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.

Nerve block, nerve damage, and fluid injection pressure: overturning the myth.

Histological and micro-ultrasound evidence rebuffs deep-rooted views on the nature of nerve block, nerve damage, and injection pressure monitoring. We propose that the ideal position of the needle tip for nerve block is between the innermost circumneural fascial layer and outer epineurium, with local anaesthetic passing circumferentially through adipose tissue. Thin, circumferential, subepineural expansion that is invisible to the naked eye was identified using micro-ultrasound, and could account for variability of outcomes in clinical practice. Pressure monitoring cannot differentiate between intrafascicular and extrafascicular injection. High injection pressure only indicates intraneural extrafascicular spread, not intrafascicular spread, because it is not possible to inject into the stiff endoneurium in most human nerves.

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.

Lumbar erector spinae plane block versus infrainguinal fascia iliaca compartment block for pain management after total hip arthroplasty: a randomized clinical trial.

OBJECTIVE: We aimed to evaluate the effectiveness of ultrasound-guided facia iliaca compartment (FIC) and erector spinae plane (ESP) blocks in managing postoperative pain after total hip arthroplasty surgery. METHODS: A total of 60 patients were randomized into 2 groups (n = 30): one that received FIC blocks and one that received ESP blocks. FIC and ESP blocks were performed with 30 mL 0.25% bupivacaine at the end of the surgery. The patients received intravenous tramadol and patient-controlled postoperative analgesia. The pain scores, opioid consumption, and adverse events were recorded. RESULTS: The dynamic pain scores on movement in the postoperative first hour were significantly lower in the ESP block group than in the FIC block group (3 [2-4] vs 4 [2-5], respectively; P = .035). Data are expressed as median (25th-75th percentiles). Postoperative opioid consumption within the first postoperative 8 hours was significantly higher in the FIC block group than in the ESP block group (80 mg [61-100] vs 100 mg [80-120], respectively; P = .010). The adverse effects of opioids did not differ between the 2 groups. CONCLUSION: ESP and infrainguinal FIC blocks provided similar postoperative analgesia 24 hours after total hip arthroplasty. The ESP block is more beneficial than the FIC block in terms of pain scores and opioid consumption in the early hours of the postoperative period. TRIAL REGISTRATION: www.ClinicalTrials.gov (ID: NCT05621161).

Trigeminal Postherpetic Neuralgia: From Pathophysiology to Treatment.

PURPOSE OF REVIEW: Trigeminal postherpetic neuralgia (TG-PHN) is a neuropathic pain condition complicating herpes zoster (HZ) attributed to the trigeminal nerve. It poses significant challenges due to its persistent and debilitating nature. This review explores the clinical characteristics of TG-PHN, analyzes its pathophysiological underpinnings, and addresses existent and potential therapies. RECENT FINDINGS: TG-PHN is one of the most common and complex PHN locations. It has distinguishing clinical and pathophysiological characteristics, starting with viral triggered injuries to the trigeminal ganglion (TG) and peripheral tissue and involving the ascending and descending brain modulation pathways. Current therapies include vaccines, oral and topical medications, and interventional approaches, like nerve blocks and neurostimulation. This review covers TG-PHN's clinical and physiological components, treatment options, and potential future targets for improved management. By exploring the complexities of this condition, we aim to contribute to developing more effective and targeted therapies for patients suffering from trigeminal PHN.

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).

Postoperative quality of recovery with erector spinae plane block or thoracolumbar interfascial plane block after major spinal surgery: a randomized controlled trial.

PURPOSE: Major spinal surgery causes severe postoperative pain. The present randomized, controlled, prospective study tested the short- and long-term effects of thoracolumbar interfascial and erector spinae plane blocks on patient-centered outcomes for major lumbar spinal surgery. METHODS: Sixty adult patients were randomly assigned to receive either bilateral thoracolumbar interfascial plane or erector spinae plane block after anesthesia induction using bupivacaine 0.25%, 20 mL. The primary outcome of this study was the Quality of Recovery-40 score in the postoperative 24th hour. Secondary outcomes were Comprehensive Complication Index scores, postoperative pain scores, opioid consumption, first rescue analgesic administration time, and complication incidence. RESULTS: The recovery scores of both blocks at the postoperative 24th hour were similar, with a median thoracolumbar interfascial plane block of 178 (IQR 173-180) and an erector spinae plane block of 175 (IQR 168.7-182) (p = 0.717). Thoracolumbar interfascial plane block reduced area under the curve pain with movement over 24 h compared with erector spinae plane block (p = 0.024). The pain scores between the groups were similar at all time points (p > 0.05), except the 24th hour with movement in the thoracolumbar interfascial plane block compared with the erector spinae plane block [median 3 (IQR 2-4)] vs. 4 (IQR 3-5), respectively] (p = 0.019). No differences were recorded between the block groups regarding postoperative 24th-h oxycodone consumption, time to first opioid intake, and complication incidence (p > 0.05). CONCLUSIONS: Both blocks resulted in similar quality of recovery in the postoperative 24-h period in major spinal surgery and were effective in terms of analgesia.

A novel nerve block technique for nail surgery.

In pediatric patients, nail unit anesthesia is frequently required for procedures including matrixectomy or nail avulsion. However, nail unit anesthesia is very painful and requires a significant amount of time to take complete effect, causing a great deal of distress for most pediatric patients. By targeting the palmar and dorsal digital nerves in the distal part of the fingers, our method enables fast, simple, and less painful anesthesia.

Quadratus Lumborum Block and Transversus Abdominis Plane Block in Non-emergency Cesarean Delivery: A Systematic Review and Meta-analysis.

PURPOSE: Investigate the analgesic efficacy of quadratus lumborum (QL) block versus transversus abdominis plane (TAP) block in postoperative pain management in nonemergent cesarean section. DESIGN: Systematic review with meta-analysis. METHODS: PubMed, Cochrane, CINAHL, Google Scholar, and gray literature were searched for evidence. Only randomized controlled trials examining the effects of QL and TAP block for nonemergent cesarean delivery were included. Mean difference (MD) was used to estimate continuous outcomes with appropriate effect models. The quality of evidence was rated using the Risk of Bias and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system. FINDINGS: Six studies involving 543 parturients were included. Compared to the TAP block, the cumulative 24-hour pain score at rest (MD, -0.60; 95% CI, -1.03 to -0.17; P = .007) and during activity (MD, -1.05; 95% CI, -1.54 to -0.56; P < .0001) were significantly lower in QL block. Time to the first analgesic rescue (MD, 21.67; 95% CI, -18.58 to 61.91; P = .29) and opioid consumption (MD, -1.96; 95% CI, -4.59 to 0.66; P = .14) were similar in both groups. No difference was found in the incidence of postoperative nausea and vomiting and sedation. However, patients treated with QL block reported higher patient satisfaction scores. CONCLUSIONS: There is limited evidence to suggest that QL block is superior to TAP block for postoperative pain management in nonemergent cesarean delivery. The study limitations must be considered when extrapolating the review's findings to clinical practice.

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.

Superior Hypogastric Nerve Blockade for Uterine Artery Embolization: A Systematic Review.

Superior hypogastric nerve block (SHNB) has potential to reduce pain following uterine artery embolization (UAE). However, existing studies are limited by design, sample size, or conflicting results. A systematic review of the literature was performed. Outcomes included technical success, time to complete SHNB, time under fluoroscopy, procedure time, time to recovery, needle repositioning, same-day discharge, readmission, pain, analgesic consumption, and adverse events. Of 15 included studies, the same-day discharge rate was 98.8%, and readmission rate was 6.9%. The mean pain score was 3.4 in patients who received SHNB compared to 4.3 among controls. Of patients who received SHNB, 46.7% did not require further pain medication. Major adverse events occurred in 0.4% of patients. Early clinical studies suggest that SHNB appears to reduce pain and analgesic consumption in patients undergoing UAE. Additional randomized trials are needed to confirm these findings.

Influence of Regional Nerve Block in Addition to General Anesthesia on Postoperative Delirium, Pain, and In-hospital Stay in Patients Undergoing Cardiothoracic Surgery: A Meta-analysis.

ABSTRACT: This study aims to investigate whether venous injection of sedative agent or regional nerve block in alliance with major anesthesia could decrease the risk of postoperative delirium occurrence in patients receiving cardiothoracic surgery. Electronic academic databases were retrieved for related publications, and statistical software was used for data pooling and analysis. Forest plot was used to show the pooled sensitivity, specificity, and diagnostic odds ratio. Combined receiver operating characteristic curve was used to show the area under the curve of complex data. Seven studies were included for analysis. The risk of occurrence of delirium still showed no difference (risk rate = 0.93, 95% CI, 0.85-1.03) between the intervention group and placebo group. Postoperative pain feeling was more alleviated in patients with prophylactic application of regional nerve block. In addition, prophylactic application of regional nerve block could decrease the risk of postoperative in-hospital stay (risk rate = 0.28, 95% CI, 0.02-0.54). Our study demonstrated that, in elderly patients or pediatric patients undergoing cardiac surgery, prophylactic application of regional nerve block failed to decrease the incidence of postoperative delirium. However, the option of regional nerve block could decrease the duration of in-hospitalization stay and alleviate the acute pain during the postoperative period after open-heart surgery.

Outcomes in pediatric liver transplant recipients receiving bilateral continuous erector spinae plane blocks.

BACKGROUND: Regional anesthesia allows for opioid-sparing and enhanced recovery after many major surgeries. Erector spinae blockade, with reduced bleeding risk and the option for continuous infusion, offers an opportunity to promote this principle in pediatric liver transplant patients. Our goal was to evaluate pain scores, opioid use, and return of bowel function following continuous ESP blockade in pediatric liver transplant recipients. METHODS: This retrospective cohort study included extubated patients who received a liver transplant at St. Louis Children's Hospital from July 2016 to July 2021. The control group, which did not meet the criteria for ESP blockade and received standard analgesia regimens, was compared to the group receiving continuous ESP blockade. Measured outcomes included pain scores, opioid consumption through postoperative day two, date of first bowel movement, and length of stay in the ICU and the hospital. RESULTS: Patient demographics between control and ESP groups showed no significant differences. Pain scores between control and ESP groups also showed no significant differences. Intraoperative and postoperative opioid requirements, studied in oral morphine equivalents per kilogram (OME/kg), were significantly lower for patients with ESP blockade. Time to first bowel movement was also significantly earlier for the ESP group. No significant differences were found in length of ICU or hospital stay. There were no safety concerns or complications related to ESP blockade. CONCLUSIONS: Use of continuous ESP blockade resulted in reduced opioid consumption through postoperative day two and earlier return of bowel function.

Pro-Con Debate: Peripheral Nerve Blockade Should Be Provided Routinely in Extremity Trauma, Including in Patients At Risk for Acute Compartment Syndrome.

In this Pro-Con commentary article, we discuss the controversial debate of whether to provide peripheral nerve blockade (PNB) to patients at risk of acute extremity compartment syndrome (ACS). Traditionally, most practitioners adopt the conservative approach and withhold regional anesthetics for fear of masking an ACS (Con). Recent case reports and new scientific theory, however, demonstrate that modified PNB can be safe and advantageous in these patients (Pro). This article elucidates the arguments based on a better understanding of relevant pathophysiology, neural pathways, personnel and institutional limitations, and PNB adaptations in these patients.

Anatomical and Radiological Assessments of Injectate Spread Stratified by the Volume of the Pericapsular Nerve Group Block.

BACKGROUND: The pericapsular nerve group (PENG) block was recently suggested as a regional technique for managing acute pain after hip surgery. However, few anatomical studies have confirmed the spread of injectate during the PENG block. This cadaver study aimed to analyze injectate spread to the target nerves during single-injection ultrasound-guided PENG block. METHODS: Ultrasound-guided PENG block with 3 different injectate volumes (10, 20, or 30 mL) was performed in 18 cadavers. Injectate spread by the volume was first evaluated on computed tomography, followed by cadaver dissection. The spread of the dye over the pelvis and lower limb was evaluated. RESULTS: The articular branches of the femoral nerve were stained nearly sufficiently with 20- and 30-mL specimens. The femoral nerve itself was stained simultaneously in six of 12 (50%) 20-mL specimens and 12 of 12 (100%) 30-mL specimens. The accessory obturator nerve was observed only in three (9%) of 36 specimens. The articular branches of the obturator nerve were rarely affected, regardless of injectate volume (1/12, 10 mL specimens; 2/12, 20 mL specimens; 1/12, 30 mL specimens; P > .999). Rather, the obturator nerve was affected. However, the obturator nerve was not stained consistently even with 30 mL of injectate (50%). CONCLUSIONS: After combining the dissection and radiological findings, the single-injection ultrasound-guided PENG blocks with volumes of 10, 20, and 30 mL do not support motor sparing or selective anterior hip capsule innervation in a clinical setting. If early rehabilitation is needed, high-volume PENG block might not be the ideal option, and persisting pain after PENG block might be attributed in part to the lack of obturator nerve articular branches blockade.

Analgesic Efficacy of Quadratus Lumborum Block in Patients Undergoing Nephrectomy: A Systematic Review and Meta-Analysis.

OBJECTIVE: To evaluate the analgesic efficacy of quadratus lumborum block (QLB) in adults undergoing nephrectomy. DESIGN: Systematic review and meta-analysis. PATIENTS: Adult patients (≥18 years of age) received nephrectomy under general anesthesia. METHODS: We searched PubMed, Embase, the Cochrane Library, and Web of Science on January 10, 2022, including randomized controlled trials that evaluated the analgesic efficacy of QLB for patients undergoing nephrectomy. RESULTS: A total of 12 randomized controlled trials (N = 821 patients) were included in the study. Compared with the non-block, single-shot QLB reduced postoperative opioid consumption (mean difference [MD], -8.37 mg intravenous morphine equivalent; 95% confidence interval [CI], -12.19 to -4.54 mg) and pain scores at 2 hours, 6 hours, 12 hours, and 24 hours at rest and during movement after nephrectomy. Single-shot QLB also prolonged the time to first analgesic request (MD, 6.44 hours; 95% CI, 2.23 to 10.65 hours), shortened the length of hospital stay (MD, -0.32 day; 95% CI, -0.55 to -0.09 day), and decreased the incidence of postoperative nausea and vomiting (risk ratio, 0.48; 95% CI, 0.36 to 0.65). Compared with continuous epidural anesthesia, repeated QLB could provide comparable postoperative analgesic benefits. CONCLUSIONS: Single-shot QLB provided a statistically significant but clinically small improvement in postoperative analgesia and recovery for patients undergoing nephrectomy. The QLB would be beneficial as part of multimodal analgesia. Future research might need to determine which approach of QLB is superior for postoperative analgesia after nephrectomy.

Chemical neurolysis of the genicular nerves for chronic refractory knee pain: an observational cohort study.

OBJECTIVE: Evaluate outcomes of genicular nerve chemical neurolysis (GChN) in a real-world population with chronic knee pain. DESIGN: Restrospective, observational cohort study. SETTING: Tertiary academic medical center. SUBJECTS: Consecutive patients who had undergone GChN ≥3 months prior. METHODS: Standardized surveys were collected by telephone and included the numerical rating scale, opioid analgesic use, and Patient Global Impression of Change. Age, sex, body mass index, duration of pain, history of arthroplasty, lack of effect from previous radiofrequency ablation, percentage relief from a prognostic block, and volume of phenol used at each injection site were extracted from charts. Descriptive statistics were calculated, and logistic regression analyses were performed to identify factors influencing treatment outcome. RESULTS: At the time of follow-up after GChN (mean ± SD: 9.9 ± 6.1 months), 43.5% (95% CI = 33.5-54.1) of participants reported ≥50% sustained pain reduction. On the Patient Global Impression of Change assessment, 45.9% (95% CI = 35.5-56.7) of participants reported themselves to be "very much improved" or "much improved." Of 40 participants taking opioids at baseline, 11 (27.5%; 95% CI = 14.6-43.9) ceased use. Of participants with a native knee treated, 46.3% reported ≥50% pain reduction, whereas of participants with an arthroplasty in the treated knee, 33.3% reported this threshold of pain reduction (P = .326). Logistic regression analyses did not reveal associations between treatment success and any of the factors that we evaluated. CONCLUSIONS: GChN could provide a robust and durable treatment effect in a subset of individuals with chronic knee pain with complicating factors traditionally associated with poor treatment outcomes, such as those with pain refractory to radiofrequency ablation or those who have undergone arthroplasty.

Complications and Technical Consideration of Ultrasound-Guided Rectus Sheath Blocks: A Retrospective Analysis of 4033 Patients.

BACKGROUND: Although the ultrasound-guided rectus sheath block (RSB) is usually regarded as an easy and safe procedure in clinical settings, there is currently no report on complications incidence. Therefore, the present study investigated complications in a large cohort and described the technical considerations to minimize complications of real-time ultrasound-guided RSBs. METHODS: This was a retrospective cohort study of patients who underwent real-time ultrasound-guided RSBs for perioperative pain control in laparoscopic surgery with an umbilical port between February 1, 2017, and February 28, 2021, at the Asan Medical Center in South Korea. All RSBs were performed bilaterally using a 23-gauge Quincke needle, and a bilateral 2-block placement was regarded as 1 RSB. Patient data, including demographics, preoperative laboratory data, preoperative antiplatelet or anticoagulant medication with the duration of discontinuation, and type of surgery, were collected to show the study population characteristics and explore potential factors associated with adverse events such as hematoma. Ultrasound images of patients and adverse events of RSBs, including extrarectus sheath injections, vascular injuries, bowel injury, or local anesthetic systemic toxicity, were also analyzed accordingly. RESULTS: A total of 4033 procedures were analyzed. The mean body mass index of the patients was 24.1 (21.8-26.5) kg/m2. The preoperative laboratory data were within normal range in 4028 (99.9%) patients. Preoperative antiplatelets or anticoagulants were administered in 17.3% of the patients. Overall, 96 complications (2.4%) were observed. Among them, extrarectus sheath injection occurred in 88 cases (2.2%), which included preperitoneal injection (0.9%) and intraperitoneal injection (1.3%). Vascular injuries constituted 8 cases (0.2%) and all vascular injuries resulted in hematoma: 7 cases of inferior epigastric artery injury with rectus sheath hematoma and 1 of inferior mesenteric artery injury with retroperitoneal hematoma. Bowel injury or local anesthetic systemic toxicity was not reported. CONCLUSIONS: In this study of RSBs performed on 4033 patients using a 23-gauge Quincke needle in patients with low body mass index, there were 8 cases (0.2%) of vascular injury, all of which accompanied hematoma.

Effect of erector spinae plane block with different doses of dexmedetomidine as adjuvant for ropivacaine on the postoperative quality of recovery after video-assisted thoracoscopic lobectomy surgery: a randomized controlled trial.

BACKGROUND: Erector spinae plane block (ESPB) improves postoperative analgesia and significantly enhances the quality of recovery (QoR) after video-assisted thoracoscopic lobectomy surgery (VATLS). However, it is not known whether the use of dexmedetomidine (Dex) as an adjunct for ropivacaine to ESPB affects the QoR after VATLS. The purpose of this study was to explore the effects of different Dex dosages as an adjunct for ropivacaine in combination with ultrasound-guided ESPB on the quality of postoperative recovery in patients with VATLS. METHODS: In this single-center, double-blind, randomized study, 120 patients between the ages of 18 and 65 who were scheduled for VATLS from december 2021 and october 2022 in our hospital under general anesthesia were randomly divided into three groups: ultrasound-guided ESPB with 30 mL of 0.5% ropivacaine (Group R), ultrasound-guided ESPB 0.5% ropivacaine plus 0.5 µg/kg Dex (Group RD1), and ultrasound-guided ESPB 0.5% ropivacaine plus 1.0 µg/kg Dex (Group RD2), ultrasound-guided ESPB was administrated at the T5 vertebral level before surgery. The primary outcome was the QoR-15 score 24 h after the surgery. The secondary outcomes included the QoR-15 scores at 12 h, 48 h, and 72 h after the operation, visual analogue scale (VAS) scores at 8 h, 12 h, 24 h, and 48 h after surgery, cumulative flurbiprofen consumption, postoperative nausea and vomiting (PONV), postoperative bradycardia, and hypotension. RESULTS: The QoR-15 scores were higher in group RD2 than the R and RD1 groups on postoperative day 1 (P < 0.05), in addition, no significant difference was found in the QoR-15 scores between groups R and RD1 on postoperative day 1. The VAS scores were significantly lower in group RD2 than in groups RD1 and group R 12-24 h after surgery (P < 0.05). No significant differences were observed in the QoR-15 and VAS scores at 48 and 72 h after surgery between the three groups. The cumulative flurbiprofen consumption was markedly reduced during the 72 h after surgery in the RD2 group (P < 0.05). The incidence of postoperative nausea and vomiting was lower in the RD2 group (P < 0.05). CONCLUSIONS: The combination of 1 µg/kg dexmedetomidine as an adjunct with 0.5% ropivacaine 30 ml for erector spinae plane block significantly improved the postoperative quality of recovery and provided better postoperative analgesia on postoperative day 1 in patients undergoing Video-assisted thoracoscopic lobectomy surgery. However, dexmedetomidine (1 µg/kg) as an adjunct for ropivacaine combined with erector spinae plane block did not enhance the postoperative quality of recovery at 48 and 72 h postoperatively. TRIAL REGISTRY NUMBER: The number of this clinical trial registry is ChiCTR2100053230, date of registration: 16/11/ 2021).

Pectoral Fascial Plane Versus Paravertebral Blocks for Minimally Invasive Mitral Valve Surgery Analgesia.

OBJECTIVES: This study examined the postoperative analgesic efficacy of single-injection pectoral fascial plane (PECS) II blocks compared to paravertebral blocks for elective robotic mitral valve surgery. DESIGN: A single-center retrospective study that reported patient and procedural characteristics, postoperative pain scores, and postoperative opioid use for patients undergoing robotic mitral valve surgery. SETTING: This investigation was performed at a large quaternary referral center. PARTICIPANTS: Adult patients (age ≥18) admitted to the authors' hospital from January 1, 2016, to August 14, 2020, for elective robotic mitral valve repair who received either a paravertebral or PECS II block for postoperative analgesia. INTERVENTIONS: Patients received an ultrasound-guided, unilateral paravertebral or PECS II nerve block. MEASUREMENTS AND MAIN RESULTS: One hundred twenty-three patients received a PECS II block, and 190 patients received a paravertebral block during the study period. The primary outcome measures were average postoperative pain scores and cumulative opioid use. Secondary outcomes included hospital and intensive care unit lengths of stay, need for reoperation, need for antiemetics, surgical wound infection, and atrial fibrillation incidence. Patients receiving the PECS II block required significantly fewer opioids in the immediate postoperative period than the paravertebral block group, and had comparable postoperative pain scores. No increase in adverse outcomes was noted for either group. CONCLUSIONS: The PECS II block is a safe and highly effective option for regional analgesia for robotic mitral valve surgery, with demonstrated efficacy comparable to the paravertebral block.