It is a widely used anesthetic drug for induction and short-term anesthesia, one of the side effects of this drug is pain during injection. This pain is caused by the connection of the phenol ring to the nerve endings in the endothelium of the veins, which causes discomfort for patients. This issue has led to the selection of different materials and methods to reduce pain during propofol injection. The aim of this study was to evaluate the effect of adding fentanyl to Valsalva maneuver in reducing pain caused by propofol injection.

Our study was a three-way randomized blind clinical trial in which 120 patients who were candidates for propofol anesthesia were divided into two groups. Patients in the first group were injected with 100 g of fentanyl and patients in the second group were injected with normal saline. Two minutes later, propofol was injected in a dose of 0.2 mg / kg for both groups. The amount of pain during their injection is measured using the VAS criterion. The collected data were analyzed using SPSS software version 23 and one-way analysis of variance, repeated measures analysis of variance, Kruskal-Wallis independent t-test, Friedman and Wilcoxon.

HR, MAP, systolic and diastolic Blood Pressure were higher in group that receive normal saline and close valve Valsalva than fentanyl and open valve Valsalva manometer(p-value> 0.001).

All variables were higher in the tome of injection.Fentanyl is more effective in reducing pain caused by propofol injection compared to Valsalva maneuver. However, Valsalva maneuver is not ineffective.

Peripheral blocks are commonly used in upper extremity surgery, and their success is usually evaluated by subjective methods, which may not be reliable in uncooperative and sedated patients. The aim of this study was to investigate the effectiveness of new objective methods for evaluating the success of infraclavicular block, including ultrasonographic evaluation of brachial vein diameter (BVD), perfusion index (PI), and tissue oxygen saturation (StO2).

Fifty-five ASA 1-2 patients undergoing upper extremity surgery were included in the study. Before the block, BVD, PI, and StO2 were measured, and body temperature was recorded. After the block, these values were monitored for the first 30 minutes, and pain sensation, autonomic and motor block were evaluated.

BVD and PI evaluation at the 5th minute after the block were found to be effective in evaluating the success of the block. Body temperature increased from the 15th minute, and StO2 was significantly high at the 30th minute. When compared with other tests, BVD measurement was found to be more effective in evaluating the success of the block (Table 1).

The results suggest that BVD and PI evaluation can provide objective and reliable information on the success of infraclavicular block in a short time. These methods may improve the accuracy of block success evaluation and help clinicians make more informed decisions.

Differential Target Multiplexed™ spinal cord stimulation (DTM™ SCS) is an established therapy that has shown superior back pain relief to traditional SCS [1]. Derivatives of DTM™ are being investigated to understand opportunities for therapy personalization. This prospective, multi-center, open-label, post-market study evaluated the efficacy and energy use of reduced-energy DTMTM derivative (DTM™ endurance).

SCS candidates with an overall Visual Analog Score (VAS) of ≥6 with moderate to severe chronic, intractable back and/or leg pain were eligible. Eligible subjects underwent an SCS trial programmed with DTM™ endurance and proceeded in study if successful. Evaluation visits occurred at 1-, 3-, 6-, and 12-months post-activation. Programming data was used to calculate battery energy usage (Intellis™, Medtronic). 2 tailored specific and validated models utilizing real patient programming data were used for determining recharge interval and device longevity.

57 subjects enrolled at 12 US sites from November 2020 - June 2021 (demographics in Table 1). Post-laminectomy pain/PSPS was the main etiology (91.2%). 49 subjects underwent trial, 35 were implanted, and 27 completed the 12-Month visit. Changes in overall, back, and leg pain were clinically sustained through 12-months (Figure 1). Outcomes including quality of life, disability, and safety will be presented. Therapy energy usage was consistent throughout the duration of the study, with a mean current usage of 55 µC/s at 12-months. Amplitude ranges, cycling parameters, recharge interval and duration, and longevity will be reported.

The use of a DTM™ endurance in this study resulted in clinically meaningful pain relief with reduced energy usage.

Recent reviews have reported a higher incidence for pregnant patients to be intensive care unit admission and mechanical ventilation that experiencing severe COVID 19. This study aims to evaluate the impact of COVID-19 infection on obstetric anesthesia.

The study population consisted of patients who underwent cesarean section procedures covered by the Korean National Health Insurance System (KNHI) between January 1, 2020, and December 31, 2021. The KNHI provides coverage to approximately 97% of Koreans, while the remaining 3% who cannot afford national insurance are covered by the Medical Aid Program. The database used in this study was provided by the National Health Insurance Sharing Service, which includes virtually all operations performed in Korea during the study period. The study protocol was reviewed by the Institutional Review Board of Seoul Paik Hospital (IRB No PAIK 2023-05-001) and was exempted due to the use of de-identified administrative data. The major inclusion criterion was admission with operation codes specific to cesarean section procedures (R4514, R4516, R4517, R4518, R4519, R4520, R4507, R4508, R4509, R4510, R5001, R5002). The study assessed mortality and pulmonary complications.

75,703 patients were had cesarean section, among them 383 patients (0.51%) with diagnosis code (U071) within 30 days before surgery or within 30 days after surgery. During the period, mortality were 0.05%. Overall and 30 days’ pulmonary complications were 1.06% and 0.15%. Mortality were increased in general anesthesia than regional anesthesia.

The findings support the consideration of regional anesthesia as a preferred choice in cesarean section during the COVID-19 pandemic.

Total hip arthroplasty (THA) is associated with severe postoperative pain, traditionally managed using systemic analgesia alone.The Pericapsular Nerve Group Block (PENG Block) provides an effective blockade to the articular branches of the anterior hip joint.It may allow early rehabilitation, with a potential motor-sparing effect. The aim of the study: Evaluate the efficacy of the PENG block for intra and postoperative pain control in THA.

In a controlled-blinded study, patients more than 18 years old scheduled for primary THA under general anesthesia were randomized in two groups: PENG Block group (PG) with 2 mg.kg-1Ropivacaine in 40 ml of saline. Placebo group (SG) who received only saline. Postoperative analgesia with: paracetamol 1g/6H,piroxicam 20 mg and Morphine PCA. The main endpoint was total morphine consumption for 24 hours. Secondary endpoints were: Fentanyl consumption, Pain scores (NRS) at rest and on movement and sitting position.

Sixty patients were included. The two groups were comparables. Fentanyl dose was equal in both groups: 345±106 µg in SG vs. 357±65 µg in PG. Morphine consumption was similar in both groups:8.5±5.8mg in SG vs. 9.6 ± 8.2 mg in PG. Time to first request was 1.0±0.6 h for patients in SG vs. 2.0±2.0 h in PG. Pain scores were also not different. Pain free sitting position noted in 50% of patientin two groups.

PENG block may improve the quality of recovery and reduce opioid requirements. However, our study did not show a significant impact of PENG block on intra and postoperative pain control in total hip arthroplasty.

Previous trials favoured a continuous interscalene brachial plexus block over a single injection for major shoulder surgery. However, these trials did not administer a multimodal analgesic regimen. The null hypothesis of this randomised, controlled trial is that a continuous infusion of local anaesthetic after a single injection for an interscalene brachial plexus block does not provide additional analgesia after major shoulder surgery in the setting of multimodal analgesia, inclusive of intravenous dexamethasone, magnesium, acetaminophen and ketorolac.

Sixty patients undergoing shoulder arthroplasty or arthroscopic rotator cuff repair were randomised to receive a bolus of ropivacaine 0.5%, 20mL, with or without a continuous infusion of ropivacaine 0.5% 4–8 mL.h-1, for an interscalene brachial plexus block. Patients were provided with intravenous morphine patient-controlled analgesia. The primary outcome was cumulative intravenous morphine consumption at 24h postoperatively. Secondary outcomes included pain scores at rest and on movement, and functional outcomes, measured over 48h after surgery.

Median (interquartile range) cumulative intravenous morphine consumption at 24h postoperatively was 10mg (4–24) in the continuous infusion group and 14mg (8–26) in the single injection group (p=0.74). No significant between-group differences were found for any of the secondary outcomes.

A continuous infusion of local anaesthetics after a single injection for an interscalene brachial plexus block does not provide additional analgesia after major shoulder surgery in the setting of multimodal analgesia, inclusive of intravenous dexamethasone, magnesium, acetaminophen and ketorolac. The findings of this study are limited by performance and detection biases.

Superior trunk block (STB) has been demonstrated to be non inferior to interscalene block for postoperative analgesia in arthroscopic shoulder surgery. Suprascapular block with posterior cord block was also shown to be effective in the same setting. This study aimed to determine if anterior suprascapular block combined with selective posterior cord block (ASPCB) provided superior analgesia to STB within 24 hours postoperatively.

This randomized controlled trial included 46 patients undergoing arthroscopic shoulder surgery after IRB approval. Patients either received an STB (n = 23) or an ASPCB (n = 23). The primary outcome was the worst rest pain score measured on numerical rating scale within 24 hours. Secondary outcomes included the worst pain score at motion within 24 hours, sensory and motor block duration, amount of opioid consumption, handgrip strength, incidence of significant axilla pain, adverse effects, and patient satisfaction.

All patients completed the study. The maximal NRS rest pain score within 24 hours postoperatively showed not significantly difference between groups, 1 [0, 2] in STB versus 1 [0, 2] in ASPCB group, respectively, mean difference 0.1 (95% CI,−0.3 to 0.6), (P=0.417). Median procedural time was significantly shorter in the STB group, 8 [7, 10], compared to the ASPCB group, 15 [13, 17] minutes (P < 0.001). Analgesic consumptions and other secondary outcomes were comparable between groups.

ASPCB did not provide superior analgesia to STB up to 24 hours postoperatively. We suggest STB should be a preferred postoperative analgesia technique for arthroscopic shoulder surgery due to its shorter procedural time.

Morphological changes in paraspinal muscles may be associated with the analgesic outcome after epidural adhesiolysis, especially in elderly patients. The purpose of study was to evaluate whether cross-sectional area or fatty infiltration of the paraspinal muscles affects treatment results of epidural adhesiolysis.

Patients with degenerative lumbar disease who underwent epidural adhesiolysis were enrolled in the analysis. Good analgesia was defined as ≥30% reduction in pain score at 6 months follow-up. A cross-sectional area and fatty infiltration rate of the paraspinal muscles were measured. The study population was divided based on age (by 65 years of age). Variables were compared between good and poor analgesia group.

Elderly patients showed poor analgesic outcome as fatty infiltration rate in the paraspinal muscles increased (p = 0.029), predominantly in female patients. However, cross-sectional area did not show any correlation with the analgesic outcome in patients younger than or older than 65 years (p = 0.397 and p = 0.349, respectively). Multivariate logistic regression analysis revealed that baseline pain scores <7 (OR = 4.055, 95% CI = 1.527–10.764, p = 0.005), spondylolisthesis (OR = 4.555, 95% CI = 1.237–16.776, p = 0.023), and ≥ 50% fatty infiltration of paraspinal muscles (OR = 6.691, 95% CI = 1.233–36.308, p = 0.028) were significantly associated with poor outcome in elderly patients.

Fatty degeneration of paraspinal muscles correlates with poor pain outcome after epidural adhesiolysis in elderly patients. A paraspinal cross-sectional area was not associated with pain relief after the procedure.

Regional anesthesia has become an increasingly popular approach in arteriovenous fistula(AVF) creation surgery, due to the higher primary patency rates. The sympathectomy-like effect of brachial plexus block may cause perioperative vasodilation and increased brachial artery blood flow. This study aimed to estimate the minimum effective anesthetic concentration of lidocaine required for ultrasound-guided axillary nerve block in 90% (MEAC90) of patients with chronic kidney disease undergoing AVF creation surgery.

This study was based on a biased coin design up-and-down sequential method. Patients undergoing primary AVF creation surgery were enrolled. Ultrasound-guided perineural axillary block was performed with 20 ml 0.9% lidocaine. The following concentration was determined by the result of the previous patient. If the patient underwent the operation under pure nerve block, the next patient was randomized to receive the same lidocaine concentration or a concentration of 0.1% less. However, if the rescue medications were required, the lidocaine concentration was increased by 0.1% in the next patient.

Thirty participants were enrolled, with 25 positive responses and 5 negative responses that needed additional medications during the operation. The mean MEAC90 was estimated to be 1.13% [95% confidence interval, 1.098-1.173].

In the current preliminary study, ultrasound-guided injection of 20ml of 1.13% lidocaine through perineural axillary block could provide a successful block for AVF creation surgery in 83.3% patients.

Interscalene block (ISB) has been the gold standard for perioperative analgesia of arthroscopic shoulder surgery. However, it is associated with the inevitable risk of hemi-diaphragmatic paresis (HDP). To reduce the risks of HDP, the upper trunk block (UTB) at the points of its division level is proposed. We hypothesized that UTB would show a lower incidence of HDP than ISB while providing comparable analgesic effects.

Seventy patients scheduled for elective arthroscopic rotator cuff repair were randomly allocated to receive UTB or ISB using 0.75 % ropivacaine 5 ml immediately after inducing general anesthesia. The primary outcome was the incidence of complete HDP which was assessed using ultrasound. Secondary outcomes included the parameters of respiratory function, pain intensity at rest 1 h postoperatively, and postoperative opioid use.

The UTB group had a significantly lower incidence of HDP compared with the ISB group (5.9% [2/34] vs. 44.4% [16/36], p=0.001). The parameters of postoperative respiratory function were significantly lower in the ISB group. The pain score at postop 1 h was not significantly different between the groups (0 [1–2] in the ISB group vs. 1 [0–2] in the UTB group). No significant difference was observed in cumulative opioid consumption and first analgesic request time between the two groups.

As an alternative to ISB, UTB might allow safety, especially in patients with respiratory compromised patients while providing excellent analgesic effects.

Hip fractures are a serious health concern and a major contributor to healthcare resource utilization. We aimed to investigate nationwide trends in the United States in demographics and outcomes in patients after hip fracture repair surgery.

After Institutional Review Board approval (IRB#2012-050), we identified patients who underwent hip fracture repair surgery (internal fixation, hemiarthroplasty, or total hip arthroplasty) in the Premier Healthcare Database from 2016 to 2021. Patient demographics, comorbidities, complications, and anesthetic and surgical details were analyzed. Cochran–Armitage trend tests and simple linear regression were used to determine trends.

We identified 347,086 hip fracture surgical repair cases. The proportion of femoral neck relative to multi-location, pertrochanteric, and subtrochanteric fractures, increased. General anesthesia as the sole anesthetic trended downward (68.9% to 56.8%; P =.01). The use of peripheral nerve block stayed stable (5.6% to 5.7%). The incidence in preexisting comorbid conditions either increased or did not significantly change for all Elixhauser comorbidities, with the exception of valvular disease, which decreased. Regarding major complications (measured in counts per 1000 inpatient days), decreased rates were seen for acute myocardial infarction (from 1.71 to 1.29; p=0.032), other cardiac complications (from 12.59 to 10.67; p=0.043), pneumonia (from 4.17 to 2.72; p<.001), and pulmonary complications (from 9.54 to 6.78; p=0.032). Mortality did not change. (Table 1)

From 2016 to 2021, the overall comorbidity burden increased among patients undergoing hip fracture repair surgery. Throughout this same period, incidence of postoperative complications either remained constant or declined. Moreover, use of general anesthesia decreased over time.

Transforaminal lumbar epidural steroid and erector spinae block has been used for treating lumbar radiculopathies. We aim to compare transforaminal epidural steroid injection with high-volume lumbar erector spinae block in patients with low backache and radicular pain.

After obtaining institute ethical committee clearance and written informed consent, 60 patients aged between 18 to 50 years complaining of unilateral low backache were randomly allocated in 2 groups of 30 each- Group T and Group E. Group E received using ultrasound erector spinae block. with 30 ml of 0.25% bupivacaine with 20 mg triamcinolone 20 mg whereas, Group T received TFESI using fluoroscopy with 2 ml of 0.25% bupivacaine with triamcinolone 20 mg. The primary objective of the study was to assess post-intervention NRS at 1 hr, 1 month and at 3 months. The secondary objective was to assess the modified Oswestry disability index(MODI), requirement of rescue analgesia.

The mean post NRS at 1 hr, 1 month and 3 months was significantly lower in group T (p of 0.001, 0.013 and 0.007 respectively). The requirement for rescue analgesics was significantly higher in group E.(p<0.03). The MODI was significantly lower in both groups post-treatment. (p<0.001).

Both TFSI and ESP are effective in low backache with radiculopathy. However, TFSI is superior to ESP block in better control of pain post-intervention and at follow-up.

Analgesic options are limited for postoperative pain after renal transplantation. This study aimed to investigate whether a unilateral anterior quadratus lumborum block would reduce postoperative opioid consumption after living donor renal transplantation in the context of multimodal analgesia.

Eighty-eight adult patients undergoing living donor renal transplantation were randomly allocated to receive either unilateral anterior quadratus lumborum block (30ml ropivacaine 0.375%) or sham block (normal saline) on the operated side. All patients received multimodal analgesia including scheduled administration of acetaminophen and a fentanyl intravenous patient-controlled analgesia. Primary outcome was total opioid consumption for the first postoperative 24 hours (oral morphine milligram equivalent [MME]). Secondary outcomes included pain scores, time to first opioid, cutaneous distribution of sensory blockade, motor weakness, nausea/vomiting, quality of recovery scores, time to first ambulate, and hospital stays.

Total opioid consumption in the postoperative 24 hours was not significantly different between the intervention group and control group (median [IQR], 160.5 [78–249.8] vs. 187.5 [93–309] MME; median difference [95% CI], -27 [-78 to 24], P=0.285). There were no differences in secondary outcomes.

Anterior quadratus lumborum block did not reduce opioid consumption after living donor renal transplantation in the setting of multimodal analgesia. These findings do not support the routine administration of the anterior quadratus lumborum in this surgical population.

Posterior quadratus lumborum block is accepted analgesic strategy in abdominal surgery. We examined whether bilateral, single-injection posterior quadratus lumborum block with ropivacaine could improve on postoperative analgesia compared to 0.9% saline in patients undergoing laparoscopic hepatectomy.

Ninety-four patients were randomized to receive bilateral posterior quadratus lumborum block (20 mL of 0.375% ropivacaine on each side, 150 mg total) or control group (20 mL of 0.9% saline on each side). Primary outcome was cumulative opioid consumption during the first 24 h after surgery. Secondary outcomes included pain scores, intraoperative parameters and recovery parameters.

Mean cumulative opioid consumption during the first 24 h after surgery was 31.2 ± 22.4 mg in quadratus lumborum block group (n=46) and 34.5 ± 19.4 mg in control group (n=46, mean difference : -3.3 mg, 95% confidence interval, -12.0 to 5.4, p=0.453). Median resting pain score at 1 h post-surgery was significantly lower in quadratus lumborum block group (5 [4, 6.25] vs. 7 [4.75, 8] , p=0.035). There were no significant differences in resting or coughing pain scores at other time points and other secondary outcomes.

Bilateral posterior quadratus lumborum block did not reduce the cumulative opioid consumption during the first 24 h after laparoscopic hepatectomy.

Horner’s syndrome is characterized by miosis, partial ptosis, anhidrosis and apparent enophthalmos. After epidural analgesia, it is the result of the stellar ganglion blockade, suggesting a high level (C8–T4) of anaesthetic effects.

We report a full-term parturient submitted to labor analgesia under epidural technique. We administered ropivacaine and sufentanil, which produced a relatively symmetric sensitive block at T6/T7. Fifteen minutes later we noticed the patient developed Horner syndrome. Upon detection of the symptoms, a dilemma arose on whether to keep the catheter, which was resolved through discussions with the patient. Together we decided to keep it in place for the following boluses. Two additional fractioned boluses were administered. The patient maintained an adequate sensitive block at T6/T7, had no additional neurological findings and kept hemodynamic stability throughout the entire period. The condition was reversed completely three hours later with no additional interventions.

Horner's syndrome is associated with epidural anesthesia and pregnancy: due to reduced epidural volume from uterine pressure and increased local anesthetic sensitivity. Symptoms tend to be mild, but cardiorespiratory arrest is a possible complication due to high sympathetic block and close vigilance should occur. In this case, the decision to administer further boluses was based on the cardiorespiratory stability, the relatively mild presentation and the patient’s understanding of the situation.

This case highlights the importance of careful technique and vigilant monitoring during epidural analgesia, as well as the necessity of considering patient comfort and autonomy in the decision-making process.

Hypertonic saline is used for treating chronic pain, but clinical studies with optimal therapy protocols are lacking. This study aimed to determine the concentration at which the effect reaches its peak and the antinociceptive mechanism of Hypertonic saline.

A spinal nerve ligation (SNL, left L5, and L6) model was used to induce neuropathic pain in rats weighing 250–300 g. One week after implantation of the intrathecal catheter, different concentrations of NaCl were injected intrathecally into the rats. Behavioral tests (von Frey filaments, hot-plate, and cold-plate tests) were used to derive the results at baseline, 30 minutes, 2 hour, 1 day, and 1 week. After the same preparation, the rats were randomly divided into four groups of 10: the control group, hypertonic group, bicuculline group, and phaclofen group. Behavioral tests were then performed at weeks 1 and 3 after each drug administration, which followed the administration of intrathecal 5% NaCl. This study was reviewed and apporoved by the Institutional Animal Care and Use Committee Asan Institute for Life Sciences.

Using more than 5% NaCl in the rats induced mechanical allodynia and thermal hyperalgesia has a significant therapeutic effect. Moreover, more than 5% NaCl showed a partial time- and dose-dependent antinociceptive effect on cold hyperalgesia. Pretreatment of the γ-Aminobutyric Acid (GABA) receptor antagonist inhibited the antinociceptive effect of hypertonic saline in the SNL rats.

Intrathecally injected hypertonic saline is effective at concentrations greater than 5% for treating neuropathic pain, and its effects may be associated with the GABAA and GABAB receptors.

This study aimed to compare the effect of the pericapsular nerve group (PENG) block with suprainguinal fascia iliaca compartment block (FICB) on dynamic pain during the positioning for spinal anesthesia as well as postoperative pain and motor blockade.

In this study, 79 patients undergoing surgery for hip fractures with baseline pain scores of ≥ 4 using the numerical rating scale (NRS) were randomly allocated to receive either an ultrasound-guided PENG block (n = 40) or a suprainguinal FICB (n = 39). The primary outcome was to assess the reduction of pain scores during hip flexion for spinal anesthesia 30 minutes after the peripheral nerve block. Secondary outcomes included the pain score at postoperative 6, 24, and 48 hours, cumulative opioid consumption up to postoperative 24 and 48 hours, postoperative intensity of motor blockade and cognitive dysfunction, and postoperative complications.

The study found that both FICB and PENG block reduced dynamic pain during hip flexion for spinal anesthesia, with no significant difference between the two groups (- 2.90 ± 2.52 vs. - 3.08 ± 2.43; P = 0.75). There was also no significant difference between the two groups in pain scores (static and dynamic) at 6, 24, and 48 hours postoperatively, intensity of motor blockade, time to ambulation, or other outcomes.

In patients with hip fractures, the PENG block may provide a comparable analgesic effect to suprainguinal FICB on dynamic pain during position change for spinal anesthesia, with no difference in postoperative pain and motor blockade.

This study aimed at investigating the efficacy of PECS Blocks in alleviating symptoms in the immediate post-operative period and in reducing the occurrence of chronic pain following surgical treatment for breast cancer

We enrolled 64 women who were randomized to the performance or not of PECS blocks. Evaluation of pain was based on the numerical pain rating scale (NRS) ranging from 0 to 10. In addition, the required supplemental morphine dose in the immediate post-operative period was compared between the two groups. All patients were evaluated at 3 and 6 months after surgery using the DN4 questionnaire for neuropathic pain

The incidence of postmastectomy pain syndrome (DN4≥4) in the PECS group was 28.1% at 3 months and 3.1% at 6 months, while in the non-PECS group it was 46.9% at 3 months and 28.1% at 6 months, with the difference between the groups being statistically significant at 6 months (p=0.016). The NRS values at three different time points (immediately postoperatively, at 12 and 24 hours) were higher in the non-PECS group compared with the PECS group and this difference was statistically significant at all three time points (p<0.001). Significant differences were found in supplemental morphine doses after discharge from PACU and for 24 hours, with the PECS group requiring 1.5 ± 2.48 mg and the non-PECS group requiring nearly four times more (p < 0.01)

The peri-operative use of PECS blocks reduced acute postoperative pain, diminished postoperative morphine requirements and lowered the risk of development of chronic pain

Laparoscopic cholecystectomy (LC) is a common minimally invasive surgery that reduces risks and complications. To manage postoperative pain in LC, different regional anesthesia techniques have been explored. One such technique is the External Oblique Intercostal Plane Block (EOIPB), which is relatively new and lacks clinical trial evidence. This study aimed to evaluate the effectiveness of EOIPB in managing postoperative pain after LC.

This randomized, controlled trial was conducted from December 2022 to April 2023, with approval from the Institutional Review Board (IRB) and clinical trial registration (NCT05444985). ASA I-III patients aged 35-65 years scheduled for LC were included. All patients received standardized general anesthesia and analgesia. In the experimental group, an ultrasound-guided EOIPB was performed bilaterally using 30mL of 0.25% bupivacaine at the end of the surgery. Tramadol consumption, postoperative pain scores (numeric rating scale - NRS), time to first opioid dose, and the quality of recovery (QoR-15) scores were recorded.

Comparing the EOIP group and the control group, descriptive statistics showed no significant differences (p>0.05). However, the EOIP group had significantly higher cumulative tramadol consumption at all time points, except for the first hour (p<0.001). NRS scores were similar throughout all time intervals (p>0.05). The EOIP group demonstrated significantly higher average QoR-15 scores compared to the control group (128.2±10.23 vs 112.83±12.06, respectively, p<0.001) (Table 1,2-Figure 1).

Bilateral ultrasound-guided EOIPB provides effective analgesia and reduces analgesic requirement in the first 24 hours for patients undergoing LC.

Pathologic changes in coracohumeral ligament (CHL) on MR or US is suggestive of diagnosis of adhesive capsulitis (AC). Objective is to compare the elasticity measured at the CHL between the patients with AC and healthy controls using shear wave elastography (SWE), and to suggest cut-off value.

This prospective study included 24 shoulders with clinical diagnosis of AC and 32 healthy shoulders. Longitudinal B-mode image and SWE of CHL were obtained in axial oblique plane on the lateral border of the coracoid process. In between-group comparison, thickness and elasticity of CHL in patient group obtained with maximal ER were compared with those of healthy group obtained with maximal ER and with 30° ER, respectively. Cut-off value and inter-/intra-rater reliability were calculated by ROC analysis and ICC, respectively.

Baseline characteristics were similar between two groups (Table 1). Elasticity of CHL with maximal ER was similar between two groups. However, elasticity of CHL with maximal ER in patient group were significantly higher than those of CHL with 30° ER in healthy group (Table 2). Cut-off value of CHL elasticity in 30° ER was 107.4 (Figure 1). SWE showed good inter-rater reliability and intra-rater reliability for CHL elasticity (with 30° ER, ICC 0.662 and 0.514; with maximal ER, ICC 0.660 and 0.506).

Shear wave elastography can show increased tissue elasticity of CHL in adhesive capsulitis of shoulder compared to healthy group with good intra- and inter-rater reliability. Also, the optimal cut-off value of CHL elasticity to predict adhesive capsulitis was presented.

ExparelTM, a liposomal bupivacaine formulation, is a long-acting local anesthetic that can provide pain relief after total hip or knee arthroplasty (THA/TKA) when used for local wound infiltration or peripheral nerve blocks. At the same time, Exparel is a relatively expensive medication, and its use can increase healthcare costs. As population-level trend data remain rare, we aimed to investigate nationwide trends of Exparel use in the United States for THA/TKA.

This study was approved by the institutional review board of the Hospital for Special Surgery (IRB#2012-050). We identified patients from the Premier Healthcare database who underwent elective THA/TKA using a standard set of International Classification of Diseases -ninth/tenth revision codes from 2012 to 2021. We examined the use of Exparel over time at both the patient and hospital levels.

Among 103,165 cases, Exparel use increased from 2012 to 2015 (0.36% to 22.8%), and decreased afterward (15.7% in 2021) (Table 1). At the hospital level, 599 hospitals (59.7%) ever used Exparel during the study period. In 2013, 30% of hospitals started to initiate Exparel use, and the rate has been decreasing over time (compared to 3.1% hospital initiated Exparel use in 2021). In 2014, hospitals started to terminate Exparel (1.1%); this termination rate increased and peaked in 2019 (9.5%). (Figure 1)

The use of Exparel peaked around the year 2014-2015 and has been decreasing afterward. The reason for hospitals stopping Exparel use may be related to recent evidence for its modest efficacy and should be studied further.

Persistent pain may occur after modified radical mastectomy(MRM) in 20% and 50% of patients. This post-mastectomy pain syndrome (PMPS) is multifactorial, affects the quality of life(QoL) of patients and its treatment is often ineffective. Our aim was to determine whether adjuvant rTMS of motor cortex reduces pain and improves QoL in patients with PMPS.

After ethics approval, 30 adult females with PMPS after MRM were randomised into two groups of 15 each to receive 15 sessions of rTMS and sham rTMS respectively. The pain of patients and QoL was assessed using VAS, short form McGillpain[SF-MPQ] questionnaire, somatosensory evoked responses and FACT-B respectively. rTMS was given in 20 trains of 60 pulses with an inter-train interval of 60 seconds. In sham group the coil was angled away from the head to produce subjective sensations of rTMS to ensure that the magnetic field did not penetrate the scalp.(Figure 1) Each session lasted 20 minutes and 58 seconds.

The demography parameters, and pre-therapy pain scores were comparable.(Table 1) rTMS resulted in a significant decrease in VAS score, SF-MPQ, CDT, WDT and CPT scores. The overall quality of life as assessed using FACT-B scores was also significantly better with rTMS.(Figure 2)

Administration of 15 sessions of 10 Hz rTMS on motor cortex resulted in the improvement of pain status, quality of life and thermal sensitivity in patients with PMPS. No serious adverse effects were found indicating that rTMS is safe and can be given as an adjuvant therapy to PMPS patients.

Lumbar central spinal stenosis(LCSS) is debilitating disorder with spine degeneration that results in disability and persistent chronic pain.

Randomized controlled study compares efficacy of conservative therapy(CT), interlaminar epidural steroid injections(IESI) and their both combination(CT+IESI). Primary outcomes included pain(Numeric Pain Rating Score (NRS)), disability(Oswestry Disability Index (ODI)) and quality of life(European Quality of Life Questionnaire). Outcomes analysed as short-term(≤ 3 months), intermediate-term(3 to 6 months), long-term(6 months to 1 year). Patients included with NRS ≥ 7.

229 patients with symptomatic LCSS randomly assigned to CT, IESI, CT+IESI group: 87(age 63±9), 82(age 57±9) and 60 patients(age 61±6), respectively. Mean physical function improvement for CT, IESI, CT+IESI groups 19.2 (95% confidence interval (CI)13.6 to 24.8), 22.4 (95% CI 16.9 to 27.9) and 26.7 (95% CI 21.5 to 32.7), respectively. IESI valuable for pain relief at short-term (MD 1.23, 95% CI 0.54-1.89; P=0.0002), CT+IESI at long-term (MD 0.85, 95% CI 0.46-1.24; P<0.0001)compared with CT. There were no statistically significant differences in functional improvement after CT and IESI at short-term and intermediate-term follow up (MD 3.65, 95% CI 2.24-5.06; P=0.21), long-term functional improvement observed in CT+IESI group (MD 0.81, 95% CI 0.48-1.14; P<0.0001). Patients' satisfaction with treatment was significantly higher in CT+IESI group (MD 1.30, 95% CI 1.12-1.48; P<0.0001).

Use of combined CT+IESI therapy is more effective for relieving severe chronic LCSS pain than each of these therapy methods separately at long-term. Patients noticed more successful outcomes receiving CT+IESI. This study might help clinicians to make decisions for severe pain treatment of patients with LCSS.

Minimally-invasive, on-bypass cardiac surgery (MIC) through a unilateral mini-thoracotomy is increasingly popular but associated with high levels of postoperative pain, opioid consumption and opioid-associated side effects. This study aimed to elucidate whether adding a PECS block II to conventional multimodal analgesia improves opioid consumption, pain and quality of recovery.

After approval by the ethics committee, patients scheduled for MIC were randomized between ultrasound-guided, preoperative unilateral PECS block with ropivacaine 0.5% vs. placebo (saline). Patients, practitioners and data collectors were blinded to the intervention drug; a standardized multimodal analgesic protocol was applied to all patients. Numerical rating scores (NRS), analgesic consumption and the Overall Benefit of Analgesia Score (OBAS) were collected at different time points up to 24 hours postoperatively, and compared between groups.

57 patients were included (ropivacaine n=28, vs. placebo n=29). Block performance (after central venous access) took 5±2.5 minutes. Patients in the ropivacaine group had significantly lower morphine milligram equivalents (MME) during the first 24 hours after extubation (median (interquartile range): 4.2 (2.1-7.6) vs 8.3 (4.2-15.7) mg, p=0.016). NRS at extubation was lower in the ropivacaine group (0.0 (0.0-2.0) vs 1.5 (0.3-3.0), p=0.041). Non-opioid analgesic consumption was similar. The OBAS was, by trend, improved in the ropivacaine group (4.0 (3.0-6.0) vs. 7.0 (3.0-9.0), p=0.082). (Table 1)

The addition of PECS II block to conventional, opioid-based multimodal analgesia protocols is a simple, yet effective measure to optimize opioid consumption, pain relief and side effect profile in patients undergoing MIC.

Lumbar radicular pain (LRP) is a challenging clinical symptom. Pulsed radiofrequency (PRF), a neuromodulation technique that uses short pulses of radiofrequency current, is effective in treating pain disorders. This study aimed to determine the intraoperative parameters of PRF of the lumbar dorsal root ganglion (DRG) that are related to clinical effects in patients with LRP.

This was a prospective, double-blind, randomized pilot study. The patients were allocated to two groups, the high-voltage (60 V) and standard-voltage (45 V) groups, according to the preset maximum voltage at which the active tip temperature does not exceed 42°C. The primary outcomes were radicular pain intensity, physical functioning, global improvement and satisfaction with treatment, and adverse events. The assessments were performed until 3 months.

The patients in the standard-voltage group showed significant improvements in the numerical rating scale (NRS) (P = 0.007) and Oswestry disability index (ODI) (P = 0.008) scores after PRF; but no difference in the high voltage group. Among the intraoperative parameters, the output current showed a significant negative linear relationship with analgesic efficacy and also a significant association with NRS (P = 0.005, R2 = 0.422) and ODI score (P = 0.004, R2 = 0.427) in the multiple regression analysis. The optimal cut-off value of the output current was 163.5 mA with sensitivity of 87.5%, specificity of 100%, and an area under the receiver operating characteristic curve value of 0.92 (95% CI: 0.76–1.00).

We found that lower output currents during PRF to lumbar DRG associated with higher analgesic effects.

Knee osteoarthritis (KOA) is a prevalent degenerative disease characterized by pain and functional impairment. While traditional pain management provides limited relief, Transcranial Direct Current Stimulation (tDCS) has emerged as a potential modality for non-invasive pain modulation. We conducted a systematic review and meta-analysis evaluating the efficacy of active versus sham tDCS in these patients.

PubMed, EMBASE and Cochrane were searched for randomized controlled trials (RCTs) comparing active M1-SO tDCS to sham tDCS in patients diagnosed with KOA experiencing chronic pain. We assessed WOMAC (Western Ontario and McMaster Universities Osteoarthritis) index and pain score changes in different time points following treatment sessions. RevMan 5.4 and the RoB-2 tool were used for statistical analyses and risk of bias evaluation, respectively.

We pooled 9RCTs including 476 patients, 50% undergoing active tDCS. The initial assessment, comparing treatment-end pain scores with baseline scores revealed a significantly favorable effect for tDCS (Figure 1). Two additional measurements were conducted after the conclusion of the treatment. The first, performed after 3-5 weeks, revealed significantly reduced scores in the active tDCS group (Figure 2). The second, conducted after 2-3 months, indicated no statistically significant differences (Mean Difference -0.65; 95%CI -1.35 to 0.05; p<0.07; I2=49%; 3RCTs; 278 patients). Regarding the WOMAC scores, active tDCS also exhibited a significant decrease in comparison to the control group (Figure 3).

Our findings suggest that active tDCS holds promise as an adjunctive therapy to standard pain management of chronic pain in knee OA as it may decrease pain and increase function.

Pain management of arthroscopic shouder day-case surgery is a real challenge. Intravenous dexamethasone and dexmedetomidine are two adjuncts to local anaesthetics used independently to prolong analgesia after peripheral nerve block, when no perineural catheter is used.

This randomised, controlled, triple-blinded trial tested the hypothesis that the intravenous combination of dexamethasone and dexmedetomidine would provide superior analgesia than intravenous dexamethasone alone in patients undergoing arthroscopic rotator cuff repair with an interscalene brachial plexus block. After induction of general anaesthesia, 122 patients were randomised to receive intravenously either dexamethasone 0.15mg.kg-1 (Dexa group) or a combination of dexamethasone 0.15mg.kg-1 and dexmedetomidine 1µg.kg-1 (Dexa-Dexme group). The primary outcome was the duration of analgesia measured from the time of block procedure to first oral morphine intake. Secondary outcomes included duration of sensory and motor blocks, pains scores at rest and on movement, cumulative oral morphine consumption at 48h and rates of hypotension.

The mean (standard deviation) duration of analgesia was 24.5h (2.0h) in the Dexa group and 22.4h (1.6h) in the Dexa-Dexme group (p=0.42). Similarly, there were no significant differences in all the secondary outcomes, with the exception of rates of hypotension that was higher in the Dexa-Dexme group (83.3% vs 43.5%, p<0.001)

In conclusion, the intravenous combination of dexamethasone and dexmedetomidine does not provide superior analgesia than intravenous dexamethasone after an interscalene brachial plexus block. The administration of dexmedetomidine is associated with more episodes of hypotension.

Transforaminal and caudal epidural steroid injections are use to treat lumbar radiculopathy. The aim of this study was to investigate the clinical effects and physical examinations of transforaminal steroid injection compared to caudal through a targeted catheter in lumbar radiculopathy.

Fifty patients with lumbar radiculopathy candidates for epidural steroid injection were divided into transforaminal (T) and caudal (C) groups. Steroid injection was performed in group T with transforaminal method, and in group C with caudal method using a targeted catheter for each involved spinal nerve root. Pain intensity (VAS), Oswestry Disability Index (ODI), daily analgesic consumption, and physical examinations on 4 follow-ups were evaluated.

Pain score (VAS) and functional disability index (ODI) were similar in both groups, and there was no significant difference between the two groups (p>0.05). The positive Lasègue test was significantly higher in the caudal group than in the transforaminal group only in the third month (p<0.05). Other physical examinations in both groups did not have significant differences in all the follow-ups. Also, there was no difference in the amount of analgesic consumption in the two groups. No complications were observed in both groups.

This study showed that transforaminal and caudal steroid injection (with a targeted catheter) in patients with lumbar radiculopathy had similar effects in controlling pain and improving functional disability of patients in the short term. Cases of recurrence of positive Lasègue test in physical examinations in the long term (third month) in the caudal group may indicate the preference of the transforaminal approach.

Neurofibromatosis is a multisystem genetic disorder which manifests with pigmentary skin changes, neurofibromas, increased risk of central nervous system gliomas and other malignant tumors and learning disabilities. Performing an epidural technique in patients with neurofibromatosis is subject to careful consideration due to potential challenges including the presence of neurofibromas involving the spinal cord.

Description of a case of an epidural performed for labour analgesia in a patient with neurofibromatosis.

We present a case of a 31-year-old woman, ASA II, 40 weeks pregnant, diagnosed with neurofibromatosis, who was admitted at our hospital in active labour. The patient expressed the will to receive epidural analgesia. She was asymptomatic except for the presence of café-au-lait spots and cutaneous neurofibromas. Her magnetic resonance imaging (MRI) of the brain and spine showed thickening of the optic chiasm and hypothalamus and absence of spinal lesions. There was no history of back pain, headache, neurological deficits or hypertension. Neurological examination was normal, with no sensory or motor deficits. She had normal curvature of the spine. We proceed with the epidural technique. An epidural catheter was placed at L3-L4 level in the midline after finding the epidural space using a loss of resistance to saline technique. There were no complications associated with the technique and the patient had adequate level of analgesia. The patient had a vaginal birth with no complications.

The report suggests that epidural labour analgesia may be a suitable option when spinal cord neurofibromas have been ruled out by magnetic resonance imaging and clinical examination.

Postpartum hemorrhage (PPH) remains to be one of the leading causes of maternal morbidity and mortality attributed to the rising rate of uterine atony. Dexmedetomidine, a highly-selective alpha-2 agonist, has been used in obstetric practice due to its desirable effects. It has applications as an adjunct during neuraxial anesthesia, as well as in general anesthesia (GA) for caesarean delivery. Information on dexmedetomidine’s effect on the contractility of human myometrium remains limited.

Term pregnant patients scheduled for elective CD under regional anesthesia were included. Myometrial tissues were collected by the obstetrician after the delivery of the fetus and placenta and were immediately placed in buffer solution and transferred to the laboratory. Tissue samples were divided into 3 strips and were mounted individually in organ bath chambers filled with physiological salt solution (PSS). Myometrial contractions recorded and were used for analysis as baseline equilibration contractions. The myometrial strips were pre-treated with oxytocin 10-5M for 2 hours and assigned to 3 groups: 1) Dex group (subjected to dose-response testing with increasing concentrations of dexmedetomidine10-9M to 10-4M), 2) Dex + Oxy group (received oxytocin at 20nM along with dexmedetomidine 10-9M to 10-4M), and 3) Control (only oxytocin 20nM).

There is a 363% increase in relative motility index recorded in the Dex group at 10-4M concentration. There is also an increase in relative MI in Dex + Oxy group however it was not significant (196%) owing to the desensitization phenomenon.

Dexmedetomidine significantly caused an increase in myometrial contractility of pregnant human myometrium at 10-4M concentration.

To our knowledge, the effect of oral dexamethasone on block duration has never been assessed. Previous trials used subanalgesic doses of dexamethasone (≤10 mg), and it is unclear if there is a ceiling effect.

We randomised 180 participants undergoing osseous surgery of the hand or forearm to one oral dose of 24 mg dexamethasone, 12 mg dexamethasone, or placebo prior to performing a lateral infraclavicular block with 30 ml of 5 mg/ml ropivacaine. The primary outcome was the duration of analgesia assessed by the time to first sensation of pain in the surgical area. We pre-defined a 33% increase in the duration of analgesia as clinically important.

The duration of analgesia was 1256 ± 395 minutes with 24 mg dexamethasone, 1171 ± 318 with 12 mg dexamethasone, and 841 ± 327 minutes with placebo (Figure 1). When compared with placebo, the duration of analgesia was greater with 24 mg dexamethasone (mean difference (MD) 412 minutes, 98.33% CI 248 to 577) and with 12 mg dexamethasone (MD 330 minutes, 98.33% CI 186 to 474). There was no significant difference between 24 mg and 12 mg dexamethasone (MD 85 minutes, 98.33% CI -78 to 249). The increase in the duration of analgesia exceeded the pre-defined level of clinical importance for both 24 mg and 12 mg dexamethasone when compared with placebo.

Oral dexamethasone of 24 mg and 12 mg increased the duration of analgesia to a clinically important extent when compared with placebo. There was no significant dose-response effect of dexamethasone.

The activation of the obturator nerve during transurethral resection of bladder tumors(TUR-BT) may result in unintentionally leg move known as the "obturator reflex"(leg jerking).It is better to avoid this condition because it might lead to a number of issues. In this study, we compared the effectiveness of obturator nerve block with different anesthetic solutions.

In this study randomly assigned were, 40 patients scheduled for TUR-BT. Ultrasound-guided obturator nerve block was given with lidocaine 2%10ml and bupivacaine 0.5%5ml (Group I) or lidocaine 1%10ml and bupivacaine 0.5%5ml (Group II) by single injections (n=20 in each group).The length of the process in both groups was noted since an adductor spasm may make it more challenging; so were the time for obturator block performance, the severity of the motor blockade, and the length of the procedure.Throughout the procedure, the surgeon's level of satisfaction was observed.The patient's satisfaction and any problems that might have occurred were also recorded.

Block performance time between groups was similar. The onset time until nerve blockade was 7.3±4 minutes for group I and 12±3 minutes for group II. The ease of access for the two groups was similar. The characteristics of the obturatorius nerve block are presented in Table 1.

Our research confirms a significant difference in onset time and surgeon satisfaction when obturatorius motor nerve blockade was performed using different anesthetic solutions.The beginning of action and the surgeon's satisfaction are the primary issues in this treatment because the length of the blockade is not of importance.

Interscalene brachial plexus block confers a high risk of transient phrenic nerve palsy, which may lead to respiratory compromise. Novel ultrasonographic approaches use a high-frequency linear probe to evaluate diaphragmatic functionary simple to perform and easy to teach, therefore accessible to the everyday anaesthetist. We evaluated two techniques in assessing diaphragmatic function after interscalene brachial plexus block.

Two ultrasound techniques: 1) Change in thickness and calculation of the thickening fraction in M-mode as described by Santana et al in 2020 2) Qualitatively and quantitatively determining diaphragmatic excursion in the simplified technique described by El-Boghdadly et al in 2017. Patient parameters including body mass index and respiratory comorbidity, peak expiratory flow rate and local anaesthetic type and volume were recorded.

We collected data on 21 patients (all gave consent). Average BMI 28.6 (range 20-42) and average age 54.6 years (range 25-70). 3 patients required oxygen in recovery, 1 had subjective dyspnoea. Ultrasonographic data on diaphragmatic thickening and excursion can be seen in the attached table of results. Average total scan time scan time was 10 minutes (range 5-20).

Our results show a greater decrease in both diaphragmatic thickening fraction and excursion on the side of the interscalene block. Point of care ultrasound is a useful technique in identifying phrenic nerve palsy following ultrasound-guided interscalene brachial plexus block. It is a simple and effective technique that can be easily learned, readily applied, and utilised in the acute setting to provide an immediate picture of diaphragmatic function.

Many patients that undergo cardiac surgery via median sternotomy experience uncontrolled postoperative pain leading to prolonged intubation, impaired recovery, and the development of chronic pain. The erector spinae plane (ESP) block and the pecto-intercostal fascial (PIF) plane block have been used as multimodal analgesia for sternotomy pain. The purpose of this study was to compare the analgesic efficacy of ESP blocks and PIF blocks versus no block in patients under general anesthesia undergoing sternotomy for cardiac surgery.

This randomized prospective control trial was conducted at an academic care center and included 90 participants. The primary endpoint was opioid consumption during post operative days (POD) 0, 1, 2, 3, 4, and 5. Secondary endpoints included Visual Analog Scale pain scores, time to extubation, ICU length of stay (LOS), total postoperative LOS, and nausea/vomiting after extubation.

Among the patients included, 30 received bilateral ESP block, 30 received bilateral PIF block, and 30 received no block. No significant differences in post-operative opioid consumption as measured in MME on POD 0, 1, 2, 3, 4, or 5 were seen between groups. When analyzing VAS scores at POD 0,1,2, and 3 between groups, there was a statistically significant difference between the ESP block group compared to the control group.

These results indicate that the administration of ESP or PIF block for sternotomy does not modulate opioid use throughout the average ICU LOS duration for these patients, as compared to the control however may contribute to improved patient experience as indicated by lower pain scores.

Chronic residual pain after total knee arthroplasty (TKA) is one of the challenges of postoperative pain management. Duloxetine in controlling neuropathic pain and pregabalin by affecting nociceptors can be effective in postoperative pain management. The aim of this study is to compare the effect of perioperative oral duloxetine and pregabalin in pain management after knee arthroplasty.

In this clinical trial, 90 patients scheduled for TKA under spinal anesthesia were randomly assigned to one of three groups A (Pregabalin 75 mg), B (Duloxetine 30 mg), and C (Placebo). Drugs were administered 90 minutes before, 12 and 24 hours after surgery. Visual analog pain score (VAS), the first analgesic request time, postoperative analgesic consumption (i.v. paracetamol), and WOMAC score six months after surgery were recorded.

VAS score and analgesic consumption 48 hours after TKA in groups A and B had a significant decrease compared to placebo (p<0.05). The first analgesic request time in groups A and B was longer than the group C (p<0.05). Of note, while the differences were statistically significant, they are most likely not clinically significant. The WOMAC score before and 6 months after the arthroplasty did not differ between the groups (p>0.05).

Perioperative oral pregabalin and duloxetine similarly reduces pain and the need for analgesic consumption within 48 hours after TKA, but has no effect on knee mobility status.

Placenta accreta(PA) remains as one of the leading causes of peripartum hemorrhage. Regional anesthesia and hypervolemic hemodilution techniques remain controversial in the PA case. We aim to describe the use of combined spinal epidural(CSE) anesthesia with hypervolemic hemodilution technique and fetomaternal outcomes in our patients.

We present four cases of parturient with a median age of 32 years old, who have a history of section cesarean surgery and are suspected of placenta accreta in their current pregnancy.

Physical examination and laboratory results show no abnormalities in all patients. The probability of PA using placenta accreta index(PAI) was about 19-69%. Two large 18G calibers of intravenous line and arterial line were inserted, then hypervolemic hemodilution calculated using formula: Estimated Blood Volume(EBV)×[(Initial hematocrit(HO)-targeted hematocrit(Hf))/Hf] given around 1,5-2,5 liters of fluid before we conducted CSE anesthesia. The placenta accreta was documented and hysterectomy was done in all patients. Intra-operative hypotension was quickly resolved with fluid loading and vasopressor drugs. The bleeding was around 2-4 liters replaced by a<50% red pack cell transfusion. Post-operative hematocrit level was 28-30%. The APGAR score was good in all the babies. The patients are then transferred to the intensive care unit(ICU) in a stable condition without vasopressor drugs. We used epidural analgesia for post-operative pain management. They were moved to a regular ward after 24 hours of monitoring with uneventful adverse effects.

CSE anesthesia with hypervolemic hemodilution technique showed good fetomaternal outcomes with uneventful adverse effects, acceptable post-operative hematocrit level and excellent post-operative pain management in our patients.

Moderate to severe pain is common after cardiac surgery, peaking during the first and second postoperative day. Several nerve blocks for sternotomy have been described, however the optimal location for continuous catheters has not been established. This study sought to assess the feasibility of a larger trial assessing the efficacy of serratus anterior plane (SAP) catheters for sternotomy pain.

This was a double-blinded trial including patients undergoing cardiac surgery via sternotomy. Bilateral SAP catheters were placed in all patients, randomized to Ropivacaine or placebo. Feasibility was assessed based on pre-determined endpoints: 1. Average recruitment rate >4 per month; 2. Protocol adherence rate >90%; 3. Primary outcome measurement rate >90%; 4. Major catheter-related adverse event rate >2%. Quality of recovery index (QoL-15) was compared using an independent t-test.

Fifty-two patients were randomized with feasibility data for 50 (2 were withdrawn). There was a poor recruitment rate (2.4 patients per month). There were no major protocol deviations but there were minor deviations in 12% of patients. The primary outcome (QoL-15) was measured in 96% cases. QoL-15 at 72 hours was not different between groups (Ropivacaine 100 +/- 22 vs Placebo 97 +/- 18, p=0.63). The overall incidence of pneumothorax was found to be 12%.

A single-center RCT was deemed to be not feasible due to low recruitment rate. It was unclear if the pneumothorax was related to the block since there was not a no-block group. This factor needs to be explored before considering the possibility of a multi-center study.

Postoperative pain poses a significant challenge to the healthcare system and patient satisfaction and is associated with chronic pain and long-term narcotic use. However, systemic assessment of the quality of postoperative pain management in China remains unavailable.

In this cross-sectional study, we analyzed data collected from a nationwide registry, China Acute Postoperative Pain Study (CAPOPS), between September 2019 and August 2021. Patients aged 18 years or above were required to complete a self-reported pain outcome questionnaire on the first postoperative day (POD1). Perioperative pain management and pain-related outcomes, including the severity of pain, adverse events caused by pain or pain management, and perception of care and satisfaction with pain management were analyzed.

A total of 26193 adult patients were enrolled. There were 48·7% of patients who had moderate-to-severe pain on the first day after surgery, and pain severity was associated with poor recovery and patient satisfaction. The systemic opioid use was 68% on the first day after surgery, and 89% of them were used with intravenous patient-controlled analgesia, while the rate of postoperative nerve blocks was low.

Currently, almost half of patients still suffer from moderate-to-severe pain after surgery in China. The relatively high rate of systemic opioid use and low rate of nerve blocks used after surgery suggests that more effort is needed to improve the management of acute postoperative pain in China.

The optimal postoperative analgesic technique for hip surgery is still controversial. The present study aimed to compare the pericapsular nerve group (PENG) with the lateral femoral cutaneous nerve (LFCN) and quadratus lumbroum blocks (QLB) in terms of analgesic efficacy, quadriceps motor preservation and side effects in patients undergoing total hip arthroplasty (THA) surgery.

Eighty patients (ASA I-III) were randomly allocated to receive either a QLB (n=40) using 30 mL 0.25% bupivacaine or the PENG and LCFN blocks (n=40) using 30 mL 0.25% bupivacaine (25 mL for the PENG block and 5 mL for the LFCN block) in this prospective, double-blind study. The primary outcome was the consumption of postoperative morphine in a multimodal analgesic regimen after spinal anesthesia. The secondary outcomes also included pain scores (static and dynamic), quadriceps muscle strength, patient satisfaction, and incidence of postoperative complications.

There was no significant difference between the two groups in terms of morphine consumption and pain scores in the first 12 hours (p>0.05). Patients receiving the combination of the PENG and LFCN blocks had significantly higher quadriceps muscle strength at 6 h, less morphine consumption, and static pain scores at 24 h hour, compared to QLB (p<0.05). Patient satisfaction, dynamic pain scores, and block-related complications were similar between the groups (p >0.05).

PENG with the LFCN block provides longer analgesia and better preservation of quadriceps strength after THA. However, further studies with larger sample sizes are needed to determine if these differences are clinically significant.

In osteoarthritis (OA), injectable medications like platelet rich plasma (PRP) or corticosteroids, causing regenerative changes are palliative and preventive against replacement surgeries. This study aimed to compare the efficacy of a single intra-articular dose of PRP to single intra-articular corticosteroid for the treatment of moderate knee OA.

Patients aged 40-70years with knee OA grade II/III (Kellgren-Lawrence classification) were enrolled. Refusal to consent, varus/valgus knee deformity, rheumatoid arthritis, hemophilia, previous knee surgery, drug or alcohol addiction, use of anticoagulant or nonsteroidal anti-inflammatory drugs in previous 7 days were the exclusion criteria. Patients were divided into two groups: Group A (corticosteroid group) and Group B (PRP group). Both groups were assessed for pain VAS score, functional WOMAC score and ultrasound guided femoral cartilage thickness.

After ethical approval, 68patients were included, 34 in each group. Both groups were statistically comparable for age, BMI, baseline VAS and WOMAC score, preintervention femoral cartilage thickness. The mean VAS and WOMAC score was significantly lower in group B at 3 and 6 months compared to group A. The mean changes in VAS and WOMAC scores from preintervention to 1, 3 and 6 month were significantly improved in both groups. There was no change in mean femoral cartilage thickness at 6month from baseline in both groups.

Single intra-articular PRP injection showed better improvement in pain and functional score than corticosteroid injection. Improvement started one month after injection and best improved pain scores were seen at six months. PRP as a treatment option for OA knees has promising outcomes.

Caesarean section (CS) is the most performed operation worldwide. In the UK 1 in 4 women give birth by CS. Poorly managed acute pain following CS can complicate recovery, new-born care, prolong hospital stay and risk the development of chronic post-surgical pain. The PROSPECT working group advises regional techniques post-operatively. A recent update highlights ilioinguinal-iliohypogastric blocks in reducing postoperative opioid-consumption and advocates erector spinae plane blocks following CS, as an alternative to neuraxial opioids. We investigated the current practice in our trust to ascertain what pain relief is given to women following such surgery.

A survey was sent to all anaesthetist in our department. Data was collected anonymously with reference to their current practice. A literature search using Medline and Embase to explore the efficacy of regional blocks post CS provided a framework for best practice.

39 relevant studies investigating fascial plane or peripheral nerve blocks for post CS pain were considered. Literature was unified in the beneficial outcomes of regional blocks in this patient group particularly in absence of neuraxial opioids, however 42% of anaesthetists surveyed at our trust never provide them.

Interest in regional anaesthesia is growing following the adoption of “Plan A blocks” in the new curriculum. However, the list does not include a block for a Pfannenstiel incisions. Our results highlight a space for regional analgesia following CS, though further investigation regarding implementation is required. An enhanced recovery programme following CS including regional anaesthesia to compliment multi-modal analgesia might improve the daily lives of many women.

Assessing pain deception is challenging due to its subjective nature. This study explores using Minnesota Multiphasic Personality Inventory-2 (MMPI-2) analysis with machine learning (ML) to detect malingering. We hypothesize that ML analysis of MMPI-2 can detect pain deception. The main goal of this study was to evaluate the diagnostic value for pain deception using ML analysis with MMPI-2 scales, considering accuracy, precision, recall, and f1-score as diagnostic parameters.

We conducted a single-blinded, randomized controlled trial to evaluate the diagnostic value of the MMPI-2, Waddell's sign, and salivary alpha amylase (SAA). We grouped the non-deception (ND) group and the deception (D) group randomly.

Of the total of 96 participants, 46 were assigned to group D and 50 to group ND. In the logistic regression analysis, pain and MMPI-2 did not show diagnostic value, however in ML analysis, values of selected MMPI-2 (sMMPI-2) which is related to malingering showed accuracy 0.684, precision 0.667, recall 0.800, and f1-score came out as 0.727. When performed with whole MMPI-2(wMMPI-2), accuracy 0.621, precision 0.692, recall 0.562, and f1-score 0.651 was showed. The f1-score was higher in sMMPI-2.

We suggest that the diagnosis of pain deception through the pattern changes of MMPI-2 scales using ML could be valuable. It could be a benefit to clinicians to detect deception exactly and objectively in various situations. Further large-scale studies would be needed to screen and predict more precisely

Tendon-derived stem cells (TDSCs) in tendons are responsible for tenogenesis and tendon regeneration. Aberrant nontenogenic differentiation of TDSCs, such as chondrogenic metaplasia, have been suggested as a pathogenesis of tendinopathy. Additionally, pain mediators, such as substance P, calcitonin gene-related peptide (CGRP) and macrophage migration inhibitory factor (MIF), have been increasingly discussed as an important factor in the pathogenesis of tendinopathy. The purpose was to evaluate whether the pain mediator affects differentiation of TDSC.

TDSC was isolated and cultured from the Achilles tendon of SD rats. TDSC were treated with recombinant MIF, recombinant substance P, or recombinant CGRP. For gene knockdown, TDSC were transfected with MIF small interfering RNA (siRNA), substance P siRNA, or CGRP siRNA. The TDSC culture mediums were prepared for RT-PCR. Expression of tenogenic genes (SCX, Egr1, Tnmd, Col type 1) and chondrogenic genes (BMP2, aggrecan, Sox9) of TDSC were compared with control group.

Treatment of recombinant pain mediators (MIF, Substance P or CGRP) in TDSC showed down-regulated tenogenic genes expression (Fig 1A, 2A, 3A) and up-regulated chondrogenic genes expression (Fig 1B, 2B, 3B) compared with control (p<.05). Knockdown of pain mediator genes (MIF, Substance P or CGRP) in TDSC showed down-regulated chondrogenic gene expression (Fig 1B, 2B, 3B) while expression was up-regulated in a few tenogenic gene (Col type 1 with MIF and SCX with Substance P).

Pain mediators, such as Substance P, CGRP and MIF, appear to be associated with pathogenesis of tendinopathy via enhance the aberrant chondrogenic differentiation and suppression of tenogenic differentiation of TDSC.

There is insufficient evidence on which ultrasound (US) view can predict epidural depth for midline epidural procedure in children with scoliosis. We hypothesized that the US estimated distance from the skin to the epidural space (US-ED) in the paramedian sagittal oblique (PSO) plane is comparable with the US-ED in the TM plane to predict actual epidural depth.

The institutional review board of the Severance Hospital has been granted (IRB no. 4-2021-0266). 55 patients being placed in a flexed left-sided position, US-EDs was measured in the bilateral PSO and TM plane at the L2/3 interspace. During the midline epidural puncture using the loss-of-resistance technique to air, the needle depth from the skin to the epidural space was sought (Table 1). Correlation between the US-EDs and the needle depth was investigated with Pearson's correlation coefficient (PCC), Concordance Correlation Coefficient (CCC). The graded visibility of posterior dura complex was compared.

PCC and CCC between the US-EDs and the needle depth were excellent in all planes. Amongst all US-EDs, the longer value of the US-ED in the PSO taken from both sides showed highest PCC and CCC value (Table 2). The ‘good’ visibility is significantly higher in the PSO view than in the TM view (72.7% vs. 38.2%, P-value <0.001).

PSO and TM planes are both interchangeably feasible to predict the needle depth in pediatric patients with lumbar scoliosis. However, the longer of the two US-EDs in the bilateral PSO view is more reliable than US-ED in the TM view with better visualization.

Blocking brachial plexus with an injection in the costoclavicular fossa has been defined recently. It is aimed to compare infraclavicular techniques including lateral and medial approach costoclavicular, and traditional lateral sagittal approach. A quicker sensory block onset time was hypothesized for "lateral" costoclavicular approach.

After obtaining ethical approval, lateral sagittal (LSB), costoclavicular medial (CMB) or costoclavicular lateral (CLB) blocks were performed according to randomization. Single local anaesthetic injections were made posterior to the subclavian artery in LSB group, and to the central of cord cluster in costoclavicular block groups. Depending on the trajectory of needle, costoclavicular blocks are named medial (CMB) or lateral (CLB). Sensory and motor block onset times, block performance properties (ideal ultrasound visualization time, number of needle maneuver, perceived block difficulty), and time to complete resolution of motor and sensory block were investigated.

Table 1 summarizes demographics. Sensory block onset was fastest in CLB (n=18) comparing to LSB (n=20), and also CMB group (n=18) (10[5-15] vs 15[10-15], and 10[10-20] minutes, respectively, p=0.01) (Figure 1A). This was also valid for motor block onset (15[10-20], 20[15-20], and 22.5[15-25] minutes, respectively, p=0.004). Block performance properties did not differ between the three groups (Table 2). Motor and sensory blocks were diminished between 12th and 18th hours in all groups (Figure 1B), and postoperative pain scores were similar (p>0.05).

Lateral approach to costoclavicular block exhibited faster sensory and motor block onset than medial costoclavicular and lateral sagittal approach. All techniques were similar in terms of performance properties, and demonstrated similar perioperative comfort.

Ambulatory hip arthroscopies are associated with severe pain requiring opioid analgesia. Novel motor sparing blocks, the pericapsular nerve group (PENG) and lateral femoral cutaneous nerve block (LFCN) have been reported with efficacy in hip surgery. The purpose of this study is to investigate the analgesic benefits of these novel blocks in terms of opioid-sparing and discharge efficiency.

After obtaining institutional review board approval (IRB # 2020-2031), we retrospectively identified 1559 patients who underwent elective hip arthroscopy at our institution from January 2019 to December 2020. We used propensity scores to match each block group (PENG, PENG/LFCN) to a control group (neuraxial only). The outcomes of interest include post-anesthesia care unit (PACU) mean opioid consumption, maximum NRS pain score, intravenous rescue analgesia and PACU readiness for discharge times.

PENG/LFCN block group required significantly less opioids in the PACU (25.98 ± 13.04 versus 14.58 ± 5.77, p <.001) and were discharged earlier 2.72 ± 1.16 hours versus 4.42 ± 1.63 hours, p <.001) than the control group. The combined PENG/LFCN group also used less intravenous rescue opioids (0.47±1.18 mg versus 1.44±2.1 mg, p = 0.099) than the control group. The PENG block alone group did not show a significant difference in opioid reduction (21.95± 15.83 versus 27.72± 15.01, p = 0.108), but was discharged from the PACU earlier (3.62± 1.35 versus 45.5± 3.2 hours, p = 0.002). (Table 1)

Combined PENG and LFCN block were associated with expedited PACU discharge and a clinically significant reduction in post-operative opioid use.

A Obstetric-specific recovery tool (ObsQoR-10) were developed to assess the quality of recovery (QoR), however, its correlation with maternal outcomes has not been investigated. We correlated the ObsQoR-10 at post-Caesarean 24 hours with validated assessments of Breastfeeding self-efficacy (BSES-SF), Hospital Anxiety and Depression Scale (HADS), Edinburgh postpartum depression scale (EPDS), pain catastrophizing scale (PCS), and EQ-5D-3L at day 7.

Post-Caesarean questionnaires were administered to parturients after elective caesarean delivery at KK Hospital in Singapore at (i) 24 hours (ObsQoR-10, HADS, EQ-5D-3L, EPDS, PCS); (ii) 48 hours (ObsQoR-10, EQ-5D-3L); (iii) 7 days after Caesarean delivery (ObsQoR-10, BSES-SF, EQ-5D-3L, EPDS).

158 patients completed the questionnaires between Sep 2022 and Apr 2023. ObsQoR-10 demonstrated significant internal consistency (Cronbach’s-alpha=0.89) but only limited test-retest reliability (Pearson’s r=0.26). The ObsQoR-10 score had moderate correlation with EQ-5D-3L global health visual analogue scale (VAS) at post-Caesarean 24 hours (Pearson’s r=0.31) but only weak correlation at 48 hours and 7 days (Pearson’s r=0.28, 0.18 respectively). It had moderate-to-high degree of correlation with PCS subscales on rumination (Pearson’s r=0.51), magnification (Pearson’s r=0.43), helplessness (Pearson’s r=0.47) at 24 hours. ObsQoR-10 exhibited moderate correlation with measures of anxiety (Pearson’s r=0.43) and depression (Pearson’s r=0.49) especially at 24 hours as measured by HADS and EPDS (Pearson’s r=0.41) but the degree of correlation decreases at day 7 (Pearson’s r=0.31).

These results suggest ObsQoR-10 could be used in assessing the QoR in domains of pain catastrophizing-rumination, depression, pain, and quality of life in the Asian population especially within the first 24 hours after delivery.

Regional anaesthesia makes a substantial contribution to the care of patients undergoing surgical fixation of neck of femur (NOF) fractures, a group at significantly increased risk of perioperative complications due to their frailty and comorbidities. We reviewed current management at our district general hospital, comparing it to the latest Association of Anaesthetists’ guidelines (2020).

Pre-, intra- and post-operative data points were collected prospectively on patients undergoing NOF fixation over a 10-week period.

101 patients were included. The study group was found to be elderly (mean age 81y), comorbid (ASA III: 59.6%, ASA IV: 22.0%) and frail (Clinical Frailty Scale ≥4: 80.2%). Peripheral nerve blocks (PNB) were performed in 78.2% of cases and showed wide variation in technique (see Table 1). 21.8% of patients did not receive a PNB, 90.9% of whom received a spinal anaesthetic. Regarding spinal anaesthesia, hyperbaric 0.5% bupivacaine was used in 84.6% of cases and isobaric 0.5% bupivacaine in 15.4%, whilst local anaesthetic volume ranged from 1.8 - 2.6 ml. Neuraxial opiates were used in 61.5%.

The Association of Anaesthetists recommend all patients receive a PNB. This target was not met, primarily in those receiving neuraxial anaesthesia. In some PNBs, local anaesthetic volume may have been subtherapeutic. Opiate use in neuraxial blocks is no longer recommended and a maximum dose <2 ml 0.5% bupivacaine advised to minimise adverse effects. These discrepancies between current practice and latest evidence were presented and our local guidelines are now under review. Further education and training in regional anaesthesia will be undertaken.

Multimodal approach to pain in critical patients, using different drugs combined with regional analgesia can improve clinical outcomes. This study aims to assess nurse´s perspective regarding this approach, namely pain management outcome and practical aspects regarding epidural analgesia manipulation.

The authors designed an anonymous survey, applied to nurses of a mix case ICU (12-beds), from a tertiary Portuguese Hospital. Questions focused on clinical details, pain management and daily routines.

The survey was answered by 85.3% of the team (29/34), epidemiological results can be consulted in table 1. From nurse´s perspective, multimodal analgesia with epidural globally benefits patient outcome (100%), reduces sedation days (96.6%) and allows early ventilator weaning (93.1%) and rehabilitation (96.6%), contributes to a better sleep quality (89.7%) and doesn´t negatively impact the digestive tract (100%). Epidural analgesia doesn´t appear to interfere with nurse´s daily care (96.6%), neither makes pain assessment more difficult (86.2%). Differing opinions were seen regarding drug infusion ballon (65.5% better than perfusion pump) and which patient benefits the most (55.2% surgical and 44.8% surgical and medical), the latter with an apparent connection to professional experience.

From nurse’s perspective, a multidisciplinary approach has a clear benefit for critical care patients, with no interference with their daily routine. It was interesting to verify that the greater the professional experience, the bigger recognition of epidural analgesia benefits in different patients. The authors recognize the small sample bias, but highlight the importance of epidural analgesia in ICU from nurse´s perspective, essential in patient management, rarely addressed in literature.

Neuraxial anesthesia use with improved postoperative outcomes has been widely debated and its utilization has likely changed over time. Data from total hip and knee arthroplasty (THA/TKA) patients were used to assess anesthesia choice and compare choice of anesthesia with several complications and resource utilization outcomes from 2006–2021.

After Institutional Review Board approval (IRB #2012-050), using the Premier Healthcare Database we identified patients undergoing a THA/TKA from 2006–2021. Demographics, complications, resource utilization and anesthetic choice (general, neuraxial, and combined general-neuraxial) were analyzed. We used logistic regression models to compare complication and resource utilization outcomes between neuraxial vs. general anesthesia, and neuraxial vs. combined anesthesia groups. Patients with missing anesthesia were excluded from analysis.

We identified 906,364 THA patients and 1,603,324 TKA patients. General anesthesia was used in 71.0% of procedures, neuraxial anesthesia in 17.2%, and combined anesthesia in 11.8%. General anesthesia use [range: 63.3% to 76.4%] decreased from 70.4% in 2006 to 64.8% in 2021, neuraxial use increased from 12.4% to 28.2%, and combined use decreased from 17.2% to 7.0% (Figure 1). After adjustment, we found decreased odds for all outcomes among patients who received neuraxial anesthesia in comparison with patients under general anesthesia (Table 1).

Neuraxial anesthesia use for THA/TKA increased from 2006–2021, whereas the use of general anesthesia and combined anesthesia decreased. Neuraxial use is associated with decreased odds for all complications and resource utilizations outcomes. Further research is needed to determine the association between neuraxial use and improved outcomes in comparison to general anesthesia.

Adductor canal block (ACB) is a peripheral nerve block that provides good pain control and faster recovery in patients undergoing total knee arthroplasty (TKA). Ultrasound-guided local anesthetic infiltration of the interspace between the popliteal artery and theposterior knee capsule (IPACK) has shown promising results in reducing postoperative pain without affecting the motor nerves. The aim of this study is to compare the postoperative analgesic and functional effects between the combination of ACB +IPACK and continuous ACB alone after TKA.

This was a prospective, randomized, and double blinded study including patients undergoing unilateral primary TKA under spinal anesthesia anddivided into 2 groups: Group 1: IPACK + ACB (n=42) and Group 2: ACB (n=41). All patients received a standardized anesthetic and analgesic protocol.The main endpoint was total morphine consumption at 48 h, and secondary endpoints were the Numeric Rating Scale(NRS) and the ambulation test.

We enrolled 83 patients. General characteristics and preoperative data were comparable in both groups. There were no differences in pain intensity using NRS at rest or during movement (90 flexions of the knee) (figure 1 and figure 2). Also, there were no differences in the duration of the ambulation test or the distance ambulated between groups on POD1 and 2. However the NRS score during ambulation test was higher in group 1( p=0,032) (table 1 ).

Our results suggest that the combination of ACB with IPACK block may be an alternative to continuous ACB regarding faster recovery.

Horner syndrome is a rare complication of epidural analgesia. Pregnancy may predispose to it, since epidural space may be narrower. This case report aims to present the management of Horner syndrome after combined-spinal epidural (CSE) labour analgesia.

A 20-year-old primigravida (40w1d), presented to the emergency department with premature rupture of membranes. She was obese (BMI 32.5kg/m2) and asthmatic. A CSE was performed, at L3-L4 level. We used a 18G Tuohy needle and loss of resistance technique. A 27G Quincke needle was introduced through it. Once cerebrospinal fluid was obtained, we injected 2.5mg of hypobaric levobupivacaine 0.5% plus 2.5µg of sufentanil. Then, the epidural catheter was advanced cranially and fixed at a depth of 10cm in the skin (4.5cm length in the epidural space).

The patient remained painless for 2 hours. After negative aspiration and negative test dose, we injected 10mL 0.2% ropivacaine. 30 minutes after, the patient had left ptosis, miosis and conjunctival hyperemia. 30 minutes after, the symptoms resolved. 1h30min after, she needed further analgesia. We injected 5mL 0.2% ropivacaine and no symptoms developed but analgesia was not enough, so we injected more 5mL and she remained asymptomatic. 1h30min later, we injected 10mL 0.2% ropivacaine and the same symptoms resurged. 30 minutes after she gave birth. 1 hour later, symptoms were completely resolved. She remained hemodynamically stable and had no motor block the whole time.

As Horner syndrome is indicative of a high neuraxial block, anesthesiologists need to act with caution as a total spinal anesthesia may develop.

Epidural catheter movement and fallouts causes inadequate analgesia so different fixation methods have been devised to prevent it. We compared five different fixation methods and their effects on catheter complications such as catheter migration, falling off of dressing, pericatheter collection of blood and fluid and local inflammation.

Five groups consisted of 20 patients each and the method of catheter fixation was randomly allocated. Groups consisted of Plain Tegaderm dressing as control group, Lockit epidural clamp, Suturing of the catheter to the skin, fixation with Nectacryl( Skin adhesive glue) and subcutaneous tunnelling. All the patients were followed up 12 hrly upto 4 days and scores were noted . Discomfort scores were also noted at the time of insertion. Statistical analysis was done using appropriate tests.

Sex distribution and mean age was found to be comparable in all the groups. Catheter migration and falling off of dressing was found to be maximum in plain Tegaderm group and least in Nectacryl group. Pericatheter collection of blood was found to be maximum in plain tegaderm group and least with Nectacryl group. Discomfort score and local inflammation was found to be maximum in subcutaneous tunnelling group. Pain scores were comparable in all the groups.

Additional fixation of catheter along with plain tegaderm dressing decreases migration. Migration was minimum with nectacryl ,tunnelling and Lockit group and tegaderm dressing remained intact in Nectacryl group due to sealing of the entry point and preventing any ooze and collection. Additional fixation improves epidural analgesia and recovery of the patient.

Calculating local anesthetic (LA) dosing is essential to decrease the risk of Local Anesthetic Systemic Toxicity (LAST). Determining the maximum allowable dose in individual patients is challenging, particularly when nerve blocks are used in combination with intraoperative local infiltration anesthesia (LIA) by surgeons. We polled anesthesia practitioners on their methods to estimate the maximum allowable LA dose and how they factor-in the administration of LA by the surgeon in addition to regional anesthesia.

A survey on the methods to determine the maximum allowable LA dose was sent to 82.820 NYSORA newsletter subscribers. The survey comprised questions on the methods of LA dose calculation, questions on LA mixtures, and questions on ultrasound guidance (Appendix 1).

Of the 82.820 survey recipients, 461 (0.6%) replied. Over half of the responders (52%) witnessed LAST at least once in their practice. Nevertheless, 26.5% indicated that they do not routinely factor-in additional doses of LIA by surgeons. Forty percent reported that there is insufficient communication with surgeons to estimate the maximum allowable dose of LA, with 71% of responders expressing concern that this may increase the risk of LAST.

Over half of the respondents observed LAST at least once, suggesting that the risk of LAST continues to threaten patient safety. Not routinely calculating the maximum dose, including the additional intraoperative LIA by surgeons, may increase the risk for LAST. Developing a tool to determine the maximum allowable dose for multiple LA administrations (i.e., regeneration rate) in individual patients may be beneficial to patient safety.

Oncological breast surgery is associated with significant postoperative pain. PROSPECT guidelines recommend regional anaesthesia for postoperative pain management following mastectomy [1]. Single shot blocks with standard local anaesthetics are limited in duration. We aimed to compare two regional techniques that are currently used at our trust to prolong the duration of post operative analgesia.

We prospectively reviewed 37 mastectomies (September 2021 - March 2023). The patients either received serratus anterior plane catheters through which local anaesthetic was delivered for up to 72 hours postoperatively or preoperative serratus anterior plane blocks using Liposomal Bupivacaine. We compared patient satisfaction and quality of recovery scores in the two groups.

There was no clinically significant difference in use of rescue oral opioids in PACU or at home up to post operative day 2 between the groups. Post operative sleep quality was also similar apart from day 2 when Liposomal patients reported better sleep quality. Both patient groups reported high satisfaction scores with analgesia and recovery.

1. High patient satisfaction with both groups 2. Patients highly recommend both techniques. 3. Marginally better sleep quality in the group that received Liposomal Bupivacaine. 4. Both are valid techniques, providing similar pain relief and quality of recovery.

A variety of treatments are utilized in outpatient settings to manage chronic pain. Evidence for long-term treatment effectiveness is lacking, particularly for rare conditions such as complex regional pain syndrome (CRPS). There is limited patient- and encounter-level data from outpatient pain clinics to guide practice and spur innovation. The goal of this project was to create an automated, standard of care analytical registry embedded within a single institution’s electronic health record system that can be used as a clinical and research tool.

After IRB approval, logic functions were programmed within the electronic health record (Epic) to automatically identify new patients who meet inclusion criteria of having a spine-related or neuropathic pain condition. For every registry patient, the database is being programmed to save key metrics and outcomes including demographics, history of present illness, interventional procedures performed and patient-reported outcomes over 2 years (Figure 1).

As of the registry go-live (January 20, 2022) through April 30, 2023, the census includes 11,804 active patients, of which 1.2% (n=146) suffer from CPRS type 1 (Figure 2). Collectively, patients were treated by 26 providers in the pain management and physiatry departments at over eight locations in the New York tri-state area.

This registry represents a proof-of-concept, automated data repository collecting key metrics and longitudinal outcomes from patients being treated for chronic, subacute and acute pain across affiliated outpatient clinics. It will serve as a data-driven tool to facilitate dialogue between providers and patients, promote quality assurance, and enable research and innovation in pain management.

It is known that more than 40% of pregnant women have a deficiency of vitamin D. Many clinicians used hyperuricemia as indicator for preeclampsia. We study the relationship of pain in childbirth, characteristics of epidural analgesia in women with preeclampsia, blood serum level of uric acid and free vitamin D.

The study group included patients with severe and moderate preeclampsia, alone have given birth vaginally with epidural analgesia. The control group - patients with physiological pregnancy, independently gave birth vaginally with epidural analgesia. Free vitamin D level was performed by enzyme immunoassay kits. The concentration of uric acid was determined spectrophotometrically. Primary study end points defining a base for the conclusions were as follows: level of free vitamin D, uric acid, the average period for delivery systolic and diastolic blood pressure in mmHg, dose of local anesthetic.

In patients with severe preeclampsia revealed: a pronounced deficiency of vitamin D, a tough hyperuricemia, had higher numbers mean arterial pressure du ring labor epidural analgesia in the background: on average during all periods of childbirth 140/90-150/100 mm Hg. In patients with moderate preeclampsia was diagnosed moderate vitamin D deficiency, mild hyperuricemia, blood pressure during childbirth averaged 130/90-125/85 mm Hg. In the control group the level of free vitamin D and the concentration of uric acid were in the normal range, blood pressure during labor averaged 105/60-120/70 mm Hg.

In women with preeclampsia, low levels of free vitamin D and hyperuricemia are associated with higher demand for local anesthetics during epidural analgesia.

Successful ultrasound-guided supraclavicular block (SCB) requires the understanding of sonoanatomy and identification of the optimal view. Segmentation using a convolutional neural network (CNN) is limited in clearly determining the optimal view. The present study aims to develop a computer-aided diagnosis (CADx) system using a CNN that can determine the optimal view for complete SCB in real time.

Ultrasound videos were retrospectively collected from 881 patients to develop the CADx system (600 to the training and validation set and 281 to the test set). The CADx system included classification and segmentation approaches, with Residual neural network (ResNet) and U-Net, respectively, applied as backbone networks. In the classification approach, an ablation study was performed to determine the optimal architecture and improve the performance of the model. In the segmentation approach, a cascade structure, in which U-Net is connected to ResNet, was implemented. The performance of the two approaches was evaluated based on a confusion matrix.

Using the classification approach, ResNet34 and gated recurrent units with augmentation showed the highest performance, with average accuracy 0.901, precision 0.613, recall 0.757, f1-score 0.677 and AUROC 0.936. Using the segmentation approach, U-Net combined with ResNet34 and augmentation showed poorer performance than the classification approach.

The CADx system described in this study showed high performance in determining the optimal view for SCB. This system could be expanded to include many anatomical regions and may have potential to aid clinicians in real-time setting.

We aimed to compare the postoperative pain scores, opioid consumption, and systemic effects of Transversus Abdominis Plan (TAP) block with morphine added as an adjuvant and TAP block and morphine administered intramuscularly for postoperative analgesia in gynecological surgery.

This prospective, double-blind, randomized controlled trial included 52 patients (26 each in the intramuscular (IM) and TAP groups). In the intramuscular (IM) group, 0.1 mg/kg morphine was administered intramuscularly according to the ideal body weight, and ultrasound-guided TAP block was performed bilaterally with 40 mL of 0.25% bupivacaine. In the TAP group, ultrasound-guided TAP block, including 40 mL of 0.25% bupivacaine and 0.1 mg/kg morphine according to the ideal body weight of patients, was administered bilaterally

The total 24-hour morphine consumption was lower in the TAP groups. The morphine consumption after 6, 12, and 24 hours was lower in the TAP group than in the control group (p = 0.033, p = 0.003, and p = 0.008, respectively). The VAS scores at rest and during movement did not differ between the two groups. The total 24-hour ondansetron consumption was higher in the IM group (p = 0.046). The postoperative heart rates, blood pressure, and peripheral oxygen saturation at 0, 1, 6, 12, 24 hours did not differ significantly between the groups.

Conclusions: The addition of morphine to the TAP block may be an effective method for postoperative analgesia in gynecologic surgery and may not increase systemic side effects.

Early ambulation and initiation of physiotherapy following total hip arthroplasty (THA) are essential in diminishing pain and avoiding complications. This audit compared the effectiveness of two popular blocks: the pericapsular nerve group (PENG) and the fascia iliaca block (FIB). Audit approval was granted by our local audit department without ethics committee approval.

We retrospectively analysed 57 elective patients undergoing THA in University Lewisham Hospital. Patients were divided into two groups: those undergoing PENG (group 1) and those undergoing FIB (group 2). Demographic data, morphine equivalent requirements (MER) at day 1 and 2, earliest mobilisation, hip flexion angles, and numeric rating scores (NRS) were recorded. Data was analysed using SPSS statistical software.

Nineteen patients (33.3%) underwent PENG and 38 (66.7%) patients underwent FIB. Patients in group 1 were found to have a significantly greater degree of hip flexion when compared to those undergoing FIB (p=0.008). Additionally, patients in group 1 appeared to have near significant lower day 2 resting NRS (p=0.06). However, when analysing NRS scores overall there was no significant difference between the two groups. Additionally, there was no significant difference between mean MER doses at day 1 or 2.

In patients undergoing THA, addition of a PENG block can significantly improve hip flexion ranges and may improve resting NRS values when compared to those undergoing FIB. We therefore suggest the addition of a PENG block may preserve hip motion and allow early physiotherapy initiation, all of which may lead to improved prosthesis function in the longer term.

Post dural puncture headache (PDPH) is a rare complication of neuroaxial analgesia/anesthesia, estimated to be less than 3%. However, it can impair neonatal care in the post-partum period. The aim of this audit was to evaluate the incidence of PDPH in our obstetric resident department and the need for different treatment options.

Records’ review including all obstetric patients submitted to neuroaxial techniques between 2020 and 2021 in our obstetric department.

In a total of 5574 neuroaxial techniques performed in pregnant women, 33 were signaled for PDPH (0.59%). Of these, 17 were after an epidural technique, 11 following a sequential technique and 5 after a subarachnoid puncture. Out of 36 accidental dural punctures (ADP), only 15 presented symptoms of PDPH. Of the total 33 PDPH cases, 29 were initially treated with conservative measures, of which 8 had to escalate to sphenopalatine ganglion block (4 cases), great occipital nerve block (1 case) or epidural blood patch (EBP) (3 cases); The other 4 cases were initially treated with conservative treatment + sphenopalatine ganglion block (3 cases, of which 2 needed EBP) and 1 with conservative treatment + great occipital nerve block.

Despite being a resident-teaching hospital, there is a relatively low incidence of PDPH, even after ADP - this could be due to preemptive conservative treatment instituted to avoid symptoms of PDPH. Even though PDPH is a rare complication of neuraxial technique, it is necessary to recognise its impairment in neonatal care and institute regular audits and adequate referencing and treatment protocols.

Erector Spinae Plane Block (ESPB) is a truncal fascial block with a disputed mechanism and anatomical site of effect. This study aimed to perform a one-sided ESPB and utilize magnetic resonance imaging (MRI) to investigate the spread of the local anesthetic (LA) and the corresponding dermatomal loss of sensation to pinprick and cold.

Ten volunteers received a right-sided ESPB at the level of Th7, consisting of 30 ml 2,5 mg/ml ropivacaine with 0,3 ml gadolinium. The loss of sensation to cold and pinprick was registered 30 minutes after the block was performed. One-hour post block an MRI was performed.

All volunteers had a spread of LA on MRI in the erector spinae muscles and to the intercostal space. 9/10 had spread to the paravertebral space and 8/10 had spread to the neural foramina. 4/10 volunteers had spread to the epidural space. One volunteer had extensive epidural spread as well as contralateral epidural spread. Four volunteers had a loss of sensation both posterior and anterior to the midaxillary line, while six volunteers had loss of sensation only on the posterior side.

We found that LA consistently spreads to the intercostal space, the paravertebral space and the neural foramina after an ESPB. Epidural spread was evident in 4 volunteers. Sensibility testing after an ESPB is variable and does not consistently reflect the visualized spread on MRI.

Chronic low back pain (CLBP) represents a major health problem, often insufficiently managed using medications and physical therapy. ESP block has shown promising results in the treatment of acute and chronic pain. Our aim was to reveal influence of ESP block on the treatment of moderate to severe CLBP

We obtained data of 29 CLBP patients treated in our hospital during 2022, refractory to pharmacological and physical therapy, with average NRS pain > 6. All patients received standard medical therapy ( gabapentinoids +- SNRI + opioids). All patients received three ESP blocks (30-40ml of 0,25% levobupivacain +4mg of dexamethasone) at the L4 or L5 level during 10 days. Data collected were: demography, pain at NRS before intervention, 14 days, 1 and 3 months after the first ESP block and abolition or reduction of opioid therapy

Our study included 11 male and 18 female patients with mean age of 59,3 . Before the first ESP block average pain at NRS was 7.64 ± 0.95 and 14 days after the beginning was 5.54±1.82 ( p= 0.03). One month after the first block pain was 5.32 ± 1.71 (p=0.02) and three months after was 4.96 ± 1.91 (p=0.001). For 11 patients ( 38%) we have obtained 50% reduction or complete abolition of opioid therapy.

ESP block has shown a significant impact on average pain for CLBP patients in short and medium time period and potential influence on opioid therapy. This is a useful tool allowing easier daily functioning and physical rehabilitation

The aim of our study is to compare medial and lateral approaches of the costoclavicular BPB which has become procedure of choice for upper limb anaesthesia. We hypothesized that costoclavicular block through medial approach would result in shorter performance time owing to the absence of bony anatomical structures in medial aspect.

After IEC approval, 62 patients were assessed for eligibility of which 2 patients declined to participate in the study. In group M, needle was advanced in a medial to lateral direction, whereas in Group L, needle was advanced in lateral to medial direction. 20ml of 0.5% bupivacaine were used in both groups. The primary outcome assessed was performance time. The secondary outcomes analysed were Imaging time, Needling time, Block onset time, Total Anaesthesia time, Anaesthesia success, Performer difficulty score. As two patients were switched over to Group L due to unfavourable anatomy, we ran statistical analysis by modified Intention to treat analysis.

The mean +/- SD for performance time (in mins) were 11.9+/-3.8 in Group M and 9.4+/-4.1 in Group L with difference of mean (95%CI) of 2.4 (0.3 to 4.5) with p-value <0.05.Similarly, imaging, needling, total anaesthesia time were also higher in Group M. Performer difficulty score (Grade 2&3) [66.67% vs 48.2%,p-value- 0.032] was also higher in Group M compared to Group L.

Our findings revealed medial approach have no significant advantage over lateral approach with regards to performance time, imaging time, needling time, total anaesthesia time and performer difficulty but with marginally higher block success rate.

The aim of this study is to compare the postoperative analgesic efficacy of Suprainguinal Fascia Iliaca Block(FIB) and Lumbar Erector Spinae Plane Block(L-ESPB) in patients undergoing proximal femur fractures surgery.

Patients with ASA(American Society of Anesthesiology)II-III were included and randomized into: FIB, L-ESPB, and control groups. Surgery was performed under spinal anesthesia in each group and preoperative block was performed in the related groups. Postoperative intravenous morphine via PCA(patient controlled analgesia) was administered and pain intensity was evaluated using NRS(Numeric Rating Scale).

A total of 63 patients were included. NRS scores at 12, 24 and 36th hours postoperatively were significantly lower in the FIB (1.18+-0.13, 0.82+-0.14, 1.0+-0.17) compared to the control group (2.05+-0.25, 2.14+-0.27, 1.81+-0.25) (p=0.006, p=<0.001, p=0.011, respectively). While the 12th and 36th hour NRS in the FIB were similar to those in the L-ESPB group, the 24th hour NRS in the FIB was significantly lower than in the L-ESPB group(1.60+-0.23) (p=0.01). NRS was similar between groups at 0, 2, 6 and 48th hours. Morphine consumption in the first 2hours and 2-6-hour period were significantly higher in the control group compared to other groups(p=0.018, p=0.021 respectively) and after 6th hour was similar among the three groups. The cumulative opioid use was higher in the control group at 6h,12h,24h,36h,48h hours where as it was similar between the FIB and L-ESPB groups in each time period.

Combining FIB or L-ESPB with spinal anesthesia effectively reduced postoperative opioid consumption and provided better pain control. FIB demonstrated longer-lasting pain relief compared to L-ESPB.

Chronic pain is prevalent and poses challenges in perioperative management. Opioid-dependent patients often require higher opioid doses and experience uncontrolled postoperative pain. Ketamine, a non-competitive NMDA-receptor-antagonist, has shown promise in reducing postoperative opioid-consumption and pain intensity. This study aims to evaluate ketamine-infusion safety and side-effects in postoperative wards and its impact on monitoring protocols, as well as its potential to reduce opioid-use in chronic opioid-dependent patients.

In this retrospective chart-review we compared: patients who received intraoperative and postoperative ketamine-infusion(Ketamine-Group) and patients who did not(Control-Group). Outcomes included severity of ketamine-related adverse-effects, opioid-related side-effects measured via validated 11 item scale, and length of hospital stay.

This study included 202patients, ketamine-group(94-patients) and control-group(108-patients). No ketamine-related severe side-effects were observed in any group. Mild to moderate ketamine-related side-effects were reported in both groups, with mild-hallucinations being more frequent in the ketamine-group(p=0.006). Mild Nausea(P =0.052) and urinary-retention(p<0.001) was observed more frequently in ketamine-group. Constipation was observed more frequently in control-group(p=0.033). Ketamine-group had significantly higher median intraoperative opioid-use(p<0.001), and second 24-hour postoperative opioid-use(p=0.033). Median length of hospital stay in the ketamine-group was 174.55-hours compared to 116.66-hours in control-group(p<0.001)(Table-1,Figure-1).

This study demonstrated the feasibility of ketamine-infusion for postoperative opioid consumption in patients with chronic pain without 1:1 monitoring in the ICU or step-down units. The use of ketamine was not associated with any major adverse effects requiring intense resource utilization. There was no direct association between ketamine-related side-effect and increased length of hospital stay. However, the long-term effects of ketamine-infusion on postoperative pain remain to be evaluated.

The purpose of this study was to evaluate whether using a cocktail of intercostal nerve blocks during thoracoscopic surgery results in better clinical outcomes than using patient-controlled analgesia.

Patients who underwent video-assisted thoracoscopic surgery (VATS) from the same medical group in West China Hospital of Sichuan University during 2021, June to 2022, June were enrolled. The groups were divided into two subgroups based on their analgesic program, which were thoracoscopic intercostal nerve block group (TINB group) and patient-controlled intravenous analgesia group (PCIA group). After propensity score matching (PSM), We assessed the patients' pain at different time points after surgery using the visual analogue scale (VAS) and recorded any analgesic related adverse events (ARAEs).

The difference of resting VAS (RVAS) and active VAS (AVAS) at different stage during hospitalization was only related to the change of period, and the two groups showed no significant differences in RVAS or AVAS during hospitalization. However, the rates of dizziness (4.92% vs 26.23%, p < 0.05), nausea and vomiting (0 vs 22.95%, p < 0.05), fatigue (4.75% vs 34.43%, p < 0.05), and insomnia (0 vs 59.02%, p < 0.05) in TINB group were significantly lower than that in PICA group. Besides, AVAS and RVAS at 7, 14, and 30 days after discharge in TINB group were both significantly lower than that in PICA group (p < 0.05, p < 0.05).

Based on this single-center analysis, cocktail analgesia TINB provided better analgesia after discharge and reduced the incidence of ARAEs in patients undergoing VATS.

Along with the edema, proteinuria, hypertension, many clinicians as indicator of preeclampsia using high content of uric acid in blood serum - hyperuricemia. It was also found that the hypoxanthine, xanthine and uric acid (UA) are present in the brain, UA is end product of purine degradation in the brain, and then in UA and can be a source of free radicals, endogenous increased production, with the"side" synthesis of xanthine oxidase oxygen free radicals, reflects the severity of ischemic andreperfusion injury. Our attention was attracted by a comparative assessment of the features of purine metabolism in women with preeclampsia and acute brain stroke.

The study involved 33 women with preeclampsia and 350 women in acute period of cerebral stroke, in which, in addition to conventional laboratory parameters were determined in blood and cerebrospinal fluid - guanine, hypoxanthine, adenine, xanthine and uric acid by direct spectrophotometry.

It was established that between preeclampsia and cerebral stroke there are clinical and pathobiochemical parallels, including according to the characteristics of purine metabolism. Hyperuricemia the most famous and at the same time the most pronounced adverse metabolic factor (marker or predictor) for preeclampsia, and for cerebral stroke. High value level of oxypurines (hypoxanthine, xanthine and uric acid) in the cerebrospinal fluid is good sign for a stroke, and low value level of oxypurines is good sign for preeclampsia.

Cerebrospinal liquor can be seen not only medium of administration of drugs for spinal anesthesia, but also and a source of valuable diagnostic (and predictive) information.

As part of multimodal analgesia techniques, regional anesthesia plays a crucial role in reducing opioids usage. The aim of our study was to analyze the efficacy of intraoperative ilioinguinal block with liposomal bupivacaine (IIB/LB) in reducing intra- and post-operative use of narcotics in lower extremities vascular surgeries.

We reviewed the clinical data of 107 patients who underwent elective lower extremities vascular surgeries at our institution from January 2017 to December 2022. Patients were divided into two groups: Group I (n=41 [38%]) received an intraoperative IIB/LB; Group II (n=66 [62%]) did not receive regional anesthesia. Endpoints included procedural metrics, intra- and post-operative narcotic use at 12, 24, 48 and 72 hours after surgery.

Both groups had similar demographics and operative indications. Median dose of intraoperative opioids in IV morphine equivalents was lower for Group I versus Group II (22.5 ± 10.1 vs 28.4 ± 12.2, P=0.01). Median postoperative IV morphine equivalents were lower for Group I versus Group II (at 12h 81.5±36.1 vs 108.1±44.5, P <0.001; at 24h 88.5±45.3 vs 125.4± 54.9, P <0.001; at 48h 121.7±75.2 vs 161.8±78.6, P=0.02; at 72h 121.7±76.1 vs 199.8±109.4, P<0.001). There were no significant differences in mortality or major adverse events between the two groups.

Ilioinguinal block with liposomal bupivacaine significantly reduced the intra- and post-operative opioids use up to 72 hours, and it should be considered as part of multimodal analgesia approach for infra-inguinal vascular surgeries.

Two-jaw plastic surgery is associated with severe perioperative pain due to osteotomy. The efficacy of ultrasound-guided maxillary nerve block (MaxNB) and inferior alveolar nerve block (InfNB) has been reported. However, no study evaluates the efficacy of simultaneous blocks (Max/InfNB).

This study was approved by the ethics committees of two institutions (322-271, 2104). Forty-two patients aged 16 years or older undergoing two-jaw plastic surgery under general anaesthesia were randomly allocated to block group: ultrasound-guided bilateral Max/InfNB were performed under general anaesthesia, or to control group: general anaesthesia alone. The block group received 5 mL of 0.375% levobupivacaine per site for 20 mL. The primary outcome was the rescue analgesics number used up to 24 hours after the block. In addition, intraoperative opioid consumption was recorded. In the block group, arterial levobupivacaine blood levels were measured five times up to 60 minutes after the block by Liquid Chromatograph-tandem Mass Spectrometer.

Eighteen and 22 patients completed the study in block and control group, respectively. The median[IQR] rescue analgesics numbers were not significantly different (block: 0[0-1.25] vs. control: 0[0-1.0], p=0.79). However, the mean(SD) intraoperative fentanyl/remifentanil consumption was significantly lower in the block group (fentanyl: 561(218) vs. 791(250) μg, p=0.004, remifentanil: 3.75(1.20) vs. 5.46(1.54) mg, p<0.001). The maximum mean(SD) levobupivacaine blood level was 1.46(0.40) μg/mL 5 minutes after the block.

Max/InfNB for two-jaw plastic surgery decreased intraoperative opioid consumption compared to general anaesthesia alone, but did not provide effective postoperative analgesia. The arterial levobupivacaine levels after the block remained in the safe range.

Suprainguinal fascia iliaca compartment block (FICB) and anterior quadratus lumborum block (QLB) have been shown to provide analgesia after hip surgery. We tested whether suprainguinal FICB would result in less postoperative analgesic requirements than QLB in patients undergoing total hip replacement arthroplasty (THRA) under spinal anesthesia.

Patients were randomly assigned to the FICB or QLB group. After the surgery, the FICB group received ultrasound-guided suprainguinal FICB using 30ml of 0.375% ropivacaine with 75µg of epinephrine added, and the QLB group received ultrasound-guided anterior QLB using the same mixture. A standardized multimodal analgesic regimen was used for postoperative pain control. The primary outcome was the total amount of opioids administered for 24 hours after surgery. Secondary outcomes were pain scores at rest and during movement for 24 hours, time to the first analgesic request, incidence of side effects, patient satisfaction, quality of recovery 24 hours after surgery, and time to discharge readiness.

Out of 80 patients, there was no significant difference in 24-hour opioid consumption in morphine milligram equivalents between the two groups (92.9 [60.3–122.9] mg vs. 86.2 [42.0–139.4] mg; P=0.725). The time to first analgesic request was longer in the FICB group (768 [385–970] min) than in the QLB group (448 [355–565] min; P=0.028). However, no difference was found in other parameters.

Although total opioid consumption during the postoperative 24 hours did not differ, the time to first analgesic request was longer in the FICB group. Therefore, FICB may have a potential advantage in controlling breakthrough pain after spinal anesthesia.

Regional anaesthesia (RA) plays a vital role in perioperative care, providing superior analgesia, reduced postoperative complications, shorter recovery time, and earlier hospital discharge [1]. Recent efforts have been made to improve RA education [2, 3], but many trainers lack confidence in performing or teaching RA [4]. This not only restricts patients’ access to optimal analgesia but also limits learning opportunities for trainees. The aim of our study is to assess the availability and provision of RA education for consultants and specialists, which will inform strategies to promote broader competence, enhance training experience, and ultimately improve perioperative care.

We conducted a nationwide survey among anaesthetic consultants and specialists to evaluate the availability of regional anaesthesia education for trainers. The survey was distributed through UK college tutors and social media platforms.

A total of 369 consultants and specialists participated in the survey, representing all UK National Health Service (NHS) deaneries. The provision of RA teaching varied significantly across the country. The most common formats of teaching included peer-led learning (n=256), teaching with human models (n=166), ad hoc pop-up teaching in operating theatres (n=163), teaching using phantom models (n=99) and e-learning programmes (n=91).

Understanding the availability of RA education is crucial for enhancing training experiences and ensuring consistent delivery of RA techniques to patients. Our study reveals variability in the provision of RA teaching across the UK for consultants and specialists. Further research utilising qualitative methods may provide deeper insights into the nuances and challenges associated with RA education for trainers.

Spinal dysraphism is a heterogeneous group of vertebral arches disorders with direct implications for the peripartum anaesthetic care. In fact, even if labour analgesia is a common regional anaesthetic technique to provide pain relief during labour, the presence of spinal dysraphism generally contraindicates the use of neuraxial approaches.

We present the case of a 30-year-old female, ASA 2, who presented to our department at 38 weeks of gestation for pre-operative evaluation. During the clinical evaluation, a skin dimple was noted in the sacral area and no visible scoliosis was identified. An accurate neurological examination was completely negative without any related symptoms. A lumbar magnetic resonance imaging (MRI) revealed a tethered cord syndrome with an interrupted sacral posterior neural arch located at S2 and associated with an abnormally low positioned conus medullaris (Fig.1).

Epidural analgesia was selected to avoid a possible spinal cord injury using combined spinal-epidural technique. Consequently, an epidural catheter was inserted at L2-L3 level and 10mcg epidural sufentanyl bolus followed by intermittent top-up 15-20ml ropivacaine 0.1-0.2% injections allowed an optimal pain management during the labour. No complications and adverse effects occurred in the postpartum period.

This case suggests that a proper evaluation of spinal dysraphism is a key element to improve the labour’s anaesthetic management and for determining the feasibility of neuraxial analgesia. In fact, labour analgesia can be safely performed in well selected patients with tethered cord syndrome.