Locoregional versus general anesthesia in prolonged carotid endarterectomy: a propensity-score matched study from ACS-NSQIP database from 2011-2022.

BACKGROUND: Carotid endarterectomy (CEA) is an effective treatment for carotid stenosis. Previous studies yielded conflicting findings regarding postoperative outcomes after CEA when comparing those under general and locoregional anesthesia. However, these findings may be influenced by an inherent selection bias, as general anesthesia is frequently selected for more complex CEA. To counteract this selection bias, this study compared the 30-day outcomes of locoregional and general anesthesia in patients who underwent prolonged CEA. METHODS: Adult patients undergoing CEA were identified in ACS-NSQIP targeted database from 2011-2022. Only cases with prolonged operative times (over third quartile) were selected. Patients who had symptomatic and asymptomatic carotid stenosis were examined separately. A 1:3 propensity-score matching was used to address pre-operative differences between patients under locoregional and general anesthesia to assess thirty-day postoperative outcomes. Moreover, factors associated with prolonged CEA were identified by multivariable logistic regression. RESULTS: Among symptomatic patients who underwent prolonged CEA, 246 and 4,286 were under locoregional and general anesthesia, respectively. In asymptomatic patients, 388 had locoregional anesthesia and 5,137 had general anesthesia. After propensity-score matching, patients under locoregional and general anesthesia had comparable 30-day mortality (symptomatic: 1.63% vs 0.81%, p=0.28; asymptomatic: 0.77% vs 0.52%, p=0.70) and stroke (symptomatic: 4.88% vs 4.34%, p=0.72; asymptomatic: 1.29% vs 1.46%, p=1.00). All other 30-day outcomes were comparable between groups, except for symptomatic patients under locoregional had shorter operation time (p<0.01) and asymptomatic patients under locoregional had lower cranial nerve injury (2.06% vs 4.90%, p=0.02). High-risk anatomical factors, male sex, younger age, and certain comorbidities were associated with prolonged operative times. CONCLUSION: Patients under both types of anesthesia had mostly comparable 30-day postoperative outcomes, including mortality and stroke, for both symptomatic and asymptomatic patients. Therefore, locoregional and general anesthesia appear to be equally effective in CEA cases characterized by anticipated complexity and, consequently, prolonged operative times.

Comparative analysis of perioperative outcomes in endovascular abdominal aortic aneurysm repair: Fascia iliaca block versus general anesthesia, a retrospective study.

OBJECTIVE: This retrospective study aimed to compare rates of perioperative mortality and morbidity, especially pulmonary complication, between endovascular aneurysm repair (EVAR) performed under general anesthesia (GA) and under fascia iliaca block (FIB). METHODS: Patients diagnosed with infrarenal abdominal aortic aneurysm (AAA) who were treated with EVAR were included. Retrospective review of electronic medical records was performed. Patient characteristics, operative details, and postoperative results including mortality and morbidity within 30 days were collected. Statistical analysis to compare postoperative outcomes between EVAR under FIB and EVAR under GA was performed. A univariate analysis was conducted to identify factors associated with increased 30-day mortality. RESULTS: This study included 119 patients, 75 in the FIB group and 44 in the GA group. Most patients were male, with 62 (82.5%) in the FIB group and 31 (70.2%) in the GA group, and most patients were hypertensive, with 57 (76%) in the FIB group and 36 (81.8%) in the GA group. Smoking and coronary artery disease (CAD) was more prevalent in the FIB group, p < .05. Thirty-day mortality was not significantly different between the FIB group and the GA group (1 (1.3%) vs 2 (4.5%), p = .554). Pulmonary complication was lower in the FIB group than in the GA group (1.3% vs 11.4%, p = .026). ICU stay was shorter in the FIB group than in the GA group (0.2 vs 4.5 days, p = .012). Univariate analysis showed that chronic obstructive pulmonary disease (COPD) was associated with higher 30-day mortality. CONCLUSIONS: Endovascular aneurysm repair under FIB was feasible. Compared to GA, this approach resulted in lower postoperative pulmonary complications and shorter ICU stay.

Ultrasound-guided ventral approach to the brachial plexus block in barred owls (Strix varia): a cadaveric study.

OBJECTIVE: To develop an ultrasound (US)-guided ventral approach to the brachial plexus (BP) and evaluate nerve anatomy and staining in barred owl cadavers. STUDY DESIGN: Prospective, cadaveric study. ANIMALS: Eleven adult male and female barred owl cadavers with a body mass of 0.43-0.98 kg. METHODS: Eleven frozen cadavers were thawed for 48 hours, weighed and assigned a body condition score. Ten cadavers were placed in dorsal recumbency with wings abducted. US-guided visualization of the BP was achieved by placing a 13-6 MHz linear probe over the ventral aspect of the scapulohumeral joint, parallel to the sternum. A 22 gauge, 50 mm insulated needle was advanced in-plane in a caudal-to-cranial direction. In each owl, injection targeting one BP was performed with 0.4 mL kg-1 of a 1:1 0.5% ropivacaine and 1% methylene blue solution. Dissection was performed 15 minutes postinjection. Nerve staining was deemed successful if ≥ 1 cm of circumferential staining was achieved. The eleventh owl cadaver was injected with a 1:1 solution of 1% methylene blue and 74% ioversol contrast into both wings, and computed tomography (CT) was performed just before and 15 minutes after injection. RESULTS: The BP was clearly identified ultrasonographically in cadavers weighing > 0.5 kg. An injectate volume of 0.4 mL kg-1 provided complete staining of the BP branches in all cadavers. CT scan revealed no contrast within the coelomic cavity. CONCLUSIONS AND CLINICAL RELEVANCE: The US-guided BP injection using a ventral approach was easily performed in barred owl cadavers weighing > 0.5 kg. The injection of 0.4 mL kg-1 of a ropivacaine-dye solution resulted in complete staining of the BP branches in all wings, suggesting that this technique could provide analgesia for structures distal to the scapulohumeral joint. Clinical studies are necessary to confirm the safety and efficacy of this technique in barred owls and other bird species.

Epidural administration of combinations of ropivacaine, morphine and xylazine in bitches undergoing total unilateral mastectomy: a randomized clinical trial.

OBJECTIVE: To investigate the epidural administration of combinations of ropivacaine, morphine and xylazine in bitches undergoing unilateral mastectomy. STUDY DESIGN: Prospective, randomized, blinded, clinical study. ANIMALS: A total of 22 bitches scheduled to undergo unilateral mastectomy for mammary tumor excision. METHODS: Dogs were anesthetized with acepromazine (0.02 mg kg-1) and morphine (0.3 mg kg-1) intramuscularly, propofol intravenously (IV) and isoflurane. Prior to the beginning of surgery, dogs were randomly administered one of three epidural treatments: ropivacaine (0.75 mg kg-1) with morphine (0.1 mg kg-1) (group RM, n = 7); ropivacaine with xylazine (0.1 mg kg-1) (group RX, n = 8); or ropivacaine with morphine and xylazine (group RMX, n = 7). Cardiopulmonary variables and the expired concentration of isoflurane (Fe'Iso) were recorded intraoperatively. Meloxicam (0.1 mg kg-1) was administered IV during skin closure. Postoperative pain scores were evaluated with the Glasgow composite measure pain scale short form for 24 hours, and rescue analgesia with morphine (0.5 mg kg-1) was administered intramuscularly when pain scores were ≥ 6/24. RESULTS: Fe'Iso was significantly higher in group RM than in groups RX and RMX. Heart rate decreased significantly in groups RX and RMX, but blood pressure remained within acceptable values. The number of dogs administered rescue analgesia within 24 hours was significantly higher in group RX (seven dogs, 87.5%) than in groups RM (one dog, 14.3%; p = 0.01) and RMX (two dogs, 28.6%; p = 0.04). Time to standing was significantly longer in group RX than in group RM. CONCLUSIONS AND CLINICAL RELEVANCE: All epidural treatments provided adequate antinociception with minimal cardiovascular adverse effects during mastectomy. The inclusion of morphine (groups RM and RMX) provided the best postoperative analgesia. Owing to the undesirable effect of xylazine on ambulation, the combination ropivacaine-morphine appeared to provide greater benefits in bitches undergoing unilateral mastectomy.

Development of an ultrasound-guided transgluteal injection of the pudendal nerve in cats: a cadaveric study.

OBJECTIVE: To develop an ultrasound-guided interfascial plane technique for injection of the pudendal nerve near its sacral origin in cats. STUDY DESIGN: Prospective, randomized, anatomical study. ANIMALS: A group of 12 feline cadavers. METHODS: Gross and ultrasound anatomy of the ischiorectal fossa, the pudendal nerve relationship with parasacral structures, and the interfascial plane were described. Computed tomography was employed to describe a cranial transgluteal approach to the pudendal nerve. Bilateral ultrasound-guided injections were performed in eight cadavers using low [(LV) 0.1 mL kg-1] or high volume [(HV) 0.2 mL kg-1] of ropivacaine-dye solution. Dissections were performed to determine successful staining of the pudendal nerve (>1 cm) and inadvertent staining of the sciatic nerve, and any rectal, urethral, or intravascular puncture. Pudendal nerve staining in groups LV and HV were compared using Fisher's exact and Wilcoxon rank-sum test as appropriate (p = 0.05). RESULTS: The pudendal nerve and its rectal perineal and sensory branches coursed through the ischiorectal fossa, dorsomedial to the ischiatic spine. The pudendal nerve was not identified ultrasonographically, but the target plane was identified between the sacral transverse process, the ischiatic spine, the pelvic fascia and the rectum, and it was filled with dye solution. Both branches of the pudendal nerve were completely stained 75% and 87.5% in groups LV and HV, respectively (p = 1.00). The dorsal aspect of the sciatic nerve was partially stained in 37% of injections in group HV. Rectal or urethral puncture and intravascular injection were not observed. CONCLUSIONS AND CLINICAL RELEVANCE: In cats, ultrasound-guided cranial transgluteal injection successfully stained the pudendal nerve in at least 75% of attempts, regardless of injectate volume. Group HV had a greater probability of sciatic nerve staining.

The effect of erector spinae plane block on perioperative analgesic consumption and complications in dogs undergoing hemilaminectomy surgery: a retrospective cohort study.

OBJECTIVE: To compare the perioperative use of analgesics and complication rates in dogs administered an erector spinae plane (ESP) block or a traditional opioid-based (OP) treatment as part of analgesic management during hemilaminectomy. STUDY DESIGN: Retrospective cohort study. ANIMALS: Medical records of 114 client-owned dogs. METHODS: General data included demographics, duration of procedure, number of laminae fenestrated, perioperative use of steroid and non-steroidal anti-inflammatory drugs. Intra- and postoperative analgesics used in 48 hours and complications rates were compared between groups. Opioid use was expressed in morphine equivalents [ME (mg kg-1)]. Continuous data were compared using the Mann-Whitney U test and incidence of events with a Fisher's exact tests. Multiple linear regression was used to evaluate association between perioperative ME consumption (dependent variable) with other independent variables. Data are presented as median (range). Differences were considered significant when p < 0.05. RESULTS: Group ESP comprised 42 dogs and group OP 72 dogs. No differences were observed in the general data. Intraoperative ME was 0.65 (0.20-3.74) and 0.79 (0.19-5.60) mg kg-1 in groups ESP and OP, respectively (p = 0.03). Intraoperative infusion of lidocaine was administered intravenously (IV) to 23.8% and 68% of groups ESP and OP, respectively (p < 0.0001). Intraoperative infusion of ketamine was administered IV to 21% and 40% of groups ESP and OP, respectively (p = 0.04). Regression analysis revealed the ESP block as the only independent variable affecting the perioperative ME consumption. Pharmacological intervention to treat cardiovascular complications was administered to 21.4% and 47.2% of dogs in groups ESP and OP, respectively (p = 0.008). There were no differences in postoperative complication rates. CONCLUSIONS AND CLINICAL RELEVANCE: ESP block was associated with reduced perioperative opioid consumption, intraoperative adjuvant analgesic use and incidence of pharmacological interventions to treat cardiovascular complications in dogs undergoing hemilaminectomy.

What is the role of locoregional anesthesia in breast surgery? A systematic literature review focused on pain intensity, opioid consumption, adverse events, and patient satisfaction.

BACKGROUND: Breast surgery in the United States is common. Pain affects up to 50% of women undergoing breast surgery and can interfere with postoperative outcomes. General anesthesia is the conventional, most frequently used anaesthetic technique. Various locoregional anesthetic techniques are also used for breast surgeries. A systematic review of the use of locoregional anesthesia for postoperative pain in breast surgery is needed to clarify its role in pain management. OBJECTIVES: To systematically review literature to establish the efficacy and the safety of locoregional anesthesia used in the treatment of pain after breast surgery. METHODS: Embase, MEDLINE, Google Scholar and Cochrane Central Trials Register were systematically searched in Mars 2020 for studies examining locoregional anesthesia for management of pain in adults after breast surgery. The methodological quality of the studies and their results were appraised using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist and specific measurement properties criteria, respectively. RESULTS: Nineteen studies evaluating locoregional anesthesia were included: 1058 patients underwent lumpectomy/mastectomy, 142 breast augmentation and 79 breast reduction. Locoregional anesthesia provides effective anesthesia and analgesia in the perioperative setting, however no statistically significant difference emerged if compared to other techniques. For mastectomy only, the use of locoregional techniques reduces pain in the first hour after the end of the surgery if compared to other procedures (p = 0.02). Other potentially beneficial effects of locoregional anesthesia include decreased need for opioids, decreased postoperative nausea and vomiting, fewer complications and increased patient satisfaction. All this improves postoperative recovery and shortens hospitalization stay. In none of these cases, locoregional anesthesia was statistically superior to other techniques. CONCLUSION: The results of our review showed no differences between locoregional anesthesia and other techniques in the management of breast surgery. Locoregional techniques are superior in reducing pain in the first hour after mastectomy.

Serratus Plane Block Is Effective for Pain Control in Patients With Blunt Chest Trauma: A Case Series.

BACKGROUND: Rib fractures occur frequently following blunt chest trauma and induce morbidity and mortality. Analgesia is a cornerstone for their management, and regional analgesia is one of the tools available to reach this objective. Epidural and paravertebral blocks are the classical techniques used, but the serratus plane block (SPB) has recently been described as an effective technique for thoracic analgesia. METHODS: This case series reported and analyzed 10 consecutive cases of SPB for blunt chest trauma analgesia in a level 1 trauma center from May to October 2018. SPB was performed with either a single shot of local anesthetic or a catheter infusion. RESULTS: Ten patients were treated with 3 single shots and 7 catheter infusions (median length 3 days [interquartile range (IQR) 2.5 to 3.5]). The Median Injury Severity Score was 16 (IQR 16 to 23), and the number of broken ribs ranged from 3 to 22. Daily equivalent oral morphine consumption was significantly decreased after SPB from 108 mg (IQR 67 to 120) to 19 mg (IQR 0 to 58) (P = 0.015). The Numeric Pain Rating Scale (NPRS) score during cough was significantly decreased from 7.3 (IQR 5.3 to 8.8) to 4 (IQR 3.6 to 4.6) (P = 0.03). The NPRS score at rest remained unchanged. One complication occurred, due to a catheter section. CONCLUSIONS: The SPB technique (with or without catheter insertion) in 10 patients who had blunt chest trauma with rib fractures is effective for cough pain control, with a significant decrease in morphine consumption.

Journal of clinical monitoring and computing 2016 end of year summary: anesthesia.

Clinical monitoring and computing are essential during general anesthesia. As a result it would be impossible to review all the articles published in the Journal of Clinical Monitoring and Computing that are relevant to anesthesia. We therefore will limit this summary to those articles that are uniquely related to anesthesia. The topics include: anesthesia machines; ensuring the airway; anesthetic depth; neuromuscular transmission monitoring; locoregional anesthesia; ultrasound; and pain.

Effects of dexmedetomidine combined with ropivacaine on sciatic and femoral nerve blockade in dogs.

OBJECTIVE: To evaluate motor and sensory blockade of combining dexmedetomidine with ropivacaine, administered perineurally or systemically, for femoral and sciatic nerve blocks in conscious dogs. STUDY DESIGN: Randomized, controlled, experimental study. ANIMALS: Seven healthy Beagle dogs, aged 3.3 ± 0.1 years and weighing 11.0 ± 2.4 kg. METHODS: Dogs were anesthetized with isoflurane on three separate occasions for unilateral femoral and sciatic nerve blocks and were administered the following treatments in random order: perineural ropivacaine 0.75% (0.1 mL kg-1) on each nerve and intramuscular (IM) saline (0.2 mL kg-1) (Gcon); perineural dexmedetomidine (1 µg mL-1) and ropivacaine 0.75% (0.1 mL kg-1) on each nerve and IM saline (0.2 mL kg-1) (GDPN); and perineural ropivacaine 0.75% (0.1 mL kg-1) on each nerve and IM dexmedetomidine (1 µg mL-1, 0.2 mL kg-1) (Gdim). Nerve blocks were guided by ultrasound and electrical stimulation and dogs were allowed to recover from general anesthesia. Sensory blockade was evaluated by response to clamp pressure on the skin innervated by the saphenous/ femoral, common fibular and tibial nerves. Motor blockade was evaluated by observing the ability to walk and proprioception. Sensory and motor blockade were evaluated until their full recovery. RESULTS: No significant differences in onset time to motor and sensory blockade were observed among treatments. Duration of motor blockade was not significantly different among treatments; however, duration of tibial sensory blockade was longer in the Gdpn than in the GDIM treatment. CONCLUSIONS AND CLINICAL RELEVANCE: Although a longer duration of sensory blockade was observed with perineural dexmedetomidine, a significant increase compared with the control group was not established. Other concentrations should be investigated to verify if dexmedetomidine is a useful adjuvant to local anesthetics in peripheral nerve blocks in dogs.

The importance of internal carotid artery occlusion tolerance test in carotid endarterectomy under locoregional anesthesia.

BACKGROUNDS: Carotid endarterectomy is considered a safe and effective method for preventing stroke in the short and long term in patients with severe carotid stenosis. The internal carotid artery (ICA) occlusion tolerance test was performed to evaluate cerebral tolerance during temporary carotid occlusion, defined as the capacity of the cerebral hemisphere to maintain adequate cerebral blood flow during occlusion of the ICA. Thus, the aim of the present study is to determine the importance of this test in patients undergoing carotid endarterectomy. METHODS: From August 2008 to May 2015, 115 consecutive patients (39 female, 77 male) were referred for carotid endarterectomy at the Santa Casa de Belo Horizonte by the main author. RESULTS: Of the 115 patients who participated in the study, 107 were submitted to carotid endarterectomy. Morbi-mortality was 2.7 %. The presence of deficits during the ICA occlusion tolerance test in less than 30 s was associated with the presence of complications. Among the 104 patients who showed no deficits during the test, only one case (0.9 %) presented complications, while among the three cases that showed deficits during the test and who were submitted to carotid endarterectomy, two cases presented complications (p < 0.0001). CONCLUSIONS: The carotid endarterectomy under locoregional anesthesia is a safe surgical procedure. The internal carotid artery occlusion tolerance test can help identify high-risk patients who have been assigned this treatment.

Journal of Clinical Monitoring and Computing 2015 end of year summary: anesthesia.

Clinical monitoring is an essential part of the profession of anesthesiology. It would therefore be impossible to review all articles published in the Journal of Clinical Monitoring and Computing that are relevant to anesthesia. Because other reviews will address monitoring of the respiratory and cardiovascular system, the current review will limit itself to topics uniquely related to anesthesia. The topics are organized according to the chronological order in which an anesthetic proceeds: secure the airway; ventilate and deliver anesthetic gases; monitor vital organ function and anesthetic depth; and ensure analgesia during/after emergence from anesthesia (locoregional anesthesia and pain control).

Ultrasound-guided quadratus lumborum block with 0.5 mL of 0.2% bupivacaine/kg is a valuable perioperative analgesic adjunct for cats undergoing ovariectomy.

OBJECTIVE: To assess the perioperative analgesic effects of bilateral ultrasound (US)-guided quadratus lumborum block (QLB) using low-volume (LV) or high-volume (HV) bupivacaine, compared to a control group, in cats undergoing ovariectomy. ANIMALS: 48 healthy female cats. METHODS: Cats were sedated with IM dexmedetomidine (5 µg/kg), ketamine (1 mg/kg), and methadone (0.2 mg/kg) followed by IV propofol induction and isoflurane maintenance. Cats were randomly assigned to 3 groups of 16 patients each: QLB-LV group (0.3 mL/kg/side), QLB-HV group (0.5 mL/kg/side), and control group (no QLB). Bilateral, in-plane, US-guided QLB was performed with lateral approach at the L2 transverse process with bupivacaine 0.2%. Physiological variables were recorded intraoperatively by a masked investigator. If intraoperative nociception occurred, fentanyl (1 µg/kg) was administered IV. Rescue postoperative analgesia (buprenorphine, 0.2 mg/kg) was administered in case of a Feline Grimace Scale score ≥ 4 after a 4-hour evaluation period. RESULTS: In the control group, heart rate (HR) was higher than the QLB-LV group during the first ovarian manipulation (P < .001) and higher than the QLB-HV group during both ovarian manipulations (P < .001 and P = .006). The need for intraoperative rescue analgesia and postoperative pain scores were significantly higher in the QLB-LV (P = .005 and P = .047) and control (P < .001 and P < .001) groups compared to the QLB-HV group. Buprenorphine was administered once in the control group. No clinical signs of bupivacaine toxicity or QLB complications were observed. CLINICAL RELEVANCE: Bilateral US-guided QLB-HV may effectively provide perioperative analgesia in feline patients undergoing ovariectomy.

A prospective comparison of WALANT technique and general anesthesia in forefoot surgery.

INTRODUCTION: Wide Awake Local Anesthesia No Tourniquet (WALANT) technique has been widely used in hand surgery, but there are few prospective data on its use in forefoot surgery. HYPOTHESIS: The WALANT technique reduces pain compared to general anesthesia for bone surgery on the first ray of forefoot. METHODS: This was a prospective, longitudinal, comparative, non-randomized cohort study in adult patients undergoing bone surgery on the first ray of forefoot. The primary objective was the level of pain (0-10 visual analogic scale) 4 h after the procedure with WALANT technique versus general anesthesia supplemented by ropivacaine infiltration. RESULTS: A total 37 patients were analyzed in the WALANT group and 24 in the general anesthesia group (women, 90.2%; mean age, 51.3 years; hallux valgus, 85.2%; first metatarsal osteotomy, 80.3%). After generalized linear regression adjusted on a priori defined factors, there was no statistically difference for pain ≤3 at 4 h in WALANT vs. general anesthesia (odds-ratio 1.66; 95% CI, 0.17-20.49; p = 0.2548). At 24 h, pain level was also comparable in the two groups. Time spent in operating room was significantly shorter with WALANT (40.8 vs. 49.7 min; p = 0.0001). Mean length of stay in the recovery room was also significantly shorter with WALANT (4.4 vs. 75.6 min; p < 0.0001). Anxiety before/after surgery, uptake of analgesic/anti-inflammatory drugs and quality of life were comparable in the two anesthesia groups. CONCLUSION: Postoperative pain with WALANT technique or general anesthesia was comparable. Time spent in the operating room and in recovery room was significantly shorter with WALANT technique. LEVEL OF EVIDENCE: III; prospective non-randomized comparative study.

Description and Outcomes of an Ultrasound-Guided Technique for Catheter Placement in the Canine Quadratus Lumborum Plane: A Cadaveric Tomographic Study and Clinical Case Series.

This study aimed to describe an ultrasound-guided technique for implanting catheters for local anesthetic administration into the quadratus lumborum (QL) inter-fascial plane in canine cadavers and assessing the spread along the vertebral bodies (VBs) by computed tomography (CT). Phase 1: eight canine cadavers received one catheter per hemiabdomen, followed by injection of contrast media solution [low volume (LV) 0.3 mL kg-1 or high volume (HV) 0.6 mL kg-1]. Phase 2: postoperative pain of five dogs was managed by injecting 0.3 mL kg-1 of ropivacaine 0.5% through QL catheters every eight hours, up to 72 h after abdominal surgery. Pain was assessed using the Short Form of the Glasgow Composite Measure Pain Scale, and methadone 0.2 mg kg-1 was administered intravenously when the pain score was ≥6. The number of VBs stained by the contrast solution between the QL and psoas minor muscles was significantly higher in group HV than group LV. The catheter tip was visualized in the retroperitoneal space in 1/16 and 2/10 hemiabdomens in phases 1 and 2, respectively. Rescue analgesia was required in 3/5 dogs during the postoperative period. The QL catheter placement technique appears feasible and may be included in a multimodal analgesic approach for dogs undergoing abdominal surgeries.

Fascial plane blocks for cardiothoracic surgery: a narrative review.

In recent years, there has been a growing awareness of the limitations and risks associated with the overreliance on opioids in various surgical procedures, including cardiothoracic surgery.This shift on pain management toward reducing reliance on opioids, together with need to improve patient outcomes, alleviate suffering, gain early mobilization after surgery, reduce hospital stay, and improve patient satisfaction and functional recovery, has led to the development and widespread implementation of enhanced recovery after surgery (ERAS) protocols.In this context, fascial plane blocks are emerging as part of a multimodal analgesic in cardiac surgery and as alternatives to conventional neuraxial blocks for thoracic surgery, and there is a growing body of evidence suggesting their effectiveness and safety in providing pain relief for these procedures. In this review, we discuss the most common fascial plane block techniques used in the field of cardiothoracic surgery, offering a comprehensive overview of regional anesthesia techniques and presenting the latest evidence on the use of chest wall plane blocks specifically in this surgical setting.

[Local versus locoregional anesthesia in transfemoral TAVI procedures]. / Anesthésie locale comparée à l'anesthésie locorégionale dans les procédures TAVI par voie transfémorale.

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) has become the treatment of choice for the most fragile patients with severe aortic stenosis. The transfemoral route is preferred as the simplest and safest. The aim of our study was to compare the efficacy, tolerance and safety of local vs. locoregional anesthesia in trans-femoral TAVI procedures. MATERIAL AND METHOD: This was a single-center retrospective study. Patients treated with femoral TAVI between February 25 and November 15, 2022 at the University Hospital of Reims were included, and two groups (local and locoregional anesthesia) were compared. RESULTS: TAVI success rate (92.9%), death rate (3.0%) and procedure duration (90.5 ± 13.5 minutes) did not differ between groups (p = 0.18, 0.15 and 0.55 respectively). For intra- and post-procedural treatments, the use of sedation, analgesics and benzodiazepines did not differ between groups. The cumulative dose of Remifentanil used per-procedure was lower in the local anesthesia group than in the locoregional anesthesia group (148.6 ± 71.9 mcg vs. 208.9 ± 110.0 mcg; p = 0.025). CONCLUSIONS: In this non-randomized retrospective study, local and locoregional anesthesia had comparable safety and efficacy in transfemoral TAVI procedures. In a constrained context and with a view to simplification, these results encourage transfemoral TAVIs to be performed under local anaesthesia, and to consider a "PCI-like" approach, without the presence of an anaesthetist, for selected patients without respiratory, musculoskeletal or agitation disorders, or vascular approach difficulties.

Locoregional Anaesthesia for Laparotomy: A Literature Review and Subsequent Case Series Highlighting the Potential of an Alternative Anaesthetic Technique.

Laparotomy is a surgical incision utilised in both emergency and elective scenarios to gain access to abdominal surgery. General anaesthesia is usually necessitated due to the substantial insult of the approach and to facilitate organ relaxation and paralysis. However, this brings with it the need for an assessment of the suitability of the anaesthetic technique, with a large number of patients having comorbidities significant enough to exclude them from surgery. Locoregional anaesthesia, provided via spinal, epidural, or a combined approach offers a means of providing anaesthesia that places a reduced level of strain on patients' cardiorespiratory function. We review the existing literature on the topic of so-called "awake laparotomy" performed with locoregional anaesthesia and present a case series including both elective and emergency procedures.

Clinical efficacy of an ultrasound-guided bilateral rectus sheath block for umbilical hernia repair in calves: A prospective randomized trial.

Introduction: Surgical umbilical hernia repair is a frequent procedure in newborn calves, requiring mandatory pain management. This study aimed to develop an ultrasound-guided rectus sheath block (RSB) and to evaluate its clinical efficacy in calves undergoing umbilical herniorrhaphy under general field anesthesia. Methods: Gross and ultrasound anatomy of the ventral abdomen and the diffusion of a new methylene blue solution after injection within the rectus sheath were described in seven fresh calf cadavers. Then, fourteen calves undergoing elective herniorrhaphy were randomly assigned to receive either bilateral ultrasound-guided RSB with 0.3 mL/kg of bupivacaine 0.25% and 0.15 µg/kg of dexmedetomidine or 0.3 mL/kg of 0.9% NaCl (control). Intraoperative data included cardiopulmonary variables and anesthetic requirements. Postoperative data included pain scores, sedation scores and peri-incisional mechanical threshold assessed by force algometry at specific time points after anesthetic recovery. Treatments were compared using Wilcoxon rank-sum, Student's t-test, and Cox proportional hazard model as appropriate. Mixed effect linear models on rank, with random effect calf; fixed effects time, treatment, and their interaction were used to compare pain scores and mechanical thresholds over time. Significance was set at p = 0.05. Results and Discussion: Calves receiving RSB recorded lower pain scores between 45 - 120 minutes (p < 0.05) and at 240 min after recovery (p = 0.02). And they recorded higher mechanical thresholds between 45 and 120 min after surgery (p < 0.05). Ultrasound-guided RSB provided effective perioperative analgesia in calves undergoing herniorrhaphy under field conditions.