia and analgesia. In light of these findings, we have incorporated dexmedetomidine and dexamethasone into our nerve block protocol. METHODS: This study is a randomized controlled trial conducted at a single center, with 50 participants being randomized in a 1:1 ratio to either the ESPB group or the control group. The trial aims to investigate the efficacy of ESPB in patients diagnosed with kidney cancer who are scheduled for laparoscopic nephrectomy. The primary outcome measure is the total consumption of intraoperative sufentanil. Secondary outcomes include the VAS score at rest and during coughing at 1 h, 6 h, 12 h, 24 h, and 48 h after surgery; total intraoperative remifentanil consumption; the number of times rescue analgesia is required; and the incidence of nausea and vomiting in the first 24 h after surgery. This study is registered for a duration of 1 year and is being conducted in China. DISCUSSION: The objective of our study is to evaluate the potential benefits of erector spinae plane block (ESPB) in patients undergoing laparoscopic nephrectomy, with a focus on the impact of dexmedetomidine and dexamethasone as adjuvants on the quality and duration of the block, as well as postoperative pain and opioid consumption. By investigating the effects of these adjuvants in the context of ESPB, we hope to contribute to the growing body of literature on the use of adjuvants in nerve blocks and provide further insight into the potential benefits of this approach for improving patient outcomes following laparoscopic nephrectomy. This trial was approved by the Ethics Committee of the Second Affiliated Hospital of Army Medical University. TRIAL REGISTRATION: China Clinical Trial Register ChiCTR2300068578 . Registered on 20 February 2023.

Effect of ultrasound-guided continuous erector spinae plane block on postoperative pain and inflammatory response in patients undergoing modified radical mastectomy for breast cancer: study protocol for a randomised controlled trial.

BACKGROUND: A single injection of local anaesthetic (LA) in the erector spinae plane block (ESPB) can reduce pain after modified radical mastectomy (MRM) surgery, but the duration of analgesia is affected by the duration of the LA. The aim of this study is to investigate the effect of continuous ESPB on acute and chronic pain and inflammatory response after MRM surgery. METHODS: In this prospective, randomised, controlled trial, we will recruit 160 patients, aged 18-80 years, scheduled for elective MRM surgery under general anaesthesia. They will be randomly assigned to two groups: a continuous ESPB group (group E) and a sham block group (group C). Both groups of patients will have a nerve block (group C pretended to puncture) and an indwelling catheter fixed prior to surgery. Electronic pumps containing LA are shielded. The primary outcome is the total consumption of analgesic agents. The secondary outcomes include the levels of inflammation-related cytokines; the occurrence of chronic pain (post-mastectomy pain syndrome, PMPS); static and dynamic pain scores at 2, 6, 12, 24 and 48 h postoperatively; and post-operative and post-puncture adverse reactions. DISCUSSION: Analgesia after MRM surgery is important and chronic pain can develop when acute pain is prolonged, but the analgesic effect of a nerve block with a single injection of LA is limited by the duration of drug action. The aim of this trial is to investigate whether continuous ESPB can reduce acute pain after MRM surgery and reduce the incidence of chronic pain (PMPS), with fewer postoperative analgesic drug-related complications and less inflammatory response. Continuous ESPB and up to 12 months of follow-up are two innovations of this trial. TRIAL REGISTRATION: Chinese Clinical Trial Registry ( https://www.chictr.org.cn/ ) ChiCTR2200061935. Registered on 11 July 2022. This trial is a prospective registry with the following registry names: Effect of ultrasound-guided continuous erector spinae plane block on postoperative pain and inflammatory response in patients undergoing modified radical mastectomy for breast cancer.

Efficacy of ultrasound-guided erector spinae plane block on analgesia and quality of recovery after minimally invasive direct coronary artery bypass surgery: protocol for a randomized controlled trial.

BACKGROUND: Minimally invasive direct coronary artery bypass (MIDCAB) surgery offers an effective option for coronary artery disease (CAD) patients with the avoidance of median sternotomy and fast postoperative recovery. However, MIDCAB is still associated with significant postoperative pain which may lead to delayed recovery. The erector spinae plane block (ESPB) is a superficial fascial plane block. There have not been randomized controlled trials evaluating the effects of ESPB on analgesia and patient recovery following MIDCAB surgery. We therefore designed a double-blind prospective randomized placebo-controlled trial, aiming to prove the hypothesis that ESPB reduces postoperative pain scores in patients undergoing MIDCAB surgery. METHODS: The study protocol has been reviewed and approved by the Ethical Review Committee of Peking University People's Hospital. Sixty adult patients of either sex scheduled for MIDCAB surgery under general anesthesia (GA) will be included. Patients will be randomly allocated to receive either a preoperative single-shot ESPB with 30 mL of ropivacaine 0.5% (ESPB group) or normal saline 0.9% (control group). The primary outcomes are the difference between the two groups in numeric rating scale (NRS) scores at rest at different time points (6, 12, 18, 24, 48 h) after surgery. The secondary outcomes include NRS scores on deep inspiration within 48 h, postoperative hydromorphone consumption, and quality of patient recovery at 24 h and 48 h, using the Quality of Recovery-15 (QoR-15) scale. The other outcomes include intraoperative fentanyl requirements, the need for additional postoperative rescue analgesics, time to tracheal extubation and chest tube removal after surgery, incidence of postoperative nausea and vomiting (PONV) and postoperative cognitive dysfunction (POCD), intensive care unit (ICU) length of stay (LOS), hospital discharge time, and 30-day mortality. Adverse events will be also evaluated. DISCUSSION: This is a novel randomized controlled study evaluating a preoperative ultrasound-guided single-shot unilateral ESPB on analgesia and quality of patient recovery in MIDCAB surgery. The results of this study will characterize the degree of acute postoperative pain and clinical outcomes following MIDCAB. Our study may help optimizing analgesia regimen selection and improving patient comfort in this specific population. TRIAL REGISTRATION: The study was prospectively registered with the Chinese Clinical Trial Registry (trial identifier: ChiCTR2100052810). Date of registration: November 5, 2021.

Regional anaesthesia truncal blocks for acute postoperative pain and recovery: a narrative review.

Significant acute postoperative pain remains prevalent among patients who undergo truncal surgery and is associated with increased morbidity, prolonged patient recovery, and increased healthcare costs. The provision of high-quality postoperative analgesia is an important component of postoperative care, particularly within enhanced recovery programmes. Regional anaesthetic techniques have become increasingly prevalent within multimodal analgesic regimens and the widespread adoption of ultrasonography has facilitated the development of novel fascial plane blocks. The number of described fascial plane blocks has increased significantly over the past decade, leading to a burgeoning area of clinical investigation. Their applications are increasing, and truncal fascial plane blocks are increasingly recommended as part of procedure-specific guidelines. Some fascial plane blocks have been shown to be more efficacious than others, with favourable side-effect profiles compared with neuraxial analgesia, and are increasingly utilised in breast, thoracic, and other truncal surgery. However, use of these blocks is debated in regional anaesthesia circles because of limitations in our understanding of their mechanisms of action. This narrative review evaluates available evidence for the analgesic efficacy of the most commonly practised fascial plane blocks in breast, thoracic, and abdominal truncal surgery, in particular their efficacy compared with systemic analgesia, alternative blocks, and neuraxial techniques. We also highlight areas where investigations are ongoing and suggest priorities for original investigations.

Combined erector spinae plane block with surgical intercostal nerve cryoablation for Nuss procedure is associated with decreased opioid use and length of stay.

BACKGROUND AND OBJECTIVES: Pain management for patients undergoing the Nuss procedure for treatment of pectus excavatum can be challenging. In an effort to improve pain management, our institution added bilateral single injection erector spinae plane (ESP) blocks to surgeon placed intercostal nerve cryoablation. We aimed to assess the efficacy of this practice change. METHODS: Retrospective clinical data from a single academic medical center were evaluated. Due to an institutional change in clinical management, we were able to perform a before and after study. Twenty patients undergoing Nuss procedure who received bilateral ultrasound-guided single-shot T6 level ESP blocks and intercostal nerve cryoablation were compared with a historical control cohort of 20 patients who underwent Nuss procedure with intercostal nerve cryoablation alone. The primary outcome variables included postoperative pain scores, total hospital opioid use, and hospital length of stay. RESULTS: Median total hospital intravenous morphine milligram equivalents was lower for the ESP group than for the control group (0.60 (IQR 0.35-0.88) vs 1.15 mg/kg (IQR 0.74-1.68), p<0.01). There was no difference in postoperative pain scores between the two groups. Mean hospital length of stay was 2.45 (SD 0.69) days for the control group and 1.95 (SD 0.69) days for the ESP group (p=0.03). No adverse events related to block placement were identified. CONCLUSIONS: In a single-center academic practice, the addition of bilateral single injection ESP blocks at T6 to surgeon performed cryoablation reduced opioid consumption without a change in subjectively reported pain scores. The results from this pilot study can provide effect size estimates to guide the design of future randomized trials.

Does the impact of peripheral nerve blocks vary by age and comorbidity subgroups? A nationwide population-based study.

INTRODUCTION: A large body of literature suggests that peripheral nerve blockade (PNB) is associated with improved perioperative outcomes in total hip and knee joint arthroplasty patients. However, it is unclear to what extent this association exists across patient subgroups based on age and health status. METHODS: Patients who underwent total joint arthroplasty were identified from the Premier Healthcare database (2006-2019). Mixed-effects models were applied to assess the relationship between exposure of interest (PNB use on the day of surgery) and various outcomes (postoperative respiratory complications, acute renal failure, delirium, intensive care unit admission, prolonged length of stay, and high opioid consumption) across multiple subgroups stratified by patient age and pre-existing comorbidities. RESULTS: PNB use and outcome association varies based on the patient's health and age characteristics. For adults and older adults with excellent or fair, there was a decrease in the likelihood of respiratory complication with the use of PNB (OR: 0.92, 95% CI 0.86 to 0.98; OR: 0.88, 95% CI 0.81 to 0.95; OR: 0.94, 95% CI 0.89 to 0.99, respectively). Peripheral nerve blocks were also associated with a reduction in the odds of high opioid consumption across all categories except adult patients in poor health. CONCLUSION: PNB use is associated with beneficial effects more commonly observed among patients with a lower comorbidity burden, without a clear pattern of association with patient age.

Ultrasound-guided erector spinae plane block in coronary artery bypass surgery: the role of local anesthetic volume-a prospective, randomized study.

BACKGROUND: Erector spinae plane block has been shown to help with pain management in different regions and many areas with different indications. However, the effectiveness of this block in cardiac surgery has been shown in the literature, the optimal volume remains unclear. The aim of this study is to determine the analgesic efficacy of two different volumes of local anesthetic injection used in ultrasound-guided bilateral-thoracic erector spinae plane block in patients undergoing coronary artery bypass graft. METHODS: This study was conducted on adult patients undergoing surgery with coronary artery bypass graft, and 70 patients were analyzed in each group. Group 20 received erector spinae plane block with 20 ml of 0.25% bupivacaine, Group 30 received 30 ml of 0.25% bupivacaine bilaterally. Postoperative sternotomy and chest tube-related pain were evaluated using the numerical rating scale (NRS) at rest and during movement. RESULTS: There were significant differences between the groups regarding rescue tramadol consumption was higher in Group 20 than in Group 30 (25/35 vs. 2/35, p < 0.001). In addition, there were substantial differences between the two groups concerning the time of the first-rescue analgesic requirement. The mean time ± standard deviation was 11.26 ± 9.57 h and 24.03 ± 4.12 h in Groups 20 and 30 (p < 0.001). The median scores, both at sternotomy and chest tubes, were significantly lower in Group 30 than in Group 20 at the different time points after the surgery (p < 0.05). CONCLUSIONS: In coronary artery bypass graft surgery, erector spinae plane block performed with 30 ml instead of 20 ml on each side resulted in less pain in the sternum and chest tube region, less need for rescue analgesics, and delayed first-rescue analgesic requirement.

The Role of Multilevel Intercostal Nerve Block in Local Anesthetic Thoracoscopy.

BACKGROUND: Intercostal nerve block (ICNB) has long been used in thoracic surgery. Local anesthetic thoracoscopy (LAT) is performed under conscious sedation with local anesthesia at the port insertion site. This alone, however, does not anesthetize the parietal pleura from where biopsies are taken and patients can experience pain. OBJECTIVES: To compare LAT with multilevel ICNB versus standard care to determine whether it reduces pain during and post-LAT, its effect on analgesia use, the hospital length of stay (LOS), and related complications. METHODS: Prospective analysis of patients undergoing LAT between January and June 2021. In the ICNB group, levobupivacaine/xylocaine is administered at the angle of the rib immediately before LAT (up to 5 rib spaces). Visual Analog Score for pain (0 to 100 mm) was measured at 1 and 2 hours post-LAT and daily including analgesia use. RESULTS: Twenty patients (10 ICNB vs. 10 standard care group). The mean age is 68 years with 70% males. Visual Analog Score for pain in the ICNB group reduced by 55 mm at 1 and 2 hours post-LAT and 45 mm at day 1 ( P <0.05) (minimal clinically important difference >16 mm]. Median LOS was reduced by 50% in the ICNB group ( P <0.05). Paracetamol use reduced by 56% ( P <0.05). CONCLUSION: ICNB not only significantly reduces postprocedure pain but also reduces LOS.