Dexmedetomidine induced hypotension and hemostatic markers.

Background and Aims: The hemostatic system undergoes extensive alterations following surgical trauma leading to a hypercoagulable state. We assessed and compared the changes in platelet aggregation, coagulation, and fibrinolysis status during normotensive and dexmedetomidine-induced hypotensive anesthesia in patients undergoing spine surgery. Material and Methods: Sixty patients undergoing spine surgery were randomly allocated into two groups: normotensive and dexmedetomidine-induced hypotensive groups. Platelet aggregation was assessed preoperatively, 15 min after induction, 60 min, and 120 min after skin incision, at the end of surgery, 2 h and 24 h postoperatively. Prothrombin time (PT), activated partial thromboplastin time (aPTT), platelet count, antithrombin III, fibrinogen, and D-dimer levels were measured preoperatively, 2 h and 24 h postoperatively. Results: Preoperative platelet aggregation (%) was comparable between both groups. Platelet aggregation significantly increased intraoperative at 120 min after skin incision and postoperatively in the normotensive group compared to the preoperative value (P < 0.05) but it was insignificantly decreased during the intraoperative induced hypotensive period in the dexmedetomidine-induced hypotensive group (P > 0.05). Postoperative PT, aPTT significantly increased and platelet count, and antithrombin III significantly decreased in the normotensive group compared to the preoperative value (P < 0.05) but they were not significantly changed in the hypotensive group (P > 0.05). Postoperative D-dimer significantly increased in the two groups compared to the preoperative value (P < 0.05). Conclusion: Intraoperative and postoperative platelet aggregation significantly increased in the normotensive group with significant alterations of the coagulation markers. Dexmedetomidine-induced hypotensive anesthesia prevented the increased platelet aggregation that occurred in the normotensive group with better preservation of platelet and coagulation factors.

Inter-semispinal plane (ISP) block for postoperative analgesia following cervical spine surgery: A prospective randomized controlled trial.

STUDY OBJECTIVE: We evaluated the perioperative analgesic effects of the inter-semispinal plane (ISP) block in patients undergoing posterior cervical spine surgery. DESIGN: Prospective, randomized, controlled, double-blinded trial. SETTING: Operating room and surgical ward. PATIENTS: 60 patients aged 18-60 years of either gender, ASA I-II, undergoing elective posterior cervical spine surgery. INTERVENTIONS: Patients were randomly assigned into a control group (general anesthesia only), ISP group received bilateral ultrasound guided ISP block at the level of C5 using 20 ml bupivacaine 0.25% on each side. MEASUREMENTS: Visual analog scale (VAS), intraoperative fentanyl and 24 h postoperative pethidine consumptions and time to first rescue analgesic request were documented. MAIN RESULTS: The median (quartiles) of 24 h postoperative rescue pethidine consumption was significantly lower in the ISP group [0 (0-46.25) mg] compared to that of the control group [143 (116.75-169.00) mg]; P < 0.001). VAS was significantly lower in the ISP group at 30 min, 1 h, 2 h,4 h, 6 h, 8 h and 12 h postoperative compared to control group (P < 0.05). At 18 and 24 h, VAS was not significantly different between groups. The median (quartiles) of intraoperative fentanyl consumption in the ISP group [0 (0-40.75) µg] was significantly lower compared to that of the control group [63.5 (39.5-90.25) µg]; P < 0.001]. The time to first rescue analgesic administration was significantly longer in the ISP group compared to the control group (P < 0.001). CONCLUSION: Bilateral ultrasound-guided ISP block can provide decreased 24 h postoperative analgesic consumption as well as lower pain scores in the first 12 postoperative hours in patients undergoing posterior cervical spine surgery.

The Interspace Between Popliteal Artery and Posterior Capsule of the Knee (IPACK) Block in Knee Arthroplasty: A Prospective Randomized Trial.

BACKGROUND: Optimal analgesia following knee surgery is essential for early mobilization and rehabilitation and minimizing morbidity. OBJECTIVES: We compared the addition of the interspace between the popliteal artery and the posterior capsule of the knee (IPACK) block to the adductor canal block (ACB) versus ACB alone on postoperative analgesia and ambulation ability in patients undergoing total knee arthroplasty (TKA). STUDY DESIGN: A prospective randomized study. SETTING: An academic medical center. METHODS: Eighty patients undergoing TKA were randomly allocated to receive either ACB or combined ACB-IPACK block at the end of surgery. ACB was performed using 20 mL bupivacaine 0.25% in both groups, while IPACK block using 30 mL bupivacaine 0.25% was added in the ACB-IPACK group only. Visual analog scale (VAS) was evaluated at rest and with 45° knee flexion at 4, 6, 12, and 24 hours postoperatively. The quadriceps muscle power and mobilization ability were assessed at 12 hours and 24 hours postoperative. Total 24 hour postoperative morphine consumption, time to first rescue analgesic request, and patient satisfaction were documented. RESULTS: The mean postoperative morphine consumption was higher in the ACB group (20.93 ± 7.17 mg) than the ACB-IPACK group (9.68 ± 3.56 mg) (P < 0.001, 95% CI; 8.71; 13.79). The time to 1st rescue analgesic consumption was longer in the ACB-IPACK group (645 ± 254 min) than ACB group (513 ± 247 min) (P = 0.021, 95% CI; 20.4; 243.6). At 4 hours, 6 hours, and 12 hours postoperative, the median postoperative VAS scores were higher in the ACB group than those of the ACB-IPACK group at rest (P = 0.003, 0.001 and 0.007) and on 45° knee flexion (P = 0.001, 0.001, 0.002) respectively. At 24 hours, the median VAS score was comparable between both groups both at rest and on 45° knee flexion (P = 0.358 & 0.054), respectively. The TUG test and the straight leg raise (MRC) scales at 12 hours, and 24 hours postoperative were comparable between both groups (P > 0.05). LIMITATIONS: This study was limited by its small sample size. CONCLUSION: The addition of IPACK to the ACB significantly reduced the postoperative morphine consumption and postoperative pain scores compared to the ACB alone without significant difference in mobilization ability in patients undergoing TKA.

Continuous Pectoral Nerve Block Compared With Continuous Thoracic Paravertebral Block and Intravenous Opioid Analgesia for the Postoperative Analgesic Efficacy in Patients Undergoing Modified Radical Mastectomy: A Prospective Randomized Trial.

OBJECTIVES: Postoperative pain following mastectomy is often severe and pain management is necessary. We evaluated the analgesic efficacy of continuous pectoral nerve block (PEC) in comparison with that of the continuous thoracic paravertebral block (TPVB) and the intravenous opioid analgesia in patients scheduled for modified radical mastectomy (MRM). MATERIALS AND METHODS: A total of 90 female patients aged 20 to 70 years, American Society of Anesthesiologists (ASA) I to III, undergoing unilateral MRM were randomly allocated into 3 groups. All patients received postoperative morphine patient-controlled analgesia (PCA). Continuous TPVB and continuous PECs were added in group II and group III, respectively. Postoperative morphine consumption during the first 48 hours and postoperative visual analog scale were recorded. RESULTS: The cumulative morphine consumption in the first 24 hours postoperative was higher in the PCA-M group (27.47±4.95 mg) than that of the TPVB group (8.43±2.67 mg) and PEC group (13.47±3.89 mg) (P<0.001, confidence interval: 16.6-21.5 and 11.6-16.4, respectively). It was significantly higher in the PEC group as compared with the TPVB group (P<0.001, confidence interval: 2.6-7.5). On admission to postanesthesia care unit till 2 hours postoperative, the median visual analog scale score at rest was higher in the PCA-M group than that of the TPVB group (P<0.05) and PEC group (P<0.05) without statistical difference between the TPVB group and PEC group. DISCUSSION: Continuous PEC and continuous TPVB reduced the postoperative morphine consumptions as compared with the intravenous opioid analgesia in patients undergoing MRM with greater reduction in TPVB and without increased adverse effects.

Ultrasound-Guided Erector Spinae Plane Block in Patients Undergoing Laparoscopic Bariatric Surgery: A Prospective Randomized Controlled Trial.

BACKGROUND: Bariatric surgery is frequently complicated with considerable postoperative pain. We evaluated the impact of ultrasound-guided erector spinae plane block on perioperative analgesia and pulmonary functions following laparoscopic bariatric surgery. METHODS: A total of 60 patients aged 18 to 65 years with a body mass index (BMI) of ≥ 40 kg/m2 were randomly allocated into two groups. Patients received either bilateral erector spinae plane block using 20 mL bupivacaine 0.25% at the level of the T7 transverse process or bilateral sham block using 20 mL normal saline on each side. Visual analog scale, intraoperative fentanyl consumption, the cumulative 24-hour postoperative morphine consumption, and postoperative pulmonary functions were recorded. RESULTS: Visual analog scale for the first eight postoperative hours were significantly lower in the erector spinae plane block group than the control group. The median (interquartile range [IQR]) intraoperative fentanyl consumption was higher in the control group (159.5 [112.0 to 177.8] µg) than in the erector spinae plane block group (0.0 [0.0 to 74.5] µg) (P < 0.001). The median (IQR) cumulative 24-hour postoperative morphine consumption was lower in the erector spinae plane block group (8.0 [7.0 to 9.0] mg) than in the control group (21.0 [17.0 to 26.25] mg) (P < 0.001, 95% CI [11.00, 15.00]). Postoperative pulmonary functions were significantly impaired in both groups compared with baseline values without significant difference between both groups. CONCLUSION: Ultrasound-guided erector spinae plane block provided satisfactory postoperative analgesia following laparoscopic bariatric surgery with decreased analgesic consumption without significant difference in postoperative pulmonary functions compared with the control group.

The Analgesic Efficacy of Pecto-Intercostal Fascial Block Combined with Pectoral Nerve Block in Modified Radical Mastectomy: A Prospective Randomized Trial.

BACKGROUND: Pectoral nerve (Pecs) block is one of the most promising regional analgesic techniques for breast surgery. However, Pecs II block may not provide analgesia of the medial aspect of the breast or the entire nipple-areolar complex. OBJECTIVES: The aim of the present study was to investigate the efficacy of combining the pecto-intercostal fascial block (PIFB) and Pecs II block for perioperative analgesia following modified radical mastectomy (MRM). STUDY DESIGN: A prospective randomized study. SETTING: An academic medical center. METHODS: Sixty women undergoing unilateral MRM were randomly divided into 2 groups. The Pecs II group received Pecs II block using 20 mL bupivacaine 0.25% between the serratus anterior and the external intercostal muscles, and 10 mL bupivacaine 0.25% between the pectoralis major and minor muscles, together with sham PIFB using 15 mL normal saline solution in the interfascial plane between the pectoralis major muscle and the external intercostal muscle. PIFB-Pecs II group received the same Pecs II block combined with PIFB using 15 mL bupivacaine 0.25%. RESULTS: The median (interquartile range [IQR]) time to the first morphine dose was significantly longer in the PIFB-Pecs II group (327.5 [266.3-360.0] minutes) than the Pecs II group (196 [163.8-248.8] minutes) (P < 0.001, 95% confidence interval [CI] 79.98, 150.00).The median (IQR) cumulative morphine consumption was higher in the Pecs II group (14.0 [11.0-18.0] mg) than the PIFB-Pecs II group (8.0 [7.0-9.0] mg) (P < 0.001; CI, 4.0-8.0). Intraoperative consumption of fentanyl was significantly lower in PIFB-Pecs II group with a median (IQR) of 0 (0-15 mu g) than the Pecs II group median 57.5 (0-75 mu g) (P = 0.022, CI; 0-60). The Visual Analog Scale scores for the first 12 postoperative hours were lower in the PIFB-Pecs II group than the Pecs II group at rest and on moving the ipsilateral arm (P < 0.001). The dermatomal block on the lateral chest wall was comparable between the 2 studied groups. PIFB-Pecs II provided extensive sensory block on the anterior chest wall, whereas Pecs II block failed to achieve any sensory block. LIMITATIONS: This study was limited by its small sample size. CONCLUSIONS: The combination of Pecs II and PIFB provide better perioperative analgesia for MRM than Pecs II alone.

Ultrasound-guided erector spinae plane block for postoperative analgesia in pediatric patients undergoing splenectomy: A prospective randomized controlled trial.

BACKGROUND: Many analgesic modalities have been investigated in pediatrics. We studied the analgesic efficacy of bilateral ultrasound-guided erector spinae plane block in pediatric patients undergoing open midline splenectomy. METHODS: Sixty patients aged 3-10 years were randomly assigned into two groups: Control group received general anesthesia with bilateral sham erector spinae plane block using 0.3 mL/kg normal saline on each side. Erector spinae plane block group received bilateral ultrasound-guided erector spinae plane block using 0.3 mL/kg bupivacaine 0.25% (on each side) with a maximum dose of 2 mg/kg. Children's Hospital Eastern Ontario Pain Scale (CHEOPS), total consumption of intraoperative fentanyl (1 µg/kg IV in case of inadequate analgesia), time to first rescue analgesic administration, and postoperative paracetamol consumption were recorded over the first 24 hours postoperatively. RESULTS: The median (IQR) postoperative CHEOPS score at 1 hour was lower in erector spinae plane block group (5.0 (4.75 -5.25)) than the control group (7.0 (6.0-10.0)) (P < .001, 95% CI: 1.0; 5.0). The CHEOPS scores for the first eight postoperative hours were lower in the erector spinae plane block group (5.0 (5.0-6.0)) than the control group (6.0 (6.0 -10.0)) (P Ë‚ .001, 95% CI: 1.0; 2.0). Intraoperative fentanyl administration was higher in the control group 40.0 (21.5-50.0) µg compared to erector spinae plane block group 0.0 (0.0-0.0) µg (P Ë‚ .001, 95% CI: 23.0; 48.0). The total postoperative paracetamol consumption was higher in the control group (37.5 ± 17.1 mg/kg) compared to erector spinae plane block group (8.5 ± 10.9 mg/kg) (P Ë‚ .001, 95% CI: 21.57; 36.43). The time to the first postoperative rescue analgesic requirement was longer in the erector spinae plane block group. CONCLUSION: Ultrasound-guided erector spinae plane block reduced CHEOPS score for the first eight hours postoperatively with the reduction of intraoperative fentanyl and postoperative paracetamol consumptions.

Ultrasound-Guided Erector Spinae Plane Block in Patients Undergoing Open Epigastric Hernia Repair: A Prospective Randomized Controlled Study.

BACKGROUND: Hernia repair is associated with considerable postoperative pain. We studied the analgesic efficacy of bilateral ultrasound-guided erector spinae plane block in patients undergoing open midline epigastric hernia repair (T6-T9). METHODS: Sixty patients 18-65 years of age were randomly allocated into 2 groups. Patients in the erector spinae plane block group received bilateral ultrasound-guided erector spinae plane block at the level of T7 transverse process using 20 mL of bupivacaine 0.25% on each side, while the control group received bilateral sham erector spinae plane block using 1 mL of normal saline. All patients underwent general anesthesia for surgery. Pain severity (visual analog scale), consumption of intraoperative fentanyl, time to first request of rescue analgesia, and postoperative pethidine consumption were recorded over the first 24 hours postoperatively. RESULTS: At 2 hours postoperatively, the visual analog scale pain score was significantly lower in the erector spinae plane block group compared to the control group (estimated main effect of 2.53; P < .001; 95% CI, 1.8-3.2) and remained lower until 12 hours postoperatively (P < .001 from postanesthesia care unit admission to 4 hours postoperatively, .001 at 6 hours, .025 at 8 hours, and .043 at 12 hours). At 18 and 24 hours, visual analog scale pain scores were not significantly different between both groups (P = .634 and .432, respectively). Four patients in the erector spinae plane block group required intraoperative fentanyl compared to 27 patients in control group. The median (quartiles) of intraoperative fentanyl consumption in the erector spinae plane block group was significantly lower (0 µg [0-0 µg]) compared to that of the control group (94 µg [74-130 µg]). Ten patients in the erector spinae plane block group required postoperative rescue pethidine compared to 25 patients in control group. The median [quartiles] of postoperative rescue pethidine consumption was significantly lower in the erector spinae plane block group (0 mg [0-33 mg]) compared to that of the control group (83 mg [64-109 mg]). Time to first rescue analgesic request was significantly prolonged in the erector spinae plane block group compared to control group (P < .001). CONCLUSIONS: Ultrasound-guided bilateral erector spinae plane block provided lower postoperative visual analog scale pain scores and decreased consumption of both intraoperative fentanyl and postoperative rescue analgesia for patients undergoing open epigastric hernia repair.

Thoracic paravertebral block for the anesthetic management of percutaneous radiofrequency ablation of liver tumors.

BACKGROUND AND AIMS: Percutaneous radiofrequency ablation (PRFA) is a minimally invasive treatment for hepatic tumors. We assessed and compared the efficacy of right thoracic paravertebral block (TPVB) with that of local anesthetic infiltration for the anesthetic management of PRFA of liver tumors. MATERIAL AND METHODS: Sixty patients with hepatic tumors aged 50-80 years were randomly allocated into two groups. Group I received local anesthetic infiltration along the path of the ablation device with sedation. Group II received right TPVB at the level T7 and T9 with sedation. The pain was assessed using visual analog scale (VAS) at 1 min and then every 5 min during PRFA procedure, on admission, and discharge from the post-PRFA observation area. The total dose of rescue analgesia during PRFA procedure, number of patients requiring general anesthesia, patient and radiologist satisfaction were reported. RESULTS: VAS was significantly lower in group II than group I during and after PRFA procedure (P < 0.05). General anesthesia was administered in 7 patients in group I, whereas no patient required general anesthesia in group II (P < 0.05). Patient and radiologist satisfaction were significantly higher in group II compared to group I (P < 0.05). There were no significant complications in group II compared to group I (P > 0.05). CONCLUSIONS: Right TPVB with sedation is an effective and safe anesthetic technique for the management of PRFA procedure of hepatic tumors. It is more effective than local anesthesia with sedation in relieving pain during PRFA procedure of hepatic tumors.

Value of procalcitonin as a biomarker for postoperative hospital-acquired pneumonia after abdominal surgery.

BACKGROUND: Hospital-acquired pneumonia (HAP) is a common complication after abdominal surgery. The aim of this study was to evaluate the role of procalcitonin (PCT) and C-reactive protein (CRP) as early biomarkers for the diagnosis of postoperative HAP after abdominal surgery. METHODS: This study was conducted on 100 patients undergoing abdominal surgery. White blood cell counts, highest body temperature, and serum levels of CRP and PCT were recorded preoperatively and daily postoperatively until postoperative day (POD) 5. Chest radiography was performed preoperatively and daily postoperatively until POD 5. RESULTS: HAP was diagnosed in 14% of patients. Regarding the biomarkers studied after POD 1, CRP and PCT were significantly higher in patients with HAP than in those without HAP (P < 0.05). On POD 2, PCT had higher sensitivity and specificity (84% and 72%, respectively) than those for CPR (70% and 60%, respectively). The cut-off value of PCT on POD 2 was 1.4 ng/ml. On POD 3, 4, and 5, the sensitivity and specificity of PCT and CRP were not significantly different. CONCLUSIONS: PCT and CRP are accurate biomarkers for early prediction of postoperative HAP after abdominal surgery. The diagnostic ability of PCT was significantly better than that of CRP on POD 2. After POD 2, the diagnostic ability was not significantly different between the biomarkers.

The effect of ultrasound-guided transversus abdominis plane (TAP) block on postoperative analgesia and neuroendocrine stress response in pediatric patients undergoing elective open inguinal hernia repair.

BACKGROUND: Transversus abdominis plane block (TAP) is a compartmental block of the anterior abdominal wall. Surgical trauma produces multisystem reactions. Anesthetic techniques can modify the neuroendocrine surgical stress response. AIM: The aim of this study was to evaluate the effect of TAP block on the modification of the surgical neuroendocrine stress response as well as its analgesia effect in children undergoing open inguinal hernia repair. METHOD: Sixty children aged 3-10 years undergoing elective unilateral open inguinal hernia repair were randomized into group I (general anesthesia) or group II (received TAP block after induction of general anesthesia). Serum cortisol, blood glucose, quality of analgesia, postoperative need for rescue analgesia, and complications and degree of satisfaction of the patients and their parents were assessed. RESULTS: Serum cortisol level was significantly lower in group II as compared to group I intraoperatively (17.73 ± 1.51 vs 21.80 ± 2.22 µg·dl-1 ) and 30 min postoperatively (15.03 ± 1.56 vs 18.30 ± 1.53 µg·dl-1 ). Blood glucose level was significantly lower in group II as compared to group I intraoperatively (107.57 ± 3.77 vs 115.40 ± 6.30 mg·dl-1 ) and 30 min postoperatively (104.13 ± 3.78 vs 110.73 ± 4.83 mg·dl-1 ). The quality of analgesia as indicated by CHEOPS and OPS scales was significantly better in group II. The consumption of postoperative rescue analgesia was significantly higher in group I as compared to group II (27.00 ± 9.97 vs 13.00 ± 9.43 mg·kg-1 ). CONCLUSION: TAP block is effective as a part of multimodal analgesia for children undergoing open inguinal hernia repair with significant attenuation in the neuroendocrine stress response induced by surgery.