Thoracic epidural analgesia improves pain relief, bowel function, patient satisfaction and accelerates recovery in patients undergoing abdominal surgeries. Effective postoperative epidural analgesia depends on inserting the catheter correctly in the epidural space. The primary aim of this study was to observe the frequency of appropriate epidural catheter insertion site in adult patients scheduled for major abdominal surgeries and secondary objectives were to observe the frequency of ineffective postoperative analgesia, side effects, and complications.

This study was conducted for a period of three months (1st July to 30th September 2022), after the approval from the Ethical Review Committee. All adult patients who underwent elective major abdominal surgery under general anaesthesia with an epidural catheter placed for postoperative pain management were included in this study. Data were collected at Aga Khan University Hospital Karachi.

One hundred and eighty-two patients were included in this study. Ninety-six (52.75%) of patients were male. The epidural catheter was inserted congruent to the surgical incision that is at T10/T11 interspace or above in only forty-three (23.6%) patients, below T11 but till L1 in seventy-three (40.15%) of patients, and below L1 in sixty-six (36.3%) patients. In the postoperative period, overall effective epidural analgesia was observed in seventy-nine (43.4%) of patients. Regarding the side effects of epidural infusion, the motor block was observed in sixty-six (36.26%) of patients in the immediate postoperative period.

The frequency of appropriate epidural catheter insertion was found in 23.6% of patients. The frequency of ineffective postoperative analgesia was found in 56.6% of patients.

Perioperative thoracotomy pain management with reduced opioid consumption is beneficial for early recovery. Both erector spinae and serratus anterior plane block have been used in thoracic surgeries. We aimed to compare the USG erector spinae and serratus anterior plane blocks on cumulative opioid consumption and recovery.

After ethical committee clearance, a prospective, randomised study was conducted in patients aged 5 to 14 years undergoing open thoracotomy under general anaesthesia. Seventy patients were allocated randomly into two equal groups of 35 each: Group 1 received Serratus anterior plane block while Group 2 received Erector spinae block respectively. Each group received 0.5 ml/kg of 0.25% bupivacaine with 2 micrograms/ml of fentanyl. The primary outcome of our study was to compare the cumulative opioid consumption between the two groups. The study's secondary outcome was to determine the time of chest physiotherapy initiation, postoperative hospital stay, postoperative pain scores and complications between the two groups.

Mean opioid requirement during intraoperative, postoperative period and cumulative was more in Group 1 than in Group 2 with p values of 0.0002, 0.0032 and 0.0024 respectively. The mean time to start chest physiotherapy & mean postoperative hospital stay were higher in Group1 than in Group2 (p-value 0.002 & 0.046 respectively).

Ultrasound-guided Erector Spinae block is superior to Serratus anterior plane block in children undergoing thoracic surgery with decreased perioperative opioid analgesia, early chest physiotherapy initiation, and lesser hospital stay.

Hip fracture is a common and serious injury, particularly in older adults, which can lead to significant morbidity, mortality, and decreased quality of life. Surgery is the standard treatment for hip fractures, and its timing is crucial for optimal outcomes. Studying the time from hip fracture to surgery can help identify best practices for timely surgery and improve patient outcomes.

This study was approved by the Institutional Review Board at our hospital review board (IRB#2012-050). From the Premier Healthcare database (Premier Healthcare Solutions, Inc., Charlotte, NC; 2006-2021) we identified patients who had a primary diagnosis of hip fracture and underwent surgical procedures. The primary exposure of interest was time from hip fracture diagnosis to surgery (categorized as 0-1 day, 2 days, and 3 days). Outcomes of interest included any major complications, length of stay, ICU admission (identified by billing code), and total opioid consumption during hospitalization.

We identified 65,111 patients who underwent surgical treatment within 3 days of hip fracture onsite, with 29.1 of patients receiving the surgery within 1 day, and 53.8% of patients receiving the surgery within 2 days. Prolonged wait time to have surgery increased the risk of having major complications, mortality, ICU admission, and longer hospitalization. (Table 1)

Delayed surgery after hip fracture is associated with increased morbidity and mortality, increased length of hospital stay, and increased use of resources. It is recommended that healthcare providers prioritize timely surgical intervention for patients with hip fractures to optimize their chances of a successful recovery.

Suprascapular nerve block (SSNB) is commonly used for shoulder analgesia. Two approaches are described but associated with risk and difficulties. We designed a cadaveric anatomical study to assess availability of an easier posterior approach.

The probe is place above the scapula, move from medial to lateral to identify the upper edge of the scapula which will be shorter until it reaches the suprascapular notch (1-3). We continue until identify a superior bony growth of the scapula (corresponding to the coracoid process) (4). By moving laterally, we identify the infraspinous notch(5). Between the image of the suprascapular notch and the spinoglenoid notch, neurovascular bundle runs the fossa (4). At that point, we advance the needle "out of plane", from medial to lateral, until bone contact. We injected 5ml of contrast, methylene blue and ropivacaine 0.5% mixture. We realize CT scanner and then dissected the suprascapular nerve in order to determine spread injection.

In all of the 20 blocks performed, suprascapular fossa was fully covered by contrast. Contrast passed through suprascapular notch (in 80%) and through spinoglenoid notch (in 75%). Anatomical dissections demonstrated that suprascapular fossa was colored in 90%. In 2 case, methylene blue move into suprascapular muscle. Suprascapular nerve is blue-toned in 85% of case before its separation in sensitive and motor branches.

In this pre-clinical study, this SSN approach seems to be effectiveness. We postulate is easier referring to easy identifiable bone structure and associate with less risk.

Open subpectoral biceps tenodesis is often performed to treat biceps tendinopathy in conjunction with shoulder arthroscopy. We tested the hypothesis that a Pecs 2 block would provide better analgesia than surgical infiltration following open biceps tenodesis surgery.

Patients were randomly assigned to either the treatment group (Pecs 2 block with 20 mL of 0.25% bupivacaine) or the control group (local infiltration of up to 15 mL of 0.25% bupivacaine by the surgeon). All subjects received an interscalene nerve block using 20 mL of 0.5% bupivacaine, as well as either intravenous sedation or general anesthesia. The primary outcome was opioid utilization during the first 24 hours after surgery (PACU + POD1). Secondary outcomes were NRS pain scores in PACU, on POD1 and POD3, reaction to surgical subpectoral incision (such as motion or tachycardia) and postoperative skin assessment of sensation in the axilla (to evaluate block or infiltration success).

At the time of submission, complete data for at least POD1 is available for only 107 participants out of 133 patients enrolled (81%). For the first 24 hours after surgery, the treatment group used 29.8 ± 9.3 mg morphine mg equivalents (MME) vs. 32.2 ± 9.6 for the control group; p = 0.19. There were no differences in terms of reaction to incision, postoperative paresthesia/anesthesia on skin distal to surgical dressing, or postoperative pain scores.

Reynolds et al., comparing Pecs 2 block to a sham block, found an analgesic benefit. However, surgical infiltration is simpler and appears to provide comparable analgesia.

One of the important concepts that has an impact on health services is the frailty of the elderly. The preoperative assessment of the older patients can be improved by using of a frailty scale in order to identify the high-risk patients. The aims of this study were to identify the frail older patients proposed for major orthopedic surgery, to evaluate the prognosis and the discharge prospectives.

In this prospective study, we enrolled adults 65+ years admitted for elective or traumatic major orthopedic surgery between December 1st and June 1st. For preoperative frailty evaluation, we used the Fried Frailty Index for Elders (FIFE) from 0-10 points and the patients were divided by the number of positive answers: non-frail: 0 points, frailty risk: 1–3 points and frail: ≥4 points.

150 patients, with mean age (SD) 76,56 (7,31) years, female 55,15% were screened for frailty. The frailty prevalence divided by age stratification was 32% for ages 65-70 years, 35% for ages 71-80 years, and 43,33% for older than 81 years. The age category over 81 years influences the frailty score to the extent of 92.2%, there is no significant difference between the women and men, in terms of frailty score with p>0.05, the length of stay and the need for community services post-discharge were significantly longer (p<0,05).

We conclude that FIFE score is an independent tool for frail patients’ assessment. Its implementation in the hospital setting could improve perioperative outcomes and enhance the postoperative recovery of older surgical patients.

Shoulder surgery is commonly performed in the beach chair position (BCP). However, it may cause hemodynamic instability, especially when general anesthesia (GA) with a preoperative interscalene brachial plexus block (ISB) is used. Moreover, Hypotension or Bradycardia episodes (HBE) occurring during the BCP may be associated with an increased risk of neurological complications. The objectives of this study were to investigate the incidence and characteristics of HBEs and their associated factors.

The Institutional Review Board approved this study. We retrospectively reviewed the medical records of patients who underwent arthroscopic shoulder surgery under GA combined with ISB in the BCP between January 1, 2015, and July 31, 2022. HBEs, patient demographics, anesthetic, and surgical factors were collected and analyzed for their association with HBEs.

From the identified cohort of 660 patients, 482 (73%) experienced HBEs. The onset of HBEs mainly occurred earlier after patient positioning, as the mean time to the first hypotension and bradycardia episodes were 12.96 ± 18.21 minutes and 10.44 ± 13.13 minutes, respectively. Multivariable analysis showed that increasing age, female gender, and history of hypertension were associated with HBEs. In contrast, bispectral index (BIS) monitoring was associated with a lower risk of HBEs.

Age, female gender, and history of hypertension were independent risk factors for HBEs. BIS monitoring, in contrast, was a protective factor. Despite the high incidence of HBEs, no patient in this study suffered from a neurological complication. Further study is required to ascertain the advantages of BIS monitoring during the beach chair position surgery.

At University Hospital Lewisham (UHL), a 450-bed district general hospital in South East London, we have observed an increase in the use of Infiltration between the Popliteal artery and Capsule of the Knee (IPACK) blocks in the last year, with anecdotal improvement in pain outcomes. We aim to compare the effectiveness of different regional anaesthetic techniques observed, in order to enhance patients’ acute pain management and recovery.

Using SPSS software, we retrospectively analysed 100 patients who underwent total knee arthroplasty at UHL. The patients were identified using the Acute Pain Team's review pro-forma which includes pre-admission analgesic requirement, morphine equivalent requirements (MER) at day 1 and 2, and pain assessment using Numeric Rating Scale (NRS). We used the electronic records system for tourniquet time and time to mobilisation. We subdivided patients into three groups: 1)IPACK+adductor canal block (ACB)+local infiltration of analgesia (LIA); 2)ACB+LIA; 3)LIA only.

There were no statistically significant differences in MER or in time to mobilisation between the groups. Although there was a decrease in NRS score at rest and during mobilisation on day 1, we did not detect any significant difference (Table 1). However, the largest proportion of the patients with >= 100mins tourniquet time (Table 2) and pre-admission opioid use was found in group 1 (Table 3).

Our data, although suggestive, showed using IPACK blocks has no statistical benefit. IPACK blocks are growing in popularity; with increased regular practice and honing of technique, studies with a higher patient population may show statistical benefits.

Spinal anesthesia (SA) is considered contraindicated in patients with aortic stenosis (AS), due to the sympathetic block, decrease in peripheral vascular resistance, hypotension, decrease in coronary perfusion, and potential for acute myocardial ischemia. However, low-dose isobaric bupivacaine (ISOBUPI) is often used in clinical practice with little hemodynamic consequences. This study evaluates the use of SA with ISOBUPI in AS patients receiving lower limb surgery.

Medical records of patients with moderate to severe AS having lower limb orthopedic surgery and receiving SA (≤ 10 mg ISOBUPI 0.5%) were screened for the occurrence of hypotension, intraoperative vasopressor therapy, and 24-hour and 30-day mortality. Hypotension was defined as a systolic blood pressure (SBP) < 80 mmHg or mean arterial pressure (MAP) < 65 mmHg.

Thirty-five patients with moderate (n=16) to severe AS (n=19) receiving SA for lower extremity surgery were included. No 24-hour or 30-day mortality was observed. Hypotension with SBP < 80 mmHg occurred in 20% of the patients, and 51% had a MAP < 65 mmHg. Hypotensive events were treated with norepinephrine 0.04 mcg/kg/min (IQR: 0.04 - 0.04) or ephedrine 10 mg (IQR: 10 - 20), phenylephrine 200 mcg (125 - 275). No severe hemodynamic instability or other vasoactive interventions were observed.

Spinal anesthesia in patients with AS did not result in refractory hypotension or adverse outcomes. These data suggest that AS should not constitute an absolute contraindication and that studies are needed to formally evaluate the utility and safety of low-dose SA with ISOBUPI in patients with AS.

Costal fractures are a significant cause of morbidity in polytrauma patients. Poor pain control contributes directly to the appearance of complications. Multimodal analgesia is highly recommended for optimal treatment. We aimed to review the pain management of costal fractures in our center during 2021-2022.

We reviewed all the polytraumatized patients admitted to our center during 2021 and 2022, selected those with costal fractures described in chest x-ray or CT-scan and described the analgesic strategy used within the first 48 hours. We also evaluated the analgesic quality by the need of rescue analgesia (opioid vs non opioid) and the appearance of complications related to analgesia.

31 of 220 polytraumatized patients had costal fractures. All of them received an intravenous regime (IV) and only in 4 of them (13%) an only regional technique (RA) was performed: 3 ECI (epidural continuous infusion) and 1 ESP (erector spinae plane) continuous block. From this 4 patients, 3 had unilateral fractures and 1 had 13 (bilateral) fractures. There was only one complication associated in the RA group and no complications in the IV alone group. 90% of the patients had good pain control and did not need rescue analgesia. 3 of the 30 patients (10%) needed an analgesic rescue.

Multimodal analgesia is chosen in our clinical practice for pain control with good results. A shift towards RA techniques was made in 2022 in patients with numerous fractures (more than 6), even though is not exempt from complications.

Various diaphragm-sparing alternatives to interscalene block have been studied. Costoclavicular block(CCB) as the alternative, demonstrated low hemidiaphragm paralysis(HDP) occurrence but inconsistent analgesic effect in our previous study. We hypothesized that a larger volume for CCB could provide sufficient analgesia by achieving supraclavicular spreading. Therefore, we compared analgesic efficacy and HDP occurrence of two different volumes of local anesthetic(LA) for CCB in arthroscopic shoulder surgery.

Sixty patients who scheduled for elective arthroscopic rotator cuff repair were randomly allocated into either of groups; CCB20(0.75% ropivacaine 20mL) or CCB40(0.375% ropivacaine 40mL). After induction and CCB, supraclavicular spreading at supraclavicular fossa and HDP were evaluated with ultrasound observation. The primary outcome was the rate of participants who reported zero pain score at rest 1 hour postoperatively. Postoperative analgesia outcomes and outcomes HDP related were evaluated.

The rate of complete analgesia with NRS 0 at PACU were 23.3%(7/30) in CCB20 and 33.3%(10/30) in CCB40(p=0.567). The pain score at 1 hour postoperatively was no significantly different between the groups(3 [1 to 5] in CCB20 vs 2 [0 to 4] in CCB40; p=0.395). There were no statistically significant differences between the groups(p<0.098) in complete HDP occurrence. Multivariate logistic regression analysis showed that the ultrasound observation of supraclavicular spreading was significantly associated with no and mild pain(pain score <4) at immediate postoperative period regardless allocated group.

The larger volume of LA doesn’t guarantee supraclavicular spreading of CCB. Observing supraclavicular spreading using the ultrasound after CCB can be used as a tool to predict acute pain after shoulder surgery.

To study the pharmacokinetic 、 pharmacodynamic effects and histocompatibility of bupivacaine PLGA microspheres intrathecally in rabbits.

The 12 rabbits were divided randomly into two groups(n=6). One group was injected with bupivacaine solution 5mg/kg intrathecally, the other group was intrathecally injected with bupivacaine PLGA microspheres 5mg/kg. A high performance liquid chromatographic method was developed to determine bupivacaine plasma concentration. A rabbit model for evaluation of spinal anesthesia was presented on the pharmacodynamic study.

The Cmax of bupivacaine by intrathecally adminstration with Bupi-PLGA-MS were lower than that with plain bupivacaine injection(P<0.01), Tmax and MRT of Bupi-PLGA-MS were prolonged evidently compared with plain bupivacaine injection(P<0.01).A new spinal administration in rabbits has been established to research the sustained release of Bupi-PLGA-MS in vivo, and a method to evaluate the spinal anaesthetic effect first was set up. The anaesthetic time of bupivacaine microspheres groups were longer than that of plain bupivacaine injection group (P<0.01). The anaesthetic time of different anaesthetic stage by spinal administration with Bupi-PLGA-MS was prolonged compared with that of bupivacaine injection (P<0.01). There was no irritation of Bupi-PLGA-MS to the pinal tissues. The degradation occurred at the surface and the inner of microspheres, moreover, there were remained microspheres matrix after 14days degradation.

The incorporation of local anesthetics into injectable PLGA microspheres can be useful in providing prolonged spinal anesthesia effects.

The Erector Spinae Plane Block (ESPB) and the Serratus Anterior Plane Block (SAPB) are potential options for surgeries in the thorax. This study aims to compare the efficacy and safety between them.

PubMed, EMBASE, and Cochrane were searched for RCTs comparing the ESPB to the SAPB. The outcomes included opioid consumption intraoperatively and in the first 24 h, pain scores, postoperative nausea and vomiting (PONV), and block-related complications incidences. RevMan 5.4 analyzed data and sensitivity analysis was conducted by systematically removing each study. (PROSPERO - CRD42023415421)

The study analyzed six RCTs with 405 patients, 50% underwent ESPB. Intraoperative opioid consumption was significantly lower in the ESPB group (Figure 1). No significant differences were found in pain scores at rest or movement at 2h (MD4 -0.28; 95% CI -1.01 to 0.44; p=0.44 and MD -0.14; 95% CI -0.54 to 0.27; p=0.51) and 12h (MD -0.15; 95% CI -0.53 to 0.22; p=0.43 and MD -0.55; 95% CI -1.24 to 0.14; p=0.12). However, at 24h, there were significantly lower pain scores for the ESPB group when in movement (Figure 2A) and a similar tendency when in rest (Figure 2B). As for PONV (Figure 3) and overall block-related complications, there were no significant differences. Sensitivity analysis did not change the overall conclusion in any of the outcomes evaluated.

Our findings suggest that ESPB may be more effective than SAPB for thoracic surgeries, although the safety profile is similar.

Obese parturients are frequently encountered in the maternity wards and this population is expected to increase, in accordance with the obesity prevalence in the general population. Anesthetists may confront difficulties mainly regarding airway management and neuraxial techniques.

Parturients with a BMI>30kg/m2 at the time of labor were retrospectively identified, form January 2022 to January 2023. Data was collected from patient record and details of anesthetic management and obstetric complications were recorded, after Ethics Committee approval was granted.

106 obese parturients identified during the aforementioned period. The mean BMI was 34.7kg/m2, ranging from 30.1 to 49.4 kg/m2. 92 (86.7%) of them received an intrapartum neuraxial technique. 90 (89.5%) of them had an unassisted vaginal delivery, 16 (15%) an operative or instrumental delivery and 27 (25.4%) cesarean delivery (7 as emergency). Overall, 92 (86.7%) obese parturients received a labor epidural or a dural puncture epidural. 3 women requested labor epidural, but that was not achieved. 5 labor epidural attempts were recorded as vigorous. Regarding cesarian sections, 25 (92%) were performed under regional anesthesia (new spinal/ combined spinal epidural anesthesia or successful top-up of the labor epidural) and 2 (7%) under general anesthesia. 44 deliveries (41.5%) were completed out of hours, while another 15 lasted for over 12 hours.

Obese obstetric population frequently requires regional anesthetic care, while clinical pressures demand highly skilled senior anesthetists. Out of hours deliveries and long-lasting labors are common. Thus, antenatal anesthetic assessment, antenatal counseling and senior involvement is considered very important.

Ocular ultrasonography is a noninvasive method to detect intracranial hypertension through the measurement of the optic nerve sheath diameter (ONSD). Higher diameters have been reported in preeclampsia and eclampsia, but it is not known if this finding is associated with adverse maternal and neonatal outcomes. This study aimed to determine whether there is an association between the hypertensive syndromes of pregnancy and ONSD or between this measurement and adverse maternal and neonatal outcomes.

Cohort study with 183 pregnant women in the third trimester and puerperal women up to 24 hours after delivery, with the following final distribution: control group (30), gestational hypertension (14), chronic hypertension (12), preeclampsia without severe features (12), preeclampsia with severe features (62), superimposed preeclampsia (23) and eclampsia (30). Ocular ultrasonography was performed. Pregnancy data and outcomes were collected by chart review.

The ONSD was not significantly different between hypertensive syndromes and controls (p=0.056). Larger diameters were associated with maternal Intensive Care Unit (ICU) admission (p=0.00002) and maternal near miss (p=0.05). There was no association between ONSD and neonatal ICU admission (p=0.1), neonatal near miss (p=0.34), or neonatal death (p=0.26). Diameters greater than 5mm were associated with headache (p=0.008), maternal ICU admission (p<0.01), delivery with a gestational age of less than 34 weeks (p=0.01), and a newborn Apgar score below seven in the first minute of life (p=0.009).

There were no significant differences in ONSD between the hypertensive syndromes of pregnancy and controls without hypertension. Larger diameters were associated with maternal ICU admission and maternal near miss.

Robot-assisted laparoscopic radical prostatectomy (RALP) has replaced open prostatectomy. However, RALP does not reduce postoperative pain significantly compared to open prostatectomy. The acute pain response after laparoscopic surgery consists of a parietal and a visceral pain component. Although rectus sheath block (RSB) aids to control parietal pain originating from incision sites in abdominal surgeries, visceral analgesia should also be considered. We explored whether multimodal analgesia including intravenous dexmedetomidine and ketorolac reduced postoperative pain after RALP in patients receiving RSBs.

The Ethics Committee of Seoul St. Mary’s Hospital approved this prospective, non-randomized observational study on August 10, 2020 (approval number: KC20OISI0520). All patients received ultrasound-guided RSBs preoperatively for analgesia after RALP. Multimodal analgesic drugs including intraoperative intravenous infusion of dexmedetomidine and ketorolac were administered in the study group (n = 30) but not in the control group (n = 30). The pain scores and total postoperative opioid requirements were compared between the two groups until 24 h after surgery.

Demographic characteristics were comparable between the two groups. During surgery, patients in the study group were administered less remifentanil than controls. The study group showed significantly less pain scores during rest and coughing at 1 and 6 h after surgery, and less opioid requirements until the 24 h after surgery. The two groups were similar in all other postoperative characteristics.

The multimodal analgesia (intravenous dexmedetomidine and ketorolac) improved postoperative analgesia after RALP in patients with RSBs. Further studies on various combinations of multimodal analgesics are needed to promote patient recovery.

Posterior spine instrumentation and fusion (PSF) is a painful surgery undertaken to treat adolescent idiopathic scoliosis (AIS). Ultrasound-guided Erector Spinae Plane Block (ESPB) may present a new opportunity to apply regional analgesia to pediatric patients undergoing this surgery. To date, there exist limited applications of regional anesthesia for PSF in a comprehensive enhanced recovery pathway. We assessed the feasibility of performing ESPB in patients with AIS undergoing PSF.

This randomized control trial was approved by the institutional review board of the Hospital for Special Surgery (IRB# 2019-2131). A total of 24 patients were enrolled; 12 patients were randomized to receive the bilateral ESPB with local anesthesia and 12 did not receive the bilateral ESPB. Patients in both the ESPB group and no block group received the same standard anesthetic/analgesic regimen.

To reach our enrollment target of 24 participants, we approached 57 eligible patients. Out of the 12 patients randomized to the ESPB group, 9 (75.0%) successfully received the allocated intervention. Completion of the block in two patients was unsuccessful. In addition, one case was cancelled due to an unrelated intraoperative complication. Patients and their parents in the ESPB group were on average more satisfied with their pain management postoperatively than the control group.

Within our cohort, we successfully administered ESPB to 75% of the patients in the treatment group. Further studies are needed to investigate the potential benefits of ESPB improving postoperative analgesia and decreasing patient opioid requirements in patients with AIS undergoing PSF.

Pain fellow performance evaluations have historically emphasized categories such as medical knowledge, communication skills, and professionalism. Objective evaluation of procedural skills, while extremely important, has historically been neglected due to lack of standardization, subjectivity, and a wide variety of procedures between institutions. Due to this deficiency, an objective “Pain Procedure Rating System” (PaPRS) was adapted from the “Operative Performance Rating System” (OPRS) used in general surgery residencies for evaluating surgeries such as cholecystectomy. Similarly, the PaPRS provides a standardized rubric which converts individual operative performance observations into an objective performance assessment for the most fundamental pain medicine procedures.

The study was considered IRB-exempt. Procedure-specific rubrics were developed for nine of the most common fluoroscopically guided procedures (e.g. epidural steroid injection, radiofrequency ablation, spinal cord stimulation, etc). Each pain procedure rating instrument used 5-point Likert scales across procedure-specific technical skill items and general performance competencies with overall performance is then calculated based on the total score of the individual instruments (example survey: https://ucdenver.co1.qualtrics.com/jfe/form/SV_a3pO4Zk3PKnoc7A). The PaPRS was then implemented at two different major academic medical centers to demonstrate feasibility in objective assessment of trainee procedural performance.

The PaPRS assessment tools were successfully utilized at two academic medical centers with 23 trainees (13 pain fellows and 10 residents). Evaluators and trainees confirmed the ease of use, appreciation of objective measures, and longitudinal tracking ability of the scored assessments.

The PaPRS is a feasible tool to objectively assess procedural competence. Future studies include a year long longitudinal study for trainees at the academic centers.

The Perioperative Pain Service (POPS) at Hospital for Special Surgery (HSS) is a multidisciplinary team that manages acute and complex pain in orthopedic surgical patients. The team is dichotomized into an acute pain service (APS) and chronic/complex pain service (CPS). APS is consulted during hospitalization for patient-controlled analgesia (PCA) when a patient experiences uncontrolled postsurgical pain without any previously known risk factors, or when surgeons pre-emptively request this pain management strategy. The aim of this study was to identify APS utilization and case characteristics in a single, high-volume orthopedic specialty hospital.

After IRB approval for a prospective, standard of care POPS registry, cases requiring an APS consult during hospitalization for orthopedic surgical procedures between January 2022 and May 2023 were identified, and metrics extracted.

Between January 2022 and May 2023, 7,228 surgeries were captured in the POPS registry of which 4,786 (66%) involved APS. Arthroplasty and spine represented 36% and 28% of the APS cases, respectively (Figure 1). PCA was administered to 98% of cases, 71% of which were intravenous (IV) opioid only and 26% were epidural PCAs. Most spine (99%) and arthroplasty (54%) cases received IV opioid only PCA. Perineural catheters were utilized in 43 (<1%) of cases, 30 (69%) of which were for upper extremity surgeries. Overall, 3% of APS cases required inpatient CPS involvement.

APS was the most frequently used pain consult, and most patients successfully received a PCA. A small subset of APS cases required CPS involvement, suggesting that some pain management issues required escalation.

In 2021, following extensive review the Safe Anaesthesia Liaison Group updated the Stop Before You Block (SBYB) process into three explicit steps: (1) Preparation, (2) a Stop moment followed immediately by (3) performance of the Block. Two years on, this initiative had yet to gain traction within our department and a wrong side block prompted further action.

We evaluated awareness of the Prep, Stop, Block process amongst anaesthetists and anaesthetic assistants.

Though 100% of respondents (n=34) were aware of SBYB, less than 50% were aware of Prep, Stop, Block. Furthermore, only 40% of consultants felt that SBYB or Prep, Stop, Block was being carried out correctly ≥80% of the time. Based on these results we undertook further steps to address this. We began an education campaign to promote Prep, Stop, Block, including strategic placement of posters on ultrasound machines and ‘tea trolley training’ incorporating a video demonstration. We included it in teaching for both anaesthetists, anaesthetic assistants and students. We are making it a part of our standard operating policy for regional anaesthesia.

We increased awareness of Prep, Stop, Block, improved compliance with its processes and hope to have reduced the incidence of wrong side regional anaesthetic block. Despite national safety initiatives, local implementation often remains inadequate. Proactive steps are necessary to promote their uptake and improve patient safety.

Several pain management guidelines recommend administration of analgesics based on patients’ numeric rating scale(NRS) scores. This study aimed to identify which threshold patients prefer to receive analgesics with and without the risk of postoperative nausea and vomiting(PONV) in the post anaesthetic care unit(PACU).

This study was approved by the institutional Ethics Committee. Patients scheduled for elective surgery under general anaesthesia were screened between August 2019 and April 2022. Immediately after awakening from anaesthesia, patients were asked to score their pain intensity using the NRS and whether they desired no analgesic, an analgesic with or without the risk of PONV. Receiver Operating Characteristic(ROC) curves were used to assess the specificity and sensitivity of different NRS scores for receiving analgesics. Upon leaving the PACU, patients were asked which NRS score they preferred as a threshold value to receive an analgesic with and without risk of PONV.

120 patients were enrolled. ROC curves show that an NRS threshold of >2 should be used to treat patients with a mild analgesic and of >5 to administer a strong analgesic. In contrast, upon leaving the PACU, patients report a median NRS threshold of 5 to receive a mild analgesic and of 8 to receive a strong analgesic.

The thresholds perceived by patients to receive mild or strong analgesics are lower when patients are just awakening, compared to awake patients preferred threshold. We presume that sedatives might influence patients’ ability to assess their need for analgesics.

To evaluate the influence of bupivacaine baricity and fentanyl on quality of low-dose spinal anesthesia in knee arthroscopy.

The research included patients (BMI>25), who underwent short-term knee surgery under low-dose spinal anesthesia. 3 groups formed: 7 mg/165cm(±1mg/5cm) isobaric bupivacaine +10µg fentanyl intrathecally (IF group); HF – 7 mg/165cm(±1mg/5cm) hyperbaric bupivacaine +10µg fentanyl; H – 7 mg/165cm(±1mg/5cm) hyperbaric bupivacaine alone. Groups compared for sensory/motor blockade extension and duration, haemodynamics, complications, pain-satisfaction rates.

The highest superficial[Th7] and deep[Th8-12] sensory blockade levels of operated limb at 60th min recorded in IF and HF groups. Lower sensory blockades[Th9; L1] detected in H group, compared with HF (p=0.003). Shorter (p<0.0001) sensory blockade caused by isobaric bupivacaine (-137.5 min), compared to hyperbaric with fentanyl. Lasting sensory blockade (+80 min) recorded in HF vs H group (p<0.0001). The motor blockade in groups HF and H was deeper (Bromage3), but only Bromage2 in IF group with shorter duration (-122 min vs HF; -59.5 min vs H (p<0.0001)). On the opposite limb sensory blockade was higher in HF than in H group[Th9 vs L4] (p=0.006); in latter – without motor blockade. Pruritus manifested 30% with fentanyl use. One patient developed hypotension, single case of urinary retention and nausea observed (HF group).

Isobaric bupivacaine with fentanyl in low-dose spinal anesthesia ensured shorter duration of sensory/motor blockade, but sufficient analgesia – therefore had advantages over hyperbaric bupivacaine. Co-administration of fentanyl to hyperbaric bupivacaine associated with prolonged action, effects on unoperated limb, and we would not recommend for outpatient knee arthroscopy.

Radiofrequency (RF) is the main treatment for patients suffering from low back pain originating in the lumbar facet joints; since there is lot of 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 lumbar medial branch; shared trough the Spanish pain society, 91 people answered it.

13/91 perform one ultrasound-guided diagnostic block, 44/91 perform one fluoroscopy-guided block, 14/91 perform either one fluoroscopy or ultrasound-guided block depending on the patient and 6/91 perform two fluoroscopy-guided blocks. 55/91 do the parallel approach and 22/91 the perpendicular approach. 80/91 guide the RF with fluoroscopy, 8/91 with ultrasound and 3/91 combining ultrasound and fluoroscopy. 82/91 use conventional RF, 2/91 use cooled and 8/91 use pulsed. For cannula diameter, 12/91 use 22G, 39/91 use 20G, 42/91 use 18G and 3/91 use 16G. For active tip, 1/91 use 2mm, 15/91 use 5mm and 71/91 use 10mm. 11/91 use blunt-straight, 21/91 use sharp-straight, 25/91 use blunt-curved and 37/91 use sharp-curved. 6/91 apply the RF at 42°C, 8/91 at 45-60°C, 61/91 at 80°C, 12/91 at 85°C and 4/91 at 90°C. 3/91 apply 60 seconds of RF, 61/91 apply 90 seconds, 12/91 apply 120 seconds, 1/91 apply 150 seconds and 6/91 apply 180 seconds. 51/91 do one lesion, 16/91 two lesions and 15/91 three lesions.

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

Spinal anesthesia in obese parturients is difficult yet there are no guidelines to direct best practice. Ultrasonography (US) is considered standard care for regional anesthesia. The aim of this study was to evaluate the benefits of preprocedural US scanning to improve the first-attempt success rate in obese parturients.

After agreement from the local ethics committee and informed patient consent, we conducted a prospective, randomized controlled study including parturients over the age of 18 with a body mass index ≥30 kg/m2 and scheduled for elective cesarean delivery. Participants were randomized into 2 groups: a standard palpation group (standard group) and a pre-puncture US-guided neuraxial anesthesia group (US-group). The primary outcome was first pass success rate. The secondary outcomes were the number of punctures and intervertebral interspaces attempted, needle redirection, procedure Time, incidence of complications and patient satisfaction score. For all statistical tests, the significance level was set at 0.05.

Until now, 71 parturients were recruited: 33 in US-group and 38 in standard group. No clinically intergroup differences were noted regarding the demographic data. The US-group had a higher first-attempt success rate: 51.5% vs 28.9% in standard group but not significant statistically (p=0.052). There were no significant differences between the groups regarding the secondary outcomes. However, more time was required to perform the procedure in US-group (P <0.001) (Table1).

Preliminary results demonstrated that preprocedural US didn’t increase the first pass success rate. We probably need a larger sample and an US scan to be performed by operators with competence in this area.

Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiological entity characterized by headaches, seizures, altered consciousness and visual disturbances. The authors describe a clinical case of PRES to highlight the importance of clinical differences between this syndrome and post-dural puncture headache (PDPH).

45-year-old female, ASA II, with 2 previous cesarian sections (CS) was admitted for an elective CS. Anesthesia was performed uneventfully with combined spinal-epidural anesthesia. No history of gestational hypertension, neurological pathology, vascular malformations or cranioencephalic trauma. A headache with PDPH characteristics developed 24h post CS and responded favorably to conservative analgesic therapy. At 72h post CS, the characteristics of the headache changed, becoming continuous with associated tinnitus and photophobia. Simultaneously she presented high blood pressure, nausea and vomiting. An epidural blood-patch was performed, with no evidence of complications and immediate symptomatic relief was achieved.

Three hours after the epidural blood-patch, the patient had a seizure. The brain CT was compatible with reversible cerebral vasoconstriction syndrome. She was admitted in the Intensive Care Unit for monitorization and treatment of blood pressure as well as symptomatic surveillance. She then performed a brain MRI which confirmed PRES. The patient demanded hospital discharge against medical advice and suspended therapy at this point. She is asymptomatic since then, maintaining a normal baseline arterial pressure.

PRES is an entity that can simulate an obstetric emergency, being an extremely important differential diagnosis of PDPH. This requires additional brain imaging exams and a multidisciplinary discussion.

Women face gender-based challenges in both their medical education and careers¹. We explored how regional anaesthetic (RA) career experiences were affected by gender and evaluated international differences.

We designed a survey open to healthcare professionals with an RA interest. This was disseminated via social media.

We received 96 responses (58:38 female:male split) across 15 countries. (See table). 32.8% of women, and 2.6% of men reported being treated unfairly at work due to gender. Regarding RA, half of women’s free text answers (8/16) cited being overlooked for opportunities in favour of male counterparts. Male responses cited mostly positive or neutral experiences in RA. Seven explicitly acknowledged perceiving female disadvantage and four explicitly stated there were no gender differences. Both genders reported bullying and harassment from surgeons. Women additionally cited RA trainers as perpetrators and reported incidents of sexual harassment. Similar numbers (76%:79% female:male) reported having caring responsibilities but women were more than 2.5x more likely to say it affected their RA career.

Women have different experiences in their RA careers compared to men. Our high female response rate reflects data collection via social media #ThisGirlBlocks campaign. Common RA career barriers faced by women were lack of time and missed opportunities - due to caring commitments, maternity leave and being less than full time (LTFT). Men cited childcare and LTFT as obstacles, but less frequently. To achieve equity, our community must acknowledge gender imbalances and institute systemic change. There is global under-representation of women². From our study, it’s easy to see why.

Median sternotomy (MS) is the most commonly used incision in cardiac surgery. Sternal dehiscence is a rare but alarming complication. Re-administration of general anesthesia may be a problem in these patients. Parasternal intercostal plane (PIP) blocks may not have adequate anesthesia coverage in the lower sternum [1]. In our cadaver study, we injected local anesthetic in the fascial plane between the 6th-7th costal cartilages and the rectus abdominis muscle, which we called recto-intercostal plane block, and it dyed the nerves where the PIP missed (Figure 1). In this study, our aim was to present the use of a combination of superficial PIP and RIP block as the main anesthesia method in patients undergoing sternum revision surgery and to demonstrate its feasibility.

For this retrospective study, IRB approval was obtained, and included patients undergoing post-MS sternal revision surgery who gave written informed consent to the combination of these blocks as main anesthetic technique.

A total of 9 patients who underwent post-MS sternum revision between June 2022 and March 2023 received this combined anesthesia approach. Surgeries were completed without complications, without the need for deep sedation or general anesthesia. Figure 2 shows the surgical incisions, and Table 1 presents patient and block characteristics and additional anesthesia requirements.

The PIP block combined with the newly described RIP block and mild sedoanalgesia provides safe and adequate anesthesia for high-risk patients. However, more studies are needed to assess dermatome effects and examine data regarding recovery quality.

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 now 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.

The transversus abdominis plane (TAP) block is commonly used for postoperative analgesia. We aimed to compare postoperative analgesic effects and opioid consumption between oblique subcostal (OSTAP), posterior, or dual TAP blocks in laparoscopic cholecystectomy (LC) patients.

In this prospective, randomized-controlled, double-blinded study, 85 patients undergoing LC aged 18-65, and ASA 1-2 were enrolled after ethical approval (NCT04693156). Patients were randomized into three groups. In Group 1 OSTAP, Group 2 posterior TAP, and Group 3 dual (OSTAP and posterior) TAP blocks were performed with 0.5% Bupivacaine, 1% Prilocaine, and saline (each 10mL) ultrasound-guided, right unilaterally and postoperatively; to maintain blindness in Group 1 posterior TAP and Group 2 OSTAP block were performed with saline 30mL. Pain severity by numerical rating scale (NRS), analgesic consumption, and sensory dermatomal involvement (T6-L2) was recorded at 0th-2nd-4th-6th-8th-12th-24th hours. If 7>NRS≥4 dexketoprofen 50mg, if NRS≥7 tramadol 100mg was administered. P<0.05 was considered statistically significant using SPSS 22.0.

Seventy-one patients' data were analyzed. At initial assessment, 12 patients in Group 1(n=21), six patients in Group 2(n=24), and three patients in Group 3(n=26) had NRS≥4 (p=0.008). None of the patients in Group 3 required tramadol, whereas 33.3% in Group 1 and 8.3% in Group 2 required tramadol (p=0.001). Dermatomal involvement was wider in Group 2 and Group 3 than in Group 1 (p=0.001).

With dual TAP block, more effective analgesia is provided than OSTAP block, and posterior TAP block is as effective as dual TAP block therefore both can be chosen for postoperative pain control in LC patients.

The incidence of unruptured intracranial aneurysm is 2% of the general population with a significant prevalence in the generative period, when the risk of rupture is more pronounced. The main feature is accidental detection due to non-specific resistant headaches.

Our case report shows the anesthetic management of caesarean section in the presence of an unruptured basilar artery aneurysm

36-year-old pregnant woman was prepared for a caesarean section under neuraxial anesthesia based on neurosurgical recommendations according to an accidentally discovered unruptured aneurysm of the basilar artery. One year ago, she was regularly monitored neurologically and radiologically, perioperatively without neurological expression. She denied allergies, and stated regular antiarrhythmic therapy (Verapamil tbl 40mg). Pre-anesthetic examination revealed unremarkable vital signs. The anesthetic technique of choice was epidural anesthesia, L3-L4 level and administration of local anesthetic - levobupivacaine 0.5% with opioid adjuvant - fentanyl. Concomitantly, a ephedrine infusion was started and continuously titrated to maintain systolic and mean arterial pressure. Intraoperatively and postoperatively, the emphasis was on hemodynamic stability. Pain control was provided regularly for 6 hours with Levobupivacain 0.25% with opioid adjuvant. The patient did not exhibit any neurological deficits.

The relationship between the mode of delivery and risk for aneurysm rupture is not well defined. The decision on anesthetic management is significantly influenced by the physiological changes of pregnancy because they increase the risk of aneurysm rupture as a result of sudden changes in intracranial pressure. Hemodynamic stability is crucial for safe and secure anesthesia and controlling the risk of aneurysm rupture

The physiological and anatomical changes of the pregnant woman are sometimes challenging for the anesthesiologist1. The goal should be to keep the mother safe while maintaining the pregnant state and minimizing the interference with the fetus1 and the choice of the anaesthetic technique is of the utmost importance.

Description of a case of spinal surgery in a pregnant woman.

35-year-old woman, ASA II, 21 weeks pregnant, scheduled for L5-S1 discectomy due to disabling lumbar pain. Anaesthetic technique was established as general anaesthesia. The induction of anaesthesia was uneventful and accomplished with rapid sequence induction with lidocaine, propofol, rocuronium and remifentanil in perfusion. Intubation was successful at first attempt with videolaryngoscope and ramped position. After intubation the patient was rolled over to the prone position. Sevofluran was used for maintenance of anaesthesia. Analgesia was accomplished with 1g of paracetamol and with administration of ropivacaine and morphine in the epidural space under direct visualization by the surgeon. The patient maintained hemodynamic and ventilatory stability during surgery. Emergence from anaesthesia was uneventful. The patient was taken to the post anaesthesia care unit awake and well. Fetal viability was confirmed with US.

Regional anaesthetic techniques during pregnancy are preferred because they minimize fetal drug exposure. Nevertheless, in this case the benefits of general anaesthesia outweighed those of regional one. The length of surgery, the prone position required and the risk of difficult surgical intervention conditioned the choice of anaesthetic technique. However, we minimized fetal exposure to systemic opioids by adopting a multimodal analgesia strategy.

Herpes zoster(HZ) inflammation in the ganglia and the retrograde transport along peripheral nerves result in severe neuropathic pain and skin rash. HZ is often diagnosed based on the dermatome affected by skin rash of the ventral rami of the thoracic spinal nerves. However, the HZ rash and pain are not always accompanied by symptoms on the posterior trunk innervated by the dorsal ramus of the spinal nerve. We investigated whether zoster-associated posterior trunk pain, innervated by the dorsal ramus of the spinal nerve, contributes to the chronicity of pain.

We conducted a retrospective cohort study in our department. We reviewed the medical records of 82 outpatients who had initiated treatment for thoracic zoster-associated pain within 90 days of onset. The participants were divided into two groups based on the presence or absence of posterior trunk pain at the initial visit: 51 patients with pain (+) and 31 patients without pain (-). We compared the duration of treatment and the rate of chronicity in the two groups using Excel statistics.

No significant differences in the background of the patients were observed between the two groups. The median (interquartile range) duration of treatment was 86 (39-157) days for the (+) group and 75 (36.5-115) days for the (-) group. There was no significant difference in the rate of chronicity or duration of treatment based on the presence or absence of pain.

It was not possible to confirm that zoster-associated posterior trunk pain innervated by the dorsal ramus contributes to the chronification.

Lumbar discectomy is commonly performed for prolapsed intervertebral disc and degenerative spine. The erector spinae block is paravertebral by proxy fascial plane block whereas, the thoracolumbar interfacial plain block is a paraspinal plane block. We aimed to compare the efficacy of ultrasound-guided - Erector spinae block Vs thoracolumbar interfascial plane block for postoperative analgesia in lumbar discectomy surgeries.

After obtaining institute ethical committee clearance and written informed consent, 60 patients were randomly allocated into 2 groups- Group E (bilateral lumbar ESP block) and Group T(bilateral TLIP block) received 40 ml of 0.2% ropivacaine and 1mcg/kg of dexmedetomidine after general anaesthesia. The primary objective was to compare VAS at rest and at activity at 30 mins, 1, 6, 12 and 24 hours postoperatively. The secondary outcome of the study was to compare the time to the first dose of rescue analgesia and the number of times rescue analgesia was needed.

The VAS score at activity was significantly lowered at all times in group E as compared to group T.(p<0.001) At rest, group E had lower VAS at all durations except at 1st hour. The time to 1st analgesic requirement and number of times rescue analgesia was needed was significantly lowered in group E than in group T.(P<0.001)

Ultrasound-guided erector spinae block is a better technique as compared to ultrasound-guided thoracolumbar interfascial block for post-operative analgesia in lumbar discectomy surgeries.

The Perioperative Pain Service (POPS) at Hospital for Special Surgery (HSS) is a multidisciplinary team specializing in the management of acute, chronic, and complex pain in orthopedic surgical patients. The aims of this project were to create an automated registry embedded in the electronic health record that captures surgical cases with any POPS encounter and stores patient metrics over time (Figure 1).

After IRB approval, logic functions were programmed within the electronic medical record to capture surgical cases that had an encounter with POPS before, during or after surgery (Figure 2). Case characteristics saved daily within the database include patient demographics, pain intensity, and surgery details, with more metrics being programmed and validated.

Between January 2022 through April 2023, 6,475 scheduled surgical cases met registry criteria (Figure 2). Out of these cases, 1,183 (18%) had a preoperative pain consultation, 4,561 (70%) involved the acute pain service, 1,580 (24%) involved the chronic pain service, and 31 (0.46%) required a post-discharge pain consultation. Patient-controlled analgesia was utilized in 5,668 (88%) cases of which 3,810 (60%) received only intravenous opioid and <1% received a perineural catheter.

As the first encounter-based, analytical registry at HSS, the POPS registry represents a proof-of-concept, auto-updating data repository designed for an inpatient pain management specialty service. Research and quality improvement projects leveraging this registry may elucidate improvements in the preoperative pain screening referral workflow and identify modifiable risk factors and multimodal strategies to mitigate severe acute pain, opioid consumption, and resource utilization in complex pain patients.

Preoperative rehabilitation in femoral-neck fracture patients has been shown to improve postoperative outcomes but it can be challenging due to intolerable pain. The pericapsular nerve group (PENG) block has been utilized for postoperative pain control for femoral-neck fracture repair with motor-sparing features. This study seeks to assess the efficacy of PENG block in preoperative rehabilitation for femoral-neck fracture patients.

Ten patients with Garden classification 3-4 femoral-neck fractures scheduled for total hip arthroplasty, were prospectively enrolled from April-July 2022 at Kameda Medical Center, Japan (PENG group). These patients received PENG block with 20 ml of 0.375% ropivacaine before the initial preoperative rehabilitation. The rehabilitation program included nine mobility levels of bed-sitting, edge-sitting, standing, wheelchair-transfer, marching, walking with two or one staff, and walking with or without a device. Data from twenty-six patients with the same eligibility who received the same rehabilitation program with standard pain management from April 2021-March 2022 were collected as a control group. The primary outcome was the cumulative outcome of the rehabilitation program. The secondary outcomes included the numerical rating scale (NRS) score and home-discharge rate.

One patient in the PENG group could not perform rehabilitation due to high blood pressure. The primary outcome achievement was significantly greater in the PENG group (44.4% vs. 8.5%; odds ratio: 8.5, 95% CI: 4.3-17.0; p<0.0001). The PENG group also had a significantly lower NRS score and a higher home-discharge rate. No adverse events related to PENG block were observed.

PENG block may facilitate preoperative rehabilitation in femoral-neck fracture patients.

General anesthesia is commonly preferred in laparoscopic cholecystectomies (LC). However, different anesthesia approaches can be applied in high-risk patients. In this study, we aimed to present a case of a pulmonary high-risk patient who underwent LC with paravertebral block and Quadratus Lumborum-III block (QLB).

The 62-year-old male patient had a history of hypertension, COPD, and previous tuberculosis. The patient's test results revealed FEV1 of 49%, FEV1/FVC ratio of 68%. The patient had dyspnea, and computed tomography showed destructive, fibrotic changes and pleural thickening in the lungs. Due to high pulmonary risk, regional anesthesia was planned for this patient. Bilateral paravertebral block(Fig-1) and bilateral QLB-III(Fig-2) were applied for 30 minutes before the operation at the thoracic 8 level. The patient, who had T4-T12 dermatome involvement, was sedated with 2 mg midazolam and 50 mcg fentanyl, and then taken to the operation room(Fig-3). The patient's Richmond Agitation Sedation Scale remained at -1 during the operation.

The patient was transferred to the ward without any complications or pain after the operation. The patient consumed 4 g of paracetamol, 50 mg of dexketoprofen, and 50 mg of tramadol in postoperative analgesia during 24 hours , and was discharged without any issues at the end of the 24th hour.

This case report describes the successful use of Paravertebral and QLB-III in a pulmonary risk patient undergoing LC. We believe that Paravertebral and QLB-III can be a safe and an effective option for regional anesthesia in pulmonary risk patients undergoing LC.

Ultrasound-guided regional anaesthesia techniques are recent congeners in multimodal pain management, leading to the development of fascial plane blocks. With the advent of ultrasound, alternative paraspinal blocks have been explored which include the Erector spinae plane [ESP] block and Sub-transverse interfragmentary [STIL] block. We aimed to assess the effectiveness and safety of STIL block in comparison with ESP block in patients undergoing Modified Radical Mastectomy.

After ethical committee clearance, 150 female patients undergoing Modified Radical Mastectomy between 18-65 years of age with ASA grade I & II with informed consent were selected. After induction of general anaesthesia patients were placed in a lateral position and using a high-frequency linear ultrasound probe, 20 mL of 0.25 % Levobupivacaine was given each in Group 1( ESP block) and Group 2(STIL). Post-operative pain in the form of the Numerical Rating Scale [NRS] was assessed. Changes in hemodynamic parameters, the total dose of opioid requirement, total duration of analgesia, total time taken for procedure and the number of doses of rescue analgesia required were also recorded.

NRS scores and requirement of rescue analgesia were significantly low and duration of analgesia was significantly high in Group 2 patients. Variations in haemodynamics were significantly less in group 2. The time taken for performing the procedure was significantly less in group 1.

STIL block provides longer-acting analgesia with better hemodynamic outcomes as compared to ESP block in patients undergoing MRM. STIL block is however technically more challenging than ESP block.

This study aimed to validate a predictive model of postpartum depression in patients having undergone Caesarean delivery to determine clinical relevance of pre-operative determinants for post-Caesarean pain management.

Parturients undergoing Caesarean delivery and requiring regional anaesthesia were recruited. Pre-delivery pain and anxiety assessment were conducted via pain scoring, mechanical temporal summation assessment and questionnaires. Outcome on incidence of postpartum depression is defined as having an Edinburgh Postpartum Depression Scale (EPDS) score of 10 or more. Other information on pain scores, analgesia consumption, opioid-related side effects, and patient satisfaction were also collected.

In this validation study, postpartum depression at 6 to 10 weeks post-delivery occurred in 18.9% (34 of 180) of patients who underwent elective Caesarean delivery. Having pre-delivery EPDS score ≥ 10 (adjusted odds ratio (aOR) 4.61, 95%CI 1.19-17.77, p=0.0266), pre-operative pain score with movement (aOR 1.65, 95%CI 1.03-2.67, p=0.0385), anxiety about upcoming surgery (aOR 1.01, 95%CI 0.99-1.04, p=0.4056), higher pre-operative Hospital Anxiety and Depression Scale (HADS) subscale on anxiety (aOR 1.21, 95%CI 0.99-1.48, p=0.0610), and higher pre-operative central sensitization inventory (CSI) scores (aOR 1.04, 95%CI 0.99-1.10, p=0.0915) were associated with an increased risk of postpartum depression. Anticipated pain medication needs was associated with reduced risk of postpartum depression (aOR 0.59, 95%CI 0.31-1.12, p=0.1041). Internal cross validation and external validation AUC is 0.80 (95%CI 0.69-0.90) and 0.81 (95%CI 0.71-0.91) respectively.

The proposed model performed well in our local population. Further refinement may be necessary to test the proposed model in other clinical settings of different social and cultural contexts.

Hemophilia A is a hereditary coagulation disorder related to congenitally low levels of factor VIII. Although pregnant women with this condition are at risk of bleeding, these values typically rise during pregnancy. Multiple professional societies recommend factor VIII level above 50% for neuraxial approach and delivery.

We report the successful management of a 35-year-old pregnant woman with hemophilia A (pregestational factor VIII values of 30%) undergoing C-section to minimize fetal vaginal trauma. Preoperative factor VIII level was 84%. After multidisciplinary discussion, spinal anesthesia was performed, using levobupivacaine 8mg, sufentanil 2.5μg and morphine 100μg. Standard ASA monitoring was used. Transient hypotension was managed successfully using phenylephrine 100mcg. Tranexamic acid was administered before the procedure and continued postoperatively. Surgery was uneventful and blood loss was estimated at 250mL. Postoperative intravenous analgesia was provided with paracetamol and ketorolac. The patient was transferred to the recovery room and discharged on postoperative day 3, without any complications.

Spinal anesthesia is a viable option for pregnant women with hemophilia A who require a C-section. The use of tranexamic acid and neuraxial techniques can help reduce the risk of bleeding, while avoiding general anesthesia. Epidural catheter was not used in this case due to the potential postpartum decreases in factor VIII levels. Adequate preoperative planning and multidisciplinarity are crucial in managing these patients.

Pregnant women with hemophilia A can safely undergo spinal anesthesia for a C- section with careful management and monitoring of factor VIII levels.

TPVB is considered the gold standard for breast surgery but is associated with complications. Though PEC block has been used with good results, it spares the medial part of the breast. PIFB targets the anterior cutaneous branch of the intercostal nerve, which supplies the medial aspect of breast. We hypothesised that USG guided combined pectoral nerve block and pecto intercostal fascial block will provide better perioperative analgesia and less adverse effects in MRM patients as compared to paravertebral block.

30 ASAI and II patients posted for MRM under general anaesthesia were included in this double blinded RCT. Patients in Group A received US guided TPVB, whereas Group B received a combined PEC with PICF block. Post-operatively patients were administered intravenous morphine via patient-controlled analgesia (PCA) pump. Time to first rescue analgesia, total opioid consumption, NRS at various time intervals, Total rescue dose required, Patient satisfaction score were noted.

There was no difference in intraoperative opioid consumption. The time to first rescue analgesia was more in TPVB group (GA 673 min +/- 496) than PEC-PICF group. (GB 518 min +/-413). P value:0.18. The 24-hour opioid consumption (162+/-41.7mcg Vs 149+/-44.5mcg), median NRS scores (GA Rest2/Motion2 Vs GB Rest2/Motion3) and patient satisfaction (GA 2.6 vs GB 2.8) was similar in both the groups. There was no adverse effects in wither groups. (vascular puncture, pneumothorax, vomiting).

PECS block provides similar analgesia in terms of 24 hours opioid consumption, NRS scores and PSS in MRM patients. Further increase in sample size will validate our results.

Thyroid surgery maybe associated with mild-moderate pain, with 66-90% patients requiring opioids on the first postoperatively. This study compared superficial cervical plexus block (SCPB) [USG subcutaneous local anaesthetic (LA) injection at Erb’s point] and intermediate CPB (IMCPB) [USG LA injection below posterior SCM border] for thyroid surgery under general anaesthesia. Primary outcome was 24-hr postoperative fentanyl requirement; secondary outcomes included time to first analgesic, 24-hr pain at rest and swallowing, pre and 20 min post block diaphragmatic excursions (normal, deep breathing, sniffing), diaphragmatic thickening fraction (TFdi), PFT (phrenic nerve function), hoarseness (RLN nerve function), Horner’s syndrome and dermatomes blocked.

Following ethics committee approval, 57 consenting ASA I-II, 18-75-year patients undergoing thyroidectomy were randomly allocated to IMCPB (n=28) or SCPB (n=29) groups. Ropivacaine 10ml, 0.375% was injected bilaterally, pre-induction in both groups.

C2-C4 dermatomes were blocked in both groups. 24-hr postoperative fentanyl requirement was significantly lower and time to first rescue analgesic was shorter in the IMCPB group. (Table 1) VAS on rest and swallowing was significantly lower in the IMCPB group for 2-hrs and at 24-hrs. (Figure 1) 53% IMCPB patients developed a sympathetic haemodynamic response 5min post-block that lasted for 30-45min. Diaphragmatic excursions on deep breathing and PEFR were significantly reduced in the IMCPB group. Incidence of hoarseness, ear lobe numbness, Horner’s syndrome was significantly higher in the IMCPB group. (Table 2)(Table 2)

IMCPB resulted in better analgesia but more adverse effects. Further studies need to ascertain optimal LA dose for IMCPB in patients undergoing thyroid surgery.

In 2020, 11.7% of cancers diagnosed were female breast cancers, making it the most common cancer worldwide(1). With alarming incidence, surgery remains the main modality of management of resectable breast cancer. Despite the PROSPECT(2) guidelines, the regional anaesthetic /analgesic practices for breast surgery vary greatly. This survey aims to determine the current regional anaesthetic /analgesic practices for oncological breast surgery across several centres of the UK.

60 anaesthetists from the Association of Breast Surgery(3) database of hospitals across the UK were emailed survey (Microsoft) forms, in order to ascertain their regional anaesthetic /analgesic practices for oncological breast surgery. The choice of regional block (if performed), its timing and the follow-up practices were determined.

A 40 % response to the survey was received, of which 62% responded positively to the use of regional blocks. 66% of anaesthestists preferred blocks post, rather than pre-induction (12%) or at the end of surgery (12%). Follow up of patients for persistent post-surgical pain is not being done at present in any of the centres surveyed. The pectoral nerve block (PECs I/II) and thoracic paravertebral blocks (PVB) were the preferred choices of blocks, with PECs I/II overtaking PVB for most breast surgeries. Serratus anterior plane (SAP) and Erector spinae plane block (ESP) are yet to gain their popularity, and axillary clearance has limited regional options at present.

Though supplementing a regional technique over GA alone, for oncological breast surgery has a well-established advantage(4), further work in the field will help identify the barriers in its execution.

Post-operative hyponatremia is a relatively common occurrence. We identified risk factors (see Table 1) for the development of hyponatremia and developed a risk calculator (https://orthoapps.shinyapps.io/Hponatremia_TJA/) (Kunze, 2022). In a prospective study, a best practice alert (BPA) was sent to the practitioner advising them to use plasma-lyte instead of lactated rangers along with other precautions for patients having 3 of the 4 pre-op risk factors.

We examined joint replacement patients at the Hospital for Special Surgery from March 2022 to March 2023. Prescribers received best practice alerts (BPA) when patients were determined to be at risk for hyponatremia. Descriptive statistical analyses were performed.

Between March 2022 and March 2023, the hospital's overall hyponatremia rate dropped from 29% to 14% (p<0.05). Moderate hyponatremia dropped from 3.4% in March 2022 to 1.3% in March 2023. During the same period, severe hyponatremia dropped from 0.57% to 0.22%. The instituted BPA was sent 16,357 times across 1,078 patients at risk for hyponatremia. 31% of these patients developed mild hyponatremia (Na = 130-134) and 10% developed moderate (Na < 130). Plasma-lyte usage is on the rise throughout hospitals and will soon become the standard IV fluid solution for surgical patients.

A best practice alert helped identify patients at risk for hyponatremia, resulting in a reduction of postoperative hyponatremia. Additionally, concurrent plasma-lyte administration decreased the incidence and severity of hyponatremia. Pre-operative detection of postoperative hyponatremia may improve if the hyponatremia risk calculator includes post-operative risk factors such blood loss and surgery duration.

Vertebral canal haematoma following obstetric regional anaesthesia, although rare, can lead to catastrophic and life changing neurological damage. Early detection is essential to limit avoidable harm. In 2020, guidelines published by the AAGBI/OAA(1) recommended all women recovering from neuraxial anaesthesia should be: 1. Able to straight-leg raise (SLR) four hours following the last epidural/spinal dose. 2. Informed of the four hour timescale. 3. Encouraged to alert staff if recovery from neuraxial anaesthesia is delayed. The aim of this project was to implement the Regional Anaesthetic Alert Bracelet (RA-AB) (2) to comply with UK national recommendations.

An RA-AB was designed to empower the patient to inform the multidisciplinary team (MDT) if unable to SLR four hours following their last neuraxial dose (fig.1). Following a patient survey and pre-implementation MDT education (fig.2), the RA-AB was introduced in Worthing Hospital delivery suite in April 2023. Nationally, RA-AB has been successfully implemented in over 50 NHS Trusts.

Pre-wristband implementation questionnaires surveyed 18 patients undergoing neuraxial anaesthesia for elective caesarean section, with over a fifth (22%) answering they would not know who to contact should they have concerns regarding residual neurological symptoms. A further question revealed fifty percent of patients surveyed would appreciate further information regarding expected recovery and complications.

Introduction of the RA-AB project has been a simple, cost-effective way of meeting AAGBI/OAA recommendations. It empowers patients in their recovery and educates staff on safe recovery from neuraxial anaesthesia. Future work will assess wristband compliance, patient satisfaction and identify any delayed neurological recovery.

To evaluate the results of ultrasound-guided interscalene block on wound healing and immunity in open shoulder surgery cases.

Participants were randomized into 2 groups. Group GA : Standard ASA monitoring, 2 mg/kg propofol, 0.6mg/kg rocuronium bromide, induction with 1µcg/kg fentanyl, 2MAC sevoflurane + 40% air mixture, and maintenance with 2L/min. Before extubation, 1 mg/kg tramadol and 15 mg/kg paracetamol iv. Paracetamol was repeated at 8 hour intervals. Group IS : Standard ASA monitoring and ultrasound guided interscalene block with 20 ml of 0.25% bupivacaine. Before postoperative unit, 1 mg/kg tramadol and 15 mg/kg paracetamol iv. Paracetamol was repeated at 8 hour intervals. Platelet count, PDGF (Platelet growth factor), TGF-α (transforming growth factor), EGF (epidermal growth factor), IL-1/IL-2, TNF-α (tumor necrosis factor alpha) measurements were taken half an hour before the operation, repeated 24 and 48 hours postoperatively. The patients were called for wound evaluation on the 14th day). Demographic data, VAS scores, side effects, additional analgesic requirement, mobilization time, hospital stay were recorded and evaluated statistically. The study is ongoing and the parameters of the immunity arm will be shared

The platelet values at the postoperative 24th and 48th hours were significantly higher in the IS group (Table 1) (p < 0.05)(Figure 1).The VAS scores and the amount of additional analgesic used, side effects, mobilization time were higher in the GA (p < 0.05) (Figure 2-3).

The positive effects of interscalene block on wound healing and postoperative period were observed.Results on immunity will also be shared

Spine surgery is a complex and traumatic intervention that require sufficient anaesthesia supplementation. Erector spine plane block (ESPB) is an effective method of reducing pain intensity, but there is insufficient data on its effect on hemodynamic parameters, blood loss (BL) and possible complications. Aim. Compare the impact of anaesthesia with ESPB and without on amount of opiates, BL, infusion therapy (IT), intensity of pain, study the consequence of two methods of anaesthesia on hemodynamic parameters, time of weaning from ventilation (TWV) and duration of hospitalization (DH).

151 patients which underwent spine surgery were divided into groups: G1 - general anaesthesia with ESPB, G2 - general anaesthesia alone. Outcomes: intensity of pain at rest (IPR) and movements (IPM) after surgery, DH, TWV, amount of fentanyl used intraoperatively and morphine postoperatively, mean arterial pressure (MAP), heart rate (HR), BL, diuresis, and IT during surgery.

IPR, IPM were lower (p< 0,01) in G1(Fig.1). DH, TWV were longer (p< 0,01) in G2 (14,09±7,27days;23,68±5,16minutes) in comparison with G2 (8,33±3,91;9,07±2,70respectively). Amount of fentanyl and morphine was lower (p< 0,01) in G1 (1,84±0,75μgkg-1;5,62±5,00mg) in contraindication to G2 (3,64±1,21μgkg-1;28,97±9,75mg). HR, MBP were higher (p< 0,01) in G2 (Fig.1, Fig.2). BL, IT were higher (p=0,04;p=0,14) in G2 (610,26±406,31ml;1949,36±917,45) in comparison with G1 (480,82±354,60ml; 1597,12±809,54ml). Diuresis didn't differ (p=0,627) in groups (G1-102,74±10,46ml;G2-110,32±17,78).

ESPB as a component of anaesthesia reduces intensity of pain at all stages of observation after surgery, decrease amount of opiates, duration of ventilation and hospitalization. ESPB diminish HR and SBP, minimize BL and IT without affecting diuresis.

Percutaneous Nephrolithotomy (PCNL) is associated with moderate to severe postoperative pain. Thoracic paravertebral block (TPVB and ultrasound-guided (USG) interfascial plane block can effectively reduce postoperative pain following PCNL. Newer interfascial plane blocks: Erector Spinae Plane Block (ESPB), and Costotransverse Foramen Block (CTFB), both single and multiple-level injections, have shown wide dermatomal spread and provide adequate analgesia. We hypothesize that triple-level USG-ESPB has analgesic efficacy not inferior to triple-level USG-CTFB in patients undergoing PCNL.

This prospective randomized, double-blind, inferiority trial was conducted after ethics committee approval. Fifty patients scheduled for PCNL were included in the trial. Patients received either triple-level USG-ESPB or triple-level USG-CTFB. Seven ml of 0.375% Ropivacaine at each level (21ml.) was injected for either block after induction of anaesthesia in the prone position. Total analgesic requirement (total cumulative morphine consumption in 24 hours), intraoperative analgesic requirement, time for the first analgesic, and 11-point NRS at various intervals for 24 hours were noted.

Median cumulative morphine consumption in 24 hours was 7mg (4-11.75 mg) and 7mg (3-11 mg) in ESPB and CTPB groups, respectively (P=.26). The mean time for the first analgesic requirement in the postoperative period in ESPB group was 189.8 ± 80.2 minutes and 199.6 ± 79.8 minutes in CTFB group (P=.66). No significant difference in the median NRS scores at rest and at movement at various time-intervals were observed. No adverse event was observed.

Our study demonstrated that in patients undergoing Percutaneous Nephrolithotomy, triple-level USG-ESPB is not inferior to triple Level USG-CTFB in providing postoperative analgesia.

The present study aimed at comparing the analgesic efficacy of intrathecal morphine and bupivacaine (ITMB) and rectus sheath block (RSB) in patients who underwent robotic-assisted laparoscopic prostatectomy (RALP).

The institutional review board of Seoul St. Mary's hospital granted this prospective observational study on April 29, 2020 (approval number: KC20OISI0124). Fifty patients scheduled for elective RALP were randomly allocated into the ITMB (n = 30) and RSB (n = 30) groups. The ITMB group received an intrathecal injection of 0.2 mg morphine and 7.5 mg bupivacaine, preoperatively. Using 20 mL of 0.25% bupivacaine, RSB was performed bilaterally after the induction of general anesthesia in the RSB group. The fentanyl-based patient-controlled analgesia was intravenously infused after surgery in all patients. Cumulative opioid consumption and the numeric rating scale (NRS) score were assessed at 1, 6, and 24 h postoperatively.

Demographic findings were comparable between the two groups. During surgery, patients in the ITM group were administered less remifentanil than the RSB group. The ITM group showed significantly less NRS scores during rest and coughing, and less cumulative opioid consumptions at 1 h, 6 h, and 24 h after surgery. No significant differences in complications were observed, during or after surgery.

ITMB enhanced analgesia during the early postoperative period in patients who underwent RALP, compared with RSB. The postoperative requirement for opioid analgesics were also significantly decreased in the ITMB group. Thus, intrathecal analgesia is considered an effective analgesic modality for RALP. Further studies are needed to promote patient recovery.

Needle trauma has been associated to peripheral nerve injury and neurological dysfunction. However, inadvertent needle puncture is not infrequent while post-block dysfunction is rare. We conducted a cadaveric study to evaluate the association between needle puncture and fascicular injury.

Five median and five ulnar (isolated) nerves were obtained from unembalmed fresh human cadavers. 4 different needles were used for the punctures: A 22G nerve block needle (Stimuplex 360, 30 degrees beveled), and 22G, 25G and 27G spinal needles (Yale, 15 degrees beveled). 10 transfixing punctures were made with each needle type on each nerve (40 punctures per nerve). Needles were withdrawn and nerves fixed in 5% formalin for 72 hours. Perpendicular microtome sections of the punctured segments were obtained. Samples were embedded in paraffin and analyzed under microscope with hematoxylin-eosin staining. For each section, the following variables were obtained: ratio of fascicular /epineurial tissue, number of fascicles per nerve, number of injured fascicles.

A total of 400 transfixing punctures were made (200 in median and 200 in ulnar) and 144 histological nerve sections analyzed (74 median and 70 ulnar). Median nerves had 15 +/-3 fascicles and ulnar 17+/- 4. The ratio of fascicular/epineural tissue was 47 +/-14% in median and 43+/-6% in ulnar. Three fascicular injuries were found (1 in median, 2 in ulnar). All 3 injuries were caused by a 15 degree beveled needle (22G in median, 27G and 22G in ulnar).

The risk of fascicular injury is low following a transfixing needle puncture.

Achieving rapid onset of surgical anaesthesia after an ultrasound-guided popliteal sciatic nerve block (PSNB) is still a challenge. We hypothesised that two subparaneural injections below the divergence (BD) of the sciatic nerve would hasten sensory-motor block onset when compared to two injections above its divergence (AD).

After ethical approval and informed consent, 70 ASA I - III patients, aged 18 to 75 years, scheduled for elective foot and ankle surgery were randomised into two groups. Patients in group AD received two subparaneural injections anterior and posterior to the sciatic nerve above its divergence, while group BD received subparaneural injections into the individual subparaneural compartments of the common peroneal nerve (CPN) and tibial nerve (TN) below the divergence, with 30 ml of 0.5% levobupivacaine. To achieve this, the subparaneural compartment of the sciatic nerve was initially distended with normal saline at the divergence. A blinded observer assessed sensory and motor blockade using a numeric rating scale (NRS 0-100) and a Likert scale (0-2) respectively. 'Readiness for surgery' (sensory score ≤ 30/100 and motor score ≤ 1/2) was the primary outcome variable of this study.

The median [IQR] time to ‘readiness for surgery’ (Figure 1) was significantly faster (p=0.02) in group BD (15 min [10-30 min]) than in group AD (30 min [15-40 min]) .

Ultrasound-guided subparaneural PSNB as two separate injections below the divergence of the sciatic nerve hasten the time to ‘readiness for surgery’ when compared to two injections above the divergence.

Continuous regional analgesia at home is a technique for postoperative pain management but is not exempt from complications. The following retrospective cohort study aims to determine the incidence and nature of the complications related to continuous regional analgesia at home.

A retrospective analysis was conducted on 1,370 patients receiving continuous peripheral nerve analgesia at home, taken from our Pain Unit database. Data were collected on patient demographics, medical history, surgical procedure, catheter placement, and complications associated with the technique.

Our patients were primarily females (59.6%) with a mean age of 48.0 (SD ± 17.7) years and a mean BMI of 27.1 (SD ± 4.5). Most patients (68.6%) were ASA II; the most common blocks were continuous popliteal, interscalene, or infraclavicular blocks. The most common complication reported was accidental catheter removal during follow-up, affecting 7.8% of patients. Only 80 (5.84%) of our patients required re-consultation and 3 of them were re-admitted. No significant complications were found in this cohort.

In this series of patients, the most common problems described during the follow-up period were minor problems with a low incidence and without significant impact on re-consultation or re-admissions. Overall, continuous regional analgesia at home is a feasible practice that benefits patients and clinicians.

Opioids can form an integral role in the post-operative multi-modal discharge prescribing plan, however, in Ireland the prescribing rates of opioids are increasing yearly and inappropriate opioid prescribing from acute hospitals is unfortunately happening. The international guidance for acute post-operative pain specifies simple analgesia with 5 days of opioids (7 days maximum). Sustained release opioids are not recommended [1][2]. Our project aimed to investigate postoperative prescribing patterns in a large teaching hospital in Ireland. Difficulties in accurate data collection under current technological conditions were also explored.

Local ethics approval was acquired prior to initiation of this project. We performed a retrospective chart review, inclusion criteria were patients over 18 years old who underwent elective or emergency surgery between October to December 2022. Exclusion criteria were patients with extended stays (over three weeks) and specialities with written discharge analgesia protocols.

238 charts were included. Median age was 55, range 18-91. 13% of our prescriptions were in line with guidance wherein all patients on opioids should be prescribed simple analgesia. Of these prescriptions only 7.02% had opioids for 5 days or less. 46.2% of patients received a sustained release opioid. Only 23% received NSAIDs. 5 patients received paracetamol in conjunction with a separate paracetamol-codeine combination.

This audit has shown a heavy over-reliance on sustained release opioids. It also shows low levels of compliance with national or international guidance on discharge prescribing. Additionally, data collection is hugely complicated using the current system. Digital infrastructure and centralised databases will be necessary in the future.

Our anaesthetic department provides labour epidural as part of a secondary care maternity service. Recently there has been concern that our rate of accidental dural punctures (ADPs) has increased so we undertook a service evaluation of labour epidurals. We compared our data to the standards set out in ‘Raising the Standards: RCoA Quality Improvement Compendium’.

Prospective data collection over a 3 month period. Reviewed the anaesthetic logbook and patient notes to gather: time, grade anaesthetist, epidural technique, incidence of re-siting, incidence of ADP and subsequent management.

Standards were met in the following domains block success 93 % (target >85 %), resites 7 % (target <15 %), satisfaction at follow-up 98 % (target >98 %). However, our ADP rate was above range at 3.2 % (target < 1 %). Despite a range of loss of resistance (LOR) techniques used, this did not impact ADP. Evenings appeared to be the safest time of day, but otherwise even spread over 24 hours. Possibly higher ADP rates from experienced anaesthetists who were returning to the labour ward after a break.

Our ADP rate was unacceptable, without a clear explanation. Possibly causes include a change of equipment (we only had combined spinal-epidural sets the year before), a busier labour ward, and turnover of anaesthetic staff newly restarting epidurals. It could be anomalous due to a short data collection window. We gained a model epidural back which is always available for practice and have started collecting data again to see if our unit has improved.

The erector spinae plane (ESP) block is widely used as alternative to more complex neuraxial and para-neuraxial blocks. However, the extent and reproducibility of the injectate spread remain unclear. The aim of this study was to investigate the pattern, extent, and variation in the spread of injectate during simulated ESP blocks.

Bilateral ultrasound-guided ESP blocks were performed at T5 transverse process using iodised-contrast solution in fresh cadavers (20ml x 2). Computed Tomography (CT) imagining was performed 30 minutes after block administration. Two cadavers were dissected after injectate containing dye was administered.

The study included 20 sides on 10 cadavers; mean age 58years and mean height 163.6cm. Table 1 shows the frequency of spread across intramuscular planes and neural structures. There was a consistent spread to the dorsal ramus, while spread to neural structures and lateral spread was less predictable (Table 2). There was greater spread cephalad than in the caudal direction. An inverse relationship was observed between the extent of LA spread and height. This pattern remained consistent after controlling for confounding variables (Table 3).

The spread of injectate during ESP blocks varied widely and was inversely proportional to the height of the specimen. Consistent spread was observed to the dorsal ramus. Further studies should be conducted on live subjects. Overall, the study provides valuable insights into the pattern and extent of injectate spread in simulated ESP blocks.

Genicular nerve block (GNB) is an increasingly popular technique for pain relief after knee surgery. However, the reproducibility in terms of local anesthetic diffusion in each nerve of the block remains unclear. The objective of present study was to investigate the diffusion of contrast agent following GNB in cadaveric knees and assess the reproducibility of the infiltration volume and its distribution.

Ten cadaveric knees undergoing 4 ml GNB were included, targeting the superior medial (SM), superior lateral (SL), inferior medial (IM), inferior lateral (IL), and recurrent tibial (RT) genicular nerves. Helical CT scans were performed to assess contrast distribution. Image processing, including segmentation and surface reconstruction, was performed using Amira software. Quantitative analysis was carried out to evaluate the diffusion of the infiltrated volume in each genicular nerve.

The mean volumes (± SD) of the contrast in SM, SL, IM, IL, and RT GNB were 15.2 ± 8.6 ml, 12.2 ± 7.9 ml, 15.0 ± 6.6 ml, 11.9 ± 9.2 ml, and 21.6 ± 15.0 ml, respectively. The mean diffusion in the three axes showed variations and coefficients of variation were calculated for each nerve to assess reproducibility.

This study demonstrates variability in the volume and diffusion of contrast agent following GNB in cadaveric knees. Certain nerves, such as IM, exhibited greater variability compared to others. More research is needed to determine the optimal volume required to cover a relevant bony area for each nerve and to assess whether this diffusion is accompanied by clinically significant outcomes.

With the advent of the 2021 RCoA curriculum, there has been a move to produce consultants with broader skill sets. The curriculum now places greater emphasis on experience and competence in RA.

To gain insight into the trainee experience a nationwide survey was sent using Google Forms to all welsh anaesthetic trainees. The results were compared to a previous survey carried out by Fox et al in 2016, focusing on changes in the last seven years in relation to availability of training. The results in teaching, experience and confidence were assessed and thematic analysis was also carried out on free text comments.

Results represented as tables Figs 1-3.

The new curriculum has been a step change in expectations placed on trainees to reach significantly increased levels of competence. From our work, only 10% of trainees feel confident performing all plan A techniques at supervision levels appropriate for their stage. Ideally, opportunities should be provided to develop skills in line with requirements. Through our results we intend to work alongside the deanery to implement certain key improvements; engagement with surgical colleagues, blocks of time on regional lists to cement skills, use of virtual trainers, and encouragement of under represented trainee groups to undertake regional advanced modules. This work will act as the basis for feedback and engagement with the deanery.

This retrospective study aims to evaluate the efficacy, safety, and complications associated with two types of interscalene nerve catheters used in shoulder arthroscopy surgeries: the conventional-catheter and the catheter-over-needle.

A comprehensive 7-year retrospective analysis was conducted at a single institution, involving 696 patients who underwent shoulder arthroscopy surgeries after taking an approval from the Local Ethics Committee (2020.023.IRB2.004). Patient characteristics included a mean age of 50.4 years, American Society of Anesthesiologists (ASA) classifications of ASA-1 (53.4%), ASA-2 (33.3%), and ASA-3 (13.2%), and a mean Body Mass Index of 25.34. Various surgery types were included, and the analysis focused on 610 patients with catheters.

Dyspnea was observed in 8.6%, while Horner syndrome was present in 13.2% of patients. Early catheter-dislodgement occurred in 5.2% of the conventional-catheter group and 1.9% of the catheter-over-needle group demonstrating a statistically significant difference (p=0.041). Late catheter dislodgement rates were 5.6% in the conventional-catheter group and 2.8% in the catheter-over-needle group, which did not reach statistical significance. Pain scores at 24-hours postoperatively were significantly lower in the catheter-over-needle group (mean NRS-score: 1.98) compared to the conventional-catheter group (mean NRS-score: 2.36).

This retrospective evaluation of interscalene nerve catheter types in shoulder arthroscopy surgeries demonstrates that the catheter-over-needle technique yields a lower incidence of early catheter dislodgement, reduced rates of dyspnea and Horner syndrome, and significantly lower pain scores at 24 hours compared to the conventional catheter technique. The increasing utilization of the catheter-over-needle technique over time may have influenced the results due to the operator's growing expertise.

Multimodal pain analgesia strategies are common in perioperative management of total knee arthroplasty (TKA), although the role of adductor canal blocks (ACB) versus femoral nerve block on early postoperative recovery for revision knee surgery is not investigated. The purpose of this study is to independently evaluate the effect of ACB on short-term postoperative outcomes including (1) length of stay (LOS), (2) postoperative narcotic utilization, and (3) function with physical therapy in revision TKA.

We retrospectively identified a cohort study of consecutive 40 patients from January 2021 to July 2021 who had undergone unilateral revision TKA using a single-shot ACB (19 patients) vs femoral nerve block (21 patients) under spinal anesthesia (hyperbaric 0.5% Marcaine 2.5 ml and 20 microgram fentanyl) in addition to a standardized multimodal pain analgesia protocol. These 2 groups were compared using independent sample t-tests with primary end points of interest being distance ambulated after surgery, and inpatient narcotic use.

Quadriceps strength was better preserved in adductor group than in femoral group. Walking meters and going upstairs were better results in adductor group. IV morphine consumption within the first 48 hours period were less in adductor group comparing to femoral group.

Adductor nerve block showed better early recovery in revision TKA when comparing to femoral nerve block (FNB).

This service evaluation project assesses patient satisfaction with home analgesia following a single-shot sciatic popliteal nerve block versus combined single-shot sciatic popliteal nerve block and perineural catheter technique with local anaesthetic infusion continued at home via an elastomeric pump for up to 48 hours post hospital discharge. Both nerve block techniques were initiated preoperatively for ambulatory ankle replacement surgery.

Retrospective data on the nerve block technique and patient satisfaction were collected from anaesthetic charts and follow-up home calls for patients who underwent ambulatory ankle replacement between April 2022-December 2022. Thirty patients, 15 who received a single-shot block (group A) and 15 who received a combined single-shot block and perineural catheter technique with local anaesthetic infusion continued at home via an elastomeric pump (group B), were included in this service evaluation. The following responses were collected from patients via follow-up home calls: 1. What is the level of satisfaction with your pain control up to one week after hospital discharge (not satisfied, satisfied, very satisfied)? 2. Would you be happy to receive the same nerve block technique if you were to have the operation again?

Patient satisfaction with the block technique is summarised in the table below.

Patients who received a combined single-shot block and perineural catheter technique reported better satisfaction with home analgesia than with a single-shot block.

Injection of local anesthetic with anatomical landmark following paraesthesia of the middle two fingers results in >97% block efficacy. Injections in ‘Corner pocket’ and ‘Intra-cluster’ in the supraclavicular brachial plexus under ultrasound-guidance have been suggested for better coverage. We hypothesized that a single injection of dye at the level of the middle trunk (MT) would result in diffusion in the superior and inferior trunks.

After ethics approval, 12 ultrasound guided injection was performed with needle tip positioned within fatty connective tissue at the level of the MT bilaterally in 6 soft embalmed cadavers. We injected 3.5ml, 7.5ml and 15ml diluted methylene blue dye in 2 cadavers (4 specimens) each. Bilateral neck dissections was performed in the posterior triangle of the neck 30 minutes after injection in all cadavers and dye spread was visualized beneath investing layer of deep cervical fascia.(Figure1)

Injection of the lower volume of dye (3.5ml) consistently spared the superior trunk while an injection of the higher volume of dye (15ml) consistently stained all trunks when a single injection was performed at the MT level. Suprascapular nerve and phrenic nerves were consistently stained with 15 ml injections while they were spared with low and intermediate-volume injections. The dissections revealed dye dispersion with a dense (15ml) to differential stain pattern (3.5ml and 7.5ml resulted in a mild to moderate) of the cadaveric brachial plexuses.(Figure2)

We propose the use of a single injection MT block technique using an injectate volume more than 7.5ml for an effective supraclavicular brachial plexus block.

ESPB has shown variable efficiency. We evaluated the efficacy of ESPB in elective lumbar spinal fusion surgery patients with different surgical approaches

Retrospectively 45 elective lumbar TPF patients with TLIF or TLIF+ALIF approaches were divided into 2 groups: general anesthesia (GA,n=24), general anesthesia with ESPB (GA+ESPB,n=21). Primary we analyzed efficacy of ESPB in terms of pain intensity in the first 48h. Secondary – fentanyl free patients and opioid consumption in the first 24h postoperatively. Comparative analysis (SPSS®v.28.0).P<0.05.

Out of 45 patients (27 female),21 received GA+ESPB and 24 GA. Average age was 60.3±14.3 years. ESPB was performed in 17 TLIF and in 4 TLIF+ALIF patients. ESPB significantly reduced pain intensity at rest in both approaches 48h after surgery; p<0.05. GA+ESPB when compare with GA increased the number of fentanyl free patients immediately after surgery in TLIF (77%vs.29%;p=0.01) and TLIF+ALIF (82%vs.0%;p=0.004) approaches. For those with ESPB fentanyl infusion was started in 6.8±3.2h (23.5% of TLIF) and 8.9±7.6h (75% of TLIF+ALIF) after surgery. ESPB shortened fentanyl infusion time when compare with GA with mean difference(MD) 3.2±4.2h in TLIF;p=0.045, 6.7±5.3h in TLIF+ALIF;p=0.028. Only in TLIF+ALIF approach, ESPB reduced total fentanyl consumption compared with GA 1.43±0.45mg/24h vs.0.93±0.68mg/24h;p=0.015.

ESPB reduces pain at rest after lumbar fusion surgery and the number of patients requiring immediate postoperative fentanyl in both approaches, reducing the total fentanyl consumption and duration of infusion. However, application of ESPB not always provide enough analgesia to completely avoid fentanyl administration after surgery in the first 48h.

Pneumocephalus (PC), defined as presence of air in the intracranial space, is a rare complication of neuraxial techniques. We describe a case of a pregnant woman submitted to a combined spinal-epidural (CSE) technique who developed PC with late presentation.

16-year old pregnant woman, 41 weeks of pregnancy, asked for labor pain relief. A CSE with loss of resistance with saline (LORS) technique was performed. The epidural catheter (EC) was used for analgesia during labor work, with complete pain relief and no complications. 9 hours after, the patient was submitted to urgent cesarean section (CS) because of nonreassuring fetal status. Shortly after the anesthetic bolus via EC, the patient developed apnea, coma and anisocoria and was promptly intubated and ventilated. At the end of CS the patient woke up without neurologic deficits. Cerebral CT scan showed air densities in the right lateral and third ventricle. Bedrest and oxygen therapy was instituted. She developed postural headache treated with analgesia and was discharged 8 days after, fully recovered.

PC is often associated with identification of epidural space trough loss of resistance to air (LORA). However, in this case we used LORS. Also, she developed postural headache in the postoperative period, which suggests a dural lesion. The air entrance through the dural defect to the intracranial cavity, during the epidural bolus, seems to be the most likely mechanism of PC.

PC usually manifests with headache and resolves spontaneously, however presentation can be atypical and surgical treatment may be necessary in cases of tension PC.

This systematic review has been performed to assess the efficacy of post-operative analgesia using bolus infusions of local anaesthetic given via rectus sheath catheters in patients undergoing laparotomy via midline incisions.

A PubMed search of the literature has been used to capture all the relevant publications. All studies where rectus sheath analgesia has been compared with placebo and with epidural anaesthesia have been analysed. The review has revealed that there is considerable variation in the methodologies used in the published studies comparing rectus sheath and epidural analgesia and the majority are non-randomised observational studies. Some of the studies suggest that rectus sheath analgesia is less effective than epidural analgesia when assessed with post-operative pain scores and the need for additional opiate analgesia. Others suggest that rectus sheath analgesia gives equivalent pain relief to epidural anaesthesia. Some of the studies show that patients receiving rectus sheath analgesia mobilise quicker than those receiving epidural anaesthesia.

All the studies emphasise that rectus sheath analgesia is safer than epidural anaesthesia as it avoids the major complications that can occur with epidural anaesthesia, which include post-operative hypotension leading to anastomotic leakage, epidural haematoma, and epidural abscess formation. The literature shows that complications from rectus sheath analgesia are extremely rare.

This systematic review has shown that although further prospective randomised studies are required, rectus sheath analgesia is safe and effective and should be used in preference to epidural anaesthesia in most patients undergoing laparotomy via midline incision.

Spinal and Epidural anesthesia (SA, EA) is the main type of anesthesia for caesarean section (SC). COVID-19 pneumonia which complicates the course of pregnancy, requires a rational choice of sedation and respiratory support to ensure SA and EA.

The safe conduct of SA ore EA was ensured by the temporary discontinuation of the use of heparinoids in the perioperative period. SA ore EA was performed exclusively in the sitting position, then the patient was transferred to the horizontal position with the head end elevated by 30-45 degrees (depending on the needs). Respiratory support was used at all stages of preparation, performance, and administration of anesthesia: high-flow oxygenation (HFO) through nasal cannula or face mask, and non-invasive mechanical lung ventilation through the face mask. Maintenance of normotension was provided by intravenous boluses phenylephrine. Sedation was provided by intravenous bolus small doses of propofol or ketamine.

The above-described features of SA/EA were used by us during CS in 60 women in labor with severe coronavirus pneumonia. Compliance with the characteristics of SA/EA for CS by coronavirus pneumonia was expressed in thefollowing: 1) half sitting at all stages of the perioperative period; 2) constant respiratory support, mainly HFO; 3) early transfer to the pron-position in the postoperative period; 4) predominant use 25-50-75 mg ketamine (not propofol!) for sedation. This approach ensured that there was no need to use general anesthesia for CS.

Supplemented with HFO, ketamine, half-sitting SA or EA is the method of choice for CS in labor with severe coronavirus pneumonia.

Epidural anesthesia has been optimal for pain management in obstetric anesthesia for over 20 years. This anesthetic is placed between L3-L4 of the lumbar region, it allows expecting mothers to be anesthetized from the lower back to the upper portion of the legs. Spinal nerves are numbed which blocks the pain signals, but pressure sensation is present. Through various research studies, it has come to light that women have suffered from lower back pain post-delivery. Our goal is to determine the correlation between epidural anesthetic and chronic lower back pain in women who have given birth.

Cross sectional study comparing data presented in six different studies ranging from 1990 through 2019. Studies were selected using The National Library of Medicine media sources. Sources used had more than 6,000 patients total and also included criteria that evaluated the presence of an epidural and pain patients felt in the lower back. Excluded from these studies were time frames in which results from surveys for back pain were obtained vary significantly between studies.

Based on the obtained data from previous research studies, it cannot be determined if an epidural is the main cause of lower back pains in women postpartum.The graphs demonstrate no significant difference between women who had an epidural and those that did not receive an epidural.

To conclude, more research studies would need to be done or reviewed in order to determine that the anesthetic epidural is the cause of lower back pain in women.

ESPB’s provide postoperative analgesia for patients undergoing breast, thoracic and abdominal surgery (1-3) and improve respiratory function in rib fracture patients (4,5). Lack of awareness, competence or belief in practicality are intrinsic barriers for regional anaesthesia implementation (6). ‘Tea-trolley’ teaching is a novel and fun modality of condensed practical skill teaching within working clinical environments (7,8). We delivered ESPB ‘tea-trolley’ teaching at Russells Hall Hospital (RHH) to overcome these barriers and increase ESPB provision.

The ‘tea-trolley’ teaching team attended RHH ICU and each operating theatre (day case, main and obstetric). A three minute ESPB presentation (9) was delivered (along with hot beverages/biscuits) followed by each candidate undergoing live-volunteer scanning practice and then immediate ESP mannequin needling practice. Each candidate completed pre-/post-teaching surveys.

There were 17 survey respondents; 9 consultants, 8 trainees. Pre-teaching, 76% respondents had not seen/performed an ESPB (including 8 consultants) and 65% of respondents were unaware of relevant anatomical landmarks for safe performance; post-teaching 100% respondents were aware. Pre-teaching, 82% of respondents felt either quite/very under-confident performing an ESPB (12% felt neither confident/under-confident); post-session 88% of respondents felt either quite/very confident performing an ESPB. Of those respondents involved in management of rib fractures or breast surgery 100% responded the training would change their practice (50% ‘yes definitely’/50% ‘yes maybe’).

‘Tea-trolley’ is a low-tech, inclusive and effective teaching modality for ESPB. Our data suggests 'tea-tolley' training is an effective modality to overcome intrinsic barriers of regional anaesthesia implementation and therefore a useful modality for teaching other regional anaesthetic techniques.

Rebound pain is an acute increase in pain severity after a peripheral nerve block (PNB) has worn off, generally manifesting within 24 h after the block performance. This observational study aims to observe the incidence and factors of rebound pain after PNB.

Before subject enrollment, the ethics committee approved the study (137/01), and it was registered at ClinicalTrials.gov (NCT03048214). Ortopedia surgery patients who received PNB for anesthesia or analgesia for 10 months were included. Postoperatively, all subjects received multimodal analgesia. Patients were visited at 0, 12, and 24 hours postoperatively and were analyzed for the incidence of rebound pain, numeric rating scale (NRS) pain score, motor and sensory block times. Rebound pain was mainly described as burning, dull aching pain and severe pain (NRS score >7).

In the preliminary report was enrolled 119 subjects, and the rebound pain rate was 24.3%. Rebound pain is more common in upper extremity blocks (p<0.01). Rebound pain was seen more in PNB applied for anesthesia than in PNB used for analgesia. (p=0.018). Opioid analgesic consumption rates were high during the rebound pain.

Despite multimodal analgesia, we think rebound pain can be seen more, especially in upper extremity blocks and when applied for anesthesia.

Knee arthroplasty is one of the most effective surgeries in terms of efficiency in the treatment of gonarthrosis or rheumatoid arthritis and one of the most frequent orthopedic surgeries. The infiltration of local anesthetic around the femoral nerve has been, for years, the fundamental pillar of regional anesthesia in knee surgery. The two most frequent methods to treat this nerve are the infiltration of local anesthetic in a single puncture or in the form of continuous blockade with a catheter. Carry out a comparison to contrast the analgesic capacity of both forms of femoral block, assessing if there is an advantage of between them

This project consists of a retrospective observational study based on data collected in the Acute Pain in routine clinical practice. The patients were divided according to whether they received a single puncture femoral block (34 cases) or a continuous femoral catheter (69 cases) and the QoR15 score on the first day after the surgery.

The comparison of the results of the QoR15 in patients with femoral block in a single puncture versus femoral block shows statistically significant differences between the groups to be studied, with a p=0012. Therefore, with the data from our sample, the patients presented a better ranking on the QoR15 scale.

Femoral nerve block continues to be a fundamental pillar in the treatment of pain in knee arthroplasty surgery. Single puncture femoral block could be superior in analgesic control when compared to continuous infusion.

The aim of this study is to evaluate the confirmation of double lumen tube placement with thoracic USG in thoracic surgery operations with one lung ventilation.

In this prospective and observational study, 130 patients aged between 18-65 years in ASA (American Society of Anesthesiology) I-III risk class who will undergo thoracic surgery with the application of single-lung ventilation were included in the study. A double-lumen endobronchial tube was placed in the patients blindly. One-lung ventilation was confirmed by thoracic USG by the anesthesiologist. The patient's demographic data, rapid clinical evaluation and USG data results, and intraoperative surgeon satisfaction were recorded.

The success of estimating DLT position with thorax USG was found to be statistically significant when compared with other methods (p=<0.001). The sensitivity and specificity values of DLT position success estimation of fiberoptic bronchoscopy were found to be higher than other methods. BMI was found to be higher in patients with failed USG and rapid clinical evuluation estimation of DLT position (p<0.001).

The results of this study showed that thoracic USG can be used as an alternative to rapid clinical evaluation method in thoracic surgery patients undergoing one lung ventilation.