Pharmacological and clinical implications of local anaesthetic mixtures: a narrative review.

Various techniques have been explored to prolong the duration and improve the efficacy of local anaesthetic nerve blocks. Some of these involve mixing local anaesthetics or adding adjuncts. We did a literature review of studies published between 01 May 2011 and 01 May 2021 that studied specific combinations of local anaesthetics and adjuncts. The rationale behind mixing long- and short-acting local anaesthetics to hasten onset and extend duration is flawed on pharmacokinetic principles. Most local anaesthetic adjuncts are not licensed for use in this manner and the consequences of untested admixtures and adjuncts range from making the solution ineffective to potential harm. Pharmaceutical compatibility needs to be established before administration. The compatibility of drugs from the same class cannot be inferred and each admixture requires individual review. Precipitation on mixing (steroids, non-steroidal anti-inflammatory drugs) and subsequent embolisation can lead to serious adverse events, although these are rare. The additive itself or its preservative can have neurotoxic (adrenaline, midazolam) and/or chondrotoxic properties (non-steroidal anti-inflammatory drugs). The prolongation of block may occur at the expense of motor block quality (ketamine) or block onset (magnesium). Adverse effects for some adjuncts appear to be dose-dependent and recommendations concerning optimal dosing are lacking. An important confounding factor is whether studies used systemic administration of the adjunct as a control to accurately identify an additional benefit of perineural administration. The challenge of how best to prolong block duration while minimising adverse events remains a topic of interest with further research required.

PROSPECT guidelines for video-assisted thoracoscopic surgery: a systematic review and procedure-specific postoperative pain management recommendations.

Video-assisted thoracoscopic surgery has become increasingly popular due to faster recovery times and reduced postoperative pain compared with thoracotomy. However, analgesic regimens for video-assisted thoracoscopic surgery vary significantly. The goal of this systematic review was to evaluate the available literature and develop recommendations for optimal pain management after video-assisted thoracoscopic surgery. A systematic review was undertaken using procedure-specific postoperative pain management (PROSPECT) methodology. Randomised controlled trials published in the English language, between January 2010 and January 2021 assessing the effect of analgesic, anaesthetic or surgical interventions were identified. We retrieved 1070 studies of which 69 randomised controlled trials and two reviews met inclusion criteria. We recommend the administration of basic analgesia including paracetamol and non-steroidal anti-inflammatory drugs or cyclo-oxygenase-2-specific inhibitors pre-operatively or intra-operatively and continued postoperatively. Intra-operative intravenous dexmedetomidine infusion may be used, specifically when basic analgesia and regional analgesic techniques could not be given. In addition, a paravertebral block or erector spinae plane block is recommended as a first-choice option. A serratus anterior plane block could also be administered as a second-choice option. Opioids should be reserved as rescue analgesics in the postoperative period.

Efficacy of fascia iliaca nerve block in daily routine for children with femoral fractures in a pediatric emergency department.

OBJECTIVES: We aimed to evaluate the efficacy of fascia iliaca nerve block (FINB), routinely used for children with femoral fractures, in a pediatric emergency department (PED). METHODS: This retrospective, single-center, observational study examined FINB using ropivacaine and a 1% lidocaine hydrochloride solution, in all patients under 18 years of age admitted with a femoral fracture from January 2012 to December 2016. Pain was assessed using two validated pediatric pain scales: EVENDOL or a visual analog scale. A level of ≥ 4 on either scale indicates the need for an analgesic. The primary outcome was the percentage of patients who were pain free after the FINB procedure defined by a pain score of < 4. Secondary outcomes were the time spent between PED admission and FINB, the need of additional analgesics, side effects, and the success rate of FINB. RESULTS: Of 161 patients screened, 144 were included. The median age was 3.2 years (range 2 months to 16 years) and 74% were boys. The number of children determined to be pain free (pain score < 4) increased from 36 (25%) before the FINB to 123 (85%) after the FINB (absolute risk difference 60%, 95% CI: 51%-70%). Overall, 21 children (15%) required a second analgesic after the FINB. CONCLUSION: The routine use of FINB with ropivacaine and lidocaine by pediatric ED physicians provided effective pain relief for children admitted for a femoral fracture in the emergency department. Our data support the efficiency and feasibility of FINB for the antalgic management of children with femoral fracture.

Postoperative pain after clitoral reconstruction in women with female genital mutilation: An evaluation of practices.

INTRODUCTION: More than 200 million women and girls have undergone genital mutilation. Clitoral reconstruction (CR) can improve the quality of life of some of them, but is accompanied by significant postoperative pain. OBJECTIVE: Assess and describe the management of postoperative pain after CR, and the practices amongst specialists in different countries. METHODS: Between March and June 2020, 32 surgeons in 14 countries (Germany, Austria, Belgium, Burkina Faso, Canada, Ivory Coast, Egypt, Spain, United States of America, France, the Netherlands, Senegal, Switzerland, Sweden) responded to an online questionnaire on care and analgesic protocols for CR surgery. RESULTS: At day 7 post CR, 97% of the surgeons observed pain amongst their patients, which persisted up to 1 month for half of them. 22% of the participants reported feeling powerless in the management of such pain. The analgesic treatments offered are mainly step II and anti-inflammatory drugs (61%). Screening for neuropathic pain is rare (3%), as is the use of pudendal nerve block, used by 8% of the care providers and only for a small percentage of women. CONCLUSION: Pain after CR is frequent, long-lasting, and potentially an obstacle for the women who are willing to undergo clitoral surgery and also their surgeons. Most surgeons from different countries follow analgesic protocols that do not use the full available therapeutic possibilities. Early treatment of neuropathic pain, optimisation of dosing of standard analgesics, addition of opioids, use of acupuncture, and routine intraoperative use of pudendal nerve block might improve the management of pain after CR.

Role of paracervical block in reducing postoperative pain after laparoscopic hysterectomy: A systematic reivew and meta-analysis of randomized controlled trials.

OBJECTIVE: We aimed to perform a systematic review and meta-analysis in order to evaluate the effect of paracervical anesthetic block among women undergoing laparoscopic hysterectomy. METHODS: A systematic search was done in Cochrane Library, PubMed, ISI web of science, and Scopus during January 2021. We selected randomized clinical trials (RCTs) compared paracervical anesthetic block versus normal saline (control group) among women undergoing laparoscopic hysterectomy. We pooled the continuous data as mean difference (MD) and dichotomous data as risk ratio (RR) with the corresponding 95% confidence intervals using Revman software. Our primary outcome was pain scores evaluated by visual analog scale (VAS) at 30 min and 1 hour. Our secondary outcomes were postoperative additional opioids requirement and length of hospital stay. RESULTS: Three RCTs met our inclusion criteria with a total number of 233 patients. We found that paracervical anesthetic block was linked to a significant reduction in VAS pain score at 30 min and 1 hour post-hysterectomy (MD= -2.13, 95% CI [-3.09, -1.16], p>0.001 & MD= -1.87, 95% CI [-3.22, -0.52], p = 0.006). There was a significant decrease in additional opioids requirement postoperatively among paracervical anesthetic block group in comparison with control group (p = 0.002). No significant difference was found between both groups regarding the length of hospital stay. CONCLUSION: Paracervical anesthetic block is effective in reducing postoperative pain after laparoscopic hysterectomy with decrease in opioids administration postoperatively.

Was femoral nerve block effective for pain control of medial opening-wedge high tibial osteotomy?: A single blinded randomized controlled study.

BACKGROUND AND PURPOSE: Medial compartment femoro-tibial osteoarthritis (OA) is a common disease and opening-wedge high tibial osteotomy (OWHTO) is the common surgical procedure carried out for these patients. While most researchers are focusing on the surgical techniques during operation, the aim of this study is to evaluate the pain control effect of femoral nerve block (FNB) for OWHTO patients. METHODS: In this prospective, single-center, randomized controlled trial (RCT) study, 41 patients were operated on by OWHTO for OA during 2017 to 2018. Twenty of them (group A) accepted epidural anesthesia with FNB and 21 patients (group B) only had their single epidural anesthesia. All blocks were successful and all the 41 patients recruited were included in the analysis and there was no loss to follow-up or withdrawal. Systematic records of visual analog scores (VAS), quadriceps strength, mean number of times of patient-controlled intravenous analgesia (PCIA), using of additional opioids or nonsteroidal anti-inflammatory drugs (NSAIDs), and complications were done after hospitalization. The Student t test and Chi-Squared test was used and all P values ≤.05 were considered statistically significant. RESULTS: VAS scores at rest (3.48 ±â€Š1.0 vs 4.68 ±â€Š1.1) and on movemment (4.51 ±â€Š0.6 vs 4.97 ±â€Š0.8) decreased more in group A than group B with significance at follow-up of 12 hours. The quadriceps strength, consumption of additional opioids or NSAID injections and mean number of times that the patients pushed the PCIA button didnot differ significantly within each group. CONCLUSION: This RCT study shows that FNB in patients undergoing OWHTO for unicompartmental osteoarthritis of the knee could result in significant reduction in VAS scores at 12 hours postoperatively.Research registry, Researchregistry4792. Registered April 7, 2019 - Retrospectively registered, http://www.researchregistry.com.

Peripheral Nerve Blockade with Combined Standard and Liposomal Bupivacaine in Major Lower-Extremity Amputation.

BACKGROUND AND OBJECTIVES: Optimizing perioperative analgesia for patients undergoing major lower-extremity amputation remains a considerable challenge. The utility of liposomal bupivacaine as a component of peripheral nerve blockade for lower-extremity amputation is unknown. METHODS: We conducted an observational study comparing three different perioperative analgesic techniques for adults undergoing major lower-extremity amputation under general anesthesia between 2012 and 2017 at an academic medical center: (1) no regional anesthesia, (2) peripheral nerve blockade with standard bupivacaine, and (3) peripheral nerve blockade with a mixture of standard and liposomal bupivacaine. The primary outcome of cumulative opioid oral morphine milligram equivalent utilization in the first 72 hours postoperatively was compared across groups utilizing multivariable linear regression. RESULTS: A total of 631 unique anesthetics were included for 578 unique patients, including 416 (66%) without regional anesthesia, 131 (21%) with peripheral nerve blockade with a mixture of standard and liposomal bupivacaine, and 84 (13%) with peripheral nerve blockade with standard bupivacaine alone. Cumulative morphine equivalents were lower in those receiving peripheral nerve blockade with combined standard and liposomal bupivacaine compared with those not receiving regional anesthesia (multiplicative increase 0.67; 95% CI 0.50 to 0.90; P = 0.007). There were no significant differences in opioid utilization between peripheral nerve blockade groups (P = 0.59). CONCLUSIONS: Peripheral nerve blockade is associated with reduced opioid requirements after lower-extremity amputation compared with general anesthesia alone. However, the incorporation of liposomal bupivacaine is not significantly different to blockade employing only standard bupivacaine.

The Anatomical Distribution of the Pudendal Nerve Block Injection: A Cadaveric Study.

OBJECTIVE: The objective of this study was to assess the accuracy of commonly used injection locations of the pudendal nerve block by examining the proximity of the injected dye to the pudendal nerve in a cadaveric model. METHODS: Pudendal block injections at 4 sites were placed transvaginally on 5 cadaveric pelvises. These sites were 1 cm proximal to the ischial spine (black dye), at the ischial spine (red dye), 1 cm distal to the ischial spine (blue dye), and 2 cm lateral and 2 cm distal to the ischial spine (green dye). The cadavers were dissected via a posterior approach. RESULTS: We measured the shortest distance from the center of the dye-stained tissue to the pudendal nerve. As expected, the injections at the ischial spine (red) resulted in a distribution of dye closest to the pudendal nerve, averaging 3.0 ± 0.95 mm. Dyes at other sites were close to the nerve: 3.1 ± 1.00 mm (black), 3.6 ± 1.14 mm (blue), and 4.05 ± 1.28 mm (green). CONCLUSIONS: Regardless of the injection site, all dyes were close the pudendal nerve, indicating accuracy. We observed wide variation in the dye distribution even though all injections were performed by the same provider, implicating lack of precision. Based on our findings, we propose that the most effective injection location is at the ischial spine because it is the closest to the pudendal nerve; however, all injections were within 4 mm of the pudendal nerve, suggesting that only 1 to 2 injections may be sufficient.

Transversus abdominis plane block: A new method in renal colic pain management.

In recent decades, regional plane blocks via ultrasonography have become very popular in regional anesthesia and are more commonly used in pain management. The transversus abdominis plane (TAP) block is a procedure where local anesthetics are applied to block the anterior divisions of the tenth thoracic intercostal through the first lumbar nerves (T10-L1) into the anatomic space formed amidst the internal oblique and transversus abdominis muscles located in the antero-lateral part of the abdomen wall. The most important advantage of this block method is that ultrasonographic identification is easier and its complications are fewer compared with central neuroaxial or paravertebral blocks. Here, we describe three cases where pain management in renal colic was treated with the TAP block.

Prospective Evaluation of a Standardized Opioid Reduction Protocol after Anorectal Surgery.

BACKGROUND: Surgery for anorectal disease is thought to cause significant postoperative pain. Our previous work demonstrated that most opioids prescribed after anorectal surgery are not used. We aimed to evaluate a standardized protocol for pain control after anorectal surgery. METHODS: We prospectively evaluated a standardized opioid reduction protocol over a 13-mo period for all patients undergoing elective anorectal surgery at our institution. Protocol components include preoperative query, procedural local-anesthetic blocks, first-line nonopioid analgesic use ± opioid prescription of five pills, and standardized postoperative instructions. Patients completed questionnaires at postoperative follow-up. Patients with history of opioid abuse or use within 30 d of operation, loss to follow-up, or surgical complications were excluded. Primary outcome was quality of pain control on a five-point scale. Secondary outcomes included use of nonopioid analgesics, opioids used, and need for refill. RESULTS: A total of 55 patients were included. Mean age was 47 ± 17 y with 23 women (42%). Anorectal abscess/fistula procedures were the most common (69%) followed by pilonidal procedures (11%) and hemorrhoidectomy (7%). Most had general anesthesia (60%) with the remainder local anesthesia ± sedation. Fifty-four (98%) had procedural local-anesthetic blocks. Twenty-six patients (47%) were prescribed opioids with a median of five pills. Forty-seven patients (85%) reported the use of nonopioid analgesics. Forty-six patients (84%) reported excellent to very good pain control. About 220 opioid pills were prescribed, and 122 were reported to be used. One patient (2%) received an opioid refill. CONCLUSIONS: Satisfactory pain control after anorectal surgery can be achieved with multimodality therapy with little to no opioid use for most patients.

Wrong-site nerve blocks: evidence-review and prevention strategies.

PURPOSE OF REVIEW: There has been increasing attention to wrong site medical procedures over the last 20 years. This review aims to provide a summary of the current understanding and recommendations for the prevention of wrong-site nerve blocks (WSNB). RECENT FINDINGS: Various procedural, patient, practitioner, and organizational factors have been associated with the risk of WSNB. Recent findings have suggested that the use of a checklist is likely to reduce the incidence of WSNB. However, despite the widespread use of preprocedural checklists, WSNB continue to occur at significant frequency. This may be due to the inability of practitioners and teams to implement checklists correctly or the cognitive errors that prevent checklists from being executed as designed. SUMMARY: Though the evidence is limited, it is recommended that a combination of multiple strategies should be employed to prevent WSNB. These include the use of preprocedural markings, well constructed checklists, time-out/stop-moments, and cognitive/physical aids. Effective implementation requires team education and engagement that empowers all team members to speak up as part of a culture of safety.

Intraoperative Intercostal Nerve Block for Postoperative Pain Control in Pre-Pectoral versus Subpectoral Direct-to-Implant Breast Reconstruction: A Retrospective Study.

Background and Objectives: Patients undergoing mastectomy and implant-based breast reconstruction have significant acute postsurgical pain. The purpose of this study was to examine the efficacy of intercostal nerve blocks (ICNBs) for reducing pain after direct-to-implant (DTI) breast reconstruction. Materials and Methods: Between January 2019 and March 2020, patients who underwent immediate DTI breast reconstruction were included in this study. The patients were divided into the ICNB or control group. In the ICNB group, 4 cc of 0.2% ropivacaine was injected intraoperatively to the second, third, fourth, and fifth intercostal spaces just before implant insertion. The daily average and maximum visual analogue scale (VAS) scores were recorded by the patient from operative day to postoperative day (POD) seven. Pain scores were compared between the ICNB and control groups and analyzed according to the insertion plane of implants. Results: A total of 67 patients with a mean age of 47.9 years were included; 31 patients received ICNBs and 36 patients did not receive ICNBs. There were no complications related to ICNBs reported. The ICNB group showed a significantly lower median with an average VAS score on the operative day (4 versus 6, p = 0.047), lower maximum VAS scores on the operative day (5 versus 7.5, p = 0.030), and POD 1 (4 versus 6, p = 0.030) as compared with the control group. Among patients who underwent subpectoral reconstruction, the ICNB group showed a significantly lower median with an average VAS score on the operative day (4 versus 7, p = 0.005), lower maximum VAS scores on the operative day (4.5 versus 8, p = 0.004), and POD 1 (4 versus 6, p = 0.009), whereas no significant differences were observed among those who underwent pre-pectoral reconstruction. Conclusions: Intraoperative ICNBs can effectively reduce immediate postoperative pain in subpectoral DTI breast reconstruction; however, it may not be effective in pre-pectoral DTI reconstruction.

Infiltración con OnabotulinumtoxinA y bloqueos en el paciente con cefalea y neuralgia: recomendaciones de seguridad frente a la infección por SARS-CoV-2 / OnabotulinumtoxinA infiltration and nerve blocks in patients with headache and neuralgia: safety recommendations to prevent SARS-CoV-2 infection

INTRODUCCIÓN: La infección por SARS-CoV-2y la situación de pandemia hacen necesario un cambio en nuestra práctica clínica, en relación con la adopción de nuevas estrategias que permitan la asistencia integral de los pacientes con cefalea y neuralgia. MATERIAL Y MÉTODOS: Ante la elevada capacidad de transmisión del virus, determinados procedimientos, como la infiltración de OnabotulinumtoxinA y la realización de bloqueos anestésicos, deben realizarse adoptando medidas que garanticen un nivel adecuado de seguridad. RESULTADOS: Nuestro objetivo es presentar una serie de recomendaciones basadas en las medidas establecidas por nuestro sistema sanitario para evitar el contagio. Diferenciaremos entre aquellas medidas relacionadas con el paciente y el facultativo, con la técnica, con la infraestructura (sala de espera y consulta) y con la gestión asistencial

INTRODUCTION: The COVID-19 pandemic has given rise to the need for changes in clinical practice, with new strategies to enable integrated care for patients with headache and neuralgia. METHODS: Given the high spreadability of SARS-CoV-2, new safety measures are required in such procedures as onabotulinumtoxinA infiltration and nerve blocks. RESULTS: We present a series of recommendations based on the measures implemented to prevent infection in our healthcare system. We differentiate between measures related to patients and physicians, to technique, to infrastructure (waiting room and consultation), and to healthcare managemen

Adductor canal block with periarticular infiltration versus periarticular infiltration alone after total knee arthroplasty: A randomized controlled trial protocol.

BACKGROUND: Effective postoperative analgesia may enhance early rehabilitation after total knee arthroplasty (TKA). The purpose of this study is to perform a randomized controlled trial to compare the efficiency of adductor canal block (ACB) with periarticular infiltration (PAI) versus PAI alone for early postoperative pain treatment after TKA. METHODS: After institutional review board approval, written informed consent was obtained from patients undergoing elective TKA. Subjects were randomized into 2 groups as follows: adductor canal blockade with 30 mL of 0.5% ropivacaine and 100 mcg of clonidine. All patients received a periarticular infiltration mixture intraoperatively with scheduled and patient requested oral and IV analgesics postoperatively for breakthrough pain. The primary outcome was morphine consumption in the first 24 hours. Secondary outcomes included pain scores, morphine consumption at 48 hours, opioid-related side effects (post-operative nausea/vomiting, sedation scores), functional outcomes, quadriceps strength, and length of hospital stay. CONCLUSIONS: For the present trial, we hypothesized that patients receiving adductor canal block + PAI would have significantly lower morphine consumption and pain scores after surgery. TRIAL REGISTRATION NUMBER: researchregistry5490.

Implementation of the Obturator Nerve Block into a Supra-Inguinal Fascia Iliaca Compartment Block Based Analgesia Protocol for Hip Arthroscopy: Retrospective Pre-Post Study.

Background and Objectives: The effect of supra-inguinal fascia iliaca compartment block (SI-FICB) in hip arthroscopy is not apparent. It is also controversial whether SI-FICB can block the obturator nerve, which may affect postoperative analgesia after hip arthroscopy. We compared analgesic effects before and after the implementation of obturator nerve block into SI-FICB for hip arthroscopy. Materials and Methods: We retrospectively reviewed medical records of 90 consecutive patients who underwent hip arthroscopy from January 2017 to August 2019. Since August 2018, the analgesic protocol was changed from SI-FICB to SI-FICB with obturator nerve block. According to the analgesic regimen, patients were categorized as group N (no blockade), group F (SI-FICB only), and group FO (SI-FICB with obturator nerve block). Primary outcome was the cumulative opioid consumption at 24 hours after surgery. Additionally, cumulative opioid consumption at 6 and 12 hours after surgery, pain score, additional analgesic requests, intraoperative opioid consumption and hemodynamic stability, and postoperative nausea and vomiting were assessed. Results: Among 87 patients, there were 47 patients in group N, 21 in group F, and 19 in group FO. The cumulative opioid (fentanyl) consumption at 24 hours after surgery was significantly lower in the group FO compared with the group N (N: 678.5 (444.0-890.0) µg; FO: 482.8 (305.8-635.0) µg; p = 0.014), whereas the group F did not show a significant difference (F: 636.0 (426.8-803.0) µg). Conclusion: Our findings suggest that implementing obturator nerve block into SI-FICB can reduce postoperative opioid consumption in hip arthroscopy.

Ultrasound-guided continuous thoracic paravertebral block alleviates postoperative delirium in elderly patients undergoing esophagectomy: A randomized controlled trial.

BACKGROUND: Delirium is a common postoperative complication in older patients undergoing thoracic surgery and presages poor outcomes. Postoperative pain is an important factor in the progression of delirium. The purpose of this study was to test whether continuous thoracic paravertebral block (PVB), a more effective approach for analgesia, could decrease the incidence of delirium in elderly patients undergoing esophagectomy. METHODS: A total of 180 geriatric patients undergoing esophagectomy were randomly divided into 2 groups and treated with PVB or patient-controlled analgesia (PCA). Perioperative plasma CRP, IL-1ß, IL-6, and TNF-α levels were detected in all patients. Pain intensity was measured by a numerical rating scale. Delirium was assessed using the confusion assessment method. RESULTS: The incidence of postoperative delirium was significantly lower in the PVB group than in the PCA group. Patients in the PVB group had lower plasma CRP, IL-1ß, IL-6, and TNF-α levels and less pain when coughing after surgery. CONCLUSIONS: Ultrasound-guided continuous thoracic paravertebral block improved analgesia, reduced the inflammatory reaction and decreased the occurrence of delirium after surgery.

Adductor canal block versus periarticular infiltration for pain control following total knee arthroplasty: Study protocol for a randomized controlled trial.

BACKGROUND: Periarticular infiltration (PAI) and adductor canal block (ACB) have become popular modes of pain management after total knee arthroplasty. The purpose of our study is to evaluate the efficacy of ACB in comparison with PAI for pain control in patients undergoing primary total knee arthroplasty. METHODS: This study is a prospective, 2-arm, parallel-group, open-label randomized controlled trial that is conducted at a single university hospital in China. A total of 120 patients who meet inclusion criteria are randomized in a ratio of 1:1 to either ACB or PAI group. The primary outcome is visual analog scale score at rest 24 hours after surgery, whereas the secondary outcomes include visual analog scale score at 48 hours after surgery, satisfaction, opioid consumption, and complications. All pain scores are assessed by an independent observer who is blinded to the allocation of groups. RESULTS: This study has limited inclusion and exclusion criteria and a well-controlled intervention. This clinical trial is expected to provide evidence of better therapy for the pain management after total knee arthroplasty. TRIAL REGISTRATION: This study protocol was registered in Research Registry (researchregistry5410).

Continuous versus single shot adductor canal block for postoperative pain relief after total knee arthroplasty: A protocol for randomized controlled trial.

BACKGROUND: Adductor canal block has become a popular mode of pain management after total knee arthroplasty. This study compared a single-injection adductor canal block (SACB) with continuous adductor canal block (CACB). The hypothesis was that the 2 groups would have equivalent analgesia at 48 hours post-neural blockade. METHODS: This is a double-blinded, randomized, controlled, equivalency trial that is conducted at a single university hospital in China. A total of 60 patients who meet inclusion criteria are randomized in a ratio of 1:1 to either CACB (0.5% ropivacaine 20 mL followed by continuous infusion of 0.2% ropivacaine at 5 mL/h for 48 hours) or SACB (0.5% ropivacaine 20 mL) group. The primary outcome is pain scores at 48 hours utilizing the visual analog scale, whereas the secondary outcomes include opioid consumption, Timed Up & Go test, ambulation distances at discharge, length of stay, and maximal flexion at discharge. All pain scores are assessed by an independent observer who is blinded to the allocation of groups. RESULTS: This study has limited inclusion and exclusion criteria and a well-controlled intervention. This clinical trial is expected to provide evidence of better therapy for the pain management after total knee arthroplasty. TRIAL REGISTRATION: This study protocol was registered in Research Registry (researchregistry5431).

Feasibility and initial experience with continuous nerve blocks by emergency physicians.

INTRODUCTION: Peripheral nerve blocks and regional anesthesia are routinely used to alleviate pain in the emergency department. Our objective is to report on the feasibility and initial experience of emergency physicians initiating and managing continuous nerve blocks for trauma patients. METHODS: This was a retrospective, observational cohort study of a convenience sample of patients 18 years or older presenting with either rib or hip fractures between August 15, 2016 and January 15, 2019. Demographic and clinical data was abstracted using a structured data collection form. Data collected included basic demographics, mechanism of injury, type of regional anesthesia, admission location, respiratory complications, pre- and post-procedure opioid use, efficacy of anesthesia and duration of continuous nerve blockade. All analyses were descriptive in nature, including means, median, and range when appropriate. RESULTS: Forty-one patients presented during the study period with rib or hip fractures and received a nerve block catheter and a continuous infusion pump. The mean age of patients was 65.9 years and 26 (63.4%) patients were male. The mean duration of continuous nerve blockade was 3.4 days (range 1-9 days). Hourly opioid use was reduced by 58%. The most common complication was accidental dislodgement of the catheter;, no patient developed a pneumothorax, hemothorax, catheter related infection, or hematoma. CONCLUSIONS: It is feasible and effective for emergency physicians to initiate and manage continuous nerve blockade for acute hip and rib fractures. Continuous nerve blockade may allow trauma patients to significantly decrease their use of opioids.

Are repetitive pericranial nerve blocks effective in the management of chronic paroxysmal hemicrania?: A case report.

INTRODUCTION: Paroxysmal hemicrania (PH) is a chronic headache disorder characterized by unilateral pain attacks accompanied by cranial autonomic symptoms and responds to indomethacin completely. There are few alternative treatment options for the patients who cannot tolerate indomethacin. Studies exploring the effects of repetitive peripheral cranial nerve blocks in the management of chronic PH are limited. PATIENT CONCERNS AND DIAGNOSIS: A 34-year-old woman with a 4-year history of PH was evaluated. Her pain was prevented by indomethacin without side effects; however, she wanted to try to conceive. INTERVENTIONS: Repetitive pericranial nerve blocks, great occipital nerve, infraorbital nerve, supraorbital nerve, and sphenopalatine ganglion block, using local anesthetics and steroids were performed once a week for a 6 weeks period. OUTCOMES: A follow-up of 3 months showed that there was no pain relief following the injections and patient was needed to be maintained on indomethacin. CONCLUSION: Although pericranial nerve blocks have been tried in chronic PH cases with positive influences, this case indicated that repetitive nerve blocks were not always a successful therapy option.