Effect of Ultrasound-Guided External Oblique Intercostal Block on Postoperative Recovery After Subxiphoid Video-Assisted Thoracoscopic Thymectomy: A Randomized Controlled Trial.

OBJECTIVE: Severe postoperative pain can occur after subxiphoid video-assisted thoracoscopic thymectomy (SVATT), affecting the quality of postoperative recovery. This study aimed to evaluate the effect of ultrasound-guided external oblique intercostal (EOI) block on recovery after SVATT. METHODS: A total of 60 patients undergoing SVATT were randomly divided into the EOI group (group E, n = 30) and the control group (group C, n = 30). Group E underwent ultrasound-guided bilateral EOI block at the 6th rib level and was injected 20 mL of 0.375% ropivacaine on each side. Group C was injected with 20 mL of 0.9% saline at the same site. After the operation, both groups received a patient-controlled intravenous analgesic (PCIA) pump. The 15-item Quality of Recovery (QoR-15) scores were recorded at 24 hours before surgery (T0), 24 hours after surgery (T3), and 48 hours after surgery (T4). The sufentanil usage in the first 24 hours postoperatively, the remifentanil dosage during surgery, the time of first pressing PCIA, and the cases of rescue analgesia were recorded. The visual analog scale (VAS) scores of patients at 6 (T1), 12 (T2), 24 (T3), and 48 hours (T4) after an operation during rest and coughing were recorded. The dermatomes of the sensory plane, block complications in group E, and the incidence of other postoperative adverse reactions in both groups were also recorded. RESULTS: Compared with group C, the QoR-15 scores of patients were significantly higher at T3 and T4 in the group E. The VAS scores were significantly lower at T1, T2, and T3 during rest and coughing in the group E. The sufentanil usage in the first 24 hours postoperatively, the remifentanil dosage during surgery, and the cases of rescue analgesia were significantly lower in group E, and the time of first pressing PCIA was significantly increased in group E (all P < .05). CONCLUSION: Ultrasound-guided EOI block can be safely used in patients undergoing SVATT, which can improve the quality of postoperative recovery and reduce postoperative pain.

The efficacy of loco-regional ropivacaine analgesia via intercostal catheters after lung resection: a randomized, double-blind, placebo-controlled, superiority study.

OBJECTIVES: Postoperative pain remains a burden for patients after minimally invasive anatomic lung resection. Current guidelines recommend the intraoperative placement of intercostal catheters to promote faster recovery. This trial aimed to determine the analgesic efficacy of continuous loco-regional ropivacaine application via intercostal catheter and establish this method as a possible standard of care. METHODS: Between December 2021 and October 2023, patients were randomly assigned to receive ropivacaine 0.2% or a placebo through an intercostal catheter with a flow rate of 6-8 ml/h for 72 hours after surgery. Patients were undergoing anatomic VATS lung resection under general anaesthesia for confirmed or suspected stage I lung cancer (UICC, 8th edition). The sample size was calculated to assess a difference in NRS (numerical rating scale) associated with pain reduction of 1.5 points. RESULTS: 14 patients were included in the ropivacaine group, whereas the placebo group comprised 18 participants. Patient characteristics and preoperative pain scores were similar in both groups. There was no statistically significant difference in postoperative pain scores and morphine consumption between the two groups. The mean NRS when coughing during the first 24 hours postoperatively was 4.9 (SD: 2.2) in the ropivacaine group and 4.3 (SD: 2.4); P = 0.47 in the placebo group. We were unable to determine any effect of administered ropivacaine on the postoperative pulmonary function (FEV1, PEF). CONCLUSIONS: Our preliminary results suggest that continuous loco-regional ropivacaine administration via surgically placed intercostal catheter has no positive effect on postoperative pain scores or morphine requirements.

The Efficacy and Safety of the Rhomboid Intercostal Block for Postoperative Analgesia in Chest Surgery and Breast Surgery: A Systemic Review and Meta-Analysis.

BACKGROUND: Prior research has suggested that the rhomboid intercostal block (RIB) may contribute to postoperative analgesia after surgeries of the chest and breast. OBJECTIVE: To explore the effectiveness and safety of RIB for postoperative analgesia, as well as whether RIB is superior to other types of nerve blocks. STUDY DESIGN: A systematic review and meta-analysis. SETTING: Querying electronic databases, including the Cochrane Library, PubMed, Embase, and Web of Science, was part of the process in searching for eligible clinical trials for this meta-analysis and systematic review. METHODS: The Cochrane Collaboration's tool for quality evaluation was utilized in assessing the bias risk in the selected randomized controlled trials (RCTs). meta-analysis was facilitated through the utilization of Review Manager 5.3. The determination of the evidence's quality adhered to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. RESULTS: After the inclusion and exclusion criteria were established, the incorporation of 8 RCTs, encompassing 714 patients, took place. During the first 24 hours after the operation, patients in the RIB group exhibited lower pain scores and less opioid consumption than did those in the no-block group. Furthermore, a decrease in the incidence of postoperative vomiting and nausea was noted in the RIB group. Nevertheless, when comparing outcomes, it was revealed that the RIB group and the other nerve block group did not differ significantly. LIMITATIONS: No subgroup analysis to investigate the sources of heterogeneity was performed. The number of studies in this meta-analysis of RIB compared to those that focus on other types of nerve block is relatively small. The optimal concentrations and volumes of local anesthetics were not evaluated. CONCLUSIONS: RIB may be a new option for pain relief after chest and breast surgery.

Assessment of intercostal nerve block analgesia and local anesthetic infiltration for thoracoscopic pulmonary bullae resection: a comparative study.

OBJECTIVE: The purpose of this study was to compare the analgesic effects of intercostal nerve block (ICNB) and local anesthetic infiltration (LAI) on postoperative pain and recovery following thoracoscopic resection of pulmonary bullae. METHODS: A total of 160 patients undergoing thoracoscopic pulmonary bullae resection were randomly assigned to receive either ICNB (n = 80) or LAI (n = 80). An experienced anesthesiologist administered ultrasound guided ICNB at the T4 and T7 levels with 5 mL of 0.375% ropivacaine hydrochloride for the ICNB group. Instead, the LAI group received 10 mL of the same concentration of ropivacaine hydrochloride at the same concentration used for ICNB for infiltration anesthesia at the incision sites. Out of the initial cohort, 146 patients completed the study (ICNB group, n = 71; LAI group, n = 75). The collected data included preoperative clinical characteristics, visual analog scale (VAS) scores for pain at various time points post-surgery (6, 12, 24, 48, and 72 h). Additionally, the Quality of Recovery-15 (QoR-15) questionnaire was administered 24 h after surgery, and sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI). RESULTS: No significant differences were found in drainage volume, use of additional analgesics, duration of chest tube placement, or hospital stay between the two groups. However, the ICNB group had significantly lower VAS scores and QoR-15 scores 24 h postoperatively (p < 0.05), indicating better pain management and recovery. The ICNB group also reported better sleep quality, as reflected by lower PSQI scores. CONCLUSION: ICNB provides superior analgesia compared to LAI after thoracoscopic resection of pulmonary bullae, significantly improving postoperative recovery.

Polyzwitterion-grafted decellularized bovine intercostal arteries as new substitutes of small-diameter arteries for vascular regeneration.

Coronary artery bypass grafting is acknowledged as a major clinical approach for treatment of severe coronary artery atherosclerotic heart disease. This procedure typically requires autologous small-diameter vascular grafts. However, the limited availability of the donor vessels and associated trauma during tissue harvest underscore the necessity for artificial arterial alternatives. Herein, decellularized bovine intercostal arteries were successfully fabricated with lengths ranging from 15 to 30 cm, which also closely match the inner diameters of human coronary arteries. These decellularized arterial grafts exhibited great promise following poly(2-methacryloyloxyethyl phosphorylcholine) (PMPC) grafting from the inner surface. Such surface modification endowed the decellularized arteries with superior mechanical strength, enhanced anticoagulant properties and improved biocompatibility, compared to the decellularized bovine intercostal arteries alone, or even those decellularized grafts modified with both heparin and vascular endothelial growth factor. After replacement of the carotid arteries in rabbits, all surface-modified vascular grafts have shown good patency within 30 days post-implantation. Notably, strong signal was observed after α-SMA immunofluorescence staining on the PMPC-grafted vessels, indicating significant potential for regenerating the vascular smooth muscle layer and thereby restoring full structures of the artery. Consequently, the decellularized bovine intercostal arteries surface modified by PMPC can emerge as a potent candidate for small-diameter artificial blood vessels, and have shown great promise to serve as viable substitutes of arterial autografts.

Bilateral Ultrasound-Guided External Oblique Intercostal Block Vs. Modified Thoracoabdominal Nerve Block Through Perichondrial Approach for Postoperative Analgesia in Patients Undergoing Laparoscopic Sleeve Gastrectomy Surgery: A Randomized Controlled Study.

INTRODUCTION: The objective of the present study was to evaluate morphine consumption and pain scores 24 h postoperatively to compare the effects of a bilateral External Oblique Intercostal (EOI) block with those of a Modified Thoracoabdominal Nerve Block Trough Perichondrial Approach (M-TAPA) block in laparoscopic sleeve gastrectomy (LSG). METHODS: Fifty-eight patients aged between 18 and 65 years of with American Society of Anesthesiologists class II-III were included in this randomized, double-blinded study. Patients were assigned into two groups either EOI block or M-TAPA block. The primary outcome was cumulative morphine consumption within the first postoperative 24 h. Secondary outcomes were numerical rating scale (NRS) scores at rest and during activity, QoR-15 Patient Questionnaire scores, incidence of postoperative nausea and vomiting (PONV), number of patients requiring rescue analgesic and antiemetics drugs, and complications. RESULTS: There was no statistically significant difference between the groups in terms of morphine consumption in the first 24 h (EOI block; 10.74 ± 3.94 mg vs. M-TAPA block; 11.67 ± 4.66 mg, respectively). In addition, no significant difference between the two groups in the NRS and PONV scores, total QoR-15 scores, and the number of patients requiring rescue analgesics and antiemetics. CONCLUSIONS: EOI block and M-TAPA block showed similar effectiveness for morphine consumption within 24 h postoperatively and in pain scores in LSG.

Thoracoscopic three-port single versus multiple intercostal for radical resection of esophageal cancer: a retrospective analysis.

BACKGROUND: The purpose of this retrospective study was to compare the safety and feasibility of single-intercostal totally minimally invasive Ivor Lewis esophagectomy (MIIE) with those of multiple-intercostal MIIE. METHODS: Between January 2016 and December 2022, clinical data were collected for 528 patients who successfully underwent totally minimally invasive esophagectomy. Among these patients, 294 underwent MIIE, with 200 undergoing the single-intercostal approach and 94 undergoing the multiple-intercostal approach. Propensity score matching (PSM) was applied to the cohort of 294 patients. Subsequently, perioperative outcomes and other pertinent clinical data were analyzed retrospectively. RESULTS: A total of 294 patients were subjected to PSM, and 89 groups of patient data (178 persons in total) were well balanced and included in the follow-up statistics. Compared to the multiple intercostal group, the single intercostal group had a shorter operative time (280 min vs. 310 min; p < 0.05). Moreover, there was no significant difference in the incidence of major perioperative complications (p > 0.05). The total number of lymph nodes sampled (25.30 vs. 27.55, p > 0.05) and recurrent laryngeal nerve lymph nodes sampled on the both sides (p > 0.05) did not significantly differ. The single intercostal group had lower postoperative long-term usage of morphine (0,0-60 vs. 20,20-130; p < 0.01), total temporary addition (10,0-30 vs. 20,20-40; p < 0.01) and temporary usage in the first 3 days after surgery (0,0-15 vs. 10,10-20; p < 0.01) than did the multicostal group.There were no significant differences in age, sex, tumor location or extent of lymphadenectomy or in the clinical factors between the single-intercostal group (p > 0.05). CONCLUSIONS: Both techniques can be used for the treatment of esophageal cancer. Compared to multiple intercostal MIIE, the feasibility of which has been proven internationally, the single intercostal technique can also be applied to patients of different age groups and sexes and with different tumor locations. It can provide surgeons with an additional surgical option. TRIAL REGISTRATION: This study was retrospectively registered by the Ethics Committee of the Second Affiliated Hospital of Zhejiang University School of Medicine, and written informed consent was exempted from ethical review. The registration number was 20,230,326. The date of registration was 2023.03.26.

Comparison of postoperative analgesia by thoracoscopic-guided thoracic paravertebral block and thoracoscopic-guided intercostal nerve block in uniportal video-asssited thoracic surgery: a prospective randomized controlled trial.

BACKGROUND: Thoracoscopic-guided thoracic paravertebral nerve block (TG-TPVB) and thoracoscopic-guided intercostal nerve block (TG-INB) are two postoperative analgesia technology for thoracic surgery. This study aims to compared the analgesic effect of TG-TPVB and TG-INB after uniportal video-asssited thoracic surgery (UniVATS). METHODS: Fifty-eight patients were randomly allocated to the TG-TPVB group and the TG-INB group. The surgical time of nerve block, the visual analog scale (VAS) scores, the consumption of sufentanil and the number of patient-controlled intravenous analgesic (PCIA) presses within 24 h after surgery, the incidence of adverse reactions were compared between the two groups. RESULTS: The VAS scores were significantly lower during rest and coughing at 2, 6, 12, and 24 h in the TG-TPVB group than in the TG-INB group (P < 0.05). The consumption of sufentanil and the number of PCIA presses within 24 h after surgery were significantly lower in the TG-TPVB group than in the TG-INB group (P < 0.001).The surgical time of nerve block was significantly shorter in the TG-TPVB group than in the TG-INB group (P < 0.001). The incidence of bleeding at the puncture point was lower in the TG-TPVB group than that in the TG-INB group (P < 0.05). CONCLUSION: TG-TPVB demonstrated superior acute pain relieve after uniVATS, shorter surgical time and non-inferior adverse effects than TG-INB.

Assessing the clinical advantage of opioid-reduced anesthesia in thoracoscopic sympathectomy: a prospective randomized controlled trial.

BACKGROUND: Opioid-reduced multimodal analgesia has been used clinically for many years to decrease the perioperative complications associated with opioid drugs. We aimed to assess the clinical effects of opioid-reduced anesthesia during thoracoscopic sympathectomy. METHODS: Surgical patients (n = 151) with palmar hyperhidrosis were randomly divided into control (Group C, 73 patients) and test (Group T, 78 patients) groups. All patients were administered general anesthesia using a laryngeal mask. In Group C, patients received propofol, fentanyl, and cisatracurium for anesthesia induction, and maintenance was achieved with propofol and remifentanil, along with mechanical ventilation during the operation. In Group T, anesthesia was induced with propofol, dezocine, and dexmedetomidine (DEX) and maintained with propofol, DEX, and an intercostal nerve block, along with spontaneous breathing throughout the operation. Perioperative complications related to opioid use include hypotension, bradycardia, hypertension, tachycardia, hypoxemia, nausea, vomiting, urine retention, itching, and dizziness were observed. To assess the impact of these complications, we recorded and compared vital signs, blood gas indices, visual analogue scale (VAS) scores, adverse events, and patient satisfaction between the two groups. RESULTS: Perioperative complications related to opioid use were similar between groups. There were no significant differences in the type of perioperative sedation, analgesia index, respiratory and circulatory indicators, blood gas analysis, postoperative VAS scores, adverse reactions, propofol dosage, postoperative recovery time, and patient satisfaction. CONCLUSIONS: In minimally invasive surgeries such as thoracoscopic sympathectomy, opioid-reduced anesthesia was found to be safe and effective; however, this method did not demonstrate clinical advantages. TRIAL REGISTRATION: Chinese Clinical Trial Register: ChiCTR2100055005, on December 30, 2021.

Inpatient Outcomes of Intercostal Nerve Cryoablation With Surgical Rib Fixation.

INTRODUCTION: Rib fractures are associated with significant pain and morbidity. Intercostal nerve cryoablation (INCA) offers targeted, prolonged pain relief for these patients. Over the last decade, more patients have undergone surgical stabilization of rib fractures (SSRF) after injury. However, data on INCA use in SSRF patients are limited. This study aimed to identify the relationship of INCA in blunt trauma patients (BTPs) undergoing SSRF, hypothesizing INCA coupled with SSRF would decrease hospital length of stay (LOS). METHODS: The Trauma Quality Improvement Program database (2017-2021) was queried for BTPs ≥18 y old who underwent SSRF. Patients who received INCA ((+)INCA) were compared to patients who did not ((-)INCA). The primary outcome was LOS. Secondary outcomes included intensive care unit (ICU) LOS and in-hospital complications. A subgroup analysis of only flail chest patients was performed. RESULTS: From 15,784 BTPs, 750 (4.8%) received INCA. Hospital LOS was similar between groups (12 versus 12 d, P = 0.10); however, the (+)INCA patients had decreased ICU LOS (6 versus 7 d, P < 0.001). The (+)INCA cohort also had decreased hospital complications (20.4% versus 24.4%, P = 0.01), including pulmonary embolism (0.7% versus 1.8%, P = 0.02) and ventilator-associated pneumonia (2.1% versus 3.8%, P = 0.02). On subgroup analysis of flail chest patients, decreased ICU LOS in the (+)INCA patients remained a significant outcome (7 versus 8 d, P = 0.02). CONCLUSIONS: Nearly 5% of SSRF patients received INCA. While overall LOS was similar, the (+)INCA cohort had decreased ICU LOS and in-hospital complications. Future studies are needed to corroborate these findings and evaluate any long-term complications associated with INCA before widespread adoption.

Clinical anatomy of the right intercostal arteries: Another neighbor to know before pulmonary vein isolation.

BACKGROUND: Hemothorax caused by a right intercostal artery (ICA) injury behind the left atrium (LA) is a potentially fatal complication during pulmonary vein isolation. However, their anatomical relationship has not been fully elucidated. OBJECTIVE: This study aimed to investigate the clinical anatomy of the right ICA in relation to the LA. METHODS: This retrospective study included 100 patients (70.2 ± 10.6 years, 39.0% female) who underwent cardiac computed tomography. The patients were divided into sinus rhythm (SR) and atrial fibrillation (AF) groups. We focused on the distance between the LA and right ICAs and its predictive factors. RESULTS: On average, 3.7 ± 0.7 right ICAs were found behind the LA. Among these, the eighth ICA was the closest in 54% of the cases, followed by the seventh ICA in 29%, and the ninth ICA in 14%. The average closest distance between them was 3.8 ± 3.8 mm, which was significantly shorter in the AF group than in the SR group (3.0 ± 3.2 mm vs. 4.7 ± 4.2 mm, p = 0.006). Multivariate analysis revealed that a thinner chest cavity (ß = -0.512, p = 0.002) and LA dilatation (ß = -0.432, p = 0.001) were predictors of shorter distance. The closest points distributed along the vertebral column, generally near the inferior pulmonary vein orifices. CONCLUSIONS: Right ICA-LA proximity was systematically clarified. Particularly in cases with an enlarged LA and/or thin chest cavity, operators should be aware of the potential risk of injuring the right ICA during pulmonary vein isolation.

Spontaneous Chest Wall Hernias: Intercostal Lung Hernia and Inverted Intercostal Hernia.

Intercostal lung hernia and inverted intercostal hernia are rare chest wall hernias usually asymptomatic and detected incidentally on chest radiograph. In this case report, we discussed here on the chest radiograph and computed tomography imaging findings of two cases of these rare hernias with an emphasis being in differential diagnosis of chest tumors.

A prospective multi-institutional study to verify the non-inferiority of postoperative pain in robot-assisted thoracic surgery in comparison with video-assisted thoracoscopic surgery for lung cancer: The Japanese RATS interest group 01 (J-RATSIG 01).

OBJECTIVES: We sought to compare the latest data on postoperative pain between robot-assisted thoracic surgery (RATS) and video-assisted thoracoscopic surgery (VATS), and to clarify the relationship between the number or placement of ports and postoperative pain in patients with lung cancer. METHODS: Patients who underwent anatomical lung resection by RATS or VATS and whose chest tube was removed within 7 days were enrolled. The primary endpoint was the percentage of patients with a numeric rating scale (NRS) score ≤ 3 on postoperative day 30 (POD30). The target sample size was 400 patients. RESULTS: Four hundred five patients (RATS, n = 196; VATS, n = 209) managed at 12 institutions were included. Ninety-nine patients in the VATS group underwent a uniport procedure. Significant differences were observed between the RATS and VATS groups in the mean number of inserted ports (5.0 vs. 2.2), number of injured intercostal sites (2.9 vs. 1.9), largest wound size (3.4 vs. 3.7 cm), operation time (202 vs. 165 min), and use of epidural anesthesia or continuous nerve block (45 vs. 31 %). In the RATS and VATS groups, the rates of NRS≤3 on POD30 were 82.0 % and 94.7 % (95 %CI: -19.0 to -6.6 %), respectively, which could not prove noninferiority. However, in a multivariable analysis, the RATS approach was not proven to be a significant risk factor. CONCLUSION: In the current status of minimally invasive thoracic surgery in Japan, RATS involves a greater number of ports, longer operation time, and higher frequency of local anesthesia than VATS and may be inferior in terms of postoperative pain.

Greater ipsilateral rectus muscle atrophy after robotic thoracic surgery compared with open and video-assisted thoracoscopic surgery approaches.

Objective: Robotic thoracic surgery provides another minimally invasive approach in addition to video-assisted thoracoscopic surgery (VATS) that yields less pain and faster recovery compared with open surgery. However, robotic incisions are generally placed more inferiorly, which may increase the risk of intercostal nerve injury that affects the abdominal wall. We hypothesized that a robotic approach causes greater ipsilateral rectus muscle atrophy compared with open and VATS approaches. Methods: The cross-sectional area and density of bilateral rectus abdominis muscles were measured on computed tomography scans in patients who underwent lobectomy in 2018. The differences between the contralateral and ipsilateral muscles were compared between preoperative and 6-month surveillance scans. Changes were compared among the open, VATS, and robotic approaches through a mixed effects model after adjustments of correlation and covariates. Results: Of 99 lobectomies, 25 (25.3%) were open, 56 (56.6%) VATS, and 18 (18.1%) robotic. The difference between the contralateral and ipsilateral rectus muscle cross-sectional area was significantly larger at 6 months after robotic surgery compared with open (31.4% vs 9.5%, P = .049) and VATS (31.4% vs 14.1%, P = .021). There were no significant differences in the cross-sectional area between the open and VATS approach. Conclusions: In this retrospective analysis, there was greater ipsilateral rectus muscle atrophy associated with robotic thoracic surgery compared with open or VATS approaches. These findings should be correlated with clinical symptoms and followed to assess for resolution or persistence.

Critical tasks and errors associated with intercostal chest drain insertion.

INTRODUCTION: To describe critical tasks and errors associated with intercostal chest drain insertion, in order to develop enhanced procedural guidelines for task performance and training. METHODS: Expert emergency medicine physicians participated in a three-phased study. First, hierarchical task analyses was used to identify tasks, sub-tasks, and the sequence of tasks. Second, systematic human error reduction and prediction approach was used to identify and classify the errors associated with each sub-task culminating in a probability, criticality, and detectability rating for each error. Third, failure modes, effects and criticality analysis technique was used to convert probability and criticality estimates to occurrence and severity scores. Criticality index score, a measure of the propensity for the error to cause harm or procedural failure for each error, was calculated and the top 20 errors most likely to cause harm were ranked. RESULTS: Thirteen tasks and 61 sub-tasks were identified and yielded 86 potential errors. Error classification included errors of action, checking, and selection. The error with the highest criticality score was 'identifying a point of entry lower than the fifth intercostal space'. The top four ranked errors all relate to the identification and correct marking of the location site for the intercostal drain within the safe triangle. CONCLUSIONS: Tasks and sub-tasks associated with intercostal chest drain insertion was described and evaluated for criticality. The most critical task was the correct identification of a safe insertion point. Applications include development of procedural guidelines with tasks vulnerable to error highlighted and training interventions that promotes safe task performance.

Assessment of ultrasound-guided intercostal nerve block for acute herpes zoster and its' possible prophylaxis for postherpetic neuralgia: a retrospective and case-controlled trial.

Background: This study aimed to compare the intercostal nerve block (ICNB) and thoracic paravertebral block (TPVB) for acute herpes zoster-associated pain (ZAP) and possible prophylaxis for post-herpetic neuralgia (PHN). Methods: This study enrolled 128 patients with ZAP. Their records were stratified into standard antiviral treatment (AVT) plus US-guided TPVB (the TPVB group), AVT plus US-guided ICNB (the ICNB group) or AVT alone (the control group). Herpes zoster (HZ)-related burden of illness (HZ-BOI) within the post-procedural 30 days was defined as the primary endpoint, determined by a composite of pain severity and follow-up duration. Procedure time, rescue analgesic requirement, PHN incidence, health-related quality of life and side effects were also recorded. Results: Significantly lower HZ-BOI-AUC30 was reported in the TPVB and ICNB groups as compared to the control group, with a mean difference of 57.5 (P < 0.001) and 40.3 (P = 0.003), respectively. However, there was no difference between the TPVB and ICNB groups (P = 0.978). Both TPVB and ICNB reported significantly greater improvements in PHN incidence, EQ-5D-3L scores and rescue analgesic requirements during follow-up, as opposed to the control AVT. Shorter procedure time was observed in ICNB as compared to TPVB (16.47 ± 3.39 vs. 11.69 ± 2.58, P < 0.001). Conclusions: Both US-guided TPVBs and ICNBs were effective for ZAP, and accounted for possible prophylaxis for PHN, as compared to AVT alone. The ICNB approach could be recommended as an alternative to conventional TPVB with a better consumed procedure time and side effect profile.a.

Successful use of ultrasound guided pecto-intercostal fascial plane block to provide intraoperative analgesia in four dogs undergoing median sternotomy.

OBJECTIVE: To evaluate the impact of pecto-intercostal fascial plane block on providing intraoperative analgesia in dogs undergoing median sternotomy. ANIMALS: 4 dogs. CLINICAL PRESENTATION: The dogs were presented with a history of inappetence, lethargy and respiratory distress. Thoracic radiographs, point of care ultrasound, thoracocentesis, bronchoscopy and computed tomography was performed to characterize the disease. RESULTS: 4 male castrated, 5.3 ± 3 years old dogs weighing 19.7 ± 13.5 kg and belonging to Dalmatian, Beagle, Siberian Husky and Rottweiler breeds were included. Three dogs were diagnosed with suppurative pleural effusions because of pulmonary abscesses and one dog with spontaneous pneumothorax due to the presence of pulmonary bullae. All dogs underwent median sternotomy under general anesthesia to explore the thorax. A pecto-intercostal fascial plane block was performed by injecting local anesthetic bupivacaine in the parasternal fascial plane between the deep pectoral and external intercostal muscles to provide antinociception by anesthetizing ventral cutaneous branches of intercostal nerves second through sixth. Analgesia from the block resulted in reduced requirement of inhalant anesthesia and minimal requirement for opioid to augment analgesia intraoperatively. CLINICAL RELEVANCE: Median sternotomy is required to perform thoracic surgery in dogs with various thoracic pathologies. Pecto-intercostal fascial plane block is a locoregional technique that can blunt nociception arising from the ventral thorax and can significantly improve perioperative patient care in dogs undergoing median sternotomy by providing effective intraoperative and potentially postoperative analgesia.

Dorsal intercostal artery flap; A reliable option for coverage of myelomeningocele defects: A case series.

Meningomyelocele is a common congenital condition and its reconstruction poses a challenge for surgeons. The dorsal intercostal artery (DICA) flap offers a one-stage tension-free closure with adequate results. This study, spanning from January 2019 to September 2022, analyses the outcome of nine DICA flaps for meningomyelocele reconstruction, where the average size of the DICA flap was 6.8 x 4.6 cm for an average defect of 6.33 x 4 cm. Notably, no post-operative blood transfusion was required, nor any complications occurred except for one patient's septic shock-related death. Two had post-operative cerebrospinal fluid (CSF) leak, repaired primarily with one requiring VP shunt. Based on our experience, the DICA flap, with its consistent anatomy, is a reliable option for the reconstruction of meningomyelocele defects.

Prediction Model for Outpatient Opioid Use Following the Minimally Invasive Repair of Pectus Excavatum.

INTRODUCTION: To minimize unused outpatient opioids while providing adequate pain control, we sought to create a model to predict outpatient opioid use following the minimally invasive repair of pectus excavatum with cryoablation MIRPE-C. METHODS: A retrospective review was conducted at a single center from May 2023 to January 2024 among patients <21 years who underwent MIPRE-C. Demographic and clinical data, including inpatient and outpatient opioid use were reviewed. Patients completed opioid use questionnaires at their first postoperative visit. Simple linear regression was employed to create a model for outpatient opioid use. RESULTS: Sixty-eight patients underwent MIRPE-C: 84% were male (mean age of 15.2 ± 1.7 years, and median Haller index 4.2[IQR:3.7-5.7]). Daily mean inpatient opioid requirement and daily opioid doses were 0.3 ± 0.2 OME/day/kg and 2 ± 1.2 opioid doses/day. At the first outpatient follow-up visit, patients reported using a median of five 5-mg oxycodone tablets [IQR:1.6-10] for 5 days [IQR:2-7] with 22% of patients needing an opioid refill. On linear regression, inpatient opioid use had a significant relationship with the number of outpatient doses taken, while patient factors were not associated with outpatient opioid use. A simple equation for predicting opioid need based on best fit (R2 = 0.211) was developed: #OUTPATIENT OPIOID TABLETS = 3 TABLETS + (0.82 x #INPATIENT OPIOID RECIEVED). CONCLUSION: The proposed outpatient opioid prescription model is simple to calculate and tailors the prescription to individual patient need. This model has the potential to provide effective pain control and avoid prescription refills, while minimizing over-prescription of opioids. LEVEL OF EVIDENCE: Treatment study Level III.