Analgesic benefits of pre-operative versus postoperative transversus abdominis plane block for laparoscopic cholecystectomy: a frequentist network meta-analysis of randomized controlled trials.

BACKGROUND: Transversus abdominis plane (TAP) block has been utilized to alleviate pain following laparoscopic cholecystectomy (LC). However, the optimal timing of administration remains uncertain. This study aimed to compare the efficacy of pre-operative and postoperative TAP blocks as analgesic options after LC. METHODS: A frequentist network meta-analysis of randomized controlled trials (RCTs) was conducted. We systematically searched PubMed (via the National Library of Medicine), EMBASE, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science up to March 2023. The study included RCTs that enrolled adult patients (≥ 18 years) who underwent LC and received either pre-operative or postoperative TAP blocks. The primary outcome assessed was 24-hour postoperative morphine consumption (mg). Additionally, pain rest scores within 3 hours, 12 hours, and 24 hours, as well as postoperative nausea and vomiting (PONV), were considered as pre-specified secondary outcomes. RESULTS: A total of 34 trials with 2317 patients were included in the analysis. Postoperative TAP block demonstrated superiority over the pre-operative TAP block in reducing opioid consumption (MD 2.02, 95% CI 0.87 to 3.18, I2 98.6%, p < 0.001). However, with regards to postoperative pain, neither pre-operative nor postoperative TAP blocks exhibited superiority over each other at any of the assessed time points. The postoperative TAP block consistently ranked as the best intervention using SUCRA analysis. Moreover, the postoperative TAP block led to the most significant reduction in PONV. CONCLUSIONS: The findings suggest that the postoperative TAP block may be slightly more effective in reducing 24-hour postoperative opioid consumption and PONV when compared to the pre-operative TAP block. TRIAL REGISTRATION: PROSPERO, CRD42023396880 .

Single-shot regional anesthesia for laparoscopic cholecystectomies: a systematic review and network meta-analysis.

BACKGROUND: Different regional anesthesia (RA) techniques have been used for laparoscopic cholecystectomy (LC), but there is no consensus on their comparative effectiveness. Our objective was to evaluate the effect of RA techniques on patients undergoing LC using a network meta-analysis approach. METHODS: We conducted a systematic review and network meta-analysis. We searched PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and Web of Science (Science and Social Science Citation Index) using the following PICOS criteria: (P) adult patients undergoing LC; (I) any RA single-shot technique with injection of local anesthetics; (C) placebo or no intervention; (O) postoperative opioid consumption expressed as morphine milligram equivalents (MME), rest pain at 12 h and 24 h post-operation, postoperative nausea and vomiting (PONV), length of stay; and (S) randomized controlled trials. RESULTS: A total of 84 studies were included. With the exception of the rectus sheath block (P = 0.301), the RA techniques were superior to placebo at reducing opioid consumption. Regarding postoperative pain, the transversus abdominis plane (TAP) block (-1.80 on an 11-point pain scale) and erector spinae plane (ESP) block (-1.33 on an 11-point pain scale) were the most effective at 12 and 24 h. The TAP block was also associated with the greatest reduction in PONV. CONCLUSIONS: RA techniques are effective at reducing intraoperative opioid use, postoperative pain, and PONV in patients undergoing LC. Patients benefit the most from the bilateral paravertebral, ESP, quadratus lumborum, and TAP blocks.

Myocardial Protection in Cardiac Surgery: Exploring the Influence of Anesthetic Agents.

This review assesses the efficacy of inhalation anesthetics and propofol in cardiac surgery, primarily focusing on their impact on myocardial protection and subsequent clinical outcomes. The review provides a concise summary of the current scientific information regarding the protective efects of inhalation anesthetics and propofol, particularly in the context of ischemia-reperfusion injury during cardiac surgery. The review delves into the mechanisms of action and discusses clinical studies comparing the 2 anesthetic strategies regarding mortality, complication rates, and length of hospital stay. Inhalation anesthetics exhibit cardioprotective properties through many mechanisms, such as preconditioning, scavenging of free radicals, and stabilizing mitochondria. Propofol demonstrates certain protective benefits but does not possess the preconditioning capability of inhalation medications. Clinical investigations yield contradictory findings, as several studies indicate enhanced outcomes with inhalation anesthetics, while others observe no substantial disparity between the 2 approaches. The cardioprotective efcacy of propofol against ischemia-reperfusion injury remains limited. While its inherent antioxidant properties ofer direct myocardial protection, propofol demonstrably lacks the preconditioning-mediated signaling pathways triggered by inhalation anesthetics. As a result, propofol's protective efect may be slightly inferior to preconditioning strategies, and its potential to inhibit organ-protective impact of other interventions needs further investigation. The question of which anesthetic approach ofers superior myocardial protection remains debatable. Current evidence is inconclusive, potentially due to patient heterogeneity, surgical complexity, and methodological limitations of existing studies. Future research, including pharmacogenetic studies and large, welldesigned, randomized controlled trials, are necessary to provide definitive guidance on anesthetic selection for optimal myocardial protection in cardiac surgery.

Superior vena cava perforation complicating ultrasound-guided subclavian venous catheterization: A case report.

We present a case of a severe mechanical complication (superior vena cava [SVC] perforation) that developed after subclavian vein catheterization using an ultrasound-guided static approach in a patient who underwent right lower lobectomy with video-assisted thoracic surgery. The use of ultrasound during catheterization is reported to reduce mechanical complications. Despite the use of ultrasound in our patient, surgical exploration showed that the catheter placed in the right subclavian vein penetrated the superior portion of the SVC. At the end of the surgery, the catheter was removed under direct visualization. The surgeon attempted to stop bleeding in the SVC by compressing with gauze. However, bleeding could only be stopped by administering a hemostatic matrix. It is concluded that to reduce the incidence or size of iatrogenic perforation of the SVC, catheters with the smallest possible diameter should be used, and the dilator should only be inserted deep enough to enter the vein. If the static approach is used, the modifiedSeldinger technique is useful and to provide training to improve the ultrasound experience, especially if the dynamic approach is used.