Comparison of Postoperative Opioid Consumption of Paravertebral Block and Erector Spinae Plane Block After Thoracotomy: A Randomized Controlled Trial.

Background Thoracotomy is associated with severe postoperative pain. Pain developing after thoracotomy causes lung infections, inability to expel secretions, and atelectasis as a result of deep breathing. Effective management of acute pain after thoracotomy may prevent these complications. A multimodal approach to analgesia is widely employed by thoracic anesthetists using a combination of regional anesthetic blockade and systemic analgesia, with both non-opioid and opioid medications and local anesthesia blockade. Nowadays, regional anesthesia techniques such as thoracic epidural paravertebral block (PVB), erector spinae plane block (ESPB), and serratus plane block are frequently used to prevent pain after thoracotomy. In this study, we compared paravertebral block with erector spinae block for pain relief after thoracotomy. Our primary aim was to determine whether there was a difference between postoperative opioid consumption and pain scores. We also compared the two regional anesthesia techniques in terms of intraoperative hemodynamic data and postoperative complications. Methodology Patients aged between 18 and 75 years with an American Society of Anesthesiology (ASA) physical status I-III and scheduled for elective thoracotomy were included in the study. Using www.randomizer.org, patients were divided into two different groups, namely, ESPB and PVB. All patients were provided with a patient-controlled analgesia device preloaded with morphine. Postoperative 24-hour morphine consumptions were recorded. Results Data from 45 patients were used in the final analyses. Morphine consumption was higher in the ESPB group than in the PVB group at 24 hours postoperatively (19.2 ± 4.26 mg and 16.2 ± 2.64 mg, respectively; p < 0.05). There was no significant difference in numerical rating scale scores both at rest and with coughing (p > 0.05). Intraoperative heart rates were similar between groups. However, mean intraoperative blood pressure was significantly lower in the PVB group at 30 minutes (p < 0.05). Nausea and vomiting were observed in two patients in the ESPB group and one patient in the PVB group. The complication of nausea and vomiting was not statistically significant between the two groups (p > 0.05). Catastrophic complications such as hematoma, pneumothorax, and local anesthetic systemic toxicity were not observed in either group. Conclusions We found that patients who underwent PVB consumed less morphine postoperatively than patients who underwent ESPB. However, we did not observe any difference in pain scores between both groups. We think that ESPB can be considered a reliable method in thoracotomy surgery due to its ease of application and the fact that the place where the block is technically performed is farther from the central structures compared to PVB. In light of the results of our study, ESPB can be used as an alternative to PVB, which has been proven as postoperative analgesia in thoracic surgery.

The Effect of Modified Early Warning Score (MEWS) and Nursing Guide Application on Postoperative Patient Outcomes: A Randomized Controlled Study.

PURPOSE: The aim of this study is to determine the effect of nursing guide application (NGA) on patient outcomes in patients followed up according to the modified early warning score (MEWS) in the postoperative period. DESIGN: A randomized controlled clinical trial. METHODS: The sample of the study consisted of 252 patients who underwent surgical intervention under general anesthesia in a university hospital between July 29, 2022, and October 31, 2022. FINDINGS: Results showed that the development of complications was less in the study group (SG) compared to the control group (CG) during anesthesia (P = .027), in the postanesthesia care unit (PACU) (P = .017), and in the clinic (P = .001). It was found that the duration of stay in PACU in the CG was significantly shorter than in the study group (P < .001), and as the duration of stay in PACU in CG decreased, the MEWS increased (r = -0.201, P = .024). We found that there were fewer patients transferred to the intensive care unit (ICU) after PACU (P = .007), the MEWS was lower, and the number of nursing interventions applied to patients was higher (P < .05). CONCLUSIONS: In patients followed up according to MEWS, NGA had a positive effect on preventing the development of complications and shortening the intervention time for complications, decreasing ICU admission, decreasing MEWS and increasing the number of nursing interventions. Based on the results, it may be recommended to use MEWS+NGA in the early postoperative period as it positively affects patient outcomes.

[Plan A blocks]. / Plan A bloklari.

With the increase in ultrasound use, regional anesthesia practices have gained popularity and many novel techniques are being described. However, the rapidly increasing number of new block techniques also led to confusion. Therefore, seven basic regional anesthesia techniques that are effective in most of the surgeries have been listed as 'Plan A Blocks.' The purpose of this review is to introduce the basic sono-anatomy and indications of Plan A blocks.

Modified pectoral nerve block versus bi-level erector spinae plane block for postoperative analgesia after radical mastectomy surgery: a prospective, randomized, controlled trial.

BACKGROUND: Regional anesthesia techniques constitute an important part of successful analgesia strategies in the perioperative care of patients undergoing breast surgery. The advent of ultrasound-guided regional anesthesia has led to the development of fascial plane blocks. The large array of blocks available for postoperative analgesia in breast surgery has increased the accessibility of regional anesthesia but has also created a dilemma of choice. This study compared the analgesic efficacy of the ultrasound-guided modified pectoral nerve (PECS) block and erector spinae plane block (ESPB) in patients undergoing radical mastectomy. METHODS: Seventy women were enrolled in this prospective, double-blind, randomized control trial. After exclusion, 67 female patients who underwent radical mastectomy were finally analyzed. Ultrasound-guided PECS blocks and ESPBs were performed with 30 ml 0.25% bupivacaine. Postoperative morphine and pain scores were compared between the groups. RESULTS: Postoperative total morphine consumption in the first 24 h was significantly higher in the PECS group (P < 0.001). The ESPB group exhibited significantly reduced morphine consumption at all postoperative time points. Numeric rating scale scores were lower in the ESPB group at 6, 12, and 24 h postoperatively at rest and when coughing. CONCLUSIONS: Ultrasound-guided bi-level ESPBs provided better postoperative analgesia than PECS blocks after radical mastectomy surgery.

Bilateral versus unilateral erector spinae plane block for postoperative analgesia in laparoscopic cholecystectomy: a randomized controlled study

Abstract Introduction Laparoscopic cholecystectomy (LC) is the common surgical intervention for benign biliary diseases. Postoperative pain after LC remains as an important problem, with two components: somatic and visceral. Trocar entry incisions lead to somatic pain, while peritoneal distension with diaphragm irritation leads to visceral pain. Following its description by Forero et al., the erector spinae plane (ESP) block acquired considerable popularity among clinicians. This led to the use of ESP block for postoperative pain management for various operations. Materials and methods This study was conducted between January and June 2019. Patients aged between 18 and 65 years with an American Society of Anesthesiologists (ASA) physical status I-II, scheduled for elective laparoscopic cholecystectomy were included in the study. All the patients received bilateral or unilateral ESP block at the T8 level preoperatively according to their groups. Results There was no significant difference between the groups in terms NRS scores either at rest or while coughing at any time interval except for postoperative 6th hour (p = 0.023). Morphine consumption was similar between the groups but was significantly lower in group B at 12 and 24 hours (p = 0.044 and p = 0.022, respectively). Twelve patients in group A and three patients in group B had shoulder pain and this difference was statistically significant (p = 0.011). Discussion In conclusion, bilateral ESP block provided more effective analgesia than unilateral ESP block in patients undergoing elective LC. Bilateral ESP block reduced the amount of opioid consumption and the incidence of postoperative shoulder pain.

Bilateral versus unilateral erector spinae plane block for postoperative analgesia in laparoscopic cholecystectomy: a randomized controlled study.

INTRODUCTION: Laparoscopic cholecystectomy (LC) is the common surgical intervention for benign biliary diseases. Postoperative pain after LC remains as an important problem, with two components: somatic and visceral. Trocar entry incisions lead to somatic pain, while peritoneal distension with diaphragm irritation leads to visceral pain. Following its description by Forero et al., the erector spinae plane (ESP) block acquired considerable popularity among clinicians. This led to the use of ESP block for postoperative pain management for various operations. MATERIALS AND METHODS: This study was conducted between January and June 2019. Patients aged between 18 and 65 years with an American Society of Anesthesiologists (ASA) physical status I.ÇôII, scheduled for elective laparoscopic cholecystectomy were included in the study. All the patients received bilateral or unilateral ESP block at the T8 level preoperatively according to their groups. RESULTS: There was no significant difference between the groups in terms NRS scores either at rest or while coughing at any time interval except for postoperative 6th hour (p = 0.023). Morphine consumption was similar between the groups but was significantly lower in group B at 12 and 24 hours (p = 0.044 and p = 0.022, respectively). Twelve patients in group A and three patients in group B had shoulder pain and this difference was statistically significant (p = 0.011). DISCUSSION: In conclusion, bilateral ESP block provided more effective analgesia than unilateral ESP block in patients undergoing elective LC. Bilateral ESP block reduced the amount of opioid consumption and the incidence of postoperative shoulder pain.

Deciding between moral priorities and COVID-19 avoiding behaviors: A moral foundations vignette study.

Novel moral norms peculiar to the COVID-19 pandemic have resulted in tension between maintaining one's preexisting moral priorities (e.g., loyalty to one's family and human freedoms) and avoiding contraction of the COVID-19 disease and SARS COVID-2 virus. By drawing on moral foundations theory, the current study questioned how the COVID-19 pandemic (or health threat salience in general) affects moral decision making. With two consecutive pilot tests on three different samples (ns ≈ 40), we prepared our own sets of moral foundation vignettes which were contextualized on three levels of health threats: the COVID-19 threat, the non-COVID-19 health threat, and no threat. We compared the wrongness ratings of those transgressions in the main study (N = 396, M age = 22.47). The results showed that the acceptability of violations increased as the disease threat contextually increased, and the fairness, care, and purity foundations emerged as the most relevant moral concerns in the face of the disease threat. Additionally, participants' general binding moral foundation scores consistently predicted their evaluations of binding morality vignettes independent of the degree of the health threat. However, as the disease threat increased in the scenarios, pre-existing individuating morality scores lost their predictive power for care violations but not for fairness violations. The current findings imply the importance of contextual factors in moral decision making. Accordingly, we conclude that people make implicit cost-benefit analysis in arriving at a moral decision in health threatening contexts. Supplementary Information: The online version contains supplementary material available at 10.1007/s12144-021-01941-y.

Comparison of haemodynamic response to tracheal intubation with two different videolaryngoscopes: A randomized clinical trial.

BACKGROUND: Endotracheal intubation (ETI), which is the gold standard in coronary artery bypass grafting (CABG), may cause myocardial ischaemia by disturbing the balance between haemodynamic changes and oxygen supply and consumption of the myocardium as a result of sympathetic stimulation. In this study, we aimed to compare two different videolaryngoscopes (C-MAC and Airtraq) in the hemodynamic response to ETI. METHODS: Fifty ASA II...III CABG surgery patients were randomly assigned to C-MAC or Airtraq. The hemodynamic data included arterial blood pressure [systolic (SAP), diastolic (DAP) and mean (MAP)] and heart rate (HR) and were recorded at six different points in time: before laryngoscopy-T1, during laryngoscopy-T2, immediately after intubation-T3, and 3 (T4), 5 (T5) and 10 (T6) minutes after intubation. Intraoperative complications were recorded. Patients were questioned about postoperative complications 2 and 24...hours following extubation. RESULTS: The hemodynamic response to ETI was significantly greater with C-MAC. The increase in HR started with the laryngoscopy procedure, whereas increases in SAP, DAP, and MAP started immediately after ETI (p...=...0.024; p...=...0.012; p...=...0.030; p...=...0.009, respectively). In group analyses, T1...T2, T2...T3 and T1...T3 comparisons did not show any significant differences in HR with Airtraq. However, with C-MAC, HR after intubation increased significantly compared to the pre-laryngoscopy values (T1...T3) (p...=...0.004). The duration of laryngoscopy was significantly reduced with C-MAC (p...<...0.001), but the duration of intubation and total intubation were similar (p...=...0.36; p...=...0.79). CONCLUSIONS: Compared to C-MAC, the hemodynamic response to ETI was less with Airtraq. Thus, Airtraq may be preferred in CABG patients for ETI.

Comparison of haemodynamic response to tracheal intubation with two different videolaryngoscopes: A randomized clinical trial

Abstract Background: Endotracheal intubation (ETI), which is the gold standard in coronary artery bypass grafting (CABG), may cause myocardial ischaemia by disturbing the balance between haemodynamic changes and oxygen supply and consumption of the myocardium as a result of sympathetic stimulation. In this study, we aimed to compare two different videolaryngoscopes (C-MAC and Airtraq) in the hemodynamic response to ETI. Methods: Fifty ASA II-III CABG surgery patients were randomly assigned to C-MAC or Airtraq. The hemodynamic data included arterial blood pressure [systolic (SAP), diastolic (DAP) and mean (MAP)] and heart rate (HR) and were recorded at six different points in time: before laryngoscopy-T1, during laryngoscopy-T2, immediately after intubation-T3, and 3 (T4), 5 (T5) and 10 (T6) minutes after intubation. Intraoperative complications were recorded. Patients were questioned about postoperative complications 2 and 24hours following extubation. Results: The hemodynamic response to ETI was significantly greater with C-MAC. The increase in HR started with the laryngoscopy procedure, whereas increases in SAP, DAP, and MAP started immediately after ETI (p = 0.024; p = 0.012; p = 0.030; p = 0.009, respectively). In group analyses, T1-T2, T2-T3 and T1-T3 comparisons did not show any significant differences in HR with Airtraq. However, with C-MAC, HR after intubation increased significantly compared to the pre-laryngoscopy values (T1-T3) (p = 0.004). The duration of laryngoscopy was significantly reduced with C-MAC (p < 0.001), but the duration of intubation and total intubation were similar (p = 0.36; p = 0.79). Conclusions: Compared to C-MAC, the hemodynamic response to ETI was less with Airtraq. Thus, Airtraq may be preferred in CABG patients for ETI.

Comparison of the lateral sagittal and costoclavicular approaches for ultrasound-guided infraclavicular block in pediatric patients: a prospective randomized study.

BACKGROUND: The lateral sagittal brachial plexus block is the most used method for pediatric upper extremity surgery, whereas the applications of costoclavicular brachial plexus block are limited. This study aimed to compare the lateral sagittal and costoclavicular approaches for the ultrasound-guided infraclavicular block in pediatric patients. METHODS: Sixty pediatric patients aged 5-15 years undergoing hand or forearm surgery were randomly assigned to two groups. Group LS (n = 30) received ultrasound-guided lateral sagittal block, and Group CC (n = 30) received ultrasound-guided costoclavicular block. The block performing time, needling time, imaging time, needle visibility, number of passes, sensorial/motor block time, and postoperative pain scores were evaluated. RESULTS: The needling time (82.90 ± 28.17 seconds vs. 64.77 ± 28.11 seconds respectively, p = 0.004) and total block performance time (109.53 ± 29.75 seconds vs. 89.70 ± 29.98 seconds respectively, p = 0.005) were significantly longer in Group LS than in Group CC. However, there was no significant difference between the groups in imaging time, needle visibility, number of passes, sensorial/motor block time, and postoperative pain scores (p > 0.05). CONCLUSIONS: Costoclavicular and lateral sagittal brachial plexus blocks resulted in similar anesthetics effects. Moreover, the costoclavicular method can be a better alternative to lateral sagittal as it has a shorter block performance time.

A Pseudocoarctation of the Aorta With a Left Subclavian Artery Aneurysm, A Case Report and A Review of the Literature.

Here we present a 47-year-old male diagnosed with a pseudocoarctation of the aorta and a funnel-like subclavian artery aneurysm with a large orifice and severe aortic valve insufficiency. The patient underwent a two-stage repair for both pathologies. After an aortic valve replacement, postcardiotomy pericardial effusion occurred and was medically managed. Six months later, the patient underwent a distal arcus aorta and subclavian artery replacement with a left posterolateral thoracotomy as the second stage. Due to the strict adhesions, pulmonary veins were not cannulated and an extracorporeal bypass between the pulmonary artery and femoral artery was used for distal body perfusion. The coincidence of subclavian aneurysms and a pseudocoarctation of the aorta is rare and a literature review was performed to identify treatment options for this pathology.

A randomized comparison between ultrasound-guided costoclavicular and infraclavicular block for upper extremity surgery

Background/aim: This study compared ultrasound guided costoclavicular (CC) and lateral sagittal infraclavicular (LS) brachial plexus block in patients undergoing upper extremity surgery. Materials and methods: A total of 80 patients undergoing upper extremity surgery were randomly classified into two groups: Group CC (costoclavicular (n = 40)) and Group LS (lateral sagittal infraclavicular (n = 40)). Both groups received a 25 mL containing a mixture of 1% lidocaine and 0.25% bupivacaine. A blinded observer recorded the block onset time and decided which patients who were admitted to the operation room needed general anesthesia or rescue block or without any iv. narcotics for the surgical procedure. Results: The sensorimotor onset time was found to be faster in the CC group [(15.95 2.97) min] compared to the LS group [(17.72 4.15) min]. There was a statistically significant difference between two groups in terms of sensorimotor onset time (p = 0.031). There was no difference between two groups in terms of the block performance times and post-block motor block dissolution times. Conclusion: The CC approach provides faster onset of sensorimotor blockade than LS approach when the 4 major terminal nerves of the brachial plexus were evaluated.

Erector spinae block for postoperative pain management in lumbar disc hernia repair.

PURPOSE: Lumbar disc herniation is the most common spinal disorder and various less invasive techniques such as microdiscectomy have been described. However, postoperative pain management in patients undergoing discectomy is still commonly inadequate. Erector spinae plane (ESP) block is a relatively easier technique with lower risks of complications, and can be performed to provide postoperative analgesia for various procedures. The current study aimed to determine the effect of ESP block on postoperative analgesia in patients who underwent elective lumbar disc herniation repair surgeries. METHODS: Fifty-four ASA I-II patients aged 18-65 years scheduled for elective discectomy surgery were included in the study. Patients were randomized either to the ESP or control group. Ultrasound-guided ESP block with 20 mL of 0.25% bupivacaine was performed preoperatively in the ESP group patients and a sham block was performed with 20 mL normal saline in the control group patients. All the patients were provided with intravenous patient-controlled analgesia devices containing morphine. Morphine consumption and numeric rating scale (NRS) scores for pain were recorded 1, 6, 12, and 24 h after surgery. RESULTS: A significantly lower morphine consumption was observed at 6, 12, and 24 h timepoints in the ESP group (p < 0.05 for each timepoint). Total morphine consumption at 24 h after surgery decreased by 57% compared to that of the control group (11.3 ± 9.5 mg in the ESP group and 27 ± 16.7 mg in the control group). NRS scores were similar between the two groups. CONCLUSION: This study showed that ESP block provided effective analgesia in patients who underwent lumbar disc herniation surgery. CLINICAL TRIALS REGISTRY: NCT03744689.

People respond with different moral emotions to violations in different relational models: A cross-cultural comparison.

Consonant with a functional view of moral emotions, we argue that morality is best analyzed within relationships rather than in individuals, and use Fiske's (1992) theory of relational models (RMs: communal sharing [CS], authority ranking [AR], equality matching [EM], and market pricing [MP]) to predict that violations in different RMs will arouse different intensities of other-blaming emotions (anger, contempt and disgust) in both observers and victims, together with different intensities of self-blaming emotions (shame and guilt) in perpetrators, and to predict that these patterns of emotion will show similarity across both individuals and cultures. Three studies, using vignettes portraying moral violations in all RMs in different experimental designs, supported these expectations, while also producing some unexpected results. The intensity of shame and guilt varied markedly across RMs, but with little difference between the two emotions. The intensity of all 3 other-blaming emotions also varied across RMs. Anger was the most intense emotional response to violation in all RMs, whereas disgust and contempt were stronger in CS than in other RMs. Disgust and shame were linked more strongly in CS than in other RMs, and anger and guilt were more strongly linked than other emotion pairs in EM. Moral emotions in RMs involving hierarchy (AR and MP) differed widely depending on the perpetrator's dominant or subordinate status. Both Turkish (TR) and English-speaking (EN) samples showed similar patterns of all moral emotions across RMs. Understanding the functions of moral emotions in relationships using relational models can help to clarify multiple aspects of moral psychology. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

General Anesthesia Practices During the COVID-19 Pandemic in Turkey: A Cohort Study With a National Survey.

Introduction This study aimed to examine the anesthesia practices applied to the cases during the pandemic, to analyze the rate of the precautions taken in emergency/elective operations in non-COVID patients, what precautions were taken, what resources the clinics had, and the patient management in the perioperative period by organizing a survey among anesthesiologist in Turkey. Methods After obtaining approval from the Turkish Ministry of Health (2020-05-04T09_30_03) and the local ethics committee (GOKAEK-2020/10.09), a survey consisting of 21 questions was formed over the online survey inquiry (surveymonkey.com). The survey was conducted in Turkish. Results The survey aimed at reaching the anesthesiologists, who were Turkish Anesthesiology and Reanimation Society (TARD) members, by e-mail, and it was seen that 120 people out of approximately 2700 members who had received our e-mail participated in the survey. After the first case was reported in our country, it was understood that 62.1% of the participants stopped accepting elective cases in their institutions. The anesthesia method preferred in this period was general anesthesia by 47.6%, regional anesthesia by 52.1%, and sedation by 0.3%. The arrival time of coronavirus disease COVID-19 tests (PCR and/or rapid diagnostic kits showing antibodies) to the hospital was questioned; seven people (5.83%) stated that tests were not performed at their hospitals. It was observed that tests arrived and were applied at the hospitals of the remaining participants in an average of 2.7 ± 1.6 weeks. It was determined that 59.32% of the participants avoided positive pressure ventilation after induction, 5.98% of the intubation on the patients were performed by anesthesia technicians, 66.67% by anesthesiologists, 25.64% by senior resident doctors with at least two years of experience, and 1.71% by junior anesthesia assistants with less than two years of experience. The use of personal protective equipment (PPE) is applied by 95% of the participants. 22.69% of the participants stated that they preferred to use supraglottic airway (SGA) devices during this period. While 45.06% of the participants stated that they provided oxygen support to the patient with the mask belonging to the circuit after extubation, 14.8% preferred the nasal cannula, and 33.1% used an oxygen mask. Our results showed that 90% of additional precautions were taken in our country's clinics, and 95% of PPE was used. Also, the use of video laryngoscope (VL) was 75% in this period. Finally, it was found that 50.85% of the patients were taken to the recovery unit after being extubated, and 49.15% were sent directly to the service. Conclusion We can reveal that each clinic made arrangements according to its own conditions. We think that plans should be made to standardize clinical facilities and algorithms throughout the country. Apart from technological and financial facilities, we believe that the continuity of the training organized by national and international associations should be ensured so that anesthesiologists' knowledge, skills, and experience who manage this process can remain at the highest level.

Regional Anesthesia Practices in Turkey During the COVID-19 Pandemic.

Introduction The aim of the survey was to investigate the changes, methods, and preferences in regional anesthesia (RA) applications during the COVID-19 pandemic in Turkey. Methods The questionnaire prepared on surveymonkey.com was sent to anesthesiology and reanimation specialists by e-mail. Results A total of 126 physicians participated in the study. Forty-two point sixty-two percent (42.62%) of the participants reported an increase in RA practices in their clinical anesthesia applications, whereas 57.38% did not state any change. Neuraxial anesthesia was determined to be the most preferred RA application, with a rate of 74%. The distribution of peripheral nerve blocks (PNBs) showed that upper extremity blocks were used at a rate of 64.9%, lower extremity blocks at 30.38%, and trunk blocks at 15%. Investigation of neurostimulator (NS) and/or ultrasound (US) use with PNB showed that 44% of the participants used only US while 50% used both US and NS. Conclusion Neuraxial blocks play an important role in RA applications. PNB comprise one-quarter of RA applications during the pandemic. The importance of ultrasound has gradually increased in RA applications worldwide, as well as in Turkey, during the pandemic.

[Surgical anesthesia using ultrasound-guided penile nerve block for adult hemophilia patient]. / Eriskin hemofili hastasinda ultrason rehberliginde penil blok ile cerrahi anestezi.

Ultrasound-Guided Dorsal Penile Nerve (DPNB) Block was performed to provide surgical anesthesia for a 22 years old ASA II patient who had hemophilia A and was undergoing circumcision surgery. 20 ml of 0.25% bupivacaine was used for the DPNB. Surgery was completed under block without complication. Twenty-four hours of the analgesia was provided following surgery.