Incidence of acute post-operative pain varies widely in different studies and is largely undertreated. Role of a protocolised acute pain service in alleviating postoperative pain is well recognised. Absence of a dedicated acute pain team due to logistics often acts as an impediment in delivering this service. In this retrospective audit, we have compared the results of acute postoperative pain management before and after implementing acute pain service.

Two consecutive audits before and after implementation of a structured acute pain service were conducted on adult patients, who had undergone major elective abdominal surgery between April,2021-August,2021 (audit A1) and 31st May,2022-31st December,2022 (audit A2). Sources of data were patients’ medical record file and hospital electronic health record. Variables evaluated were patients’ demography, ASA, type and duration of surgery, analgesic modalities, pain scores and complications.

In our audit, 250 and 683 patients were analysed in A1 and A2 respectively. Notable reduction in severe dynamic pain score was observed in A2 as compared to A1 for both open (31.49% vs 2.4%) and minimally invasive surgeries (34% vs 77%). A decreasing trend of thoracic epidural analgesia was observed ( A1- 80.2% vs A2- 68.49%). A 6.45% decrease in post-operative nausea and vomiting was also observed in A2 ( A1- 22.70% vs A2- 16.25%).

Introduction of a structured acute pain service resulted in better pain control.

Recent studies show that multimodal analgesia may be the best approach to acute postoperative pain control1. Nonsteroidal anti-inflammatory drugs (NSAIDs) provide effective analgesia and have shown to reduce the opioids consumption2. Despite their analgesic, anti-inflammatory and antipyretic properties, NSAIDs use is associated with gastrointestinal, cardiovascular and renal risk. Intravenous (IV) ibuprofen presents a better safety profile than other NSAIDs and fewer associated adverse effects (AEs) while maintaining adequate analgesic profile.

60 patients scheduled for hip surgery (demographic characteristics: Table 1) were enrolled in this retrospective observational study and divided in two groups based in postoperative treatment: IV dexketoprofen 50mg TID (n=30) or an IV ibuprofen 600mg TID (n=30). The main objective was to assess postoperative pain with: the visual analog scale (VAS), the quality of postoperative recovery with the Quallity-of-Recovery-15 (QoR-15) score, and on-demand morphine requirements after two days. The incidence of AEs was also studied.

VASs, QoR-15 and required morphine dose are summarized in Table 2. A statistically significant T-student test was obtained when comparing QoR-15 scores (p=0.018). Greater increases in creatinine levels, digestive AEs and mean arterial pressure were observed in the dexketoprofen group (Table 3), obtaining significant results in the T-student in the case of creatinine levels increase (p=0.011).

IV ibuprofen shows a favorable security profile resulting in fewer AEs3 compared to subjects who received IV dexketoprofen with equivalent acute postoperative pain control. This drug may be safely given as a component of a multimodal management strategy, especially in those patients at risk of kidney function impairment.

The aim of this study was to analyze the impact of chronic low back pain as the cause of disability retirement in Croatia, comparing surgical and nonsurgical treatment approach.

Data was collected from disability pension register of Department of Medical Assessors in Ministry of Labor and the Pension System for the period 2016-2022. Assessment was done individually depending on the specific limitation caused by disease, and patient's current job. There are two different types of disability pensions: complete loss of working capacity for any form of employment and partial loss, meaning there is still residual working capacity.

During 7 years period (2016-2022), 42 % of patients with musculoskeletal diseases assessed as having complete or partial loss of working ability, were patients with chronic low back pain: 63% were surgically treated. Complete loss of working ability was determined in 36% of surgically treated patients, while 64 % were assessed as having partial loss, median age was 53, and 55% were male. Concerning nonsurgical treatment approach, complete loss of working ability was determined in 27% of patients, while 73 % were assessed as having partial loss, median age was 55, and 34% were female. There was no difference in eduacation level: 42 % low education, 56% secondary education, and 2% with universitiy diploma.

Higher percentage of patients with chronic low back pain who were assessed to have complete or partial loss of working ability were treated surgically. These findings could have certain impact on treatment approach to patients with low back pain.

Innervation of the knee is intricate, originating from branches of the sciatic nerve, femoral and obturator nerves. Achieving effective post-operative analgesia whilst ensuring motor sparring is crucial in facilitating early mobilisation and optimising patient outcomes. Here we describe our current clinical approach for patients undergoing knee arthroplasty and the outcomes of these patients.

All patients received spinal anaesthesia followed by blocks of the: distal femoral triangle, nerve of vastus intermedius (NVI), interspace between the popliteal artery and capsule of the knee (iPACK), and four genicular nerves. All blocks described here were performed or supervised by the same anaesthetic consultant. We worked closely with the orthopaedic surgical and physiotherapy teams to ensure a smooth day case pathway, emphasising the importance of early mobilisation. We collected data for consecutive patients undergoing this approach to knee arthroplasty during an 8 month period.

There were 50 patients in total. 39 total knee replacements (TKR), 8 unicompartmental knee replacements (UKR) and 3 revision TKR. Eight patients (4 TKR, 4 UKR) were discharged on the day of surgery. All patients mobilised within 24 hours. The mean time to requiring post-operative morphine was 17 hours. All 7 blocks could be performed in less than 10 minutes by an anaesthetic trainee.

Our experience highlights the feasibility and potential advantages of employing a precise and targeted regional anaesthetic strategy for knee arthroplasty. Our findings demonstrate that this anaesthetic modality offers excellent pain relief while preserving motor function, thus enabling the provision of knee arthroplasty as day case operation.

Hip fractures are often painful and its management is difficult because of the patients are usually geriatric and with multiple comorbidities. Traditional pain management in the elderly population is difficult because of physiologic changes and comorbidities. Regional anesthesia is an increasingly used option in Emergengy Department, which not only reduces pain but also might reduce the adverse events of parenteral analgesics. The purpose of this study was to assess the effectiveness of suprainguinal FICB for pain control, compared with Femoral Block with proximal femoral fracture. We hypothesized that suprainguinal FICB can provide a satisfactory analgesic effect while avoiding the risk of procedure-related complications.

Between January 2019 and October 2019 all adult patients (aged18 years and older) with a radiologically confirmed proximal femoral fracture presenting to the KSU Faculty of Medicine Emergency Department were included in this study. The primary study outcome was decrease in NRS pain scores, as measured at 20 min after administration of the FICB compared to baseline during initial presentation in the Emergency Department.

Block onset time was statistically lower at FICB group (p<0.001). VAS scores at 20. min was 0 at two groups. VAS scores at 4. hour and 6.hour was higher in FICB group (p<0.001). First analgesic use time was statistically lower in FICB group (p<0.001).

The Ultrasound guided supra-inguinal FICB and femoral nerve block leads to a significant and clinically relevant decrease in NRS pain scores in the majority of hip fracture patients in the Emergency Department.

Renal surgeries in children, are associated with important post-operative pain. Good post-operative analgesia is essential to allow effective coughing and early mobilisation to reduce the occurrence of post-operative complications. This study was undertaken to compare the analgesic efficacy of morphine spinal anlgesia with ultrasound-guided single-shot paravertebral block in children undergoing renal surgeries

sixty children aged 4 - 14 years, of ASA status I/II, posted for elective renal surgeries. Interventions: The children were randomised into two groups (Group MSA : morphine spinal analgesia, Group PVb :paravertebral block). After induction of general anesthesia, SA or paravertebral block was performed under ultrasound guidance, with respectivly morphine or 0.2% ropivacaine. Measurements: Time to first rescue analgesia, intraoperative and post-operative hemodynamics, post-operative FLACC scores, incidence of complications, parental satisfaction scores were recorded

Children in Group PVB had significantly longer duration of analgesia (p < 0.0004) than Group MSA. Post-operative FLACC scores (p < 0.005) and analgesic requirements (p < 0.0004) were lower in Group PVB. The mean fentanyl requirement over 24 h in group PVB was 0.56 ± 0.82 μg/kg, compared to 1.8 ± 1.2 μg/kg in groupMSA. Parents in Group PVB reported greater satisfaction (p < 0.02). No complications were seen in either of the groups.

This study showed superior analgesia and parental satisfaction with single-shot paravertebral block in comparison to spinal anlgesia for renal surgeries in children. However, the block performance in children requires adequate expertise and practice

Post-herpetic neuralgia (PHN) is a painful condition that presents after herpes zoster reactivation in the peripheral and central nervous system. When medical treatment fails, options are limited, and patients may suffer with chronic pain indefinitely. A man in his 80’s was referred to our clinic with a three-year history of right-sided posterior scalp and periauricular pain after herpes zoster infection presenting as Ramsay Hunt Syndrome. He rated the pain between 6-10 and averaging a 9 on a scale of 10 with distribution in the right occipital and periauricular areas.

The patient was brought to the procedure suite, and, prior to the procedure, ultrasound guidance was used to visualize the right lesser occipital and greater auricular nerves. Ultrasound imaging identified the optimal needle path of the affected target nerves. Next, using a combined in-plane and out-of-plane technique (Figure 1), a linear array electrode was advanced in close proximity to the right lesser occipital nerve and right greater auricular nerve.

The patient returned for lead removal on post-procedural day 65. He reported 90% improvement in the presence of his symptoms with pain averaging a 0 out of 10.

PNS is an effective and safe option for the treatment of chronic pain, and we present a report of successful treatment of PHN in a particularly difficult anatomic distribution. PNS of the lesser occipital and greater auricular nerves is a novel treatment for PHN and shows promise as an effective, safe therapy when other treatment fails.

Transition-related surgery (TRS) is an effective treatment for gender dysphoria, but the perioperative analgesic management of transgender patients may be complicated by higher rates of mood and substance use disorders. Regional anesthesia techniques reduce pain severity and opioid requirements, thereby improving postoperative recovery. However, little is known regarding the effectiveness of regional anesthesia techniques for transgender patients undergoing TRS.

A literature search was performed using Medline, Embase, Cochrane, and CINAHL databases. Original studies describing regional anesthesia approaches for patients undergoing TRS were included. The primary outcomes were pain scores and opioid requirements on the first postoperative day (POD1). Due to the heterogeneity of interventions and outcomes, findings underwent qualitative synthesis without meta-analysis.

Of 1652 studies identified, eight met criteria for inclusion. Three studies described chest surgery, comprising 201 patients of whom 84% were transgender men undergoing mastectomy with pectoralis blocks or local instillation anesthesia devices. The remaining five studies described genital surgery, comprising 50 patients of whom 56% were transgender women undergoing vaginoplasty with lumbosacral erector spinae plane blocks or epidural anesthetics. Overall, the eight studies broadly ascribed benefits to nerve blocks. Few studies directly compared regional and non-regional anesthesia; however, these studies unanimously reported lower pain scores and opioid requirements on POD1 with nerve blocks compared to none. Furthermore, anesthetic complications were rare among included studies.

Regional anesthesia for TRS is understudied, which may be attributable to pervasive marginalization of transgender individuals. However, the limited existing literature does support regional anesthesia techniques as an effective option for TRS.

The incidence of rib fractures has increased by 43.7% 1990 to 4.11 million in 2019. Hypoperfusion due to pain and damaged lung tissue as a result of rib fractures leads to respiratory complications such as pneumonia which is associated with increased mortality. The aims of this review are to compare to other regional anaesthetic techniques and draw conclusions from the data on the effectiveness of the ESPB at reducing respiratory complications.

A literature search was conducted using PubMed and Scopus databases. The search yielded 433 results with 45 duplicates. The titles and abstracts of 388 records were screened for relevance, leaving 52 records. Application of the inclusion and exclusion criteria resulted in 8 studies to be included. A ‘snowball’ search was carried out which yielded no relevant papers.

4 studies reported a significant reduction in pain and OME with ESPB compared to baseline however, only 1 study reported a significant difference between ESPB and the comparative analgesia (SAB). No significant difference was found for respiratory complications between ESPB and SAB or opioid analgesia however there was a significant increase in complications when ESPB was given after 48hrs compared to before. Similarly, diaphragmatic activity improved significantly with ESPB compared to SAB. Finally, there was no significant reduction in hospital or ICU length of stay.

Despite appearing to be safe and giving significant improvements in pain and OME consumption, the links between ESPB and directly improved respiratory outcomes are tenuous. This demonstrates the need for further robust clinical trials with suitable outcomes.

Continuous interscalene brachial plexus block (ISB) provides superior analgesic benefits in major shoulder surgery but has a high risk of hemidiaphragmatic paresis (HDP). Using proximal longitudinal oblique (PLO) approach, catheter can be placed without interfering with surgical site, and the local anesthetic can be injected more distally. We expected supraclavicular brachial plexus block using PLO approach (PLO-SCB) would provide equivalent analgesia compared with ISB while sparing the phrenic nerve.

Patients were randomly allocated to receive continuous PLO-SCB (n = 40) or continuous ISB (n = 40) after low-volume single-shot injection. The primary outcomes were HDP incidence and worst pain scores. Secondary outcomes included respiratory function, postoperative analgesic consumption, sensory and motor function, and complications. This study was appoved by the Institutional Review Board of Asan Medical Center.

Incidence of HDP was significantly lower in the PLO-SCB group than in the ISB group at 30 min after block (28 of 38 [73.7%] vs. 0 of 38 [0%]; p<0.001) and 24 h after surgery (18 of 38 [47.4%] vs. 9 of 38 [23.7%]; P=0.002). Pain scores measured immediately (1 [0,2] vs. 1 [0,1]; p=0.06), and 24 h after surgery (6 [4,8] vs. 5 [3,7]; p=0.199) were similar between the two groups.

Continuous PLO-SCB showed minimal effect on phrenic nerve function while providing equivalent analgesia to continuous ISB in patients undergoing arthroscopic shoulder surgery. For single-shot injection, low-volume PLO-SCB achieves a 0% rate of HDP while maintaining analgesia. PLO-SCB could be applied even in patients with a high risk of postoperative respiratory complications.

CRPS is a debilitating condition of chronic pain that challenges both patient and physician, with often detrimental results that can go all the way even to decision of mutilating the affected limb. Our objective is to evaluate efficacy, decision making and patient satisfaction, as well as complications of treatments of a very rare and complex case of CRPS that progressed with dysautonomia syndrome.

Analysis of data collected from progression of disease through a nine years follow-up of a specific patient with CRPS of the left arm, with onset of symptoms after a procedure for epicondylitis that injured the left radial nerve at the level of the elbow. A review of literature is included to examine the connection of the two conditions.

Through the course of nine years the patient underwent approximately 34 interventions, from conservative medical treatments to intravenous ketamine, neuromodulation techniques, spinal injections and other blocks, radiofrequency ablations, intrathecal pump implantation in various pain centers. The recent years there was a need to incorporate treatments also for more generalized autonomic dysfunction, like neurogenic bladder, respiratory and cardiovascular manipulations, and also gastrointestinal dysfunction.

CRPS is a condition that requires continues medical care, adjustment of treatments and monitoring for new symptoms. Although it is not clear that dysautonomia directly connects with CRPS, studying cases for a long period of time may reveal there is a common basis. More important is that all symptoms should be addressed in time and any physician’s bias should not hinder their diagnosis and treatment.

Ultrasound guided peripheral nerve blocks (USG-PNBs) have many benefits in a high burden low resource settings. These range from reduced airway related complications to decreased need for opioid analgesics. Barriers to performing USG-PNBs tend to surround education agnd equipment accessibility. At Queen Elizabeth Central Hospital, Malawi, there was access to ultrasound equipment and a learning cohort of over 30 anaesthetic trainee providers. As visiting anaesthetists to Malawi, our aim was to explore the delivery of USG-PNBs within this clinical setting.

An assessment of current practice for performing USG-PNBs in theatres was carried out. This involved reviewing theatre workflow and stakeholder (surgical, recovery, and anaesthetic providers) discussions. Following this, practical teaching and supervision sessions were provided. This included the consent process, anatomy revision using free apps, scanning and needling techniques and safe use of local anaesthetics.

We found that stakeholders were receptive to USG-PNB use. Concerns raised included delays to theatre lists and desire for trainee supervision. Collaboration with surgeons and flexibility in timing of blocks increased the delivery of PNBs. Some trainees had received previous teaching, as such, we focused on technique and building confidence. Over a 2-month period, 20 lower limb,14 upper limb and 10 abdominal plane blocks were performed by physician and clinical officer trainees (Figure 1).

The use of USG-PNBs was well received by surgical and anaesthetic providers. We found a flexible supervisory approach enhanced the opportunities. A follow up study will need to be carried out to address issues of sustainability and skill retention.

Arthroscopic shoulder surgery is associated with moderate/severe postoperative pain, which may prevent rehabilitation of patients and increase hospital stay. Erector spinae plane block (ESPB) is a block in which different levels of local anesthetic (LA) are applied between the erector spinae muscle and the transverse process of the vertebrae. We aimed to present the analgesic effect of the block in the first 24 hours postoperatively in 10 patients to whom we applied ESPB at T2-T3 level for analgesia in shoulder surgery.

Patients written consent was obtained. Ultrasound guided ESPB was performed at T2-T3 level in 10 patients with ASA I, II who will undergo shoulder surgery under general anesthesia. Anesthesia was maintained with sevoflurane-air and remifentanil iv infusion according to hemodynamic parameters. Paracetamol, dexketoprofen iv was administered to the patients in the perioperative period. Patients 0, 1, 6, 12, 24 h, NRS scores were recorded.

Ten patients aged 33-75 (male/female = 5/5; mean age = 58.3 [SD = 16.5] ) were included in the case series. The distribution of sensory nerve blockade varied between C2 and C7 in the anterolateral region, between T2 and T7 in the posterior region. The mean surgical time was 85.4 minutes. The mean consumption of remifentanil was 81.4 μg (0-210). The PACU, 1st, 6th, 12th, 24th hour NRS scores of the patients were between 2 and 4.

ESPB in shoulder surgery reduced intraoperative opioid consumption and postoperative NRS scores. We think that ESPB could be a part of multimodal analgesia in shoulder arthroscopy surgeries.

From 8% to 44% of patients after knee arthroplasty experience pain of varying severity (Qudsi-Sinclair S. et al., 2016; Hagedorn JM et al., 2020), which prevents successful rehabilitation. Interventional techniques are most effective in the treatment of pain of various origins, however, there is not enough information about their use after knee arthroplasty. The aim of the study was to evaluate the analgesic efficacy of N. saphenus blockade at the 2nd inpatient stage of medical rehabilitation after knee arthroplasty.

The study included 12 patients who underwent rehabilitation after knee arthroplasty at stage 2 in the inpatient medical rehabilitation department. Inclusion criteria - pain syndrome 5-6 points according to the CRS at rest, 7-8 points during movement. Patients were randomly divided into 2 groups. In group I (n=6), rehabilitation measures were carried out without the use of therapeutic and diagnostic blockades. In group II (n=6), rehabilitation was supplemented by N. saphenus blockade on days 7-8 after joint arthroplasty. Blockades were performed using local anesthetic solutions and glucocorticosteroids with online ultrasound navigation. The criterion of effectiveness of rehabilitation measures is the Knee Society Score.

The use of N. saphenus blockade has a positive effect on the range of motion in the knee joint and the ability to walk up the stairs due to a significant decrease in the intensity of the pain.

The study showed the high efficiency of therapeutic and diagnostic blockades of N. saphenus to increase the effectiveness of rehabilitation measures after arthroplasty at the 2nd inpatient stage of rehabilitation.

Sciatic nerve block(SNB), a well-established and widely used for lower limb surgeries. The distal SNB (popliteal fossa block) is used peripheral nerve block for below knee surgeries. Popliteal fossa block with bupivacaine provide 12-24 hours of analgesia, irrespective of the nerve localisation technique used, complete sensory and motor block is associated with slow onset time(20-60 mins). To evaluate and compare the onset of action of sciatic nerve block proximal to its bifurcation and immediately after bifurcation using ultrasound with local anaesthetic injection inside the paraneural sheath.

After Ethical Committee Approval, USG sub paraneural popliteal SNB performed in 50 patients undergoing lower extremity surgeries and were randomly divided into 2 groups (A & B). Group A recieved 20ml 0.5% bupivacaine 8 cm above the bifurcation into tibial and common peroneal nerve. Group B recieved 20ml 0.5% bupivacaine immediately after its bifurcation. Performance time, adverse events, onset of sensory, motor blockade of sciatic nerve were recorded.

SNB proximal to the bifurcation had a shorter onset of sensory and motor block than distal bifurcation. Time taken for scanning was more, whereas needling time was less in the pre bifurcation group. Total time taken to perform pre bifurcation and post bifurcation SNB was (4.5+0.9) min and 4.5+1.0) min respectively, P=0.766 which is comparable. Demographic data, ASA grade, BMI were comparable in both the groups.

In conclusion, SNB administered at pre bifurcation has faster onset of action compared to post bifurcation. Block performance time was comparable and independent of BMI in both the groups

Radiofrequency (RF) is an effective treatment for patients suffering from cervical pain originating in the facet joints; since there is some variability in performing the technique, our objective is to analyse it current situation in Spain.

We have performed a survey to analyse the situation of the use of RF to treat the cervical medial branch; shared trough the Spanish pain society, 91 people answered it.

15/91 perform one ultrasound-guided diagnostic block, 30/91 perform one fluoroscopy-guided block, 15/91 perform either one fluoroscopy or ultrasound-guided block depending on the patient, 5/91 perform two fluoroscopy-guided blocks and 1/91 perform two ultrasound-guided blocks. 35/91 do the parallel approach and 27/91 the perpendicular approach. 57/91 guide the RF with fluoroscopy, 22/91 with ultrasound, 10/91 combining ultrasound and fluoroscopy and 1 with CT. 58/91 use conventional and 27/91 use pulsed. For cannula diameter, 17/91 use 22G, 44/91 use 20G, 16/91 use 18G and 1/91 use 16G. For active tip, 3/91 use 2mm, 50/91 use 5mm and 26/91 use 10mm. 15/91 use blunt-straight, 30/91 use sharp-straight, 13/91 use blunt-curved and 19/91 use sharp-curved. 27/91 apply the RF at 42°C, 9/91 at 45-60°C, 45/91 at 80°C, 4/91 at 85°C and 1/91 at 90°C. 1/91 apply 60 seconds of RF, 50/91 apply 90 seconds, 9/91 apply 120 seconds, 1/91 apply 150 seconds and 6/91 apply 180 seconds. 49/91 do one lesion, 13/91 two lesions and 11/91 three lesions.

We need to stablish the best form to perform RF for treating cervical pain originating in the cervical facet joints.

Pulsed radiofrequency (RF) is performed for treating several clinical conditions causing chronic pain. There are many variables in its application that are not well established based on the available evidence, voltage being one of them. Voltage can

We have performed a survey to analyse the situation of the use of pulsed RF to treat several clinical conditions causing chronic pain; shared trough the Spanish pain society, 91 people answered it.

In trigeminal ganglion, 23/91 use 45V, 15/91 use 65V, 3/91 use 85V and 1/91 use 100V. In stellate ganglion, 31/91 use 45V, 17/91 use 65V and 1/91 use 85V. In cervical medial branch, 27/91 use 45V, 9/91 use 65V and 1/91 use 85V. In thoracic medial branch, 18/91 use 45V, 3/91 use 65V and 2/91 use 85V. In lumbar medial branch, 18/91 use 45V, 8/91 use 65V and 3/91 use 85V. In thoracic dorsal ganglia, 36/91 use 45V and 15/91 use 65V. In lumbar dorsal ganglia, 53/91 use 45V, 19/91 use 65V and 1/91 use 85V. For peripheral nerves (using the suprascapular nerve as an example), 46/91 use 45V, 20/91 use 65V and 1/91 use 85V. For peripheral nerves, 11/91 do not apply control of temperature with pulsed RF. 61% apply the variation of the voltage in the temperature control; 34% apply the variation of the pulse width in the temperature control.

There is lot of variability in applying different voltages in pulsed radiofrequency for several clinical conditions; we need better evidence to stablish the best voltage for any indication.

Opioids are effective medications that have been used extensively for in-hospital management of acute pain. Worldwide including in Ireland, number of opioid prescriptions is increasing, although many reports encourage controlled usage and warned against the potential health, economic and social hazards involved in opioid usage. To address this problem and to increase knowledge and safety regarding opioid usage, The HSE has issued guidelines for opioid prescribing for the in-hospital management of acute pain. Aim: -To improve compliance with the relevant HSE prescribing guidelines. - Ensure that opioids were prescribed appropriately as per national guidelines. - Check opioid usage is part of multimodal analgesia as per WHO analgesia ladder.

- A retrospective medical record review for opioid prescriptions for acute pain was conducted 3 times over the past year. anonymous data was collected. - survey for Junior Doctors to understand opioid prescription behavior. - teaching conducted at departmental and hospital levels to increase awareness.

24% of the sample received SR opioid preparation. Regarding Immediate release opioids. Only 12% had a documented stop/review date. In terms of multimodal analgesia, a good portion of the sample received regular paracetamol (68%) however NSAIDs were generally underused, and only prescribed for 38% of patients.

In our study, we observed a High rates of SR opioid preparation use in opioid naive patients to treat acute pain. Also, IR opioid recommended duration was not considered in most of the cases. Additionally. Multimodal analgesia usage to reduce opioid consumption could be improved.

There is substantial literature on the use of spinal anesthesia in pediatric patients with bupivacaine, particularly in infants. Bupivacaine is a long-acting local anesthetic which is well suited to surgery in infants but less ideal for ambulatory surgery procedures in older children. Mepivacaine is an intermediate-acting agent commonly used for spinal anesthesia in adults and has potential benefits for use in older children. Currently, there are no published pediatric dosing guidelines for spinal mepivacaine. At Hospital for Special Surgery, mepivacaine is routinely used for spinal anesthesia in children. The aim of this study is to generate mepivacaine dosing guidelines based on milligrams per kilogram (mg/kg) and age.

We performed a retrospective chart review of children who received mepivacaine for spinal anesthesia between 2016 to 2022.

The data extraction yielded 5,448 cases. Patient age ranged from 5 to 21 years. Mean surgery duration was 119 minutes (SD=48). Mean PACU length of stay was 222 minutes (SD=95). Weight in kilograms (kg) and mepivacaine dosage in milligrams (mg) was recorded for all patients (Figure 1). The range and SD of total milligrams administered by age was also recorded (Table 1). Median dosage in mg/kg of mepivacaine was calculated for each age group. Our analysis reveals that required dosage in mg/kg decreases by patient age and begins to plateau at age 15 (Figure 2).

We describe mepivacaine dosage as a function of age and weight in children. As age and weight increase, a lower dose of mepivacaine per kg is required for spinal anesthesia.

Pain is usually severe after cardiac surgery and can limit respiratory function. Parasternal block is used to control this pain; anyway, the block effect is limited to the sternal region and do not cover upper abdominal quadrants, where pleural and mediastinal drainages are positioned. Rectus sheath block is an analgesic technique widely used in abdominal surgery.

5 patients underwent CABG through median sternotomy. With patients consent, we performed ultrasound guided bilateral parasternal block (ropivacaine 0,5% 40 ml + dexamethasone 2 mg) after induction and ultrasound guided bilateral rectus sheath block (ropivacaine 0,25% 20ml + dexamethasone 2mg) at the end of the surgery. Multimodal i.v. analgesia: ketorolac 90mg/24h and acetaminophen 1 gr 3/die. Data regarded: perioperative pulmonary performance evaluated with the TriFlo Inspiratory Exerciser® and expressed in balls moved up during inspiration, pain during incentive spirometry at extubation/after 12 hours (0-10 NRS scale), opiates consumption.

Patients moved up a median of 2 (2-3) balls before surgery and a median of 2 (1-2) balls at extubation. 2 patients completely recovered respiratory function after 12 hours. Pain during spirometry at extubation was a median of 4 (3,5-5,5). Maximum pain in the first 12 hours was a median of 4 (3,5-5,5). Morphine consumption in the first 12 hours was a mean of 1 + 0,9 mg. No pulmonary complications occurred.

Rectus sheath block added to parasternal block seems to improve respiratory function and control breathing pain after median sternotomy and drainages insertion for CABG. Research studies are needed to confirm these data.

Devic disease, or neuromyelitis optica, is a rare autoinflammatory demyelinating disease of the central nervous system, characterized by axonal damage, affecting mainly optic nerves and the spinal cord. The anesthetic management of a parturient suffering Devic disease in the delivery room, is presented.

A 43-year-old, 90 kg, 167cm, G2P1 woman, diagnosed with Devic disease, presented for labor induction at 39 weeks of gestation. Initial neurologic symptoms, diplopia and facial nerve palsy, had developed during her first pregnancy and were diagnosed as brain stem syndrome in remission; the parturient received then uneventful epidural labor analgesia. A year later, Devic disease was diagnosed, further confirmed by positive NMO – IgG/anti-AQP4 antibody. Currently, during pre-anesthesia assessment, the risk of potential neurological symptoms deterioration after labor epidural was weighed against the risk of a labor stress-induced disease relapse. Anesthesiologist and Obstetrician communicated the planned procedure and its risks and the parturient opted for labor epidural analgesia.

An indwelling epidural catheter was placed uneventfully in the delivery room, ropivacaine 0.2% was administered and an adequate sensory block was established. An enhanced sensitivity to the local anesthetic, presumably deriving from spinal cord damage, was postulated, due to unilaterally denser sensory block. Length of catheter insertion into the epidural space was optimal. Several hours later, the parturient underwent cesarean section for obstetric indications after successful epidural top-up.

This case illustrates the safe and effective use of epidural labor analgesia and anesthesia in a patient with Devic disease; thorough pre-anesthetic and obstetric counseling is vital.

Off-pump coronary artery bypass (OPCAB) surgery is a widely performed surgical procedure for coronary artery disease. Adequate postoperative pain management is crucial for patient overall recovery. The erector spinae plane block (ESPB) has gained recognition as a promising regional anesthesia technique. Our aim is to compare standard pain management with the ESPB in patients undergoing OPCAB.

Pubmed, EMBASE, and Cochrane were searched for randomized controlled trials (RCTs) comparing bilateral ESPB to control. We assessed pain scores, opioid consumption, and duration of mechanical ventilation, intensive care unit (ICU) and hospital stay. Data was analyzed with RevMan 5.4.

We analyzed 4 RCTs with 267 patients, of whom 50.56% underwent the ESPB. The pain scores at 6 and 12 hours after extubation were significantly decreased in the ESPB group (Figure 1) but not at 24 hours (MD -1.37; 95% CI -2.95 to 0.20; p < 0.09; I2 = 93%, 3 RCTs, 238 patients). Opioid consumption also favoured the ESPB group (MD -14.30; 95% CI -21.39 to -7.22; p < 0.0001; I2 = 98%, 3 RCTs, 238 patients). Time to extubation was significantly shorter for the ESPB intervention (Figure 2), as well as the ICU and hospital lengths of stay (Figure 3).

ESPB may reduce opioid consumption, extubation time, ICU and hospital stay after OPCAB. It effectively reduces pain at 6 and 12 hours post-extubation, but not at 24 hours, probably due to its duration. Larger studies are needed for comprehensive conclusions.

Risks and benefits associated with peripheral nerve blockade (PNB) are often discussed between anesthesiologists and patients before surgery. The aim of the study is to determine how patients who had the option of having a PNB for surgical anesthesia felt about the informed consent discussions they had with their anesthesiologist and which parts of these discussions were most beneficial.

Patients who underwent ambulatory upper extremity surgery amenable to brachial plexus block (BPB) for surgical anesthesia were identified through the block room records. Patients were contacted by phone after discharge. If agreeable, a qualitative, semi-structured one-on-one interview was completed 1-4 weeks following surgery. Audio of the interviews were recorded and transcribed into de-identified versions for analysis. A team-based approach was used to analyze the transcripts using thematic analysis.

Thematic saturation was reached at 15 patients. All 15 patients had undergone a BPB for surgical anesthesia. No patients who declined a BPB agreed to participate. The results showed there was overall satisfaction with the consent for a PNB. Interviewees thought that good consent should include a detailed description of the patients’ experience, a relaxed and reassuring bedside manner, a discussion of specific risks, description of the benefits, personalized advice based on prior experience, and the use of supplemental visual materials. Participants described reassurance or potential to be reassured if they were informed about the block process.

Patients emphasized that strong consent procedures include many other aspects outside of a description of risks.

In hip dislocation surgery, adequate analgesia is crucial for early rehabilitation. Anterior quadratus lumborum block (AQLB) may be superior to caudal epidural block (CB) for analgesia in hip surgery with fewer complications. In this study, we aimed to confirm superiority of AQLB compared to CB in children for analgesia in open hip surgery.

We conducted a double-blind study with 40 patients aged 2-7 years, undergoing unilateral open hip surgery and randomized into two groups. Ultrasound blocks were performed using 1 ml/kg Ropivacaine 0.2%. all patients had Paracetamol every six hours. Tramadol was planned as rescue analgesia when CHEOPS score was >6(2mg/kg). The primary outcome was the total consumption of analgesics in the first 24 postoperative hours. Secondary outcomes included time to realize block, intraoperative fentanyl consumption, occurrence of intraoperative tachycardia or hypertension, postoperative pain scores, time to first analgesic rescue and total dose of postoperative analgesic consumption.

The two groups were comparable. No difference was noted in the time to perform the block(p=0.17). The consumption of intraoperative fentanyl was similar between the groups (p=0.36) with no difference in intraoperative hemodynamic parameters. We noted no differences in pain scores. The time to first analgesic rescue was similar (p=0.40). The postoperative total tramadol consumption in the CB group was 40±33 mg and 35±27 mg in the AQLB group(p=0.21).

Our study showed that the AQLB and the CA were comparable regarding intra- and postoperative analgesic demand.

The management of acute pain during surgical correction of the funnel chest is an interdisciplinary challenge. For the first time in Poland (in May 2022) intraoperative cryolesia was performed using Cryo-S Painless Metrum Cryoflex device during minimally invasive modified Nuss surgery in the Department of Pediatric Orthopedics and Oncology of Musculoskeletal System of Pomeranian Medical University in Szczecin, Poland. The aim of the study was to compare the short and long-term effectiveness of intercostal cryoanalgesia in terms of pain relief, risk of sensory disturbances and patient comfort.

A total of 100 patients who were operated on with the Nuss method were enrolled. The control group of 52 patients (15 years +/- 2, 4 girls) had multimodal analgesia protocol according to the standard of acute pain management in children. The intervention group of 48 patients (15 years +/- 3 years, 5 girls) had intraoperative intercostal cryolesia bilaterally from Th3 to Th8.

In the intervention group significantly better control of postoperative pain assessed according to the numerical rating scale (NRS) in the first postoperative days (p<0.01) was achieved. Additionally, there was shorter duration of intravenous opioid use (p<0.01), faster independence and correctness of exercises performed during postoperative rehabilitation (p<0.01) and shorter hospitalisation time (p<0.01). In the intervention group, better results were obtained in terms of quality of life according to the modified Nuss questionnaire. Conclusion

Adding cryolesia to multimodal analgesia during modified Nuss surgery gives better results in terms of pain control, improved rehabilitation, and reduced hospitalisation time.

The exact mechanism of action of erector spinae plane (ESP) block remains an enigma. We injected dye in ESP and other paraspinal spaces to compare the dye diffusion pattern along the paraspinal region in human cadavers.

In 6 soft-embalmed cadavers(12 specimens), 20mL methylene blue dye (ESP and paravertebral space) or indocyanine green dye (inter-ligament space) was injected bilaterally using an in-plane ultrasound-guided technique at the level of the costotransverse junction of T4 vertebrae. Dye spread was evaluated bilaterally in the coronal plane in the paravertebral and intercostal spaces from the 1st and the 12th rib. Axial and sagittal sections were performed at the level of the 4th thoracic vertebrae. After cross-sections, the extent of dye spread was investigated in the ESP, inter-ligament and paravertebral spaces. The staining of the ventral and dorsal rami and spread into the intercostal spaces were also evaluated.

The ESP injection was mainly restricted dorsal to the costotransverse foramen and did not spread anteriorly to the paravertebral space. The paravertebral injection involved the origin of the spinal nerve and spread laterally to the intercostal space. The inter-ligament space injection showed an extensive anterior and posterior dye spread involving the ventral and dorsal rami.(Figure1)

Following injections in erector spinae plane, there was no spread of the dye anteriorly to the paravertebral space and it only involved the dorsal rami. Inter-ligamentous space injection appears to be the most promising block in future as the dye spread both anteriorly to paravertebral space and posteriorly toward the erector spinae plane.

Diaphragmatic paralysis (DP) can pose challenges during caesarean delivery (CD), as it may increase the risk of respiratory complications. While there is limited information on anesthesia techniques for patients with DP, central nerve blocks sparing upper intercostal muscles have been utilised in similar procedures.

A 20-year-old woman with idiopathic diaphragmatic paralysis who required an emergent CD due to persistent variable fetal decelerations and intrapartum fever in the labour ward. Diaphragmatic paralysis was incidentally discovered during investigations for recurrent syncope, with no identifiable cause. The patient had a functional capacity of 5 METs. Epidural anesthesia (EA) was performed using titrated ropivacaine 0.75% through an epidural catheter, which had been placed at the beginning of the first stage of labor, 12 hours prior to the development of fever. A total volume of 14mL of ropivacaine was administered. Standard ASA monitoring, multimodal analgesia, and broad-spectrum antibiotics were employed.

The patient remained hemodynamically stable and ventilated spontaneously throughout an uneventful CD. No respiratory or neurological complications were observed in the postoperative period.

The compressive effect of the dural sac allowed us to limit the spread of local anaesthetic, sparing upper thoracic myotomes. Although EA is an option in patients with diaphragmatic paralysis, decisions should be tailored to individual cases. Further studies are needed to evaluate the impact of EA on patients with diaphragm lung paralysis and other restrictive lung diseases.

This study compares perioperative complications of patients undergoing general anaesthesia (GA), spinal anaesthesia (SA) or isolated peripheral triple nerve blocks (NB) for total knee replacement surgery in high risk patients.

In this retrospective single center study, 329 patients (ASA≥III), scheduled for elective total knee replacement between 2014 and 2020 were included. All patients received a femoral catheter and a proximal sciatica nerve block for perioperative analgesia. Patients in the NB group received an additional obturator nerve block. Due to failure resulting from insufficient block or patients expressing their wish for a general anaesthesia, patients were assigned according to the definitive anaesthesia method. There were 22 individuals in the NB-, 171 patients in the SA – and 136 patients in the GA group. Perioperative parameters, events and costs were compared. Differences between groups were compared using the chi-square test.

The NB group showed a significantly better haemodynamic stability intraoperatively with less vasopressor consumption, respectively less relevant hypotension. In 73% of patients in the NB group a PACU-Bypass was achieved (vs 34% in SA group vs 13%in GA group). This influenced the overall costs positively. Remarkably, during the initial 24 hours, no episodes with severe pain (visual analog scale score > 30) were observed in the NB group. Regarding other postoperative complications we could not observe a statistically significant difference.

In summary, the use of triple block as an isolated technique for total knee replacement surgery in specific high-risk patients appears to be a safe option with less haemodynamic complications.

The occurrence of hypothermia increases complications during and after surgery.This study was conducted with the aim of comparing the effect of lavage fluid temperature in terms of the incidence of hypothermia in TURP surgery candidates under spinal anesthesia.

70 patients candidates for elective TURP were randomly divided into two groups. The first group (37) received irrigation fluid at room temperature and second group(33) received irrigation fluid heated to 37 degrees Celsius for surgery.Parameters of patients were initially measured upon entering the operating room, after spinal, at the beginning of the operation, at the end of the operation and also during recovery.

The drop in the body temperature in the control group was more than the intervention group (p=0.04). There was no statistically significant difference between two groups in the analysis of changes in mean arterial blood pressure and heart rate (p>0.05). There was no statistically significant difference between the two groups in terms of the average volume of lavage serum consumed during the operation, the comparison of hemoglobin before and after the operation, the incidence and severity of shivering and the duration of recovery and hospitalization. However, in terms of the need for blood transfusion and the number of blood units consumed during the operation, there was a statistically significant difference between the two groups (p<0.05).

use of heated irrigation fluid to body temperature is associated with less occurrence of hypothermia, shivering and less need for blood transfusion than the group receiving washing solution at room temperature.

According to national hip fracture database report 2022 nearly 75000 patients a year need hospital admission with hip fracture and some of them need surgery. AAGBI 2020 hip fracture guidelines suggests use of either general or spinal anaesthesia with a nerve block. We aimed to look at how the anaesthetic and postoperative analgesia techniques have evolved across UK post COVID 19 pandemic in comparison to existing guidelines.

We conducted an online international survey of anaesthetists who work in trauma list along with an infographic of various nerve blocks for hip fracture. We publicised through emails, social media and face to face during RA-UK conference 2023. We had 64 responses with the participation (48) skewed towards East midlands region of England.

In Hip fracture database of England and Wales 2019 report 57.2 % patients had general anaesthesia with nerve block and 39.8% had spinal anaesthesia with nerve block. In our survey anaesthetists' preference has changed drastically with 76.6 % preferring spinal anaesthesia with nerve block and 10.9% preferring general anaesthesia with nerve block. 6.3% of responding anaesthetists do not prefer to perform any nerve blocks.

We conclude that post COVID-19, there's a slight shift towards regional anesthesia, specifically spinal anesthesia with nerve block for hip fracture surgeries. However, our survey results may not be applicable beyond the East Midlands region. Also based on the results of our survey, we aim to improve compliance to AAGBI Hip fracture guidelines by setting up monthly Plan A nerve block teaching sessions in our hospital.

A freely available visual guide with optimal angles for paramedian approaches, depending on the skin-dural sac distance (S-DS-d) (https://diposit.ub.edu/dspace/handle/2445/179594) and viable paths for needle insertions perpendicular to the back, below the upper spinous process in a given interspinous space, had been described. Our aim was to verify needle location applying the guide in ex-vivo samples.

Random selection of ex-vivo samples with flexed lumbosacral spines (n=7), determination of S-DS-d in the interspinous spaces by ultrasound, needle insertions at axial 0º, below the upper spinous process at different interspinous spaces, from L4-L5 to L1-L2 [n=42; median (n=21), 1cm paramedian (n=16) or individualized paramedian, previsualizing the longest interlaminar height, pre-estimating the angle by means of a protractor (n=5)], computed tomography, three-dimensional reconstruction and verification of needle location (Fig1).

When osteoporotic compression fracture was found (38%), the contact between adjacent spinous process impeded the median approach (Fig2), but most needle insertions were located within the spinal canal in the other cases (85.7% median or 81% 1cm paramedian) (Fig3). In 23% the needle remained within the canal beside the dural sac. In 13% a certain bone penetration occurred. Individualization of the paramedian approach led to successful insertions at very variable angles and distances (up to 32,2º and 2,64 cm paramedian, respectively).

Ultrasound may indicate if the interspinous space is visible. Then, the insertion of needles at 0º regarding the axial plane, taking the upper process as reference, is viable. If not, the alternative optimal paramedian approach must be individualized in fractured or rotated spines.

Carpal tunnel syndrome is the most common mononeuritis, placing a significant strain on both patients and public health. Acupuncture is one of the conservative treatments used for this syndrome. The aim of this study is to evaluate the effect of electroacupuncture in patients with carpal tunnel syndrome through clinical, electrophysiological and ultrasonographic assessments.

Seventeen wrists of twelve patients who were diagnosed with mild or moderate carpal tunnel syndrome were included. Eight acupuncture sessions were performed twice a week. The outcome measures evaluated at baseline and three to seven days after the last treatment were: The visual analogue scale (VAS) score, the Symptom Severity Scale (SSS) and Functional Status Scale (FSS), sensory and motor conduction studies of the median nerve and the cross-section area of the nerve (CSA) at the inlet of the carpal tunnel with ultrasound.

There was a decrease in pain intensity on the VAS scale with median difference -2.45 (p=0.000), a decrease in the severity of symptoms by -0.60 on the SSS scale (p=0.001) and an improvement of the function of the affected limb by -0.25 on the FSS scale (p=0.02). In addition, there was a reduction in the CSA at the inlet of the carpal tunnel by -2.00 mm² (p=0.003). Side effects were observed in 8% of all electroacupuncture sessions and were of local and self-limiting nature.

Electroacupuncture is a safe treatment which improves the symptoms and function of the affected limb in patients with carpal tunnel syndrome and induces morphological changes in the median nerve.

Neuraxial anaesthesia is a core skill in anaesthetic training and of the first techniques learned by trainees. It has been documented that a combination of lecture and simulation-enhanced training improves trainees’ performance on real-life situations.

As part of a teaching programme consisting on multiple workshops for first-year trainees in anaesthesiology, we developed two 2-hour workshops on neuraxial anaesthesia. One focused on spinal anaesthesia, and another one on epidural anaesthesia. The former is undertaken before starting their global anaesthesia training and the latter before the specific obstetrics rotation. Both consist on a brief theoretical introduction followed by an hour of practice on high fidelity commercial mannequins. Trainees also participate in a simulated case scenario to practice communication skills and the suitability of the performance of a neuraxial technique. The case on spinal anaesthesia simulates an operation room situation, while the case on epidural anaesthesia consists on delivering epidural anaesthesia for labour pain. Both workshops conclude with a discussion on the case scenario and a wrap-up debriefing. Finally, a survey regarding workshop satisfaction is sent through e-mail to all trainees.

First-year trainees on anaesthesiology at our centre fulfil both workshops. Surveys indicate a high degree of satisfaction (9,4/10). Trainees believe goals are well defined (9,5/10), they believe it is necessary in their training (9,8/10) and they would recommend it to their peers (9,7/10).

Our workshops fulfil the role on teaching trainees how to perform neuraxial anaesthesia and giving them a first exposure to a real-life situation with a simulated case scenario.

In cervicogenic headache the pain originates from the cervical structures. The goal of this study was to investigate whether there is a better outcome by treating cervicogenic headache with paracetamol and ibuprofen versus the injection of hypertonic dextrose solution (prolotherapy)

Forty patients suffering from cervicogenic headache were randomized to treatment by either paracetamol and ibuprofen or by prolotherapy. Patients subjected to prolotherapy were injected in 10 symmetrical points of the neck and upper back. The frequency of headache per week, the duration of headache in hours and the pain intensity with the VAS score 0-10 were assessed

Prolotherapy showed higher rates of successful treatment of cervicogenic headache, with statistically significant differences between the first and the last assessment in all aspects of headache. Reduction by 81.25% of the frequency of attacks per week, reduction by 89.75% of the duration in hours and reduction by 77.84% of the headache intensity were demonstrated between the first and the last visit. Changes were less spectacular in the conventional treatment group: treatment with conventional pain killers resulted in 6.25% decrease in the frequency of attacks per week, in 44.61% decrease in the duration of pain in hours and in 26.81% decrease in the headache intensity between the first and last visit. Differences between groups were statistically significant

In cases of cervicogenic headache, patients treated with prolotherapy have significant improvement. It appears that prolotherapy, by strengthening the ligaments and tendons of the cervical area can target the trigger points that cause the headache