Erector Spinae Plane Block Decreases Narcotic Requirements in Patients Undergoing Subcutaneous Implantable Cardioverter-defibrillator Placement Under Sedation.

Providing adequate analgesia perioperatively during subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation can be a challenge. The objective of our study was to assess the efficacy and safety of the erector spinae plane (ESP) block technique in providing analgesia and minimizing the risk of opioid use in high-risk patient populations. We enrolled consecutive patients >18 years of age undergoing S-ICD implantation from February 2020 to February 2022 at our center prospectively. Patients were randomly assigned to receive the ESP block or traditional wound infiltration. A total of 24 patients were enrolled, including 13 patients randomized to ESP block and 11 patients as controls who received only wound infiltration. The primary outcome assessed was the overall use of perioperative analgesic medications in the ESP block group versus the surgical wound infiltration group. A significant reduction in intraoperative fentanyl use was observed [median ([interquartile range]) in the ESP block group (0 [0-50] µg) compared to the wound infiltration block group (75 [50-100] µg) (P = .001). The overall postoperative day (POD) 0 fentanyl use was also significantly decreased (75 [50-100] µg) in the ESP block group compared to the surgical wound infiltration group (100 [87.5-150] µg) (P = .049). There was also a trend of decreased POD 0 oxycodone-acetaminophen use. Finally, the number of days to discharge was less in the ESP block group. These results indicate that ESP block is an innovative, safe, and effective technique that decreases intraoperative and postoperative opioid consumption and may be a useful adjunct pain-management technique in these high-risk patients. Larger studies are needed to further validate its use.

Postoperative Pain Management: Efficacy of Caudal Tramadol in Pediatric Lower Abdominal Surgery: A Randomized Clinical Study.

BACKGROUND: One of the methods of pain control after pediatric surgical procedures is regional techniques, including caudal block, despite their limitations. OBJECTIVES: In this study, the pain score and complications of caudal tramadol were evaluated in pediatrics following lower abdominal surgery. METHODS: In this study, 46 children aged 3 to 10 years were allocated into two equal groups (R and TR) for performing caudal analgesia after lower abdominal surgery. The injectate contained 0.2% ropivacaine 1 mL/kg in the R group (control group) and tramadol (2 mg/kg) and ropivacaine in the TR group. The pain score, duration of pain relief, amount of paracetamol consumption, hemodynamic alterations, and possible complications at specific times (1, 2, and 6 hours) were evaluated in both groups. RESULTS: No considerable difference was observed in the pain score between the groups in the first and second hours (P > 0.05). However, in the sixth hour, the TR group had a significantly lower pain score than the R group (P < 0.05). Compared to the R group, the TR group had a longer period of analgesia and lower consumption of analgesic drugs (P < 0.05). Heart rate and blood pressure differences were not significant between the two groups (P > 0.05). Similarly, the duration of operation and recovery time were not remarkably different between the two groups (P > 0.05). Complications had no apparent differences between these two groups, as well (P > 0.05). CONCLUSIONS: In this study, the addition of tramadol to caudal ropivacaine in pediatric lower abdominal surgery promoted pain relief without complications.

High turnover for ambulatory orthopedic surgery.

PURPOSE OF REVIEW: The trend in the perioperative management of patients having orthopedic surgery in the ambulatory setting emphasizes time-efficiency and rapid turnovers. Anesthetic techniques and management continue to evolve to increase efficiency and decrease time spent in recovery. RECENT FINDINGS: Minimizing time patients spend in phase 1 recovery or bypassing phase 1 altogether, known as fast-tracking, has become an important goal in containing costs in high turnover, ambulatory settings. Anesthetic techniques, particularly implementation of regional anesthesia and multimodal analgesia, have evolved to maximize efficiency. SUMMARY: Anesthetic goals in the setting of high-turnover orthopedic surgery include effective multimodal analgesia, decreasing monotherapy with opioids, and patient education. Regional anesthesia as part of a multimodal analgesic regimen is increasingly used in ambulatory surgery fast-tracking protocols.

Use of Serratus Anterior Plane and Transversus Thoracis Plane Blocks for Subcutaneous Implantable Cardioverter-Defibrillator (S-ICD) Implantation Decreases Intraoperative Opioid Requirements.

OBJECTIVES: The present study investigated whether regional anesthetic techniques, especially truncal blocks, can provide adjunct anesthesia without the additional risk of general anesthesia and neuraxial techniques for subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation. DESIGN: Single-center, prospective, randomized study. SETTING: Holding area and operating room at a single-center tertiary care hospital. PARTICIPANTS: The study comprised 22 American Society of Anesthesiologists (ASA) physical status 3 or 4 patients with severe cardiac disease undergoing S-ICD implantation. INTERVENTIONS: Patients received either a combination of serratus anterior plane block and transversus thoracis plane block or surgical infiltration of local anesthetics. MEASUREMENTS AND MAIN RESULTS: Perioperative analgesic medication in the fascial plane block group versus the surgical wound infiltration group, visual analog pain scale score (0-10), intraoperative vital signs, total procedure time, and length of stay in the intensive care unit were measured. Total intraoperative fentanyl requirements (µg) were significantly less in the truncal block group versus the surgical infiltration group (45 [25-50] v 90 [50-100]; p = 0.026), and no patients had any adverse sequelae related to the study. Median intraoperative propofol use in the surgical infiltration group was 66.48 (47.30-73.73) µg/kg/min, and 65.95 (51.86-104.86) µg/kg/min for the truncal block group. This difference between the groups was not statistically significant (p = 0.293). CONCLUSIONS: The performance of both the serratus anterior plane block and transversus thoracis plane blocks for S-ICD implantation are appropriate and may have the benefit of decreasing intraoperative opioid requirements.

Regional Analgesia for Cardiac Surgery. Part 2: Peripheral Regional Analgesia for Cardiac Surgery.

The introduction of regional analgesia in the past decades have revolutionized postoperative pain management for various types of surgery, particularly orthopedic surgery. Nowadays, they are being constantly introduced into other types of surgeries including cardiac surgeries. Neuraxial and paravertebral plexus blocks for cardiac surgery are considered as deep blocks and have the risk of hematoma formation in the setting of anticoagulation associated with cardiac surgeries. Moreover, hemodynamic compromise resulting from sympathectomy in patients with limited cardiac reserve further limits the use of neuraxial techniques. A multitude of fascial plane blocks involving chest wall have been developed, which have been shown the potential to be included in the regional analgesia armamentarium for cardiac surgery. In myofascial plane blocks, the local anesthetic spreads passively and targets the intermediate and terminal branches of intercostal nerves. They are useful as important adjuncts for providing analgesia and are likely to be included in "Enhanced Recovery after Cardiac Surgery (ERACS)" protocols. There are several small studies and case reports that have shown efficacy of the regional blocks in reducing opioid requirements and improving patient satisfaction. This review article discusses the anatomy of various fascial plane blocks, mechanism of their efficacy, and available evidence on outcomes after cardiac surgery.

The Effect of Add-on Buprenorphine to Matrix Program in Reduction of Craving and Relapse Among People With Methamphetamine Use Disorder: A Randomized Controlled Trial.

BACKGROUND: Methamphetamine addiction is a global issue. Buprenorphine might have beneficial roles in reducing craving to methamphetamine use via altering neurotransmission signaling and dopaminergic system-related reward mechanisms. PROCEDURES: This clinical trial was performed in 2019 to 2020 in Khorshid Hospital, Isfahan, Iran. The study was conducted on patients with methamphetamine use disorder. The intervention group received sublingual buprenorphine for 8 weeks, and the other group also received placebo tablets. Patients were followed up and visited every month for the next 4 months. Both groups were treated simultaneously by matrix program for 2 months and observed for the next 4 months. Patients filled out the Cocaine Craving Questionnaire-Brief (CCQ-Brief) every week during intervention time (first 2 months) and every month during follow up visits (4 months). The Depression Anxiety Stress Scale (DASS-21) was also filled out before and after interventions for all of the patients. Data were analyzed using SPSS software using χ2, independent t test and repeated-measure analysis of variance tests. RESULTS: Our data indicated significantly lower CCQ-Brief scores in the intervention group compared with the placebo group (P < 0.05). It was also indicated that changes in CCQ-Brief scores were also significant among both groups (P < 0.001). We also showed that the anxiety, depression, and stress scores reduced significantly after interventions (P < 0.001). These scores were also significantly lower in the intervention group compared with placebo group (P < 0.05). CONCLUSIONS: Buprenorphine may be effective and may have positive potential roles in reducing methamphetamine craving. This drug is also helpful in reducing the anxiety, depression, and stress of patients with methamphetamine use disorders.

Revisiting a case of difficult airway with a rigid laryngoscope.

A cook airway exchange catheter is a long hollow and semirigid catheter which is routinely used for endotracheal tube (ETT) exchange in the intensive care unit setting or even in the operating room in an event of unexpected difficult airway. We describe a novel technique of using an ETT exchanger with the help of a rigid laryngoscope to facilitate intubation as a strategy in a patient with an anticipated difficult airway due to laryngeal cancer presenting as stridor with respiratory distress.

Continuous interscalene block in patients having outpatient rotator cuff repair surgery: a prospective randomized trial.

BACKGROUND: We performed this randomized trial to compare the recovery profile of patients receiving single injection (SISB) and continuous interscalene brachial plexus block (CISB) or general anesthesia (GA) for arthroscopic rotator cuff repair surgery through the first postoperative week. Our primary hypothesis was that the highest pain numeric rating scale (NRS) (worst pain score) at the end of the study week would be lower for patients in the CISB group than for patients in the SISB or GA groups. METHODS: Seventy-one patients scheduled for elective outpatient arthroscopic rotator cuff repair were enrolled. CISB patients received 20 mL of 0.5% ropivacaine as a bolus through a catheter, whereas SISB patients received the same injection volume through a needle. CISB patients received an infusion of 0.2% ropivacaine at 5 mL/h with a patient-controlled bolus of 5 mL hourly for 48 hours. GA-only patients received a standardized general anesthetic. Postoperative highest NRS pain scores through the first postoperative week, time-to-first pain, analgesic consumption, fast-tracked postoperative anesthesia care unit (PACU) bypass rate, length of PACU stay, time-to-discharge home, total hours of sleep, and related adverse effects were recorded in the PACU and at home on postoperative days 1, 2, 3, and 7. RESULTS: No patient in the CISB or SISB groups reported a NRS ≥1 or required analgesics while in the PACU. While most patients in the CISB and SISB groups were fast-tracked to PACU discharge, no patient in the GA group was fast-tracked (Χ P = 0.003). Length of stay in the PACU was significantly shorter for the CISB and SISB groups than for the GA group (20 ± 31, 30 ± 42, and 165 ± 118 minutes, respectively (CISB vs GA, P < 0.001; SISB vs GA, P <0.001), and time-to-discharge home was significantly shorter when compared with the GA group. Time to first pain report was longer in the CISB group. Mean NRS scores were lower for patients in the CISB group than in the SISB and GA groups on postoperative days 1 and 2, and use of narcotics (doses ≥1) was lower until postoperative day 3. Patients who received CISB slept significantly longer than patients who received SISB or GA (P < 0.01) during the first 48 hours postoperatively. By the end of the study week, 26% of patients in the CISB group, 83% in the SISB group, and 58% of GA patients reported NRS ≥4 (both P-values ≤ 0.05). CONCLUSION: The analgesic benefits of CISB found in the PACU and immediately after discharge extend through the intermediate recovery period ending on postoperative day 7.

High-definition ultrasound imaging defines the paraneural sheath and the fascial compartments surrounding the sciatic nerve at the popliteal fossa.

BACKGROUND AND OBJECTIVES: The connective tissue layers that surround the sciatic nerve at the popliteal fossa are poorly defined. We present high-definition ultrasound images of the sciatic nerve, which were acquired during ultrasound-guided popliteal sciatic nerve block (SNB), that clearly demonstrate these fascial layers. METHODS: Four patients undergoing hallux valgus surgery received an ultrasound-guided popliteal SNB using a high-definition ultrasound system. In the ultrasound images, the paraneural sheath was identified as a hyperechoeic fascial layer between the outer surface of the sciatic nerve (epineurium) and the epimysium of the surrounding muscles. The paraneural sheath was distinct from the epineurium, better delineated after the local anesthetic injection, and enveloped not only the sciatic nerve but also the common peroneal and tibial nerves separately. In the postblock sonograms, the local anesthetic was compartmentalized into 2 broad areas, that is, external (subepimyseal) and internal (subparaneural) to the paraneural sheath. The popliteal SNB was effective for surgical anesthesia in all 4 patients. CONCLUSIONS: We have demonstrated the paraneural sheath and the fascial compartments, that is, the "subepimyseal perineural compartment" and the "subparaneural compartment" that surround the sciatic nerve and act as conduits for local anesthetic spread during a popliteal SNB.

Comparison of the Shear Bond Strength of Resin Modified Glass Ionomer to Enamel in Bur-Prepared or Lased Teeth (Er:YAG).

OBJECTIVE: The purpose of this study was to evaluate the effect of Er:YAG laser on the shear bond strength of resin modified glass ionomer (RMGI) to enamel. MATERIALS AND METHODS: Twenty extracted caries-free human premolars were selected. The teeth were embedded in acrylic resin. The buccal surfaces of each sample were ground to plane enamel with carbonated disc. The teeth were randomly divided in two groups. In the first group, the surfaces were treated by Er:YAG laser (350mJ/10Hz). The second group was prepared by carbide bur. Fuji IX RMGI was adhered to surfaces of the samples in both groups in rod shape. The shear bond strength of samples was measured by a universal testing machine. The results of the two groups were analyzed by T- test. RESULTS: The means and standard deviations of shear bond strength of the laser-treated group and the bur-treated group were 6.75 ± 1.99 and 4.41 ± 1.62 Mpa, respectively. There is significant difference in the shear bond strength of RMGI between the two groups (P-value=0.01). CONCLUSION: The laser group showed better results. Er:YAG laser can be an alternative technology in restorative dentistry.