The effect of ultrasound-guided rectus sheath block on postoperative analgesia in robot assisted prostatectomy: A randomized controlled trial.

BACKGROUND: Postoperative pain continues to represent an important problem even after minimally invasive robotic-assisted laparoscopic radical prostatectomy, which results in discomfort in the postoperative period and sometimes prolongs hospital stays. Regional anesthesia and analgesia techniques are used in addition to systemic analgesics with the multimodal approach in postoperative pain management. Ultrasound-guided fascial plane blocks are becoming increasingly important, especially in minimally invasive surgeries. Another important cause of discomfort is urinary catheter pain. The present randomized controlled study investigated the effect of rectus sheath block on postoperative pain and catheter-related bladder discomfort in robotic prostatectomy operations. METHODS: This randomized controlled trial was conducted from March to August 2022. Written informed consent was obtained from all participants. Approval for the study was granted by the Clinical Research Ethics Committee. All individuals provided written informed consent, and adults with American Society of Anesthesiologists Physical Condition classification I to III planned for robotic prostatectomy operations under general anesthesia were enrolled. Following computer-assisted randomization, patients were divided into 2 groups, and general anesthesia was induced in all cases. Rectus sheath block was performed under general anesthesia and at the end of the surgery. No fascial plane block was applied to the patients in the non-rectus sheath block (RSB) group.Postoperative pain and urinary catheter pain were assessed using a numerical rating scale. Fentanyl was planned as rescue analgesia in the recovery room. In case of numerical rating scale scores of 4 or more, patients were given 50 µg fentanyl IV, repeated if necessary. The total fentanyl dose administered was recorded in the recovery room. IV morphine patient-controlled analgesia was planned for all patients. All patients' pain (postoperative pain at surgical site and urethral catheter discomfort) scores and total morphine consumption in the recovery unit and during follow-ups on the ward (3, 6, 12, and 24 hours) in the postoperative period were recorded. RESULTS: Sixty-one patients were evaluated. Total tramadol consumption during follow-up on the ward was significantly higher in the non-RSB group. Fentanyl consumption in the postanesthesia care unit was significantly higher in the non-RSB group. Total morphine consumption was significantly lower in the RSB group at 0 to 12 hours and 12 to 24 hours. Total opioid consumption was 8.81 mg in the RSB group and 19.87 mg in the non-RSB group. A statistically significant decrease in urethral catheter pain was noted in the RSB group at all time points. CONCLUSION: RSB exhibits effective analgesia by significantly reducing postoperative opioid consumption in robotic prostatectomy operations.

The cervical blood patch: A therapeutic "miraculous" for cerebrospinal fluid leaks: A case report.

RATIONALE: Cerebrospinal fluid (CSF) leaks, arising from abnormal openings in the protective layers surrounding the spinal cord and brain, are a significant medical concern. These leaks, triggered by various factors including trauma, medical interventions, or spontaneous rupture, lead to the draining of CSF-an essential fluid safeguarding the nervous system. A classic symptom of CSF leaks is an incapacitating headache exacerbated by sitting or standing but relieved by lying down. Spontaneous intracranial hypotension (SIH) denotes the clinical condition marked by postural headaches due to spontaneous CSF leakage and hypotension, often misdiagnosed or underdiagnosed. While orthostatic headaches are the hallmark, SIH may manifest with an array of symptoms including nausea, tinnitus, hearing loss, visual disturbances, and dizziness. Treatment options encompass conservative measures, epidural blood patches (EBP), and surgery, with EBP being the primary intervention. PATIENT CONCERN: The patient did not express any specific concerns regarding their medical diagnosis. However, they did harbor apprehensions that their condition might necessitate surgical intervention in the future. DIAGNOSIS: The patient had been treated with antibiotics with a pre-diagnosis of sinusitis and was admitted to the neurology department of our hospital when his symptoms failed to improve. Cranial magnetic resonance imaging was interpreted as thickening of the dural surfaces and increased contrast uptake, thought to be due to intracranial hypotension. Cranial MR angiography was normal. Full-spine magnetic resonance imaging revealed a micro-spur at the C2 to 3 level and the T1 to 2 level in the posterior part of the corpus. INTERVENTIONS: The cervical EBP was performed in the prone position under fluoroscopic guidance. There were no complications. OUTCOMES: The patient was invited for follow-up 1 week after the procedure, and control examination was normal. LESSONS: SIH poses a diagnostic challenge due to its diverse clinical presentation and necessitates precise imaging for effective intervention. Cervical EBP emerges as a promising treatment modality, offering relief and improved quality of life for individuals grappling with this condition. However, clinicians must carefully assess patients and discuss potential risks and benefits before opting for cervical blood patches.

Comparison of anterior suprascapular nerve block versus interscalane nerve block in terms of diaphragm paralysis in arthroscopic shoulder surgery: a prospective randomized clinical study.

OBJECTIVE: This prospective, randomized study aimed to compare anterior suprascapular nerve block versus interscalene block in terms of diaphragm paralysis in arthroscopic shoulder surgery. METHODS: Fifty-two patients undergoing shoulder arthroscopy surgery were prospectively randomly assigned to interscalene block (n=25) or anterior suprascapular nerve block groups (n=27) (each group receiving 5 mL, 0.5% bupivacaine). The ipsilateral diaphrag matic excursion was assessed in all patients using ultrasound imaging before (baseline), 30 minutes, and 24 hours after block completion. Pain scores were recorded 1 hour preoperative, 30-60 minutes in the postoperative recovery unit, and at 6 and 24 hours postoperatively. RESULTS: No complete paralysis was observed in either treatment group. The incidence of a partial decrease in diaphragm movements was significantly lower in the anterior suprascapular nerve block than in the interscalene block group (1 vs. 21 patients) (P < .01). Twenty-six patients in the anterior suprascapular nerve block and 4 in the interscalene block group had less than a 25% decrease in hemidiaphrag matic movements, 30 minutes after the blockade. Pain scores were similar in the 2 groups. However, mean pain scores at 24 hours post operatively were significantly higher in the interscalene block than in the anterior suprascapular nerve block group (P < .05). Time to first pain post-block was significantly longer in the anterior suprascapular nerve block compared to the interscalene block group (677.04 ± 52.17 minutes vs. 479.2 ± 99.74 minutes, P < .05). CONCLUSION: Anterior suprascapular nerve block and interscalene block both appear to be clinically effective in providing postoperative analgesia for patients undergoing arthroscopic shoulder surgery under general anesthesia. However, the time to first pain is significantly longer with anterior suprascapular nerve block. Pain scores at 24 hours postoperatively were significantly lower in the anterior supra scapular nerve block compared to the interscalene block group. Diaphragmatic movements after anterior suprascapular nerve block were also better preserved at both 30 minutes after the block and 24 hours after surgery. LEVEL OF EVIDENCE: Level I, Therapeutic Study.

The Minimum Effective Analgesic Volume of 0.5% Bupivacaine for Ultrasound-Guided Anterior Suprascapular Nerve Block.

Objective The interscalene brachial plexus block (ISBB) constitutes the gold standard for analgesia after shoulder procedures. Ipsilateral phrenic nerve block remains the most common adverse effect after ISBB. Alternative nerve blocks are performed in shoulder surgery in order to prevent hemi-diaphragmatic paralysis (HDP). The purpose of the present study was to investigate the minimum effective local anesthetic volume of 0.5% bupivacaine for postoperative analgesia with an anterior suprascapular nerve block (ASSB). The secondary aim was to investigate diaphragm functions with the local anesthetic doses used while conducting effective volume research. Method This prospective observational study was conducted at the American Hospital of Istanbul, Turkey, from March to July 2022. The initial injected volume of 0.5% bupivacaine was 10 ml. Our clinical experience indicates that this yields a complete sensory block of the anterior suprascapular nerve. In accordance with the up-and-down method, the volume of 0.5% bupivacaine used for a particular patient was determined by the outcome of the preceding block, which represented block success. In case of effective ASSB being achieved, the volume of 0.5% bupivacaine to be administered to the next patient was lowered by 1 ml. In case of block failure, however, the volume of 0.5% bupivacaine to be applied in the subsequent case was increased by 1 ml. Ipsilateral hemi-diaphragmatic movement measurements were taken before (baseline) and 30 minutes after the block. General anesthesia was induced 60 minutes after the completion of the block performance by means of a standardized protocol. Results Sixty-seven patients were included in the study. The ED50 and ED95 calculated for anterior suprascapular nerve block using probit transformation and logistic regression analysis were 2.646 (95% CI, 0.877-2.890) and 3.043 ml (95% CI, 2.771-4.065), respectively. When complete paralysis was defined as 75% or above, partial paralysis as 25-50%, and no paralysis as 25% or less, volumes of 6 ml or lower appeared to cause no paralysis for the anterior suprascapular nerve block. Conclusion We, therefore, recommend using a volume of 6 ml or less in order to achieve diaphragm-sparing features for anterior suprascapular nerve blocks.

The analgesic contribution of external oblique intercostal block: Case reports of 3 different surgeries and 3 spectacular effects.

INTRODUCTION: Abdominal wall blocks are frequently used due to the use of effective blocks, such as the transversus abdominis plane (TAP) block and the widespread use of ultrasound (US) imaging. A good knowledge of abdominal innervation is required for the use of abdominal wall blocks. We describe the extraordinary performance of external oblique intercostal (EOI) blocks in 3 different surgeries. PATIENT CONCERNS, DIAGNOSIS AND INTERVENTIONS: Case 1: A man aged 30 to 35 was taken to the operating room for open liver surgery. After surgery, unilateral EOI block and bilateral TAP block were performed with the patient in the supine position, and a catheter was placed under the external oblique muscle. Postoperative analgesia was followed by patient-controlled analgesia (PCA) through the catheter. Case 2: A male patient aged 35 to 40 was taken to the operating room for laparoscopic liver surgery. After surgery, unilateral (EOI) block and bilateral TAP block were performed with the patient in the supine position. The patient received iv tramadol PCA (bolus dose 10 mg only, lockout 20 minutes). Case 3: A man aged 25 to 30 was taken to the operating room for laparoscopic bariatric surgery. After the surgery, bilateral EOI and bilateral rectal sheath blocks were performed with the patient in the supine position. The patient received iv tramadol PCA (bolus dose 10 mg only, lockout 20 minutes). OUTCOMES: All patients had low NRS scores in the recovery unit and very low opioid consumption in the first 72 hours postoperatively. All were satisfied with the quality of analgesia. CONCLUSION: We think that EOI block will come to occupy a significant place in upper abdominal analgesia, especially in obese patients, due to its wide innervation area and ease of application.

Can Postoperative Pain Be Prevented in Bariatric Surgery? Efficacy and Usability of Fascial Plane Blocks: a Retrospective Clinical Study.

BACKGROUND: Providing analgesia after bariatric surgery might be challenging due to a high prevalence of obstructive sleep apnea syndrome and the increased sensitivity to respiratory depression triggered by opioid overuse after surgery. Various combination methods with paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), and other pain medications such as ketamine or gabapentin have been suggested for reduction of the opioid usage. Regional anesthetic techniques represent a valuable option as they improve patient comfort while reducing opioid-related side effects. In this study, we have evaluated the adjuvant benefits of these various techniques in reduction of the postoperative pain in bariatric surgery. METHODS: After the approval of the IRB Ethics Committee, the records of the patients who had laparoscopic bariatric surgery between January 2019 and December 2021 were reviewed retrospectively. RESULTS: Records of 120 patients who underwent laparoscopic bariatric surgery between January 2019 and December 2021 were reviewed. In total, 113 patients with full documentation were included in this study. Among these, 74 patients were administered regional analgesia. The main regional analgesia techniques were transversus abdominis plane and rectus sheath block. The pain scores of those receiving regional analgesia were statistically low. The opioid consumption after transversus abdominis plane and rectus sheath block was significantly lower than that of others. External oblique intercostal block alone provides a postoperative opioid consumption similar to those of transversus abdominis plane and rectus sheath block. CONCLUSION: The use of fascial plane blocks in bariatric surgery significantly reduces opioid consumption. Transversus abdominis plane and rectus sheath block combination and external oblique intercostal block seem to be the most effective options. CLINICAL TRIALS NUMBER: NCT05284695.

Regional analgesia techniques for effective recovery from coronary artery bypass surgeries: a retrospective study involving the experience of a single center.

BACKGROUND: Pain after cardiac surgery is both multifocal and multifactorial. Sternotomy, sternal retraction, internal mammary dissection, posterior rib dislocation or fracture, potential brachial plexus injury, and mediastinal and pleural drains all contribute to pain experienced in the immediate postoperative period. Ineffective pain management can result in systemic and pulmonary complications and significant cardiac consequences. METHODS: This study compared the effectiveness of regional anesthesia techniques for perioperative pain management in cardiac surgery patients at our clinic. The effects of different analgesic methods, in terms of contributing to recovery, were examined. RESULTS: The records of 221 patients who had undergone coronary bypass surgery were evaluated retrospectively. The extubation rate in the operating room was 91%. No patient received balloon pump support, and 20 patients were transferred to the cardiovascular intensive care unit while intubated. Regional anesthesia was performed on two of these 20 patients, but not on the remaining 18. Examination of intraoperative and postoperative opioid consumption revealed significantly lower levels among patients receiving regional anesthesia. The most effective results among the regional anesthesia techniques applied were achieved with double injection erector spinae plane block. CONCLUSION: Regional anesthesia techniques severely limit opioid consumption during cardiac surgery. Their importance will gradually increase in terms of rapid recovery criteria. Based on our study results, double injection of the erector spinae plane block seems to be the most effective technique in cardiac surgery. We therefore favor the use of fascial plane blocks during such procedures. Trial Numbers The study is registered with ClinicalTrials (NCT05282303). Ethics committee registration and approval were Granted under Number 2021.464.IRB1.131.

[Comparison of intraoperative and postoperative analgesic properties of ilioinguinal/iliohypogastric and sacral epidural block in pediatric unilateral inguinal hernia operations]. / Çocuklarda unilateral inguinal herni operasyonlarinda ilioinguinal/iliohipogastrik ve sakral epidural blogun intraoperatif ve postoperatif analjezik özelliklerinin karsilastirilmasi.

OBJECTIVES: Central blocks such as caudal, spinal, and sacral epidural are frequently used in pediatric inguinal surgeries. Furthermore, peripheral blocks have been used and successful results have been obtained in pediatric inguinal surgeries. In this study, we aimed to compare the intraoperative and postoperative analgesic efficacy of the ilioinguinal/iliohypogastric (IL/IH) block under general anesthesia with the sacral epidural block. METHODS: This study was carried out in Gazi University Faculty of Medicine, Department of Anesthesiology and Reanimation, after obtaining permission from the Ethics Committee of Gazi University Faculty of Medicine and the Central Ethics Committee of the General Directorate of Pharmaceuticals and Pharmacy of the Turkish Ministry of Health, numbered B.10.0.IEG.011.00.01. Sixty patients in the American Society of Anesthesiologists I-II group between the ages of 1 and 8 years who will undergo elective unilateral inguinal hernia operation under general anesthesia were randomly divided into two groups. Group S (n=30) sacral epidural block and group I (n=30) IL/IH nerve block were planned. RESULTS: Hemodynamic values were found to be statistically significantly lower than control values in both groups. The minimum alveolar concentration values for sevoflurane were statistically significantly lower values in both groups at all surgery periods. In terms of additional analgesic requirement, the group I was found to be statistically significantly lower than the group s at the 8th-12th h. When the first analgesic intake hours were examined, no significant difference was found between the two groups. CONCLUSION: In our study, group I and group S analgesic efficacy was found to be similar.

[Ultrasound guided thoracic wall blocks]. / Toraks duvari fasyal plan bloklar.

Epidural anesthesia and thoracic paravertebral blocks have been the mainstay of regional anesthesia for thoracic surgery for many years. Following introduction of ultrasound use during regional anesthesia practices, new blocks named interfascial plane blocks have been introduced into clinical practice. Although interfascial plane blocks fail to provide surgical anesthesia their contribution to providing analgesia is clinically important. In this review we mention the most commonly accepted blocks namely pectoral blocks, serratus anterior plane block, erector spinae plane block and rhomboid blocks.

Could Interscalene Block Possibly be Protective Against Cerebral Ischemia During Shoulder Surgery in a Beach Chair Position?

Introduction Arthroscopic shoulder surgeries are usually performed in a sitting position. The sitting position is known to cause physiological changes related to cardiovascular adaptation. Interscalene nerve blocks (ISB) are the most commonly used techniques and are considered gold standard regional anesthesia methods for shoulder surgeries. Cerebral vessels located around sympathetic ganglia provide sympathetic system integrity. This local anesthetic spreading during ISB could be a side effect or provide a protective effect on cerebral ischemia. Our study aimed to investigate the cerebral protective effect of the ISB in arthroscopic shoulder surgeries in a sitting position. Material and methods After the approval of Koç University Clinical Research Ethics Committee (2020.020.IRB1.011), records of patients between January and December 2019 with shoulder arthroscopy at the Vehbi Koç Foundation (VKV) American hospital were retrospectively reviewed. Records of the hemodynamic response, INVOSTM (Medtronic, Minneapolis, USA) (rSO2) parameters, pain scores, and additional analgesic needs of all cases were examined in the intraoperative and postoperative period. Results Data of 40 patients who met the criteria to be included in the study was analyzed. Our study showed that the sitting position leading to hypotension coincided with a decrease in INVOS values. Nevertheless, we did not record any significant hypotension after ISB, and this may be due to the use of a minimal dose of local anesthetic. There was a certain increase in near-infrared spectroscopy (NIRS) values ​​after ISB. We saw that the value of regional oxygen saturation (rSO2) increased on both the ISB side and the non-ISB side. This shows that the ISB can have a global impact on the brain. Specificially, the increase in rSO2 values ​​in the ISB side compared to the other side suggests that ISB has possible positive effects on cerebral blood flow. Conclusion Our study has shown that ISB may transiently increase the rSO2 levels in the sitting position during shoulder surgery.

Analgesic Effect of Dual Injection Technique for the Erector Spinae Plane Block in Beating Heart Coronary By-Pass Surgeries.

Introduction Various regional anesthesia techniques such as thoracic epidural, thoracic paravertebral block, erector spinae plane block (ESPB), parasternal intercostal blocks are used in cardiac surgery for postoperative analgesia. In our study, we investigated the analgesic efficacy of the dual injection technique of ESPB in beating heart coronary bypass surgeries. Methods The records of patients with coronary artery bypass (CABG) surgery in the beating heart at the VKV American Hospital between January and December 2019 were retrospectively analyzed. The data of 30 patients who met the criteria to be included in the study were analyzed. Whether any opioid use is required for maintenance of anesthesia it is recorded. The pain scores of the patients are recorded by the intensive care team and cardiovascular service nurses for the first 48 hours. Results The absence of secondary responses to pain in all surgical periods, including skin incision and sternotomy, and low number of rating scale (NRS) scores in the postoperative 0- to 24-hour period show that the technique we developed can produce effective analgesia. After the 24th postoperative hour, the patients were followed up in the cardiovascular service and there was no opioid use between 24- to 48-hour period. Conclusion Our approach, in which the local anesthetic is applied by approaching the superior costa-transverse ligament (SCTL) in the ESPB, provides an effective analgesia in coronary artery bypass surgeries in the beating heart. The main purpose of our new approach is to increase the amount of local anesthetic in the paravertebral area. We recommend using our modified technique for effective analgesia after CABG surgeries.