Effect of postoperative intermittent boluses of subcostal quadratus lumborum block on pulmonary function recovery and analgesia after gastrectomy: a randomized controlled clinical trial.

BACKGROUND: Following the gastrectomy, the reduction in pulmonary function is partly attributed to postoperative pain. Subcostal quadratus lumborum block (QLB) has recently emerged as a promising component in multimodal analgesia. We aimed to assess the impact of intermittent boluses of subcostal QLB on pulmonary function recovery and analgesic efficacy after gastrectomy. METHODS: Sixty patients scheduled for gastrectomy were randomly assigned to either control group (multimodal analgesia) or intervention group (intermittent boluses of subcostal QLB plus multimodal analgesia). Two primary outcomes included the preservation of forced expiratory volume in the first second (FEV1) and the pain scores (0-10 cm visual analog score) on coughing 24 h postoperatively. We assessed the pulmonary function parameters, pain score, morphine consumption and number of rescue analgesia at a 24-h interval up to 72 h (Day1, Day2, Day3 respectively) as secondary outcomes. RESULTS: 59 patients were analyzed in a modified intention-to-treat set. The preservation of FEV1 (median difference: 4.0%, 97.5% CI: -5.7 to 14.9, P = 0.332) and pain scores on coughing (mean difference: 0.0 cm, 97.5% CI: -1.1 to 1.2, P = 0.924) did not differ significantly between two groups. In the intervention group, the recovery of forced vital capacity (FVC) was faster 72 h after surgery (interaction effect of group*(Day3-Day0): estimated effect (ß) =0.30 L, standard error (SE) =0.13, P = 0.025), pain scores at rest were lower in the first 3 days (interaction effect of group*(Day1-Day0): ß = - 0.8 cm, SE = 0.4, P = 0.035; interaction effect of group*(Day2-Day0): ß = - 1.0 cm, SE = 0.4, P = 0.014; and interaction effect of group*(Day3-Day0): ß = - 1.0 cm, SE = 0.4, P values = 0.009 respectively), intravenous morphine consumption was lower during 0-24 h (median difference: -3 mg, 95% CI -6 to -1, P = 0.014) and in total 72 h (median difference: -5 mg, 95% CI -10 to -1, P = 0.019), and the numbers of rescue analgesia was fewer during 24-48 h (median difference: 0, 95% CI 0 to 0, P = 0.043). Other outcomes didn't show statistical differences. CONCLUSION: Postoperative intermittent boluses of subcostal QLB did not confer advantages in terms of the preservation of FEV1 or pain scores on coughing 24 h after gastrectomy. However, notable effects were observed in analgesia at rest and FVC recovery.

Comparison between ultrasound-guided multi-injection intertransverse process and thoracic paravertebral blocks for major breast cancer surgery: a randomized non-inferiority trial.

BACKGROUND: This study investigated whether a novel multi-injection intertransverse process block could provide non-inferior analgesia and recovery quality following major breast cancer surgery compared with the multi-injection thoracic paravertebral block. METHODS: Eighty-eight females who underwent mastectomy plus sentinel or axillary lymph node dissection were randomized to receive either intertransverse process block or thoracic paravertebral block, both performed at T2-6 with 5 mL of 0.5% ropivacaine per level. The primary outcome was the worst resting pain score (11-point Numerical Rating Scale) within 30 min in the recovery room. The secondary outcome was recovery quality (15-item quality of recovery scale) 24 hours after surgery, which was tested following a gatekeeping procedure. RESULTS: The worst resting pain scores were 0 (0, 1) in the intertransverse process block group vs 0.5 (0, 2) in the thoracic paravertebral block group, with a median difference of 0 (95% CI 0 to 0); the upper 95% CI limit was lower than the prespecified non-inferiority margin of 1 point (non-inferiority p<0.001). Aggregate scores of recovery quality at 24 hours postoperatively were 137.5 (126.5, 142.8) and 137.5 (127.8, 145.0) for the intertransverse process and thoracic paravertebral block groups, respectively, with a median difference of -1 (95% CI -6 to 3); the lower 95% CI limit was larger than the prespecified non-inferiority margin of -8 (non-inferiority p=0.006). CONCLUSIONS: Compared with a multi-injection thoracic paravertebral block, the multi-injection intertransverse process block provided non-inferior analgesia within 30 min in the recovery room and recovery quality at 24 hours following major breast cancer surgery in females. TRIAL REGISTRATION NUMBER: ChiCTR2000037963.

Comparison Between Subparaneural Upper Trunk and Conventional Interscalene Blocks for Arthroscopic Shoulder Surgery: A Randomized Noninferiority Trial.

BACKGROUND: Although interscalene nerve block is the standard for shoulder analgesia, the risk of hemidiaphragmatic paralysis restricts its use in patients with compromised pulmonary function. We hypothesized that a novel subparaneural upper trunk block would provide noninferior postoperative analgesia but superior diaphragmatic sparing effect compared to interscalene block. METHODS: This randomized controlled trial comprised 96 patients who underwent arthroscopic shoulder surgery under either subparaneural upper trunk block (5 mL of 0.5% ropivacaine) or interscalene block (15 mL of 0.5% ropivacaine), followed by supraclavicular nerve block (5 mL of 0.5% ropivacaine). General anesthesia was standardized. The coprimary outcomes were (1) recovery room resting pain score at 30 minutes, measured on an 11-point numerical rating scale, with a prespecified noninferiority margin of 1 point and (2) the incidence of hemidiaphragmatic paralysis, diagnosed using ultrasound. Among secondary outcomes, resting pain scores were assessed with numerical rating scale at 4, 8, and 24 hours postoperatively. RESULTS: Recovery room resting pain scores at 30 minutes were 0 (0-1) in the subparaneural upper trunk group versus 0 (0-0) in the interscalene group, with a median difference of 0 (95% CI, 0-0); the upper 95% CI limit was lower than the prespecified noninferiority margin (noninferiority P < .001). Hemidiaphragmatic paralysis was observed in 16.7% of patients in the subparaneural upper trunk group versus 100% of those in the interscalene group (RR, 0.17; 95% CI, 0.09-0.31; P < .001), with complete paralysis occurring in 6.3% and 93.7% of patients, respectively. In this study, any reported differences in pain scores at 4, 8, and 24 hours postoperatively were not clinically important. CONCLUSIONS: The subparaneural upper trunk block compared to interscalene block provided noninferior analgesia at 30 minutes in the recovery room after arthroscopic shoulder surgery but resulted in less hemidiaphragmatic paralysis.

Erector spinae plane block at lower thoracic level for analgesia in lumbar spine surgery: A randomized controlled trial.

BACKGROUND: Patients undergoing lumbar spine surgery usually suffer severe pain in the postoperative period. The erector spinae plane block (ESPB), first published in 2016, can anesthetize the ventral and dorsal rami of thoracic nerves and produce an extensive multi-dermatomal sensory block. AIM: To assess whether bilateral ultrasound-guided ESPB at a lower thoracic level could improve pain control and quality of recovery in patients undergoing lumbar spine surgery. METHODS: A total of 60 patients aged 18-80 years scheduled to undergo lumbar spine surgery with general anesthesia were randomly assigned to two groups: ESPB group (preoperative bilateral ultrasound-guided ESPB at T10 vertebral level) and control group (no preoperative ESPB). Both groups received standard general anesthesia. The main indicator was the duration to the first patient controlled intravenous analgesia (PCIA) bolus. RESULTS: In the ESPB group, the duration to the first PCIA bolus was significantly longer than that in the control group (h) [8.0 (4.5, 17.0) vs 1.0 (0.5, 6), P < 0.01], and resting and coughing numerical rating scale (NRS) scores at 48 h post operation were significantly lower than those in the control group (P < 0.05). There was no significant difference between the two groups regarding resting and coughing NRS scores at 24 h post operation. Sufentanil consumption during the operation was significantly lower in the ESPB group than in the control group (P < 0.01), while there was no significant difference between the two groups regarding morphine consumption at 24 or 48 h post operation. In the ESPB group, Modified Observer's Assessment of Alertness/Sedation score within 20 min after extubation was higher and duration in the post-anesthesia care unit was shorter than those in the control group (P < 0.01). CONCLUSION: In patients undergoing lumbar spine surgery, ultrasound-guided ESPB at a lower thoracic level improves the analgesic effect, reduces opioid consumption, and improves postoperative recovery.

Bilateral Erector Spinae Plane Blocks for Open Posterior Lumbar Surgery.

PURPOSE: Erector spinae plane block (ESPB) is a newly reported interfascial plane block in pain management, and it can block the nerves exactly in line with the area of the posterior lumbar surgery. The objective of this research was to determine the effectiveness of pre-operative ESPB in enhancing recovery of posterior lumbar surgery. PATIENTS AND METHODS: A total of 60 patients undergoing open posterior lumbar decompression surgery under general anesthesia were randomized into two groups. T12 group was performed pre-operatively bilateral ESPB with ropivacaine at the T12 level, but control group did not receive the block. The primary outcome was the Modified Observer's Assessment of Alertness/Sedation (MOAA/S) score at 10 minutes after extubation. Secondary outcomes included intraoperative sufentanil consumption, postoperative morphine consumption, first time to ambulation after surgery and hospital length of stay after surgery. All participants were followed up to hospital discharge. RESULTS: The mean (SD) MOAA/S scores at 10 minutes after extubation were 4.2 (95% CI, 4.0 to 4.4), and 3.4 (95% CI, 3.2 to 3.6) in the T12 and control groups (P <0.001), respectively. Intraoperative sufentanil consumption (P =0.007) and postoperative morphine consumption (P =0.003) were lower in the T12 group than in the control group. Although first time to ambulation after surgery was sooner in the T12 group than in the control group (P =0.003), hospital length of stay was similar (P=0.054). CONCLUSION: Pre-operative bilateral ESPB at T12 can enhance recovery after posterior lumbar surgery and reduce perioperative opioid consumption.

Effect of different types of laryngeal mask airway placement on the right internal jugular vein: A prospective randomized controlled trial.

BACKGROUND: In recent years, with the popularity of laryngeal mask airway (LMA) for the management of clinical anesthesia, the influence of the LMA on the position and blood flow of the internal jugular vein (IJV) has attracted an increasing amount of attention. AIM: To investigate the effect of placement of different types of LMA (Supreme LMA, Guardian LMA, I-gel LMA) on the position and blood flow of the right IJV. METHODS: This was a prospective randomized controlled trial. A total of 102 patients aged 18-75 years who were scheduled to undergo laparoscopic abdominal surgery with general anesthesia were randomly assigned to three groups: Supreme LMA (group 1), Guardian LMA (group 2), and I-gel LMA (group 3) groups. The main indicator was the overlap index (OI) of IJV and the common carotid artery (CCA) at the high, middle, and low points before and after the placement of the LMA. The second indicators were the proportion of ultrasound-simulated needle crossing the IJV and CCA, and the cross-sectional area and blood flow velocity of the IJV before and after placement of the LMA at the middle point. RESULTS: Data from 100 patients were included in the statistical analysis. The OI increased significantly after placement of the LMA in the three groups at the three points (P < 0.01), except group 2 at the low point. In group 2 and group 3, the OI was lower than that in group 1 after LMA insertion at the high point (P < 0.0167). At the middle point, after LMA insertion, the proportion of simulated needle crossing the IJV significantly decreased in all three groups (P < 0.05), and the proportion in group 2 was higher than that in group 3 (P < 0.0167). The proportion of simulated needle crossing the CCA or both the IJV and CCA significantly increased in group 1 and group 2 (P < 0.05), which increased with no statistical significance in group 3. After LMA insertion, the cross-sectional area of ​​the IJV significantly increased, while the blood flow velocity significantly decreased (P < 0.01). There was no significant difference among the three groups. CONCLUSION: The placement of Supreme, Guardian, and I-gel LMA can increase the OI, reduce the success rate of IJV puncture, increase the incidence of arterial puncture, and cause congestion of IJV. Type of LMA did not influence the difficulty of IJV puncture. Therefore when LMA is used, ultrasound is recommended to guide the IJV puncture.

Langerhans cell sarcoma originating from left knee subcutaneous tissue: A case report and literature review.

Langerhans cell sarcoma (LCS) is a neoplastic proliferation of Langerhans cells with notably malignant cytological features. Reports of LCS are sparsely available in English literature; to the best of our knowledge, only 55 cases have been reported. The present study reports a case of LCS originating from subcutaneous tissue of the left knee in a 75-year-old man. The diagnosis of LCS was supported by the results of magnetic resonance imaging, histological and immunohistochemical studies. The tumor began to metastasize to inguinal lymph nodes and eventually involved multiple organs. Chemotherapy and radiotherapy were administered but were ineffective, and the patient died within 2 years of diagnosis. The present case should aid in expanding the currently available knowledge concerning LCS.