Investigation of the effect of ultrasonography-guided bilateral erector spinae plane block on postoperative opioid consumption and pain scores in patients undergoing hepatectomy: a prospective, randomized, controlled study

ABSTRACT BACKGROUND: There is still a debate about what constitutes effective and safe postoperative analgesia in hepatectomy surgery. Erector spinae plane (ESP) block may be an important part of multimodal analgesia application in hepatectomy surgery. OBJECTIVES: To compare the effects of ultrasound-guided bilateral erector spinae plane block combined with intravenous (iv) patient-controlled analgesia (iv PCA), in comparison with iv PCA alone, in hepatectomy surgery. DESIGN AND SETTINGS: Randomized prospective single-blinded study in a tertiary university hospital. METHODS: Fifty patients scheduled for elective hepatectomy surgery were included in the study. Patients were randomized into the ESP group or the control group. In the ESP group, bilateral ESP block was performed preoperatively and iv PCA was used. In the control group, only iv PCA was used. Numerical rating scale (NRS) scores at rest and coughing, analgesic requirements and occurrences of nausea and vomiting were recorded. RESULTS: Intraoperative and postoperative opioid consumption, rescue analgesia requirement and resting and dynamic NRS scores were significantly lower in the ESP group (P < 0.05). There was no significant difference between two groups in terms of the presence of dynamic pain after the first postoperative hour. While all patients in the control group had nausea and vomiting, 24% of the patients in the ESP group did not have nausea and vomiting. CONCLUSION: This study showed that ESP block can be used as a part of multimodal analgesia, with the benefit of reducing opioid consumption and postoperative nausea and vomiting in hepatectomy surgery. CLINICAL TRIAL REGISTRATION: ACTRN12620000466943.

Investigation of the effect of ultrasonography-guided bilateral erector spinae plane block on postoperative opioid consumption and pain scores in patients undergoing hepatectomy: a prospective, randomized, controlled study.

BACKGROUND: There is still a debate about what constitutes effective and safe postoperative analgesia in hepatectomy surgery. Erector spinae plane (ESP) block may be an important part of multimodal analgesia application in hepatectomy surgery. OBJECTIVES: To compare the effects of ultrasound-guided bilateral erector spinae plane block combined with intravenous (iv) patient-controlled analgesia (iv PCA), in comparison with iv PCA alone, in hepatectomy surgery. DESIGN AND SETTINGS: Randomized prospective single-blinded study in a tertiary university hospital. METHODS: Fifty patients scheduled for elective hepatectomy surgery were included in the study. Patients were randomized into the ESP group or the control group. In the ESP group, bilateral ESP block was performed preoperatively and iv PCA was used. In the control group, only iv PCA was used. Numerical rating scale (NRS) scores at rest and coughing, analgesic requirements and occurrences of nausea and vomiting were recorded. RESULTS: Intraoperative and postoperative opioid consumption, rescue analgesia requirement and resting and dynamic NRS scores were significantly lower in the ESP group (P < 0.05). There was no significant difference between two groups in terms of the presence of dynamic pain after the first postoperative hour. While all patients in the control group had nausea and vomiting, 24% of the patients in the ESP group did not have nausea and vomiting. CONCLUSION: This study showed that ESP block can be used as a part of multimodal analgesia, with the benefit of reducing opioid consumption and postoperative nausea and vomiting in hepatectomy surgery. CLINICAL TRIAL REGISTRATION: ACTRN12620000466943.

Immunological mechanism of postherpetic neuralgia and effect of pregabalin treatment on the mechanism: a prospective single-arm observational study.

BACKGROUND: Although neuropathic pain is a severe and common pain, its pathophysiology has not been elucidated yet. Studies in recent years have focused on the immune system's role in the pathogenesis of neuropathic pain. The aim of this study was to investigate the role of immunological mechanisms in neuropathic pain and the effect of pregabalin by measuring immunological marker levels in peripheral blood before and after pregabalin treatment in postherpetic neuralgia (PHN) patients with neuropathic pain. METHODS: Forty patients diagnosed with PHN were included in the study. CD4, T follicular cells (Tfh: CD4+CXCR5+PD1+), Th17 (CD4+CCR6+ and CD4+IL17A+), regulatory T cells (Treg: CD4+ CD25+foxp3+), Th1 (CD4+ CXCR3+ and CD4+ IFN-γ+) and Th2 (CD4+ IL-4+) cell ratios were measured in peripheral blood samples before treatment and after 3 months of treatment. RESULTS: When immunological marker and inflammation parameter levels were compared before and after treatment, the helper T cell ratio (CD3+, CD4+) was 30.28 ± 12.27% before treatment and 34.93 ± 11.70% after treatment, so there was a statistically significant increase (P = 0.028). Th17 was 4.75 ± 5.02% before treatment and 5.80 ± 3.13% after treatment, and there was a statistically significant increase (P = 0.036). CONCLUSIONS: Immunological mechanisms play an essential role in the pathogenesis of neuropathic pain, immunologically based treatment approach will be the critical point of treatment.

The place of ultrasonography in confirming the position of the laryngeal mask airway in pediatric patients: an observational study.

BACKGROUND AND OBJECTIVES: Laryngeal mask airways are increasingly used as supraglottic devices during general anesthesia. Ultrasonography can provide a dynamic image simultaneous to placing the supraglottic airway device. In the current study, the incidence of suboptimal laryngeal mask airway position and replacement in children was evaluated using simultaneous ultrasonographic imaging. METHODS: A prospective observational study was conducted on 82 patients aged 3-15 years with American Society of Anesthesiologists (ASA) physical status I or II. Patients under general anesthesia and with airway provided by a laryngeal mask airway were included. The position of the laryngeal mask airway was evaluated by ultrasonography on two planes. According to our scoring system, Grade I and Grade II were determined to indicate acceptable placement, while Grade III was determined to indicate unacceptable placement. Suboptimal laryngeal mask airway placement rates and the requirement of replacement were determined. Laryngeal mask airway placement optimized by ultrasonography was evaluated with both leak tests and a fiberoptic laryngoscope. RESULTS: The average age of the patients was 6.27 ±â€¯4.66 years. After evaluation with ultrasonography, 65 (79.3%) of the laryngeal mask airways were found to be optimally positioned, while the position of 13 (15.9%) had to be corrected, and 4 (4.9%) had to be replaced. There was a moderate positive correlation between the ultrasonographic evaluation and leak test evaluation (p < 0.001; r = 0.628). Relocation of the laryngeal mask airway was determined to be an independent risk factor affecting the development of complications (OR = 2.961; p = 0.046; 95% Cl 2.850-30.745). CONCLUSION: The use of ultrasonography to verify and relocate laryngeal mask airway placement is noninvasive and effective.

Sugammadex for Cesarean in a Patient with Multiple Sclerosis.

The aim of the present study was to discuss the management of anesthesia in our case with multiple sclerosis (MS) and to present the effects of sugammadex administration. A 36-year-old pregnant patient with MS disease was followed up for 6 years. She was on steroid treatment. The patient had not suffered the entire pregnancy. In addition to performing routine monitoring, "train of four" (TOF) monitorization was used. General anesthesia was given using propofol and rocuronium. At the end of the operation, muscle relaxation was reversed using sugammadex in the patient with a low TOF score. The patient was discharged on postoperative day 3. The most reliable method should be preferred in patients with MS. In patients under general anesthesia, the muscle relaxant effect is prolonged, and sugammadex can be safely used.

The Effects of Sugammadex on Progesterone Levels in Pregnant Rats.

BACKGROUND: Sugammadex has been shown to decrease the efficiency of progesterone-containing oral contraceptive drugs which possess a steroid structure. AIMS: The aim of the present study was to evaluate the effects of sugammadex on progesterone levels in pregnant rats as well as on the physiological course of the pregnancy. STUDY DESIGN: Animal experiment. METHODS: This study was approved by the Selçuk University Ethical Committee for Experimental Animal Research. Pregnant Winster Albino rats (n=26) were divided into three groups and administered with various intravenous injections on the 7(th) day of pregnancy. The control group (Group K, n=6) received 1.5 mL serum physiologic, the sugammadex group (Group S, n=10) received 30 mg/kg sugammadex and the sugammadex + rocuronium group (Group SR, n=10) received 30 mg/kg sugammadex and 3.5 mg/kg rocuronium. Progesterone levels were measured and the offspring were monitored for morphologic status. RESULTS: Mean progesterone levels were 94.16±15.54 ng/mL in Group K, 87.86±12.48 ng/mL in Group S, and 94.53±16.10 ng/mL in Group SR (p>0.05). No stillbirth or miscarriage was observed in the rats. The mean number of offspring was 6.8±1.47 in Group K, 6.5±1.35 in Group S, and 6.4±1.17 in Group SR. The offspring appeared macroscopically normal. CONCLUSION: Sugammadex does not appear to affect the progesterone levels in pregnant rats in the first trimester and the clinical course. Successful completion of pregnancy and the absence of stillbirth or miscarriage will guide future studies about the use of sugammadex, particularly in the first trimester of the pregnancy.

Comparison of the effect of the Trendelenburg and passive leg raising positions on internal jugular vein size in critically ill patients.

Central vein catheterization is a common procedure performed on patients under intensive care. The safe and successful placement of the central venous catheter depends on vein size. Although used for this purpose, the Trendelenburg position can be hazardous in some patients. The aim of this study was to compare the effects of the Trendelenburg and passive leg raising (PLR) positions on the size of the right internal jugular vein (IJV) in mechanically ventilated patients under intensive care. Seventy-eight mechanically ventilated patients under intensive care were included into the study. Sonographic images of the right IJV were recorded in supine (control), 10° Trendelenburg and 40° PLR positions. Anterior-posterior and transverse diameter, cross-sectional area (CSA), and depth were calculated from the recorded images. The size of the right IJV (CSA, transverse and vertical diameters) was significantly larger in the Trendelenburg and PLR positions than in supine position. An increase of 26% in the IJV CSA was obtained in the Trendelenburg position and 23% in the PLR position, compared to the supine position. There was no significant difference between the measurements obtained from the Trendelenburg and PLR positions. The study shows that the Trendelenburg and PLR positions increase the size of the IJV to a similar extent in mechanically ventilated patients under intensive care.

Comparison of the C-MAC D-Blade, Conventional C-MAC, and Macintosh Laryngoscopes in Simulated Easy and Difficult Airways.

OBJECTIVE: Recently, to further enhance the potential in the management of difficult airways, the highly angulated D-Blade was added to the C-MAC system. The purpose of this study was to investigate the laryngoscopic view and intubation parameters using the new C-MAC D-Blade in comparison to the conventional C-MAC video laryngoscope and Macintosh direct laryngoscope in simulated easy and difficult airways. METHODS: We recruited 26 experienced anaesthesia providers into a randomized trial. Each performed tracheal intubation of a Laerdal SimMan(®) manikin with each laryngoscope in the following laryngoscopy scenarios: (1) normal airway, (2) cervical spine immobilization, and (3) tongue edema. The intubation times, success rates, number of intubation attempts, laryngoscopic views, and severity of dental compression were recorded. RESULTS: In all scenarios, video laryngoscopes provided better laryngeal exposure than the ML and appeared to produce less dental pressure. In the cervical spine immobilization scenario, D-Blade caused less dental pressure and showed better Cormack-Lehane (CL) classes than the other devices (p<0.001). There were no differences between video laryngoscopes in success of tracheal intubation (p>0.05). The CMAC provided the most rapid intubation. The rate of failure was 19% with ML. In the tongue edema scenario, the CMAC provided the most rapid and successful intubation (p<0.001). There were no differences between video laryngoscopes in laryngoscopic views according to CL classification and dental pressure (p>0.05). The rate of failure was 46% with the ML and 7% with the D-Blade. CONCLUSION: The CMAC D-Blade caused less dental pressure than the conventional C-MAC and ML in the cervical immobilization scenario. The conventional CMAC performed better than the D-Blade and ML in the tongue edema scenario. These two video laryngoscopes may complement each other in various difficult airway situations.

A comparison of ketamine and paracetamol for preventing remifentanil induced hyperalgesia in patients undergoing total abdominal hysterectomy.

BACKGROUND: The aim of this prospective, randomized, placebo-controlled study was to compare the effects of ketamine and paracetamol on preventing remifentanil induced hyperalgesia. METHODS: Ninety patients undergoing total abdominal hysterectomy were randomly assigned to one of three groups to receive (I) either saline infusion; (II) 0.5 mg/kg ketamine iv bolus or (III) 1000 mg iv paracetamol infusion before induction of anesthesia. Until the skin closure, anesthesia was maintained with 0.4 µg/kg/min remifentanil infusion in all groups, additionally Group II received 5 µg/kg/min ketamine infusion. Pressure pain thresholds were measured the day before surgery during the preoperative visit for baseline measurements and repeated postoperatively at 24 and 48 hours (hrs). Pressure pain thresholds were established by digital algometer on three different peri- incisional regions for calculating mean pressure pain threshold values. The visual analogue scale (VAS), sedation scores, total morphine consumption and side effects were assessed postoperatively. RESULTS: Demographic characteristics, duration of surgery and anesthesia were similar in the three groups. Pain thresholds at the incision region were significantly lower at 24 and 48 hrs postoperatively in Group I than the other Groups (p<0.05). In Group І, pain thresholds were lower compared with preoperative baseline values. Thresholds in Group ІІ and Group ІІІ were higher compared with preoperative baseline values (p<0.05) The VAS scores at all evaluation times were significantly higher in Group І when compared to Group ІІ and at 2, 4, 6 ,12 hrs were higher in Group I than Group ІІІ (p<0.05). The morphine consumption was higher in Group ІІІ at 24 and 48 hrs postoperatively (p<0.05). CONCLUSION: It was shown that ketamine and paracetamol were both effective in preventing remifentanil induced hyperalgesia.