Thoracic paravertebral block for postoperative pain management after renal surgery: A randomised controlled trial.

BACKGROUND: Thoracic paravertebral block (ThPVB) combined with general anaesthesia is used in thoracic and general surgery. It provides effective analgesia, reduces surgical stress response and the incidence of chronic postoperative pain. OBJECTIVE: To assess the efficacy of ThPVB in reducing opioid requirements and decreasing the intensity of pain after renal surgery. DESIGN: A randomised, open label study. SETTING: A single university hospital. Study conducted from August 2013 to February 2014. PARTICIPANTS: In total, 68 patients scheduled for elective renal surgery (open nephrectomy or open nephron-sparing surgery). INTERVENTIONS: Preoperative ThPVB with 0.5% bupivacaine combined with general anaesthesia, followed by postoperative oxycodone combined with nonopioid analgesics as rescue drugs. Follow-up period: 48 h. MAIN OUTCOME MEASURES: Total dose of postoperative oxycodone required, pain intensity, occurrence of opioid related adverse events, ThPVB-related adverse events and patient satisfaction. RESULTS: A total of 68 patients were randomised into two groups and, of these, 10 were subsequently excluded from analysis. Patients in group paravertebral block (PVB; n = 27) had general anaesthesia and ThPVB, and those in group general (anaesthesia) (GEN) (n = 31) formed a control group receiving general anaesthesia only. Compared with patients in group GEN, patients who received ThPVB required 39% less i.v. oxycodone over the first 48 h and had less pain at rest (P < 0.01) throughout the first 24 h. Group PVB patients also experienced fewer opioid-related adverse events and were less sedated during the first 12 postoperative hours. Patients in the PVB group had higher satisfaction scores at 48 h compared with the control group. There were no serious adverse events. CONCLUSION: In our study, preoperative ThPVB was an effective part of a multimodal analgesia regimen for reducing opioid consumption and pain intensity. Methods and drugs used in both groups were well tolerated with no serious adverse events. Compared with the control group, patients in the ThPVB group reported increased satisfaction. TRIAL REGISTRATION: Clinical Trials NCT02840526.

Recommendations for effective documentation in regional anesthesia: an expert panel Delphi consensus project.

BACKGROUND AND OBJECTIVES: Documentation is important for quality improvement, education, and research. There is currently a lack of recommendations regarding key aspects of documentation in regional anesthesia. The aim of this study was to establish recommendations for documentation in regional anesthesia. METHODS: Following the formation of the executive committee and a directed literature review, a long list of potential documentation components was created. A modified Delphi process was then employed to achieve consensus amongst a group of international experts in regional anesthesia. This consisted of 2 rounds of anonymous electronic voting and a final virtual round table discussion with live polling on items not yet excluded or accepted from previous rounds. Progression or exclusion of potential components through the rounds was based on the achievement of strong consensus. Strong consensus was defined as ≥75% agreement and weak consensus as 50%-74% agreement. RESULTS: Seventy-seven collaborators participated in both rounds 1 and 2, while 50 collaborators took part in round 3. In total, experts voted on 83 items and achieved a strong consensus on 51 items, weak consensus on 3 and rejected 29. CONCLUSION: By means of a modified Delphi process, we have established expert consensus on documentation in regional anesthesia.

Postoperative analgesia in a morbidly obese patient with chronic renal failure.

BACKGROUND: The number of surgical interventions performed in obese patients has recently been increasing. Anaesthesia in a morbidly obese patient may be difficult, due to many pathophysiologic changes and co-morbidities, together with altered pharmacokinetics and pharmacodynamics of anaesthestic agents. We present a case of multimodal preventive analgesia in a bariatric patient with chronic renal failure. CASE REPORT: A 36-year-old, morbidly obese man (BMI 47.8 kg m-2) was scheduled for a laparoscopic adjustable gastric banding (LAGB). The anaesthetic risk was increased because of hypertension, chronic renal failure, steatohepatitis and obstructive sleep apnoea syndrome. 30 minutes before anaesthesia, the patient received 2 g iv paracetamol. After induction, he was given 8 mg dexamethasone and 100 mg tramadol. All port-sites were infiltrated with 0.5% bupivacaine and adrenaline, both before skin incision, and before wound closure. Since NSAIDs and opioids were contraindicated because of the patient's co-morbidities, postoperative analgesia consisted of tramadol and paracetamol, given alternately, every 3 hours. The patient was discharged home 28 hours after surgery. DISCUSSION AND CONCLUSION: According to the Polish Postoperative Pain Management Recommendations 2008, the pain after LAGB is multifactorial and rated as category 2. The pre-emptive analgesia and postoperative regimen presented in this case can be recommended in similar cases.

Comparison of different methods of postoperative analgesia after thoracotomy-a randomized controlled trial.

BACKGROUND: Continuous thoracic epidural analgesia (TEA) is a preferred method of postoperative analgesia in thoracic surgery. Intravenous patient-controlled analgesia (IVPCA) may be an effective alternative. One of the most commonly used opioids in PCA is morphine. It has high antinociceptive efficacy but is associated with many adverse events. Oxycodone can be an alternative. A small number of scientific reports comparing morphine and oxycodone in PCA for the treatment of acute postoperative pain after thoracotomy was the reason to conduct this study. METHODS: Prospective, randomised, observational study. In total of 99 patients scheduled for elective thoracotomy were randomized into three study groups. TEA group received continuous TEA as a method of postoperative pain management, morphine (MF) group received morphine IVPCA, and morphine (OXY) group oxycodone IVPCA. For 48 hours' hemodynamic parameters, level of pain, sedation and the need for rescue analgesia were monitored. After 48 hours' patients were asked about their satisfaction with pain treatment using Likert scale and assessment of opioid related adverse events via overall benefit of analgesia score (OBAS). RESULTS: The level of pain in visual analogic score (VAS) and Prince Henry Hospital Pain Score (PHHPS) scales was significantly lower in TEA group with no significant difference between groups MF and OXY. Using morphine in PCA was associated with a significantly higher likelihood of need of rescue analgesia. The level of sedation in Ramsay scale was significantly higher in MF compared to OXY and TEA group. There were no significant differences between groups in OBAS scale. TEA group was characterized by the highest degree of patient satisfaction. CONCLUSIONS: TEA provided superior anaesthesia compared to PCA in our study group. Use of PCA oxycodone in postoperative pain management after open thoracotomy provides similar nociception control compared to morphine but is associated with less sedation and patients using oxycodone IVPCA require smaller doses of rescue analgesia compared to systemic morphine IVPCA.

Postoperative pain management - 2018 consensus statement of the Section of Regional Anaesthesia and Pain Therapy of the Polish Society of Anaesthesiology and Intensive Therapy, the Polish Society of Regional Anaesthesia and Pain Therapy, the Polish Association for the Study of Pain and the National Consultant in Anaesthesiology and Intensive Therapy.

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Thoracic combined spinal-epidural anesthesia for laparoscopic cholecystectomy in an obese patient with asthma and multiple drug allergies: a case report.

Drug allergies, asthma, and obesity are more common in modern societies, and patients with these problems are often a challenge for anesthetists. Different techniques of regional anesthesia can be beneficial particularly for this group of patients. We present a patient who suffered from all of the above-mentioned conditions and successfully underwent laparoscopic cholecystectomy under thoracic combined spinal-epidural anesthesia. It is still not a popular practice, and we would like to show another indication for using it.

Neuropathic pain after spinal cord injury resistant to conventional therapies - case report. / Ból neuropatyczny po urazie rdzenia kregowego niepoddajacy sie konwencjonalnej terapii - opis przypadku.

OBJECTIVES: There are patients with neuropathic pain in whom the treatment is ineffective, despite the fact that is conducted with adherence to the current guidelines. In these patients alternative treatment methods such as hypnosis could be effective. METHODS: The paper presents a case of a 58-year-old man with central neuropathic pain after cervical spinal cord injury. The conservative treatment with antiepileptics including gabapentoids), antidepressants (tricyclic and selective noradrenaline and serotonin inhibitor - SNRI) and opioids was not effective. In the pain management centre the celiac plexus stimulation and neuromodulation was performed, however, with no positive results. The patient was referred to the psychiatrist using hypnosis in his medical practice. RESULTS: The psychiatrist qualified the patient to pain treatment with hypnosis. After several hypnotic sessions the pain intensity score in numeric rating scale (NRS) decreased from NRS 7 to NRS 5 points and became acceptable for the patient. CONCLUSIONS: Hypnosis can be considered an effective method of neuropathic pain treatment in some patients.

A comparison of selective and conventional spinal anaesthesia for ambulatory surgery.

BACKGROUND: Selective spinal anaesthesia is the practice of employing minimal doses of intrathecal agents so that only the nerve roots supplying a specific area and only the modalities that require to be anaesthetised are affected. The study is based on the hypothesis that small dose lidocaine spinal anaesthesia may be adequate for elective surgical procedures, providing limited motor and sensory block, and thus enabling earlier patient's discharge. The aim of this study was the comparison of the low and the conventional dose of lidocaine spinal anaesthesia discharge time. METHODS: The study was a prospective, randomized controlled single-blind trial, with 84 patients enrolled. Patients in study group (SS-L, Selective Spinal Lidocaine) were administered 3 mL of a 0.8% lidocaine solution containing 24 mg of lidocaine and 15 µg of fentanyl for spinal anaesthesia. Patients in the control group (CD-L, Conventional Dose Lidocaine) received 5 mL of a 1% lidocaine solution containing 50 mg of lidocaine and 25 µg of fentanyl for spinal anaesthesia. Discharge time was evaluated. RESULTS: In the SS-L group time to discharge were shorter (P < 0.01) compared to the CD-L group. CONCLUSION: Selective spinal anaesthesia with low dose of lidocaine decreases the time of patient discharge compared with conventional lidocaine dose spinal anaesthesia.

Ryszard Rodzinski-A Forgotten Polish Inventor and Pioneer of Combined Spinal-Epidural Anesthesia.

Dr. Ryszard Rodzinski was a Polish surgeon who, in spite of his short life, had a productive career. His most important discovery was a safer method of performing regional anesthesia for abdominal surgery. The first description of combined spinal epidural anesthesia is generally attributed to Soresi in 1937. In the early 20th century, Rodzinski invented a novel technique, "combined lumbosacral anesthesia," which combined lumbar spinal anesthesia and sacral epidural anesthesia. During the 19th Meeting of Polish Surgeons in July 1922 in Warsaw, Rodzinski presented an article entitled "On Combined Lumbosacral Anaesthesia," in which he described this technique used in surgical clinic in Lwów since October 1921. Given this presentation, Rodzinski could be considered to have made the first known presentation of the combined spinal and epidural anesthesia.

Objective assessment of pain-related stress in mechanically ventilated newborns based on skin conductance fluctuations.

BACKGROUND: In the process of intensive care, neonates are exposed to stress and pain related to the repeated therapeutic- diagnostic procedures. The aim of this study was the objective assessment of stress intensity pain while performing selected procedures in neonates in the intensive care unit. METHODS: 32 neonates, with a mean body mass of 2,495 g, intubated and mechanically ventilated, and who underwent sedation and analgesia were qualified to the study. A stress reaction to suctioning from endotracheal tube and capillary blood taking for blood gas analysis was evaluated. For the pain stress evaluation, the conductance fluctuation method was used. RESULTS: 0.20 oscillations per second during the mechanical ventilation were obtained; during the suctioning, the number of oscillations increased to 0.33. With finger tip puncture, the number of oscillations was 0.35. The mean values obtained in the cases of suctioning and puncture differed significantly from the ones obtained at mechanical ventilation (P < 0.001) and did not differ between one another (P = 0.558). The oscillation proportion ≥ 0.33 s-1 was the lowest during the ventilation and it was significantly different (P < 0.001) from the values obtained at suctioning and finger tip puncture. There were no significant differences between these values. CONCLUSION: The measurement of conductivity of the skin as an objective tool to measure pain and discomfort during invasive procedures in neonatal intensive care shows that, despite the use of sedation and analgesia, neonates experience discomfort associated with the selected performance of therapeutic and diagnostic procedures.