The aim of this abstract is to present and analyze the effectiveness of lower leg analgesia using ultrasound-guided popliteal nerve block in pediatric patients with ankle fractures in the course of opioid free anesthesia and also to conduct a comparative clinical study compared to classical conventional intravenous analgesia, including opioids.

For period of 2 years we followed and compared 108 pediatric patients (7y-17y), undergoing surgical treatment of ankle fractures. All patients were ASA I. 35 (32.4%) children underwent ultrasound-guided popliteal nerve block with Lidocaine 1% + Ropivacaine 0.5% = 0.3ml/kg with sedation (propofol V=2mg/kg/h) and 78 (67.6%) children received general anesthesia (TIVA with propofol), including opioid analgesia (fentanyl). Intraoperatively analgesia is estimated by hemodynamics (objective criteria) and postoperatively-by hemodynamics (objective criteria) and standard pain scale scores - VAS, BOPS and PADS (subjective criteria).

In the regional anesthesia group 6 children (17.15%) required single dose of additional intravenous opioid analgesia (fentanyl -.8-0.9mcgr/kg) and the rest of 82.85% (29 children) were opioid free during the procedure.

Opioid-sparing and opioid free anesthesia are becoming more and more tempting and desired as being safer and more comfortable both for the patients and the anesthesiologist. Ultrasound-guided regional blocks provides perfect conditions for the above mentioned. Nevertheless, pediatric patients still remain a challenge for performing regional nerve blocks from the perspective of cooperation, understanding and feedback. Our study revealed a safe profile of the ultrasound-guided popliteal nerve block in children with uneventful course, no side effects and prevalence of opioid free anesthesia.

Inadequate postoperative pain control after cesarean delivery is linked to delayed functional recovery and mobilization. Mostly, the intrathecal opioids are utilized for optimal pain management, though it has its own inherent side effects. Regional anesthesia block techniques can also improve quality of analgesia and reduce associated side effects. This study aimed to assess the role of ESPB in comparison with other blocks in controlling postoperative pain and opioid consumption in patients who underwent cesarean section under spinal anesthesia.

The current meta-analysis was carried out following PRISMA guidelines. It was registered with PROSPERO database. The literature search was carried out utilizing online databases such as Cochrane library, Science Direct, PubMed and Google Scholar. The studies that included in this review reported opioid use, time to FAR (first analgesic request), the pain control following surgical treatment as well as side effects linked to using erector spinae plane block (ESPB) vs other blocks among females experiencing cesarean delivery. We utilized the software Review manager and RevMan for MAC 5.4 to conduct the meta-analysis. The mean differences, standard mean differences, and odds ratios (ORs) were computed for different outcomes. Random effect models were performed.

During this systematic review and meta-analysis, 16 randomized controlled trials (RCTs) were included. A significantly reduced opioid consumption was observed among individuals who received ESPB compared to other abdominal wall blocks for cesarean deliveries (P=0.003). Time to 1st analgesic request was also considerably prolonged among patients who received ESPB (P<0.00001). Insignificant difference was noticed in postoperative pain scores between both groups.

ESPB significantly reduced 24 hours opioid consumption after cesarean delivery compared to other blocks. Time to 1st analgesic request was also significantly prolonged among females who received ESPB. Insignificant difference was observed in the pain scores postoperatively between both groups.

We have previously demonstrated that an extrafascial injection of 20 mL of local anaesthetic for interscalene brachial plexus block reduces the rate of hemidiaphragmatic paralysis by 70% compared with an intrafascial injection, with similar efficacy. In this double-blind trial, we tested the hypothesis that a local anaesthetic volume of 10 mL injected extrafascially would reduce the rate of hemidiaphragmatic paralysis versus a volume of 20 mL, while providing similar analgesia.

Sixty ASA I-III patients scheduled for elective shoulder surgery under general anaesthesia were randomised to receive ultrasound-guided extrafascial interscalene brachial plexus block using ropivacaine 0.75% 20 mL (control group) or 10 mL (low volume group) injected lateral to the brachial plexus sheath. The primary outcome was incidence of hemidiaphragmatic paralysis (diaphragmatic excursion reduction of >75%), measured by M-mode ultrasonography, at 30 minutes after the procedure. Secondary outcomes included duration of analgesia and intravenous morphine consumption at 24 postoperative hours.

The 30-minute hemidiaphragmatic paralysis rate was 80% (95% confidence interval [CI] 61–91%) in the control group and 19% (95% CI 8–40%) in the low volume group (p<0.001). Patients in the low volume versus control group had a shorter duration of analgesia (550 vs. 873 min; p<0.01) and higher intravenous morphine consumption (20 vs. 12 mg; p=0.03).

A low volume of local anaesthetic injected extrafascially reduced the rate of hemidiaphragmatic paralysis, but at the expense of a shorter duration of analgesia compared with standard dose extrafascial anaesthetic injection.

Nerve injury during brachial plexus blocks remains a significant challenge in regional anesthesia. This study utilizes Finite Element Analysis (FEA) to simulate the biomechanical and electrical interactions between needles and tissues, emphasizing the role of tissue dynamics in reducing nerve injury risks.

A 3D FEA model was developed using FreeFEM, incorporating MRI-based anatomical structures of muscle, adipose tissue, and nerves. Electrical properties were assigned based on literature values (muscle conductivity: 0.93 S/m, permittivity: 75; fat conductivity: 0.06 S/m, permittivity: 10). An 18-gauge stimulation needle was simulated under varying insertion angles (30°–90°), depths (2–6 cm), and pressures (5–20 psi). Mesh refinement ensured accurate stress and electric field distribution analysis.

Simulations demonstrated that muscle tissue’s higher conductivity reduced the stimulation radius compared to adipose tissue. Optimal insertion angles (45°–65°) minimized nerve stress, while pressures above 15 psi increased nerve injury risk. Tissue boundaries significantly altered electric field distribution, affecting nerve activation thresholds.

FEA provides a robust framework for optimizing brachial plexus blocks by considering tissue dynamics and electrical properties. This approach enhances procedural safety, reduces nerve injury risks, and offers valuable insights for training and clinical application.

Anterior knee pain is a common manifestation in spondyloarthropathy (SpA), frequently attributed to enthesopathy triggered by an inflammatory cascade. Some cases remain refractory with conventional treatment including anti-inflammatory medications and rehabilitation. Focused shockwave has been widely used for calcific lesions and tendinopathy, but reports of its application in spondyloarthropathy is limited. This report presents a novel use of focused shockwave therapy in managing SpA-related knee pain, highlighting its potential role in pain relief and tissue recovery.

A 27-year-old male with peripheral SpA presented with right anterior knee pain for six months, unresponsive to oral hydroxychloroquine, NSAIDs and physical therapy. The pain was activity-related, with morning stiffness and localized tenderness at the distal patella and Hoffa’s fat pad. Focused shockwave was administered under ultrasound guidance to the proximal patellar tendon and Hoffa’s fat pad three times every other day (2500 pulses/session, energy flux density: 0.142–0.341 mJ/mm²).

Following two sessions, the patient's visual analog scale improved from 8 to 0. The Knee injury and Osteoarthritis Outcome Score (KOOS) also improved significantly, increasing from 59% to 90%, with the greatest improvements observed in the pain and sports subscales, which increased by 113% and 78%, respectively. The Victorian Institute of Sport Assessment Questionnaire for Patellar Tendon (VISA-P) improved from 32 to 79. Follow-up ultrasonography at one month, comparing both the affected and asymptomatic sides, along with pre- and post-treatment images, revealed reduced tendon thickness, improved fibrillar pattern, and resolution of fat pad inflammation (Figure 1, 2, 3).

The patient experienced complete resolution of pain and sonographic signs of enthesopathy without adverse effects. Focused shockwave may enhance recovery of soft tissue structures in SpA-associated knee pathology, and appears to be a promising adjunct for refractory patellar enthesopathy in SpA. Its non-invasive nature and favorable safety profile warrant further evaluation in larger studies and controlled trials.

Effective postoperative pain management is critical for patients undergoing modified radical mastectomy (MRM). Serratus anterior plane block (SAPB) with ropivacaine provides regional analgesia, but its duration and efficacy may be enhanced with adjuvants. This study compares dexamethasone and dexmedetomidine as adjuncts to ropivacaine in SAPB for postoperative pain control in MRM patients.

In this prospective, randomized, double-blind clinical study, 60 female patients (ASA I-II, aged 18-65 years) undergoing MRM were enrolled after institutional approval(IHECSR/AIIMSBPL/AUG/05) and CTRI (CTRI/2024/10/075350). Patients were randomly assigned to two groups (n=30 each): Group RD (ropivacaine 0.5% 20 mL + dexamethasone 8 mg) and Group RM (ropivacaine 0.5% 20 mL + dexmedetomidine 1 µg/kg). SAPB was performed under ultrasound guidance preoperatively. The primary outcome was the duration of analgesia, defined as the time to the first analgesic request. Secondary outcomes included postoperative pain scores (Visual Analog Scale, VAS) at 2, 6, 12, and 24 hours, total analgesic consumption (tramadol), and adverse effects.

Group RM exhibited a significantly longer duration of analgesia (18.4 ± 2.3 hours) compared to Group RD (14.7 ± 2.1 hours; p<0.001). VAS scores were lower in Group RM at 12 and 24 hours (p<0.05). Total tramadol consumption was reduced in Group RM (85.3 ± 20.1 mg) compared to Group RD (120.5 ± 25.4 mg; p<0.01). Adverse effects, including nausea and sedation, were comparable between groups, with no significant differences (p>0.05). No serious complications, such as pneumothorax or local anesthetic toxicity, were reported.

Dexmedetomidine as an adjunct to ropivacaine in SAPB provides a longer duration of analgesia, lower pain scores, and reduced analgesic consumption compared to dexamethasone in MRM patients, with a similar safety profile. Dexmedetomidine may be a superior adjuvant for enhancing SAPB efficacy.

Mid-thoracic epidural analgesia is a standard practice for postoperative pain relief following transthoracic esophagectomy. However, in minimally invasive surgeries, non-epidural systemic analgesics are more frequently utilised for pain management. This study aimed to compare the efficacy and safety of two modalities in minimally invasive esophagectomy (MIE) procedures.

Following PROSPECT recommendations, the institutional policy shifted from epidural to systemic analgesics in MIE surgeries. 1 After obtaining Ethics Committee approval, we compared a historical cohort of patients receiving epidural analgesia (n=96) with those who received systemic analgesia (n=97) during the period from 2019 to 2023. Information on the historical cohort was retrieved from the institutional electronic medical records, while prospectively recruited patients were followed for up to four postoperative days by the designated team. For both groups, we noted information on postoperative pain [i.e. Numerical Rating Scale (NRS) score from day 0 to day 4, worst pain scores, and analgesic modalities, along with the incidence of their side effects on each day].

The NRS scores (at-rest and dynamic) were significantly lower in the epidural group compared to the non-epidural group for the first two postoperative days [Day1- Median (IQR) NRS-5 (5,6) versus 6 (5,6), p <0.001, Day 2- 4 (4,5) versus 5 (4,5) p < 0.001)][Fig. 1.0]. Requirement of patient-controlled analgesia (as a rescue analgesic) was significantly more in non-epidural group.[day 1- 1% versus 14.4%, p = 0.001] [fig 2.0] Intensity of the pain scores and the requirement for opioid analgesics decreased from the third postoperative day and were comparable in both groups. Postoperative outcomes (mortality and hospital stay) were similar in both groups (p=0.465).

NRS scores following MIE surgeries ranged from mild to moderate. Epidural analgesia significantly reduced the pain; however, the clinical difference is minimal compared to systemic analgesics. Multimodal systemic analgesics provide adequate pain relief after MIE surgeries.

The Perioperative Pain Service (POPS) at Hospital for Special Surgery (HSS) is a multidisciplinary team specializing in pain management in orthopedic surgical patients. Under POPS, the Chronic/Complex Pain Service (CPS) preoperatively identifies high-risk patients and tailors perioperative pain management plans while the Acute Pain Service (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 PCAs. The aim of this study was to map and compare acute pain trajectories in patients undergoing Total Knee Arthroplasty (TKA) with and without POPS involvement.

After IRB approval, adult patients undergoing unilateral total knee arthroplasty receiving neuraxial anesthesia between January 10th, 2022, to February 28th, 2025 at HSS were extracted from an institutional registry. Baseline patient characteristics, length of stay, and pain trajectories were generated from patients managed by APS, CPS, and without the pain team.

A total of 11,760 TKA cases were identified; patients managed by CPS had a higher comorbidity burden for certain comorbidities, more frequently used prescription opioids and self-reported substance use preoperatively and had higher average hourly pain scores and incidences of severe pain over 72 hours postoperatively (Table 1 and Figure 1). High-risk patients who received preoperative pain consults had lower acute pain scores (Figure 2).

Acute pain trajectories after TKA vary depending on pre-existing known and yet to be identified patient and surgical factors. Patients with complex/chronic pain experience more severe acute pain and preoperative pain consultations may modify the trajectory.

The Midclavicle Block combines the clavipectoral fascia plane block with a targeted injection into the subclavius muscle to enhance anesthetic spread. Objective: To evaluate the anatomical distribution pattern of the Midclavicle Block in cadaveric specimens with midshaft clavicle fractures, with a focus on periosteal coverage and involvement of the fracture site.

An anatomical study was conducted on ten cadavers (twenty clavicular regions). A midshaft clavicle fracture model was created, and the MCB technique was applied under ultrasound guidance. A methylene blue solution was injected, and dissections were performed to evaluate dye spread primarily in the deep muscular and the clavicular plane, including the fracture site. Probabilistic maps of dye distribution were generated.

The anatomical dissection in the deep muscular plane revealed consistent staining of the fracture site in all specimens, along with the subclavius muscle and the clavipectoral fascia, while the pectoralis minor muscle remained unaffected in every case (Figure 1). As the dissection progressed toward the infraclavicular brachial plexus plane, no staining of the plexus was observed, with dye spread restricted to the subclavius muscle and adjacent clavipectoral fascia (Figure 2). The mean staining of the anterosuperior and posteroinferior periosteal surfaces was 55.3% ± 10.4 and 54.2% ± 9.0, respectively (Figure 3). The highest dye concentration was observed in the middle third of the clavicle, corresponding to the fracture zone.

The Midclavicle Block resulted in effective periosteal coverage and targeted fracture site staining. Clinical studies are needed to confirm its in vivo efficacy, given the limitations inherent to cadaveric specimens.

Sub-acute pain after childbirth(SAPC) is defined as self-reported persistent pain at 6 weeks post-childbirth. With an incidence of 9.5%, it could adversely affect maternal quality of life and mental health[1]. The EQ-5D-3L(EuroQol-five-dimension-scale) is a standardised instrument used to measure health-related quality of life. Lower EQ-5D-3L is often associated with poorer medical outcomes[2, 3]. Hence, we aimed to investigate whether lower EQ-5D-3L VAS score would be associated with an increased risk of developing SAPC. We also investigated other risk factors to develop an association model of SAPC development.

This is a prospective cohort study which included women with singleton pregnancy at ≥36weeks gestation at KK Women’s and Children’s Hospital, Singapore. Self-reporting types of validated questionnaires were administered at pre-delivery and at post-partum 6-10 weeks. Other potential risk factors such as obstetric factors, labour analgesia, and neonatal outcomes were also collected.

Of 816 recruited women, 99(12.1%) developed SAPC. We found that lower general health score via lower EQ-5D-3L VAS score, was associated with increased risk of developing SAPC(Adjusted-OR(aOR)3.42, 95%CI 1.33to8.77). Other association factors include use of prostin induction as mode of delivery(aOR1.87, 95%CI 1.13to3.10), greater blood loss during delivery(aOR1.002, 95%CI 1.001to1.003), greater number of pain relief administered(aOR1.51, 95%CI1.20to1.90), use of artificial rupture of membranes and oxytocin for labour onset(aOR2.62, 95%CI 1.45to4.73), greater infant weight(aOR1.13, 95%CI 1.00to1.28) and experiencing 3rd degree tear during childbirth(aOR3.65 95%CI 1.12to11.95) were associated with an increased risk of developing SAPC. The area under the curve (AUC) of the multivariable model used was 0.732.

Lowered baseline general health score was associated with increased SAPC development. The multivariate model also revealed several obstetric factors which may suggest childbirth complications could be important association factors. This study would allow for risk stratification for women who should be monitored and treated for pain that extends beyond the acute pain during childbirth process.

The objectives of this scoping review are to map the breadth of existing research on the strategies available to anaesthesiologists in applying human factors and ergonomics (HFE) principles to the design of regional anaesthesia (RA) services in operating theatres, and to identify gaps in the literature.

A scoping review was carried out in line with the Joanna Briggs Institute (JBI) methodology for scoping reviews. A systematic, three step, search strategy was applied to the MEDLINE, Embase, CINAHL, Scopus, and Web Of Science databases. Key information from each included source was recorded on a charting instrument. Descriptive statistics and narrative synthesis were used to report the results.

A total of 41 publications, arising out of various study designs, were identified. These discussed 67 unique strategies to implement HFE principles in the areas of system design, barriers, mitigations, as well as education and training. The main topics of the publications included prevention of wrong-site nerve blocks through the use of pre-procedural checklists and action prompts for site verification, and improvements in the quality and safety of nerve blocks and neuraxial anaesthesia.

While numerous strategies for the implementation of HFE principles in RA exist in the literature, there is a paucity of research examining the effectiveness of specific HFE interventions. Further research to address this knowledge gap is required prior to systematic review and subsequent specialty guideline creation.

Postoperative analgesia in pediatrics could be challenging. Meanwhile, "opioid free" days are of a great importance for patients, especially children. In this study we followed and evaluated tdhe pain management of pediatric patients after an ultrasound-guided popliteal nerve block for the purposes of ankle surgery.

We observed 35 children, ASA I, between 7y and 18y of age after an ankle surgery priori to which they were all treated with ultrasound-guided popliteal nerve block. We estimated the postoperative pain and comfort using subjective criteria (pain score VAS) for a period of 48 postoperative hours.

Two children (5.71%) received paracetamol 15mg.kg in a single i.v. dose in recovery room right after the end of surgery as they self estimate their pain as VAS 3 points. The rest of the patients (38 children = 94.29%) didn't require additional pain treatment as they were comfortable and satisfied with the analgetic effect of the regional anesthesia for the whole followed up period of two postoperative days

In conclusion, our small centralized study showed that 100% of our observed pediatric patients remained opioid free for the two postoperative days of pain evaluation. Ultrasound-guided popliteal nerve block provided sufficient and effective postoperative analgesia for all children, sparing additional pain medicine and opioid loading, which on other hand facilitated their enhanced recovery, after surgery (ERAS), faster mobilization and rehabilitation and therefore - accelerated dehospitalization.

Chronic spinal pain is associated with various behavioral responses as individuals adapt to persistent pain. These behavioral patterns may influence functional outcomes and potentially perpetuate pain cycles. This study aimed to examine pain activity patterns in individuals with chronic spinal pain and compare pain duration and severity parameters across these different behavioral patterns.

This cross-sectional study included 109 individuals with chronic spinal pain persisting for more than six months. Participants' sociodemographic characteristics and spinal pain regions were recorded. Pain severity was assessed using the Numerical Rating Scale, and daily activity patterns were evaluated with the Patterns of Activity Measure-Pain.

The mean age of participants was 38.23±13.19 years, with 71.6% being female. The most common pain regions were lumbar (37.6%), cervical (33.0%), and cervicothoracic (15.6%). Participants were categorized into avoidance (n=40), overdoing (n=51) and pacing (n=18) behavior patterns according to the results of the Patterns of Activity Measure-Pain. Mean pain duration was 72.25±77.69 months in the avoidance group, 52.55±51.42 months in the overdoing group, and 46.17±52.36 months in the pacing group. No statistically significant differences were found between the three activity pattern groups in terms of pain duration or pain severity parameters (p>0.05).

Individuals exhibiting avoidance behavior demonstrated notably longer pain duration, suggesting potential clinical relevance despite the lack of statistical significance between activity patterns. This finding aligns with current literature indicating that fear-avoidance behaviors may contribute to pain chronification. Early identification of maladaptive activity patterns could be valuable in clinical assessment and intervention planning. For physiotherapists and pain specialists, understanding these behavioral adaptations may enhance the effectiveness of rehabilitation approaches and pain management strategies in chronic spinal pain patients, particularly in targeting and modifying avoidance behaviors early in the treatment process.

Placenta praevia with concurrent placental abruption is a rare, high-risk obstetric emergency typically managed with general anesthesia due to the potential for massive hemorrhage and hemodynamic instability. However, recent oral intake can elevate the risk of aspiration, complicating general anesthesia. This case highlights the successful use of spinal anesthesia providing insight into a potentially safer anesthetic approach under these circumstances.

A 34-year-old primigravida at 33 weeks with diagnosed placenta praevia was admitted for observation following painless vaginal bleeding. On hospital day 7, she developed sudden abdominal pain and uterine tenderness. Ultrasound confirmed placental abruption. Due to fetal distress and maintained maternal stability, an emergency cesarean section was indicated. The patient had eaten a light meal an hour prior, increasing aspiration risk. Given her stable vitals and absence of coagulopathy, spinal anesthesia was chosen.A subarachnoid block was administered with a 25G pencil-point needle at the L3–L4 interspace using 15 mg hyperbaric ropivacaine and 20 µg fentanyl, with full preparation for blood transfusion and general anesthesia if needed.

A T4 sensory level was achieved, and surgery proceeded without complications. Estimated blood loss was 1,500 mL, the patient received 1 unit each of packed red blood cells and fresh frozen plasma. A healthy neonate was delivered with Apgar scores of 9 and 10 at 1 and 5 minutes. The patient remained hemodynamically stable and had an uneventful postoperative recovery.

This case demonstrates that spinal anesthesia can be a viable and safe option in hemodynamically stable patients with placenta praevia complicated by abruptio placentae. This approach avoids the risks of airway manipulation and aspiration, particularly in parturients with recent food intake. With careful assessment and appropriate multidisciplinary support, spinal anesthesia can offer benefits over general anesthesia, even in high-risk obstetric emergencies.

Nonpharmacologic analgesic adjuncts like acupuncture remain underutilized in the perioperative period. Although opioids are effective, they have undesirable side-effects like nausea, vomiting, pruritis, sedation, and decreased gut motility, delaying discharge readiness. This is essential in orthopedic surgeries like total joint arthroplasty (TJA), where recovery times are substantially different depending on opioid consumption. Given the move towards ambulatory TJA, exploring potential effectiveness of non-opioid approaches like acupuncture in treating post-operative pain should be prioritized.

This triple-blinded randomized controlled trial (IRB approval #2021-1496), enrolled 484 patients (242 per group). Both groups received a standard mepivacaine spinal anesthetic with propofol sedation. Intraoperative medications were standardized to midazolam, ketamine, ondansetron, famotidine, dexamethasone, and ketorolac. Patients randomized to the intraoperative acupuncture group received the CHENG Protocol - auricular acupuncture with electrostimulation at 30Hz after induction but prior to incision (Figure 1).

Acupuncture patients showed lower total opioid consumption at 14/30 days (p>0.05, Figure 2(A)), and reported significantly lower average PACU NRS scores (median+/-IQR: 4+/-3 vs 5+/-3, p=0.002, Figure 2(B)), compared to patients without acupuncture. Other demographics and outcomes were included in Table 1.

Significant progress has been made toward making ambulatory TJA feasible and attractive for select patients without compromising safety or satisfaction. Patient perception and pain scores, especially during initial recovery, are very important for discharge and cumulative opioid consumption. Although the decrease in opioid consumption was not statistically significant, it may be still clinically meaningful. As we refine approaches to reduce opioid use and recovery time after joint surgery, it is important to consider acupuncture as part of a multimodal fast-track protocol.

Traumatic rib fractures are associated with significant morbidity and mortality, particularly in older patients. Fascial plane blocks have been used in the last decade to enhance analgesia, minimise the Opioid related side effects, reduce the respiratory complications and the associated critical care admissions. This study evaluates the impact of fascial plane nerve blocks compared to conservative management on mortality and hospital length of stay (LOS) in patients with rib fractures.

A retrospective cohort study was conducted on adult patients admitted with rib fractures to QEQM hospital between 2018 and 2023. Patients were divided into two groups: those who received a nerve block (serratus plane and erector spinae blocks, n=149 patients) and those who were managed conservatively (n=830 patients). Outcomes assessed included in-hospital mortality and LOS. Subgroup analysis by age was also performed. A p-value <0.05 was considered statistically significant.

The fascial plane block group showed a lower overall in-hospital mortality compared to the conservative management group (7.4% vs 11.32%) and across all age groups except those over 80 years, where mortality was comparable (12.3% vs 12.17%). These differences were not statistically significant (p-values >0.05)(fig.1). The mean hospital LOS was significantly reduced in the nerve block group compared to conservative management group (11.127 days vs 14.620 days, p = 0.0305). The most notable reduction was in patients over 80 years (12.41 vs. 17.92 days, p = 0.0264) (fig.2).

Fascial plane blocks in patients with traumatic rib fractures are associated with a significant reduction in hospital LOS and a trend toward lower mortality. They also have the advantage of avoiding the side effects and the high-level monitoring associated with epidurals. These findings support the use of nerve blocks as part of multimodal pain management, especially in older populations. Larger prospective studies are needed to confirm the mortality benefit.

Pain management after liver surgery is challenging due to the nature of the procedure and postoperative metabolic changes. While epidural analgesia is considered the gold standard, liver dysfunction and coagulopathy limit its use. Superficial peripheral nerve catheters have emerged as potential alternatives. The external oblique intercostal (EOI) block targets T6–T10 intercostal nerves, offering upper abdominal analgesia. However, high systemic absorption of local anesthetics—especially in patients with impaired liver function—raises safety concerns.

Following Institutional Review Board approval (IRB32044), we retrospectively reviewed patients undergoing liver surgery with peripheral nerve blocks between January 2021 and October 2024. Of 115 screened, we included those who received EOI catheters. Data collected included demographics, block technique, local anesthetic regimen, postoperative pain scores (POD 0–2), and lidocaine plasma levels through POD4.

Seven patients met inclusion criteria, including one pediatric case (<18 years). Mean age was 53 years (range 14–78), with five males and two females. Techniques included bilateral catheters (n=4), unilateral catheters (n=2), and one unilateral catheter with a contralateral rectus sheath block. All blocks were ultrasound-guided and primed with ropivacaine. Two patients received ropivacaine infusions; five received lidocaine programmed intermittent boluses (four with patient-controlled boluses). Mean pain scores were 3.4 on POD0, 3.2 on POD1, and 2.4 on POD2. Median lidocaine levels (IQR) were 1.6 mcg/mL (1.2–2) on POD1, 2.6 (1.9–2.9) on POD2, 2.4 (1.7–3) on POD3, and 4.5 (1.8–5.1) on POD4. Two patients peaked at 4.8 and 5.1 mcg/mL.

EOI catheters provide effective pain control after liver surgery and are associated with variable plasma lidocaine levels. High systemic absorption of local anesthetics is known after fascial plane blocks. While the EOI block offers uniquely favorable coverage for liver procedures—unlike other fascial plane techniques—its use requires careful monitoring to minimize the risk of local anesthetic systemic toxicity.

Catheter-related bladder discomfort (CRBD) is a distressing postoperative complication following indwelling urinary catheterization. The objective of this study was to evaluate the efficacy and tolerability of pre-emptive oral melatonin in preventing CRBD in patients undergoing transurethral resection of the prostate (TURP) in terms of postoperative pain, sedation, rescue analgesics requirement, and patient/surgeon satisfaction.

Seventy adult males aged between 40–75 years undergoing TURP with intraoperative urinary catheterization were randomised to Group M (to receive Melatonin 5 mg oral melatonin night before and morning of surgery) and Group D (to receive vitamin C as placebo). The primary outcome was assessment of the incidence of CRBD at 24 h. The secondary outcomes were assessment of severity of CRBD, postoperative pain, sedation, number of rescue analgesics, patient/surgeon satisfaction, and adverse effects if any. Independent t test was used to compare normally distributed quantitative data, while Mann–Whitney U test was conducted to analyse non normally distributed quantitative variables. The Chi squared test or Fisher’s exact test was employed to assess the association between categorical variables. Tests were two-tailed with a significance level set at p <0.05.

The incidence of CRBD was significantly lower in Group M as compared to Group D at 2 h (p=0.005), 4 h (p=0.004), 12 h and 24 h (p< 0.0001). The severity of CRBD was less in Group M at all time intervals (p< 0.001). The visual analogue scale (VAS) scores were lower in Group M at 2, 8, 12 and 24 h ( p<0.0001) and fewer patients required rescue analgesics in group M as compared to group D (p=0.0006). Patient satisfaction was higher with melatonin (p=0.121), with a trend toward higher surgeon satisfaction (p=0.064). Melatonin was well tolerated with no significant sedation differences.

Preemptive oral melatonin effectively reduces CRBD incidence/severity, enhances postoperative comfort, without sedation or adverse effects.

Postoperative pain management following total knee arthroplasty (TKA) is critical, particularly for the posterior knee capsule. The IPACK (infiltration between the popliteal artery and the capsule of the knee) block and the popliteal plexus block (PPB) are increasingly used as motor-sparing alternatives to sciatic or tibial nerve blocks for postoperative analgesia. We conducted a double-blind, randomized controlled trial to evaluate whether PPB offers superior motor preservation compared to IPACK, focusing on ankle dorsiflexion and plantarflexion strength.

Eighty-seven patients undergoing TKA were randomized to receive either IPACK or PPB with 15 mL of 0.25% levobupivacaine. All patients received an adductor canal block with 10 mL of 0.25% levobupivacaine. The primary outcome was dorsiflexion strength at 6 hours post-block, expressed as a percentage of the preoperative baseline. Secondary outcomes included plantarflexion strength, time to meet discharge criteria (>90° knee flexion, adequate pain control, and ambulation), pain scores, supplemental analgesic use, knee ROM, quadriceps function, and anesthesia-related complications.

Dorsiflexion strength at 6 hours post-block was significantly higher in the PPB group (78% ± 17%) than in the IPACK group (61% ± 17%) (difference: 17%; 95% CI: 7–21%; p < 0.001). A similar difference was observed at 24 hours (PPB: 94% ± 17% vs. IPACK: 81% ± 18%; difference: 13%; 95% CI: 8–23%; p < 0.001). Plantarflexion strength also differed significantly between groups (6 hours: 83% vs. 68%; 24 hours: 98% vs. 90%). No significant differences were observed in other secondary outcomes.

PPB demonstrated superior preservation of dorsiflexion and plantarflexion strength at 6 and 24 hours postoperatively compared to IPACK. However, this motor-sparing advantage did not translate into improved outcomes such as pain control or discharge readiness. Nevertheless, PPB may offer benefits for early rehabilitation by minimizing motor nerve blockade.

Background: Abdominal pain is common in advanced upper abdominal malignancies, often requiring adjunct therapies when opioids are insufficient or poorly tolerated. Celiac plexus neurolysis (CPN) offers targeted pain relief in such cases. Objective: To evaluate the safety and efficacy of contrast-enhanced ultrasound (CEUS)-guided CPN, assess the correlation between drug dispersion and pain relief, and compare dispersion patterns on CEUS and computed tomography (CT).

A total of 23 patients diagnosed with advanced-stage abdominal malignancies and experiencing severe, intractable pain were enrolled in this prospective study. Each patient initially underwent a diagnostic celiac plexus block to evaluate the potential effectiveness of neurolytic intervention. Upon confirmation of a positive response, celiac plexus neurolysis was subsequently performed under real-time guidance using contrast-enhanced ultrasound (CEUS). This technique enabled direct visualization of needle placement and drug dispersion during the procedure. Immediately following the neurolysis, a contrast-enhanced computed tomography (CT) scan was conducted in all patients to assess the extent and pattern of neurolytic agent spread. Pain intensity was systematically evaluated using the Visual Analog Scale (VAS) at multiple intervals: immediately post-procedure, on day 1, at the end of the first week, and then at one, two, and three months post-intervention.

CEUS-guided CPN resulted in significant pain reduction, with an average relief duration of 1.1 months. Greater drug spread (>90°) correlated with superior analgesia. CEUS and CT showed substantial agreement in visualizing spread (Kappa = 0.72). Minor complications occurred but required no intervention.

CEUS-guided CPN is a safe, effective, and radiation-free technique for managing upper abdominal cancer pain, with drug dispersion extent being a key predictor of pain relief.

This study is designed to test the efficacy of adding Depomedrol a long-acting steroid to lidocaine for relieving chronic osteoarthritic knee pain and reducing opioid requirements. For this purpose, Depomedrol is added to lidocaine for ultrasound-guided Genicular nerve block. A genicular nerve block is a minimally invasive procedure used for diagnosing and treating knee pain, particularly in patients with osteoarthritis or those who have undergone knee surgery but still experience discomfort. It targets the genicular nerves, which are responsible for transmitting pain signals from the knee to the brain. The procedure involves the precise injection of a local anesthetic (and sometimes a steroid for longer-lasting relief) around the genicular nerves. This effectively interrupts the pain signals, providing temporary relief from knee pain.

60 patients were enrolled prospectively in this study , aging from 40-85 year old, ASA II-III. 30 patients as controlled group with lidocaine 2% (6 ml) US guided genicular nerve block,30 patients were in Depomedrol Group with 80 mg depomedrol mixed with lidocaine 2% (6 ml). All nerve blocks were performed in out patient clinic as pain clinic. follow up with patients last over 3 months duration following injection.

In the Depo Group, patients showed more satisfaction than lidocaine group regarding their pain relief score , ability to walk long distances, decreasing analgesic medications consumption.

Adding Depomedrol to local anesthesia medication as adjuvant can provide extended pain relief for chronic osteoarthritic knee pain lasting weeks to few months.

Neuraxial anesthesia (epidural and spinal) is widely used in surgical and obstetric procedures. However, in patients receiving thromboprophylaxis with low molecular weight heparin (LMWH), there is a risk of hemorrhagic complications, with spinal hematoma being the most feared due to its severe neurological consequences. Although its incidence is low, the clinical implications are significant. This systematic review aims to evaluate the incidence of spinal hematoma in patients receiving LMWH undergoing neuraxial anesthesia and identify associated risk factors.

A systematic search was conducted in PubMed, Embase, Cochrane Library, and Google Scholar using terms such as "Neuraxial anesthesia," "Low Molecular Weight Heparin," "Spinal hematoma," and "Risk factors." Filters included articles in English and Spanish published within the last 5 years. Clinical trials, cohort studies, case series, and systematic reviews were included; animal studies, pediatric studies, or those not reporting spinal hematoma incidence were excluded

Of 2,819 identified articles, 50 studies met inclusion criteria. The overall incidence of spinal hematoma in patients with LMWH and neuraxial anesthesia was 0.1% (10 cases per 10,000 patients). Associated risk factors included advanced age, concomitant antiplatelet use, and therapeutic LMWH doses. Most studies recommended a 10–12-hour interval between the last LMWH dose and neuraxial block, with close postoperative neurological monitoring

The risk of spinal hematoma in patients receiving LMWH during neuraxial anesthesia is low (0.1%) but requires caution, particularly in those with risk factors. A safe interval between LMWH administration and neuraxial block, along with vigilant neurological monitoring, is recommended. Future research should focus on identifying high-risk subpopulations and strategies to further minimize bleeding risks

Laparoscopic cholecystectomy often results in moderate to severe postoperative pain. While systemic opioids remain a mainstay for pain management, their association with multiple side effects underscores the need for effective regional anesthesia alternatives. This study aimed to compare the effectiveness of the Transversus Abdominis Plane (TAP) block and the Erector Spinae Plane (ESP) block in relieving postoperative pain in patients undergoing laparoscopic cholecystectomy.

In this single-blind, parallel-group trial, 60 ASA I-II patients undergoing elective laparoscopic cholecystectomy were randomized to receive either bilateral ESP blocks (T12-L1 level, n=30) or subcostal TAP blocks (n=30), both administered pre-incision with 20 mL 0.375% ropivacaine per side under ultrasound guidance (Esaote L4-15 probe). The primary outcome was dynamic Visual Analog Scale (VAS) pain score at 12 hours postoperatively. Secondary outcomes included: 24-hour opioid consumption, time to first rescue analgesia, ambulation, bowel function recovery, length of hospital stay, adverse effects.

The study showed that the ESP block provided lower dynamic VAS scores at H2, H4, H8 and H24 with significant differences compared to the TAP block. More patients achieved adequate analgesia (VAS <4) at H12 with the ESP block (66.7% vs. 36.7%; p = 0.022). Regarding analgesic consumption, patients in the ESP group required a significantly lower cumulative dose of tramadol (median 100 [IQR 100-150]mg vs 200 [IQR 150-200]mg, p<0.001), with a longer delay before the first opioid use (p=0.033). The ESP block allowed earlier ambulation (p=0.018) and quicker return of bowel function (p<0.001). Both techniques showed similar incidences of postoperative nausea and vomiting with comparable tolerability.

The ESP block appears to provide better pain control and improved postoperative recovery compared to the TAP block. However, additional studies are required to validate these findings and support its clinical implementation.

Awake craniotomy is a specialized neurosurgical procedure that demands optimized anesthetic techniques to ensure patient comfort and facilitate intraoperative neurological monitoring. Scalp nerve block using local anesthetics combined with adjuvants has emerged as a key strategy. Literature regarding the dexamethasone vs dexmedetomidine as adjuvants in scalp block is less limited.The primary objective was to assess the time to the first rescue analgesic dose, with secondary objectives including onset of sensory block, hemodynamic stability, postoperative pain, and overall analgesic consumption.

This prospective, double-blinded, randomized controlled trial was conducted over 12 months in a tertiary care center. Fifty adult patients (aged 18– 65 years) undergoing elective awake craniotomy were randomized into two groups: Group RMED received a scalp nerve block with 0.5% Ropivacaine combined with Dexmedetomidine (1 µg/kg), and Group RMETH received 0.5% Ropivacaine combined with Dexamethasone (8 mg). Outcomes included the time to first rescue analgesia (primary outcome), onset of sensory block (pinprick test), intraoperative hemodynamic stability (HR and MAP), postoperative pain scores (NRS at intervals up to 24 hours), total 24-hour analgesic consumption, and the incidence of adverse events, including bradycardia, hypotension, and respiratory depression.

Both groups achieved effective sensory blockade with minimal complications. Group RMED demonstrated a significantly prolonged duration of analgesia compared to Group RMETH (median: 16 hours vs. 12 hours; p<0.05). The onset of sensory blockade was similar between groups (median: 6.5 minutes for RMED vs. 7 min for RMETH; p>0.05). Postoperative pain scores (NRS score) were significantly lower in Group RMED, and total 24-hour rescue analgesic consumption was significantly reduced in RMED (p<0.05).

Dexmedetomidine, as an adjuvant to 0.5% ropivacaine in scalp nerve blocks, provided a superior analgesic profile compared to dexamethasone in term of duration of pain relief, enhanced postoperative comfort, reduced analgesic requirement and ensured stable perioperative hemodynamics.

Regional anesthesia (RA) is a key component of modern anesthesia practice, offering advantages such as reduced postoperative complications and opioid consumption (1). Ultrasound (US) guidance significantly improves the safety and accuracy of RA procedures (2). This study aimed to evaluate the effectiveness of simulation-based RA training using various models, focusing on participants’ ability to implement these techniques in clinical practice.

Between 2018 and 2024, over 300 anesthesiologists participated in a series of courses on ultrasound-guided regional anesthesia. The training includes lectures followed by hands-on low-fidelity simulation sessions with three types of simulation models: specialized commercial simulators, custom-made ballistic gel models, and animal tissue models. A survey was conducted to assess the perceived efficacy of each model and the impact of the course on clinical practice.

According to the survey, 85% of participants successfully incorporated ultrasound-guided RA into their daily practice, and 70% expanded the RA techniques use to other anatomical areas after the course. Additionally, 60% of participants started teaching RA techniques to their colleagues, further increasing the reach of the training. Participants also reported a 50% reduction in the time required to perform nerve blocks and a 40% reduction in complications during RA procedures. Both ballistic gel and agar-agar models demonstrated similar effectiveness, with 90% of participants rating them as highly effective. However, the agar-agar model was significantly more cost-efficient, making it a practical alternative for broader adoption in educational settings.

This study highlights the importance of simulation-based learning in improving the skills required for safe and effective RA. Low-cost models, such as the agar-agar phantom, provides an affordable yet effective alternative to more expensive commercial simulators. Furthermore, the courses significantly impacted participants' clinical practice, with a large percentage reporting the adoption and expansion of RA techniques in their hospitals.

Case report of a 29-year-old woman, 38 weeks gestation, that came to our pre-anesthetic consultation with personal history of congenital FVII deficiency with history of gingivorrhagia and, as a remarkable antecedent, major bleeding after mammoplasty that required 24h admission to the ICU, despite having administered rFVIIa (Novoseven) before the operation. Aims: Individualised analysis of this particular case and establishment of recommendations for the delivery agreed by a board of experts.

A serch of the available scientific evidence in databases (PubMed, UpToDate....).

Both in the choice of anesthetic technique and type of delivery, the personal history of postoperative hemorrhage despite Novoseven prophylaxis weighed heavily. Therefore, the apparently safest option was chosen: cesarean delivery under general anesthesia. The delivery was completely normal and without complications. Bleeding was controlled without requiring hematite concentrate transfusion or extra doses of Novoseven.

Until larger studies and clear guidelines are available, the management of labor in women with FVII deficiency should be addressed on a case-by-case basis in multidisciplinary meetings involving obstetrics, anesthesiology and hematologist with expertise in hemostasis. FVII level alone does not predict bleeding risk; management discussions should take into account the patient's bleeding history, third trimester PT, multiple gestation, and mode of delivery. In healthy women, during pregnancy, concentrations of many coagulation factors increase and may have a protective effect against bleeding. The risk of thrombotic complications associated with pregnancy and cesarean section is independent of FVII levels.

Managing pain in recurrent oral squamous cell carcinoma (SCC), particularly with post-radiotherapy(RT) mucositis, remains challenging. An 85-year-old female with recurrent right palatal SCC with ongoing palliative RT presented with severe refractory orofacial pain exacerbated by oral intake. Despite high-dose fentanyl, pregabalin, nortriptyline and ibuprofen, her pain control remained inadequate. A maxillary nerve block was proposed to target localised orofacial pain.

An 85-year-old female with severe post-radiotherapy mucositis-associated pain in the V2/V3 distributions had inadequate relief despite escalating opioids, with pain mainly localized to the V3 region. Distal V3 nerve blocks were not feasible due to an exophytic tumor and overlying skin changes. A right maxillary nerve and sphenopalatine ganglion block was performed via the pterygopalatine fossa using an ultrasound-guided infrazygomatic approach. A linear probe guided a 5 cm Stimuplex needle out-of-plane under aseptic conditions with local lignocaine infiltration. After confirming correct placement with hydrodissection and negative aspiration, 3 ml of 0.5% bupivacaine and 8 mg dexamethasone were administered.

The patient experienced immediate pain relief and stable pain control with no need for breakthrough doses despite stopping the fentanyl infusion. The block appeared to provide modest but meaningful pain relief with no observed complications or neurological deficits. This suggests that anaesthetic spread from the PPF to the mandibular nerve may occur, potentially facilitated by anatomical communications within the region. Additionally, modulation of the SPG may contribute to the analgesic effect. These findings indicate that maxillary nerve blocks via the PPF can serve as a viable and potentially safer alternative to direct mandibular nerve blocks in cases of peripheral compression from tumor involvement.

Ultrasound-guided maxillary nerve block via the pterygopalatine fossa is a safe, feasible option for managing focal orofacial pain in palliative head and neck cancer patients. It offers short-term relief and serve as a bridge to more definitive neurolytic techniques.

Epidural analgesia is pivotal in labour pain management, yet the transient efficacy and adverse effects of local anesthetics (LAs) drive the need for adjuvants. This review evaluates the efficacy and safety of diverse adjuvant classes—opioids, α2-adrenoceptor agonists, cholinergic agonists, NMDA antagonists, GABA receptor agonists, and corticosteroids—in enhancing analgesia, prolonging duration, and minimizing LA-related toxicity, while prioritizing maternal and neonatal safety.

A systematic review of randomized controlled trials (RCTs) and meta-analyses (2010–2024) from PubMed, EMBASE, and Cochrane Library was conducted. Studies assessing adjuvants combined with LAs (e.g., ropivacaine, bupivacaine) were included. Outcomes analyzed included pain scores (VAS), analgesia duration, LA consumption, maternal side effects (hypotension, pruritus), and neonatal outcomes (Apgar scores).

Opioids (fentanyl, sufentanil) provided rapid analgesia (onset <20 minutes) but increased pruritus risk (RR 2.5 vs. non-opioids). α2-agonists (dexmedetomidine) prolonged analgesia by 2–3 hours (MD: 145 minutes, 95% CI 120–170) but extended motor blockade (MD: 55 minutes). Corticosteroids (dexamethasone 4–8 mg) reduced LA requirements by 25% and delayed analgesia onset by 30 minutes, with minimal maternal side effects. NMDA antagonists (ketamine) and GABA agonists (midazolam) showed preliminary efficacy in reducing hyperalgesia but lacked robust obstetric safety data. Cholinergic agonists (neostigmine) demonstrated mixed results, with limited adoption due to nausea risks. Neonatal outcomes remained unaffected across all adjuvants.

Dexmedetomidine and dexamethasone emerge as optimal adjuvants, balancing prolonged analgesia with tolerable side effects. Opioids remain valuable for rapid relief but require pruritus management. Novel agents (NMDA/GABA agonists) warrant further investigation to establish safety profiles. Standardized dosing protocols and multimodal approaches integrating corticosteroids with traditional adjuvants may optimize labour analgesia while minimizing risks.

Patient positioning significantly influences spinal needle insertion and successful block in obstetric patients. Traditional sitting position (TSP) or lateral decubitus positions are common, with the crossed leg sitting position (CLSP) being an alternative that enhances lumbar flexion, potentially improving needle placement success. This study aims to predict successful spinal needle placement in CLSP and TSP using sonographic measurements of spine, and to compare CLSP and TSP for successful spinal needle placement in parturients undergoing elective caesarean section.

Neuraxial ultrasonography was done in 116 parturients with gestational age ˃37 weeks, in both TSP and CLSP to measure Interlaminar distance (ILD), skin to Ligamentum flavum (LF), and Posterior longitudinal ligament (PLL) distance. Following scanning, patients were randomly assigned to Group TSP and CLSP (n=58 each). The primary outcome was prediction of successful first attempt spinal needle placement in CLSP and TSP using sonographically measured length of PLL, ILD, and LF. Secondary outcomes included total number of attempts for spinal needle placement, ease in landmark palpation, and comfort level in both positions.

Sonographic measurements of ILD, LF, and PLL were more in CLSP than TSP (p<0.001 each). Successful first-attempt spinal needle placement was significantly greater in Group CLSP (63.79%) than in Group TSP (43.10%) (p=0.026). ILD measurement in CLSP, with a cut-off value of 1.36 cm, showed the best prediction of successful first-attempt spinal needle placement [AUC (0.718); sensitivity of 78%; specificity of 62%; p= 0.006]. CLSP showed better ease of landmark palpation (p=0.001). Comfort level was comparable between TSP and CLSP.

Interlaminar distance (ILD), measured in CLSP, was the best sonographically measured parameter for predicting successful first-attempt spinal needle placement. Present study supports the use of USG spine measurements in guiding spinal needle placement. It demonstrates that CLSP can be an alternative position to TSP for neuraxial block in parturients

Various methods are commonly employed with regards to analgesia during transvesical prostate adenomectomy (TPA). We analysed whether there is a difference between a treatment applying two abdominal blocks versus one without any regional block for patients undergoing TPA.

Prospectively 28, ASA II – III, 71.2 ± 7.7 y. males, BMI 25 ± 3.6 were analysed. Approval nr. Nr. 71-35/184. GA was applied for 5 and spinal for 23 of the patients. Patients were randomized into three groups: transversus abdominis plane (TAP group, n=10), rectus sheath block (RS group, n =10) and one without any regional block (control group, n=8). Multimodal analgesia was used for all. The main focus was on analysing pain intensity (NRS scale) 2, 6, 12 and 24 hours (h) after the surgery. A secondary objective was to analyse patient satisfaction (1-5 scale). SPSS, p< 0.05, Cramer’s V for clinical significance.

Patients experienced the most severe pain 12h after surgery. RS group showed lower rest pain - median RS 2.0 (Q1, Q3 0 – 3.5) vs. TAP 3.5 (Q1, Q3 1.7-4.2) vs. control 3.5 (Q1, Q3 – 0.5-5.0) and movement evoked pain - median RS 3.5 (Q1, Q3 1.7-6.0) vs. TAP 4.5 (Q1, Q3- 3.0-6.0) vs. control 7.0 (Q1, Q3- 4.5-8.0). A substantial variation in pain levels was identified 6h after surgery when the RS and control groups were compared; P<0.05. Moreover, 87.5% control patients received opioids vs. 50% RS and 60% TAP patients. Highest satisfaction with pain relief was found in TAP/RS with 90% vs. 62% in control group.

RS patients experience overall less pain and opioid consumption 24h after surgery, showing the highest difference after 6h compared to patients without the block. Peripheral blocks therefore are useful to increase patient satisfaction with analgesia.

The management of chronic hip pain requires accurate diagnosis and a multimodal approach. This study aimed to evaluate the effect of posterior quadratus lumborum block (QLB) on pain and quality of life in patients with chronic hip pain.

After Ethical committee´s approval (PI 21-PI104) and registration (Trial registration number: NCT04438265) we started this prospective cohort study. A sample size of n=200 was calculated to ensure that a two-sided test with α = 0.05 would have 90% power to detect a 5% difference in the proportion of patients receiving pain treatment, with 95% confidence. All patients were suffering from chronic hip pain. The intervention group received posterior quadratus lumborum block as an analgesic technique and control group did not. Pain (NRS) and quality of life (WOMAC questionnaire) were assessed at baseline, three weeks, three and six months in both groups. The block was considered effective if, three months after the block, in the QLB group, pain decreased by a mean NRS ≥ 3 during daily activity or a WOMAC global score of 24-26 points.

There were no differences in demographic data(Table 1),The QLB group showed significant improvements in pain and quality of life at three months compared to baseline (NRS mean 7/4; and WOMAC mean 59/35) (p value = 0.001), while the control group scores remained unchanged (NRS 7/8; and WOMAC (61/61) (Figure 1). At three months, 50 patients in the QLB group showed an improvement more than 50% in NRS and WOMAC scores (ten of those patients had an improvement for more than one year). We observed that patients with avascular necrosis showed a minor improvement. Only two adverse events were registered (an unexpected spread and an allergic reaction)

Our results suggest that posterior QLB could represent a minimally invasive option in chronic hip pain.

In a single paediatric centre, a wide variability of perioperative analgesia regimes existed in elective knee surgery patients, leading to unpredictable post-operative pain outcomes. In adults, knee surgeries have a high incidence of severe post-operative pain, and various motor sparing regional anaesthesia techniques have been assessed. In paediatrics, multiple international guidelines exist for best practice postoperative pain management. Therefore, a review of departmental practice was undertaken.

A retrospective chart review of any patient who underwent an elective knee procedure over an eighteen month period was performed. A total of 41 cases were identified to analyse. Data was collected and inputted into an excel audit tool on a hospital password encrypted computer.

Demographics revealed 54% male (n=22), 46% female (n=19). Patient age range 11-18 years old. Postoperative simple analgesia prescribing; 93% for paracetamol, 90% for non-steroidal anti-inflammatory drugs (NSAID). Numerical pain scores were documented in 88% (n=36). Rescue opiate analgesia was prescribed in 98% (n=40) and used in 59% (n=24). Rescue antiemetic was prescribed in 93% (n=38) and used in 22% (n=9). 100% of patients received local anaesthetic intra-operatively; peripheral nerve block (PNB) in 68%, local infiltration of anaesthetic (LIA) in 5%, PNB and LIA in 27%. PNB choice was 37% adductor canal (AC) (n=15), 27% AC and iPACKS (n=11), 15% AC, iPACKs and Genicular (n=6), 7% AC and Genicular (n=3). The AC and iPACKS combination had the lowest post-operative pain scores, rescue opiate usage and average opiate usage. 42% (n=17) were daycases, with 5% (n=2) resulting in delayed discharge.

This study shows excellent departmental compliance with international post-operative pain management recommendations. Given the variability in PNB performed, there is a role for a future randomised control trial to further analyse postoperative outcomes comparing PNB to LIA, with the potential to introduce a formal analgesia pathway for this cohort of patients.

Total hip arthroplasty is a major procedure with significant postoperative pain.The aim of this study is to evaluate the effect on postoperative pain using a combination of regional blocks in total hip arthroplasty compared to standard pain management strategies.

In the BLAST trial (Blocks in ArthroplaSTY), 204 patients scheduled for hip arthroplasty were included. The patients were randomized to receive either standardized multimodal analgesia comprising paracetamol, celecoxib, oxycodone, and betamethasone, or standardized multimodal analgesia in conjunction with a PENG block (Pericapsular Nerve Group) and either an iliohypogastric block or an LFCN block (Lateral Femoral Cutaneous Nerve). For the posterior surgical approach, the iliohypogastric block was administered, while the lateral approach involved the LFCN block. Anesthesia was performed using either spinal anesthesia with 0.5% bupivacaine or general anesthesia with propofol and remifentanil following a TCI protocol. During the administration of the PENG, iliohypogastric, and LFCN blocks, 0.5% ropivacaine with clonidine was injected. Postoperative pain was assessed using the Numeric Rating Scale (NRS), and opioid consumption, time to mobilization, and the incidence of PONV were recorded.

General anesthesia group without a block exhibited a mean NRS score of 5.04, whereas the block group had a mean NRS score of 3.29 upon arrival at the postoperative unit. The mean postoperative oxycodone requirement was 15.64 mg for the non-block group and 10.83 mg for the block group. Spinal anesthesia group showed NRS scores of 1.07 and 0.48 for the standard and block groups, respectively. The oxycodone requirement in the spinal anesthesia group was 4.38 mg and 4.58 mg for the standard and block groups, respectively.

When using PENG and Iliohypogastric blocks combined with general anesthesia during hip arthroplasty patients experience less postoperative pain, evaluated by NRS, and has lower opioid requirement compared to the reference group with multimodal analgesia.

Paravertebral block (PVB) is the gold standard regional technique for breast surgery but due to proximity of the pleura and neuroaxis, can be challenging to perform. Fascial plane blocks are potentially safer alternatives. We describe incidence of pneumothorax for patients who received PVB, PECS-1, serratus, and erector spinae blocks for mastectomy.

After institutional review board approval was granted for this retrospective analysis, we identified 6334 mastectomies with 9290 individual blocks, between 1/5/2016 - 5/30/2024. 61% of cases were bilateral; 54% had one block type, most commonly PVB. Most common combination blocks were serratus plus PECS-1 and PVB plus PECS-1. We calculated risk of pneumothorax for all cases, all blocks as well as for laterality and block type. All blocks were placed with ultrasound-guidance by an experienced anesthesiologist or supervised trainee.

There were four cases of pneumothorax (Table 1). Two were diagnosed shortly after the block resulting in surgery cancellation (one after PVB, one after serratus). Incidence for all cases was 0.06% (CI 0.02%, 0.16%); for individual block types, 0.04% (CI 0.01%, 0.11%). For unilateral cases, incidence was 0.04% (CI 0.001%, 0.22%); for bilateral cases, 0.08% (CI 0.02%, 0.23%). Three cases occurred after PVB, 0.07% (CI 0.01%, 0.20%); one after serratus, 0.05% (CI 0.001%, 0.30%).

Incidence of pneumothorax in our cohort was rare. Only 2 cases in >9000 blocks were attributable to the block itself; the remaining 2 cases were identified after discharge with unclear etiology (nerve block versus surgery). We confirmed pneumothorax risk in a high-volume practice is extremely low and comparable between PVB and fascial plane blocks.

Enhancing recovery after cardiac surgery is a major goal of regional anesthesia. The erector spinae plane (ESP) block is gaining traction in this field, but the impact of perineural dexamethasone—particularly when combined with serial pain assessments at rest and movement—remains unexplored. Objective: To evaluate whether dexamethasone as an adjuvant to ESP block improves early recovery markers, including mechanical ventilation duration and dynamic pain scores, in patients undergoing coronary artery bypass grafting (CABG).

In this double-blind, randomized controlled trial, patients received bilateral ESP block with 0.2% ropivacaine ± 8 mg perineural dexamethasone. Pain was rigorously assessed at rest and during movement over 48 hours using NRS/VAS scales. Other endpoints included opioid use and extubation time.

Among 43 patients (21 control, 22 dexamethasone), static and dynamic pain scores were low and comparable. However, the dexamethasone group exhibited a significantly shorter time to extubation (751 ± 333 vs. 848 ± 236 min, p = 0.041). This earlier ventilatory liberation occurred despite similar opioid requirements, suggesting improved pain tolerance during active respiratory effort. No block-related complications were reported.

This is the first study to integrate perineural dexamethasone with dynamic pain assessments following ESP block in cardiac surgery. Although acute pain scores were similar, dexamethasone significantly accelerated extubation—highlighting its role in enhancing recovery. These findings advocate for its inclusion in ERACS pathways and warrant multicenter validation.

New Stobhill Hospital, Glasgow, is a satellite hospital with a dedicated day surgery service. Patient selection criteria are employed to reduce chance of complications or failed discharge- patients are either Red (unsuitable), Amber (require consultant anaesthetic review for decision) or Green (suitable). A dedicated block room with awake regional anaesthesia as default began in October 2024. We aimed to review how many patients meeting traditional Amber or Red criteria were successfully undergoing day case surgery using this service.

Ethical approval for the project was granted. We retrospectively reviewed and sorted the first 7 months of patients through the block room using the Green, Amber or Red criteria. We then reviewed patients on the available waiting list using the same criteria.

Between October 2024 and April 2025, 130 patients successfully underwent day case surgery via the block room. 10% were Red, and would not have been offered day case surgery in this hospital. 30% were Amber, and would have required consultant review prior to proceeding. There were no cases of failed day case discharge due to anaesthetic or surgical complications. There were 84 patients on the waiting list, of which 28.8% were Amber and 12.5% were Red.

Introducing a regional anaesthesia block room has widened access to day case surgery for previously unsuitable patients. This improves waiting lists and relieves bed and theatre space in our tertiary centre. Having over 40% of patients not meeting traditional criteria shows the opportunity to streamline the preassessment process for day case block room patients.

Median sternotomy is associated with significant postoperative pain, especially in the first 24 hours following cardiac surgery. The deep parasternal intercostal plane (DPIP) block has emerged as a promising regional technique for sternotomy pain. However, variability in dermatomal coverage due to anatomical differences in the transversus thoracis muscle raises questions about optimal injection strategies. This study aimed to compare the analgesic efficacy of single-level versus two-level DPIP block in adult patients undergoing cardiac surgery via median sternotomy.

In this prospective, randomized controlled trial (ClinicalTrials.gov ID: NCT06558123), 40 adult patients undergoing elective CABG or valve surgery were randomly assigned to receive either a bilateral single-level (T4-5) or two-level (T2/3 and T5/6) DPIP block with a total of 20 mL of 0.25% bupivacaine. Pain scores at rest and during movement were assessed using the numeric rating scale (NRS) and non-verbal pain scale (NVPS) at 4, 6, 8, 12, and 24 hours postoperatively.

Both block techniques were safe and effective. However, the single-level DPIP block group showed significantly lower NRS scores at 8 and 12 hours (p < 0.05). No significant differences were observed at other time points or in hemodynamic parameters. A strong negative correlation between age and NRS scores was identified, suggesting age-related differences in pain perception.

Both single- and two-level DPIP blocks offer effective analgesia after median sternotomy. However, single-level block at the T4–5 intercostal space may provide longer-lasting pain relief. These findings highlight the importance of anatomical considerations and suggest that simpler single-level techniques may be preferable in clinical practice.

Genicular nerve block (GNB) is performed using both fluoroscopy (FL) and ultrasound (USG) guided techniques. These techniques identify the targets using specific approaches. Our primary aim was to measure the difference in needle position between USG and FL guided techniques

We had recruited 48 patients. GNB was performed by experienced anaesthesiologist using echogenic needle under USG guidance. The conventional USG landmarks were the targets in superomedial (SM), superolateral (SL), and Inferomedial (IM) GNB. After injection, all needles were kept in situ. Then, both anterior-posterior (AP) and lateral fluoroscopic images of the knee were taken. Post-block pain scores were assessed at one hour, six hours, 24 hours, and one month. Later, the needles from fluoroscopic image were removed using software. The edited image was shown to anaesthesiologist and asked to mark the target for FL guided GNB. Both the original and edited images were superimposed and the distance between two points were measured. The first point was USG guided needle position and second point was the target point for fluoroscopy as marked. This was measured in SM, SL, and IM needle position. The second point was considered as acceptable if it was within 5 mm radius of the first point

The average distance between two points in AP view was 3.9±2.6, 4.4±3.0 and 3.8±2.6 in SM, SL, and IM respectively. In the lateral view it was 6.2±3.0, 6.8±3.5 and 6.3±2.9 in SM, SL, and IM respectively. Mean NRS scores at baseline, 1 hour, 6 hours, 24 hours, and 1-month were noted. Though only eight patients had acceptable needle position in both images, all 48 patients had a significant pain relief

Average distance between the between the needle tip of USG and FL guided GNB was 4.0±0.3 mm and 6.4±0.3mm in AP and lateral images respectively

Blocks of the individual nerves in the forearm is well established, but data regarding the spread of local anesthetics is scarce/infrequent. Based on the cadaveric injection of latex in the following nerves- Median (MN), Ulnar (UN), and Superficial radial The primary aim was to evaluate the latex spread, circumferential or non-circumferential. The secondary aim was to investigate the dye diffusion in muscles, paraneural, epineural tissue, longitudinal spread along the nerve, and anatomic barriers.

With 6 soft embalmed cadavers (12 specimens), a total of 36 injections were performed. At a point, 5cm from the elbow crease 1) 5ml of blue latex was injected in close vicinity of the MN. 2) 5ml of green latex was injected between the ulnar artery and the UN. 3) 5ml of green latex was injected close to the SRN. After injection, all specimens were dissected, and the three nerves were traced from the elbow crease to the wrist joint.

The blue latex disintegrated into various thin bands, though remaining in the same plane of FDP and FDS in the close vicinity of the median nerve. Beneath the brachioradialis and superficial to ECRL, a greenish discoloration was observed, which encroached upon the bicipital aponeurosis. The superficial radial nerve was engulfed significantly than the deep radial nerve. 9 Figures 1,2,3) Deep to the flexor carpi ulnaris (FCU), the green latex spread linearly along the ulnar nerve and the ulnar artery.

Based on our cadaveric injection study, we recommend a forearm nerve block at ‘5cm’ distal to the elbow crease. We conclude that in the forearm nerves, a non-circumferential, longitudinal spread pattern is consistent with a ‘3ml’ latex injection. The lateral antebrachial cutaneous and the medial cutaneous nerves of the forearm were spared and would require separate injections.

Artificial Intelligence (AI) is reshaping anaesthesiology. This narrative review provides a comprehensive understanding of AI's mechanisms, an extensive overview of current applications, and a critical examination of ethical, legal, and implementation challenges. It also highlights practical considerations for safe adoption and future integration opportunities.

A systematic literature search was conducted via PubMed on April 17, 2025, using the terms "Artificial Intelligence"[Mesh] AND "Anesthesia"[Mesh]. Full-text, English-language publications from the past five years were included. 126 out of 180 identified studies met eligibility after exclusion of retracted and inaccessible articles. Relevant references from academic lectures were also incorporated.

AI is increasingly impacting anaesthesiology training and clinical practice. In training, AI-driven virtual environments promise improved resident engagement and skill acquisition. In preoperative assessment, machine learning (ML) models already surpass risk stratification tools, although clinical implementation remains limited due to interpretability and validation concerns. Intraoperatively, AI might support airway assessment, automated tracheal access, hemodynamic prediction and anaesthetic closed-loop systems. In regional anesthesia, AI potentially enhances ultrasound interpretation, image acquisition and procedural confidence. Postoperatively, ML can predict complications and enable remote monitoring. Integrating physiological, laboratory, and genomic data may provide the necessary infrastructure for developing human digital twins. (HDT). However, many applications lack prospective validation, standardized evaluation frameworks and present significant ethical, legal and logistical challenges that need urgent medical attention.

AI holds great promise for advancing anaesthetic care, but its clinical implementation remains limited by challenges in interpretability, data security, and a lack of prospective validation. Anaesthesiologists must critically assess these tools to ensure they improve patient safety and quality of care.

Dexmedetomidine is a selective alpha-2 adrenergic agonist widely used for conscious sedation. It inhibits the release of excitatory neurotransmitters and has a synergistic effect with local anesthetics. Prolongs the duration of both sensory and motor block in a dose-dependent manner and delays the need for postoperative analgesia without increasing adverse effects. Younger patients require higher doses of bupivacaine and experience shorter durations of sensory and motor block compared to elderly patients. Adjuvants allow to reduce local anesthetic doses. Also, dexmedetomidine provides anxiolysis, improving patient satisfaction.

Eight cases reports, ASA I-II patients, described at Table 1 (Image 1). Surgeries lasted approximately 150 minutes and were completed without changing the anesthetic plan or administrating rescue analgesics. Postoperative analgesia consisted of scheduled NSAIDs every 8 hours. Motor block duration was measured using the time taken to reach a Bromage scale score of II. Sensory block was assessed through examiner palpation. Pain was evaluated using the visual analog scale (VAS) at one hour and 24 hours post-procedure. Sedation was monitored with the MOAA/S scale at 30-minute intervals. Adverse events such as oxygen saturation < 92%, mean arterial pressure <65 mmHg, and bradycardia <50 bpm were also recorded. We used 2ml ampoules of Dexmedetomidine 100mcg/ml. The content is sterile and contains water for injectable preparations and sodium chloride as excipients. Each ml contains less than 1 mmol (3.5 mg) of sodium, having that concentration and volume no potential for neurotoxicity.

Described at table 2 (image 1).

- Intrathecal dexmedetomidine as an adjuvant is a safe strategy to prolong sensory block in spinal anesthesia without increasing the dose of local anesthetic and without excessively prolonging motor block. - Intrathecal dexmedetomidine has an anxiolytic effect that improves intraoperative analgesic quality in young patients. - 10 mcg dose is safe to achieve benefits without increasing adverse effects.

Introduction: Genitofemoral neuralgia is a severe, debilitating condition that significantly reduces patients’ quality of life. While oral analgesics are a viable treatment option for some, other cases prove refractory to standard management and require more invasive approaches. Ultrasound-guided genital branch of genitofemoral nerve blocks have shown success, providing adequate pain relief in up to 70% of cases.

Case description: A 38-year-old male presented to the urology clinic with left-sided grade II varicocele and underwent spermatic vein ligation. During the procedure, the left inguinal peritoneum was accidentally lacerated and promptly sutured upon recognition of the laceration. One month later, he presented to the emergency urology clinic with persistent left testicular pain and marked tenderness, pain during intercourse and neuropathic pain ongoing since the procedure. Following an inconclusive microbiological, imaging, and laboratory workup, he was referred to the pain clinic almost two years after surgery. At the pain clinic, following a sterile skin preparation and draping, an ultrasound-guided genital branch of the genitofemoral nerve block was performed using 6 mg (1,5 mL) of dexamethasone, 4 mL of 0.5% levobupivacaine, and 2.5 mL of normal saline. A volume of 4 mL of anesthetic solution was deposited within the inguinal canal but outside the spermatic cord, with another 4 mL deposited inside the spermatic cord.

The patient experienced complete pain relief for 3 days, with the intensity decreasing from VAS 10/10 to VAS 6/10 over the following three weeks. A repeat block using the same technique was administered one month later, again resulting in significant pain reduction.

Ultrasound-guided genitofemoral nerve block is a viable, safe and effective option for managing chronic or postoperative testicular pain.

A previous analysis from our group suggested that the use of peripheral nerve blocks may decrease hip and knee osteoarthritis outcome scores (HOOS/KOOS) among outpatient (<24h stay) total joint arthroplasty patients. The purpose of this study was to further analyze the effect of adductor canal blocks (ACBs) on mean KOOS scores as well as acute and 90-day outcomes exclusively among outpatient TKA patients.

Institutional review board (IRB) approval was obtained from the Mayo Clinic IRB. A retrospective review of 338 TKA patients was performed, including 202 patients who received an ACB. All patients received periarticular injections and multimodal analgesia. Intraoperative and post-anesthesia care unit (PACU) narcotic usage (oral morphine milligram equivalents, OME), numerical pain scores, first ambulation distance, length-of-stay (LOS), 90-day complications (readmissions or reoperations) and KOOS scores were compared. Pearson Chi-Square and Fisher’s Exact tests evaluated categorical variables and Wilcoxon-Mann-Whitney tests evaluated continuous variables.

There were no significant differences in baseline values between the two groups. The mean patient age was 64.6 years, 54.1% were male, 89.1% were Caucasian, mean body mass index was 32.8 kg/mg2 and 91.1% of patients had a spinal anesthetic. Mean KOOS scores were not different for ACB patients compared to non-block patients (71.7 vs 64.0, respectively, p=0.0743). ACBs resulted in no significant differences in postoperative OME or pain scores. Additionally, PNB resulted in no difference in LOS (10.3 vs 11.2 hrs, p=0.1544), mean ambulation distance (147.5 vs 146.9 feet, p=0.9699) or 90-day complications.

Our results suggest that, within the context of a multimodal analgesia outpatient protocol, the use of ACB is not associated with an improvement in KOOS scores, 90-day complications or immediate postoperative outcome improvement. Among low-risk patients who qualify for an outpatient pathway with a multimodal analgesia protocol, the use of ACB may not influence postoperative functional and other outcomes.

Spinal anesthesia is often preferred for cesarean surgery. As hemodynamic stability is crucial during cesarean sections, this study compares the effects of intrathecal dexmedetomidine combined with bupivacaine versus bupivacaine alone on hemodynamic changes and postoperative pain management in pregnant women undergoing cesarean sections under spinal anesthesia.

A double-blind, randomized clinical trial involving 82 pregnant women undergoing cesarean surgery compared dexmedetomidine-bupivacaine (intervention) and bupivacaine alone (control). Patients were randomly assigned to groups using a block method. Hemodynamic parameters (systolic blood pressure, diastolic blood pressure, and heart rate) were measured at 1, 3, 5, 30, and 60 minutes during surgery.

The average patient age was 29.41±4.75 years (n=82). Surgery duration averaged 158.78±19.26 minutes in the intervention group and 127.31±23.02 minutes in the control group. Systolic and diastolic blood pressure did not differ significantly between the dexmedetomidine-bupivacaine and bupivacaine-only groups at times 1, 3, 5, 30, and 60 minutes during surgery. Dexmedetomidine prolonged pain control compared to the control group (P=0.02). Heart rate did not differ significantly between groups at times 1, 3, and 60 minutes, but was significantly lower in the dexmedetomidine-bupivacaine group at times 5 (P=0.03) and 30 minutes (P=0.001).

This study found no difference in systolic or diastolic blood pressure between the two groups. However, dexmedetomidine-bupivacaine significantly impacted heart rate at 5 and 30 minutes during cesarean surgery and improved postoperative pain management. Further research in this area is recommended.

Regional anesthesia methods in LSG operations are very important in preventing many postoperative complications and in pain management. Modified thoracoabdominal nerves block through a perichondrial approach (M-TAPA), defined by Tulgar et al., targets a wider area covering the T5-T12 dermatomes, providing effective analgesia in upper abdominal surgeries. This study compares the analgesic efficacy of subcostal transversus abdominis plane (TAP) block and modified thoracoabdominal nerves block through perichondrial approach (M-TAPA) in patients undergoing laparoscopic sleeve gastrectomy (LSG).

In this retrospective, single-center study, 41 patients who underwent LSG between January–November 2024 and received either a bilateral subcostal TAP or M-TAPA block preoperatively were analyzed. Data on intraoperative opioid use, postoperative analgesic consumption, and numeric rating scale (NRS) pain scores were collected. Exclusion criteria included chronic pain, preoperative opioid use, and incomplete records. All surgeries were performed using a standardized technique.

Demographics, surgical characteristics, and block application details were similar between groups. No significant difference was observed in intraoperative remifentanil requirements. In the first 24 postoperative hours, both groups showed comparable consumption of NSAIDs, paracetamol, and tramadol. NRS scores at rest and during activity, as well as postoperative nausea and vomiting incidence, were also statistically similar. No block-related complications were reported.

Both block techniques provided effective analgesia during and after LSG. Although M-TAPA theoretically covers a wider dermatomal area (T5–T12), this did not translate into superior clinical outcomes. The lack of significant difference may stem from the limited surgical area or the retrospective design. Stable hemodynamics and low postoperative analgesic needs in both groups suggest adequate pain control regardless of block type. Subcostal TAP and M-TAPA blocks are equally effective and safe for analgesia in LSG. Despite M-TAPA’s broader anatomical coverage, neither method showed clear superiority. Larger, prospective studies incorporating patient-reported outcomes are warranted to determine the optimal technique for clinical practice.

Postoperative pain control following any surgical procedure is very crucial, and it is associated with increased patient satisfaction and improved pulmonary function. Parenteral opioids not only decrease the colonic motility and increases chances of postoperative ileus [9]. Multimodal analgesia is the fundamental component of enhanced recovery after surgery. A randomized controlled trial was done that shows reduced perioperative morbidity and mortality with neuraxial techniques, when compared with other analgesic techniques

Non-probability consecutive sampling technique was used to collect the data. After the Approval to conduct this audit was obtained from ethical committee of the hospital (can be presented on request), data was collected from Surgical Epidural Registers of Anaesthesia department. All the calculations were done manually and then put in Microsoft Word Document.

A total of 308 surgical epidurals were inserted over the period of three years in our institute. Orthopaedic procedures constitute 125 (40.6%), 41 (13.31%) for thoracic surgery procedures, 36 (11.7%) for general surgery procedures, 25 (8.11%) for hepatobiliary procedures and 14 (4.54%) for urology procedures and 12 (3.89%) for Gynaecological procedures. Level of insertion is as per recommended guidelines in 200 patient out of 308. Bupivacaine is the most commonly used drug, while 0.1% concentration is generally preferred in our setup. Among the adjuvants, fentanyl, dexmedetomidine and tramadol were used. Overall complications rate is 40(12.98%), with motor blockade being the most common, followed by nausea/vomiting, hypotension, dural tap and blood tap.

: This audit will help us in rectifying the loop holes in the surgical epidural analgesia services provided by our department, but also other epidural analgesia services providers to make changes in their practices for better outcomes in future.

This study aimed to evaluate the analgesic effectiveness and perioperative outcomes of paravertebral block (PVB) using 0.25% bupivacaine alone versus 0.25% bupivacaine combined with dexmedetomidine in patients undergoing atypical lobectomy.

Thirty patients undergoing atypical lobectomy were randomly assigned to two equal groups. Group A received a single-shot US-guided paravertebral block with 0.25% bupivacaine (20 ml), while Group B received the same concentration and volume of bupivacaine combined with 50 µg of dexmedetomidine. All patients underwent general anesthesia.Parameters assessed included demographic and intraoperative data, fentanyl consumption, postoperative pain using the visual analog scale (VAS) at 1 and 3 hours, duration of analgesia, and type of surgical procedure. Statistical comparisons were made using appropriate tests, with a significance level of p < 0.05.

The mean age in Group A was 56.9 ± 8.47 years, and in Group B it was 54.7 ± 8.70 years (p = 0.489). The male-to-female ratio was 9:10 in Group A and 7:10 in Group B. ASA physical status II- III. The mean duration of surgery was 135.0 ± 49.93 minutes in Group A and 137.0 ± 50.21 minutes in Group B (p = 0.914).None of these differences were statistically significant.Pain scores at 3 hours postoperatively were significantly lower in Group B (1.9 ± 1.13) compared to Group A (5.5 ± 1.55), p = 0.000. The duration of analgesia was significantly longer in Group B (9.3 ± 1.01 hours vs. 4.8 ± 1.10 hours, p = 0.001). No significant differences were found in VAS at 1 hour, intraoperative fentanyl use.

The addition of dexmedetomidine to bupivacaine in paravertebral block significantly enhances the quality and duration of postoperative analgesia in patients undergoing atypical lobectomy. This combination is a safe and effective strategy to optimize pain management in thoracic surgery.

Postoperative management in multi-pathological patients, especially those with a history of intravenous drug addiction and chronic pain, can be challenging in our routine clinical practice. Multimodal and individualised analgesia is essential to prevent opioid overdose-related, postoperative complications and improve prognosis.

A 39-year-old man, with a history of intravenous drug addiction, on treatment with oral methadone 40mg/24h, scheduled for 6-level arthrodesis (T2-T9) and debridement due to spondylodiscitis. Before surgery, NSAIDs (dexketoprofen 50mg), paracetamol (1g) and gabapentinoids (300mg) were administered, in addition to the usual dose of methadone (40mg) and benzodiazepines (diazepam 5mg). Intraoperatively, a multimodal approach was used including intrathecal morphine (300mcg), dexmedetomidine bolus (0.5mg/kg), ketamine (0.5mg/kg), lidocaine (1mg/kg) and dexamethasone (8mg) before induction and surgical incision, followed by ketamine (0.2mg/kg/h) and remifentanil (TCI 1ng/mL) infusions. In the immediate postoperative period, he presented minimal pain (maximum VAS 1/10 at rest) and patient-controlled analgesia (PCA) was started with morphine (1mg/bolus: administered 21/attempted 32 in the first 24 hours), in addition to conventional pharmacotherapy (dexketoprofen 50mg/8h and paracetamol 1g/6h). He was discharged 24h after admission to the post-surgical critical care unit, with optimal pain control (maximum VAS 1/10 at rest), no opioid-related problems and no significant clinical incidents.

This case highlights the efficacy and efficiency of a multimodal strategy in the postoperative management of complex opioid-tolerant patients. By addressing multiple targets, such as central nociceptive modulation with intrathecal morphine (mu receptor agonist), ketamine (non-competitive NMDA receptor antagonist) and peripheral with NSAIDs, lidocaine (voltage-dependent sodium channel blocker), gabapentinoids (prevention of central sensitisation with calcium channel modulation) and dexamethasone (inflammation), adequate pain control and early recovery were achieved. It is essential to adapt anaesthetic management according to the characteristics of the patient and the surgery performed, in order to allow individualised pain control that reduces morbidity in surgical critical care units and optimises hospital resources

Quadratus lumborum block (QLB) and modified thoracoabdominal plane (m-TAPA) block can be used for postoperative analgesia in laparoscopic cholecystectomies (LC). The aim of this study is to evaluate the analgesic efficacy of anterior QLB and m-TAPA blocks during the first 24 hours postoperatively.

This study was designed as a randomized, prospective, single-blinded trial. Preoperatively, patients were divided into two groups: Group QLB (n=55) and Group m-TAPA (n=53). The anterior QLB block was applied to Group QLB, while the m-TAPA block was applied to the other group. After the blocks were administered, the dermatome areas covered at the 20th and 30th minutes were evaluated using a cold test. Intraoperative remifentanil consumption was recorded, while NRS scores (iNRS and dNRS), opioid consumption, time to first rescue analgesic use, and complications were evaluated during the first 24 postoperative hours.

There was no statistically significant difference between the groups in terms of total analgesic consumption during the first 24 hours, iNRS and dNRS values at hours 1, 4, 8, 12, and 24, time to first rescue analgesic use, intraoperative remifentanil consumption and complications. When comparing dermatome involvement between the groups, it was observed that dermatome coverage in the m-TAPA group was mostly distributed in the T7-T10 dermatomes, while in the QLB group, it was mostly distributed in the T10-L1 dermatomes.

We believe that both anterior QLB and m-TAPA blocks can be used as part of opioid-free multimodal analgesia for postoperative analgesia during the first 24 hours in LCs.

Shoulder arthroscopy increasingly uses exclusive regional anaesthesia (RA). While interscalene plus supraclavicular nerve blocks (ISB + SCNB) reliably numb most tissues, the posterior‑portal “Soft Point” may remain sensitive, risking pain and conversion to general anaesthesia (GA). The primary aim of the CAESAR study is to map the anaesthetised area and quantify the incidence of Soft Points that escape regional anaesthesia (RA).

Ninety‑seven adults scheduled for outpatient shoulder arthroscopy received ultrasound‑guided ISB followed by SCNB. After 30 min, dermatomes and the surgeon‑marked Soft Point were tested with ice (0 = no sensation; 1 = pain). A painful Soft Point was infiltrated with 3 mL 0.35 % ropivacaine. Primary outcome: proportion of sensitive Soft Points. Secondary outcomes: incision pain (VAS > 3/10), GA conversion, propofol use, time to active mobilisation, and pain/analgesia through day 7

The Soft Point remained sensitive in 10/97 patients (10.3 %); all were infiltrated. Two GA conversions (2.1 %) occurred (anxiety, surgical difficulty). Mean propofol dose was 75 ± 28 mg; surgery lasted 65 ± 13 min. Analgesia lasted 28 ± 5 h, permitting active mobilisation after 29 ± 6 h. On day 1, 92 % of patients recorded Numeric Rating Scale < 3.

Roughly one patient in ten has a Soft Point not covered by ISB + SCNB, yet intra‑operative discomfort and GA conversion are rare. Systematic Soft Point infiltration is therefore unwarranted; simple pre‑operative testing can identify the minority who benefit. Our findings corroborate those of Chavez‑Gama et al., who reported 12 % cold‑negative areas after regional anaesthesia without significant clinical impact. Exclusive RA provides excellent, opioid‑sparing analgesia for day‑case shoulder arthroscopy, corroborating previous mapping studies.

Hip fracture is an increasingly common emergency surgical presentation amongst elderly and a rising social and economic burden. This reflects the high morbidity and mortality of the condition, particularly among the frail elderly. Providing patients with effective analgesia has been shown to reduce delirium. Aim is to evaluate the efficacy of FICB-S and PENG block in reducing pain scores in first 24 hours of admission

After obtaining approval from the institutional ethics committee (IEC-2020-44-IP-114), 50 patients of either sex, of age above 18 years who present with fracture of hip to the emergency department with pain of numerical rating score >4, were randomly divided into two groups (Group A and Group B) by computer generated slips for on arrival analgesia. Patients of Group A received FICB-S and those of group B received PENG block with 30 ml of 0.2 % ropivacaine. Thirty minutes after block placement, pain was assessed by numerical rating scale and thereafter every 6 hours for 24 hours. Patient demographics, type of hip fracture, opioid consumption in 24 hours were also recorded.

Demographic characteristics in terms of age, gender and BMI, were comparable in both the groups (p > 0.05). When NRS was compared at different time interval, it was found that Group B (PENG) was better and significant (P< 0.05) at time point 30 min, 6 hr and 24 hr in comparison to Group A (FICB-S). Total fentanyl consumption in 24 hr was less and significant (P< 0.05) in PENG group (142±64) in comparison to FICB-S group (212±45).

PENG block is superior to FICB-S block in reducing pain scores for on arrival analgesia in patients of hip fracture.

Opioid-tolerant patients presenting for elective orthopedic surgery are at increased risk for various adverse outcomes and risk mitigation can be complex. In our high-volume orthopedic specialty hospital, we have pioneered intraoperative auricular acupuncture through the CHENG Protocol; this protocol is routinely employed by anesthesiologists. While preliminary data suggest promise in the CHENG protocol by enhancing multimodal analgesia via potentially reducing pain, stress, and inflammation, it is unclear to what extent these findings translate to high-risk groups such as patients who use opioids chronically before elective surgery.

We conducted a retrospective study using institutional data from January 2021 to March 2025, including 2,372 elective inpatient total hip arthroplasty (THA) surgery. Overall, 7.9% (n=187) were opioid-tolerant. Two groups were compared: those with acupuncture and without a peripheral nerve block (PNB) [Acu+PNB-], and those without acupuncture and with a PNB [Acu-PNB+]. The primary outcome was total opioid utilization in milligram morphine equivalents (MME) within 48 hours. Adjusted regression models measured associations between intervention groups and outcomes. These analyses were conducted separately for opioid-naïve and opioid-tolerant patients.

Among opioid-naïve THA patients, 28.2% received auricular acupuncture without a peripheral nerve block (Acu+PNB−), while 71.8% received a nerve block without acupuncture (Acu−PNB+). Among opioid-tolerant patients, 18.2% were in the Acu+PNB− group and 81.8% in the Acu−PNB+ group. In adjusted analyses, opioid-naïve patients in the Acu+PNB− group had similar 48-hour opioid consumption (50.6 MME) compared to those in the Acu−PNB+ group (56.2 MME); p=0.051. However, among opioid-tolerant patients, those in the Acu+PNB− group had significantly lower 48-hour MME use (86.7 vs. 134.4; p=0.002).

Intraoperative auricular acupuncture using the CHENG protocol may reduce opioid use, specifically among high-risk patients and those on opioids preoperatively. Given the complexities associated with managing these high-risk patients, these findings warrant further investigation into this promising non-pharmacologic adjunct to standard care.

Spinal anesthesia (SA) is the "gold standard" for cesarean section, but its effectiveness is limited by the duration of action of the local anesthetic. Adjuvants are used to prolong analgesia. In Uzbekistan, dexmedetomidine is used as an α2-adrenergic receptor agonist, but its use in obstetrics remains poorly understood. Objective: To improve SMA using dexmedetomidine as an adjuvant.

The study involved 53 women aged 20–38 years (73% planned cesarean, 27% emergency). Anesthesia: 0.5% bupivacaine solution (0.2 mg/kg, up to 15 mg) with the addition of dexmedetomidine (10 mcg). Efficiency was assessed using the VAS and RASS scale at 3 stages: during surgery, 2 and 6 hours after it. Nausea, vomiting and shivering were also studied.

The use of dexmedetomidine provided excellent results in 80–85% of cases: adequate analgesia for 14–16 hours, no need for opioids, satisfactory sedation (12–15 min after administration). The incidence of intraoperative shivering was 55%. Dexmedetomidine did not increase the incidence of nausea and vomiting. A significant improvement in early rehabilitation (activation after 6-8 hours) and the creation of optimal conditions for breastfeeding were noted.

Dexmedetomidine as an adjuvant in SA during cesarean section provides effective and safe pain relief with minimal side effects, which contributes to the fastest recovery of patients.

Labor analgesia (LA) contributes to the provision of high-quality maternal care. Understanding the demographic characteristics helps to improve practices. This study aims to conduct a descriptive analysis from a labor and delivery unit at a tertiary care center, to identify trends in maternal and LA used and the overall childbirth experience.

This cross-sectional study was conducted at the Obstetrics and Gynecology Department from July to October 2023. A questionnaire was applied to within 48 hours following vaginal delivery.

172 postpartum women participated. The mean age was 31 years. Most were employed (81.4%) and Portuguese (86%). Planned pregnancies were reported by 68.8% and 55% were nulliparous. Spontaneous labor onset occurred in 45.3% of cases. Eutocic deliveries accounted for 64.5% of the cases. Most deliveries (81.7%) occurred at full term. Epidural analgesia was the most common form of LA (95.9%), initiated predominantly during the latent (43.7%) phase of labor. Manual bolus on demand was the most frequently used technique (45.8%), while fixed bolus with patient-controlled epidural analgesia accounted for 12%. Most patients had no complications associated with LA (77.8%). Regarding patient expectations with LA, 44.2% and 42.4% reported that their expectations were exceeded or met, respectively. Regarding satisfaction with the anesthesiologist, 68% of women were 'very satisfied'. Overall, 74.4% of participants expressed 'very satisfied' with their labor experience. No participants reported 'very dissatisfied'.

Expectations regarding LA were largely met and most experienced a complication-free process. This highlights the effectiveness and acceptability of the LA protocols in place, contributing to maternal care.

Major organ transplantation cases are often associated with poorly controlled acute postoperative pain. This can negatively impact hemodynamics, myocardial oxygen demand, incidence of postoperative delirium, time to extubation, and length of intensive care unit (ICU) stay. Traditionally, high-dose opioids were a mainstay of treatment, however, their side effect profile and dependency risk limit long-term use. Considering this, we present two cases advocating for alternative regional analgesia techniques: (1) in a high-risk multi-organ transplant patient and (2) in a patient undergoing combined open cardiac surgery with abdominal organ transplantation. The first patient who underwent a dual liver and bilateral orthotopic lung transplant, received bilateral serratus plane blocks at T5 and external oblique intercostal (EOI) plane blocks at T6 and T7 levels with bupivacaine 0.25% and liposomal bupivacaine on postoperative day (POD) 3. He was successfully extubated immediately post-block with declining daily oral morphine equivalents (OME) from POD3 to POD5. The second patient, who underwent a 2-vessel coronary artery bypass graft via midline sternotomy and orthotopic liver transplantation, received superficial parasternal at T2 and T4 and EOI plane blocks at T6 and T7 on POD1. He was also successfully extubated immediately following the block with declining daily OME requirements.

All fascial plane blocks were performed with the patient supine. Each regional technique was chosen based on somatic coverage of the surgical incision. The sonoanatomy for each block was easily identified and performed cautiously on anticoagulated patients without altering hemodynamics. Because of the extensive surgical incision, it was essential to be mindful of the safe upper limit of local anesthetic dosage. Due to concerns and issues with multiple catheters, we opted to use long-acting bupivacaine for these cases for prolonged postoperative analgesia. In conclusion, it is beneficial to advocate for alternate regional techniques for these high-risk multi-organ transplant patients.

Fascial plane blocks can effectively reduce acute pain. Our study aimed to compare the analgesic effects of ESP-block and posterior TAP-block in patients undergoing abdominal hysterectomies and to compare the quality of recovery after anesthesia in different regional anesthesia techniques.

A total of 41 patients with ASA status II-III, aged 40-55 years old and who were scheduled for abdominal hysterectomy were included in the trial. All patients underwent general anesthesia with tracheal intubation and mechanical ventilation. Patients were randomized into two groups. In addition to general anesthesia I group received posterior TAP-block (Image 1), II group received ESP-block (Image 2). Intraoperative fentanyl consumption, daily requirement of morphine after surgery, pain level (with visual analogue scale – VAS) and quality of recovery after anesthesia (with QoR-15 questionnaire) were evaluated. The data was checked for normal distribution and the result was presented as Me [Q1; Q3].

The total amount of fentanyl perioperatively during abdominal hysterectomy was higher in the I group - 500 [300;700] mcg while in the II group it was 400 [300;700] mcg (p=0.04). There was no significant difference in the duration of anesthesia in the groups. The daily requirement of morphine was 7.5 [2,5;10,0] mg/day in the I group and 5.0 [2,5;10,0] mg/day in the II group (p = 0.003). The VAS values at 1 hour (p = 0.001) and 8 hours after the surgery (p = 0.01) were higher in the I group compared to the II group. There was no statistically significant difference in QoR-15 scores between I and II group (p > 0.05).

ESP-block demonstrated a higher opioid-sparing effect compared to posterior TAP-block and the level of pain after the surgery was higher in the group where posterior TAP-block was performed. No significant difference was found in quality of recovery after anesthesia scores in two groups.

Open fetal surgery for spina bifida offers significant fetal benefits but poses challenges in maternal postoperative pain management. Enhanced Recovery After Surgery (ERAS) principles emphasize effective, opioid-sparing analgesia to improve maternal recovery. While epidural and systemic opioids are commonly used, their application may be limited by side effects or technical difficulties. The transversus abdominis plane (TAP) block is widely used in obstetric surgery, yet its use in fetal interventions has not been clearly defined. This study aims to evaluate the efficacy of bilateral TAP block for postoperative analgesia following fetal spina bifida repair.

This case series included five pregnant women (aged 27–34) who underwent open fetal spina bifida repair at 26 weeks of gestation. Following induction of general anesthesia and prior to surgical incision, bilateral ultrasound-guided TAP block was performed using 20 mL of 0.25% bupivacaine per side. Postoperative pain was assessed using Visual Analogue Scale (VAS) scores at 2, 4, 8, 12, and 24 hours. Analgesic satisfaction and opioid requirement were also recorded.

All five patients were extubated postoperatively without complications and transferred to intensive care. VAS scores remained consistently low across all time points, with minimal variation between patients, and no scores exceeding 3. No additional systemic opioids were required. All patients reported high analgesic satisfaction and were discharged from intensive care within 24 hours and from the hospital on postoperative day three. No adverse events related to the TAP block or pain management protocol were observed.

Bilateral TAP block appears to be a safe and effective option for postoperative analgesia in fetal spina bifida surgery. This opioid-free technique may contribute to improved maternal recovery, reduced opioid-related side effects, and aligns well with ERAS principles. Further studies are warranted to confirm these findings.

Delivering local anesthetics into the obturator canal is pivotal to guarantee obturator nerve blockade because all obturator nerve divisions invariably run through it. However, local anesthetic injections in the subpectineal plane (i.e., ultrasound-guided proximal obturator nerve block techniques) may not spread to the obturator canal. We devised an ultrasound-guided technique for delivering a local anesthetic directly into the obturator canal. This cadaveric study investigated the spread of the injectates using our method.

This study was approved by the institutional ethics committee (approval number: 2024288). Six legs from four Thiel-embalmed cadavers were used. The cadavers were placed supine with the hips flexed and externally rotated. A linear ultrasound transducer was placed on the genitofemoral sulcus to observe the external orifice of the obturator canal immediately posterior to the inferior margin of the superior pubic ramus. A needle tip was positioned at the distal end of the obturator canal solely under ultrasound guidance to inject 5 mL of dye.

The presence of dye in the pelvic cavity through the obturator canal was confirmed in all specimens. The superior fascicle of the obturator externus muscle was tightly attached to the superior pubic ramus in two legs, covering the opening of the obturator canal (Figure 1). The subpectineal plane appeared non-contiguous with the obturator canal in these specimens.

Our approach can deliver even a 5 mL solution into the obturator canal. This may be helpful, especially in cases where the subpectineal plane is not open to the external orifice of the obturator canal.

Effective pain management in cancer patients with advanced disease is critical to improve quality of life. We present a case of an elderly gentleman with metastatic parotid carcinoma with bony and pulmonary metastases, experiencing severe intractable chest pain from a right lung mass. Conventional opioid therapy provided insufficient relief and caused sedation-related limitations. This case highlights the utility of interventional pain procedures in such complex scenarios.

The patient, who was unable to lie supine due to severe chest pain, was receiving high-dose transdermal and intravenous fentanyl with limited relief. Patient underwent ultrasound guided right T5–T8 intercostal nerve neurolysis using a combination of phenol and local anaesthetic under monitored anaesthesia care. The procedure was conducted with the patient in a semi-upright position to accommodate his respiratory status.

Post-procedure, the patient reported marked reduction in right-sided chest pain, allowing him to rest in a supine position and reduce opioid requirements. No immediate complications were observed. Pain relief was sustained over the following weeks and remained effective for up to 5 months, at the time of this case report, significantly improving his functional status and participation in palliative care.

Intercostal nerve neurolysis may be an effective option for managing localized, opioid-refractory chest wall pain in patients with thoracic metastases. Careful patient selection and procedural planning are essential, particularly in those unable to tolerate standard positioning due to respiratory or pain limitations.

Chronic pain is increasingly understood as a biopsychosocial condition involving neuroinflammation, central sensitization and immune dysregulation. The gut–brain axis has emerged as a key regulator of pain perception. Dysbiosis and disruption of intestinal permeability may amplify nociceptive signaling, influencing both visceral and somatic pain syndromes. Probiotic-based interventions have demonstrated promising anti-inflammatory and neuromodulatory effects in preclinical and clinical models of pain. This study aims to summarize current evidence and propose a targeted probiotic protocol for chronic pain management.

A structured review of recent publications (2010–2024) was conducted using PubMed, Scopus, and full-text clinical trials evaluating probiotics in pain modulation. Strain-specific effects, mechanisms, dosage, and duration were extracted and compared. Clinical relevance was assessed based on outcomes in patients with fibromyalgia, irritable bowel syndrome, and neuropathic pain.

Probiotic interventions can influence pain through multiple mechanisms, including modulation of microglia, reduction of systemic cytokines (IL-6, TNF-α), enhancement of GABA signaling, and reinforcement of mucosal barrier integrity. Certain strains, particularly Bifidobacterium longum, Lactobacillus rhamnosus GG, and Lactobacillus reuteri DSM 17938, demonstrate consistent analgesic potential. Table 1 summarizes evidence-based recommendations for clinical application, including strain, dose, duration, and proposed indication.

Targeted probiotic interventions may reduce inflammation and improve pain control in chronic pain patients. Based on current evidence, we propose the development of a probiotic (Table 2), a multi-strain formulation for use in specialized pain units. Administration should begin 2–4 weeks before initiating intensive treatment and continue for at least 8–12 weeks. Integration with dietary modulation and psychological support may enhance outcomes. Further clinical trials are required to validate efficacy and define optimal protocols in multidisciplinary pain management.

Chronic pain affects over 45% of Alzheimer’s disease (AD) patients, yet the interaction between pain and neurodegeneration remains unclear. Both conditions are multifactorial and share potential alterations in the endocannabinoid system (ECS), which may provide new therapeutic targets. Persistent pain is linked to accelerated cognitive decline and increased dementia risk. However, the role of ECS in AD patients with chronic pain is unexplored, and clinical data supporting cannabinoid-based therapies is lacking. This study investigates the bidirectional relationship between pain and dementia, evaluating an EU-GMP certified Cannabis sativa L. batch in a rat model.

Rats were administered Cannabixir® Medium Flos (5 mg/kg) in a chronic, intermittent regimen to evaluate its effects on neurobiological changes in a scopolamine-induced AD model, combined with chronic neuropathic pain. The impact of treatment was assessed through clinical monitoring, behavioral tests and tissue analysis to examine cognitive and nociceptive changes.

Cannabixir® Medium Flos was generally safe and yielded promising results in mechanical and thermal sensitivity tests. Tissue analysis revealed histopathological changes, consistent with improvements in nociceptive and cognitive functions, supporting the therapeutic potential of the treatment.

Neuropathic pain associated with AD may benefit from cannabinoid therapy, with preliminary results suggesting neuroprotective effects of Cannabixir® Medium Flos. These findings warrant further investigation of cannabinoids as a potential therapeutic strategy for neurodegenerative conditions with comorbid pain. Funding: This research was funded by a grant of the Ministry of Research, Innovation and Digitization, CNCS - UEFISCDI, project number PN-IV-P2-2.1-TE-2023-0879, within PNCDI IV and by a project under The Health Program (PS) 2021-2027, Policy Objective 1, Priority 5, project title "Development of translational research for vaccines, serums and other biological drugs - Acronym CANTAVAC 2.0”, SMIS code 326920.

There is no consensus on the definition of a successful brachial plexus block or the best sensory assessment method for it, making it challenging to predict brachial plexus block success (1). We attempted to identify early predictors of brachial plexus block success using the data from our published research studies (2).

We recruited 80 patients for two prospective-randomised axillary block studies and 70 for two prospective-randomised supraclavicular block studies (ethics committee-approved). Based on the data from the 10-minute assessment point after the block completion, we created four contingency tables (for each block type) to explore the association between the degree of sensory block of the ulnar, median, radial and musculocutaneous nerves and study outcomes (Fig-1) and a binary logistic regression model to predict success based on the scores for cold testing alone for these nerves and study outcomes (four predictor variables, one outcome variable). (Cold assessment: alcohol-soaked swab, scored 0-10; Pinprick assessment: sterile needle, described as sharp, touch or absent)

The studies generated the data for 150 blocks (Axillary: 66-successful/14-ineffective; Supraclavicular: 51-successful/19-ineffective). The contingency table analyses indicated a significant association between the degree of radial and ulnar nerve block and axillary and supraclavicular block success (Fig-2). The regression model fit the data well and had 85% sensitivity for correct prediction. A cold assessment score of 0-3 for the ulnar and radial nerves at 10 minutes significantly increases the likelihood of a successful brachial plexus block, with odds ratios of 30.7 and 10.7, respectively (Fig-3).

Early success at the radial and ulnar nerve is important for a successful axillary and supraclavicular brachial plexus block. The success of a nerve block depends on many factors, but these findings could help improve training for inexperienced anaesthetists, as the two nerves could be technically most challenging to access during these procedures. Ref-(1)10.1097/AAP.0b013e3182583b00;(2) https://doi.org/10.1016/j.bjao.2025.100385

Heart rate variability (HRV) serves as a sensitive indicator of the autonomic nervous system, which is influenced by anesthesia and surgical stimulation. Adequate regional anesthesia is hypothesized to modulate the autonomic nervous system response during surgery. This study aimed to evaluate the impact of neuraxial techniques and interfascial blocks on HRV dynamics in comparison to general anesthesia during hernioplasty.

The study enrolled 91 patients undergoing surgical repair of anterior abdominal wall hernias. Patients were allocated into three groups: general anesthesia (n=31), neuraxial techniques (n=30), and interfascial blocks (n=30). HRV parameters were recorded throughout the surgical procedure, and their dynamics were visualized relative to the baseline level (100%).

In the general anesthesia group, a progressive decrease in the sympathovagal balance (LF/HF ratio) was observed throughout the surgery, reaching 67.3% of the baseline value at the end. In contrast, the neuraxial techniques group exhibited a 1.6-fold increase in LF/HF at the midpoint of surgery and maintained 115.5% of the baseline level at the end. The interfascial blocks group also showed an increase in LF/HF to 127.9% of the baseline value at the end of surgery. Notably, the general anesthesia group demonstrated a significant reduction in both low-frequency and high-frequency HRV indices.

Regional anesthesia techniques, both neuraxial and interfascial blocks, demonstrated a distinct impact on HRV dynamics during hernioplasty compared to general anesthesia. They facilitated the preservation or even augmentation of the sympathovagal balance at the end of surgery, which may suggest better autonomic nervous system control and less suppression of parasympathetic activity compared to general anesthesia.

Laparoscopic cholecystectomies (LC) have become increasingly prevalent showing many benefits, including shorter hospital stays and less postoperative pain, especially when carried out in accordance with PROSPECT recommendations. In the Mercy University Hospital we aimed to carry out an audit in order to examine whether the ESRA PROSPECT recommendations were being followed.

We aimed to identify if fentanyl PCAs have been used in accordance with PROSPECT recommendations by retrospectively auditing 53 patient charts. We examined trends in fentanyl PCA use, paying attention to the amounts used up to 72 hours postoperatively and patient satisfaction. Postoperative pain data acquired was use of concomitant analgesics, PRN breakthrough analgesia and patient satisfaction with pain relief. The quantity administered in the immediate 24 hours postoperatively (mcg) and the total quantity during the recovery period were examined.

The charts of 53 patients were examined, with 17 of those being female and a mean age of 62.55 years. Prescribing in concordance with step 1 of the PROSPECT recommendations occurred in 67.92% of patients. In a previous project we carried out, LCs portrayed a higher mean consumption of fentanyl on day 1 postoperatively of 864mcg (SD= 586.35) vs. 676.92mcg (SD= 323.17) in open cholecystectomies. Fentanyl PCAs allowed 88.9% of patients to be ambulatory for every day of their stay and 83.3% of patients were capable to undergo a physiotherapy session. Some level of confusion was seen in 7.55% of patients who received fentanyl PCAs.

More education on the PROSPECT recommendations should be delivered to any prescribing clinician in the postoperative period. A recommendation to introduce this therapy option to these guidelines as the ‘opioid as rescue’ should be explored, paying particular attention to the increased firing rate of the PCA in the first 24 hours which may be due to pneumoperitoneum.

In certain clinical scenarios, expedited reversal of local anesthetic (LA) effects is warranted, such as with patient dissatisfaction, need for neurologic evaluation, longer-than-anticipated block duration, or side effects like epidural-induced hypotension. We investigated whether Intralipid® 20% can reverse LA action, providing mechanistic support for the “lipid sink” theory and laying the groundwork for clinical studies on accelerating resolution of neuraxial and peripheral nerve blocks.

This IRB-approved double blinded placebo-controlled crossover randomized trial enrolled 18 volunteers who were required to attend two in-person study visits: visit 1 saline, visit 2 Intralipid® 20%, or vice versa. Five (3mL) test solutions were subcutaneously injected in marked injection sites on volunteers’ thighs to form raised skin wheels: Lidocaine 1%, Lidocaine 2%, Bupivacaine 0.5%, Bupivacaine 0.25%, or Saline (control). An intravenous bolus of 1.5ml/kg Intralipid® 20% or normal saline was then administered. Sensation was tested every 5 minutes at all injection sites using an alcohol swab and a pinprick. Paired t-tests assessed within-subject differences in return to sensation time between intralipid and saline sessions.

Among 18 volunteers, 14 (Table 1 for characteristics) successfully completed both visits. While not statistically significant, a pattern emerged of faster mean return-to-sensation times among patients who were administered an Intralipid® 20% bolus, compared to saline (Table 2). Among the 14 volunteers, a decrease in time to sensation was more commonly found in Intralipid® visits compared to saline visits (Figure 1).

Intralipid® 20% reversal can be seen in our data in the context of skin infiltration. Further research is needed to understand the subset of volunteers that benefited from the Intralipid® 20% reversal. This method may shorten the LA effects in a clinical setting allowing for faster discharge, and reversal of undesirable effects of local anesthetics.

Transmuscular quadratus lumborum block (TQLB) is a regional anesthesia technique widely utilized in multimodal analgesia strategies for abdominal surgeries. While a few studies have inves-tigated its efficacy in multiport total laparoscopic hysterectomy (TLH), its effectiveness in single-port TLH remains uncertain. This study aimed to evaluate whether QLB reduces opioid consumption and postoperative pain in patients undergoing single-port TLH.

This prospective randomized, controlled, observer-blinded trial adhered to the principles outlined in the Declaration of Helsinki. Ethical approval (DIRB-00146_2-006) was obtained from the Institutional Review Board of The Catholic University of Korea. A total of 64 patients undergoing elective single-port total laparoscopic hysterectomy (TLH) were included in the trial. Participants were randomly assigned to either the transmuscular quadratus lumborum block (TQLB) group (n = 27) or the control group (n = 29). Bilateral TQLB was performed under ultrasound guidance after surgery. The primary outcome was cumulative fentanyl consumption within 24 hours postoperatively. Secondary outcomes included pain scores at predefined intervals, time to first opioid demand, the incidence of postoperative nausea and vomiting (PONV), and other complications.

The 24-hour cumulative fentanyl consumption, which was the primary outcome, did not differ significantly between the TQLB group 470 [191.6, 648.1] mcg and the control group 342.8 [220, 651] mcg (P = 0.714). Additionally, cumulative fentanyl consumption at other time points, including 2h, 4h, 8h, 12h, 32h, and 48h, as well as in the PACU, also showed no significant differences between the two groups. Pain scores measured at these time points, along with the time to first bolus on demand, similarly showed no significant differences between the groups.

Bilateral TQLB did not reduce opioid consumption or pain scores in patients under-going single-port TLH. These results suggest that TQLB offers no significant benefit as part of multimodal analgesia after single port TLH.

RCOA Stage 3 training curriculum stipulates that anaesthetists in training need to learn to be on the simulation training faculty and should participate both in the curriculum and personally in simulation learning. Stage 2 emphasises the importance of simulation in regional anaesthesia and ultrasonography for the ‘Personal' training of resident doctors. Generative model-based simulation (AI- generated), CT guided simulation and ultrasonography simulation are three techniques to help teach regional anaesthesia. Virtual three-dimensional animation models also help detail relevant Sono-anatomy. Technology-driven teaching modalities prevent patients bearing the burden of initial learning curve for trainees. VR leads to improvements in clinical performance sustained after 1 months of training. A previous audit demonstrated USG VR will enhance teaching and competency attainment.

In this audit, we will test and trial a modern virtual reality teaching platform that encompasses the above 3 teaching modalities to augment and develop the training of resident anaesthetists in regional anaesthesia at GEH. ARIRA offers Virtual reality, offer transformative learning experiences in regional anaesthesia. These tools create dynamic, interactive environments that can enhance traditional teaching methods.https://www.arira.co.uk/challenge-page/ultrasound-guided-regional-anaesthesia was chosen for VR as free pilot for training available. All regional anaesthetists sent a survey questionnaire for the VR platform. Survey responses and participant ratings on platform utility, visual qualities and potential benefits were recorded.

All 32 Respondents found the VR Platform useful. Glide-View feature was favoured by 23%, 3D Probe Positioning Needling chosen by 22% respondents and USG Sliding probe control was preferred for 21% of respondents .Respondents deemed VR provides Experiential, hands-on learning and immersive learning enhancing patient safety. Platform was rated as accessible, visually engaging and diverse by majority of respondents.

Augmented reality modelling helps enhance Sono anatomy and simulation-based learning in ultrasonography. ARIRA as a teaching model will help comply with the standards set out by RCOA Stage 3.

Shoulder arthroscopy procedure is a popular diagnostic and therapeutic tool in shoulder injuries. Interscalene block provides adequate analgesia as shoulder gets its major innervation through suprascapular, lateral pectoral, axillary nerves, which can be easily blocked at the level of roots. Our aim is to compare the efficacy of 0.25% bupivacaine and 0.2% ropivacaine in the ultrasound guided interscalene block (C5,C6,C7) in shoulder scopy surgeries in terms of duration of analgesia and opioid requirement in the first 24hrs postoperative period.

After obtaining institutional ethics committee approval and written informed consent, we included 60 patients belonging to ASA PS 1 and 2, anaesthesia was induced with propofol 2mg/kg, analgesia with fentanyl 2µg/kg , neuromuscular blockade with rocuronium 1mg/kg, trachea intubated and maintained with oxygen, nitrous oxide and sevoflurane with MAC of 1.5. Then patient in bupivacaine group received ultrasound guided interscalene block using 12ml 0.25% bupivacaine with 10µg dexmedetomidine, whereas patient in Ropivacaine group received 12mL 0.2% ropivacaine with 10µg dexmedetomidine . Haemodynamic parameters were noted every 15min throughout the procedure. Intravenous paracetamol 1g was given at the end of procedure. After extubation and shifting to postoperative period, analgesia was assessed using VAS score at 0hr, 6hr, 12hr, 24hr. Fentanyl 1µg/kg was given when the VAS score was more than 4, the time to first analgesic request and the total fentanyl dose given in the 24hours were noted.

We observed that mean duration of the analgesia was 636.4±212.4 minutes (mean±SD) in bupivacaine group when compared to 715.9±261.6 minutes in ropivacaine group (p=0.27) and the total analgesic requirement was not more than 2µg/kg fentanyl in the first 24hrs postoperative period in both the groups.

We concluded that there is no statistically significant difference in the duration of analgesia between bupivacaine and ropivacaine group and both provide effective analgesia for shoulder scopy surgeries.

Total knee arthroplasty is the most common orthopedic surgery in the lower extremity performed in North America. The recovery after bilateral total knee arthroplasty (BTKA) is challenging, given the need for effective pain control, early mobilization, and safe discharge home. The aim of this study is to assess the effectiveness and safety of the bilateral continuous adductor canal block (B-CACB) and compare it to the bilateral single adductor block (B-SACB) technique in BTKA.

Retrospective study including patients scheduled for BTKA from 2020-2023. Research Ethics Board approval was obtained (23-0223-C). Demographics, anesthesia technique, opioids consumed (OME=oral morphine equivalent), complications, and mobilization assessment were registered. Data were summarized using mean (standard deviation,SD) or median [interquartile range,IQR] for continuous variables, and frequency (%) for categorical. The measurements were compared using t-test , Mann-Whitney test , Kruskal-Wallis test or ANOVA depending on data distribution. Fisher exact test, logistic regression to assess association between variables were used. All analyses were performed STATA 14.0 (StataCorp, USA).

Sixty-three patients were identified(Table 1). There was no association between opioid consumption between 0-24 hours and the type of block(p=0.05). At 24-48 hours, the B-CACB group consumed an average of 20 mg/day less (p=0.04, 95% confidence interval:1.2-38.9 mg) of OME than B-SACB group (Table2). The B-CACB group was 3.5 times more likely to mobilize above 2 meters than B-SACB group in POD1 (OR:95% confidence interval=1.2–9.9) and 4.5 times in POD2 (OR:95% confidence interval=1.2–16.3,Table 3). No patients reported LAST symptoms, three patients described leaking or dislodgement.

B-CACB is associated with lower opioid requirements at 48 hours than SACB, with a higher likelihood of reaching mobilization criteria for discharge. No adverse events were reported. B-CACB is a feasible, effective, and safe plan for BTKA surgery in a selected population, helping to decrease the burden of two surgeries in one surgical event.

Intercostal nerves cryoanalgesia addresses somatic pain after Nuss procedure for pectus excavatum, but visceral pain from mediastinal structures is conducted through phrenic nerves. We aimed to preliminarily assess whether combining cryoanalgesia with a bilateral phrenic analgesic infiltration was feasible, and whether this association reduced early postoperative pain compared with cryoanalgesia alone.

After ethical committee approval, a retrospective preliminary single-centre study involved 24 patients who underwent Nuss procedure from December 2023 to April 2025, allocated to 2 groups. Nine patients received ultrasound-guided percutaneous Earlier Preoperative Intercostal Cryoanalgesia (EPIC), from 4 to 7 days before surgery. Fifteen patients received cryoanalgesia with the same protocol. Additionally, they received a bilateral PHrenic Infiltration as Cryoanalgesia Adjuvant (PHICA) at the closing phase of surgery by placing, under ultrasound guidance, 10 ml levobupivacaine 0,25% in the fascial plane between sternocleidomastoid and anterior scalene muscles. Both groups received intravenous scheduled ibuprofen and acetaminophen, and rescue tramadol. Outcomes were limited to the Post-Operative Day 0 (POD-0). Pain was assessed every at least 3 hours by ward nurses, through Numerical Rating Scale (NRS). We evaluated pain scores, tramadol doses, incidence of adverse effects and ultrasound diaphragm excursion and thickness with a linear probe.

Patients who experienced at least once moderate-severe pain, defined as NRS≥4, were 89% in the EPIC group, and 53% in the PHICA group. 22% of EPIC group patients needed rescue tramadol, compared to 13% of PHICA patients. Raw distribution of NRS values showed a median value for EPIC of 3 [1-5] and for PHICA of 1 [0-3] (p<0,001). Ultrasound diaphragm evaluations assessed appropriate excursion and thickening during normal and forced inspirations. Clinical adverse respiratory effects were absent.

This exploratory study may suggest the clinical feasibility and the possible advantage of addressing visceral pain through phrenic nerve infiltration, as a component of multimodal analgesia following pectus surgery.

Introduction- Chronic back pain is defined as pain that continues for three months or even longer .Many times the causes of chronic low back pain has not been initially well evaluated and treated. Is a condition that effects the quality of life and also the health related quality of life . Aim-Aim of this study was to evaluate the use of use of lornoxicam in elderly male patients (range 65-85 years , mean age 70 years) , with chronic low back pain.

Material and Methods- 10 elderly male patients were participated in this study. In all patients we perform clinical neurological exam and radiological exam with x-ray control, ct-images and mri images. None of the patients reported other internal medicine or cardiological problems. For 21 days they receive 8 mg lornoxicam, two times a day. We used specific performance pain tests (oswestry scale and prolo scale) in order to evaluate our results. Follow up was between 6 months and 12 months with mean period of 9 months

Results-9 of them (90%) reported optimal results and good reaction to the treatment. 1 of them (10%) reported moderate results and mild reaction to the treatment.

Conclusions- We need more patients but this therapeutic path seems to be an optimal and safe treatment, especially for elderly patients. Chronic low back pain remains a situation with necessity of adequate evaluation and management, in order to ameliorate the overall health .

Epidural, caudal block is commonly used for paediatric infra-umbilical surgeries under General Anaesthesia (GA), but the landmark technique is associated with many complications; hence, ultrasound-guided blocks are in vogue to overcome them. This study compares first-attempt success rates between short and long-axis ultrasound guided caudal blocks.

In this prospective randomized trial, 136 ASA I/II paediatric patients aged 0-6 years, undergoing infra-umbilical surgeries under GA, were randomly assigned to two groups: Group S (short-axis) and Group L (long-axis). The caudal blocks were given under USG guidance by an experienced provider in short and long axis to note the first attempt success rate, block performing time and any associated complications.

Our study revealed that the first attempt success rate was comparable for Group S and Group L, with a p-value of 0.836. On comparing the two groups regarding the number of attempts for block (p=0.719), the mean time for performing the block (p=0.286), and associated complications (p=0.722), no statistically significant difference was found.

Ultrasound-guided caudal block with short axis v/s long axis has a comparable first-attempt success rate in children < 6 years. The block performing time, and the associated complications are comparable as well in both the groups.

Selective truncal blocks have been claimed to be optimal approach for supraclavicular brachial plexus block. However, whether the sheath engulfs a single trunk or are they interspersed with another trunk remains to solved. Further, the nerves emerging from the trunk, are they encompassed in the same sheath or several sheath as it courses to its destination, is elusive. The Objective to evaluate the extent of dye dissemination at each trunk and the inter-truncal spread of dye.

In 6 soft embalmed cadavers (12 specimens), 3ml of different color dye would be injected at the Superior trunk (blue), Middle trunk (purple), Inferior trunk (green). Post injection at 24 th hour, dissection would be performed at the level of superior, middle and inferior trunks. The extent of dye dissemination would be evaluated for each trunk. All nerves would be traced delicately.

The blue latex injection at ST stained the Suprascapular nerve (SSN), posterior (PD) and anterior division (AD). The SSN was stained blue in 10/12 specimens and the 2/12 specimens stained purple. Axillary nerve from PD of ST was stained blue in all specimens. Lateral pectoral nerve (LPN) from AD of ST was stained blue in 10/12 specimens and 2/12 specimens stained green. Purple latex injection stained the Anterior and Posterior division of the MT in all 12 specimens. Green dye stained the LT and the respective sheath in all 12 specimens.

Based on our cadaveric study, the dye injected was contained in the respective sheath and there was no intermix of dye between the sheaths. The nerve originating from the respective trunk was stained with same dye, corresponding to have the same sheath except the SSN (2/12- purple) and LPN (2/12- green).

Chronic pain is a prevalent and therapeutically challenging symptom in cancer patients, often limited by intolerable side effects or inadequate response to conventional pain management strategies. Intrathecal drug delivery offers a targeted approach to pain management, potentially reducing systemic opioid requirements and associated side effects. There is a paucity of literature examining the efficacy of intrathecal pump (ITP) therapy in decreasing systemic opioid use. This retrospective review aims to assess the potential impact of ITP therapy on Morphine Equivalent Daily Dose (MEDD) in cancer patients with chronic pain.

A retrospective review was conducted on cancer patients at St. Paul’s Hospital in British Columbia, Canada, who received ITP therapy for chronic pain management between June 2022 and March 2024. Data regarding opioid use—including oral, subcutaneous, transdermal, and parenteral routes—were collected through chart review both prior to and approximately six months following ITP implantation. These opioid dosages were standardized and converted to oral Morphine Equivalent Daily Dose (MEDD). The primary analytical focus was on median MEDD, with the main outcome measure being the percent reduction in MEDD following therapy.

A total of 18 patients received ITP therapy during the review time frame. 11 patients were included in the final analysis with 7 patients being excluded due to mortality prior to the 6-month postoperative time point or incomplete data. Raw data analysis revealed a significant reduction in MEDD following ITP therapy. The pre-implant median MEDD was 868.4 mg compared to 503.9 mg 6 months post-operatively, showing a 42% reduction in MEDD. 11% (2/18) of patients discontinued systemic opioids completely.

ITP therapy has the potential to improve chronic cancer pain and reduce systemic opioid requirements. These findings support the need for further research to evaluate the efficacy of ITP therapy in improving pain control and reducing systemic opioid requirements among diverse oncological patient populations.

The conventional double-space technique for combined spinal-epidural anesthesia (CSEA) is widely used but may be time-consuming, requiring multiple attempts and needle redirections. This study evaluates our novel single-space technique, where the Tuohy needle remains in situ, during spinal needle insertion within the same interspace. This method aims to improve the success of Dural puncture and reduce epidural catheter shearing by using the Tuohy needle as a guide and shield. The aim was to compare the novel single-space (NSS) technique with the conventional double-space (DS) method in terms of procedural efficiency, Dural puncture success, and incidence of catheter shearing.

Eighty ASA I–II patients (aged 18–75) undergoing lower limb orthopedic surgery were randomized into two groups: NSS (n = 40) and DS (n = 40). In the NSS group, the Tuohy needle was inserted using the loss-of-resistance technique, followed by epidural catheter placement. A 25G spinal needle was then introduced 5 mm caudal to the in situ Tuohy needle within the same interspace in the same plane. Upon cerebrospinal fluid (CSF) confirmation, spinal anesthesia was administered. The DS group underwent spinal and epidural anesthesia at separate interspaces. Primary outcomes included T1 (time from local anesthetic injection to CSF appearance), T2 (time from spinal needle insertion to CSF), the success rate of Dural puncture, assessed by the number of attempts and needle redirections, and the incidence of catheter shearing.

The NSS group showed significantly shorter mean T1 (by 3.93 minutes) and T2 (by 43.8 seconds) times, with a higher success rate for Dural puncture, and fewer spinal needle attempts and redirections. The incidence of catheter shearing was negligible in both groups, with no significant reported complications.

The novel single-space technique is a faster, more efficient, and safer alternative to the conventional double-space method for CSEA, with negligible catheter shearing and comparable patient outcomes.

According to the literature, deep sedation may be associated with significant neurocognitive dysfunction postoperatively. The aim of the study was to compare the impact of sedation depth monitoring according to BIS versus clinical assessment on neurocognitive function in elderly patients undergoing spinal anesthesia with sedation.

The study was approved by the Local Kauno Regional Ethic Committee (Nr. BE-2-53). Elderly patients (>65 years old) scheduled for elective knee arthroplasty under spinal anesthesia with sedation were included in the study. Patients were randomly assigned into two groups. In the first group (BIS group), sedation was administered according on BIS value (targeting 70-80, light sedation). In the control group (non-BIS group), sedation was guided only by clinical signs (standard clinical practice, Ramsay sedation scale 4). For procedural sedation continuous infusion of propofol was performed according to the group. The neuropsychological testing was performed using Addenbrooke’s Cognitive Examination – Revised (ACE-R) test. Cognitive assessments were performed four times: preoperatively (preOP) and at 2, 30, and 90 days postoperatively (2 POD, 30 POD, 90 POD respectively). Results are presented as median with minimum and maximum values.

Total number of 60 patients aged over 65 were enrolled in this study. There were no statistically significant differences between two groups ACE-R scores at all time points: preOP BIS group 88 (73-96) vs. non-BIS 86 (48-95), p=0.142; 2 POD BIS group 91.5 (73-99) vs. non-BIS 88.5 (48-99); p=0.052; 30 POD BIS group 93 (66-98) vs. non-BIS 90 (45-97), p=0.064; 90 POD BIS group 92 (77-97) vs. non-BIS 92 (46-99), p=0.951.

In our study we do not found differences in neurocognitive function between two sedation depth monitoring methods (sedation depth monitoring according to BIS versus clinical assessment) in elderly patients undergoing spinal anesthesia with sedation. More studies with larger sample size are needed.

Local Anaesthetic Systemic Toxicity(LAST) remains a serious but preventable perioperative complication. Following a fatal incident linked to an overdose during elective orthopaedic surgery, we identified a critical gap in clinicians’ understanding of maximum safe local anaesthetic(LA) dosing, documentation, and communication practices. This project aimed to improve education and team-based strategies for safe LA dosing in elective lower limb joint replacements.

A departmental survey was conducted among anaesthetists and surgeons to assess current knowledge, dosing calculations, and perioperative communication around LA use. A retrospective audit of 87 patients undergoing total hip and knee replacements(June–July 2024) across two hospital sites evaluated real-world compliance with documentation and safety standards. Educational interventions were introduced, including: • Visual dosing charts • Multidisciplinary teaching during theatre briefings • Promotion of two-person dose verification This was followed by a Plan-Do-Study-Act(PDSA) cycle to prepare for re-audit and outcome measurement.

• 32% of cases had full LA dose documentation. • One patient received a 135% overdose of the recommended maximum. • 69% of staff surveyed were not using calculators, charts, or other aids. • 46% did not routinely discuss LA dosing with the team prior to administration. • Educational tools were positively received, especially by trainees and ODPs. Our findings reveal significant variability and lack of standardisation in LA dosing practices. Educational interventions that combine cognitive aids, simulation-based training, and interprofessional learning can improve safety behaviours. Introducing mandatory tools such as LA dose charts, incorporating them into team huddles encourages a shared responsibility approach and reduces reliance on memory or individual estimation.

This project highlights the importance of targeted teaching to improve safety in regional anaesthesia. Key recommendations include: • Incorporating LA safety teaching into trainee curricula • Standardising use of visual aids and calculation tools • Embedding LA dose checks into team time-outs • Encouraging multidisciplinary learning environments

Labor analgesia offers well-established benefits for both maternal and neonatal outcomes, encompassing clinical and psychological domains. Effective pain management during labor requires a tailored approach, with multiple techniques documented in the literature. Spina bifida, a congenital neural tube defect, presents unique anesthetic challenges due to anatomical variations in the spine and potential neurological deficits. This case report explores the feasibility and safety of neuraxial analgesia in a parturient with spina bifida.

A 35-year-old pregnant woman, Gravida 2 Para 0, with a medical history of spina bifida, gestational diabetes, polycystic ovary syndrome, and irritable bowel syndrome, was admitted at 38 weeks’ gestation for labor induction due to intrahepatic cholestasis of pregnancy. At 3 cm cervical dilation, the patient experienced severe, unrelieved pain despite non-pharmacological strategies and multiple intravenous analgesics. The anesthesia team was consulted. The patient expressed concern regarding neuraxial analgesia, believing herself to be ineligible. A CT scan confirmed spina bifida at the L5-S1 level. After careful assessment of the clinical scenario and a review of the available literature, a risk-benefit analysis supported the decision to proceed with epidural analgesia via catheter placement at the L3-L4 level, which was performed without complications.

Epidural administration of 12 mL boluses of 0.2% ropivacaine every hour provided effective labor analgesia and allowed for a spontaneous vaginal delivery of a healthy newborn with APGAR scores of 10 at 1, 5, and 10 minutes. No complications were reported on follow-up.

Effective pain control is a cornerstone of modern obstetric care, contributing to better maternal and fetal outcomes. Epidural analgesia remains one of the most effective methods. While spina bifida presents certain challenges, it should not be considered an absolute contraindication to neuraxial techniques. This case report highlights epidural analgesia as a viable and safe option for labor pain management in selected patients with spina bifida.

The external oblique intercostal (EOI) blocks have been reported to provide analgesia to both the anterior and lateral upper abdominal wall. However, the spread of injectate and the mechanisms of action remain to be fully elucidated. This cadaveric study aimed to evaluate the injectate spread following ultrasound-guided EOI block in human cadaver models.

Ultrasound-guided EOI block injections were performed bilaterally (n=7) on four soft embalmed Thiel cadavers. Thirty milliliters of saline-soluble dye were injected between the external oblique and external intercostal muscles at the sixth intercostal space. Anatomical dissection was subsequently conducted to assess the extent and depth of injectate spread.

In all specimens, dye spread did not extend beyond the costal arch, and the anterior branches of the thoracoabdominal nerves were not stained. The dye infiltrated within the external oblique muscle, reaching its superficial layer across a median (IQR) of 3 (3–4) intercostal levels, but did not reach the site where the lateral cutaneous branches arise from the intercostal nerves along the mid-axillary line. Limited dye spread into the intercostal space was observed in 3 of 7 specimens.

In our cadaveric study, EOI block did not involve the anterior branches of the thoracoabdominal nerves. Our findings suggest that the EOI block may affect the lateral cutaneous branches of the intercostal nerves through the spread of injectate within the external oblique muscle. Future research is warranted to clarify the precise mechanisms of action and anesthetic coverage of the EOI block.

Now in Ukraine there are 70 000 military patients with the amputations. If first-line drugs are ineffective, it becomes necessary to use second-line opioids for a long time, which can lead to serious side effects One of the innovative approaches in the treatment of chronic neuropathic pain is the use of specialized interventions in the form of injections of botulinumtoxin A ( BoNT-A), which is due to its unique mechanism of action, namely blocking cholinergic transmission in neuromuscular synapses, which leads to inhibition of acetylcholine release.

A group of patients (21 soldiers),3 months after an injury to the upper or lower extremities requiring different levels of amputation suffered from post-amputation pain without somatic comorbidity and received injections of incoBoNT-A- 100-200 units.There are the following methods of injection: into the neuroma, into the triger point, subcutaneously. The target is to diagnose a neuroma using an ultrasound. The injection of Incobotulinum neurotoxin A is performed under the navigation control of an ultrasound, using a linear sensor (frequency 5-15 MHz), in-plane or out-of-plane method of visualisation, depending on the depth of the neuroma

Statictics: 42 patients were injected BoNT- A, treatment results devided into 3 groups (depending on the treatment method), the greatest effect of pain reduced - decreased from 7,7 until 3,6 points on the scale of VAS resulted from the combination of BoNT-A + physical therapy + and antidepressant + anticonvulsant. Efect was stable and lasted for 3 months

Following the selection of patients with available treatment outcomes, analysis across three treatment groups—categorized by therapeutic approach— demonstrated that the combination of incoBoNT-A, physical therapy (PT), and an antidepressant plus anticonvulsant resulted in the most significant reduction in pain. Pain scores decreased from 7.7 to 3.6 on the Visual Analogue Scale (VAS),with the effect remaining stable over a period of three months.

Chronic low back pain originating from the lower lumbar facet joints is a frequent complaint in routine pain practice and the resulting myofascial strain often leads to an acute exacerbation. Sacral erector spinae plane (ESP) block at S2-4 has been used in the past for relieving chronic anorectal pain, acute lumbar radicular pain and chronic coccygodynia. We hypothesized that ultrasound-guided sacral ESP block at S1 level may be performed for low back pain that is presumed to be facetogenic in origin.

Patients presenting to the outpatient department for low back pain were clinically evaluated. Patients aged 18-80 years with predominantly axial back pain with a numerical rating score (NRS) of 5-8 associated with unilateral paramedian tenderness at the lower lumbar levels (L4-5/L5-S1) and a positive facet loading on examination were selected for intervention. Sacral ESP block was performed at S1 level, lateral to the foramen at the intermediate crest using a low frequency ultrasound probe (2-6Hz, GE Venue machine) with 10 ml of 0.2% ropivacaine.(Fig 1,2) Charts were reviewed for demographic profiles, history/examination findings, procedure performed, NRS, Oswestry Disability Index (ODI) scores and complications.

The records of 15 patients who underwent ultrasound-guided sacral ESP block for facetogenic pain were assessed. The average age was 64.5 years and 60% patients were female. 13/15 patients (86%) reported a > 50% decrease in NRS whilst 11/15 patients (73%) patients reported a 10-point reduction in ODI scores at 2 weeks. No complications were noted in any of the patients. (Figure 2 table)

Sacral ESP block performed at the S1 level is a safe and effective technique with easily identifiable sonographic landmarks for chronic low back pain of facetogenic origin. .

Background: Regional anaesthesia (RA) is increasingly utilised due to benefits in multimodal analgesia, suitability for high-risk patients, and environmental impact. Proficiency in RA is closely linked to both training quality and procedural exposure. With clinical opportunities varying widely, structured teaching is essential. Plan A blocks are a set of seven foundational RA techniques recommended as core competencies for anaesthetists. Aim: To improve anaesthetic trainees’ confidence in performing Plan A blocks.

Methods: "Sonoclub" was implemented at Chelsea and Westminster Hospital as a 10-session course delivered over four months. Each session featured a short didactic segment followed by hands-on ultrasound practice. Trainee confidence was assessed using pre-course and post-course surveys focusing on anatomy identification, block performance, and local anaesthetic (LA) selection

Attendance varied: 28% attended 2 sessions, 42% attended 3, and 28% attended 4. See table uploaded

Conclusion: Sonoclub significantly improved confidence in several aspects of RA. However, confidence in independently performing blocks remained limited, indicating the need for increased supervised clinical exposure and access to ultrasound equipment. References: 1. Niazi AU, Haldipur N, Prasad AG, et al Ultrasound-Guided Regional Anesthesia Performance in the Early Learning Period: Effect of Simulation Training. Regional Anesthesia & Pain Medicine 2012;37:51-54. 2. Bellew, Boyne et al. Regional anaesthesia training in the UK – a national survey. BJA Open, Volume 8, 10024. 3. Image: https://www.ultrasoundtraining.com.au/anaesthetics/ultrasound-guided-regional-anaesthesia/

Bupivacaine blood passage during chronic intrathecal infusion with an Intrathecal Drug Delivery System (IDDS) has barely been studied. The main objective of this retrospective study was to evaluate bupivacaine blood levels during chronic intrathecal infusion, as well as the different factors influencing this blood passage.

A retrospective follow-up study was conducted at the Institut de Cancérologie de l’Ouest in Angers, France. We reviewed electronic health records of patients with IDDS implanted for cancer pain treatment and followed up at ICO from July 2020 to June 2022.

Thirty-one patients were included in this study, with a total of 162 blood samples collected. The mean daily intrathecal bupivacaine infusion was 39.5mg/d (SD 31.4mg/d) and resulted in a mean bupivacaine blood levels of 167.7µg/L (SD 266.2 µg/L). A linear regression model was drawn between daily intrathecal bupivacaine infusion and bupivacaine blood levels and is materialized in Figure 1. Bupivacaine plasma levels remained unquantifiable for intrathecal bupivacaine infusion under 15.17 mg/d for 26 measures, with one exception at 34µg/L corresponding to an intrathecal infusion of 4.32 mg/d. One single blood sample had bupivacaine levels over the threshold of 2000µg/L, at 2606µg/L, associated with a mean daily intrathecal bupivacaine infusion of 243.0 mg/d. A subgroup of 34 samples, concerning 8 patients, was associated with a daily intrathecal bupivacaine infusion over 50 mg/d. The mean daily intrathecal daily bupivacaine infusion was 90.1 mg/d (SD 31.9 mg/d) with a median of 97.44 mg/d [72;99.8]. The associated mean bupivacaine blood level was 315.7 µg/L (SD 485.4 µg/L) with a median of 159.9 µg/L [123.85;281.65].

Chronic intrathecal bupivacaine infusion at clinically relevant doses results in minimal systemic absorption under 50mg/d, reinforcing its safety profile. Further research should explore individualized monitoring strategies based on patient-specific factors, including BMI and infusion parameters, to optimize efficacy while minimizing systemic exposure.

Spinal anaesthesia for obstetric surgery often includes low-dose morphine, where dosing accuracy is critical to balance analgesia and side effects. Despite this, no standardised preparation technique exists, and the impact of dead space and needle choice is often overlooked.

Anaesthetists were asked to prepare spinal drugs (bupivacaine, fentanyl, morphine) using water-filled ampoules and their usual technique. Syringes were weighed to assess dose accuracy and dead space. Participants’ use of filter needles, preparation steps, and time taken were recorded. An educational intervention followed, highlighting the effect of dead space and demonstrating a technique to minimise discrepancies and reduce contamination risk. Participants repeated the preparation, and post-intervention data and perceptions were collected.

Morphine dosing discrepancies ranged from 23.5% to 91%, largely due to dead space and preparation technique. Drawing both opioids together, failing to clear syringes/needles, and improper filter needle use contributed significantly. Post-intervention, average morphine dose error reduced from 38.2% to 6.7%. While 80% of participants were open to changing their practice, 67% noted the new method was slower. Filter needle use was inconsistent: 33% used a hypodermic needle to draw opioids, and 17% inappropriately used a filter needle to transfer drugs.

This study highlights significant variation in spinal drug preparation and the risks posed by dead space. A simple educational intervention improved dosing accuracy. While not prescriptive, adopting a more standardised approach may enhance both safety and efficacy in spinal anaesthesia preparation.

Controlled hypotension is a commonly used anesthesia technique in shoulder arthroscopy to improve visual clarity. However, hypotension-related hypoperfusion may lead to postoperative acute kidney injury (AKI). The renal resistive index (RRI) is considered an effective and reliable parameter for identifying prerenal AKI. This study aimed to evaluate changes in RRI in patients undergoing shoulder arthroscopy with controlled hypotension and to assess the utility of RRI in predicting postoperative AKI.

Following ethics committee approval, 90 adult patients undergoing elective shoulder arthroscopy were prospectively enrolled. Controlled hypotension was induced with IV remifentanil (0.01–0.2 mcg/kg/min). RRI was measured pre- and postoperatively in pain-free, stable patients. AKI was defined based on KDIGO (kidney disease improving global outcomes) criteria using serum creatinine and GFR levels. The protocol for this clinical trial was registered at ClinicalTrials.gov (NCT05945706).

Data from 65 patients were analyzed. Postoperative RI values (mean±SD:0.683±0.85) were significantly higher than preoperative values (mean±SD:0.648±0.77) (p<0.001, Figure 1), with a mean RRI increase of 5.6%. Stage 1 AKI developed in 3 patients (4.6%). Preoperative RI was positively correlated with age (p<0.001) and SPARK score (p=0.003), and negatively correlated with baseline GFR (p=0.03) (Table 2). Preoperative RI >0.7 was associated with higher age, SPARK scores, ACE inhibitor use, diabetes prevalence, and lower baseline GFR (all p<0.05, Table 3).

The increase in renal resistive index indicates that controlled hypotensive anesthesia in shoulder arthroscopy may affect renal perfusion. However, no long-term renal impairment was observed. Renal perfusion in shoulder surgeries with controlled hypotension can be assessed by monitoring delta RRI. Especially in high-risk patients undergoing hypotensive anesthesia, RRI monitoring appears promising for preserving renal function.

Peripheral nerve blocks (PNBs) are often associated with rebound pain, a significant clinical issue. Management strategies for mitigation have been discussed in the literature, and favourable outcomes may be obtained with either continuous PNB's and timed systemic analgesics. Our study aimed to formally evaluate the effect of these analgesic pathways on rebound pain following ankle fracture surgery.

This was a three armed randomised control trial involving 120 patients undergoing surgery for ankle fracture ORIF. All patients received an ultrasound guided popliteal-sciatic and saphenous nerve blocks (10ml of Bupivacaine 0.5% with 5ml of 2% lignocaine in each site) as well as a standardised general anaesthetic. Patients were randomised to a postoperative multimodal oral analgesia protocol (Group C), a timed opioid analgesic protocol (Group TO) or a sciatic catheter protocol (Group SC). Our primary outcome was median peak pain score 24 hours after block administration. Our secondary outcomes included the impact of intervention on quality of recovery, and subpopulation at highest risk of rebound pain.

120 eligible patients were randomized 1:1:1 to three groups (C=42, TO=39, SC=39). After subject attrition, 37, 33, and 35 patients were analysed in each group, respectively. There was no statistically significant difference between groups in peak postoperative pain scores at 24hrs (K-W, p=0.15), at 24-48hrs (K-W, p=0.89), in QOr9 scores at 24hrs (K-W, p=0.46 ), or in QoR9 scores at 24-48hrs (K-W, p=0.55).. A significantly higher percentage of individuals in the catheter group (34%) reported no pain at 24 hours compared to the conventional therapy group (14%) and the timed opioid group (6%).

When compared to conventional postoperative multimodal analgesia, administration of a timed opioid or use of a continuous perineural sciatic catheter is not associated with a statistically significant reduction in peak pain scores at 24 and 48 hours post ankle fracture surgery

Peripheral nerve stimulation (PNS) is a neuromodulation technique used for pain relief, including after total knee arthroplasty (TKA). Unlike traditional nerve blocks, PNS provides analgesia without motor blockade, preserving muscle strength. Post-TKA quadriceps weakness hinders recovery, making PNS a promising alternative. This study hypothesizes that perioperative femoral nerve neuromodulation matches analgesic efficacy while enhancing quadriceps strength.

A single-center, controlled trial was conducted at Hospital General Universitario de Valencia. Patients scheduled for TKA were randomized in two groups. The PNS group received 20 min of femoral nerve stimulation (100 Hz for 5 min, then 2 Hz for 16 min) adjusted to patient tolerance. The shame group had the device switched off. Both interventions were applied preoperatively. Motor function (maximal voluntary isometric contraction, MVIC) was assessed at baseline, post-intervention, and 48h post-surgery. Secondary outcomes included pain scores (NRS) and opioid consumption. This study was conceived as a proof-of-concept investigation aimed at demonstrating feasibility and gathering data to inform the design and power calculations for a subsequent clinical trial.

21 patients completed the study (14 PNS, 7 control). The PNS group showed a 26% increase in MVIC post-intervention (P < 0.001), while controls had no change. At 48h, both groups experienced MVIC decline, but the PNS group’s reduction was smaller (59% vs. 74% in controls). Pain scores at 24h were lower in the PNS group (2/10 vs. 7/10; P < 0.001), with comparable opioid use.

Perioperative femoral neuromodulation significantly improved quadriceps strength post-TKA, with sustained effects at 48h. While all patients had strength decline, the PNS group’s reduction was less severe. PNS also provided effective analgesia, similar to nerve blocks, without motor impairment. These findings suggest PNS could enhance recovery by preserving muscle function and reducing pain. Further studies are needed to assess long-term clinical benefits.

Peripheral nerve blocks are effective for surgical anesthesia and multimodal analgesia. Intravenous lipid emulsion (ILE), used to treat local anesthetic toxicity, may shorten block duration. This study compared the effects of intravenous ILE and normal saline on motor block duration in rats with percutaneous sciatic nerve block.

This randomized, double-blind study was conducted at Ondokuz Mayıs University Experimental Animals Center with 20 male Wistar Albino rats undergoing unilateral sciatic nerve block. Rats were randomized into two groups: ILE (Group L) received 7.5 ml/kg 20% lipid emulsion IV, and normal saline (Group S) received 7.5 ml/kg IV. Motor, sensory, and deep sensory block durations were assessed by a blinded researcher at multiple time points until full recovery. The primary outcome was motor block recovery time; secondary outcomes were sensory and deep sensory recovery times.

Twenty male Wistar Albino rats (average weight 355 g) with normal motor activity were included (Group S:10, Group L:10). The mean motor recovery time after sciatic nerve block was 94 ± 6.9 minutes in Group S and 36 ± 8.4 minutes in Group L, showing a significant difference (P < 0.05). Sensory block duration was 104 ± 5.1 minutes for Group S and 45 ± 9.7 minutes for Group L, while deep sensory block lasted 104 ± 11.7 minutes in Group S and 43 ± 11.5 minutes in Group L, both with significant differences between groups (P < 0.05).

In this study, we observed that intravenous lipid emulsion (ILE) administration shortened the motor block duration in rats undergoing sciatic nerve block with a percutaneous approach. Additionally, reductions in sensory and deep sensory block durations were also detected following ILE administration. Although the obtained data suggest that ILE shortens the block duration in peripheral nerve blocks, more comprehensive randomized controlled trials are needed to guide clinical practice.

The increasing prevalence of knee joint replacement surgeries necessitates optimised pain management strategies that support Enhanced Recovery After Surgery (ERAS) pathways, minimise opioid consumption, and facilitate early discharge. This study evaluates the analgesic efficacy of a novel Peripheral Nerve Block Combination (PNBC, Group A) compared to the standard regimen (Group B) in patients undergoing Medial Unicompartmental Knee Arthroplasty (UKA) and Total Knee Arthroplasty without Patellar Resurfacing (TKA-WPR) in an ambulatory setting. Group A received: 1. Genicular nerve block (GNB) of the superomedial, superolateral, inferomedial, and inferolateral genicular nerves 2. Interspace between the popliteal artery and capsule of the knee (IPACK) block 3. Distal femoral triangle block (DFTB) of the saphenous nerve and the nerve to vastus medialis 4. Medial and intermediate femoral cutaneous nerves of the thigh block (MFCN, IMFCN) 5. Periarticular local anaesthetic infiltration (PALAI) Group B received: 1. Adductor canal block (ACB) 2. PALAI

This single-centre retrospective cohort study analysed two matched groups over one year (31 UKA, 31 TKA-WPR per group). Matching was performed using Opera theatre software (GE Healthcare) to ensure comparability. Standardised anaesthetic, surgical, and postoperative analgesia protocols were applied across both groups. Primary outcome: total morphine consumption. Secondary outcomes: hospital discharge time and postoperative block-related motor weakness.

Group A demonstrated a 64.71% and 39.39% reduction in morphine consumption for UKA and TKA-WPR, respectively. Same-day discharge was achieved in 77.4% (UKA) and 45.2% (TKA-WPR) of Group A patients versus 45.2% and 12.9% in Group B. No postoperative motor weakness was reported in either group.

The novel PNBC significantly reduces postoperative opioid use and facilitates earlier discharge without increasing motor block risk, optimising ERAS pathways and improving patient outcomes following knee arthroplasty.

Precise needle tip localisation is critical for safe and effective peripheral nerve blocks. Ultrasound, nerve stimulation, and injection pressure monitoring assist in this process, but may not always ensure optimal placement. Electrical impedance (EI), sensitive to tissue composition and water content, has emerged as a potential adjunctive marker. This study aimed to characterise EI variations during ultrasound-guided sciatic nerve block (SNB) and to evaluate their utility in identifying needle position relative to the paraneural sheath.

In this prospective observational study, 45 adult patients undergoing lower-limb surgery under SNB were enrolled. EI measurements were obtained at four predefined needle positions: intramuscular, outside the paraneural sheath, within the sheath, and post-injection. Blinded video review of local anaesthetic spread by three independent anaesthetists classified patients into two groups: confirmed within-sheath injection and extra-sheath injection. Receiver operating characteristic (ROC) analysis assessed the diagnostic performance of EI changes.

Of the 45 patients, 31 had confirmed within-sheath injections, and 14 had extra-sheath injections. In the confirmed group, EI significantly increased approaching the sheath (mean difference +1.568, p = 0.0306) and decreased upon sheath entry (mean difference −1.445, p = 0.0010). No significant EI changes were observed in the extra-sheath group. ROC analysis demonstrated high diagnostic accuracy (AUC 0.890 for absolute EI change; AUC 0.860 for relative change).

Monitoring electrical impedance provides a valuable adjunct for needle tip verification during ultrasound-guided sciatic nerve block. When combined with ultrasound, it may improve block success rates and help reduce complications, enhancing both the safety and efficacy of regional anaesthesia in clinical practice.

Common blocks for THA (total hip arthroplasty) mainly target pain originating from the anterior part of the hip, overlooking posterior capsule's contribution to the overall pain. Our study aims to evaluate the benefit and safety of a complete pericapsular hip block compared with local infiltration analgesia (LIA).

Medical files of patients scheduled for elective THA were retrospectively analysed. Over the past two months, 26 patients who received a preoperative ultrasound-guided complete pericapsular hip block were matched (for age, sex and BMI) with 26 patients receiving intra-operative LIA by surgeon. The type of hip local analgesia was left to the discretion of the anaesthesiologist. All THA were performed under general anaesthesia and postoperative analgesia was standardised. Time before first rescue analgesia and morphine dose in PACU, total morphine consumption at 48h were noted.

Age was 68±10 years, BMI was 28±5.5 and preoperative opioid intake was reported by 2/26 and 3/26 patients, respectively in complete hip block and LIA group. Results are detailed in Table 1. No side effects related to any analgesic technique were noticed.

The findings suggest that an effective complete pericapsular hip block may offer superior prolonged postoperative analgesia and opioid-sparing effects compared to a surgical LIA.

The intertruncal approach of the supraclavicular block offers better block dynamics and faster onset of surgical anaesthesia and success rate comparable to other approaches like corner pocket approach. However, there are no studies comparing the two techniques of intertruncal approach (double-injection technique vs triple-injection technique). Our study aimed to assess the efficacy of the ultrasound guided double versus triple-injection techniques of intertruncal approach of supraclavicular block by comparing the proportion of patients with complete sensory blockade at 20 minutes. Secondary objectives include procedure time, NRS scores, patient satisfaction scores, onset time, diaphragmatic excursion and adverse events.

Following ethics committee approval and with a non-inferiority margin of 20%, 94 ASA I- III(aged 18 - 75 years), undergoing upper limb surgeries were randomised into two groups: double-injection group(DI, n=47) and triple-injection group (TI, n=47). Both groups received 25 ml of 0.5 % bupivacaine. In DI group, 10ml of LA was administered between the lower and the middle trunks and 15ml of LA between middle and upper trunks. In TI group, 10ml of LA was injected between the lower and middle trunks, 7.5ml of LA between middle and the upper trunks and 7.5ml of LA between upper trunk and pre-vertebral fascia. Brachial plexus block assessment and diaphragmatic excursion were recorded.

Both groups achieved comparable rates of complete sensory block at 20 minutes. The TI group showed significantly higher rates of complete motor and composite block at 25 minutes, with a faster onset. Procedure time, NRS scores, and patient satisfaction were similar between groups. Incidence of partial hemidiaphragmatic paresis was comparable, with no cases of complete paralysis in either group.

The double injection technique of intertruncal supraclavicular block is non-inferior to the triple injection technique of the same approach

Obesity is a important issue in pregnant women, who are more susceptible to complications that may affect both maternal and neonatal outcomes. Obese pregnant women more often require cesarean sections (CS), which carry additional potential anesthetic complications. The authors aim to assess the impact of obesity on anesthetic, obstetric, and neonatal outcomes in elective CS performed in 2024 at Centro Materno-Infantil do Norte (CMIN).

In 2024, a total of 735 cesarean deliveries were recorded at CMIN. After applying the exclusion criteria, the final sample included 249 pregnant women who underwent elective cesarean sections. These participants were categorized based on their preconception BMI into three groups: underweight/normal weight, overweight, and obese. Data on anesthetic management, as well as obstetric and neonatal outcomes, were collected and classified as either continuous or categorical variables. Continuous variables were analyzed using one-way ANOVA with Scheffé post hoc tests, while categorical variables were assessed using Pearson’s chi-square test. Statistical significance was defined as a bilateral p-value of < 0.05.

The prevalence of obesity was 24.9%. Obese women had a higher number of pregnancies and deliveries (p = 0.001 and p < 0.001, respectively). Newborns of women with a BMI ≥ 30 kg/m² had significantly higher birth weight, length, and head circumference (p = 0.003 and p = 0.004, respectively). Statistically significant differences were also observed in the number of neuraxial anesthesia puncture attempts (p = 0.047), which increased with higher BMI categories, and in the use of vasopressors during cesarean sections (p = 0.030), which was more frequent among overweight women. The duration of surgery was also significantly longer in the obese group (p = 0.013).

The findings are consistent with the literature on the negative outcomes associated with obesity during pregnancy, highlighting its adverse impact on affected women and the importance of prevention/ treatment strategies.

Pancreatic cancer is an aggressive malignancy with poor prognosis. Surgery is the only curative option, but optimal perioperative analgesia for minimally invasive pancreatic procedures remains unclear. Intrathecal morphine (ITM) offers prolonged analgesia and may enhance recovery, though side effects such as nausea and respiratory depression limit its use.

In this single-centre, double-blind, randomized placebo-controlled trial, patients undergoing laparoscopic or robotic pancreatic surgery within an enhanced recovery program received either ITM (4 µg/kg) or placebo. All patients received standard multimodal analgesia and patient-controlled morphine. The primary outcome was morphine consumption in the first 24 hours (see figure 1). Secondary outcomes included morphine use at 48 hours, pain scores, complications, and recovery parameters.

ITM significantly reduced cumulative morphine use at 24 hours (mean [SD]: 19 [19] mg vs 35 [30] mg; p = 0.0004) and 48 hours (30 [22] mg vs 45 [37] mg; p = 0.0083). Pain scores were similar, but ITM patients used less rescue and PCA opioids (see Table 1). No significant differences were observed in respiratory complications, nausea, surgical outcomes, or inflammatory markers. Pruritus was more common in the ITM group (58% vs 25%). Time to discharge readiness and hospital stay were similar (see Table 2).

ITM significantly reduces opioid consumption following minimally invasive pancreatic surgery without increasing serious complications. These findings support its role in multimodal analgesia within enhanced recovery protocols. Further studies should optimize dosing and assess safety in larger cohorts.

The pudendal nerve block has clinical applications in obstetric anesthesia, post-surgical perineal analgesia, and chronic perineal pain management. To conduct an anatomical study to evaluate the ultrasound-guided technique for blocking the pudendal nerve over the sacrospinous ligament (SPuB).

An anatomical study was conducted on fifteen cadaveric specimens (thirty pelvic girdles), in which the SPuB technique was performed under ultrasound guidance using a low-frequency convex transducer. Specimens were placed prone position, and the transducer was placed on the iliac bone in a superolateral oblique plane to identify the continuous bony structure. By sweeping the probe from superolateral to inferomedial, the continuous iliac bone, the beginning of the sciatic foramen, the greater sciatic notch, and the posteroinferior iliac spine were identified. At this point, the sacrospinous ligament was recognized, and by rotating the transducer into the sagittal plane, the sacrotuberous ligament was visualized superficially. Once the structures were identified, the probe was redirected to the sacrospinous ligament plane, and an in-plane lateral-to-medial puncture was performed with an 80-mm needle to inject 5 ml of a solution mixture (methylene blue + iodine). Three-dimensional (3D) reconstructions were obtained using computed tomography (CT), followed by sectional anatomy in five cadavers. Anatomical plane-by-plane dissection of each hemipelvis was carried out in ten cadavers.

The 3D reconstruction obtained from CT demonstrated the contrast distribution from the lower sacral region in an oblique direction toward the posteroinferior iliac spine and the ischial tuberosity, partially covering the lesser sciatic foramen (Figure 1). In anatomical dissection and sectional anatomy, the distribution of methylene blue was observed within the plane formed by the sacrospinous and sacrotuberous ligaments, affecting the pudendal neurovascular bundle (Figures 2 and 3).

The SPuB technique consistently affects the pudendal neurovascular bundle and is a simple and easily reproducible technique.

Opioid-free anesthesia in the perioperative period reduces the risk of opioid-related side effects and enhances recovery by minimizing postoperative nausea, sedation, and respiratory depression. We wanted to assess the effects of OFA on bowel recovery, PONV, pain scores and hospital stay inpatients undergoing Radical Cystectomy with Ileal Conduit (RCIC) and Retroperitoneal Lymph Node Dissection (RPLND).

Thirty two patients undergoing RCIC and RPLND were randomised into two groups – OFA study arm (n=16) and with standard opiods arm OA (n=16). Both the groups received propofol and vecuronium for induction of anaesthesia followed by inhalational anaesthetic agents for maintenance of anaesthesia. The OA group received fentanyl at the time of induction while the OFA group received intravenous lignocaine. Epidural catheter was placed for intraoperative and post-operative analgesia through which the OFA group received 0.125% levobupivacaine while the OA group received 0.1 levobupivacaine with 2 mcg/cc Fentanyl. Both groups received Ondansetron as PONV prophylaxis. In addition, paracetamol and diclofenac were also used for post-operative analgesia.

The study revealed that the time to passage of flatus was lower in the OFA group (51.731 vs 60.731, p=0.366) but not statistically significant. Intra-operative hemodynamic parameters, post-operative pain scores and incidence of PONV were comparable in both group of patients. However, the severity of PONV measured as number of doses of anti-emetics required to control PONV was more in the OA group (1.85 vs 0.54, p=0.099). Length of hospital stay was lower in the OFA group (9.75 vs 13.31 days, p=0.150) but not statistically significant. Remaining parameters were comparable in both the groups

OFA did not provide any advantage over opioid based anaesthesia. However, it can be used as an alternative in patients who are prone to the side effects of opioids.

Pain after inguinal hernia surgery is a major reason for delayed discharge. To minimize opioid-related side effects, regional techniques like quadratus lumborum (QL) and paravertebral (PVB) blocks are increasingly used. This study aims to compare the postoperative analgesic effectiveness of abterior and posterior QL , and PVB blocks in patients undergoing elective inguinal hernia repair under spinal anesthesia.

Following ethical approval and informed consent, the study was conducted at Gaziosmanpaşa Training and Research Hospital. Patients who underwent inguinal hernia surgery under spinal anesthesia were randomly assigned to receive either anterior and posterior QL, or PVB block postoperatively. Data collected included demographics, 24-hour total analgesic consumption, NRS (Numeric rating Scale) scores, time to first analgesic use, and side effects like nausea or vomiting.

124 patients were included (mean age 51.2 years; 91.1% male). Demographics were similar across groups. Analgesic requirement within 24 hours was highest in the control group, lower in QL groups, and lowest in the PVB group. Although early NRS scores (1–12 hrs) did not differ significantly, 24-hour resting NRS scores were significantly lower in all block groups. First rescue analgesia was required later in the anterior QL and PVB groups.

Truncal blocks such as QL and PVB effectively reduce postoperative pain after spinal anesthesia in inguinal hernia surgeries. They may support earlier mobilization and reduce the risk of chronic postoperative pain.

The interscalene brachial plexus block (ISB) is an alternative anesthesia technique frequently used in shoulder surgery. However, short-term hypertension (HT) has been reported following ISB. One of the critical determinants of success in arthroscopic shoulder surgery is the quality of intraoperative visualization. Hypertension may contribute to increased bleeding, potentially impairing visual clarity during the procedure. This study aims to compare the effects of ISB and general anesthesia (GA) on arthroscopic visualization in patients undergoing rotator cuff repair.

Following approval from the local ethics committee and informed consent from all patients, this prospective, randomized study included 80 patients aged ≥18 years who were assigned to either a GA group or an ISB group. The primary outcome was intraoperative visual clarity, which was assessed postoperatively by the operating surgeon using a 10-point arthroscopic visualization scale (grade 1 = worst visualization, grade 10 = best visualization; conversion to open surgery was considered at the lowest end of the scale).

There were no statistically significant differences between the two groups in terms of age, comorbidities, gender, or duration of surgery (p > 0.05). However, visual clarity scores were significantly higher in the general anesthesia group compared to the ISB group (6.15 ± 2.02 vs. 4.73 ± 1.5, respectively; p < 0.001).

Although interscalene brachial plexus block (ISB) is a viable anesthesia technique for shoulder arthroscopy, lightly sedated patients under ISB may experience greater hemodynamic variability, potentially compromising arthroscopic visualization. In comparison, general anesthesia appears to provide superior visual clarity during rotator cuff repair.

Regional anesthesia techniques are increasingly used as part of multimodal analgesia strategies to reduce postoperative pain and accelerate recovery after lumbar spinal surgery. This study compared the effects of erector spinae plane (ESP) block and retrolaminar block (RLB) on postoperative recovery quality and pain.

Eighty patients aged 18–75 years, classified as ASA I–III and scheduled for elective lumbar spinal surgery, were included in this prospective, randomized, double-blind study. Ethical approval was obtained, and the study was registered with ClinicalTrials.gov before the enrollment of the first patient. After obtaining verbal and written consent, patients were randomly assigned to the ESP or RLB group using computer-assisted randomization. Bilateral blocks were performed at the T10 level before surgery in both groups. The primary outcome was recovery quality measured by the QoR-40 score at 24 hours. Secondary outcomes included total opioid consumption and the patient's NRS pain scores. The number of PCA boluses, time to mobilization, discharge time, and side effects were also recorded.

There was no significant difference between the groups in recovery quality at 24 hours postoperatively (p > 0.05). Total tramadol consumption and the number of PCA button presses were significantly lower in the ESP group (p < 0.05). NRS scores at rest were significantly lower in the ESP group at 12 and 24 hours (p < 0.05). No differences were found between the groups regarding additional analgesia requirements, time to first mobilization, discharge time, or side effects.

Although ESP block provided superior postoperative pain control and reduced opioid consumption compared to RLB, this advantage did not reflect in the 24-hour recovery quality. Therefore, despite the strong analgesic efficacy of the ESP block, further studies are needed to compare its effectiveness on functional recovery.

This study compared the effects of erector spinae plane (ESP) block administered either preoperatively or postoperatively on postoperative acute pain, opioid consumption, and quality of recovery in patients undergoing spinal surgery.

A total of 46 patients aged between 18 and 75 years, classified as ASA I–III, and scheduled for elective lumbar spinal surgery were included in this prospective, randomized, double-blind study. Ethics committee approval was obtained, and the study was registered at ClinicalTrials.gov before patient enrollment. After obtaining verbal and written informed consent, patients were randomized via computer-based allocation. ESP block was performed before surgery in Group 1 and after surgery (prior to awakening) in Group 2. The primary outcome was total opioid consumption. Secondary outcomes included NRS pain scores assessed at 0, 1, 6, 12, 18, and 24 hours postoperatively, and quality of recovery measured by QoR-40 at 24 hours. Additional postoperative analgesia requirements, time to mobilization, time to discharge, and side effects were also recorded.

There was no significant difference in total opioid consumption between the groups (p>0.05). However, NRS pain scores were significantly lower in Group 2 at 18 and 24 hours (p<0.05). Among the QoR-40 subscales, only the 'comfort' score was significantly higher in Group 1 (p<0.05); no differences were observed in other subcategories. There were no significant differences between the groups in terms of additional analgesia requirements, time to first mobilization, discharge timing, or side effects.

Although total opioid consumption and overall quality of recovery scores were largely similar between the groups (except for the comfort subscale), postoperative ESP block may be more effective in controlling late postoperative pain. Despite potential anatomical disruption following spinal surgery, ESP block remains effective when performed postoperatively. Further studies are needed to explore the mechanism of action of ESP block.

To study the pharmacokinetic and pharmacodynamic effects of bupivacaine polylactic acid microspheres in rabbits.

The sixteen rabbits were divided randomly into two groups(n=8). One group was single-injected with bupivacaine solution 5mg/kg subcutaneously, the other group was single-implanted with bupivacaine polylactic acid microspheres 5mg/kg subcutaneously. A high performance liquid chromatographic method was developed to determine bupivacaine plasma concentration. A rabbit model for evaluation of regional anesthesia was presented on the pharmacodynamic study.

The HPLC revealed that plasma concentration of bupivacaine reached peak time quickly, Cmax=2.4664µg/ml,then the plama concentration of bupivacaine came down sharply in group A. The plasma concentration of bupivacaine in group B was lower, and concentration-time curve was gently. It showed that peak time delayed and MRT prolonged, Cmax=0.7781µg/ml（P＜0.05).The pharmacodynamic study showed that the time of regional sensory blockade in microspheres group was prolonged compared to the injection group（P＜0.05).

Bupivacaine polylactic acid microspheres have sustained-release effect in rabbits, it can provide theory basis for the super long-acting local anesthetics.

Spinal anesthesia is the preferred technique for cesarean sections due to its favorable profile; however, post-spinal hypotension (PSH) remains a frequent and dangerous hemodynamic complication. Despite numerous preventive approaches, the optimal non-pharmacological strategy remains controversial. We aimed to evaluate the efficacy of leg elevation (LE) versus no leg elevation (no LE) in reducing PSH in women undergoing elective cesarean section.

We conducted a systematic search in PubMed, Cochrane and Embase for randomized controlled trials comparing LE with no LE in elective cesarean sections. Studies reporting the incidence of PSH, vasopressor consumption, and heart rate changes were included. Statistical analysis was performed using a random-effects model with the Hartung-Knapp-Sidik-Jonkman method, and heterogeneity was estimated via the Restricted Maximum Likelihood approach.

A total of six RCTs comprising 505 patients were analyzed. LE significantly reduced the incidence of PSH (risk ratio: 0.63; 95% CI: 0.51–0.79; p = 0.0001), equating to a 37% risk reduction. Additionally, the LE group demonstrated a significantly lower requirement for ephedrine (mean difference: -5.51 mg; 95% CI: -7.46 to -3.56; p < 0.00001). In contrast, no significant difference in heart rate was observed between the groups (mean difference: 4.02; 95% CI: -11.40 to 19.44; p = 0.26).

In this meta-analysis of randomized controlled trials, LE significantly reduced the risk of PSH and lowered ephedrine requirement, indicating it may be a simple, cost-effective, and non-invasive intervention for reducing the need for vasopressor support in elective cesarean sections. Further research is warranted to standardize LE protocols and confirm its applicability across diverse clinical settings.

Sterile techniques in regional anaesthesia are critical to minimizing the risks of arachnoiditis and meningitis, as emphasized in the National Audit Project 3. To reduce contamination from naso-oral flora, operating department practitioners (ODPs) should wear a facemask when assisting anaesthetists during procedures. Additionally, chlorhexidine gluconate (CHG) spray has the potential to disperse beyond the intended application site, making it unsuitable for use with exposed neuraxial needles. Filter needles should be employed in a unidirectional manner, and ampoules must be wiped to maintain aseptic precautions. Dead space within syringes must be accounted for in the drawing-up process to ensure accurate dosing of intrathecal opioids, preventing sub-therapeutic administration. This re-audit aimed to assess adherence to sterility protocols and manufacturer recommendations during spinal anaesthesia procedures performed for caesarean sections.

A prospective, single-blinded observational audit was conducted on 55 spinal anaesthesia procedures within the maternity unit. A 12-point questionnaire evaluated sterility measures, ampoule preparation, filter needle usage, and awareness of dead space loss in drug preparation.

5% of patients had their back sprayed after the tray was opened. Only 1% of ODPs wore masks during drug preparation, and sterile gloves or gauze were not used when breaking ampoules. Alcohol wipes were also omitted in 100% of cases. Filter needle use was inconsistent, with 100% of cases employing the same needle for aspiration and injection rather than unidirectional usage. Dead space awareness was absent in all cases. Nil improvement in results compared to previous audit.

Further structured departmental education and training sessions will be needed to address these gaps to enhance compliance, improve patient safety, and optimize anaesthetic practices.

Optimal patient positioning for popliteal sciatic nerve blocks remains a topic of debate. This study aimed to evaluate the clarity of nerve visualisation, ease of identification, and scanning efficiency across different patient positions using ultrasound.

In a randomised, crossover observational study conducted during a 'Sonoclub' ultrasound-guided regional anaesthesia course, 40 anaesthetists scanned volunteer models in four positions: prone, lateral, supine with knee flexed, and supine with knee extended. Outcomes included time to block-ready image acquisition, image quality (rated 0–3), and volunteer comfort (rated 1–3). The study was classified as quality improvement by the NIHR decision tool, this obviated the need for formal ethical approval.

Participants had a mean of 12 years' anaesthetic experience and a median popliteal block confidence score of 4/5 (Using a Likert scale with 1 being not at all confident to 5 expert level). A one-way ANOVA to compare the effect of positioning on time to visualisation revealed there was a statistically significant difference between at least two groups (F(3,145)=3.417, p=0.019). While the majority (22/40) preferred the supine knee extended position in their clinical practice, the supine with knee flexed position yielded the fastest mean imaging time (32.5 seconds) and highest image quality (mean score 2.4). Despite the popularity in participants' clinical practice, the supine with knee extended position was surprisingly associated with the longest time to visualisation (51.4 seconds).

Although the supine with knee extended position is commonly favoured, it may not offer the most efficient or clearest visualisation of the sciatic nerve. This position also often requires assistance with elevation of the leg and there are concerns regarding nerve stretch and consequent potential increase in likelihood of nerve injury. Supine with knee flexed in our study appeared superior and it may warrant broader adoption in clinical practice.

Post-caesarean section pain and discomfort may be anticipated due to skin incision, uterine incision, and uterine contraction. Inadequate postoperative pain management may impede maternal/infant bonding and increases the risk of thromboembolism, development of chronic pain. We aimed to compare the post operative analgesic efficacy between transversus abdominis plane block and transversalis fascia plane block.

After obtaining the ethical committee clearance (vide no: AIMS/EC/22/92) and written informed consent, a prospective observational randomized double blinded study was conducted. This trial was also registered at Clinical Trial Registry of India (CTRI/2023/05/053001). 60 patients aged between 18-40 years belonging to ASA 1 and 2 patients undergoing elective Lower Segment Cesarean Section (LSCS) under spinal anesthesia were randomly allocated into two groups: Group TAP and Group TFP. Group TAP received ultrasound guided transverse abdominal plane block, whereas Group TFP received ultrasound guided transversalis fascia plane block. 20 mL of 0.375% Ropivacaine was administered in each group. Patients in both groups also received multimodal analgesia in the form of Injection Diclofenac and Paracetamol. Our primary outcome was the time to need for first rescue analgesic dosage. Secondary outcomes included pain assessment using VAS score, patient satisfaction score, and post operative nausea and vomiting.

The time to need for first rescue analgesic medication is significantly delayed in group TFP as compared to group TAP (p<0.05). The pain scores were also better in group TFP than group TAP(p<0.05).

The analgesic efficacy of transversalis fascia plane block was superior in comparison to patients receiving transverse abdominis plane block scheduled for elective lower segment caesarean section.

Effective postoperative analgesia following cesarean section is essential to promote early maternal mobilization, successful breastfeeding, and maternal satisfaction. The local CUMH protocol aligns with national and international recommendations (AAGBI, OAA, ESRA), emphasizing the use of multimodal analgesia, neuraxial opioids, and timely rescue analgesia. This audit was conducted to evaluate current clinical practices and identify areas for improvement. Aim To assess the current practice of postoperative analgesia following elective and emergency cesarean sections and to highlight areas requiring improvement.

Population: Women undergoing elective or emergency cesarean section. Sample: Consecutive patients identified from electronic record over a two-week period (1st–14th February). Data Sources: PACU records, anesthetic notes, and prescription charts. Design: Retrospective audit. Data Collection Tool: Excel-based audit proforma capturing anesthesia technique, use of intrathecal opioid, TAP block (if applicable), prescription of regular analgesics (paracetamol, NSAIDs), prescription of PRN oxycodone, and administration of rescue analgesia.

A total of 100 patients were included. Intrathecal opioids were administered in 93 patients (93%), while 7 patients received a TAP block due to contraindications for neuraxial opioids. Regular paracetamol and NSAIDs were prescribed in 97 patients (97%), demonstrating strong adherence to multimodal analgesia guidelines. PRN oxycodone was prescribed in 90 patients (90%), with some variability in documentation. Of the 15 patients who recorded a postoperative pain score greater than 4, 13 received appropriate rescue analgesia within 30 minutes (87%). Regarding opioid consumption, the total opioid dose administered (converted to oral morphine equivalents) averaged 15 mg in the first 24 hours postoperatively, 25 mg over 48 hours, and 35 mg within 72 hours.

Overall, the audit showed good compliance with recommended analgesic protocols while highlighting areas for improvement in standardizing PRN opioid prescribing, timely administration of rescue analgesia.

The nerves of the brachial plexus (musculocutaneous-MCN, median-MN ulnar-UN, and radial -RN) show significant topographic variation at the axilla . The study was aim to evaluate the use of dynamic ultrasound for identification of different nerves during axillary brachial plexus block with hypothesis that dynamic movement at the level of shoulder, elbow and wrist will lead to dynamic movement of nerves at axilla to ease identification of nerves for successful block compared to perineural technique.

This randomised controlled pilot study was conducted after approval of IRB .40 pts were divided into GROUP DY (Dynamic ultrasound ) – block was given after identify various arm and forearm movements which make muscle contraction with respective nerve supply of arm and forearm using six-point visibility, In GROUP NDY (perineural approach) – block was given by perineural technique

The visibility of MCN was good at shoulder 900/elbow flexion position with mean score (4.11± 0.471) poor at shoulder 1800 position ( 3.11± 0.963) .The UN visibility was good during wrist flexion (3.11 ± 0.90) & poor in the shoulder 180° position, ( 2.28 ± 0.826) The RN visibility was good during supination, elbow extension and wrist extension ( 3.83 ± 0.383, 3.83±0.383 &3.78±0.428 )respectively poor in the shoulder 180° position, (2.78 ± 1.060 ). The visibility of MN was good at wrist flexion and pronation position (3.50± 0.786 and 3.44±0.784) respectively & poor at shoulder1800 position with mean score( 2.33± 0.840) The visibility of the musculocutaneous (MCN), median (MN), ulnar (UN), and radial (RN) nerves differs significantly across all eight upper limb movements with p = 0.000 , Time taken was significantly higher in group DY with p = 0.000.Sensory and motor block are comparable in both group

Identification of a nerve during dynamic USG may improves the effectiveness of the blocks.

“Minute Zero” (MZ) is a structured ultrasound evaluation performed before or after anesthesia to establish a hemodynamic and pulmonary baseline. It aims to personalize anesthetic and fluid strategies, especially in elderly patients with fragility fractures. This study assessed whether MZ could reduce postoperative complications and hospital stay.

We conducted a prospective observational study in patients >70 years undergoing femoral neck fracture surgery ≥48h after hospital admission. Patients were divided into two groups: MZ group (n=41), who underwent pre- or postoperative ultrasound; and a control group (n=55), without ultrasound. The MZ protocol included lung ultrasound (to assess B-lines, pleural effusion, consolidation), cardiac contractility, and inferior vena cava evaluation. Management changes based on ultrasound findings were recorded.

Despite a higher mean age (87 vs 84 years) and longer preoperative delay (6.2 vs 5.1 days), MZ patients had a shorter postoperative hospital stay (mean reduction ~3 days). There were no significant differences in postoperative cardiac, respiratory, or infectious complications. However, anesthetic or fluid strategies were modified in over 80% of MZ cases based on findings such as hypovolemia, B-profile, myocardial dysfunction, or pleural effusion.

Minute Zero ultrasound enables early identification of key pathophysiologic conditions, allowing tailored anesthetic and hemodynamic management. In this elderly high-risk population, MZ was associated with a reduction in postoperative hospital stay and influenced perioperative decision-making in most cases.

Sub-Tenon's blocks are the most efficient fascial plain blocks, providing stand-alone analgesia for eyes. Presumably, many lessons could be drawn to improve fascial sheath blocks efficiency, especially about fluid dynamics. To visualize LA-distribution in STB, coloured mepivacaine was injected, differentiating between bulging bulk flow and viscous fingering- an arbitrating distribution pattern. Its incidence, correlation with bulk flow and its ultrasound-biomicroscopy (USBM) correlates are unknown.

20 fresh pigeyes from abattoirs underwent USBM (50 MHz probe, axial resolution 30 μm) measurements of sclera, Tenon's fascia and conjunctiva. Distribution patterns of colored LA were documented during injection. USBM measured increase of height of the gap between sclera and Tenon's after injection-the eye's interfacial sheath. Injection pressures were recorded via an X-Metra analog pressure gauge (range: 0–25 kPa, ±0.5 kPa accuracy) on the syringe. Distribution dynamics were categorized as: Bulk flow (B), Viscous fingering (VF ), Diffusion (D) Parametric and non-parametric methods based on distribution normality (Shapiro-Wilk test) applied. Continuous variables were reported as mean±SD or median[IQR]. Paired t-tests for normally distributed anatomical measurements, Wilcoxon tests for non-normal pressure curve data, and Pearson/Spearman correlations for linear/non-linear relationships were used. Analyses were performed in RStudio (v4.3.1) with significance at p<0.05.

Initial VF followed by bulk flow was observed in 14 of 20 specimens (75%). Absence of VF (5 eyes) correlated with chemosis and septation, at mean height increase of 2.984 mm vs 1.834 mm in VF-positive eyes (p=0.0096). Injection pressure analysis showed no difference between groups. Initial VF cases robustly showed less chemosis (1.67 mm vs 3.14 mm, p=0.0096) and late VFI cases demonstrating a similar though less pronounced effect (1.81 mm vs 3.05 mm, p=0.047) in normality verification.

Viscous Fingering is a third fluid dynamic in FSB along with bulk flow and diffusion and should be studied for it's potential to improve FSB

Post-operative pain has been studied quite comprehensively in recent years, however, studies on postoperative pain and its management following revision arthroplasty are understudied. As a result, standardized management protocols regarding revision arthroplasty are lacking. Patients undergoing revision arthroplasty often present with substantial pain pre-operatively, which rationalizes the importance of this study. The aim of our study is to evaluate the intensity and characteristics of postoperative pain following joint revision arthroplasty, to assess the effectiveness of pain management and identify factors that influence pain outcomes and satisfaction

A combined retrospective-prospective study of 38 patients on first postoperative day following joint revision arthroplasty. Data were collected using standardized pain register PAIN OUT questionnaires and patient medical records. Statistical analysis was done using MedCalc version 23.2.1.

Median worst pain score was 4.0 [2.0-6.8], while treatment satisfaction was high (9.0 [8.0-10.0]). Patients spent a median of 20.0% [10.0-40.0] of the first postoperative day in severe pain. Pain interfered most with movement in bed (3.5 [1.2-5.0]) and less with sleep (1.0 [0.0-3.8]). Patient participation in decisions was the only significant predictor of treatment satisfaction (ρ=0.326, p=0.046). There were no statistically significant differences in outcomes across gender, surgery type, or anesthesia technique. Despite high satisfaction, 65.8% of patients desired more information on pain management.

Patient participation in pain management decisions correlates with higher satisfaction regardless of objective pain levels. These findings highlight the need for greater patient involvement in postoperative pain management

Women's choice is significantly altered by the counselling. Majority of women's beliefs are shaped by past experience and the information they receive. This study was conducted to evaluate the effect of structured counselling on women's choice of obstetrical anesthesia for elective caesarean section

This was a cross-sectional comparative survey conducted at department of gynaecology (unit II), Abbasi Shaheed Hospital, Karachi, from 1st January, 2024 to 30th June, 2024. The study included 250 pregnant women at term ( 37 weeks) with a prior caesarean section, planned for elective caesarean having no contraindications to spinal or general anesthesia. Excluded from the study were women with obstetric emergencies like antepartum hemorrhage, cord prolapse, eclampsia, disseminated intravascular coagulation, vertebral column deformities, fetal distress and obstructed labor. They were asked about the technique of anesthesia they would prefer for their caesarean section. The women then received structured counselling and the choice was assessed again. Chi-square statistic was applied to assess the association between both choices taking p-value of 0.05 as statistically significant. Data were analyzed using the SPSS software program, version 15.0 (IBM, Armonk, USA).

Out of 250 women recruited, before counselling 116 (46.4%) chose general anesthesia, 94 (37.6%) women chose spinal anesthesia whereas 40 (16%) had no particular preference. After receiving structured counselling 68 (27.2%) women chose general, 170 (68%) women opted for spinal and 12 (4.8%) women still remained undecided. The effect of structured counselling was assessed by cross-tabulating pre counselling choice and post-counselling choice. The Chi-square test statistic was significant at p = 0.001 showing a significant association of structured counselling on the choice of anesthesia.

With structured counselling more women considered the use of spinal anesthesia. Significant improvement can be expected in near future if more consistent information is provided. Consistency can be ensured by use of patient information leaflets.

Introduction- Chronic back pain is defined as pain that continues for three months or even longer .Many times the causes of chronic low back pain has not been initially well evaluated and treated. Is a condition that effects the quality of life and also the health related quality of life and also the sports performance. Aim-Aim of this study was to evaluate the use of use of lornoxicam in amateur male athletes (range 25-45 years , mean age 35 years) , with chronic low back pain.

Material and Methods- 10 amateur male athletes were participated in this study. In all patients we perform clinical neurological exam and radiological exam with x-ray control, ct-images and mri images. None of the patients reported other internal medicine or cardiological problems. For 21 days they receive 8 mg lornoxicam, two times a day. We used specific performance pain tests (oswestry scale and prolo scale) in order to evaluate our results. Follow up was between 6 months and 12 months with mean period of 9 months.

Results-9 of them (90%) reported optimal results and good reaction to the treatment. 1 of them (10%) reported moderate results and mild reaction to the treatment.

Conclusions- We need more patients but this therapeutic path seems to be an optimal and safe treatment, especially for amateur male athletes. Chronic low back pain remains a situation with necessity of adequate evaluation and management, in order to ameliorate the overall health and the sports performance

The optimal locoregional analgesic strategy for total knee arthroplasty (TKA) remains debated. Proximal nerve blocks, such as femoral nerve block (FNB), provide effective in analgesia up to 24h postoperatively. However, this proximal approach is often associated with quadriceps weakness, potentially hindering early mobilization. The femoral triangle block (FTB), a more distal sensory nerve block, represents a promising alternative, potentially balancing effective analgesia with preservation of quadriceps strength.

We conducted a retrospective study to compare analgesic quality and functional recovery in patients undergoing TKA under general anesthesia and receiving either single-shot FNB or single-shot FTB between August 2023 and August 2024. Ethical approval was granted (S70459). Pain was assessed using the Numeric Rating Scale (NRS) over the first 24 hours postoperatively. Secondary outcomes included time to ambulation, time to full weight-bearing, opioid consumption, and early quadriceps function assessed by straight leg raise and knee extension tests.

We identified 129 patients, with 55 receiving FNB and 74 FTB. Our results showed comparable analgesia between the two groups, although a transient increase in pain was observed in the FNB group at one evaluation point (Figure 1). Opioid consumption and time to ambulation were similar between groups (Table 1). However, patient receiving FTB achieved full weight-bearing sooner (Figure 2).

In conclusion, in patients undergoing TKA, single shot FTB provides analgesia comparable to FNB and was associated with earlier achievement of full weight-bearing recovery. These findings suggest that FTB may be a beneficial analgesic strategy in this clinical context.

With global aging, the demand for joint replacement surgery has increased and many factors affect postoperative complications. However, the relationship between anesthetic techniques and postoperative complications following unilateral total joint arthroplasty (TJA) remains unclear. This study aimed to assess the impact of general anesthesia (GA) versus non-general anesthesia (non-GA) on the length of postoperative stay (LOS) and other secondary outcomes in patients undergoing unilateral TJA.

This observational retrospective cohort study included 4518 patients (≥65 years) who underwent unilateral TJA at the First Medical Center of the Chinese People’s Liberation Army General Hospital between January 2014 and December 2021. The primary outcome was length of postoperative stay. Secondary outcomes included postoperative complications such as delirium, operative area infection, stroke, myocardial infarction, acute kidney injury (AKI), myocardial injury following non-cardiac surgery (MINS), admission to the intensive care unit (ICU) and one-year mortality. To investigate the effect of anesthetic techniques, univariate, multivariate, propensity score matching (PSM), and inverse probability of treatment weighting (IPTW) analyses were performed.

The study included 4518 patients, with 2708 receiving GA and 1810 not receiving GA.. GA was associated with a shorter hospital stay than non-GA (-0.43 days, 95% CI: -0.71 to − -0.14, P = 0.003). After adjusting for confounding factors using PSM and IPTW, the length of hospital stay was reduced in the GA group compared to that in the non-GA group (-0.61, 95%CI: -0.93, -0.29, P < 0.001 in PSM; -0.52, 95%CI: -0.79, -0.25, P < 0.001 in IPTW). There were no significant differences between the two groups in terms of other postoperative complications or mortality after unilateral TJA.

General anesthesia significantly shortened the postoperative stay of elderly patients undergoing unilateral TJA without increasing the risk of postoperative complications. These results provide a valuable reference for anesthesiologists, surgeons, and patients when making decisions regarding anesthesia selection.

The addition of IT magnesium sulfate (MgSO4) has been proposed to optimize the quality of blocks during spinal anesthesia. Its anti-NMDA effect may inhibit central sensitization to pain. Few studies have evaluated its impact on post-Caesarean pain.

Our study was a prospective, randomized, controlled, triple-blind trial involving parturients aged between 18 and 42 years scheduled for cesarean delivery. The participants were randomized into three groups, each receiving IT administration of 11mg hyperbaric bupivacaine, 100 µg morphine, and 2.5 µg sufentanil. The control group (C) received 0.75 cc of saline solution IT, group A received 50mg MgSO4 plus 0.25 ml saline solution and group B received 75mg MgSO4.

We included 91 parturients (30 in group A and B/31 group C) with comparable demographic and clinical characteristics. Characteristics of sensory and motor block were almost the same for all parturients. The time to the first analgesic request was delayed in the magnesium groups: Groups A/B versus C: respectively 343.2 ± 34.28 min and. 291.6 ± 30.13 min versus 241.2 ± 16.17min; p = 0.04. The time to the first ambulation was earlier in groups A and B, respectively 446.0 ± 42.2 min and 510.9 ± 45.39 min vs. 581.9 ± 54.36 min (GroupC), and shivering was significantly less intense in these groups. Pain score evolution showed patients were pain-free at rest and had mild to moderate pain with movement; with lower values for group A, explaining reduced analgesic consumption postoperatively. Pain control at one month indicated that 16 parturients still experienced mild to moderate pain with movement, most having a history of previous pain sensitization.

The addition of MgSO4 IT could improve post-Caesarean analgesia. However, a larger sample is needed to validate the results.

Ankle blocks are often given for calcaneal fractures. They involve blocking five nerves using multiple injections. The objective of this cadaveric study is to identify the interfacial planes traversed by the nerves innervating the calcaneum.

Six fresh human cadavers (12 specimens) were used in the study. To investigate the innervation of calcaneum, foot dissection was done in three cadavers (6 specimens) to delineate the nerves of the foot, in specific inter-fascial planes. In other 3 cadavers (6 specimens), ultrasound-guided dye injections were performed in specific inter-fascial planes and diffusion of dye was evaluated. Open dissection was performed in 3/6 specimens and cross-section in 3/6 specimens.

The nerves on the medial side were situated between the proximal attachment of abductor hallucis and quadratus plantae. On the lateral aspect, the skin and subcutaneous tissue over the calcaneum were innervated by the sural nerve and its branches in the subcutaneous tissue immediately lateral to the tendo-Achillis. ( Figure 1) After reflecting the abductor hallucis, lateral, medial, and posterior tibial nerves were unstained (4/6). In contrast, the inferior calcaneal nerve and sural nerve were stained in all specimens. (6/6) In the coronal cross-section, the epimysium of the abductor hallucis was well preserved. The epimysium and medial plantar nerve were not stained.

Our cadaveric study suggests the possibility of a two-point injection technique to instil administer a site-specific local anaesthetic to block nerves supplying calcaneum. However, future clinical research based on our cadaveric study should be done to validate our findings further and make it a clinically proper technique.

The prevalence of cardiac abnormality during pregnancy was estimated at around 1-4%, and it will keep increasing along with the advancement of technologies, allowing women with cardiac abnormalities to reach reproductive age. Anesthesia management for C-section patients with cardiac abnormalities serves as a challenge; physiological changes during pregnancy might cause perioperative deterioration in heart condition and hemodynamic instability. For cesarean sections, spinal anesthesia is the most often used approach. Therefore, choosing an appropriate anesthesia technique was crucial for optimal maternal and neonatal outcome.

An observational retrospective study was conducted on 36 pregnant women who underwent C-sections. The data is then analyzed using descriptive analysis and cross-tabulation to find patterns between variables.

The average age was 27,78±5,9 years old (range of 18-45 years old). Distribution of ASA Physical Status was mostly ASA 3 (77.8%), followed by ASA 4 (22.2%). Pulmonary hypertension (PH) was the most prevalent cardiac abnormality (50.0%). Ventricular Septal Defect (VSD) was the most prevalent (22.2%) septal defect. The most prevalent combination of coexisting cardiac abnormalities was PH+TR (11.1%) and was followed by ASD+PH+TR (8.3%). The most used anesthesia technique was low-dose spinal anesthesia using Bupivacaine heavy 0,5% 7.5 mg, combined with epidural (CSE) (61.1%). Patients with PH, VSD, and RHD mostly undergo CSE, respectively 66.7%, 75.0%, and 100% of the total for each case. Only 3 patients (8.3%) experienced problems during the operation. All patients (100%) need post-operative ICU treatment, and all patients (100%) were discharged in stable condition despite the high-risk nature of this population.

Low-dose spinal anesthesia provides adequate surgical anesthesia. These results emphasize the importance of appropriate selection of anesthesia techniques suited to the type of cardiac abnormalities, comprehensive perioperative evaluation, and adequate postoperative care to optimize outcomes in this high-risk population. Further studies with a larger sample size and long-term outcome evaluation are needed.

The fracture of the upper end of the femur (FESF) is a frequent pathology considered to be one of the 10 main causes of disability in the world (1,2) affecting adults and increasingly the elderly are associated with intense pain requiring the use of high levels of perioperative opioids, which increases the risk of adverse effects and consequently the length of stay. Regional anaesthetic techniques are essential to reduce opioid consumption and improve functional recovery. Pericapsular Nerve Group Block (PENG) is a novel approach targeting the articular branches of the femoral, obturator and accessory obturator nerves while sparing the quadricipital motor system. The aim is to evaluate it efficacy in reducing perioperative opioid consumption as part of an Enhanced Recovery After Surgery protocol.

We conducted a prospective observational study including 156 patients undergoing hip fracture surgery under unilateral spinal anesthesia and preoperative ultrasound-guided PENG block. Pain scores (NRS), total opioid ; time to mobilization, and opioid-related adverse effects were assessed

The mean duration for PENG block performance was 8.56 ± 3.18 minutes. The block was well tolerated, with no major complications. Pain scores decreased significantly within 15 minutes post-block (mean NRS < 2).At the time of positioning for unilateral spinal anaesthesia, 98.7% of patients had mild pain (EN ≤ 3).Opioid-free postoperative analgesia was achieved in 89.7% of patients during the first 48 hours. Early mobilization was achieved within 24 hours in over 85% of cases. The incidence of opioid-related side effects was notably low.

The PENG block offers effective, opioid-sparing analgesia for femoral neck fractures, supporting its integration into ERAS pathways. Its technical simplicity, safety profile, and motor-sparing effect make it a promising option in geriatric orthopedic anesthesia.

Female haemophilia B carriers can present with a heterogeneous bleeding phenotype due to variable lyonisation of one of the pair of X chromosomes. Published obstetric and haemophilia society guidelines recommend Factor IX (FIX) levels above 50% for neuraxial procedures and delivery.

We report the management of a 24-year old nulliparous woman with haemophilia B carrier status who received epidural labour analgesia, and who required a replacement of her epidural catheter during her labour. The third-trimester, pre-procedural Factor IX level was 128%. She subsequently underwent a Caesarean section under regional anaesthesia with epidural top-up. The epidural catheter was removed immediately post-surgery. No haematoma or post-procedure complications were observed.

Epidural for labour analgesia and surgical anaesthesia is a viable, versatile option for female haemophilia B carriers. Neuraxial techniques avoid the risks related to general anaesthesia should a Caesarean section be indicated, especially in the context of the high risks associated with assisted instrumented vaginal delivery of an infant with unknown haemophilia status. A multi-disciplinary (obstetrician, anaesthetist, haematologist), individualised approach to the delivery plan is critical in the management of these patients.

Female haemophilia carriers may be at increased risk of peri-partum bleeding if their FIX levels are low. Epidural placement can be performed for female carriers of haemophilia B if clotting factors are normalised and can be effective for both labour analgesia and anaesthesia for Caesarean section.

The analgesic effectiveness of remifentanil patient-controlled analgesia (Remifentanil-PCA) may vary based on the stage of labor and parity, potentially influencing satisfaction with labor analgesia. The primary aim was to evaluate the degree of pain reduction considering different cervical dilations in both nulliparous and multiparous women.

Women who were ≥37 weeks pregnant with singleton cephalic fetuses, either by spontaneous onset or induction of labor, were included. From the Labour Record form, demographic and obstetric data and the onset of analgesia categorized by cervical dilation (1-3 cm, 4-6 cm, 7-9 cm, and full dilation) were collected. From the Remifentanil-PCA form, analgesia onset and duration (the time interval between the start of analgesia and the delivery), initial Visual Analog Scale (VAS0), VAS after the first hour of analgesia (VAS1), the lowest VAS (VASmin), the pain reduction during the first hour of analgesia (VAS0 - VAS1), satisfaction with labor analgesia (dissatisfied, moderately or very satisfied), and the complication rates were obtained.

513 nulliparas and 523 multiparas who delivered between January-1 and December-31, 2019 were reviewed. No differences were found in age, BMI, labour induction, OP positioning, blood loss >500 ml, or neonatal outcomes. Nulliparas exhibited a higher gestational age, longer labor duration, and increased CS and vacuum extractions rates. No differences were found in VAS0, VAS1, or pain intensity reduction (VAS₀ - VAS₁) regardless of the stage of labor or parity. A higher proportion of multiparas reported moderate (p < 0.001) and high satisfaction (p < 0.001) with remifentanil-PCA. Remifentanil-PCA consistently provided mild to moderate pain intensity reduction (Graph 1). No serious complications were observed.

Remifentanil-PCA demonstrates consistent effectiveness regardless of the stage of labour or parity, suggesting that it can be administered at any point during labor. Its availability for immediate analgesic effect further enhances the flexibility of its use in clinical practice.

Ultrasound-guided brachial plexus block (USG-BPB) is widely used in upper limb surgery but may fail in up to 12.9% of cases. Identifying contributing factors remains a clinical challenge. This study aimed to identify predictors of USG-BPB failure to improve clinical outcomes.

A retrospective cohort study was conducted in patients undergoing upper limb surgery with USG-BPB at a university hospital between 2019 and 2023. Block failure was defined as the need for supplemental blocks, multiple doses or types of analgesics or sedatives, deep sedation (propofol>100mcg/kg/min), or conversion to general anesthesia. Patient demographics, procedural details, and surgical variables were recorded. Univariate analysis was performed, followed by multivariate logistic regression including variables with p<0.1 and clinical relevance. Adjusted odds ratios (OR) were calculated, with p<0.05 considered statistically significant. This study was approved by the Institutional Ethics Committee (REC-67-249-8-4), on 11 June 2024.

Of 657 cases reviewed, 606 were included in the final analysis. Block failure occurred in 112 cases (22.67%). Significant predictors included liver disease (OR=5.11, p=0.025), surgical duration ≥120 minutes (OR=3.44, p< 0.001), block-to-incision delay >30 minutes (OR=1.75, p=0.018), and use of single-agent local anesthetics—lidocaine (OR=3.06) or bupivacaine (OR=2.94) compared to mixed solutions (p=0.011). First- and second-year residents had the highest failure risk (OR=6.19, p<0.001). Protective factors included hand surgery (OR=0.35, p=0.023), diabetes mellitus (OR=0.42, p=0.003), and higher block volume (OR=0.93, p=0.011).

Failure of USG-BPB is associated with operator inexperience, liver disease, prolonged surgical time, delayed incision, and the use of single-agent local anesthetics,while diabetes, hand surgery, and higher block volume are protective. Optimizing operator training, anesthetic technique, and timing may improve block success.

Background and Aims: Regional anaesthesia is part of multi-modal analgesia in paediatric surgery for effective pain relief. Traditional techniques like the Caudal Block (CB) and, more recently, facial plane blocks like the Erector Spinae Plane Block (ESPB) have gained popularity. This systematic review and meta-analysis compare CB and ESPB in paediatric lower abdominal and limb surgeries. It aims to clarify mixed outcomes from recent trials regarding the variability in analgesic efficacy of both techniques for future practices.

Methods: This review, registered with the International Prospective Register of Systematic Reviews (PROSPERO), includes eight randomized controlled trials comparing postoperative analgesia between ESPB and CB in paediatric lower abdominal and limb surgeries. We searched Science Direct, Google Scholar, Scopus, Proquest, and PubMed databases. The meta-analysis assessed the proportion of patients requiring rescue analgesia and post-operative pain intensity. GRADE guidelines were applied to assess the quality of evidence.

Result: Eight randomised controlled trials (575 patients) were included in the review. A meta-analysis of four RCTs (217 patients) showed reduced rescue analgesia with ESPB [OR = 0.55 (95% CI: 0.31, 0.96), p<0.05], while six RCTs (360 patients) found lower pain intensity score (SMD = -0.29, 95% CI: -0.51, -0.06; p<0.05) in the ESPB group. Both outcomes exhibited considerable heterogeneity (I² = 90% for rescue analgesia, I² = 66% for pain intensity), further emphasizing the robustness of the findings.

Conclusion: We conclude that ESPB provides better postoperative analgesia than CB in children undergoing lower abdominal and lower limb surgeries. ESPB reduces postoperative pain intensity scores and analgesic requirements compared to CB.

The rising demand for total hip arthroplasties (THA) has contributed to an increase in outpatient procedures. In the context of implementing a same-day hip (SDH) program at a tertiary care center in Belgium, we present our findings and identify factors associated with successful same-day discharge.

A retrospective analysis of 100 outpatient THA cases has been performed since May 2023 at Ziekenhuis Oost-Limburg (ZOL), Belgium. Patient demographics, perioperative management, anesthesia techniques, and discharge outcomes were reviewed. Medical records were examined to identify reasons for impaired discharge. Statistical analyses were performed to compare successful and unsuccessful SDD cases. In September 2023, three anesthesia protocol modifications were introduced based on follow-up feedback: increased dexamethasone dosage, intramuscular ephedrine administration, and exclusion of intrathecal fentanyl.

Same-day discharge was achieved in 85 patients. The primary reason for discharge failure was orthostatic intolerance (67%). General anesthesia was associated with more in-hospital stays (p<0.05). A positive trend in SDD rates was observed following the anesthesia protocol modifications.

Systematic follow-up proved valuable in identifying discharge barriers and facilitating timely interventions to improve the SDD success rate. Future research should explore the broader applicability of the interventions in outpatient THA programs and individual effect on SDD success rates.

Planning and executing appropriate plan of anaesthesia for neonates is a challenging task for every anaesthesia team. Neonates have increased risk of perioperative morbidity and mortality owing to their different physiology and pharmacodynamics of drugs used for anaesthesia. By convention we provide general anaesthesia with neuraxial block like caudal block for neonatal abdominal surgeries like laparotomy. The quadratus lumborum(QL) block provides longer duration and superior pain relief than other abdominal fascial plane techniques. This series illustrates the possibility of employing ultrasound guided quadratus lumborum blocks for analgesia and early recovery in neonates undergoing abdominal surgeries.

15 neonates greater than 34 weeks gestational age with no gross congenital anomalies undergoing laparotomy were enrolled. Informed consent for the regional technique was obtained from parents or guardians. General anaesthesia was induced with fentanyl, thiopentone, atracurium and maintained with sevoflurane. After securing airway with endotracheal tube, the patients were turned in lateral position and ultrasound guided QL blocks were performed bilaterally. 0.5 ml/kg of 0.25% ropivacaine per side were given. The dosages were well below the permissible limit. All patients received 7.5mg/kg of acetaminophen intra operatively.

Bilateral quadratus lumborum blocks were performed without complications in all patients. All patients were extubated with well controlled pain and no patients required reintubation within first 24 hours. 4 patients received scheduled IV acetaminophen postoperatively. Fentanyl 1mg/kg was administered to 2 patients with modified neonatal infant pain score equal to or greater than 4. QL block proved to provide good analgesia both intraoperatively and postoperatively, avoided over use of opioids, postoperative apnea and helped in resuming early feeds.

Ultrasound guided quadratus lumborum block provide effective postoperative analgesia and minimize postoperative opioid requirements in neonates for abdominal surgeries. Additional research on large study groups is required to further evaluate the role of QL blocks in abdominal surgeries in neonates.

Peripheral neuropathy is a rare but worrying complication of peripheral local anaesthesia. It is caused either by needle contact with the nerve root or by the direct toxicity of local anaesthetics, leading to nerve damage, injury or irritation. Although uncommon, it remains a major concern for anaesthetists. The aim of the study was to assess the prevalence of nerve block-associated neuropathy in knee surgery and to identify the contributing factors in order to minimise the occurrence of this complication. The study also assessed the severity and evolution of lesions, as well as the factors leading to neuropathic pain.

It is a retrospective observational study on cases of neuropathy related to nerve blocks of the lower limb for knee surgery over a period of seven years (2016-2022). The study included a total of 6000 patients Analyse the anaesthetic and neuropathic pain-related parameters received from these patients to determine the prevalence and severity of neuropathy.

the prevalence of nerve block-related neuropathy in our study is 5.8‰ for the sciatic nerve and 0.9‰ for the femoral nerve. This was higher compared to the reported rates in the literature, which were between 0.0 to 5‰ for the Sciatic nerve and 0.0 to 3.4‰ for the femoral nerve. These findings highlight the importance of identifying and implementing an ideal anesthesia procedure to reduce the risk of neuropathy associated with nerve blocks.

This study highlights the need to carefully examine anesthetic procedures during nerve blocks for knee surgery. The prevalence of neuropathy associated with these blocks was higher than in the literature, underscoring the importance of identifying and minimizing contributing factors. Adherence to technical safety rules is crucial to reducing this complication. This study provides valuable information for anesthetists and contributes to improving patient safety in the field of locoregional anesthesia.

Introduction: Postoperative pain management in breast oncologic surgery is a crucial issue for improving patient recovery. This study aims to compare the effectiveness of the paravertebral block (PVB) and the erector spinae plane block (ESP) in controlling acute and chronic postoperative pain, as well as their impact on patient satisfaction, opioid analgesic consumption, and hospital length of stay.

We conducted a double-blind, randomized trial involving 264 patients undergoing oncologic breast surgery for breast cancer. Patients were divided into two groups of 132, receiving either a PVB or an ESP for regional anesthesia. Evaluated parameters included acute postoperative pain measured by the visual analog scale (VAS), morphine consumption, patient satisfaction, length of hospital stay, and the incidence of chronic pain assessed.

The results show that PVB and ESP are similar in controlling acute postoperative pain, with no significant difference in morphine consumption or patient satisfaction. However, ESP demonstrated greater effectiveness in preventing chronic pain compared to PVB (p value 0.041), with a lower incidence; No significant difference was observed regarding the length of hospital stay between the two groups.

: While both the paravertebral block (PVB) and the erector spinae plane block (ESP) provide comparable results for managing acute pain after oncologic breast surgery, the ESP stands out for its better management of chronic pain. Further studies are needed to understand the mechanism of action of these blocks and to refine clinical recommendations for long-term postoperative pain management in this context.

Enhanced Recovery After Surgery (ERAS) is a multidisciplinary, evidence-based protocol involving perioperative interventions to improve recovery. Although ERAS has been applied in neurosurgical procedures especially craniotomies, its role in endoscopic endonasal skull base surgeries remains unclear. This study aimed to establish the role of ERAS versus conventional anaesthetic care on postoperative recovery in such procedures.

60 participants (30 in each group) were randomly divided into two groups: Group I (ERAS protocol) and group II (Conventional anaesthetic technique)[Table 1]. The primary objective was to compare the difference between quality of postoperative recovery using Quality of recovery (QoR 15) scoring system in both the groups. The secondary objectives were to compare the day of ambulation, duration of hospital stay and postoperative pain scores.

QoR15 score was comparable between both the groups at the baseline (p value 0.473). At 24 hours postoperatively, mean QoR 15 score was slightly higher in ERAS group (98.40±4.45) as compared to conventional group (96.56±4.40), but this difference was not statistically significant (p-value=0.11). ERAS patients ambulated earlier 2.30±0.535 days vs 3.30±0.915 days in conventional group with statistically significant difference (p<0.001) but the duration of hospital stay remained statistically non-significant (ERAS vs Conventional, 5.20±0.761 vs 5.47±0.86, mean difference = -0.27, p=0.209). NRS showed a tendency towards low pain scores in the ERAS group as compared to conventional group at all the time points from 1 hour to 24 hours post-surgery with p<0.001, showing statistically significant difference.

ERAS protocol did not confer early recovery benefit as compared to conventional anaesthesia technique within first 24 hours postoperatively as measured by QoR 15 score in patients undergoing endoscopic endonasal skull base surgeries. However, ERAS offers significant advantages over conventional technique in terms of earlier ambulation and better pain management till 24 postoperative hours.

Artificial intelligence (AI) promises to enhance performance of Ultrasound-guided regional anesthesia (UGRA). However, existing methodologies seems to lack consistency, which could compromise reliability and clinical applicability.

A prospective observational study was conducted involving 54 adult patients scheduled for elective carpal tunnel surgery. 1) Validity of ultrasound measurement was assessed by comparing surgical and ultrasound measurement of median nerve diameters. 2) Reliability was assessed by comparing the cross-section area of the median measured by ultrasound independently by 3 experts applying rigorous radiological segmentation criteria. Inter-observer agreement was assessed using different metrics (See figure 1)

1) No significant difference was observed between ultrasound (mean diameter: 6.59 mm – SD : 1.16) and surgical measurements (mean diameter: 6.62 mm, SD = 1.02, p = 0.833). 2) Inter-observer variability was minimal, demonstrated by high ICC values (0.95), and excellent segmentation overlap metrics: median(IQR) DSC = 0.94 (0.02), IoU = 0.89 (0.03), precision = 0.94 (0.03), recall = 0.95 (0.03), and low Hausdorff distance (0.29 mm, IQR: 0.11).

The consistently high inter-observer reliability suggests that standardised, rigorous segmentation criteria defining the nerve contour based on radiological practice will significantly reduce inter-observer variability. These findings should be confirmed on larger sequences at other anatomical sites. Standardised segmentation procedures do not exist and should be developed. AI-based nerve segmentation for UGRA can achieve good validity and reliability through standardized methodologies. Ensuring high-quality data acquisition and rigorous segmentation criteria optimizes clinical relevance, ultimately enhancing patient safety and procedural accuracy.

Hip fracture is one of the most severe and common traumatic injuries, especially for elderly patients. This type of injury is accompanied by severe pain syndrome, which significantly affects the patient's general condition, stress level, mobility and treatment results. Effective analgesia at all stages of medical care is one of the most important components of treatment, which directly affects recovery and prognosis. The Erector Spinae block (ESP) is a relatively new analgesia technique in a group of patients with hip fracture, which was not previously used in Latvia. Aim of our study was to analyze whether the ESP block can be used for analgesia in patients with hip fractures.

Prospective observational study. Before surgery, patients were taken to the preoperative observation ward, where they underwent ultrasound guided Erector Spinae block (ESP) with 30 ml of 0.375% ropivacaine. Then, at 5-min intervals, the patient's pain intensity was assessed using a Verbal Pain Intensity Scale (VPIS) and Analgesia Nociception Index (ANI) for 30 minutes. Statistical calculations were performed using IBM SPSS Statistics.

10 patients were included in the study. Before the ESP block, the average pain level according to VPIS was 5.7. After the block, a gradual reduction in pain was observed. After 30 minutes, the average pain level decreased to 0.8 points, indicating a significant analgesic effect of the nerve block (p=0.001). There were not statistical changes in ANI.

Our study highlights that ESP block might be an effective analgesic technique for hip fracture surgery.

The United States Food and Drug Administration recently approved Suzetrigine, a first-in-class, non-opioid, highly selective NaV1.8 pain signal inhibitor for the treatment of adults with moderate-to-severe acute pain. The aim of the study was to characterize initial prescribing practices of Suzetrigine in a high-volume outpatient pain management clinic in New York.

After IRB approval for an institutional electronic-health record-based registry capturing new patient visits with qualifying diagnoses at the outpatient pain management clinics at Hospital for Special Surgery, patients who were prescribed Suzetrigine between February 1st, 2025 to May 16th, 2025 were identified with the Epic SlicerDicer tool. Patient characteristics, primary diagnoses, Suzetrigine dosing regimens, and self-reported efficacy - where available - were extracted.

A total of 18 patients received a prescription for Suzetrigine during the study period (Figure 1 & Table 1). Patients with chronic pain were prescribed Suzetrigine to manage acute post-procedural pain, complex regional pain syndrome two months following knee arthroscopy, acute pain from re-injury, or off-label for acute flares of existing conditions such as erythromelalgia, myofascial pain, or sciatica that are not responding to current medications and treatments. Overall, available data indicate that three patients explicitly requested a prescription of Suzetrigine, one patient did not fill the prescription due to cost and not knowing it would work, and two patients received a one-month supply, one of which received two refills. Four patients did not experience any pain relief, and one patient experienced significant relief with addition of Suzetrigine (NRS 9 to 6).

Suzetrigine was prescribed on and off-label for a variety of painful conditions and in patients older than 65 years old. Most received a prescription for 2 weeks. Additional trials and pharmacoepidemiological studies are needed to evaluate Suzetrigine’s long-term safety and efficacy in well-defined populations.

Hip fractures are common and associated with adverse outcomes in older, multi-co-morbid, frail adults. Evidence based protocolised care is associated with enhanced patient outcomes. A perioperative pathway incorporating 9 standards of anaesthesia care was introduced at CUH in 2017. This pathway complemented national standards for hip fracture care (https://www.noca.ie/audits/irish-hip-fracture-database/). The 9 anaesthesia standards are: • Preoperative: regional analgesia (RA), correction of anaemia, discussion and mitigation of bone cement implantation syndrome; • Anaesthesia: low dose spinal anaesthesia (or propofol TIVA with EEG monitoring), maintenance of blood pressure within 10% of baseline or MAP≥ 80mmHg; • Postoperative: continuous RA; • All phases: avoidance of benzodiazepines, avoidance of NSAIDs, use of immediate release oral morphine. This prospective audit aimed to measure compliance with pathway standards and evaluate postoperative pain outcomes.

The medical records of 60 patients were included. Patients were visited on the first post operative day to evaluate postoperative pain scores and ability to ambulate.

Data was obtained from 60 patients, median age of 78 [50-96], median clinical frailty score of 5[5-6], of whom 39(65%) were female. Data obtained on anaesthesia standards are contained in Table 1(Preoperative, peri-operative and postoperative management under hip fracture pathway standards). Pain score (VRS on movement) was ≤5 in 37 and 43 patients on POD1 and POD2 with 42 and 49 patients ambulating onPOD1 and POD2 respectively.

Patient pain outcomes and mobilization following hip fracture surgery are largely in line with expectations. Further work is needed to improve compliance with anaesthesia standards.

Factor VII (FVII) deficiency is a rare autosomal recessive bleeding disorder, with an estimated incidence of 1:500,000 to 1:1,000,000 live births. Severity is categorized based on FVII activity levels, yet clinical bleeding symptoms often show poor correlation with serum levels. Pregnancy presents a unique hemostatic challenge due to physiological hypercoagulability in the third trimester. Data on the safety of loco-regional anesthesia in FVII-deficient patients during labor remains limited. We present the first case of a parturient with mild FVII deficiency without any hemostatic correction treatment, who received epidural anesthesia for her labor.

We report the case of a 40-year-old primigravida with mild FVII deficiency (FVII activity 39%, INR 1.4), diagnosed during pregnancy. The patient had no prior bleeding episodes, surgical history, or family history of bleeding disorders. Hemostatic evaluation (HEMOSTOP) was negative. After multidisciplinary consultation involving hematologist, OB and anesthesiology team - a plan was made for vaginal delivery with an epidural analgesia, without prophylactic hemostatic therapy.

At 40 weeks gestation, the patient underwent spontaneous vaginal delivery under epidural anesthesia. No peri- or postpartum bleeding complications occurred. Estimated blood loss was 150 mL, and no factor replacement or additional hemostatic interventions were required.

This case supports emerging evidence that, in asymptomatic patients with mild FVII deficiency, vaginal delivery and epidural anesthesia may be safely performed without prophylactic factor replacement. Multidisciplinary assessment remains critical, and further data are needed to inform clinical guidelines in this rare patient population.

There is concern regarding the optimal block site, volume and diffusion of injectate and involvement of nerves in the femoral and adductor canal, for postoperative analgesia in TKA. Simultaneous injection with different colored dyes in the proximal femoral triangle (PFT), proximal (PAC) and distal adductor canal (DAC) Objectives: 1. Evaluate the maximum dye capture rate of each nerve at each level of injection 2. Evaluate the dye spread towards the sciatic nerve posterior to femoral shaft.

Six soft embalmed cadavers (12 specimens) in supine position, all injections were performed at PFT; PAC and DAC, under ultrasound and latex solutions (10ml) were injected over 10seconds. 1. At the level of inguinal ligament (PFT), PURPLE dye was injected at the point where the facia-iliaca split open to engulf the FN. 2. At the interface of the medial borders of the sartorius and the adductors longus (PAC), BLUE dye was injected anterior-lateral to the femoral artery. 3. The adductor canal was scanned distally and GREEN dye was injected proximal and superior to bifurcation of the femoral artery (DAC). After 30 minutes, all dissections were carried out and the sciatic nerve was also explored posterior to the femoral shaft and was evaluated for stain pattern.

The stain pattern in all 12 specimens were observed during dissection and the capture rate of each nerve was measured as a percentage, examined by descriptive analysis. Purple dye stained FN, ACN, NVM and im-NVM. Blue dye stained ACN, SN, NVM, VAM, SSC, ON and anastomosis between SN/b-AON. Green dye stained the SN, im-NVM, VAM, SSC, ON, SN/b-AON anastomosis and popliteal artery. There was no sciatic nerve involvement.

Considering our cadaveric injection trials, we believe that the PAC would be a suitable technique, given the involvement of the SN, NVM, and b-AON, which supplies the Anterior knee capsule.

Pelvic fractures resulting from combat-related blast injuries are often associated with severe pain, complex trauma, and potential complications such as haemorrhage and nerve damage. Effective pain management is crucial for patient stabilisation, early mobilisation, and preventing chronic pain development. Goal. To optimise postoperative pain management in military personnel with blast-induced pelvic fractures through the use of caudal anaesthesia, and evaluate outcomes including pain relief, side effects, and patient satisfaction.

Materials and Methods. The study included two randomised groups, each consisting of 12 military patients undergoing treatment for pelvic fractures of blast injury origin. The experimental group received a single-dose CA composed of 30 ml of 0.125% bupivacaine combined with 0.12 mg of buprenorphine, administered 30 minutes before surgical intervention. The control group was on mechanical ventilatory support (ventilation) and received standard analgesic therapy with intravenous fentanyl at a dose of 1.5-2 μg/kg/hr and 10 mg of diazepam for pain management. Additionally, propofol was administered for sedation during the surgical procedure.

The CA group exhibited significantly reduced pain levels, with a Visual Analogue Scale (VAS) score nearing zero within the first 48 hours postoperatively, in contrast to the control group, which exhibited higher pain levels despite sedation. The CA group's absence of nausea and pruritus indicated a lack of notable side effects associated with regional anaesthesia. Patient satisfaction, measured using the Hospital Anxiety and Depression Scale (HADS), was substantially higher in the CA group, reflecting not only effective pain control but also overall comfort and well-being.

Caudal anaesthesia using a combination of bupivacaine and buprenorphine is an effective, safe, and well-tolerated method for perioperative pain management in military personnel with combat-related blast-induced pelvic fractures. It significantly improves pain relief, reduces reliance on systemic opioids, and enhances patient satisfaction, with minimal adverse effects.

It is widely acknowledged that, unless contraindicated, regional anesthesia (RA) techniques are preferred for cesarean sections (CS), as they are associated with fewer complications compared to general anesthesia (GA). This study examines the progress of RA use in CS over a 10-year period (2014–2023) at the General Hospital of Rhodes (GHR), the largest hospital and primary reference point in the South Aegean region of Greece.

The archives of the Department of Anesthesia and Pain Unit were examined, including all cesarean sections performed during the aforementioned time span. Data were recorded on age, type of anesthesia (spinal, epidural, general, combined spinal and epidural, and combined general and epidural), setting (regular or emergency), and provenance (Greek or foreign). No additional data were collected to ensure patient anonymity.

A total of 2,074 cesarean sections in the regular setting were recorded for the decade 2014–2023. Of these, 1,019 involved RA, while 1,055 involved GA. Greek patients generally prefer RA over GA, while foreign patients tend to prefer GA. Patients under 30 years of age are more likely to prefer GA, whereas the preference is equally divided among patients over 30. The use of RA has been progressively increasing, particularly after 2016.

The use of RA has been steadily increasing at the General Hospital of Rhodes (GHR) over the past decade. However, the incidence of GA in the regular setting remains high, particularly among foreign patients. Reasons include fear, misinformation, cultural and language barriers that hinder communication and understanding. Educational campaigns and information sessions, combined with a patient-centered approach, have shown promising results. In terms of communication, next-generation AI applications could be leveraged to overcome language barriers, thereby increasing the incidence of regional anesthesia (RA) and enhancing patient safety.

Hip fracture surgery is associated with severe preoperative pain, which can hinder positioning for spinal anesthesia and negatively impact patient experience. Preemptive analgesia, delivered prior to the noxious surgical stimulus, plays a crucial role in reducing central sensitization and optimizing perioperative comfort. The Pericapsular Nerve Group (PENG) block is a promising regional technique targeting the anterior capsule of the hip causing the pain. To assess the immediate analgesic effect of ultrasound-guided PENG block performed before spinal anesthesia in patients undergoing surgery for femoral neck fracture.

In a monocentric prospective study, 66 patients aged over 65 years with femoral neck fractures were included. Each patient received a echoguided PENG block with 20ml of bupivacaine 0.25% before unilateral spinal anesthesia as part of an ERAS protocol. . Pain intensity was measured using the Numeric Rating Scale (NRS) at baseline (H0), 15 minutes post-block (H15), and before mobilisation for spinal anesthesia. Additional outcomes included technical feasibility, block onset time, and tolerance.

The PENG block was performed successfully in all cases, with a mean execution time of 8.56 ± 3.18 minutes. NRS scores dropped significantly from a baseline mean of 7.1 ± 1.2 to 1.8 ± 0.9 at H15 (p < 0.001). No rescue analgesia was required for spinal positioning in 96.8% of patients. The procedure was well tolerated, with no block-related complications.

The PENG block provides rapid, effective preemptive analgesia in hip fracture patients, significantly reducing pain before spinal anesthesia. Its motor-sparing profile and safety make it an ideal component of ERAS pathways, especially in elderly and fragile patients.

Hip fracture surgeries are frequently accompanied by severe perioperative pain that can be managed with regional techniques such as fascia iliaca compartment block (FICB) or pericapsular nerve group (PENG) block which have been noted for their noticeable analgesic efficacy. The quadratus lumborum block (QLB) is a novel plane block that provides satisfactory analgesia in some surgeries. The aim of this study is to compare the analgesic efficacy of fascia iliaca compartment block (FICB) and quadratus lumborum block (QLB) in patients with acetabular fractures under Stoppa method.

In a double-blind, randomized, noninferiority clinical trial, the patients undergoing spinal anesthesia for acetabular fracture surgery, in Imam Hossein Hospital, Tehran, Iran, were randomly divided into two groups: FICB (n = 22) and QLB (n = 24). The visual analog scale (VAS) was used to assess the pain intensity at different times. The dose of fentanyl required to induce the patient to sit for spinal anesthesia and the pain intensity were evaluated. Moreover, the duration of analgesia and total dose of morphine consumed in the first 24 h following surgery were evaluated.

FICB and QLB demonstrated effective comparative postoperative analgesic profiles following acetabular fracture surgery; however, no significant differences in VAS values were observed between the two groups during the study (F (3.37, 77.43) = 22.49, P < 0.001) and (F (3.37, 77.43) = 22.49, P < 0.001). FICB experienced reduced cumulative fentanyl consumption during spinal anesthetic placement, whereas QLB had a significantly lower total morphine demand in the initial postoperative 24 h period.

In conclusion, our study described the lateral QLB and FICB as effective analgesic techniques for acetabular fracture surgery under the Stoppa approach, which exhibited an identical analgesic profile. However, large-scale clinical studies must confirm these pilot clinical data to exclude local factors that could influence the final results.

The suprascapular notch (SSN) exhibits various shape, and several classifications have been proposed. Ultrasounds notch recognition is essential for performing effective approach and safe block. The objective of our study is to evaluate the ultrasound characteristics of the suprascapular notch with the goal of simplifying ultrasound exploration.

We performed ultrasonography of the shoulder in 108 healthy Caucasian volunteers. According to Rengachary classification, we classified notches into 5 types and measured dimensions. We measured the superior transverse diameter (STD) and the maximal depth of the SSN.

206 scapulae were considered. In 5 volunteers, the notch was non visible, obscured by the clavicle. Results were presents in the table 1. Nonparametric tests did not reveal any impact of age, sex, weight, or height on notch type. The repartition of notch types was statistically similar between the left and right sides (p < 0.001).

Types II, III and IV are the more representatives notch types with a typical U- or V-shape. Anatomy variations, poor consensus of different classification and sonoanatomy visualization made suprascapular notch identification difficult for anesthetist. Precise determination of type of notch is poor of interest for anesthesiologist. However, we must know that notch identification may present two main general characteristics ; essential for his identification. Once is an absent or a very discrete notch as a wide depression. The second is the commonly known notch, identifiable as a bone depression. We propose an easy practical identification for ultrasounds classification base on presence or “absence” of notch in order to facilitate practical approach for anesthetist during regional anesthesia (Figure 1).

Pulmonary hypertension (PH) is associated with increased maternal mortality during pregnancy, particularly when secondary to congenital heart disease. The coexistence of Factor V Leiden mutation further raises the risk of thromboembolic complications, making anesthetic management highly challenging. This case report aims to highlight the multidisciplinary perioperative approach used in managing a pregnant patient with PH and thrombophilia undergoing caesarean section.

A 32-year-old primigravida at 37+1 weeks gestation with a history of surgically repaired Tetralogy of Fallot was scheduled for elective caesarean delivery. She was diagnosed with PH, Factor V Leiden mutation, immune thrombocytopenic purpura, and portal hypertension. Preoperative assessments included echocardiography showing severe pulmonary-tricuspid regurgitation and an estimated pulmonary artery pressure of 33 mmHg. After cardiology and hematology consultations, thromboprophylaxis and infective endocarditis prevention were planned. Epidural anesthesia was chosen to maintain hemodynamic stability. Invasive arterial monitoring was implemented, and 12 mL of 0.5% bupivacaine with 100 mcg fentanyl was administered epidurally.

Intraoperative hemodynamics remained stable without complications. The patient was monitored in the intensive care unit for 24 hours. Transient left thigh numbness was observed and resolved after epidural catheter removal, which was performed when platelet count exceeded 70,000/mm³. No thromboembolic or bleeding events occurred. Both mother and newborn were discharged in good condition.

This case underscores the importance of individualized anesthetic planning and multidisciplinary coordination in pregnant patients with PH and thrombophilia. Epidural anesthesia can be safely utilized with favorable maternal and fetal outcomes when carefully executed.

Iatrogenic dural puncture (IDP) is a recognized complication of epidural technique and often presents as post-dural puncture headache (PDPH), caused by the leak of cerebrospinal fluid (CSF). Although infrequent, excessive loss of CSF can lead to intracranial hypotension causing cranial nerves compression. Epidural blood patch (EBP) is an effective treatment for PDPH, particularly in those not responsive to conservative therapy. Diplopia resulting from sixth nerve palsy is a potential complication of intracranial hypotension following IDP and it can be completely resolved after EBP.

We report the case of a 23-year-old puerpera who developed a holocranial headache worsened by orthostasis, along with neck pain, 24 hours after receiving epidural analgesia for labor. The patient’s headache improved with conservative management and she was discharged 48 hours post-delivery. Sixteen days after delivery, she sought care at the emergency department with sudden horizontal binocular diplopia and limitation of right eye abduction, which had lasted for 5 days. No other neurological signs or symptoms were identified. An urgent cranial CT was performed, revealing imaging findings consistent with severe CSF hypotension. No signs of intracranial haemorrhage or thrombosis were identified. She was admitted to the Neurocritical Care Unit for further monitoring. An EBP was performed by the Anesthesiology team.

After EP there was an immediate improvement of the clinical condition. The patient was discharged 3 days after the procedure. One month after discharge, symptoms of diplopia were completely resolved.

Awareness of post-dural puncture nerve palsy among anesthetists, obstetricians, neurologists, ophthalmologists, and general practitioners is crucial for an early diagnosis and a prompt treatment. Postpartum patients experiencing PDPH should be informed about potential complications that may arise after hospital discharge. EBP remains an effective therapeutic approach for managing complications associated with IDP.

Total hip arthroplasty (THA) is associated with significant postoperative pain, necessitating opioid-based analgesia that may lead to side effects. The CHENG Protocol, an intraoperative auricular acupuncture technique, has shown promise in enhancing multimodal analgesia by potentially reducing pain, stress, and inflammation. At our high-volume orthopedic institution, this protocol is routinely employed by anesthesiologists. This preliminary report reports various care outcomes in a high throughput optimized surgical setting with high use of peripheral nerve blocks (PNB).

We conducted an institutional retrospective cohort study using electronic health records from January 2021 to March 2025, including 2,193 inpatient and 1,075 outpatient THAs. Two groups were compared: those with acupuncture and without PNB (Acu+PNB-), and those without acupuncture and with a PNB (Acu-PNB+). The primary outcome was total opioid utilization in milligram morphine equivalents (MME) within 48 hours. Secondary outcomes were length of hospital stay (LOS, from post-anesthesia care unit entry to discharge) and the average maximum reported pain score during the stay on the 0-10 numeric rating scale. Adjusted regression models measured associations between intervention groups and outcomes.

Among inpatient THAs, 28.3% were Acu+PNB− and 71.7% Acu−PNB+; in outpatient THAs, 42.0% were Acu+PNB− and 58.0% Acu−PNB+. In adjusted analyses of inpatients, the Acu+PNB− group showed lower 48-hour MME use (74.4 vs. 84.3), shorter LOS (50.6 vs. 59.7 hours), and lower maximum pain scores (4.7 vs. 5.1) compared to the Acu−PNB+ group. No consistent differences were found in outpatient cases.

Intraoperative auricular acupuncture using the CHENG protocol may reduce opioid use, pain, and LOS in inpatient THA patients, offering a promising non-pharmacologic adjunct to standard care. Further prospective research is needed to confirm these findings and assess its role in outpatient settings.

Complex Regional Pain Syndrome (CRPS) is a chronic pain condition with a range of sensory, autonomic, motor, and trophic changes to the extremities. Limited understanding of its mechanisms, optimal interventions, and necessary precautions in surgical settings to prevent flares and spread in patients already diagnosed with the syndrome necessitate more research. The aim of this study was to identify and characterize surgical patients with CRPS at Hospital for Special Surgery (HSS) and summarize recommended preventative perioperative pain management strategies.

After IRB approval, surgical patients diagnosed with CRPS who were seen preoperatively and during admission by the Perioperative Pain Service (POPS) from January 10th, 2022, to July 5th, 2024, at HSS were extracted from an institutional Electronic Health Record-based registry. Details of patients’ preoperative and in-patient pain consultation notes were evaluated. Descriptive statistics were used to summarize the findings including details of perioperative pain management plans.

A total of 160 surgical cases were identified; most patients (78%) were female, 41% had an anxiety disorder, and 49% had a diagnosis of lower extremity CRPS (Table 1). Overall, 56.9% had surgery on the limb affected by CRPS. Acute postoperative ketamine infusions were recommended for 53.8% of patients, 92% of which received the intervention. Peripheral nerve blocks were administered to the affected limb in 73.6% of affected-limb cases. Preoperative or postoperative sympathetic blocks were recommended in 11.3% of cases.

At HSS, surgical patients with CRPS are managed by the POPS team and typically receive recommendations for ketamine infusions, anticonvulsant medications, and patient-controlled analgesia. Future analyses will examine surgical precautions implemented such as avoidance of tourniquets, and the impact of these strategies on postoperative pain scores and incidence of flares during admission.

Neuropathic incisional pain is a recognised complication after TKA, presenting as anterior knee pain with neuropathic descriptors such as dysaesthesia, allodynia, and hyperalgesia over the anterior patella. This case report describes a patient initially referred by orthopaedics to the pain service for a genicular nerve block post-TKA, but cutaneous neuropathic pain features were identified on the day of the procedure, leading to a modified intervention.

A 74-year-old retired social worker with controlled asthma and an NSAID allergy underwent right TKA on 5 July 2021 under spinal anaesthesia (2.5 mL 0.5% Marcaine), adductor canal block (30 mL 0.25% levobupivacaine), and periarticular infiltration as part of an enhanced recovery programme. Surgery involved a midline incision and medial parapatellar approach for Grade IV osteoarthritis. The patellofemoral joint was normal, ligaments were intact, and a cemented prosthesis was implanted. In November 2023, the patient developed burning anterior knee pain extending to the proximal posteromedial calf (NRS 9/10). Imaging showed no prosthetic loosening. He was referred to the chronic pain service for a genicular nerve block. However, on assessment, neuropathic features were identified, including hyperalgesia, allodynia, and dysaesthesia over the anterior patella, with reduced pinprick and vibration sensation. The procedure was modified to a medial and intermediate femoral cutaneous nerve block (Image 1, Image 2) under ultrasound guidance, with peripheral nerve stimulation confirming the diagnosis by reproducing the pain pattern. A total of 1 mL 0.25% levobupivacaine was injected per nerve.

Post-injection, pain scores improved from NRS 10/10 to 0/10 within 24 hours, with sustained relief at one week and at day 12 follow-up.

Neuropathic incisional pain post-TKA requires targeted treatment. Options include topical agents such as capsaicin or lidocaine patches, neuromodulation (e.g., pulsed radiofrequency), or nerve denervation (e.g., radiofrequency ablation). Injectable therapies such as local anaesthetics, corticosteroids, and botulinum toxin may also be considered.

Regional anesthesia for proximal humeral orthopedic surgery facilitates awake or lightly sedated procedures, potentially mitigating risks associated with general anesthesia. Evidence supporting its comprehensive effectiveness, however, remains limited. We hypothesized that interscalene brachial plexus block with sedation, avoiding neuromuscular blockade, would improve intraoperative hemodynamic stability and other outcomes compared to general anesthesia with neuromuscular blockade.

This retrospective chart review analyzed patients undergoing open reduction and internal fixation or implant removal for proximal humeral fractures between April 2016 and January 2025. A matched-pair analysis, based on age, sex, surgery type, and ASA-PS classification, compared patients receiving interscalene brachial plexus block with appropriate sedation under spontaneous breathing (Group S) to those managed with positive pressure ventilation and neuromuscular blockade (Group P). The primary outcome measure was the ratio of the minimum mean arterial pressure (MAP) recorded during surgery to the baseline MAP at admission.

Fifty-three matched pairs were analyzed. The nadir MAP ratio was significantly higher in Group S (64.8 ± 16.6%) than in Group P (54.1 ± 10.7%) (Difference 10.7; 95% CI -16.0 to -5.3; p < 0.001), demonstrating improved hemodynamic stability. Intraoperative vasopressor use (phenylephrine and ephedrine) was significantly less frequent in Group S compared to Group P (Group S: 10 patients, Group P: 43 patients; p < 0.001). Recovery time, defined as the interval from the end of surgery to operating room discharge, was significantly shorter in Group S. Postoperative pain scores and time to cessation of supplemental oxygen administration did not differ significantly between groups.

Conclusion: Interscalene brachial plexus block with neuromuscular blockade-free sedation may enhance intraoperative hemodynamic stability, reduce vasopressor requirements, and facilitate earlier operating room discharge following proximal humerus orthopedic surgery.

Effective postoperative pain control significantly impacts patient satisfaction and recovery. Continuous peripheral nerve blocks (CPNB) via catheter placement have been shown to reduce opioid requirements and facilitate early mobilization. Two primary techniques exist for catheter placement: conventional catheter-through-needle (CTN) method and catheter-over-needle (CON) approach. This review aims to explore advantages and disadvantages of both methods.

We performed a comprehensive literature search on studies evaluating catheter placement techniques for CPNBs. A total of 8 randomized controlled trials (RCT), 2 retrospective reviews, 1 ex-vivo study, and several case reports and descriptive articles were analyzed to assess outcomes related to catheter stability, leakage, and efficacy.

Most common complications associated with CPNB include catheter dislodgement (6 to 15%) and leakage of local anesthetics at insertion site. In CTN technique, a smaller catheter is introduced through a larger-bore needle. After needle withdrawal, resulting tissue gap leads to anesthetic leakage and weaken catheter fixation, increasing risk of dislodgement (≈15%). Attempts to mitigate this issue using adhesive glues or tunneling have shown limited success. Moreover, leakage can compromise analgesia and increase infections. Leakage rates are reported as high as 34.4% in some studies. 1 RCT found that 27/29 patients (≈93%) experienced some degree of leakage. In contrast, the CON technique uses a larger catheter relative to puncture needle, ensuring a snug fit within tissue. Improved seal reduces leakage (6.1% as per 1 study) enhances catheter stability, thereby decreasing block failure and associated complications. As per literature, the overall procedure time was shorter when CON technique was used.

Evidence from reviewed literature supports superiority of catheter-over-needle technique in continuous peripheral nerve blocks. By creating a more effective tissue seal, this method significantly reduces incidence of local anesthetic leakage and catheter dislodgement compared to traditional catheter-through-needle technique. Incorporating CON into clinical practice may improve patient outcomes and block reliability.

Lumbar spine surgery is commonly associated with severe postoperative pain, which can impair recovery, extend mobilization, and cause chronic pain. Erector spinae plane block (ESPB) is a regional analgesia technique as a potent option in numerous surgical procedures. Our study aims to evaluate the effects of preoperatively administered ESPB on postoperative pain, opioid consumption, and cognitive functions in patients undergoing lumbar surgery.

This prospective, randomized, single-center study included 56 patients aged 18–65 years with ASA physical status I–II, who were undergoing elective lumbar spine surgery. Patients were randomly assigned to either the ESPB group or the sham block group. Before the surgery, both groups underwent ultrasound-guided ESPB, with one group receiving 0.3 ml/kg of 0.25% bupivacaine injection on both sides, while the other group received only hydrodissection. Pain was assessed on the Visual Analog Scale (VAS), cognition on the NuDESC scale, and additional outcomes such as opioid consumption, nausea, vomiting, anxiety, stress, and satisfaction with the patient. The data were analyzed using SPSS 11.5 software.

A total of 56 patients were included in the study. Differences in variables between the ESPB and sham block groups were examined, but no significant differences were found between the two groups for any variables (p>0.05). In the group that received ESPB, postoperative pain scores at rest and during movement (VAS scores) and opioid consumption were found to be significantly lower compared to the sham block group (p<0.05). The overall well-being was significantly higher in the ESPB group (p=0.048).

The application of ESPB after lumbar surgery is effective in controlling postoperative pain and contributes to the prevention of side effects by reducing opioid consumption. While it does not have a significant impact on postoperative cognitive functions, the use of ESPB as part of multimodal analgesia is recommended.

Emergency abdominal surgeries require an effective multimodal analgesia strategy to optimize clinical outcomes. We present the primary results of a prospective observational study investigating the perioperative efficacy of TAP block in patients undergoing emergency abdominal procedures.

11 patients, 25-66 years old, ASA I-II, underwent open (36.4%) or laparoscopic (63.6%) emergency abdominal surgery. Following induction of general anaesthesia, bilateral, ultrasound-guided TAP block was performed using a total of 40 ml of Ropivacaine 0.375%. Intraoperative analgesia with remifentanil titration was guided by Nociception Level Index and 30 minutes before surgical completion, paracetamol and nalbuphine was administered. Postoperative analgesia included paracetamol every 8 hours and tramadol as rescue analgesia for the first 24 hours. This observational study (reference number 2024-B2015-401) was approved by the hospital’s ethical and scientific committee.

The average perioperative administration of remifentanil was 200mcg, with a median NOL index of 16. PACU stay averaged 20 minutes and the median NRS pain score was 3. During the first 12 postoperative hours, the median NRS was 5, declining to 4 at 24 hours. Rescue analgesia was required in 10 patients. Median patient satisfaction was 4.7/6 and the mean 24-hour Quality of Recovery score was 96.6/150. Median time to mobilization, oral fluid intake, and food intake was 13.5, 12.4, and 20.6 hours, respectively.

The preoperative performance of bilateral TAP block is an effective adjunct in multimodal analgesia to patients undergoing emergency abdominal surgery, enhancing postoperative recovery, reducing opioid requirements and facilitating early mobilization and nutritional intake.

Wrist fracture repairs are a commonly performed trauma operation, with patients often going home on the day of surgery. Anaesthetic options include Regional Anaesthesia (RA), General Anaesthesia (GA), or a combination. Given the benefits to both patients and hospital bed pressures we aimed to analyse if anaesthesia choice affected the rate of same day discharge. We also aimed to analyse if anaesthesia choice affected perioperative opioid consumption.

We conducted a retrospective audit of 6 months of patients who underwent distal radius or scaphoid repair. We excluded those with multiple injuries. Data was collected on anaesthesia type, perioperative and recovery opioid use, day of surgery discharge, and representation to hospital. RA was defined as any nerve block performed by the anaesthetist. Ethical approval was sought and not deemed necessary by local committee.

89 patients underwent wrist fracture repair in the study period: 37.1% GA only, 37.1% RA only, and 25.9% GA plus RA. 71.9% of patients were discharged on the same day of surgery. Patients who received a regional block (with or without GA) were more likely to be discharged on the same day (82.1% vs 57.6%, p=0.012). Patients who received a regional block received less intravenous morphine equivalents in the peri- and postoperative period; mean difference -18.2mg (95% CI -14.2 to -21.8, p=0.0001). There were no cases of representation to hospital following discharge due to pain.

RA, with or without GA, was associated with improved rates of same day discharge and reduced perioperative opioid requirements in patients undergoing wrist fracture repair.

Radiotherapy-induced brachial plexopathy (RIBP) is a rare but debilitating complication of breast cancer treatment. There is limited information on the effective treatment for this condition. We describe a case of a patient diagnosed with RIBP who demonstrated excellent response to intravenous lidocaine infusion, with near-complete resolution of her symptoms.

A 68 year old female was referred to our pain clinic for severe left upper limb dysesthesia. She has a history of well-controlled schizophrenia and left breast cancer for which she underwent a left sided mastectomy with axillary clearance and chemoradiotherapy in 2017. She described her symptoms as a constant shock-like sensation radiating down her entire left arm. MRI of left brachial plexus and nerve conduction study were consistent with left brachial plexopathy. In view of her history of radiotherapy exposure to the left axilla, a diagnosis of RIBP was made.

Despite starting and escalating her gabapentin dose to 300mg TDS, converting to pregabalin 75 mg ON, and undergoing physiotherapy, her symptoms showed minimal improvement. Other neuropathic agents were limited because of her psychiatric history and use of multiple antipsychotics. She was started on a trial of intravenous lidocaine regimen consisting of a bolus of 1 mg/kg of 1% lidocaine followed by 1 mg/kg/h of 0.5% lidocaine for four hours over five consecutive days. She reported a significant reduction in her pain score on the numeric rating scale (0: no pain; 10: severe pain), improving from 10/10 to 3/10 after five cycles of lidocaine infusion, with no side effects. A follow-up clinic visit 9 months post-intervention showed persistent significant improvement in pain relief.

To our knowledge, this is the first report whereby IV lidocaine infusion has been used to successfully manage the symptoms of RIBP, highlighting its valuable role as part of the multimodal strategy for managing complex pain syndromes.

Clavipectoral fascial-plane block(CPB) is a new regional anaesthesia(RA) technique for clavicle surgeries(CS). Combined with superficial cervical plexus block (SCPB), it obviates need for general anaesthesia(GA), prevents complications of interscalene nerve-block. We aim to assess efficiency of CPB+SCPB as sole RA for CS

8 patients, May 2022- April 2024. 8ml Ropivacaine(0.5%) with 25mcg Dexmedetomidine injected on either side of fracture for CPB. SCPB given on same side with 5ml Ropivacaine(0.5%). Sensory-blockade assessed with pin-prick and touch, graded as 0-normal, 1-decreased, 2-no sensation. Sensation checked at incision site every 5minutes for 30minutes. Inadequate sensory response after 30min, or patient complaint of discomfort/pain, GA was administered. Ramsay sedation score(RSS) noted every 10minutes, throughout surgery. Numerical Rating Scale(NRS) on 1st,3rd,6th,12th and 24 hrs. Diclofenac 75mg intravenous used as post-operative analgesia, 6th hourly. If NRS=4 or above, Fentanyl 50microgram used as rescue analgesia. Time to discharge from hospital noted.

Mean age=37+/-8.96years. Mean BMI=26 +/-1.76. Mean duration of surgery=82.5 +/- 10.35minutes. Mean onset of action(4 successful cases) was 21.66 +/- 2.58 minutes. RSS= 2 in cases done under block and could not be assessed in cases which were converted to GA. NRS score < 4 in 7 out of 8 cases. In one case, NRS was 6 during 8th post operative hour. Mean time to discharge=17.25 +/- 4.89 hours.

CPB with SCPB is a motor-sparing, phrenic-nerve sparing block for mid-clavicle surgeries. In appropriately selected patients, it can be sole anaesthetic agent, avoiding GA and complications. It also provides good analgesia and decreases duration of hospital stay.

Continuous spinal anaesthesia (CSA) is a technique where a catheter is placed into the intrathecal space allowing titrated local anaesthetic to be injected producing a subarachnoid block. Advantages are better haemodynamic stability and ability to extend anaesthesia in prolonged operations.

16 CSA were performed with patient selection including, severe aortic stenosis, heart failure and respiratory disease. Surgical selection included prolonged/bilateral lower limb arthroplasty, complex hip fractures and palliative laparotomy. Patients were consented and underwent spinal sonography followed by catheter placement under aseptic conditions. We used the Pajunk® spinal catheter system NRFit intralong 21G x 90mm Sprotte special tip with 25G x 90cm PA-catheter. After placement the catheter was left 4cm in the subarachnoid space. We gave a bolus of 0.5-1ml 0.5% plain bupivacaine followed by top-up doses of 0.5ml every 30 minutes.

All 16 operations (4 general surgery and 12 orthopaedic) were carried out successfully with patients’ blood pressure variations within 20% of baseline value.

Traditionally combined spinal epidural (CSE) is used in high-risk patients where there are concerns about anaesthetic stability or length of surgery. However, the top-up doses required are always high volume which has the potential for hemodynamic compromise. The emerging technique of CSA could be a good alternative to CSE as all the patients in our series had complete hemodynamically stability with good outcomes. We started initially giving top-ups every 45 minutes but 2 patients had motor power and movement in the lower limb being operated on, therefore we changed our protocol to every 30 minutes.

Arthroscopic-assisted lower trapezius tendon (LTT) transfer, performed for irreparable posterosuperior rotator cuff tears, involves surgical incisions that extend beyond the dermatomes typically covered by brachial plexus blocks. This often results in inadequate postoperative analgesia. We implemented a novel regional anaesthesia strategy combining thoracic paravertebral block (PVB) (1), interscalene block (ISB) (2), and graft-site-specific peripheral nerve blocks to optimise pain control and recovery.

We report on 10 patients who underwent LTT transfer using this multimodal technique: single-shot T4/5 thoracic PVB, low-volume ISB (<10 ml), and additional adductor canal and medial genicular blocks based on graft harvest location. This approach provided improved perioperative analgesia (pain scores <3/10), stable intraoperative hemodynamics, and enabled same-day discharge. No block-related complications were reported. The block strategy has since been adopted into our enhanced recovery pathway.

This is the first case series describing the combined use of brachial plexus and thoracic paravertebral blocks for complex shoulder procedures. The multimodal approach effectively addresses analgesic gaps from ISB alone, especially in surgeries with multisite incisions. Success depended on multidisciplinary collaboration and operator skill in ultrasound-guided thoracic PVB. Limitations include small sample size and lack of a control group. Further studies are warranted to validate these findings. A figure is included to illustrate incision sites and corresponding sensory coverage areas. References Karmakar MK. Thoracic paravertebral block. Anesthesiology. 2001;95(3):771–780. Fredrickson MJ et al. Interscalene block for shoulder surgery. Anesth Analg. 2009;109(1):265–274.

Hip fractures in frail older adults cause considerable pain, diminished quality of life, and ethical challenges. Regional anesthesia techniques such as the pericapsular nerve group (PENG) are proposed for palliative care, but evidence remains limited. This study evaluates a neurolysis protocol at Ziekenhuis Oost-Limburg (ZOL), Genk, Belgium, and assesses whether the PENG block is sufficient as first-line analgesia in conservatively managed hip-fracture patients.

Seven patients considered for ultrasound-guided alcohol neurolysis between September 2024 and March 2025 were reviewed. As per the institutional protocol, a PENG block was used for intracapsular or intertrochanteric fractures, and a femoral nerve (FN) neurolysis for subtrochanteric fractures. In all cases, 10 mL ethanol 96 % was used. Pain (VAS/PAINAD), opioid consumption, discharge status, and survival were extracted from hospital and follow-up records. PENG failure (VAS/PAINAD ≥ 4 at 24 h) triggered rescue FN neurolysis; persistent pain prompted multidisciplinary review.

Seven patients (median age 89 years, ASA IV–V) were evaluated. Of these, one patient had a VAS below 4, one received palliative systemic opioids, and five received neurolysis (3 PENG, 2 primary FN). Two PENG patients required additional FN neurolysis. Overall, 4/5 (80 %) FN procedures achieved adequate analgesia (VAS/PAINAD ≤ 4) at 24 h, versus 1/3 (33 %) with PENG alone. One patient remained opioid-dependent despite sequential blocks. Three of five treated patients were discharged; 6/7 patients died within 30 days (median survival 12 days).

In our cohort of frail patients with hip fractures, FN alcohol neurolysis provided more consistent analgesia than PENG neurolysis. In patients with limited survival, the reliability and simplicity of FN neurolysis may outweigh PENG’s motor-sparing advantages.

Hip fragility fractures are associated with high morbidity, mortality, and risk of delirium. The British Orthopaedic Association Blue Book Guidelines (2007) and the AAGBI Guideline for the management of hip fractures (2020) emphasizes early, comprehensive assessment and management of both pain and delirium as core components of best practice. Delirium affects up to 50% of hip fracture patients and is associated with worse outcomes. Effective pain control is a modifiable risk factor for delirium. This audit evaluates use of screening tools such as the 4AT to assess for delirium and pain management of hip fracture including regional anaesthetic techniques. This audit aims to assess the documentation of delirium through the 4AT and the use of multimodal analgesia in the management of hip fracture and compare against standards set by the Blue Book Guidelines.

A clinical audit carried out in University Hospital Waterford over a two-month period in patients with hip fractures. We looked at presence of 4AT scores, pain scores, analgesia given in the preoperative, intraoperative and post-operative setting. Standards Compared To: BOA-BGS Blue Book (2007, updated 2020), AAGBI Guideline for the management of hip fractures (2020) recommendations. Approval was granted by Local Audit Committee University Hospital Waterford.

34 patients included. Fifty six percent were female, 44% male. Average age was 82 years. Most cases were carried out under spinal anaesthesia (75%). Common deficits identified included no 4AT admission, no peripheral nerve block pre-operatively (88%), use of regular opioids (71-82%) for the majority of patients.

Findings highlight incomplete compliance with national standards for pain and delirium assessment. Improved documentation of 4AT scores, implementing regional anaesthesia techniques intra-operatively when appropriate, and staff training around use of regular versus as required opioids are needed to align with BOA-BGS Blue Book guidance.

Pain, nausea, and vomiting are common concerns in post-operative period after caesarean section. Opioids used as adjuvants to spinal anaesthesia contribute to it. The study aimed to compare dexamethasone's antiemetic potential for prophylaxis through intravenous and intrathecal routes.

In this prospective randomized double-blinded study, patients were administered dexamethasone 4 mg either through intrathecal route as an adjuvant with 1.5 ml bupivacaine heavy (0.5%) (group A) or through intravenous route (group B) and compared with control group (group C), which received normal saline through both routes. Primary objective was to compare incidence of postoperative nausea and vomiting. Secondary objectives were total sensory block duration, time to first rescue analgesic, total analgesic consumption, postoperative pain scores(VAS), and patient satisfaction.

Of 30 patients per group, three patients each in intravenous and intrathecal groups (10%), and nine patients (30%) in control group had nausea, difference being statistically insignificant. Vomiting occurred in one patient (3%) and two patients (6.67%) in intrathecal and intravenous groups, respectively, when compared to nine patients (30%) in control group, difference being statistically significant. Post hoc analysis states that intrathecal dexamethasone has significant role in control of vomiting (corrected P = 0.036) while intravenous dexamethasone does not have same effect (corrected P = 0.123). There was significant difference in sensory block duration among groups (A - 79.03 (+/-6.35 minutes, B- 65.97 +/-4.78 minutes, C- 60.63+/- 2.97 minutes). Time to first analgesic was significantly longer, and resting VAS scores were significantly less in dexamethasone groups. Total analgesic requirement had significant difference between intrathecal and control group but not among intravenous dexamethasone and control group.

Intrathecal dexamethasone is associated with lesser incidence of postoperative vomiting than same dose of intravenous dexamethasone. Patients' overall satisfaction is significantly better in intrathecal group due to lesser incidence of vomiting, better pain scores and lesser analgesic consumption.

Stellate ganglion block (SGB) is conventionally performed at the C6 vertebral level; however, this method poses the risk of accidental nerve blockade and vascular injury. We propose a novel approach, first-rib neck SGB (1RN-SGB), that effectively minimises these risks (Figure 1).

[Case series] Ten patients underwent 1RN-SGB with 3–5 mL of 1% lidocaine after confirmation of contrast imaging using 3-4 mL of iohexol. Clinical outcomes, adverse effects, and extent of contrast spread were recorded. [Cadaveric study] 1RN-SGB was performed on four Thiel-embalmed cadavers (six sides) with 3 or 6 mL of 0.4% indigo carmine injected. Dye spread and nerve involvement were assessed by dissection.

[Case series] 1RN-SGB successfully achieved pain relief in all patients with Horner's sign. Two patients reported paralysis of the ulnar side of the hand and forearm. No additional adverse events were reported. Contrast spread reached adjacent to the T1 vertebra (Figure 2). [Cadaveric study] The stellate ganglion was completely stained with 6 mL of dye but only on the lateral surface by 3 mL (Figure 3). The sympathetic trunk was consistently stained at C7-T2. Recurrent laryngeal, vagus, and phrenic nerves were not stained. C8 and T1 nerves were stained in all cadavers.

Although 1RN-SGB demonstrates consistent effects, its pathway may differ from that of conventional SGB. 1RN-SGB effectively reduces severe complications; however, it is crucial to note the unintentional blockade of C8 and T1 nerves.

Chronic post-mastectomy pain (CPMP) affects 20–50% of patients, with regional anesthesia increasingly used to mitigate acute and chronic pain. While both PECS II and ESP blocks are effective for acute analgesia, their long-term impact on CPMP remains understudied. This study aimed to compare the effects of preoperative PECS I-II and ESP blocks on acute pain control, opioid requirements, and CPMP incidence at 3 months.

In this prospective cohort study, 44 patients undergoing modified radical mastectomy under general anesthesia received either ultrasound-guided PECS I-II (n=21) or ESP blocks (n=23) with 0.25% bupivacaine. Primary outcomes included postoperative Numerical Rating Scale (NRS) scores, 24-hour morphine consumption, and CPMP incidence (NRS≥1 at 3 months). Secondary outcomes included neuropathic pain (DN4/DN2 scores) and quality of life (SF-12). Statistical analysis used SPSS v27.

Both groups demonstrated comparable intraoperative fentanyl use (p=0.218) and 24-hour morphine consumption (4.8±1.9 vs. 4.3±2.0 mg, p=0.359). ESP provided longer time to first analgesia request (260±53 vs. 227±54 mins, p=0.048) and lower early NRS scores (p=0.016). At 3 months, CPMP incidence was similar (42.9% vs. 52.2%, p=0.537), with lymph node dissection (64% vs. 26%, p=0.013) and postoperative neuropathic pain (DN4≥4 at 24h, p=0.042) identified as key risk factors. SF-12 physical scores were significantly lower in patients with CPMP (49.1±5.4 vs. 55.5±2.1, p<0.001).

PECS I-II and ESP blocks equivalently reduce acute postoperative pain, but neither significantly lowers CPMP incidence. Lymph node dissection and early neuropathic pain are critical risk factors for chronicity. While ESP prolongs analgesia duration, both techniques offer viable options for mastectomy pain management. Multimodal strategies targeting neuropathic pathways and surgical modifications for lymph node preservation warrant further exploration. This study provides actionable insights for optimizing regional anesthesia choices in breast surgery while highlighting unmet needs in chronic pain prevention.

Headache disorders are complex and multifactorial. Despite research on head posture and headache, comprehensive analyses of multiple postural and proprioceptive parameters across the body are lacking.This pilot study aimed to compare foot posture, lower extremity flexibility, spinal angles (lumbar, thoracic, cervical), trunk position sense, and forward head posture between individuals with headache and asymptomatic controls.

A cross-sectional pilot study was conducted with (n:36) participants divided into two groups: individuals with headache (n:18) and matched controls without headache (n:18). Foot posture was assessed using the Foot Posture Index (FPI) and Navicular Drop Test (NDT). Lower extremity flexibility was measured through standardized goniometric assessment. Spinal angles were evaluated using digital inclinometry at lumbar, thoracic, and cervical regions. Trunk position sense was assessed by means of repositioning error tests with a dual inclinometer. Forward head posture was evaluated by measuring the distance between the tragus and malleolus from the lateral side. Between-group differences and correlations were analyzed using appropriate statistical methods with significance set at p<0.05.

No significant differences were found between groups in trunk position sense, flexibility tests, spinal angles, and foot posture measures (p>0.05), except for left gastrocnemius flexibility where controls showed better performance (p<0.05). In headache sufferers, pain severity did not correlate with trunk position sense or lower extremity flexibility. However, lumbar and cervical spinal angles significantly correlated with pain symptoms (p<0.05). The tragus to malleolus distance correlated with headache medication consumption (p<0.05).

The findings suggest that lumbar spine alignment, gastrocnemius flexibility, and cervical angle may influence headache occurrence and severity. In individuals with headache, more effective solutions can be developed in the treatment of headache by taking into account the alignment disorders of the lumbar region and especially the cervical region and treatment plans for these disorders.

Labour epidural analgesia is widely regarded as the most effective method of pain relief during childbirth. However, improper technique and knowledge gaps can contribute to complications, morbidity, and psychological distress. This study aimed to assess awareness of safety practices, recognition of procedural errors, and adherence to best practices among anaesthetists and midwives. The goal was to identify areas requiring improvement and implement multidisciplinary training through Local Action for Learning (LAfL).

A structured questionnaire survey was conducted among anaesthetists and midwives. Two distinct sets of anonymized questions were developed, each for anaesthetists and midwives, to evaluate their understanding of epidural safety measures, appropriate testing methods, and recognition of aberrations. The survey was administered in person to prevent external referencing. Participants were categorized by role and experience level. A total of 32 anaesthetists and 29 midwives were assessed in our labour ward.

Overall adherence to best practices varied among different professional groups. While most anaesthetists recognized multiple methods for testing catheter placement, a significant proportion demonstrated inconsistent knowledge of key safety checkpoints. Midwives generally exhibited strong handover practices but lacked awareness of certain procedural risks, such as the implications of high neuraxial blocks and dural punctures. Additionally, there was minimal experience with managing intrathecal catheter across both groups.

The findings highlight the need for enhanced education and structured simulation training to improve epidural safety. A multidisciplinary approach, incorporating SBAR handovers and adherence to standardized checklists, may help optimize patient outcomes and prevent critical incidents.

Physician well-being and job satisfaction are essential for maintaining high-quality patient care, particularly in demanding fields such as anesthesiology and intensive care medicine. This study investigates the predictors of job satisfaction, burnout, and psychological well-being in a nationwide of physicians working in these specialties in Germany, aiming to identify modifiable factors that could improve occupational health outcomes

Nationwide cross-sectional survey was conducted among 513 physicians working in anesthesiology and intensive care medicine across Germany. The Warr-Cook-Wall Job Satisfaction Scale assessed professional satisfaction, the Copenhagen Burnout Inventory measured occupational strain, and the WHO-5 Index evaluated psychological well-being. Multiple regression analyses were performed to identify significant predictors of these outcomes while controlling for demographic and workplace characteristics.

Recognition for work performed emerged as the strongest independent predictor of job satisfaction ( β= 0.41, p < 0.001), followed by manageable working hours ( β= 0.37, p < 0.001) and opportunities for skill utilization (β= 0.33, p < 0.001). Burnout levels were significantly correlated with both reduced job satisfaction (r = -0.586, p < 0.001) and lower psychological well-being (r = -0.689, p < 0.001). Perceiving every work hour as exhausting (OR = 2.35) and experiencing end-of-day fatigue (OR = 2.14) were the strongest predictors of burnout in logistic models. Female physicians showed significantly higher burnout scores (p < 0.001), while those working in rural areas reported lower well-being (p = 0.011). Notably, 31.2% of participants scored below the WHO-5 well-being threshold indicative of possible depression. The combined presence of high recognition, reasonable working hours, and strong collegial support was associated with a 3.7-fold increase in job satisfaction and a 2.9-fold reduction in burnout risk.

This study highlights workplace factors influencing job satisfaction, burnout, and well-being among anesthesiologists, suggesting interventions in recognition, working hours, and collegial support to improve physician health and patient care

Background The Erector Spinae Plane (ESP) block is as a simple, ultrasound guided technique, widely used to provide thoracic analgesia. In the lumbar region, a similar technique has been described, but with less success. This may be due to anatomical differences between the fascial planes in the lumbar and thoracic regions, causing a different pattern of injectate spread. This study was performed to determine which structures are reached when fluid is injected into the lumbar ESP, to indicate the clinical applications of a lumbar ESP block.

Twelve patients were included in the study, performed between January to June 2023. All were being treated for chronic hip pain. Following a therapeutic hip block, a baseline MRI was performed. Saline (30ml) was then injected on the contralateral side, into the ESP at the level of L4, using. an ultrasound guided, parasagittal, in-plane technique. A second MRI was performed after thirty minutes, and the spread of injectate analysed.

Posterior spread within the erector spinae (ES) muscles, the location of dorsal rami of spinal nerves was seen in all patients. In n=4 (33%) patients, saline also spread anteriorly, to anatomical areas where ventral rami of spinal nerves or the lumbar plexus are located, and to the paravertebral space. Epidural spread was also seen in one of these four. Average craniocaudal spread of injectate was 140.3 mm (90–194 mm). Average number of vertebral levels covered was 5.75 (4–8), i.e. approximately 5.2 ml of injectate per vertebral level.

The spread of a bolus of fluid injected into the lumbar ESP tends to be posteriorly, implying usefulness for spinal surgery. Unpredictable anterior spread suggests that this may not be such a reliable type of block for surgeries requiring anaesthesia to ventral rami of spinal nerves or related anterior structures.

Functional Neurological Disorder (FND) presents with motor and sensory symptoms incongruent with identifiable neurological pathology. Among its diverse manifestations, chronic pain remains under-recognized despite its high prevalence and substantial impact on quality of life. The aim of this review is to explore the challenges associated with pain management in FND, examine underlying pathophysiological mechanisms, and highlight gaps in current clinical practice.

A narrative review methodology was adopted. Relevant literature was sourced from databases including PubMed, Scopus, and Google Scholar, using search terms such as “Functional Neurological Disorder,” “chronic pain,” “pain management,” and “multidisciplinary care.” Inclusion criteria encompassed English-language publications between 2010 and 2024 focusing on adult FND populations. Infographics were developed to visually depict prevalence data, treatment barriers, and underlying neurobiological mechanisms.

More than 55% of FND patients report chronic pain symptoms, with comorbidities such as fibromyalgia, complex regional pain syndrome (CRPS), and irritable bowel syndrome (IBS) commonly observed. The pathophysiology is multifactorial, involving aberrant functional connectivity, heightened stress reactivity, and dysregulated emotion-pain networks. Standard therapies, including physiotherapy and cognitive-behavioral therapy, often fail to adequately address pain. Contributing barriers include diagnostic ambiguity, stigma from healthcare providers, lack of access to multidisciplinary services, and insufficient clinician training. Integrated care models, though promising, remain inconsistently applied in clinical settings.

Pain in FND is prevalent, complex, and inadequately addressed in current treatment paradigms. Effective management necessitates a shift toward a biopsychosocial model of care, emphasizing interdisciplinary collaboration and patient-centered approaches. Future efforts should aim to incorporate pain into FND diagnostic criteria and promote standardized, evidence-based interventions. Visual educational tools may further enhance provider awareness and facilitate integrated treatment planning.

Pelvic and acetabular fractures are complex injuries, often due to high-energy trauma, associated with substantial pain, morbidity, and blood loss. Pain management in the emergency setting, including post-surgery, is frequently inadequate, with many patients relying mainly on opioids, which carry risks of adverse effects and long-term dependence. Multimodal analgesia and regional anesthesia (RA) techniques—such as fascia iliaca compartment block, erector spinae plane block (ESP), and quadratus lumborum block (QLB)—are emerging as promising tools to improve pain control and reduce opioid use. Strong evidence specific to pelvic and acetabular fractures remains limited.

This prospective, single-center, pilot study evaluates the effectiveness of regional anesthesia techniques in managing pain following surgery for pelvic and acetabular fractures. Conducted at CTO Hospital in Turin, Italy, the study includes patients undergoing surgical treatment comparing multimodal analgesia alone or in association with RA techniques such as supra-inguinal fascia iliaca (SIFI) block, lumbar ESP block, and transmuscular QLB. Primary endpoints were pain scores (NRS) and opioid consumption in the acute and postoperative phases.

Preliminary data on 49 patients showed a significant drop in opioid use in the first 24 hours after surgery in the group treated with RA techniques. Morphine equivalents at 24 hours were reduced (p = 0.0406) in 23 patients who received RA blocks. Pain scores remained low and comparable between groups. Motor block rarely occurred in RA patients (17%). No significant differences were observed in hospital stay or pain persistence at 30, 60, and 90 days.

In this ongoing pilot study Regional Anesthesia techniques showed efficacy in reducing opioid requirements in the acute phase following pelvic and acetabular fractures surgery, supporting their integration into multimodal analgesia protocols. More robust data are necessary to corroborate this evidence, including more insights into which specific regional anesthesia technique best matches each surgical approach.

Minimally invasive approaches in cardiac surgery offer several advantages, including reduced surgical trauma, faster recovery, and lower risk of complications. However, they are linked to a higher risk of intercostal nerve injury, which can cause more intense postoperative pain. This pilot prospective study compared three strategies for managing pain after mini-thoracotomy: (1) intercostal nerve cryoablation, (2) regional fascial blocks—Erector Spinae Plane Block (ESPB) and Pectoralis II Block (PECS II), and (3) standard pharmacological analgesia without regional techniques.

The pilot study included ten patients aged 48 to 65 years (median 48) who underwent mini-thoracotomy for minimally invasive cardiac surgery. It was approved by the hospital ethics committee and registered at clinicaltrials.gov (NCT03915301). Group A (n = 3) received perioperative intercostal nerve cryoablation. Group B (n = 45) received regional fascial blocks (ESPB + PECS II) before thoracic closure. Group C (n = 30) received standard analgesic treatment. Pain was assessed using the Numerical Rating Scale (NRS), and daily analgesic use was recorded for five postoperative days.

Group A (cryoablation) reported the lowest pain intensity (NRS 0–1 during the first 12 hours postoperatively) and minimal use of both opioid and non-opioid analgesics. Group B (ESPB + PECS II) showed moderately higher NRS scores and greater analgesic use compared to Group A, but better outcomes than the control group. Group C had the highest pain intensity and overall analgesic requirements, including repeated bolus doses and regional blocks.

Intercostal nerve cryoablation appears to be an effective and safe method for controlling acute postoperative pain after mini-thoracotomy, significantly reducing analgesic use compared to other techniques. ESPB and PECS II are common regional anesthesia methods in thoracic procedures, including mastectomies and chest wall surgeries, and showed moderate effectiveness in this study. These findings support further research into cryoanalgesia as part of multimodal pain management after thoracotomy.

The interscalene block (ISB) is the gold standard for shoulder surgery but may be limited by respiratory complications and technical difficulty in obese patients. The pericapsular nerve group block for the shoulder (PENG-S) is a newer alternative, targeting articular branches while minimizing motor and diaphragmatic involvement. This study compares ultrasound feasibility and postoperative analgesia of ISB vs. PENG-S in patients with BMI >25.

Design: Retrospective study Population: 30 patients scheduled for shoulder surgery (arthroscopy or arthroplasty), all with BMI >25 Groups: 15 patients received ISB; 15 received PENG-S Primary outcome: Ultrasound image quality (score 0–5; 0 = optimal visibility, 5 = non-identifiable anatomy) Secondary outcome: Postoperative pain via Visual Analog Scale (VAS) in PACU, at 6h, 12h, and 24h

Ultrasound Image Quality Mean image difficulty: ISB = 2.47 ± 1.35 | PENG-S = 0.60 ± 0.63 Statistical significance: p = 0.00026 (Mann-Whitney U test) Postoperative Analgesia (VAS scores) Rescue opioids: 2 patient (PENG-S), 0 patients (ISB)

In patients with BMI >25, the PENG shoulder block provides superior ultrasound visualization and easier anatomical identification than the interscalene block, with acceptable analgesia in the first 24h. Although ISB shows slightly better pain scores, the PENG-S block remains a safer and technically simpler alternative, especially in patients with respiratory risk or complex anatomy.

Rib fractures are very common and associated with significant morbidity and mortality. Written and agreed multidisciplinary guidelines should be available as their use improves outcomes for patients (e.g., shorter ITU and hospital stay, decreased incidence of pneumonia and decreased mortality). The guidelines should comprise an agreed analgesia protocol, including indications for neuraxial and regional analgesia. The aim of the study was to analyse UK guidelines for the management of adults with rib fractures with special regard to neuraxial and regional analgesia.

Guidelines on the clinical management of adults with rib fractures and/or chest wall trauma were requested from every trust in the UK (n=161) via Freedom of Information request. Trusts that do not provide this service, did not reply, provided incomplete information or did not have a guideline in place were excluded.

11 trusts that provide care for patients with rib fractures did not have a clinical guideline on their management. Of the 120 trusts whose guidelines were reviewed, 96.6% included criteria for use of regional anaesthesia, however 4 trusts did not explicitly recommend regional anaesthesia for rib fractures. 91.6% of trust advocated early use of regional anaesthesia. The most commonly recommend regional technique was a thoracic epidural (78% of trusts), followed by erector spinae plane block +/- catheter (60%), serratus anterior plane block +/- catheter (59%) and paravertebral block +/- catheter (51%). A third of the trusts recommended choosing the block based on location of the fractures. 14% of trusts did not specify the type of regional technique to be used.

There is a significant variation between the trust guidelines on the management of rib fractures across the UK.

Hyperthermic intraperitoneal chemotherapy (HIPEC) combined with cytoreductive surgery is a difficult and painful procedure which has potential to result in different adverse events such as coagulopathy and post-operative hypotension. Previous studies have demonstrated the efficacy of Thoracic epidural analgesia (TEA) for this procedure however it is associated with hypotension. The aim of the study is to compare the outcomes of continuous erector spinae plane block for analgesia versus thoracic epidural anesthesia.

A retrospective cross-sectional study was performed which included adult patients 18 years old and above who underwent HIPEC following cytoreductive surgery. Review of medical records was performed to gather data on post-operative analgesia used (TEA or continuous ESPB), pain outcomes, and adverse events.

A total of 32 patient records were reviewed. The median Numeric Rating Scale (NRS) score immediately post-operative was 0 for the TEA group and 1 for the ESPB group, with a mean score of 1.1 for TEA and 2.2 for ESPB (p=0.248). At 24 hours post-operative,the median NRS score was 2 for TEA and 0.5 for ESPB, with mean scores of 2.3 and 1.3, respectively (p=0.148). The differences in pain score between groups immediately after surgery and 24 hour post-operatively were not statistically significant. The median total opioid dose was higher in the TEA group (42.4 mg) compared to the ESPB group (31.5 mg), with mean doses of 50.1 mg for TEA and 40.6 mg for ESPB. This difference was not statistically significant (p=0.318). A notable difference was observed in hypotension rates, with 25% of the TEA group experiencing hypotension compared to none in the ESPB group (p=0.033).

Continuous ESPB and TEA demonstrated equal efficacy in the reduction of postoperative pain among patients who underwent HIPEC following cytoreductive surgery. However, Continuous ESPB showed lower incidence of hypotension, making it a potentially safer option for pain management.

Traditionally pain is assessed using self-reported methods such as the Numerical Rating Scale (NRS), which can be affected by communication barriers and individual pain tolerance.The Perfusion index which is one of the common parameters recorded in postanaesthesia care unit (PACU) setup has been evaluated as an objective criterion for postsurgical pain. This prospective, observational study was conducted at a tertiary care cancer institute for evaluating the potential of the perfusion index (PI) as an objective pain assessment tool in oncological surgeries. The aim was to find whether PI could serve as an objective criterion,particularly in the postoperative setting.

Total of 120 adult patients, aged 18-80 years, ASA I or II, undergoing elective surface oncosurgery were included. PI and NRS scores were recorded every 30 minutes in the post-anesthesia care unit (PACU). Patients received rescue analgesics when NRS scores exceeded 3. Thereafter changes in PI, heart rate (HR), and non-invasive blood pressure (NIBP) were recorded pre- and post-analgesia.

From the 120 patients, only 45 (37.5%) required analgesics for moderate pain (NRS > 3),mostly receiving intravenous tramadol. A weak negative correlation (r = -0.200, p = 0.188) was found between changes in PI and NRS. While PI increased slightly after analgesia (median 1.8 to 2.0), which was not statistically significant (p = 0.217). The NRS scores significantly decreased (p < 0.001) from a median value of 4 to 3. Thus, PI and NRS showed weak and inconsistent correlation at various time points.

The study found correlation between PI and NRS scores as unreliable, suggesting that PI may not be a useful standalone tool for postoperative pain assessment, especially for mild to moderate pain.

This pilot cadaveric study aimed to evaluate the role of anatomical asymmetry in the thoracic paravertebral space (TPVS) and gravitational forces on dye-spread during bilateral TPVB performed in the lateral position.

The study was approved by the Ethics Committee of Sapporo Medical University between January 2022 and August 2024 (Nos. 3–1–61, 4–1–49, and 6–1–39). Twelve soft-embalmed Thiel cadavers were used: six were placed in the left-lateral position and six in the right-lateral position. A single-injection of 20 mL dye was administered to each TPVS using an ultrasound-guided intercostal approach. After 20 min, the cadavers were repositioned in a supine position. The vertebral segmental numbers of stained TPVSs and intercostal spaces (ICSs) were recorded.

TPVB performed on the left side demonstrated significantly more stained segments (median [interquartile range]) than that performed on the right side (TPVS: 4.0 [3.0–5.0] vs. 2.0 [1.0–3.0], p = 0.01; ICS: 4.0 [3.0–5.0] vs. 3.0 [2.0–4.0], p = 0.04). However, no significant differences in dye-spread were observed between the upper and lower sides (TPVS: 4.0 [1.0–5.0] vs. 2.0 [2.0–5.0], p = 0.63; ICS: 4.0 [2.0–4.0] vs. 3.0 [2.0–5.0], p = 0.69).

We demonstrated that the larger volume of the left TPVS compared with the right TPVS may contribute to a more extensive spread, whereas gravitational forces appear to be minimal. Our findings suggest that a larger volume of local anesthetic may be required on the right side to achieve analgesia comparable to that on the left side.

For awake fibreoptic intubation, it is essential to ameliorate the cough, swallowing and gag reflexes which can be done by various airway nerve blocks. The superior laryngeal nerve (supplying sensations above vocal cords) and recurrent laryngeal nerve (supplying sensations below the cords) are conventionally blocked in unison. We compared the conditions for awake fibreoptic intubation when a single transtracheal block alone was administered as compared to when bilateral superior laryngeal blocks in combination with transtracheal blocks were administered under ultrasound guidance in patients with preexisting unstable cervical spine

One hundred and forty patients with cervical spine pathology were randomly allocated to receive either a single transtracheal block or a combination of transtracheal and bilateral superior laryngeal nerve blocks under ultrasound guidance before being taken up for awake fibreoptic intubation. Comfort of awake fibreoptic intubation, represented by patients’ cough and gag scores (Malcharek et al,2015), intubation times, haemodynamic parameters, operator and patients’ experiences and complications were noted

Demographic parameters, intubation times, vital parameters were similar. (p > 0.05 each). Levels of coughing and gagging during the procedure and the time required were comparable. (p > 0.05 each).Intra procedural vital parameters or post procedure sequelae were similar (p>0.05)

Single transtracheal block provides comparable intubating conditions under fibreoptic guidance as compared to combination of transtracheal and bilateral superior laryngeal nerve blocks. Therefore, for airway anaesthesia during awake fibreoptic intubation, in view of its less invasiveness, a single transtracheal block can be preferred over the combination of transtracheal and bilateral superior laryngeal nerve blocks.

Vancouver General Hospital (VGH) is a trauma centre that receives >250 patients annually with traumatic chest injuries. The trauma service consults the anesthesia perioperative pain service (POPS) through an institutional referral pathway for high-risk patients. We identified frequent delays to POPS involvement, leading to inadequate pain control, avoidable opioid side effects, increased risk of delirium and pulmonary compromise. We aimed to reduce the time from trauma admission to POPS assessment or intervention by 15% in high-risk chest trauma patients admitted under trauma services at VGH.

Data was collected from a departmental patient database and hospital electronic medical records from November 2022 to April 2024, including times of admission, POPS consultation and POPS intervention. The time intervals between each were calculated. Discussions with POPS and trauma physicians and nurses resulted in introduction of a Chest Trauma Referral Pathway educational video in February 2024 embedded into house staff orientation materials.

Baseline data demonstrated excessive delays in optimal care: on average 15.2 hours from admission to POPS consultation, 18.0 hours to intervention, and 2.6 weeks between missed consultations (Table 1). After video implementation, there was a consistent shift in the time from admission to consultation sustained for 13 referrals (Figure 1). The average time from admission to consultation decreased to 4.2 hours (-72.4%), and to intervention to 8.2 hours (-54.4%).

Introduction of a Chest Trauma Referral Pathway video successfully reduced the time patients with traumatic chest injuries were waiting for pain management (by 72.4% to POPS consultation, and by 54.4% to POPS intervention).

Erector Spinae block has been used successfully for postoperative analgesia in Renal Transplant patients (1,2). Erector Spinae block analgesia has performed well when compared to Epidural analgesia (3). This study includes comparison of efficacy of continuous erector spinae plane block via catheter versus continuous epidural block via catheter for post operative analgesia in patients undergoing renal transplant recipient surgery. This is interim data of the ongoing trial.

We conducted randomized, open label, non-inferiority trial in patients aged 18- 60 of ASA III of either sex undergoing renal transplant surgery under general anaesthesia. Patient were randomized on basis of Computer-generated random number table. Group 1 patients received continuous erector spinae block via catheter while group 2 patients received continuous epidural analgesia via catheter. Anaesthetic plan and dosages were uniform across both groups. Fentanyl IV PCA was instituted for all patients in postoperative period. Primary outcome was total fentanyl IV PCA consumption in 48-hrs post extubation. Secondary outcomes were Static and Dynamic pain scores at 30 min. 2hr, 24hr and 48hr time points along with patient satisfaction with analgesia.

The interim study data includes 44 patients, out of which three were dropouts due to catheter dislodgement and PCA pump malfunction. Fentanyl IV PCA consumption was significantly higher in ES group(n=23) compared to Epidural group (n=18) (ES 1152.33 575.03 mcg vs Epi 429.00  103.06 mcg, p=0.001). Static & Dynamic pain scores were significantly higher in ES group compared to Epidural group at 30 min and 2 hr. time points, and they were comparable across both groups at other time points. Ambulation times were comparable in both groups. Satisfaction with analgesia was significantly higher in Epidural group compared to ES group.

According to interim data, Epidural group reported lower Fentanyl consumption and pain scores and better satisfaction with analgesia compared to ES group.

Pre-operative consultative transthoracic echocardiogram (TTE) is recommended in symptomatic patients with cardiovascular disease, those lacking recent follow-up, or unexplained dyspnea. Current recommendations do not advise for routine TTE for asymptomatic patients with ESM. Studies have shown benefits of cardiac POCUS for planning further investigations and perioperative management. We describe outcomes following application of a pre-operative workflow using cardiac POCUS to reduce the need for TTE and cardiology consults. Ethics approval was obtained for this audit.

Asymptomatic patients with ESM, patients with known heart failure and limited effort tolerance, or in whom functional capacity was unquantifiable were included. 47 patients were scanned over 22 months by anaesthetists accredited in POCUS. All 4 standard cardiac views, 2D and colour doppler evaluation of the aortic valve and visual estimate of left ventricular ejection fraction were performed. Further cardiac evaluation was arranged for patients with new abnormalities detected.

Our protocol allowed for surgery to proceed without the need for consultative TTE in 23 out of 25 patients with ESM. Two patients had 2D features suggestive of severe aortic stenosis and this was confirmed in one patient following consultative TTE, leading to postponement of surgery. New regional wall motion abnormalities were found in two patients. One patient opted to defer surgery. No patients developed major adverse cardiovascular events. No day-of-surgery cancellations occurred.

Pre-operative anaesthesia clinic cardiac POCUS allows for timely surgical planning and minimises unnecessary cardiology consultations and consultative TTEs. Further research should evaluate its impact on perioperative management and patient outcomes following surgery.

Continuous Regional Catheters (CRCs) enable pain control beyond the immediate postoperative period, improving the quality of the patient’s functional recovery. Our objective is to analyze the evolution of CRC techniques for postoperative acute pain management in recent years.

A comparative, observational, longitudinal, and prospective study was conducted. Patients were recruited between January 2021 and December 2024. Variables recorded: Age, sex, duration of CRC use, technical approach, and involved surgical specialties. Remaining data are presented in Table 1.

• Mean age: 60.3 ± 18.6 years; 50.6% were female. • Most CRCs (80.7–85.8%) were indicated for orthopedic, general, and thoracic surgeries. A decline was observed in orthopedic surgery, while thoracic surgery saw an increase (Graphic 1). • Technical approaches shifted toward thoracic paravertebral and epidural techniques, with reduced use of lumbar epidurals and femoral nerve blocks (Table 2) • Despite adequate pain control during the first 48 hours, a slight worsening was noted on the first postoperative day, potentially linked to the rising prevalence of thoracic surgeries (Table 1).

CRCs remain a widely utilized analgesic technique for specific surgeries, demonstrating high efficacy and minimal adverse effects. A trend toward thoracic techniques (epidural and paravertebral) is evident, whereas spinal and peripheral CRCs for lower limb surgeries are declining. This shift may reflect advancements in multimodal analgesic strategies and evolving surgical approaches.

Along with the classic triad of preeclampsia (PE) - edema, proteinuria, hypertension, many clinicians have used hyperuricemia (HU) as indicator of PE.

We examined 33 patients with preeclampsia, from whom, in addition to the standard clinical and laboratory examination, venous blood was collected and cerebrospinal fluid was collected during spinal anesthesia. Their parameters were compared with those of 55 practically healthy pregnant women - without background pathology and/or pathology of pregnancy; laboratory parameters and neurological status of which were assessed quantitatively at least three times - upon admission, on the 3-4th and 7-10th days of treatment. In all patients, along with generally accepted clinical, instrumental and laboratory tests, spectrophotometric determination of the concentrations of adenine, guanine, hypoxanthine, xanthine, uric acid (UA), and malondialdehyde was carried out in samples of cerebrospinal fluid and venous blood.

It has been established that there is a clinical and pathobiochemical relationship between HU and eclamptic convulsive seizures: ‘strong’ HU - above 420 mmol/l - is the most pronounced unfavorable metabolic marker, predictor and, possibly, a direct factor in the transformation of preeclampsia into convulsive eclampsia. High levels of oxypurines in the cerebrospinal fluid are also an unfavorable prognostic sign for patients with preeclampsia.

1. ‘Strong’ hyperuricemia and critically elevated levels of other oxypurines in patients with preeclampsia both in the blood serum and in the cerebrospinal fluid - is a prognostically reliable predictor of the transformation of even mild preeclampsia into convulsive eclampsia. 2.Caffeine and other methylxanthines may be proconvulsants in patients with preeclampsia.

Infantile hypertrophic pyloric stenosis (IHPS) is a condition affecting young infants, usually diagnosed during the first 3-5 weeks of life. It is characterized by an obstruction of the gastric outlet causing immediate postprandial vomiting. The treatment is surgical, by pyloromyotomy (open or laparoscopic), thus requiring anesthetic intervention. The main concerns for the anesthesia team, after guaranteeing adequate hydration and electrolyte balance, are not only the specificities of the neonate and early infant, but the risk for pulmonary aspiration and adequate analgesia. The rectus sheath block (RSB) is a useful analgesic option.

This abstract presents a tertiary center’s experience with IHPS and the use of RSB for open pyloromyotomy, in 2024 and early 2025.

In this period 4 infants with IHPS had a pyloromyotomy performed under general anesthesia (GA) combined with a RSB. The average age of intervention was 4.5 weeks and the average weight was 3570g. In every case the RSB was performed bilaterally, after induction of GA, guided by ultrasonography, using ropivacaine 0.1%. Two of them were performed with 1mL on each side (the babies with the lightest weight) and the other two with 1.5mL. No complications were identified. Non-opioid systemic analgesia was also administered, namely paracetamol 7.5mg/kg. Adequate intraoperative analgesia was achieved, without need for further opioid doses beyond induction.

The RSB is a simple and effective tool in the pain control of small infants submitted to open pyloromyotomy, a challenging demographic given the limitations in the available pharmacological arsenal.

Dexmedetomidine is used as a perineural adjuvant associated with local anesthetic, which exerts protective effects in addition to its sedative and analgesic properties. Dexmedetomidine provides prolongation of the peripheral nerve block as well as postoperative analgesia.

We conducted a prospective comparative study including a series of 194 Sick since August 2014, the patients were randomly divided into two groups undergoing knee surgery such as ligamentoplasty. Group M: a series of 97 patients who received dexmedetomidine a reason (0.5 μg/kg) or 50 μg in 15 ml of 0.5% ropivacaine. Group C: a series of 97 patients who received clonidine at a rate of 1μg/kg with ropivacaine at 0.5% and implemented at the end of the procedure of a nerve analgesia catheter in the saphenous vein maintains with ropivacaine 0.2% in 8ml/h.

The two groups were comparable in terms of age, sex, BMI and ASA. most of the patients were done with 4 blocks therefore associated with the lateral thigh, and the surgery done under arthroscopy; Patients in both groups received on average the same volumes of local anesthetic. The average duration of the intervention was one hour.

Dexmedetomidine is a promising agent for the improvement and prolongation of peripheral nerve blocks by combining it with a long-lasting local anesthetic. The aim of which is to combat postoperative pain for very painful surgeries. The methods of use of adjuvants are based as much on their pharmacodynamic properties as on the overall strategy for postoperative pain management.

We present the case of a 42-year-old female patient with chronic mixed pain following a traumatic lower limb injury resulting in a bimalleolar fracture. The patient underwent two surgical interventions; she reported initial improvement after the first procedure, followed by worsening of symptoms after the second. Her complaints included: (1) joint pain with mechanical features, exacerbated by weight-bearing, and (2) neuropathic pain characterised by paraesthesias and dysaesthesias in the distribution area of the superficial peroneal nerve (SPN). Clinical examination revealed a DN4 score >4, pain on dorsiflexion and eversion of the foot, and a positive Tinel’s sign at the surgical scar.

Initial pharmacological management with duloxetine resulted in partial relief of the neuropathic component. The patient was intolerant to gabapentinoids. Given the persistence of symptoms, an ultrasound-guided intervention—pulsed radiofrequency plus nerve block and hydrodissection of the SPN—was carried out. This led to significant, 24-hour, pain relief.

Owing to ongoing neuropathic pain and strong motivation to restore daily function, DRGS was proposed and approved following multidisciplinary assessment, including psychological evaluation. During DRGS placement, identification of the epidural space proved challenging. Two days after implantation, the patient developed postural headache and clear fluid wound discharge, requiring hospital admission. PDPH was diagnosed and symptomatic treatment with intravenous fluids and non-steroidal anti-inflammatory drugs was initiated. After 12 days, due PDPH persistence and the fact the trial was deemed unsuccessful, and the device was removed a muscle plane reinforced suture was performed. Magnetic resonance imaging with contrast excluded cerebrospinal fluid leakage 5 days after this intervention.

This case highlights the risk of persistent PDPH and cerebrospinal fluid leak following a challenging DRGS placement. Such complications can lead to prolonged hospitalisation, increased costs and decreased patient satisfaction. Early recognition and appropriate intervention are crucial to prevent further morbidity.

In this study, we aimed to compare the patients who received pericapsular nerve block (PENG) or intrathecal opioid added to low-dose spinal anesthesia in proximal femoral nail (PFN) surgery to be performed due to hip fracture in terms of block efficiency, duration of motor and sensory blockade, postoperative analgesia and opioid side effects in the postoperative period.

After the approval of the ethics committee of our hospital and the written informed consent of the patients in our clinic, 60 patients with ASA I-II-III and between the ages of 18-85 were included in the study.The patients were divided into 2 groups by computer-assisted randomization:30 for the PENG block and the other 30 for the Intrathecal fentanyl group. Data were obtained from anesthesia records and followed up with a patient follow-up form. Intraoperative hemodynamic data, motor and sensory block maximal level, motor and sensory block regression time, side effects, and surgical satisfaction were recorded.Pinprick test, straight leg raise test, and Bromage scale were used.

The demographic details of the patients were similar. Pain scores (NRS) at positions, postoperative 8th, 12th, and 24th, were lower in the PENG group. The rates of ephedrine, positional pain, and nausea/vomiting were found to be statistically significantly higher in the intrathecal fentanyl group than in the PENG group.At 30 minutes after PENG block, it was observed that all 28 patients in the group were able to perform a 15° straight leg raising and knee flexion movement without any discomfort or pain.

In hip fracture patients who will undergo PFN surgery, it has been observed that hemodynamics is preserved in the intraoperative period, additional analgesic consumption is reduced in the postoperative period, pain control is provided more easily, and early mobilization and early discharge are allowed with the application of PENG block added to low-dose local anesthetic.

Quadratus lumborum block (QLB) and intrathecal morphine are commonly used in multimodal analgesia to manage postoperative pain following cesarean section. This prospective, randomized, controlled, and single-blinded study aimed to compare the analgesic effects of anterior QLB and intrathecal morphine in patients undergoing cesarean delivery under spinal anesthesia.

Patients scheduled for cesarean delivery under spinal anesthesia were randomized into three groups: Group Q (bilateral anterior QLB), Group M (100 µg intrathecal morphine), and Group C (standard spinal anesthesia). The primary outcome was total diclofenac consumption within 24 hours. Secondary outcomes included NRS scores, time to first rescue analgesia, and side effects

There was no significant difference in total diclofenac consumption during the first 24 hours among the three groups. However, post-hoc analysis showed that patients in the QLB group required significantly less analgesic than those in the control group (p=0.027). At the 8th postoperative hour, pain scores were also lower in both the QLB and morphine groups compared to the control group. In the post hoc analyses, both iNRS and dNRS scores at the 4th postoperative hour were significantly lower in Group M compared to Group C (p = 0.030 and p = 0.029, respectively). The time to first rescue analgesia did not differ significantly between groups. Side effects such as pruritus, nausea, and vomiting were reported more frequently in the morphine group.

Both anterior quadratus lumborum block and intrathecal morphine provided effective postoperative analgesia following cesarean delivery compared to control. While pain scores and time to first rescue analgesia favored the intervention groups, only QLB significantly reduced diclofenac consumption. Moreover, QLB was associated with fewer opioid-related adverse effects, suggesting it may be a safer alternative to intrathecal morphine within multimodal analgesia protocols.

Combat injuries often lead to persistent pain, underrecognized in standard care. This study assessed pain characteristics and impact among wounded Ukrainian servicemen referred to a military outpatient pain management office. Focus was on neuropathic and phantom pain, and functional consequences.

This retrospective review used records from the outpatient pain management office. All patients were wounded Ukrainian soldiers treated between April 2024, and May 2025, for unresolved painStandardized tools included pain diagrams, the Visual Analogue Scale (VAS), and the DN4 questionnaire.

A total of 96 unique patients underwent 154 consultations. Chronic pain was reported in 71.2% of cases, phantom limb pain in 23.7%. Neuropathic pain (DN4 ≥ 4) was present in 75.8% of cases, with a mean DN4 score of 4.89 ± 2.78. Pain mechanisms included neuropathic (81.4%), nociceptive (10.2%), and mixed or unspecified types. No statistically significant differences in pain intensity (VAS) were found between pain types (p = 0.48). The distribution of average pain intensity scores is shown in Figure 1; the mean VAS score was 5.74 with a standard deviation of 2.17. DN4 scores by pain type, amputation status, and number of surgeries are summarized in Figure 2. There was no significant difference in DN4 scores between patients with and without phantom limb pain. The time elapsed from injury to first consultation varied widely (Figure 3). Functional impairment was notable: 78% reported limitations in daily activities and 55.9% experienced sleep disturbance.

Outpatient pain consultations for wounded soldiers reveal a high prevalence of chronic and neuropathic pain, significantly affecting daily activity and sleep. Despite severe trauma, pain mechanisms vary, and subjective intensity does not correlate with DN4 or pain type. Formalized protocols and early structured pain assessment improve diagnosis and treatment. Dedicated outpatient pain services are essential to address complex post-combat pain syndromes within military healthcare systems.

Perioperative services are major sources of greenhouse gas (GHG) emissions within hospitals. Inhaled anesthetics used in general anesthesia (GA) are a significant source of GHGs due to their high atmospheric lifetime and potency as climate pollutants. Regional anesthesia (RA) offers a lower-emission alternative when clinically appropriate. While RA is widely used in elective orthopaedic procedures for its clinical advantages and enhanced OR efficiency, it remains underutilized in orthopaedic trauma. We evaluated orthopaedic trauma anesthesia at a Level 1 trauma center, examining the environmental and operational impacts of RA versus GA.

This retrospective study analyzed 1,307 orthopaedic trauma surgeries performed between November 2022 and April 2024. Cases were categorized by primary anesthetic technique: RA (neuraxial (NA) and peripheral nerve blocks (PNB)), or GA. The primary outcome was the comparative environmental impact between anesthetic techniques, measured through greenhouse gas (GHG) emissions from inhaled anesthetics. Secondary outcomes evaluated efficiency via perioperative time intervals, post-anesthesia care unit (PACU) requirement and length of stay.

RA was the primary anesthetic in 23.5% of cases, with GA the primary anesthetic in 76.5%. The GA cohort generated 8,400kg CO₂ equivalents from inhaled anesthetics, compared to zero in the RA group. Patients receiving PNB had shorter pre-incision times (28.6 minutes) and OR exit times (10.5 minutes) compared to NA (36.6 minutes and 13.2 minutes) and GA (40 minutes and 18.1 minutes). PNB cases bypassed PACU 59% of the time compared to <1% of NA and GA cases. For patients requiring PACU care, PNB cases had the shortest duration (119.2 minutes), followed by GA (168.4 minutes) and NA (186.5 minutes). No significant anesthesia-related adverse events were reported in any group.

RA eliminated volatile anesthetic emissions while maintaining safety comparable to GA. Broadening RA implementation in orthopaedic trauma presents an opportunity to improve perioperative efficiency and contribute to healthcare sustainability goals.

Lumbar disc herniation (LDH) is a common degenerative condition causing low back pain (LBP) and neuropathic pain due to nerve root irritation and compression. Previous studies have examined the microscopic changes in the spinal extensor muscles in people with LBP, with the multifidus (MF) being the most studied in people with LDH due to its uni-segmental innervation. However, there are conflicting findings regarding the multifidus (MF) muscle's microscopic changes in LDH patients. So, this observational study aimed to compare the affected MF to the adjacent MF on the ipsilateral and contralateral sides in LDH patients and examined correlations with clinical features of LBP.

Four muscle biopsies were collected from each of 30 surgical participants. Immunohistochemistry was performed on tissue sections and imaged with an epifluorescence microscope. Data on muscle fibres' cross-sectional area, perimeter, diameter, and composition were analysed using two-way ANOVA, while pathological fibres were analysed using ANOVA. Pearson’s correlation was employed to examine MF microscopy associations with clinical features.

Results revealed no significant differences in the outcome measures between the affected MF and MF from other sites, though they were significantly greater for type I fibres compared to type II fibres, irrespective of MF location. There were significantly more pathological fibres present in the affected MF (p<0.05). A weak but significant negative correlation was found between type I fibres and LBP clinical features, though no such correlations were observed for type IIA fibres.

LDH primarily impacts the pathological status of the MF rather than fibre phenotype or size, and the severity of clinical features affects the size of type I fibres. The study was approved by the University’s research governance (RG22-049; ethics reference number ERN no. 22-0418) and Royal Orthopaedic Hospital Research tissue bank (17/EM/0030). All eligible participants from the elective surgical list were consented by the research team.

Preoperative anxiety is a critical yet often under-assessed factor that may influence postoperative pain and recovery. Women undergoing gynecologic oncology surgery often report higher anxiety levels due to concerns about fertility, body image, and uncertainty. This study aimed to investigate the relationship between preoperative anxiety and postoperative pain severity, opioid use, and hospital stay in patients undergoing laparoscopic gynecologic oncology surgery.

Female patients aged 18–80 years with ASA I–III, undergoing elective laparoscopic oncologic gynecologic surgery, were enrolled in this prospective observational study. State-Trait Anxiety Inventory (STAI-I and STAI-II) was administered preoperatively; STAI-I was repeated 24 hours postoperatively. Postoperative pain was assessed via VAS at 0, 2, 6, and 24 hours. Total opioid consumption (in morphine equivalent), time to first analgesia, and length of hospital stay were recorded. Statistical analysis was performed using SPSS 22.0.Ethics Approval: This study was approved by the Etlik City Hospital Ethics Committee with approval number AEŞH-EK-2025-148, dated 21.05.2025.

Higher preoperative STAI-I scores were significantly associated with increased VAS scores at 2 and 6 hours. Patients with elevated anxiety required earlier analgesia and more frequent use of tramadol. A significant correlation was also found between anxiety levels and total opioid consumption. No difference was observed in length of hospital stay.

Preoperative anxiety may predict early postoperative pain and opioid demand. Routine anxiety screening and personalized interventions may enhance recovery and patient comfort within ERAS-based care, even in minimally invasive gynecologic oncology surgery.

79 years old female with Severe Copd with Fev1 of 0.9 l and Fev1/FVC 50%, Severe Aortic stenosis,40 pack year smoking history of 20/day and limited mobility due to breathlessness after 10 yards. Spirometry revealed severe airflow obstruction. Patient presented with Bilateral shaft of femur fractures, Right Mid shaft comminuted fracture and Left Long spiral femur shaft fracture. Patient needed complex surgery to repair bilateral fractures and duration of surgery > 4 hours with difficult positioning for regional anaesthesia.

Patient consented for intrathecal catheter under Ultrasound guidance in view of difficult positioning to facilitate the complex surgery. Locoregional analgesia achieved for Patient in severe pain with Ultrasound and PNS guided Bilateral femoral-sciatic nerve blocks with 0.2% Ropivacaine 25 ml bilateral infiltration. positioning achieved by propping up with support. Ultrasound guidance used to mark the depth of anterior complex, midline and ligamentum flavum. Microcatheter insertion technique through 18 G Epidural needle after loss of resistance at the location marked with Ultrasound. CSA maintained with aliquots of Isobaric 0.5% Levobupivacaine 0.5 ml every 15-20 minutes. Good block level of T 8 bilateral achieved. Dense block and sufficient analgesia throughout surgery lasted 4 hours. Haemodynamic monitoring perioperatively and patient transferred to High Dependency unit for monitoring. Uneventful postoperative period.

Femoral-Sciatic nerve blocks with USG and PNS guidance are optimum for positioning patient with bilateral femur fractures. CSA is safe and effective technique for operating Bilateral femoral fractures with prolonged duration of surgery in frail and elderly. VAS Pain score reflects excellent analgesia achieved

USG guided marking enables microcatheter insertion to initiate CSA in a patient difficult to position bilateral arthroplasty. The titratability of CSA allows haemodynamically stable anaesthesia for Aortic Stenosis. The haemodynamic impact of a carefully titrated CSA has also been shown to be comparable with that of using peripheral nerve blocks

Trigger point injections (TPIs) are used to treat musculoskeletal pain, but their efficacy for chronic, non-musculoskeletal pain is not well-established. University Hospital Galway (UHG) in Ireland reports higher TPI utilization compared to other Irish outpatient pain clinics, making it an ideal site for auditing TPI efficacy. This audit compares TPI efficacy between newly referred and returning patients at UHG's pain clinic to understand potential differences in treatment outcomes.

Data was collected from 28 patients who received TPIs at UHG from September to December 2023. Among them, 14 were new referrals and 14 were returning patients. Follow-up phone calls were made one week post-injection to assess treatment outcomes. Other recorded parameters included demographics, medical history, pain location, and relief levels.

Of 28 patients, 50% of new referrals and 86% of returning patients reported good relief at follow-up. Most new referrals experienced multi-site pain, while returning patients had a history of positive responses to TPIs. Those with no relief were scheduled for alternative treatments, such as lignocaine infusions or sacroiliac joint injections. One new referral and one returning patient did not respond to the follow-up call.

TPIs are generally effective for chronic pain, particularly for returning patients with a history of success. However, the varying outcomes among new referrals suggest the need for personalized treatment plans and further research to improve TPI efficacy in chronic pain management.

The implementation of Enhanced Recovery After Surgery (ERAS) protocols has gained prominence in thoracic surgery. Advances in video-assisted thoracoscopic surgery (VATS) have increased interest in non-intubated techniques, which reduce physiological stress and promote faster recovery. This case highlights the use of thoracic paravertebral block (PVB) as the sole anesthetic for non-intubated VATS in a high-risk patient.

A 62-year-old female (ASA II) with breast cancer and pulmonary bronchiectasis was scheduled for right VATS wedge resection. A two-level right-sided PVB was done at T4 and T6 using 0.4% isobaric bupivacaine with 1:400,000 epinephrine. Sensory block from T2 to T7 was confirmed. A 5 mL vagal block with 0.5% bupivacaine was added to prevent cough. Sedation was maintained with dexmedetomidine (0.2 mcg/kg/hr) and remifentanil (2 ng/mL).

The patient remained hemodynamically stable and reported minimal postoperative pain, managed with paracetamol, ketorolac, and oral celecoxib. She was mobilized the same day and discharged the next day. Thoracic PVB provides effective anesthesia and analgesia without airway instrumentation, lowering risks in patients with compromised lungs. Its use in NIVATS supports opioid-free perioperative care and aligns with ERAS principles. Regional anesthesia with sedation provided stable intraoperative conditions, excellent pain control, and early recovery.

Ultrasound-guided PVB in NIVATS offers excellent anesthesia and pain management, promoting early recovery. While risks in performing this block exist, the use of ultrasound guidance can reduce complications. Further research is needed to determine specific demographic factors influencing the success of NIVATS under paravertebral block.

Effective pain management is essential for day-case hand and wrist surgeries. Regional anaesthesia (RA) provides superior postoperative analgesia but rebound pain – a significant postoperative pain after sensory blockade resolution – remains common. This prospective survey evaluates patient satisfaction and the incidence of rebound pain after awake surgery under RA.

Fifty patients who underwent ambulatory hand and wrist surgeries under peripheral nerve blocks without general anaesthesia were identified from the electronic health records. Patients were contacted by telephone to complete a survey assessing post-operative pain, analgesics consumption and satisfaction.

All 50 patients had axillary brachial plexus blocks. Overall satisfaction was high (Figure 1), although some patients expressed anxiety about the needling for the nerve block and being awake during surgery. Eighteen patients (36%) experienced rebound pain (classified as pain score greater than 7 within 24 hours of functioning block). While 49 patients (98%) were given information about post-operative pain management, only 31 (62%) recalled instructions to take pain relief regularly and before the nerve block wore off. Subgroup analysis was also conducted. (Figure 2)

Awake ambulatory hand and wrist surgeries under RA had high patient satisfaction rates. However, over a third of patients were unaware of analgesic measures to prevent rebound pain. This highlights the need for patient education on pre-emptive analgesia to enhance pain control, particularly for bone-related procedures. Non-pharmacological intraoperative anxiety-reduction techniques could further enhance patient experience during awake surgery. Inconsistent practices highlight the need for structured standard operating procedures for different types of hand surgeries.

Caesarean delivery rates are rising globally, from 7% in 1990 to 21% in 2018, with projections of 29% by 2030 as per World Health Organisation.[1] While neuraxial anaesthesia (NA) has been the gold standard for caesarean sections, general anaesthesia (GA) may be warranted in certain conditions. Studies have linked exposure to GA at birth with poorer neonatal outcomes, though these findings are based on retrospective data and neonatal outcomes was determined using Apgar scores and umbilical artery pH. Stress disrupts homeostasis and triggers hormonal responses, with anaesthesia itself acting as a significant stressor that may influence fetal development altering the hypothalamic-pituitary-adrenal (HPA) axis.[2] The study aims to compare the stress response in newborn during caesarean section between general and neuraxial anaesthesia.

This is a prospective observational single centric study. The first group comprised of newborns delivered under general anaesthesia (GA group) and second group are delivered under neuraxial anaesthesia (NA group). Institutional Ethics Committee approval obtained. The decision for neuraxial or general anaesthesia was at the discretion of the anaesthesiologist and obstetrician managing the case. All women received standard anaesthetic care as per Institutional protocol. Umbilical cord blood samples were collected in serum vial following placental delivery from the umbilical cord vein. The ELISA method was utilized for assessing interleukin-6 (IL-6) and cortisol levels in the blood samples of both groups.

Data of n=24 participants were analysed in this interim analysis. Cortisol levels was significantly higher in neonates delivered under GA group as compared to NA group (p < 0.001). The mean IL-6 concentration in GA group was significantly higher (p < 0.001) in comparison to NA group.

This study showed that the stress response biomarkers in newborn were higher under general anaesthesia than neuraxial anaesthesia administered to women undergoing caesarean section in our study.

Assessing intravascular volume in children clinically is subjective and inaccurate. Non-invasive ultrasound methods, such as assessing diameters and respiratory variations of the great vessels have enhanced volume assessment in emergency and intensive care settings as well as in adult patients. Paediatric fasting guidelines are often poorly implemented, leading to prolonged fasting. This study aimed to explore the association between inferior vena cava (IVC) and aortic diameters and their respiratory variations (IVC distensibility, collapsibility index, and caval-aortic index) with fasting duration and hypotension in paediatric patients undergoing surgery under general anaesthesia.

After ethical approval (IHECPGR/2020/PG/July/06) and informed consent, 50 patients aged 1-12 years, scheduled for elective non-cardiac surgery under general anaesthesia, were recruited. Exclusion criteria included shock, heart disease, or raised intra-abdominal pressure. IVC and aortic indices were measured at baseline, pre-operatively, and following induction of anaesthesia using a Sonosite M Turbo machine with a 2-6 MHz curvilinear transducer. Correlation analysis was performed between fasting duration, hypotension, and these indices.

The mean age of the patients was 5.8 years. 64% of patients fasted for 6-12 hours, while 34% fasted for over 12 hours. There was a significant increase in the IVC collapsibility index (IVCCI) after fasting compared to baseline (mean difference 0.24, p value < 0.001) (figure 1). The caval-aortic (IVC/Ao) index (maximum IVC/maximum aortic diameter) also increased significantly after fasting (mean difference 0.05, p value < 0.014). IVCCI was significantly higher in patients with hypotension (0.54 vs. 0.29, p < 0.001), while the aorto-caval index showed no substantial difference.

In this study, IVCCI and the caval-aortic indices correlated with fasting duration. However, only IVCCI correlated with hypotension in paediatric patients undergoing elective surgery under general anaesthesia. Further studies on ultrasound based volume assessment in children are recommended.

This meta-analysis aimed to assess the effect of mixed vs sequential administration of local anesthetic and adjuvant on the onset and duration of spinal block in patients who underwent spinal anesthesia for Cesarean delivery. This meta-analysis aimed to assess the effect of mixed vs sequential administration of local anesthetic and adjuvant on the onset and duration of spinal block in patients who underwent spinal anesthesia for Cesarean delivery.

This review was performed following the PRISMA guidelines and using the online databases, Medline, Science Direct, Google scholar and Cochrane library. We registered this review with PROSPERO database (ID-CRD42024585462) in September 2024. We included randomized controlled trials that compared the sequential and mixed administration of local anesthetic with any adjuvant in patients who received spinal anesthesia for Cesarean delivery. The included studies in this review reported onset and duration of block, opioid consumption, time to first request analgesia, pain control after surgery, and associated side effects. We utilized the Review manager software, RevMan for MAC 5.4 to conduct the meta-analysis.

A total of 12 randomized controlled trials were included in this systematic review and meta-analysis. The duration of sensory block was significantly longer in patients who received sequential administration of local anesthetic with adjuvant compared to mixed group in Cesarean delivery [P=0.004, (CI: 8.42, 45.91)]. The time to first request analgesia was significantly longer by 38.63 minutes in sequential group compared to mixed group [P=0.02, (CI: 6.59, 70.68)].

The sequential administration of local anesthetics with adjuvant increases duration of sensory and motor block compared to mixed administration in Cesarean delivery. It also increases the time to first request analgesia. There is no significant difference in incidence of adverse events between two groups.

To explore the synergistic analgesic mechanism of combining lidocaine, ropivacaine, and morphine in epidural injections and its advantages in postoperative pain management.

A prospective, randomized, double-blind trial included 120 abdominal surgery patients (18–65 years). The experimental group (n=60) received epidural lidocaine (0.75%, 10ml), ropivacaine (0.75%, 10ml), and low-dose morphine (0.03 mg/kg); the control group (n=60) received only lidocaine and ropivacaine. Pain scores, morphine consumption, side effects, and satisfaction were recorded for 48 hours postoperatively.

The experimental group had significantly lower pain scores at 6h (1.8±0.9), 12h (2.0±1.0), 24h (2.2±1.1), and 48h (2.1±1.3) compared to the control group (4.7±1.2, 4.8±1.3, 4.6±1.4, 4.8±1.5; P<0.001). Morphine consumption was lower (25±10mg vs. 50±15mg, P<0.001), and side effects (nausea/vomiting: 12% vs. 35%, P<0.01) were reduced. Patient satisfaction was higher (4.6±0.5 vs. 3.2±0.8, P<0.001).

The combination of lidocaine, ropivacaine, and morphine enhances postoperative analgesia, reduces morphine use and side effects, and improves patient satisfaction, making it a recommended strategy for epidural anesthesia.

Dwarfism encompasses a variety of conditions, each presenting unique anesthetic challenges. In this case report and scoping review, we describe the anesthetic management of a 28-year-old primigravid woman with spondyloepimetaphyseal dysplasia undergoing an elective cesarean section and conduct a scoping review exploring neuraxial anesthetic management for cesarean sections in the most common form of dwarfism, achondroplasia.

Embase, Medline, Scopus, and Web of Science were systematically searched using the keywords: Achondroplasia, skeletal dysplasia, cesarean section, anesthesia, epidural, spinal, and neuraxial. Inclusion criteria selected for studies involving patients with achondroplasia undergoing cesarean delivery with a focus on neuraxial anesthetic techniques and dosing. Studies involving general anesthesia were excluded. Extracted data was analyzed with a focus on patient demographics, neuraxial anesthetic methods, and dosing regimens to identify practices and outcomes related to neuraxial anesthesia in achondroplasia.

Neuraxial anesthetic management for patients with achondroplasia undergoing cesarean sections included single shot spinal, intrathecal catheter, epidural catheter, and combined spinal and epidural anesthesia. We highlight the most common neuraxial technique, the prevalence of each neuraxial technique, ranges of intrathecal bupivacaine and epidural lidocaine, and mean dosages of local anesthetic used. A reduced dose of local anesthetic was commonly administered for both intrathecal and epidural anesthesia to account for the patients' altered spinal anatomy with limited complications reported.

Neuraxial anesthesia appears to be a safe and advantageous option for cesarean section in patient with achondroplasia and other forms of dwarfism, allowing a positive patient experience while avoiding potentially difficult airway management.

Arteriovenous (A-V) fistula formation is the gold standard for dialysis access in adults, with benefits demonstrated in children as well. Regional anesthesia (RA) in adults provides superior analgesia, enhanced primary fistula patency, and the possibility of intraoperative spontaneous breathing. Brachial plexus blocks (BPB) are the most common RA modality, with the axillary BPB widely regarded as the primary option.

We retrospectively analyzed patient data at the University Children’s Hospital in Belgrade, from January 1st 2022 to December 31st 2024. Ten patients underwent antebrachial A-V fistula formation under procedural sedation and ultrasound guided axillary BPB. On induction patients received Fentanyl and Propofol, while sedation was maintained with continuous Propofol. All patients received an axillary BPB using 1-2% Lidocaine (2,52 ± 0,88 mg/kg) and 0,5% Levobupivacaine (1,49 ±0,4 mg/kg). Local ethics committee approval was obtained.

Patients were breathing spontaneously, maintaining hemodynamic and respiratory stability. No additional intra/postoperative opioids were given, with total opioid consumption limited to an average of 1.56mcg/kg on induction. Postoperative analgesia was satisfactory, with first NSAID administration after 14±4 hours.

Axillary BPB is a safe and effective method for managing antebrachial A-V fistula formation in children. We can eliminate the use, and associated risks of general anesthesia entirely, with the additional positive effect on the fistula itself. This proposes RA as a primary option, especially when present comorbidities enhance the risk of general anesthesia and attempted endotracheal intubation, highlighting the benefit of spontaneous breathing. RA also enables surgical planning for fistula instead of graft, thereby ensuring preferred hemodialysis access.

Patients undergoing major total shoulder arthroplasty often receive interscalene block (ISBPB) for pain management. However, it carries a risk of phrenic nerve blockade, which can lead to significant pulmonary complications, particularly in the elderly. Neuromodulation is used in chronic pain as a modality to improve prolonged analgesia. This study investigates a novel technique: low-volume superior trunk block combined with percutaneous neuromodulation (STB-PTNS). Our primary aim was to assess if this approach could prolong the analgesic effect of the block, thereby reducing opioid consumption and its associated side effects in an elderly population.

This retrospective case series analysis was conducted as a quality improvement project after local committee approval. A total of 60 patients were included: 30 received the novel STB-PTNS (4-5ml) and 30 received the standard ISBPB (10-40ml) without neuromodulation. The analgesic efficacy was evaluated by patient-reported pain scores using the Numerical Rating Scale (NRS) and recorded opioid consumption. Data were collected immediately in recovery area and at 24 hours postoperatively prior to discharge.

The average pain score in recovery was 4/10 for the STB-PTNS group and 6/10 for the ISBPB group. At 24 hours postoperatively, scores were 4/10 for STB-PTNS and 5/10 for ISBPB. A notable difference in opioid choice was observed; the STB-PTNS group predominantly utilised codeine and PRN oral morphine, while the ISBPB group required more oxycodone.

Percutaneous neuromodulation holds promise in acute pain settings due to its analgesic properties and ability to prolong block effects. Our findings suggest that low-volume superior trunk block with temporary percutaneous neuromodulation provides possible superior pain relief compared to interscalene block 24 hours postoperatively with reduced risks of phrenic nerve involvement. The effect of heterogeneity of patients and clinicians performing the block was evident. Further prospective research is warranted to evaluate long-term analgesia efficacy and opioid use.

Mindfulness meditation —a well-known practice to psychology research— is based on sustained, non-judgmental attention to the present moment. Anxiety and depression are known to affect total knee arthroplasty (TKA) outcomes such as pain and mobility and may be mitigated by meditation. This pilot study investigated, among TKA patients, the feasibility of a perioperative mindfulness meditation intervention (MMI): a pre-recorded guided meditation.

This pilot randomized controlled trial (IRB# 2023-2131) randomized 15 to an MMI and 15 to a waitlist control group (received the mindfulness intervention after data collection had finished for their group) (Table 1). Overall, 14 surveys were administered at 5 distinct timepoints. Feasibility measures focused on response rates and survey answers on the day of surgery and 14 and 90 days (POD0, 14, 90).

In the MMI group 73.3% (11/15) listened to the intervention before surgery; all 11 MMI patients indicated that the MMI intervention at least somewhat improved their emotional distress or physical pain, as indicated by MMI practice survey responses (Table 2). Only 20.0% (3/15) of MMI patients completed the MMI practice survey on POD14 and POD90.

Most MMI-randomized patients listened to the audio before surgery and provided positive feedback, however survey completion declined substantially postoperatively, raising concerns about feasibility after surgery. This decrease may reflect limitations in our data collection methods rather than limited feasibility of the intervention itself. Future efforts should focus on improving patient response rates and reducing survey attrition, perhaps through reducing survey burden while maintaining sufficient meaningful data capture.

Regional anaesthesia (RA) is crucial in battlefield surgery for effective analgesia and workload reduction. Ultrasound-guided supraclavicular brachial plexus block (SCBPB) is valuable in forward military hospitals, close to combat zones, where general anaesthesia is often less feasible.

We present 30 representative cases of upper limb combat injuries treated with ultrasound-guided SCBPB at a forward-positioned hospital (10–15 km from combat line). Patients were divided into two groups of 15: those receiving dexmedetomidine (DMM) and those without. Blocks used ropivacaine 150 mg, dexamethasone 4 mg, and DMM 1 μg/kg (in DMM group). Anaesthesia was administered within hours of evacuation. Data was recorded using a "Regional Anesthesia Card" (Image 2). Detailed medical data obtained is presented in the Attachment (Table 1 - Summary Table).

Effective surgical anaesthesia was achieved in most cases, avoiding general anaesthesia conversion. In the DMM group (n=15), mean onset time was 10.53 ± 1.82 min (7.3–14.4 min range). Postoperative analgesia averaged 802.67 ± 103.20 min (650–960 min), with mean time to first pain relief request 1272.00 ± 340.93 min. Bradycardia occurred in 6 patients (40%), hypotension in 2 (13.3%). In the non-DMM group (n=15), mean onset time was 13.56 ± 1.88 min (10.7–16.1 min range). Postoperative analgesia averaged 372.67 ± 83.45 min (240–550 min), with mean time to first pain relief request 721.33 ± 162.78 min (Image 3). Bradycardia occurred in 2 patients (13.3%), hypotension in 3 (20%). Following surgical interventions, patients were safely transported to rear hospitals, with the performed block providing effective analgesia throughout transport. The technique significantly reduced anaesthesiology workload compared to general anaesthesia.

Ultrasound-guided SCBPB with adjuvants is safe, efficient, and well-suited for forward military medical settings. Dexmedetomidine significantly prolongs analgesia, facilitating surgical care and pain control during evacuation under combat conditions.

The COVID-19 pandemic has seen an increase in the use regional anaesthesia (RA) with increased clinical benefits and improved perioperative outcomes. However, this rise in procedural volume has brought an associated increase in complications, particularly in the non-obstetric population where formal follow-up protocols are lacking. Building on findings from a prior national survey, we aimed to design and implement a local digital database to systematically capture and follow-up all non-obstetric RA procedures at the East + North Herts Hospital.

The bespoke digital RA database was launched in April 2024 with access initially restricted to credentialed RA providers. It is securely accessible by all departmental RA providers and allows real-time entry of key procedural and patient data. Collected variables include: • Patient demographics and surgical context • Block type (upper/lower limb, trunk, neuraxial, rib fracture) • Local anaesthetic dose and concentration • Anaesthetic technique (awake/sedation/GA; US-guided or landmark) • Procedural safety (sterility, complications, contact for follow-up) • Post-operative patient feedback (5-point Likert scale)

Initial data confirms high uptake and feasibility. The platform has enabled: • Audit of RA practice patterns and block volumes • Monitoring of block success and complication rates • Evaluation of postoperative analgesia and patient-reported outcomes • Targeted quality improvement and training initiatives • Follow-up pathways for identifying delayed complications

This digital RA database represents a scalable, innovative tool for enhancing procedural safety, improving patient outcomes, and supporting research within RA practice. Ongoing data collection will strengthen its role in quality assurance, education, and further evolution of the database.

Reliability and distribution of Fascial Sheath Blocks remain wanting. While hyaluronic acid-the main receiving molecule in FSB is actively researched, fluid dynamics of FSB remain unknown. We propose a functional comparison of FSB to Hele-Shaw-cells and the influence of viscous fingering (VF) -ie creeping flow in addition to LA-diffusion and turbulent bulk flow. We developed a schematic model of FSB relying on hyaluronic acid in an elastic Hele-Shaw-cell to study mepivacaine distribution.

2 ml of colored 1% hyaluronic acid serum ( molecular weight 1.5-1.8 kD) was placed in a thin layer on 6 glass plates and covered with a 10x12cm Tegaderm. Average compartment size of hyaluron depot was 70.5 cm2. 5ml mepivacaine was injected with a 70mm UPC 22 G needle at 5ml/90s. The surface of the entire artificial compartment was calculated and its filling by Mepivacain studied quantitatively (% of surface) and qualitatively (viscous fingering). Hight h after injection was measured by ultrasound.

6/6 models showed extensive distribution of LA in viscous fingering patterns (see illustration). Viscous fingering advanced in 2 circles: one initiating inner (6/6) and a secondary, wider outer circle (4/6). Compartments were filled to 64 % (45.6 cm2) mean with regards to inner circle and 80 % (58.6 cm2) with regards to outer circles after injecting 5 ml mepivacaine 1%/90 sec. VF patterns showed long, slim digitations issueing from needle tip and along shaft . Displacing the needle tip outside the first circle, immediately caused emergence of a wider outer circle. The hight of the LA-comparment after injecting 5 ml on a mean surface of 70 cm2 was 3.2 mm.

Viscous fingering is a dominant fluid dynamic pattern of LA apart from turbulent bulk flow. This simple model reproducibly shows VF and allows studying FSB fluid dynamics. Future research needs to explore added collagene network porosity!

Cardiovascular disease (CVD) is the leading cause of pregnancy-related mortality in the United States. The mortality incidence from 1987 & 2015 increased from 7.2 to 17.2 deaths/100,000 live births due to multiple reasons. Aim: How to manage a high-risk obstetric cardiac case coming for an emergency Cesarean Section in a resource-limited night call. Secondary aims are: To minimize changes in preload, maintain preload to ensure pulmonary blood flow, avoid fluid overload, maintain low to normal PVR to encourage pulmonary blood flow, and to avoid sedation, hypoxia, and hypercarbia.

24 years G1P0 at 37 weeks, History of Hypoplastic left heart syndrome with Fontan. She endorses significant exertional dyspnea and a single episode of chest pain recently. Taking Aspirin 81 mg and Enoxaparin 40 mg daily. The action plan included examination, checking of investigations, consultations, and labor analgesia plan, as well as post-procedure disposal. Goals include baseline and regular echocardiogram, and if general anesthesia is needed, the plan was to limit inspiratory pressure and PEEP and adequate minute ventilation to maintain low PVR.

We did a titrated epidural and an arterial line for a cesarean section. The patient was stable during the intra-op period with vasopressor support and transferred to the ICU after the emergent section.

Multidisciplinary care is essential to optimizing outcomes for mothers with CVD, and care plans should be distributed to all team members and kept in a location easily accessible to obstetric and anesthesia providers, nurse management, and consulting services (Cardiology, neonatology, CV surgery). Anesthesia providers play an integral role in care planning through postpartum care. When possible and safe, neuraxial anesthesia can successfully provide for pain-free and hemodynamically stable delivery experiences and is preferable to general anesthesia.

Total knee arthroplasty (TKA) is associated with significant postoperative pain. The aim of this study was to compare postoperative oral and parenteral analgesic therapy depending on the use of a single-shot femoral block at the end of surgery versus bolus administration of local anesthetic via a femoral catheter.

A retrospective observational study was conducted on 128 patients who underwent TKA in 2024. Based on power analysis, 64 patients were included per group. One group received a single 20 ml dose of 0.25% levobupivacaine at the end of surgery. The other had a femoral catheter placed and received the same initial dose, with the option of up to three additional boluses daily for 48 hours. Postoperative analgesics included parenteral ketoprofen, paracetamol, metamizole, oxycodone, and tramadol, as well as oral tramadol/paracetamol, short-acting morphine, and oxycodone/naloxone.

Groups were comparable in terms of sex, age, ASA status, and anesthesia type. No significant differences were observed in the use of paracetamol, metamizole, oxycodone, and tramadol, as well as oral tramadol/paracetamol, short-acting morphine, and oxycodone/naloxone on postoperative days 0 and 1. However, ketoprofen use on day 1 was higher in the single-shot group (180 mg vs. 151 mg; p < 0.05). In the catheter group, 56.2% received at least one bolus on day 0 and 71.4% on day 1.

Overall postoperative analgesic use did not differ between groups, although the lower use of ketoprofen in the catheter group may reflect the additional local anesthetic option. However, the femoral catheter was not fully utilized as a method of pain control.

Thoracic surgery in infants poses significant anaesthetic and analgesic challenges. Ensuring effective postoperative pain control while minimizing opioid has emerged as a valuable tool in pediatric regional anaesthesia, though reports in infants remain limited.

The authors describe the perioperative management of a 5-month-old female infant (6.8 kg) diagnosed with congenital pulmonary airway malformation proposed to elective right mid and lower lobectomy via thoracotomy. After multidisciplinary planning and informed consent of legal guardian, a balanced general anaesthesia was performed using sevoflurane, fentanyl, and rocuronium, followed by standard endotracheal intubation via video laryngoscopy. Intraoperative analgesia was provided with intravenous paracetamol, ketamine, and metamizole. For postoperative multimodal analgesia, a single-shot ultrasound-guided paravertebral block was performed at the T5 level at the end of the procedure using a high-frequency linear probe and a 22G short-bevel needle, with a total of 5 mL of 0.2% ropivacaine being administered.

Both the procedure and the anaesthetic recovery were uneventful. The infant remained under surveillance in the pediatric intensive care unit for the first 24 hours, remaining eupneic on room air with no signs of respiratory distress and controlled pain with multimodal analgesia, with reduced opioid consumption. The infant was discharged from the hospital six days after the procedure. At a two-month postoperative follow-up visit, there were no reports of respiratory or infectious complications, nor any pain signals.

Single-shot paravertebral block may be a safe and effective approach as part of a multimodal analgesic regimen in infants submitted to lobectomy via thoracotomy.

At the Orthopedic Trauma Centre (CTO) in Turin, more than 250 spine fusions are performed every year. This surgery causes a moderate to severe postoperative pain. According to the poor evidences in the use of locoregional anesthesia (ALR) in this surgery, we decide to compare intrathecal morphine (ITM) and Erector Spinae Plane Block (ESPB).

The study is a single center prospective observational study. Preliminary results show a homogeneous population of 15 patients. Group 1 (8 patients) received 75 mcg of intrathecal morphine (ITM), group 2 (7 patients) received Erector Spinae Plane Block (ESPB), 20 ml of Ropivacaine 0,375% each sides.

We found no significant side effects between the two techniques. Postoperative pain, quantified as NRS on awakening (T0), was no statistically significant between the two groups (p-value 0.23). In the postoperative period the NRS at 2-4-6-12 and 24 h was higher in the ESPB group, although the difference was statistically significant only at 4 h with a p-value of 0.04. Regarding the use of morphine in the first 24 h, as rescue therapy, it was higher in the ESPB group than in the ITM group (p-value < 0.05).

The two techniques proved to be safe, and ITM seems to provide better pain control in the postoperative period. The observational study certainly needs to be continued to enlarge the sample size and make the data stronger, possibly allowing differences between the two groups to be highlighted.

Inhaled anesthetic agents, particularly desflurane, sevoflurane, and nitrous oxide (N₂O), are among the leading contributors to greenhouse gas (GHG) emissions in hospital settings due to their high global warming potential (GWP) and minimal metabolic degradation. Their atmospheric persistence further exacerbates their environmental burden.

We conducted a retrospective analysis of anesthetic gas usage between 2015 and 2025 across two Belgian university hospitals. Volumes were extracted from institutional pharmacy databases and converted to carbon dioxide equivalents (CO₂e) using IPCC-based GWP coefficients. A targeted awareness intervention was issued in April 2025 to all anesthesia staff via a departmental communiqué. Time-series and inter-period comparisons were performed using nonparametric and parametric statistics.

Over the study period, cumulative anesthetic gas emissions totaled 14.49 million kg CO₂e. N₂O represented 82.9% of emissions (≈12 million kg CO₂e), followed by sevoflurane (≈1.0 million kg) and desflurane (≈0.43 million kg). Desflurane emissions fell from 48,464 kg CO₂e in 2016 to zero in 2024 (p < 0.001), reflecting complete institutional withdrawal. Despite gas control measures, sevoflurane emissions remained stable (median ≈98,725 kg/year). April 2025 showed a significant reduction in mean emissions per surgical case (8.18 kg CO₂e/case) versus April 2024 (9.43 kg/case, p = 0.00013) and March 2025 (8.90 kg/case, p = 0.006), indicating a rapid behavioral shift post-awareness campaign.

The study demonstrates that targeted institutional actions—such as desflurane withdrawal, restricted access to N₂O, and focused awareness efforts—can lead to substantial reductions in the carbon footprint associated with anesthetic practice. These findings support the integration of environmental sustainability into anesthetic governance and reinforce the critical role of clinician engagement in achieving climate-conscious healthcare.

Regional anaesthesia is crucial for modern healthcare, offering significant benefits when performed safely and effectively. A comprehensive understanding and proficiency in various techniques, risks, and recognition of complications is essential for ensuring patient safety. However, conventional teacher-centered education of clinicians has been proven inefficient in securing long-term knowledge retention. The aim of this study is to determine whether scenario-based learning improves long-term knowledge retention of regional anaesthesia.

Anaesthesia residents were invited to a one-day workshop on regional anaesthesia. Before the workshop, participants completed a multiple-choice exam on regional anaesthesia. They then engaged in six scenario-based learning cases, each following a structured format and concluding with a debriefing session led by an ESRA-certified instructor. To assess knowledge retention, participants completed the same exam immediately after the workshop and again three months later.

A total of 36 students were included in the study. A Wilcoxon signed-rank test showed a statistically significant improvement immediately after the simulation (median 63% vs. 70% of correct answers, p < 0.001), indicating a strong learning effect. However, no significant difference was observed between the post-workshop and three-month follow-up scores (p = 0.503), suggesting that the knowledge gains were retained over time.

Scenario-based training appears to be an effective pedagogical approach for enhancing and sustaining residents’ knowledge retention over time; however, further studies are needed to confirm these findings.

Patients’ attitudes towards pain management is critical for effective treatment strategies. However, few data are available about the relationship between different pain conditions and patients' attitudes towards pain. This study examines the pain attitudes of patients diagnosed with nociplastic (fibromyalgia) vs patients with nociceptive pain diagnoses.

We analyzed 200 patients (63% female) experiencing different pain syndromes, including nociplastic (fibromyalgia), neuropathic, arthritis or musculoskeletal pain and other nociceptive pain syndromes. Patients’ attitudes toward pain were assessed using the Survey of Pain Attitudes–Brief (SOPA-Brief), a validated 7-item scale measuring patient beliefs and perceptions related to pain control, solicitude (perceived responses from others), the role of treatment, disability, emotional influences on pain, the potential for medical cure, and pain-related harm. Chi-square tests were used to examine differences in SOPA-Brief subscale scores between patients with fibromyalgia, neuropathic vs nociceptive pain. Exploratory analyses were conducted to further investigate these differences.

Among study group (mean age = 65 years, SD = 14.8), 12.5% were diagnosed with fibromyalgia, 17% with neuropathic, and 70.5% with nociceptive pain. Chi-square tests revealed statistically significant differences between the fibromyalgia and nociceptive pain groups on the Solicitude, Emotion and Harm subscales of the SOPA-Brief. Further analysis showed that patients with fibromyalgia scored significantly higher (p < 0.01) on Solicitude (M = 15.06, SD = 1.90), Emotion (M = 9.70, SD = 3.90), and Harm (M = 9.12, SD = 2.20), compared to patients with nociceptive pain (Solicitude: M = 13.84, SD = 2.98, Emotion: M = 8.86, SD = 3.50, Harm: M = 8.48, SD = 2.33) respectively. Differences between neuropathic and nociceptive patients were not significant (p>0.05).

Nociplastic patients experience greater challenges in managing pain-related attitudes, particularly concerning solicitude, emotional reactions to pain and beliefs about pain-related harm. However, findings should be interpreted with caution and warrant validation in future studies.