Ultrasound-guided erector spinae block versus mid-transverse process to pleura block for postoperative analgesia in lumbar spinal surgery.

BACKGROUND: In recent years, promising results were achieved with the use of ultrasound (US)-guided interfascial plane blocks for effective postoperative analgesia in several surgeries. Erector spina plane (ESP) block and mid-transverse to pleura plane (MTP) block are the latest techniques in this area. The aim of this prospective and randomized study was to compare the postoperative analgesic efficacy of bilateral ESP and MTP blocks in patients undergoing lumbar spinal surgery under general anesthesia (GA). METHODS: A total of 120 adult patients were included in the study and randomized into 3 groups: group ESP (n = 40), group MTP (n = 40) and group Control (n = 40). The patients in the group ESP received a bilateral block by injecting 20 ml of 0.25% bupivacaine at a vertebrae level in the mid-point of the incision before GA. The same LA was administrated bilaterally at the T12/L1 level in the group MTP. Postoperatively, a multimodal analgesic regimen including an intravenous tramadol patient-controlled analgesia (PCA), paracetamol and dexketoprofen was used in all groups. Postoperative pain was assessed using a visual analogue scale (VAS) during the first 48 postoperative hours. Pethidine was used as a rescue analgesic when VAS score was >3. Primary outcome measure was mean pain scores. Secondary outcome measures were consumption of rescue analgesic and the amount of tramadol delivered by PCA. A p < 0.05 was considered statistically significant. RESULTS: Mean VAS scores were significantly higher in the group Control than in the group MTP and group ESP at all-time points during 48 h (Control > MTP > ESP; p < 0.001). Mean VAS scores were lower in group ESP than group MTP in postoperative 12 h (p < 0.001). Rescue analgesic consumption, number of bolus demand on PCA, PCA bolus demand dose, total PCA dose, and complications related to opioid consumption were highest in control group and lowest in ESP group (Control > MTP > ESP; p < 0.001). CONCLUSION: Both ESP and MTP blocks provided effective pain relief after lumbar spinal surgery but the ESP block was superior to MTP block regarding postoperative analgesia in the first 24 h.

Sedoanalgesia for cardioversion: comparison of alfentanil, remifentanil and fentanyl combined with propofol and midazolam: a prospective, randomized, double-blind study.

OBJECTIVE: Electrical cardioversion (EC) is a short but painful procedure to restore sinus rhythm. The aim of this study is to compare the effect of fentanyl, remifentanil and alfentanil in association with propofol and midazolam for elective EC. PATIENTS AND METHODS: Ninety-nine patients older than 18-years, American Society of Anesthesiologists I/II/III grades undergoing elective EC were randomized into 3 groups. All patients received 2 mg midazolam and propofol (0.5 mg/kg). Group A received alfentanil (5 µg/kg i.v. bolus), Group F received fentanyl (0.5 µg/kg i.v. bolus) and Group R received remifentanil (0.25 µg/kg i.v. bolus). Hemodynamics and respiratory variables [Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), SpO2, respiratory rate (RR)], and Modified Aldrete recovery score (MARS) were assessed at six different time points (baseline, right after EC, and 3rd min, 5th min, 10th min, 30th min following EC). Also, induction times (time to reach RSS to 5) and recovery times (time to reach MARS to 8) were recorded. The incidence of respiratory depression, bradycardia, hypotension and adverse effects were also recorded. RESULTS: Hemodynamic variables were similar in all groups. SpO2 values in Group R were significantly lower at 3rd min (p = 0.005). Induction and recovery times were longest in Group F. There were significant differences at 3rd, 5th and 10th minute MARS values between groups. The incidence of hypotension and bradycardia were similar in all groups (p > 0.05) but respiratory depression was higher in Group R (p = 0.047). CONCLUSIONS: Propofol alfentanil combination has more beneficial advantages in their rapid onset, early recovery time and less respiratory depression than remifentanil and fentanyl.

Acute high dose-fentanyl exposure produces hyperalgesia and tactile allodynia after coronary artery bypass surgery.

OBJECTIVE: Opioid-induced hyperalgesia is well known complication of acute high dose and chronic opioid therapy. In this study, we evaluated development of opioid-induced hyperalgesia following intraoperative short-term use of µ-opioid agonist fentanyl after coronary artery bypass surgery. PATIENTS AND METHODS: 100 patients undergoing elective coronary artery bypass graft surgery is divided into two groups. In group I (low dose), anesthesia was induced with propofol 1-2.5 mg/kg and fentanyl 2 mcg/kg, in group II (high dose) fentanyl 40-70 mcg/kg was used. In group I, propofol 5-10 mg/kg/h, fentanyl 1-3 mcg/kg/h, in group II fentanyl 5-10 mcg/kg/h was used for maintenance of anesthesia. The tactile and thermal thresholds were measured before surgery and in 1st, 3rd and 7th postoperative days by using Von Frey filaments and a thermal source, respectively. RESULTS: Tactile thresholds were significantly decreased at the first (6,08±0.21 and 3.76±0.13 g; p<0.001) and third (6.76±0.24 and 4.96±0.16 g; p<0.001) postoperative days compared to baseline preoperative values (7.72±0.26, and 7.60±0.21 g; p=816) in two groups. Postoperative 1st (13.45±0.33 and 10.05±0.24 sec; p<0.001) and 3rd day (14.77±0.28 and 13.17±0.26 sec; p<0.001) assessments showed a statistically significant thermal hyperalgesia compared to the preoperative baseline values (16.67±0.51 and 16.45±0.42 sec; p=0.997) in two groups. This decrease in both tactile and thermal thresholds returned to baseline control values at the 7th day of measurement. CONCLUSIONS: Our results showed that patients undergoing coronary artery bypass surgery receiving fentanyl anesthesia developed postoperative tactile allodynia and thermal hyperalgesia and this was more prominent in high dose group.

[A different approach to the percutaneous nephrostomy by urologists]. / Un abordaje diferente a la nefrostomía percutánea por urólogos.

INTRODUCTION: Percutaneous nephrostomy (PCN) tube placement is generally performed in radiologic departments worldwide. However, there are a few urologist-directed studies about PCN performed with ultrasound guidance. Needle direction using a convex abdominal ultrasound probe might be difficult in unexperienced hands. In order to perform this procedure easily, we propose that a probe placed on flank or intercostal region and a long grooved needle director that never allows needle movement would be useful. We considered a transrectal ultrasound (TRUS) probe was suitable to resolve this issue. MATERIAL AND METHOD: From January 2007 to April 2011, a total of 113 percutaneous renal access (PRA) were performed using a TRUS probe in 102 patients, aged 20 to 84 years old. Because of the insufficient imaging capability of the TRUS probe in obese patients whose body mass index (BMI) greater than 30kg/m(2) were excluded. Forty two PRA were performed under local anesthesia and this group was named local anesthesia (LA) group. Seventy one PRA were performed for nephrostomy insertion under local anesthesia supplemented by deep sedation and this cluster was named deep sedation (DS) group. RESULTS: Targeted calyx puncture and guide wire placement was performed in all patients (100%) but success rate of tube insertion in each group was different. Successful PCN insertion rate was 69.1% (29 of 42 cases) in LA group and 95.8% (68 of 71 cases) in DS group. No major vascular injury and/or adjacent organ injury to bowel, liver, spleen or lung was seen in any patient. CONCLUSION: Guidance of TRUS probe, deep sedation, and modified dilators may offer a high success rate to the urologists with little experience in PCN insertion which they would find it difficult to perform.