Is Right Unilateral Transversus Abdominis Plane (TAP) Block Successful in Postoperative Analgesia in Laparoscopic Cholecystectomy?

Background: Transversus abdominis plane (TAP) block is used for postoperative analgesia in laparoscopic cholecystectomy. In laparoscopic cholecystectomy, the incisions are located mainly on the upper right side of the abdomen. Aims: We aim to determine the efficacy of less-invasive ultrasound-guided right unilateral oblique subcostal TAP block in laparoscopic cholecystectomy on postoperative analgesia by comparing patients undergoing bilateral TAP block and a control group. Methods: Ninety patients were equally divided into control, unilateral, and bilateral TAP block groups. TAP blocks were conducted before anesthesia. No block was applied to the control group. Patients' demographics and postoperative pain, satisfaction, and nausea-vomiting scores and tramadol/ondansetron doses were evaluated. Results: There was no significant difference in the verbal numerical rating scale for pain scores at rest and during coughing (VNRS-R and VNRS-C) between unilateral and bilateral TAP block groups at postoperative 1 hour, 2 hour, 4 hour, 8 hour, 12 hour, and 24 hours. In addition, VNRS-R and VNRS-C scores were significantly higher in the control group than in the other two groups. Tramadol consumption in the control group was significantly higher than in the unilateral and bilateral TAP block groups (p ≤ 0.01), while no significant difference was identified between unilateral and bilateral TAP block groups (p=0.303). Nausea-vomiting scores and ondansetron consumption did not differ significantly between all the groups. Patient satisfaction was significantly higher in unilateral and bilateral groups (p < 0.01, p < 0.01) than in the control group, while there was no significant difference between unilateral and bilateral TAP block groups (p=0.793). Conclusions: Right unilateral TAP block provides postoperative analgesia as effective as bilateral TAP block in laparoscopic cholecystectomy.

Popliteal block for lower limb surgery in children with cerebral palsy: effect on sevoflurane consumption and postoperative pain (a randomized, double-blinded, controlled trial).

PURPOSE: The aim of this study was to evaluate the effects of a preoperative popliteal block on sevoflurane consumption, postoperative pain, and analgesic consumption in children with cerebral palsy (CP) following lower limb surgery. METHODS: Fifty-four patients undergoing lower limb surgery were randomized to receive either a popliteal block + general anaesthesia (group P, n = 27) or general anaesthesia without a popliteal block (group C, n = 27). After anesthesia induction with 50% N2O, O2, and 8% sevoflurane, a popliteal block was given to group P patients with ultrasound guidance as a single dose of 0.3 ml/kg body weight of 0.25% bupivacaine. Group C patients received the same regimen of anesthesia induction but no preoperative popliteal block. Both the conductance fluctuation (SCF) peak numbers per second and the Wong-Baker FACES® Pain Rating Scale (WBFS) values of the patients were recorded upon arrival at the PACU, at 10 and 20 min after arrival at the PACU, and at postoperative hours 1, 4, 8, 12, and 24 when they were in the ward. The total paracetamol consumption of the patients was also recorded. RESULTS: The end-tidal sevoflurane concentration values were significantly higher in group C patients than in group P patients, except for at 5 min after induction of anaesthesia (p < 0.001). The SCF peak numbers per second and WBFS scores were significantly higher in group C patients than in group P patients, except at Tp24h (p < 0.001). The total paracetamol consumption was 489.7 ± 122.7 mg in group P patients and 816.6 ± 166.5 in group C patients (p < 0.001). CONCLUSION: Popliteal block is effective for postoperative analgesia, decreasing the paracetamol consumption and sevoflurane requirement in children with CP undergoing lower limb surgery. Trial registration ClinicalTrial.gov identifier: NCT02507700.

Tizanidine for the management of acute postoperative pain after inguinal hernia repair: A placebo-controlled double-blind trial.

BACKGROUND: α2-Agonists are used postoperatively as a component of multimodal analgesia. Tizanidine is a centrally acting α2-agonist with muscle relaxant properties. OBJECTIVE: The aim of this study was to compare the efficacy of tizanidine with placebo in terms of postoperative pain scores, analgesic consumption, return to daily activity and health-related quality of life. DESIGN: A randomised double-blind study. SETTING: Diskapi Yildirim Beyazit Training and Research Hospital. INTERVENTIONS: After obtaining ethical approval and informed patient consent, 60 patients undergoing inguinal hernia repair under general anaesthesia were randomly allocated into one of the two groups. The patients in Group T received tizanidine 4 mg orally 1 h before surgery and twice daily during the first postoperative week. The patients in Group P received the same treatment with a placebo pill. Both the groups received a standard analgesic treatment regimen comprising intravenous dexketoprofen 25 mg prior to induction of anaesthesia, dexketoprofen 25 mg orally three times daily for 1 week and intravenous paracetamol 1 g at the end of surgery. Supplemental analgesia was provided with paracetamol if the visual numerical rating scale (NRS) was at least 4 cm. MAIN OUTCOME MEASURES: Postoperative pain was assessed using the NRS. Total analgesic consumption was determined. Return to normal daily activity was evaluated using a five-point daily activity score after the first postoperative week, and health-related quality of life was evaluated using the short form-36 one month after surgery. RESULTS: The patients in Group T had significantly lower NRS pain scores than those in Group P 6, 12 and 24 h postoperatively both at rest and during movement (P < 0.001), and on postoperative days 1, 2, 3 and 4. The analgesic consumption was also lower in patients who received tizanidine. Ten patients (33%) in Group T and 23 patients (77%) in Group P consumed supplemental paracetamol (P < 0.001) after discharge. The daily activity score was lower in Group T than in Group P (P < 0.001), and the short form-36 scores were significantly different in the pain dimension [74 (74 to 100) in Group T and 74 (31 to 80) in Group P, (P < 0.001)] and in the physical component summary score. CONCLUSION: The addition of tizanidine to the postoperative pain therapy after herniorrhaphy decreased postoperative pain and analgesic consumption and improved return to normal activity and quality of life. TRIAL REGISTRATION: ClinicalTrials.gov NCT02016443 (10 October 2013, Principal investigator D. Yazicioglu).

Spinal anaesthesia with hyperbaric prilocaine in day-case perianal surgery: randomised controlled trial.

BACKGROUND: The local anaesthetics used in day-case spinal anaesthesia should provide short recovery times. We aimed to compare hyperbaric prilocaine and bupivacaine in terms of sensory block resolution and time to home readiness in day-case spinal anaesthesia. MeTHODS: Fifty patients undergoing perianal surgery were randomized into two groups. The bupivacaine-fentanyl group (Group B) received 7.5 mg, 0.5% hyperbaric bupivacaine + 20 µg fentanyl in total 1.9 mL. The prilocaine-fentanyl group (Group P) received 30 mg, 0.5% hyperbaric prilocaine + 20 µg fentanyl in the same volume. RESULTS: Time to L1 block and maximum block was shorter in Group P than in Group B (Group P 4.6 ± 1.3 min versus Group B 5.9 ± 01.9 min, P = 0.017, and Group P 13.2 ± 7.5 min versus Group B 15.3 ± 6.6 min, P = 0.04). The time to L1 regression and S3 regression of the sensorial block was significantly shorter in Group P than in Group B (45.7 ± 21.9 min versus 59.7 ± 20.9 min, P = 0.024, and 133.8 ± 41.4 min versus 200.4 ± 64.8 min, P < 0.001). The mean time to home readiness was shorter for Group P than for Group B (155 ± 100.2 min versus 207.2 ± 62.7 min (P < 0.001)). CONCLUSION: Day-case spinal anaesthesia with hyperbaric prilocaine + fentanyl is superior to hyperbaric bupivacaine in terms of earlier sensory block resolution and home readiness and the surgical conditions are comparable for perianal surgery.

Volatile anesthetic preconditioning attenuated sepsis induced lung inflammation.

BACKGROUND: This study aimed to evaluate the differential protective effects of isoflurane or sevoflurane on lung inflammation in a rat model of cecal ligation and puncture (CLP) induced sepsis. METHODS: Seventy-two rats were assigned to control, sevoflurane, or isoflurane groups. At 2 and 4 h, tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), interleukin-1ß (IL-1ß), nitrate/nitrate levels (NO), total antioxidant capacity (TAC), and intercellular cell adhesion molecule-1 (ICAM-1) were determined. At 12 and 24 h, malondialdehyde (MDA), myeloperoxidase (MPO), and histologic changes were evaluated. Survival was monitored for 7 d after CLP. RESULTS: Sevoflurane (75%) and isoflurane (63%) significantly improved survival rate compared with control rats (38%). When sevoflurane and isoflurane groups were compared, sevoflurane pretreatment showed significant decrease in NO at 2 h [1045 (803-1274)/1570 (1174-2239) and 4 h [817 (499-1171)/1493 (794-2080)]; increase in TAC at 4 h [580.0 (387-751)/320 (239-512)]; decrease in MDA at 12 h [2.5 (1.1-4.2)/5.4 (4-73)] and 24 h [10.8 (6.0-14.0)/15.9 (9-28)]; and decrease in MPO at 24 h [145.8 (81-260)/232 (148-346)]. The difference in the ICAM-1 expression of the isoflurane and sevoflurane groups was not significant at both measurement times. The architectural integrity of the alveoli was preserved in all the groups. The injury scores of the three groups at 12 and 24 h did not show any significant difference. CONCLUSIONS: Both sevoflurane and isoflurane attenuated inflammatory response, lipid peroxidation, and oxidative stress. Furthermore, sevoflurane was more effective in modulating sepsis induced inflammatory response at the chosen concentration in sepsis model.

The end-tidal desflurane concentration for smooth removal of the laryngeal mask airway in anaesthetised adults.

BACKGROUND AND OBJECTIVE: The end-tidal desflurane concentration required for smooth removal of the laryngeal mask airway (LMA) has not been established. Therefore, we aimed to find the end-tidal desflurane concentration for safe, smooth, and uncomplicated LMA removal. METHODS: The study was approved by the Ethical Committee of the Ministry of Health, Diskapi Yildirim Beyazit Research and the Training Hospital, Ankara, Turkey. All patients provided written consent. A total of 23 adults, 18-60 years of age and American Society of Anesthesiologists physical status class I, who had been scheduled for urological surgery were included in the study. The intravenous induction of anaesthesia was performed with propofol 2.5 mg kg⁻¹ and remifentanil 10 µg within 30 s. The LMA was inserted. Maintenance of anaesthesia was provided by desflurane, with nitrous oxide and oxygen. The LMA was removed at predetermined end-tidal desflurane concentrations at the end of surgery. The concentration at which LMA removal was attempted was determined by Dixon's up-down method with 0.5% as the step size. When LMA removal was accomplished without coughing, teeth clenching, gross purposeful movements, breath holding, laryngospasm, and desaturation to SpO(2) less than 90%, it was considered a smooth (successful) removal. RESULTS: For smooth removal of the LMA, end-tidal desflurane EC50 was 2.1% [95% confidence interval (CI) 1.1-2.9%], and the EC95 value was 3.9% (95% CI 3.1-7.9%). CONCLUSION: The EC95 of end-tidal desflurane for the smooth removal of the LMA is 3.9%. LMA removal in adults receiving desflurane may be possible at approximately 0.7 minimum alveolar concentration.

Lidocaine pretreatment reduces the frequency and severity of myoclonus induced by etomidate.

The objective of this study was to assess the effects of lidocaine on the incidence and severity of myoclonic movements induced by etomidate. Sixty patients were randomly assigned to receive either 20 mg lidocaine or saline (n = 30, each), 30 s before administration of etomidate (0.3 mg/kg). One minute after etomidate administration we assessed severity of myoclonus. Pretreatment with lidocaine significantly reduced both the incidence and severity of myoclonic movements. As a conclusion, lidocaine is an effective and safe drug to reduce the etomidate-induced myoclonus without significant side effects.

Effects of suprascapular and axillary nerve block on postoperative pain relief sevoflurane consumption and visual clarity in arthroscopic shoulder surgery.

OBJECTIVES: This study aims to investigate the effects of suprascapular nerve and axillary nerve block on postoperative pain, tramadol consumption, sevoflurane consumption and visual clarity of the surgical field in arthroscopic shoulder surgery. METHODS: Forty-six patients undergoing arthroscopic shoulder surgery were randomized to receive either both suprascapular and axillary nerve block with ultrasound guidance (20 ml 0.25% bupivacaine) before general anesthesia (group SSAXB, n=23) or a subacromial local infiltration (20 ml 0.25% bupivacaine) after the procedure (group control, n=23). End-tidal sevoflurane consumption, visualization of the arthroscopic field scores of the patients were recorded during the procedure. The patient's postoperative pain scores (at PACU, 4, 8, 12, 24 hours after the surgery) and tramadol consumption were also recorded. RESULTS: End-tidal sevoflurane concentration values were similar in both groups (p>0.05). Group SSAXB had a better mean static pain score in the PACU (Group SSAXB 4.27±1.48 vs Group C 6.24±1.09 p<0.05). Tramadol consumption was lower in group SSAXB than in group C (253.1±85.3 mg vs 324.2±72 mg, p=0.005). Visual clarity scores of the arthroscopic field were higher in group SSAXB than in group C along the intraoperative period (p<0.05). CONCLUSION: SSAXB are effective in postoperative analgesia, reduce tramadol consumption and provide a clean image in the arthroscopic area of arthroscopic shoulder surgery, but these blocks do not reduce sevoflurane consumption.

Ultrasound-guided obturator nerve block: a sonoanatomic study of a new methodologic approach.

BACKGROUND: Obturator nerve block is one of the most technically challenging regional anesthesia techniques. Recently, the characteristics of the nerve have been described using ultrasound. However, clinical application of proximal ultrasound-guided obturator nerve block on patients has not been reported. In this study, we used ultrasound to describe the anatomical localization of the obturator nerve and its two branches in cadavers, volunteers, and also patients. METHODS: A hyperechoic triangular shape formed by the superior pubic ramus, posterior margin of the pectineus muscle and anterior aspect of the external obturator muscle containing the obturator vessels and nerve was defined by ultrasound imaging in cadavers. In eight volunteers, bilateral obturator nerve images were obtained and the distances to specific landmarks (femoral artery, femoral vein, and pubic tubercle) were recorded. Ultrasound-guided obturator nerve block was further performed in 15 patients by using the previously defined approach. The final distance of the needle tip to the femoral artery, distances between the needle insertion point to the pubic tubercle and the depth of needle insertion were recorded. RESULTS: The rates of common obturator nerve, anterior and branching obturator nerve pattern visibility with ultrasound were determined in 12/16, 13/16, and 7/16 sites in volunteers, respectively. Mean (SD) values of critical landmarks obtained from volunteers were obturator nerve-femoral vein 12.9 +/- 2.9 mm and obturator nerve-pubic tubercle 19.9 +/- 2.6 mm. Mean measurements obtained from patients were: femoral artery- needle tip 18.5 +/- 2.4 mm, needle depth 48.3 +/- 10.4 mm, pubic tubercle- needle insertion point (horizontal) 18.8 +/- 2.0 mm, and pubic tubercle- needle insertion point (vertical) 21.1 +/- 2.9 mm. Visual analog scale scores obtained from patients at 1 and 24 h were lower compared to baseline values (P < 0.001). Ninety-three percent (14 of 15) of the patients reported satisfaction from the block. CONCLUSIONS: Landmarks defined in this clinical trial can be used in patients for obturator nerve block with ultrasound guidance.

Comparison of intravenous and peritonsillar infiltration of tramadol for postoperative pain relief in children following adenotonsillectomy.

BACKGROUND AND OBJECTIVE: The aim of this study was to compare the postoperative analgesic efficacy and side-effects of intravenous tramadol with peritonsillar infiltration of tramadol in children undergoing adenotonsillectomy. METHODS: Sixty-six children were randomized into two groups: group I received 2 mg kg(-1) tramadol intravenously and group II received 2 mg kg(-1) tramadol in 2 ml of normal saline (1 ml per tonsil) via peritonsillar infiltration. Modified Hannallah pain scale, nausea, vomiting, bleeding, rescue analgesia, sedation and Aldrete scores were recorded at the 1st, 15th, 30th and 60th minute postoperatively. The Aldrete score was used to determine the postanaesthesia care unit discharge criteria. Patients were evaluated for the analgesic requirement, nausea and vomiting, bleeding and sedation. RESULTS: There were no differences between groups during the first 1 h. In the postanaesthesia care unit, groups I and II had comparable pain scores that were not statistically significant (P > 0.05). But during the first 24 h the additional analgesic requirement of group I (141.81 mg) was more than group II (83.63 mg) (P = 0.002). Pain scores in the postoperative ward at 6, 12 and 24 h were significantly higher in group I than in group II (P < 0.001). Also four patients (12.12%) from group I and one patient (3.05%) from group II had nausea and vomiting in the postanaesthesia care unit and none of the patients had rescue analgesics. There were no differences between groups regarding nausea and vomiting, sedation and bleeding in the postoperative ward. CONCLUSION: In adenotonsillectomy cases, peritonsillar infiltration of tramadol maintains efficient pain relief with lower incidence of nausea and vomiting.

Ultrasonographic evaluation and morphometric measurements of the suprascapular notch.

BACKGROUND: The aim of this study was to define the sonographic evaluation and morphometric measurements of the suprascapular notch. METHODS: The suprascapular notch was evaluated by ultrasound on both sides in 50 volunteers (25 males, 25 females). By means of ultrasound, the notch width, the notch depth and the distance between the skin and the notch base (skin-notch base interval) were measured and imaging of the superior transverse scapular ligament was attempted. Furthermore, imaging of the suprascapular artery and vein was performed by Doppler ultrasound. RESULTS: On the measurements performed, the notch was found to be deeper in men than in women on both the right (P = 0.022) and the left (P = 0.011) sides. Taking all volunteers into account without grouping sex, no differences were detected between the two sides with respect to the measurements of the notch width, notch depth and distance between the skin and the notch base. The superior transverse scapular ligament was demonstrated in 48 (96%) of 50 volunteers. On color Doppler ultrasound, the artery-vein complex was visualized in a total of 43 (86%) volunteers. CONCLUSIONS: Suprascapular notch measurements and the visualization of the anatomical neighborhood, which may be beneficial for the suprascapular nerve blockade procedure, can be successfully performed by the use of high-frequency ultrasound imaging.

Chronic post-surgical pain.

Chronic postsurgical pain (CPSP) has lately become a neglected phenomenon. However, in recent years, investigations of the possible risk factors (type of surgery, preoperative pain, acute postoperative pain, and psychological and genetic factors) have also gained as much importance as the clinical problem. CPSP is not only observed following major surgery, but also following minor surgical procedures, such as hernia and vasectomy. Definitive data regarding the incidence of CPSP have not been obtained yet, since it is difficult to develop standard methods to resolve this difficult and complicated clinical picture. Many different medications, such as gabapentin, ketamine, venlafaxine, lidocaine, tramadol, and steroids have been tested in addition to multimodal analgesic techniques for the management of CPSP. Hence, preventive analgesia is a broader application of preemptive analgesia that includes any preoperative analgesic regimen able to control the sensitivity induced by pain.

[The effects of lumbar plexus block and epidural block on total blood loss and postoperative analgesia in total hip arthroplasty]. / Total kalça protez operasyonlarinda lomber pleksus blogu ve epidural blogun total kan kaybi ile postoperatif analjeziye etkileri.

OBJECTIVES: In this study, the effects of lumbar plexus block and epidural block on total blood loss and postoperative analgesia in patients undergoing total hip arthroplasty (THA) under general anesthesia was documented. METHODS: The study included 45 patients undergoing THA under general anesthesia. Group GA (n=15) received general anesthesia, Group GA+E (n=15) received general anesthesia + epidural catheter and Group GA+LPB (n=15) received general anesthesia + lumbar plexus catheterization. Intraoperative blood transfusion (IOBT) requirements and intraoperative bleeding (IOB) were documented. Postoperative hemoglobin, hematocrit and total blood loss through the drains were also documented. All patients received patient-controlled analgesia through the IV route. Time to first analgesic requirement (TFAR), total IV morphine consumption (MORPH 24) and 24-hour visual analogue scale (VAS) values were evaluated. RESULTS: TFAR was the lowest (8.7+/-4.0 min.) in the GA group and highest (42.7+/-14.4 min) in the GA+LPB group, and the GA+E group had lower values than the GA+LPB (32.3+/-16.0 min) group (p<0.05). IOBT, IOB, and MORPH 24 average values were the lowest in the GA+LPB group and highest in the GA group, with GA+E in between (p<0.05). Postoperative first VAS values were significantly different between the GA group and the others (p<0.001). There was also a significant difference between the GA group and the others regarding postoperative average Hb values (p<0.02). CONCLUSION: THA using either regional technique provides less blood loss and better analgesia. We will consider LPB in our future cases in view of the lower intraoperative blood loss and better analgesia.

Caudal Epidural Steroid Injections in Postlaminectomy Patients: Comparison of Ultrasonography and Fluoroscopy.

AIM: To compare the results of ultrasound and fluoroscopy guided caudal epidural steroid injections in postlaminectomy patients. MATERIAL AND METHODS: Thirty postlaminectomy patients were randomly divided into two groups, Group I (n=15) received ultrasound-guided and Group II (n=15) received fluoroscopy-guided caudal epidural local anesthetic and steroid injection. Time of block for each patient was recorded. The patients" visual analogue scale (VAS), Oswestry Disability Index (ODI), and satisfaction with the therapy during the 3-month follow-up were evaluated. RESULTS: The caudal block performed with both methods resulted in similar improvement in low back pain and functions. Time of block was shorter in Group I than in Group II (6.06 ±0.88 minutes versus 11.2±1.14 minutes). CONCLUSION: Caudal epidural steroid injection is an effective analgesic method for postlaminectomy patients. Ultrasound-guided caudal block can be as effective as fluoroscopy-guided block and even more comfortable.

Ultrasound guided chronic pain interventions (Part I).

Recently, ultrasonography (US) is an indispensible imaging technique in regional anesthesia practice. With the guidance of US, various invasive interventions in chronic pain pathologies of the musculoskeletal system, peripheral and neuroaxial pathologies has become possible. The management includes diagnostic blocks as weel as radiofrequency ablation and institution of neurolythic agents. During these algologic interventions we are able to see the target tissue, the dispersion of the drug and all nearby vascular structures. Besides these the US also protects the team from ionic radiation that one encounters when using flouroscopy or computed tomography. Latest publications in this field show that applicability of US in chronic pain syndromes is rapidly expanding with a good future. The additional equipment (echogenic needles, 3-D US etc.) will also expand its applications in algology practice. This review highlights different applications of US in chronic pain conditions.

Ultrasound guided chronic pain interventions (Part II).

Henceforth, ultrasonography (US) is an indispensible imaging technique in regional anesthesia practice. With the guidance of US, various invasive interventions in chronic pain pathologies of the musculoskeletal system, peripheral and neuroaxial pathologies has become possible. The management includes diagnostic blocks as weel as radiofrequency ablation and institution of neurolythic agents. During these algologic interventions we are able to see the target tissue, the dispersion of the drug and all nearby vascular structures. Besides these the US also protects the team from ionic radiation that one encounters when using flouroscopy of computed tomography. Latest publication in this field show that applicability of US in chronic pain syndromes is rapidly expanding with a good future. The additional equipment (echogenic needles, 3-D US etc.) will also expands its applications in algology practice. This review highlights different applications of US in chronic pain conditions.