Investigation of Optimal Needle Position for Radiofrequency Ablation-Based Blockade of Interspace between the Popliteal Artery and the Posterior Capsule of the Knee: A Cadaveric Study.

Background and Objectives: The interspace between the popliteal artery and the posterior capsule of the knee (iPACK) block has been widely used in perioperative settings to control posterior knee pain and can additionally be used for chronic knee pain. In this cadaveric study, we aimed to investigate the needle tip position and its proximity to the articular branch of the tibial nerve (ABTN) during an iPACK-targeted radiofrequency procedure. Materials and Methods: An ultrasound-guided iPACK block was performed on 20 knees of 10 cadavers. We injected 0.1 mL each of blue and green gelatinous dye near the tibial artery (point A) and posterior knee capsule (point B), respectively, and evaluated the spread of both around the ABTN. For a hypothetical conventional radiofrequency ablation (RFA) lesion (diameter, 2.95 mm) and cooled RFA lesion (diameter, 4.9 mm), we counted the number of specimens in which the ABTNs would be captured. Results: The percentage of specimens in which the ABTN would be captured by a cooled RFA lesion was 64.71% at point A and 43.75% at point B (p = 0.334). Meanwhile, the percentage of specimens in which the ABTN would be captured by a conventional RFA lesion was 58.82% from point A and 25% from point B (p = 0.065). Conclusions: When performing an RFA-based iPACK block, the needle tip may be positioned either lateral to the tibial artery or in the space between the posterior knee capsule and the tibial artery. However, more studies with larger samples are needed to verify these results before the clinical use of this procedure can be recommended.

The effect of ultrasound-guided transversus abdominis plane block on pulmonary function in patients undergoing laparoscopic cholecystectomy: a prospective randomized study.

BACKGROUND: Transversus abdominis plane block (TAPB) is commonly used for postoperative pain control after laparoscopic cholecystectomy. However, few studies have analyzed its effect on pulmonary function. The goal of this study was to elucidate the effect of ultrasound-guided bilateral TAPB on pulmonary function preservation and analgesia after laparoscopic cholecystectomy. METHODS: We enrolled 58 patients who underwent laparoscopic cholecystectomy. Among them, 53 were randomized to group T (n = 27) and group C (n = 26). Group T and group C received ultrasound-guided bilateral TAPB with 40 ml of 0.375% ropivacaine and 40 ml of 0.9% normal saline, respectively. Visual analog scale (VAS) scores, patient-controlled analgesia (PCA) consumption, forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC, peak expiratory flow rate (PEF), and modified Borg scale scores were measured until 24 h post-surgery. RESULTS: The VAS scores were significantly lower in group T than in group C at 1 and 8 h after the surgery. PCA consumption was significantly lower in group T than in group C at all postoperative time points. FEV1, PEF, and FEV1/FVC were more preserved in group T than in group C at 1 h. Group T had significantly lower modified Borg scale scores than did group C at 1 and 8 h. CONCLUSION: Ultrasound-guided TAPB is effective in pulmonary function preservation and pain control after laparoscopic cholecystectomy. Therefore, it could be a great option for multimodal analgesia, preservation of pulmonary function, prevention of pulmonary complications including atelectasis, and promotion of postoperative recovery after laparoscopic cholecystectomy. CLINICAL REGISTRATION: This study was enrolled in the Clinical Research Information Service (Clinical Research Information Service, KCT0004435, Hwa Yong Shin, 2019-08-19).

Effect of Stellate Ganglion Block on the Regional Hemodynamics of the Upper Extremity: A Randomized Controlled Trial.

BACKGROUND: The success of stellate ganglion block (SGB) is traditionally determined on the basis of findings such as Horner's syndrome, temperature rise in the face, hyperemia of the tympanic membrane, and nasal congestion. However, decreases in vascular resistance and increases in blood flow in the arm may be more meaningful findings. To date, the effect of SGB on the regional hemodynamics of the arm has not been evaluated using pulsed-wave Doppler ultrasound. METHODS: A total of 52 patients who were to undergo orthopedic surgery of the forearm were randomly assigned to either the mepivacaine group (SGB with 5 mL of 0.5% mepivacaine) or the saline group (SGB with 5 mL of normal saline). Before surgery, a single anesthesiologist performed a SGB under ultrasound guidance. The temperature of the upper extremity and the resistance index and blood flow in the brachial artery were measured before SGB, 15 and 30 minutes after SGB, and 1 hour after surgery. The severity of pain, requirement for rescue analgesics, and side effects of the local anesthetic agent were all documented. RESULTS: After SGB, the resistance index decreased significantly and the blood flow increased significantly in the brachial artery of members of the mepivacaine group (15 minutes: P = .004 and P < .001, respectively; 30 minutes: P < .001 and P < .001, respectively). However, these values normalized after surgery. The severity of pain, need for rescue analgesics, and incidence of adverse effects were not significantly different between the 2 groups. CONCLUSIONS: Although SGB did not decrease the pain associated with forearm surgery, ultrasound-guided SGB did increase blood flow and decrease vascular resistance in the arm. Therefore, pulsed-wave Doppler may be used to monitor the success of SGB.

Comparison of the accuracy of noninvasive hemoglobin monitoring for preoperative evaluation between adult and pediatric patients: a retrospective study.

We measured noninvasive hemoglobin (SpHb) levels during the pre-anesthesia visit in patients planning elective surgery. Differences between SpHb and laboratory-measured hemoglobin (Hblab) were compared between adult and pediatric patients. In the pre-anesthesia visiting office, we routinely monitor noninvasive Hb levels with oxygen saturation and heart rate using Masimo Radical-7® Pulse CO-Oximetry (Masimo Corp., Irvine, CA, USA). We attached the R1 20 (body weight, 10-50 kg) or R1 25 (body weight > 30 kg) probe on the index finger. After signal stabilization, SpHb and perfusion index (PI) were recorded. We retrospectively reviewed the recorded data and included patients who visited the anesthesiologist within 24 h after venous sampling. Bias was calculated by subtracting Hblab from SpHb. We compared the biases of adult and pediatric patients (< 18 years) and evaluated correlation coefficients between the bias and Hblab. Records of 105 patients were reviewed and 100 data points of 50 patients in each group were analyzed. The median ± interquartile range bias was - 2.6 ± 2.2 and - 1.2 ± 1.5 g/dL in adult and pediatric patients, respectively (P < 0.001); the corresponding mean ± standard deviation PIs were 4.4 ± 3.1 and 5.9 ± 2.7, respectively (P = 0.19). Bias was inversely proportional to Hblab irrespective of age. The correlation coefficient between the bias and Hblab was - 0.81 in adults and - 0.54 in pediatric patients (P < 0.001). SpHb and Hblab measured during pre-anesthesia visits showed a smaller difference in pediatric than in adult patients. Lower Hblab corresponded to higher accuracy.

Effect of ultrasound-guided phrenic nerve block on shoulder pain after laparoscopic cholecystectomy-a prospective, randomized controlled trial.

BACKGROUND: Post-laparoscopic shoulder pain (PLSP) frequently follows a laparoscopic cholecystectomy. A proposed mechanism for PLSP is the irritation or injury of the phrenic nerve by the CO2 pneumoperitoneum during laparoscopic surgery. Here, we investigated whether a phrenic nerve block (PNB), performed under ultrasound guidance, could reduce the incidence and severity of PLSP after laparoscopic cholecystectomy. METHOD: Sixty patients were randomized into two groups, with one group receiving PNB with 4 ml (30 mg) of 0.75% ropivacaine (group P, n = 28) and a control group (group C, n = 32). The existence and severity of PLSP were assessed for 2 days postoperatively. A pulmonary function test (PFT) and diaphragmatic excursion test were performed pre- and postoperatively. RESULTS: With ultrasound guidance, all PNBs were performed successfully in group P. In group P, the overall incidence and severity of PLSP decreased significantly. There were no significant differences in incisional pain, visceral pain, and analgesic requirements between the groups. Right-side diaphragmatic excursion decreased significantly in group P at 1 h postoperatively. The PFT results and respiratory discomfort assessed by a modified Borg's scale were not different significantly between the groups. CONCLUSION: Based on these findings, ultrasound-guided PNB can prevent or reduce the PLSP without clinically significant respiratory discomfort.

Evaluation of Lung Function and Clinical Features of the Ultrasound-Guided Stellate Ganglion Block With 2 Different Concentrations of a Local Anesthetic: A Randomized Controlled Trial.

BACKGROUND: One possible complication of stellate ganglion block (SGB) is respiratory compromise. No study has yet addressed the comparison of its effect on lung function and clinical features, including Horner's syndrome, changes in temperature, sensory and motor functions, and adverse events of lower versus higher concentrations (LC and HC, respectively) of local anesthetics in an ultrasound-guided SGB. METHODS: Fifty patients were randomized into 1 of 2 groups: the LC group (5 mL of 0.5% mepivacaine) and the HC group (5 mL of 1% mepivacaine). One anesthesiologist performed a C6- SGB under ultrasound guidance. Our primary objective was to compare LC and HC of a local anesthetic in terms of its effect on lung function, and the secondary objective was to compare the clinical features between LC and HC of a local anesthetic. Lung function was compared between the 2 groups using the Mann-Whitney U test. RESULTS: The forced vital capacity at 20 minutes post-SGB was not significantly different between the HC and the LC groups (P = .360); the median difference (95% confidence intervals [CI]) was 1 (-1 to 8). Other parameters of lung function were comparable with the forced vital capacity. Patients in the HC group had significantly greater sensory changes than those in the LC group (% decrease compared with the unblocked side); 95.4 ± 2.1 (CI: 91.11-99.73) vs 87.3 ± 3.5 (CI: 80.12-94.49). CONCLUSIONS: Lung function between the LC and HC groups after SGB did not differ significantly. Clinical features between the 2 groups also did not differ clinically, except that patients in the HC group had significantly greater sensory loss in the C6 dermatomes.

Effects of a Lidocaine-Loaded Poloxamer/Alginate/CaCl2 Mixture on Postoperative Pain and Adhesion in a Rat Model of Incisional Pain.

BACKGROUND: Pain and adhesion are problematic issues after surgery. Lidocaine has analgesics and anti-inflammatory properties, and poloxamer/alginate/CaCl2 (PACM) is a known antiadhesive agent. We hypothesized that the novel combination of lidocaine as chemical barrier and PACM as physical barrier would be beneficial for both postoperative pain and adhesion. The purpose of this study was to investigate the effects of lidocaine-loaded PACM in a rat model of incisional pain. Primary outcome was to evaluate between-group differences for the mechanical withdrawal threshold (MWT) measured by von Frey filament in various concentrations of lidocaine-loaded PACM applied, PACM applied, and sham-operated groups. METHODS: Male Sprague-Dawley rats were used for the postoperative pain model. After plantar incision and adhesion formation, 0.5%, 1%, 2%, and 4% lidocaine-loaded PACM, PACM only, nothing, and 4% lidocaine only were applied at the incision site in groups PL0.5, PL1, PL2, PL4, P, S, and L4, respectively. MWT using a von Frey filament and serum levels of tumor necrosis factor-α, interleukin (IL)-1ß, IL-6, and high-sensitivity C-reactive protein were measured. Rats were euthanized 2 weeks after surgery, and inflammation and fibrosis were assessed with microscopy. Data were analyzed using the Kruskal-Wallis test, multivariate analysis of variance, and linear mixed-effect model. To compare MWT at each time point, analysis of variance with Bonferroni correction was used. RESULTS: Multivariate analysis of variance showed that 4% lidocaine-loaded PACM significantly raised the MWT up to 6 and 8 hours after surgery compared with lidocaine-unloaded groups S and P, respectively; 2% lidocaine-loaded PACM significantly increased the MWT at 4 hours after surgery compared with groups S and C. Linear mixed-effect model showed that the MWT (estimated difference in means [95% confidence interval]) was significantly increased in groups PL2 and PL4 (6.58 [2.52-10.63], P = .002; 11.46 [7.40-15.51], P < .001, respectively) compared with group P. Inflammation and fibrosis seen on microscopic evaluation were significantly decreased in groups PL2 and PL4 compared with group S. Four percent of lidocaine only showed a significant reduction in inflammation. Serum levels of tumor necrosis factor-α, IL-1ß, IL-6, and high-sensitivity C-reactive protein were decreased in lidocaine-loaded groups compared with group S or P at 1, 2, and 48 hours, and 2 weeks after surgery, respectively. CONCLUSIONS: Lidocaine-loaded PACM reduced postoperative pain, and lidocaine strengthened the antiadhesive effect of PACM.

Analgesic efficacy of two interscalene blocks and one cervical epidural block in arthroscopic rotator cuff repair.

PURPOSE: Despite its effectiveness in other surgeries, studies on continuous epidural block in upper-extremity surgery are rare because of technical difficulties and potential complications. This study compared postoperative analgesic efficacy and safety of ultrasound-guided continuous interscalene brachial plexus block (UCISB) and fluoroscopy-guided targeted continuous cervical epidural block (FCCEB) in arthroscopic rotator cuff repair (ARCR). METHODS: Seventy-five patients were randomly and equally assigned to groups FCCEB (0.2%), UCISB75 (0.75%), and UCISB20 (0.2%) according to the initial ropivacaine dose (8 ml). The background infusion (0.2% ropivacaine at 5 ml/h), bolus (3 ml of 0.2% ropivacaine), and lockout time (20 min) were consistent. Respiratory effects [respiratory discomfort (modified Borg scale), ventilatory function, and hemidiaphragmatic excursion (ultrasound)], analgesic quality [pain severity at rest and motion attempt (VAS-R and -M), number of boluses, analgesic supplements, and sleep disturbance], neurologic effects, procedural discomfort, satisfaction, and adverse effects were evaluated preprocedurally and up to 72 h postoperatively. RESULTS: FCCEB caused less respiratory depression and sensorimotor block, but had less analgesic efficacy than UCISBs (P < 0.05). FCCEB caused nausea, vomiting, and dizziness more frequently (P < 0.05) and had lower patient satisfaction than UCISBs (P < 0.05). UCISB75 can cause severe respiratory distress in patients with lung disorders. Other variables were not significantly different between the groups. CONCLUSIONS: UCISB20 may provide superior postoperative analgesia and is the most recommendable postoperative analgesic method in ARCR. LEVEL OF EVIDENCE: Randomized controlled trials, Therapeutic study, Level I.

Antihyperalgesic effects of ginseng total saponins in a rat model of incisional pain.

BACKGROUND: The aim of this study was to assess whether intraperitoneal administration of ginseng total saponins (GTS) has antihyperalgesic effects in a rat model of incisional pain. The proinflammatory responses and reversal of the antihyperalgesic effect of GTS by N-methyl-d-aspartate (NMDA) or naloxone were also evaluated. MATERIALS AND METHODS: Rats were injected intraperitoneally with 0.9% saline vehicle or various doses of GTS before or after a plantar incision. Paw withdrawal in response to application of the von Frey filament with the lowest bending force marked the mechanical withdrawal threshold (MWT). Blood samples were collected for the assessment of serum interleukin (IL)-1ß and IL-6 levels. The IL levels were measured using an enzyme-linked immunosorbent assay kit. Rats were injected intraperitoneally with NMDA or naloxone before the GTS injection to assess the reversal of the antihyperalgesic effect of GTS. RESULTS: The MWT measured 2 h after the plantar incision increased significantly after the postincision administration of 50, 100, or 200 mg/kg of GTS compared with the MWT at 2 h after plantar incision. The MWT also increased significantly after the preincision injection of 100 or 200 mg/kg of GTS compared with the MWT of the vehicle control. Administration of GTS suppressed the postincision rise in serum IL-1ß levels and NMDA inhibited the increase in the MWT compared with GTS alone. CONCLUSIONS: Intraperitoneal administration of GTS before or after surgery induces antihyperalgesic effects in a rat model of incisional pain. The effects on mechanical hyperalgesia may be associated with anti-inflammatory cytokines and NMDA signaling.

Palonosetron and aprepitant for the prevention of postoperative nausea and vomiting in patients indicated for laparoscopic gynaecologic surgery: a double-blind randomised trial.

BACKGROUND: Postoperative nausea and vomiting (PONV) is one of the most common postsurgical complications. Palonosetron, a 5-hydroxytryptamine receptor antagonist, is effective for PONV prevention. Herein, we compared palonosetron and aprepitant (a neurokinin-1 receptor antagonist) for PONV prevention in patients indicated for laparoscopic gynaecologic surgery. METHODS: Ninety-three patients who were scheduled to undergo laparoscopic gynaecologic surgery under general anaesthesia were assigned to receive either a single intravenous injection of 0.075-mg palonosetron or 40-mg oral aprepitant in a double-blind randomised trial. The primary efficacy end points included complete response (visual analogue scale [VAS] nausea score <4 and no use of rescue therapy) 0-48 h after surgery. Nausea severity (0-10) and use of rescue therapy were monitored for 0-48 h. The secondary efficacy end points were the effect of aprepitant quantified using a 10-point VAS for pain, consumption of intravenous patient-controlled analgesia, and use of rescue analgesics. RESULTS: Aprepitant was non-inferior to palonosetron in terms of complete response 0-48 hours after surgery (74% vs. 77%). At 0 and 2 h after administration, the nausea severity with 40-mg aprepitant was significantly lesser than that with 0.075-mg palonosetron (P < 0.05). At 6 and 24 h after administration, fentanyl consumption with 40-mg aprepitant was significantly lower than that with 0.075-mg palonosetron. Greater amounts of rescue analgesics were required in the aprepitant group. CONCLUSIONS: Palonosetron and aprepitant were both effective for PONV prevention in the patients indicated for laparoscopic gynaecologic surgery. The drugs can be used in combination for multimodal therapy because they bind to different receptors. More research is needed to evaluate the effects of aprepitant on pain management in humans.

Ultrasound-guided Prolotherapy with Polydeoxyribonucleotide Sodium in Ischiofemoral Impingement Syndrome.

Ischiofemoral impingement syndrome is an uncommon disorder defined by hip pain caused by the narrowing of the space between the ischial tuberosity and lesser trochanter with associated entrapment of the quadratus femoris muscle. We effectively treated two male patients using ultrasound-guided prolotherapy with polydeoxyribonucleotide sodium mixed with local anesthetics. A 24-year-old male patient with no history of trauma or surgery complained of bilateral hip and groin pain; magnetic resonance imaging demonstrated slight narrowing of the bilateral ischiofemoral spaces with mild enhancement of the left quadratus femoris muscle. A 23-year-old male patient with a history of iliotibial band release and iliopsoas tendon release complained of left hip and groin pain; magnetic resonance imaging revealed swelling of the left quadratus femoris muscle. After the fifth treatment session of prolotherapy, the pain severity score using the visual analog scale was found to be minimal (0-1/10), and follow-up magnetic resonance imaging revealed a slightly decreased enhancement of the quadratus femoris muscle compared with that on previous images. Prolotherapy with polydeoxyribonucleotide sodium was an efficacious treatment for two patients with ischiofemoral impingement syndrome who were not candidates for surgery.

Ultrasound diagnosis and treatment of intractable anterior chest pain from golf - A case report.

BACKGROUND: Pleurisy is an inflammation of the parietal pleura and is characterized by pleuritic pain. The most common cause of pleurisy is infection; other causes include rheumatoidarthritis, malignancy, rib fractures, or trauma. Possible causes of chest pain associated withgolf include costochondritis, stress fractures of the ribs, intercostal muscle strain, or, rarely,Tietze's syndrome and slipping rib syndrome. CASE: A 64-year-old female presented with intractable chest pain that began 4 months priorwhile playing golf. No specific cause was found after various examinations. There was persistent pain despite medical treatment. Ultrasonography (US) was performed over the painful areas, which revealed focal pleural effusions. A mixture of ropivacaine and triamcinolonewas injected into the focal pleural effusions using US guidance, which dramatically relievedher pain. CONCLUSIONS: This case demonstrates that US can be used as a diagnostic and therapeuticmodality for intractable chest pain with an undetected pathology.

Investigation of the existence of and a block technique for the inferior lateral genicular nerve: cadaveric study.

Background: Among the four genicular nerves innervating the anterior aspect of the knee, the inferior lateral genicular nerve has been omitted as a target of blocking. Some authors have suggested that the inferior lateral genicular nerve of the knee might pass beneath the lateral collateral ligament of knee. The authors aimed to study the location of the inferior lateral genicular nerve and the spread of injectate during the inferior lateral genicular nerve block. Methods: In ten knees from fresh frozen cadavers, the authors performed on each an ultrasound-guided block of the inferior lateral genicular nerve of the knee just below the lateral collateral ligament. The needle was inserted below the lateral collateral ligament, and 2 mL of blue dye was injected. A week later, the cadavers were dissected, and the existence of the inferior lateral genicular nerve and the spread of dye around it was investigated. Results: The proportion of inferior lateral genicular nerves branching from the common peroneal nerve was found in 8 of 10 (80.0%) cadavers. Of these eight cadavers with inferior lateral genicular nerve, five specimens (62.5%) were stained with blue dye. The common peroneal nerve was not infiltrated with dye in any specimens. Conclusions: When 2 mL of dye was inserted inferiorly to the lateral collateral ligament, the inferior lateral genicular nerve could be blocked in 62.5% of specimens. Because the common peroneal nerve was not involved in any specimen, motor weakness would be avoided with this method.

Pain from intramuscular vaccine injection in adults.

BACKGROUND: Vaccine use has been increasing worldwide, and adult populations are presented with more opportunities to experience pain from vaccine injection. The insertion of a needle through the skin is the most common source of iatrogenic pain, and needle phobia is a major concern in medical practice. However, it is unclear which factors play major roles in the perception of pain from vaccine injection in adults. AIM: To evaluate the influences of patient characteristics on pain perception due to intramuscular vaccine injection in healthy adult volunteers. MATERIAL AND METHODS: The injection of hepatitis B vaccine using a 24 mm, 24-G needle was performed as a uniform stimulus, and the intensity of injection pain was measured immediately after the injection using a 100-mm visual analogue scale (VAS). The influences of patient characteristics on pain intensity were investigated. RESULTS: One hundred sixty volunteers (65 males, 95 females) were enrolled in this study. The average VAS score was 20.8 ± 17.1 (range 0 to 67) in males and 34.4 ± 19.7 (range 2 to 76) in females (P < 0.001). However, there were no correlations between VAS score and age, body mass index or maximal pain score from previous painful experiences. The VAS score was also not affected by the experience of previous vaccine injections, a history of childbirth in females, or religion. CONCLUSIONS: Gender appears to be the only major factor that influences the pain of intramuscular vaccine injection. Therefore, pain-reducing methods will be needed when performing injection procedures, particularly in women.

Recent update on epidural blood patch.

Epidural blood patch (EBP) is the injection of autologous blood into the epidural space with the intent of sealing off a dural tear and stopping the leakage of cerebrospinal fluid (CSF). EBP may cause an increase in intracranial pressure (ICP) due to the mass effect of the injected blood volume, causing CSF from the spinal compartment to enter the intracranial compartment. EBP is usually considered in the management of moderate to severe headache (HA) attributed to low CSF pressure, such as post-dural puncture HA (PDPH), CSF fistula HA, and HA attributed to spontaneous intracranial hypotension (SIH) that does not respond to conservative management. However, prophylactic administration of EBP after accidental dural puncture can hardly be substantiated at present. EBP is generally safe but may rarely be associated with serious complications. Therefore, it should be carefully planned and performed under C-arm fluoroscopic guidance. Although many studies on PDPH and SIH have been conducted until recently, only few reviews have summarized the effectiveness of EBP from the perspective of a pain physician. This article reviews the current literature on the indication, contraindication, procedural consideration, post-procedural management, outcomes, and complications of EBP and the considerations for EBP in patients with COVID-19.

Dreaming in sedation during spinal anesthesia: a comparison of propofol and midazolam infusion.

BACKGROUND: Although sedation is often performed during spinal anesthesia, the details of intraoperative dreaming have not been reported. We designed this prospective study to compare 2 different IV sedation protocols (propofol and midazolam infusion) with respect to dreaming during sedation. METHODS: Two hundred twenty adult patients were randomly assigned to 2 groups and received IV infusion of propofol or midazolam for deep sedation during spinal anesthesia. Patients were interviewed on emergence and 30 minutes later to determine the incidence, content, and nature of their dreams. Postoperatively, patient satisfaction with the sedation was also evaluated. RESULTS: Two hundred fifteen patients (108 and 107 in the propofol and midazolam groups, respectively) were included in the final analysis. The proportion of dreamers was 39.8% (43/108) in the propofol group and 12.1% (13/107) in the midazolam group (odds ratio=4.78; 95% confidence interval: 2.38 to 9.60). Dreams of the patients receiving propofol were more memorable and visually vivid than were those of the patients receiving midazolam infusion. The majority of dreams (36 of 56 dreamers, 64.3%) were simple, pleasant ruminations about everyday life. A similarly high level of satisfaction with the sedation was observed in both groups. CONCLUSIONS: In cases of spinal anesthesia with deep sedation, dreaming was almost 5 times more common in patients receiving propofol infusion than in those receiving midazolam, although this did not influence satisfaction with the sedation. Thus, one does not need to consider intraoperative dreaming when choosing propofol or midazolam as a sedative drug in patients undergoing spinal anesthesia.

Hypertrophic osteoarthropathy in renal cell carcinoma - A case report.

BACKGROUND: Hypertrophic osteoarthropathy (HOA) is a rare clinical condition including an abnormal periosteal reaction in the long bones that causes painful swelling and tenderness of the extremities, digital clubbing, arthritis, synovitis, and joint effusions. Most cases are associated with tumorous conditions and most commonly with lung cancer. HOA has been rarely reported in association with other cancers. CASE: A patient with a history of recurrent renal cell carcinoma was referred to our clinic with bilateral leg pain, knee joint effusion, and arthritis. Simple radiography and bone scintigraphy confirmed a diagnosis of HOA. Oral non-steroidal anti-inflammatory drugs, joint fluid aspiration, and intra-articular injection of pain medications were found to be effective in the management of HOA pain. CONCLUSIONS: HOA prognosis depends on the underlying disease, therefore, cancer treatment is critical. This case demonstrates the need to consider HOA in patients with various malignancies who present with bone or joint pain of the extremities.

Diagnosis and treatment of nerve injury following venipuncture - A report of two cases.

BACKGROUND: Venipuncture is one of the one of the most commonly performed, minimally-invasive procedures; however, it may lead to peripheral nerve injury. Here, we describe the diagnosis, treatment, and prognosis of two self-reported cases of nerve injury during venipuncture with the aim of drawing attention to possible needle-related nerve injuries. CASE: Two anesthesiologists in our hospital experienced an injury of the lateral antebrachial cutaneous branch of the musculocutaneous nerve during venipuncture. Immediately, they underwent ultrasound examinations and nerve blocks with oral medication, resulting in full recovery. CONCLUSIONS: Ultrasonography is important for the early and confirmative diagnosis of a nerve injury during venipuncture, and for immediate treatment with a nerve block. Moreover, it is imperative for both the practitioner and the patient to be aware of the possible complication of nerve injury after venipuncture.

Pharmacological and non-pharmacological strategies for preventing postherpetic neuralgia: a systematic review and network meta-analysis.

BACKGROUND: Postherpetic neuralgia (PHN) is a refractory complication of herpes zoster (HZ). To prevent PHN, various strategies have been aggressively adopted. However, the efficacy of these strategies remains controversial. Therefore, we aimed to estimate the relative efficacy of various strategies used in clinical practice for preventing PHN using a network meta-analysis (NMA). METHODS: We performed a systematic and comprehensive search to identify all randomized controlled trials. The primary outcome was the incidence of PHN at 3 months after acute HZ. We performed both frequentist and Bayesian NMA and used the surface under the cumulative ranking curve (SUCRA) values to rank the interventions evaluated. RESULTS: In total, 39 studies were included in the systematic review and NMA. According to the SUCRA value, the incidence of PHN was lower in the order of continuous epidural block with local anesthetics and steroids (EPI-LSE), antiviral agents with subcutaneous injection of local anesthetics and steroids (AV + sLS), antiviral agents with intracutaenous injection of local anesthetics and steroids (AV + iLS) at 3 months after acute HZ. EPI-LSE, AV + sLS and AV + iLS were also effective in preventing PHN at 1 month after acute HZ. And paravertebral block combined with antiviral and antiepileptic agents was effective in preventing PHN at 1, 3, and 6 months. CONCLUSIONS: The continuous epidural block with local anesthetics and steroid, antiviral agents with intracutaneous or subcutaneous injection of local anesthetics and a steroid, and paravertebral block combined with antiviral and antiepileptic agents are effective in preventing PHN.

The effect of mechanical ventilation tidal volume during pneumoperitoneum on shoulder pain after a laparoscopic appendectomy.

BACKGROUND: Postlaparoscopic shoulder pain (PLSP) frequently occurs after various laparoscopic surgical procedures. Its mechanism is commonly assumed to be overstretching of the diaphragmatic muscle fibers due to the pressure of a pneumoperitoneum, which causes phrenic nerve-mediated referred pain to the shoulder. Based on this hypothesis, we speculated that during inspiration, the lung could squeeze out the phrenic nerve with carbon dioxide gas against the constantly pressurized abdominal cavity with increasing tidal volume (V(T)). Thus, we examined whether mechanical ventilation with a low V(T) (LTV, V(T) 7 ml/kg) during a pneumoperitoneum might reduce PLSP in patients undergoing laparoscopic appendectomy compared with ventilation with the traditional V(T) (TTV, V(T) 10 ml/kg). METHODS: In a prospective trial, 64 adult patients undergoing laparoscopic appendectomy were randomly assigned to two groups of 32 each (LTV and TTV groups). Intravenous ketorolac was used as a postoperative rescue analgesic. The 2-, 4-, 24-, and 48-h postoperative incidence and severity of PLSP, severity of surgical pain, and need for rescue analgesia was assessed. RESULTS: The overall incidence of PLSP was similar in both groups (57.1% in the LTV group vs. 65.5% in the TTV group). Compared with the TTV group, the incidence and PLSP verbal rating scale (VRS) did not decrease in the LTV group throughout the study period. No statistically significant differences were observed in the VRS surgical pain score, the cumulative ketorolac consumption at each time point, or the time to first rescue analgesia. CONCLUSIONS: Mechanical ventilation with a reduced 7 ml/kg V(T) during a pneumoperitoneum does not reduce the frequency and severity of PLSP after laparoscopic appendectomy compared with ventilation with the traditional V(T) (10 ml/kg).